Y Pwyllgor Iechyd a Gofal Cymdeithasol

Health and Social Care Committee

08/11/2023

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Gareth Davies
Jack Sargeant
Joyce Watson
Mabon ap Gwynfor
Russell George Cadeirydd y Pwyllgor
Committee Chair
Sarah Murphy

Y rhai eraill a oedd yn bresennol

Others in Attendance

Albert Heaney Llywodraeth Cymru
Welsh Government
Alex Slade Llywodraeth Cymru
Welsh Government
Eluned Morgan Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol
Minister for Health and Social Services
Hywel Jones Llywodraeth Cymru
Welsh Government
Irfon Rees Llywodraeth Cymru
Welsh Government
Jeremy Griffith Llywodraeth Cymru
Welsh Government
Julie Morgan Y Dirprwy Weinidog Gwasanaethau Cymdeithasol
Deputy Minister for Social Services
Lynne Neagle Y Dirprwy Weinidog Iechyd Meddwl a Llesiant
Deputy Minister for Mental Health and Well-being

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Morris Ail Glerc
Second Clerk
Lowri Jones Dirprwy Glerc
Deputy Clerk
Sarah Beasley Clerc
Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Cyfarfu’r pwyllgor yn y Senedd a thrwy gynhadledd fideo.

Dechreuodd y cyfarfod am 09:31.

The committee met in the Senedd and by video-conference.

The meeting began at 09:31.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions, and declarations of interest

Bore da. Good morning. Welcome to the Health and Social Care Committee this morning. As always, we're operating bilingually in Cymraeg or English. This morning, there are no apologies. I know that Mabon has to pop out just before 10 o'clock for a short time, but other than that, there are no other apologies to note. If there are any declarations of interest, please do say now. No. 

2. Sesiwn graffu gyffredinol gyda'r Gweinidog Iechyd a Gwasanaethau Cymdeithasol, y Dirprwy Weinidog Gwasanaethau Cymdeithasol a’r Dirprwy Weinidog Iechyd Meddwl a Llesiant
2. General scrutiny session with the Minister for Health and Social Services, the Deputy Minister for Social Services and the Deputy Minister for Mental Health and Well-being

In that case, I move to item 2. This is a general scrutiny session with the Minister for Health and Social Services, the Deputy Minister for Mental Health and Well-being and the Deputy Minister for Social Services. Thank you, all, for being with us today. It might be useful if officials around the table this morning introduce themselves as well for the public record. Shall I start from this end?

Bore da. Hywel Jones, director of finance in the health and social services group.

Bore da. Irfon Rees, director of health and well-being. 

Bore da. Alex Slade, director of primary care and mental health. 

We've got two more behind, if that's okay.

Oh, right. I was going to say—. The microphones might not pick up, but do you want to just—? I was going to say you could introduce yourselves when you come to the table, but introduce yourselves now.

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

Bore da. Good morning. Jeremy Griffith, director of operations, NHS Wales.

That's fine. Hopefully the microphones picked that up, so thank you very much. And thank you, as well, for being with us this morning.

Minister, just to start with, you set up a task and finish group for NHS accountability and I know that you've issued a statement on that today as well. I suppose the question is do you have doubts regarding the Welsh Government's capacity to impact health board performance effectively. 

I think it's an opportunity to reflect on the structure that we have, because the structure that we have was introduced back in 2008. And, of course, now that we have the NHS Wales Executive, which has come into being, I think it's a good time to reflect on whether we've got the right accountability structures in place.

I think we're in a different position to the way things, for example, are organised in England. I was just reflecting yesterday on the detail that the First Minister, for example, went into yesterday in response to a question on the potential closure of a GP surgery. He was expected to know bus routes to get to a particular GP surgery, and I just thought, 'Can you imagine that happening anywhere else in the world, where you'd expect to know that kind of detail?' The question for me is where does accountability lie. And let's just be absolutely clear about who is responsible for what. Some of it around, for example, the Betsi Cadwaladr issue showed up for me that we need to be absolutely clear about where responsibility lies. Legally, it's clear at the moment that I delegate responsibility to the health boards and the chairs of the health boards to work on my behalf, but what's clear is that that clarity wasn't understood by everybody. It may be that we need to reflect on that.

But if, for example, as a Government Minister, you are to take responsibility—. I'm more than happy to take responsibility, but if that's where we're at, then I need the tools to do the job, and I'm not sure whether those tools are where they should be at the moment. I think there are also opportunities to reflect in terms of accountability and where you can improve methods of accountability through better use of incentives and, perhaps, castigations within the system. So, I've asked the group that have been assembled—and they're very deliberately not from within Government; I have tried to get people who come with a different perspective—to look at what does that structure look like, have we got it right, is there an opportunity to rethink, perhaps, the way that we organise ourselves. Let's look at the boards, let's look at responsibility in those boards. So, I'm very pleased that that group has been set up. As you say, I've announced the membership of that group today, and they'll be reporting to me by the end of March.

09:35

From my perspective, it's a very welcome task and finish group, because, I suppose, as a committee, our job is to hold Government to account and bring forward positive ideas, but it's useful to know where accountability lies and understand that. I can see, Minister, as well, that the work is scheduled to be completed by the end of March next year. Will you be making the findings publicly available and would you be happy to report back to us? Because, obviously, it's a piece of work that we're particularly interested in, as well, in that regard. 

Sure. I'm very happy for them to publish their report. I'm not necessarily making a commitment to take on board everything that they suggest, but I'd be happy for you to see that, and then I'll be making some decisions on the basis of whether I agree or not with the recommendations they come up with. But I'm more than happy for you to see that as well.

Thank you. I really appreciate that. We'll move on to another section now. Mabon ap Gwynfor.

Diolch, Gadeirydd. Dwi'n mynd i ofyn y cwestiynau yn Gymraeg. Jest fel man cychwyn, yn gryno iawn, allwch chi, Weinidog, ddweud wrthyn ni os ydych chi'n hapus efo ffigurau adrannau brys ar hyn o bryd?

Thank you, Chair. I'm going to ask my questions in Welsh. Just to start, very briefly, could you, Minister, tell us whether you are content with the figures for accident and emergency departments at present?

Wrth gwrs ein bod ni ddim yn hapus. Mae yna bwysau aruthrol ar yr adrannau brys, ac fel y gweloch chi hyd yn oed dros y penwythnos diwethaf, mae'r pwysau yna yn cynyddu. Jest o ran yr hyn sy'n digwydd, dwi'n meddwl mai beth sydd gyda ni yw guidelines rŷn ni wedi eu rhoi i'r byrddau iechyd, a beth ŷn ni wedi ei ddweud yw ein bod ni'n barod i gael trafodaeth ynglŷn ag ydy'r guidance yna yn y lle cywir. Dyna pam rôn i wedi dod â grŵp at ei gilydd tua mis yn ôl iddyn nhw ddod lan â quality statement ar adrannau brys fel eu bod nhw'n penderfynu'r ffordd orau i'w wneud e.

Beth sy'n bwysig i fi, a beth dwi'n meddwl mae'n rhaid inni ei ystyried, yw ar hyn o bryd mae'r ffordd rŷn ni yn cyfrif fwy neu lai yr un peth â'r ffordd maen nhw'n cyfrif yn Lloegr. Os ŷn ni'n mynd i ffwrdd o hynny, bydd e ddim yn bosibl i ni wneud cymhariaeth, ac mae hwnna'n rhywbeth mae'n rhaid inni jest ei ystyried. Efallai ein bod ni ddim eisiau cario ymlaen yn y ffordd yna. Ond os ŷch chi'n cofio, gwnaethon ni newid pethau flynyddoedd yn ôl yn y ffordd roedden ni'n mesur ambiwlansys achos ein bod ni eisiau newid o goch i felyn fel bod pob un ddim yn cael ei ystyried yn yr un ffordd. Ar y pryd, roedd pob un wedi gwneud ffws mawr a dweud, 'O, rŷch chi'n symud y goalposts'. Actually, beth ddigwyddodd oedd bod Lloegr wedi ein dilyn ni wedyn. Felly, mae'n rhaid inni jest ystyried, os ŷn ni'n mynd lawr llwybr gwahanol, efallai byddwn ni'n methu gwneud y gymhariaeth yn y ffordd rydyn ni'n gallu ar hyn o bryd.

Of course we're not happy. There's a huge pressure on A&E departments at present, and, as you saw even over the last weekend, that pressure is increasing. Just in terms of what's happening, I think what we have is our guidelines that we've given to the health boards, and what we've said is that we're ready to have a discussion about whether that guidance is in the right place. That's why I brought the group together around a month ago in order for them to draw up a quality statement on A&E departments so that they can decide what the best way of doing that is.

What's important to me, and what I think we should consider, is that at present the way we count is the same as the way that they count things in England. If we go away from that, it won't be possible for us to make those comparisons, and that's something that we need to consider. Perhaps we don't want to continue in the same way. But if you remember, we changed things years ago in the way that we measure ambulances, and that was because we wanted to change from red to amber so that everything wasn't considered in the same way. At the time, everybody made a big fuss about that and said that we were changing the goalposts. But what happened then was that England followed suit. So, we need to consider that if we go down a different pathway, we may not be able to compare things in the same way as we can at present.

Yn benodol, felly, ar hynny, o ystyried breach exemptions, dydyn nhw ddim yn ystyried breach exemptions yn y gwledydd eraill—

Specifically, therefore, on that, given the breach exemptions, they don't consider breach exemptions in other countries—

Mae nhw yn. Maen nhw'n eu galw nhw'n rhywbeth gwahanol. Rydym ni wedi bod yn edrych ar y guidance sydd gyda nhw mewn lle. Maen nhw'n eu galw nhw'n rhywbeth gwahanol, ond o beth ŷn ni'n ei ddeall, mae'n nhw'n ei wneud e yn yr un ffordd. Dwi wedi edrych ar y geiriad mewn manylder.

They do. They call them something different. We've been looking at the guidance that they have in place, and they call them something different, but, from what we understand, they are doing it the same way. I've looked at the wording in detail.

Iawn. Os ydych chi'n edrych ar y ffigurau breach exemptions, mae gennym ni nifer y bobl, y flwyddyn yma, er engrhaifft, oedd, yn ôl yr ystadegau swyddogol, wedi mynd i mewn i adran frys yn 39 y cant, dwi’n meddwl, ond os tynnwch chi allan breach exemptions, mae hwnna’n 51 y cant o bobl sydd wedi bod yn aros dros bedair awr. Mae hynna’n 12 y cant o wahaniaeth mewn gwirionedd. A dwi’n gwybod ar lawr y Senedd ddaru chi ddweud hwyrach mai'r lle gorau i rai pobl ydy yn yr adran frys i gael triniaeth, ond os ydy’r ystadegau swyddogol yn dangos mai dim ond 39 y cant sydd yno, yna mae’r adnoddau sydd yn mynd mewn i adran frys yn cael eu teilwra i’r niferoedd yna, nid i’r 52 y cant sydd mewn gwirionedd yn mynd yno. Felly ydych chi’n derbyn bod angen i ni gael ystadegau cliriach am faint o bobl sydd yn aros yn ein hadrannau brys ni?

Okay. If you look at the breach exemptions figures, we have the number of people this year, for example, who had, according to the official statistics, gone into an A&E department as 39 per cent, but if you take out breach exemptions, it's 51 per cent of people who have been waiting for more than four hours. That's a 12 per cent difference. I know that on the Senedd floor, you said that maybe the best place for some people is an emergency department to have treatment, but if the official statistics show that there are only 39 per cent there, then the resources going into an emergency department are tailored to those numbers, not to the 52 per cent that really go there. So, do you accept that we need to have clearer statistics about how many people are waiting in our A&E departments?

09:40

Dwi’n meddwl ein bod ni’n gwybod faint o bobl sydd yn ein hadrannau brys ni. Dwi’n meddwl bod manijers yn ymwybodol o’r hyn sy’n digwydd, ac maen nhw’n ystyried hynny pan maen nhw'n teilwra beth sydd angen o ran lle yn yr adrannau brys, felly mae hwnna i gyd yn cael ei gymryd mewn i ystyriaeth.

I think we do know how many people are waiting in our A&E departments. I think managers are aware of what's happening, and they're considering that as they tailor what is needed in terms of space in A&E departments, so all of that's being taken into consideration.

Ond maen nhw’n gwneud hynny ar sail y ffigurau swyddogol.

But they're doing that on the basis of the official figures.

Management figures. Felly maen nhw'n gwybod y gwahaniaeth rhwng faint sydd wedi cael y driniaeth ond maen nhw'n dal yn aros yna, a'r rheini sydd yn aros.

Management figures. So, they know the difference between how many have been treated but are still waiting there, and those who are waiting.

Mabon, I was just going to say, I think the question you asked was about how many patients are waiting, but I suppose the question, really, is how long patients are waiting. That's the question, isn't it? I think that's the difference that might need to be addressed.

I think the more important issue is have they been treated. I gave an example the other day of my auntie: we took my auntie into hospital, she had a heart issue, she was treated, and they said, 'Look, can we keep her in for observations?' Nothing else happened; that was it. Nothing else was going to happen to her, but she had been treated. So, I think it's really important just to note that there is a difference between somebody who's being treated and somebody who is perhaps being kept in for observations.

Are you confident that figures aren't being massaged—that some people are asking for patients to stay in A&E as a breach exemption in order to massage those figures, and show that the numbers aren't as bad?

Because there is some anecdotal evidence that the Royal College of Emergency Medicine have come across.

I'd be very concerned if that were the case. We have asked very clearly, 'Are people following the guidance that we've set out?' And we've been given assurances by all the health boards that they are following the guidance.

I have asked them, and so we have been given assurances that they're following the guidance. What I've also said is that we are open to review the guidance if it's not appropriate as it is at the moment. But let's not forget that initially, when this guidance was brought in, it was brought in at the request of clinicians. So, if clinicians are telling us something different now—. Obviously, in the context of the development of the quality statement that we've asked them to help us formulate around what does 'good' look like in an A&E department, if they're telling us, 'Actually, you need to start measuring in a different way', obviously, we will give that consideration. They are undertaking that task now, and have been undertaking that task. We brought them all together about a month and a half ago to do that way before the issue about exemptions was raised. So, that was a process already in place.

Finally, Chair, if I may, on that, that's to be welcomed, then presumably, if you're reflecting—. The first thing you said in the session is that it's time to reflect on some decisions made some time ago. Tthis decision to have breach exemptions was brought in in 2011, we know that clinicians are saying they want to change it, and you're saying that is being reviewed now. What's the timescale, and when will we have a final decision?

We've kicked off that process with the representatives from emergency departments. It was the first time that people from all the emergency departments in Wales had come together and we're hoping that they will come up with their recommendations probably by about the end of March.

Thank you very much, Chair, and thank you all for being here this morning. I'm going to ask some questions about the workforce now. So, as we know, staff shortages in the NHS can result in increased costs and inefficiencies. This could be increased overtime and agency costs, delays in treatment, extra expenses to recruit and train new staff, which then can lead to low morale and high sickness absence. So, to what extent are staff shortages contributing to the deteriorating financial situation of the Welsh NHS, do you think?

09:45

Thanks very much. Well, I think, first of all, we've got to put a context around this. We are employing 17 per cent more staff in the NHS in Wales now, compared to June 2019. Just in the past year, we've employed 3,400 more NHS staff, but the fact is that we're doing this at a time when there is a global shortage of healthcare workers. The World Health Organization has said that there's going to be a shortage—a worldwide shortage—of healthcare workers of 10 million by 2030. It's interesting, when I went on a visit to a World Health Organization conference in February last year, that the talk of everybody around the table was the challenge around healthcare workforce. So, it's not unique to Wales. It's something we're going to just have to cope with and we're going to have to be creative in the way that we deal with things.

Now, obviously, one way to make up that shortfall is through the use of agency workers. I think it’s really important for us to put a context on this. So, around 65 per cent of our budget is spent on staff. Now, during this financial year, I think we spent about £224 million on agency, which is obviously way beyond what we would like to see, but I think it is important to set that in the context of—what are we talking, Hywel—a pay bill of about £5 billion or so. So, I think it is important to get a context on those figures. But, listen, that’s too much and we are spending a lot of our time at the moment making sure that we focus on driving down those agency costs.

There’s about a 6 per cent vacancy rate in terms of the workforce in Wales. Now, obviously, when you’re dealing with 100,000 people, there is always going to be churn. You’re always going to have a certain percentage of people who are leaving or joining or whatever. So, there will always be a percentage that you’re never going to get to, but what we’re trying to do is develop a much more effective system. The spend this year is already forecast to fall by the end of this year by some £50 million. That’s about 15 per cent, but, obviously, we’re hoping to be a bit more ambitious on that. I don’t know, Hywel, if you’ve got anything to add to that.

Thanks, Minister. So, I think, in 2023, our total locum and agency expenditure was £325 million, which did increase from the previous year, and around 70 per cent of that relates to the cover of vacancies, which is the £224 million that the Minister described. So, vacancies do contribute to the financial position that we face. It's a factor, albeit not the sole driver. And as the Minister has described, management information from health boards is that that forecast is going to reduce this year because of the number of actions that we are taking, not only in terms of recruitment, but also in terms of addressing some of our agency expenditure.

Sorry, just to correct the figure I gave, I gave a figure of £224 million, which is the vacancy rate.

That's why you have officials in the meeting, I guess. 

Thank you very much. I just wanted to ask, as you've mentioned that there are actions being taken though to reduce that cost, if that could mean, though, that there will be less spending on agency staff and that that will lead to less surge capacity this winter. So, for example, extra staff won't be brought in to open up extra wards. Do you think that that's something that the health boards are looking at to achieve the reduction?

So, we've been doing a lot of work with our trade union partners to try and see what more we can do to incentivise people to come into the system, and not to use the agency approach. So, we've been having very, very detailed conversations with them around, for example, much broader rules around flexibility and allowing people to work more flexibly, and that kind of approach to flexibility by default, and acceptance of that will, we hope, make a significant difference to people who may then agree to come into the mainstream system.

We do have to be sensitive to the fact that, during winter, we do have these surge times. Now, this year, obviously—. Last year, we were incredibly successful. Julie Morgan and I worked very, very diligently with local government to deliver about 760 new community beds. Some of those are still in place, but we haven't got the money this year to step up in the way that we did last year. So, there may be an issue relating to the number of beds. But, I think it's probably important to put a context on beds. We have about 9,100 beds within Wales, but if you look at how that looks compared to England, we have about 295 beds per 100,000 of the population, where, in England, they're on 175 beds per 100,000. So, if you compare us to England, we've got significantly more beds per head of population.

09:50

Thank you, Chair. I want to cover financial pressures, if I may. There was a statement by the Minister for Finance and Local Government recently in the Senedd announcing that there would be £400 million extra going into the Welsh NHS, and subsequent statements have alluded to the fact that it could be in excess of that. But, in September, it was reported that the Welsh NHS has overspent by up to £800 million. So, is the additional £400 million actually a real-terms cut in that case?

Look, I think it is important to put this in context. Our budget is worth £900 million less than it was when it was set in 2021. What we know is that this is as a result of—. Certainly within the health services, what we've seen are pressures coming from things like huge increases in inflation, we've had to respond to pay pressures, and the cost of medicines have gone up by 11 per cent. So, these are all things that are out of the control of the health boards themselves. So, the problem is that, all of those things you have to pay for, because you're not going to have cold hospitals and, effectively, then, you have to take that money from somewhere else within the system. And so that's the major challenge.

So, we went into this budget year already in deficit. Don't forget, with things like COVID, previously we had £150 million to cover COVID costs, for example. So, we're vaccinating, we've got the vaccination strategy that's already happening this winter—all of that. We have to pay for that. It's additional funding. So, we have to find that, but we haven't had any additional money from the UK Government to cover any of that. So, we have to find that money from somewhere, which is why we're not talking about cuts here; we're talking about what they were projecting as a deficit if they were going to carry on. Now, what we've done is we've been around the whole of the Cabinet table, who have understood that health is a priority for the Welsh Government, and they have effectively made cuts to their budgets in order to help us out in health. That's amounted to £425 million additional funding coming into health. So, it's not about cuts; this is money—additional money—coming in to make up for the fact that actually those inflationary pressures need to be addressed. So, what we've done now is share that additional funding out to health boards on an equitable basis.

That's the thing, on the face of it, it looks great, the extra £400 million, but it's simple arithmetic, that if the Welsh NHS is overspending by £800 million and then there's £400 million, there's a big deficit there, isn't there? 

There is. So, there are lots of things we've asked them to do. One of them is to make sure that they try to deliver efficiency savings of 2 per cent. So, 2 per cent of £10 billion is quite a lot of money. That's about £220 million. That's a lot to save just from efficiency savings in a year. So, that's something that we're asking them to do. All three Government Ministers, we have a pot that we manage centrally from here to try and drive change, drive efficiencies. We've had to look at where we're able to take some money from that in order to support the front line. So, we've done a huge amount of very painful cuts to that central money that we provide from us here centrally, so we're effectively helping them out with that.

09:55

It's additional money that's going into the system. Inflationary pressures mean that the money that was in there before—which has not been cut; there's more money than ever before gone into health—and the amount you can buy for that money has reduced significantly.

And, you know, in terms of—. You mentioned medicines and different areas of spending, and obviously, you know, there are certain funds for medicines as well. How is that sort of divvied up between central funding into medicines and, then, specific allocated funding for things like cancer drugs and other specific medication that might cost a premium rate, say? How is that affected by these financial pressures, and are there specific priorities to protect those certain areas so that people can still access those medications?

We spend about £1 billion a year on medication. There's a huge amount of work being done across Government. I mean, there's a kind of permanent process of trying to bear down on how much we spend on that. I don't know if, Hywel, you could just elaborate a little bit on what we do in relation to medicines.

Yes, of course. Thank you, Minister. To go back to the question, some of the additional funding that we're allocating to the system is to support inflationary pressures associated with medicines this year. There are a significant number of existing processes around access to medicines through the All Wales Medicines Strategy Group and access to medicines approved by the National Institute for Health and Care Excellence. We've established a value and sustainability board, chaired by the director general, which is looking at strengthening how we consistently implement opportunities to deliver financial improvement on a national basis, including things like switching biosimilars or equivalent clinically effective products for a reduced cost. So, that's more of our focus in terms of how we can deliver financial improvement.

Do you want to come in quickly, Joyce? And I'll come back to you, Gareth.

Yes, on medicines. I've read many reports that have outlined that, since we've left the European Union—Brexit—the inflationary costs on medicines, and also the supply of medicines, has gone through the roof. Have you assessed separately—and if you haven't, we would be happy to have a note on it—the additional cost of medicines and the accessibility to the UK as a consequence of Brexit?

So, getting hold of medicine, that's a reserved power, so that's something that—

—the UK Government have responsibility for, and I know Sarah Murphy is very aware of that. But we know that there's been about an 11 per cent increase in terms of inflation this year on medicines. I don't know if Alex would like to come in on that.

Thank you, Minister. As the Minister describes, it is reserved. We engage regularly with the Department of Health and Social Care and other devolved administrations around the UK pricing controls, which effectively determine the value that we pay. So, the cost part is the consumption in the volume that we see, and, as you know, supply has been a challenge since leaving the European Union. So, there's ongoing work around how to address that, and there will be a new system and scheme in place with the pharmaceutical industry around the supply of medicines. But it's one that we regularly monitor, and the system has the shortage notifications as soon as they arise, and we have seen a shift to different medicines, but, obviously, there are lots of different suppliers in that market. But when we think, in community pharmacies, of the primary care volume, there are around 84 million medicines handed out a year—huge volumes and, therefore, supply chains are very live and active in terms of meeting that level of demand.

I'll bring Sarah in as well. I'll come back to you then, Gareth. Sarah.

Yes, thank you, Chair. On this, obviously, I have been raising the shortage of Elvanse, which is having a hugely detrimental effect on adults and children across Wales. I know that you've been very much on this, health Minister, so thank you. But I'm also hearing now that for children in particular who are suffering with cystic fibrosis, the UK Government has decided to withdraw funding for their treatment, which can actually extend their life by 50 years. It can make such a difference to them. I was just wondering, in the context that my colleague Joyce Watson has just mentioned about the inflation and the cut to funding, how much do you speak with UK Government when they decide to make these decisions? Is there something in place so that Welsh Government can pick up the cost of this, not that I believe that they should have to? But if it does make this huge difference for children with cystic fibrosis, is this something that you are looking at and that you are aware of? Diolch.

10:00

Thank you, Minister. All, certainly, new and particularly higher value medicines are—. Advice comes from NICE and, as Hywel mentioned, the All Wales Medicines Strategy Group, which is advice then put to Ministers, which weighs up the value, clinical benefit, as you articulate. So, the mechanism for us to appraise use of new medicines in NHS Wales is through that specific route, and clearly there's a balance, I suppose, of affordability and clinical gain, so that is the evidence route that we rely on for that decision making, as was articulated by a Member. Lots of those are cancer medications, but there are specific condition medications that come through that route also, so lots of analysis to give us the best appraisal on taking forward those medicines.

Thank you, Chair. It's just one final question. What assistance are you giving to individual health boards with financial pressures, and are certain health boards in Wales more directly affected by financial pressures, given that health boards such as Betsi Cadwaladr are in special measures? Does that make them more vulnerable than others? What assistance are you giving to health boards to reflect this Government strategy?

We've shared out about £460 million to health boards; £336 million of that is on a recurrent basis, but that's conditional on them meeting certain target control totals; £150 million of that is to make up for the fact that COVID expenditure—. They needed to find £186 million inflation in relation to things like medicines. But then there's an additional £124 million, which is non-recurrent. Seventy-five million of that is for inflation, and £49 million of that is for energy, for example. The way we've tried to work it out is basically they are given it on an equitable basis. That's done on a formula that takes account of need and all of those—. There is a formula that is accepted and used on a proportionate basis. Hywel, is there anything you'd like to add to that?

Yes, thanks, Minister. So, as the Minister has described, we've issued funding to health boards, which has been allocated based on our resource allocation formula. In effect, we're asking health boards to deliver the plans that they've set out, but with a 10 per cent reduction to that planned deficit they set out at the start of the year. So, £648 million was the total of combined planned deficits at the start of the year. We're looking for a 10 per cent reduction on that. We're allocating funding in line with the formula, as the Minister described, and then effectively we set organisations target deficits, which is offset by funding within the group. So, we are looking for health boards to deliver the plans that they've set out and be consistent in our framework and approach with organisations. So, it is an equitable approach, as the Minister has described.

Just to go to what other support we're putting in place, we're obviously strengthening our system approach around implementing savings and addressing variation on a national basis. I referenced earlier the value and sustainability board that the director general will be chairing. That's a forum on a monthly basis that includes lead Welsh Government directors, health board chief executives and other specialists across the NHS in Wales. We've got a focus on the five key areas of resource utilisation across Wales, so workforce, medicines, packages of care, procurement and non-pay, and those areas where we have some clinical variation, and we know what high-value interventions we want to pursue on a national basis. Those processes are being driven nationally in support of what health boards are doing locally to deliver financial improvement. And we've also strengthened our escalation framework and support of organisations directly, so we're clear on what actions individual organisations can take to deliver financial improvement.

10:05

And is your level of intervention higher for Betsi Cadwaladr in north Wales, given that it is in special measures, or do you allow the same autonomy for Betsi Cadwaladr as other health boards who are not in special measures? So, what I'm essentially asking is: does that make— 

Does that make any difference for north Wales, given the current situation with it being in special measures?

So, the formula is done on a basis of things like population, on rurality, on poverty. So, there's a formula that is used, but these are the things that those health boards have set themselves as the plans that they said that they could deliver on at the beginning of the year. 

Thank you. And just a few questions on that as well. When will the revised total allocations for health boards be published following your statement today?

So, there should be an annex to the statement that came out, and I'm sorry if you haven't got that; I thought that would have come to you as well. 

Okay. So, that will be published either later on today, if it's been already.

Yes. And does that also outline the breakdown of the expected £123 million deficit by health board as well?

We can share that. 

So, in terms of the budget allocations, health boards have been notified. These budgets and their changes will be reflected in second supplementary budgets. We have obviously shared what the annex of the position is with health boards; we can share that, if that would be helpful to see. 

And, I suppose, the final question: so, there's still going to be a £123 million deficit across all health boards, and, of course, some health boards will have bigger deficits than others. So, I'm just trying to understand how that works following the statement as well today. 

Yes. So, as a result of the exercise the Minister's described, in terms of the Minister's work centrally, reviewing budgets, there's the equivalent funding held centrally to support that deficit position, effectively. So, we are looking for organisations to deliver those target deficits that have been set out. 

Okay. So, that £123 million won't be split by health board.

No, it's funding we retain within the main expenditure group, effectively. 

Before I go on to mental health services, which I will, I want to ask about high energy costs in the NHS, because they are significant. And in terms of savings, the one way that those savings might be helped would be by adding some green infrastructure to the buildings. But you've only got £1 million capital spend from the UK Government this year, so I'm sure that that will make it a bit tricky. But with your £1 million, do you think that you could actually put some form of green energy onto existing buildings?

To be fair, it's £1 million additional funding from the UK Government, which is not a lot, to be fair. But the problem is that we are really, really challenged when it comes to capital funding within the NHS in Wales. And the question is how we balance that off against the need to do all of the other things that we need to do in relation to keeping the show on the road, frankly, and just making sure that we have the right facilities. So, there are lots of things that we're interested in doing in relation to the NHS. We want to bring down waiting lists, for example. We want to develop more surgical hubs. We've put money into those kinds of things. So, all of these things need to be balanced off against each other. 

What I can say is that, in 2021-22, we did invest £13 million in decarbonisation schemes. So, the one, for example, in Swansea—hugely successful—made, I think, £500,000 savings per year. So, a huge contribution. Last year I did say, 'Look, if we can, can we try and focus resources onto that, so that we're trying to make savings on the revenue side from the capital?' So, we did that last year. This year, our capital fund is very, very tight indeed, so it’ll be more difficult to do it this year, but we are encouraging health boards just to take that into account. But don't forget, lots of things have been done. So, for example, there's been a huge refurbishment of the Prince Charles Hospital in Merthyr—£200 million. So, that is all done in the context of thinking about energy efficiency as well. So, when we are doing refurbs, then that is a fundamental part of the thinking.

10:10

Thank you. As I said, I'm now going to go on to mental health services. Good morning, Minister. You did say that you have got a mental health plan—that you're making one. When can we expect to see the release of that? Because it would help us to see that so that we can scrutinise it and then ask appropriate questions of yourself.  

I'll take this one because this one falls under me. Thank you, Joyce. Well, officials have been working very hard on our new mental health strategy as well as our new suicide prevention strategy. There's been absolutely loads of engagement with a range of key stakeholders as well as people with lived experience and carers, and the plan is currently to publish the two strategies for consultation by the end of this calendar year. And then, following the consultation, the plan would be to publish final strategies in the spring, along with detailed delivery plans to support implementation underneath them. We're also keen to publish an evaluation framework alongside the plan so that we can see how we're progressing against objectives.

I'm sure the committee will be pleased to hear, in light of the recent mental health inequalities inquiry, that this will be a cross-Government plan that will have indicators for Ministers outside the health portfolio. But in the meantime, obviously, we're continuing to implement the actions in our current mental health delivery plan, and we're also planning to publish a close-down report on that in due course so that people will be able to see what we've achieved through that.

I should just add as well that, as well as this work, we've now got a dedicated and expanded resource in the NHS executive with our new strategic programme for mental health, and that includes a mental health patient safety programme and the establishment of clinical networks, and timescales to establish this new infrastructure will be included in the delivery plans.

Can I ask: is that going to help accessibility to the service and equality of accessibility and treatment? 

Absolutely. Improving access will be a key part of the new strategy, so will the need to provide compassionate person-centred care, but also a recovery-focused approach to mental health as well, and we've also very much taken on board the evidence that we had from the committee through the mental health inequalities work that you did. So, tackling mental health inequalities will be a key part of the work that we are doing, and indeed has been a key part of the work that we've done developing the strategies. We've worked with black, Asian, minority ethnic communities and with other groups to make sure that all their needs are fully taken into account.

Have you had any discussions with the UK Government? We know that they postponed, but reannounced yesterday, the Mental Health Act 1983 legislation. I suspect they won't deliver it. It's a delay, it's just an announcement. So, how is that impacting?

Well, obviously, we're really disappointed that the UK Government aren't proceeding with the new mental health legislation. We've been working closely with officials in the UK Government on the new legislation. Some of it involves things that only they can do because they are reserved matters. We still haven't officially had it communicated to us that they're not going ahead with that legislation, but, obviously, we're aware that it wasn't in the King’s Speech yesterday. So, that is really disappointing. However, notwithstanding that, because we've been doing all this preparatory work, we are now looking at what we can do, without using UK Government legislation, to bring about some of the changes that were planned. So, we're doing what we can with the powers that we've got.

10:15

Diolch yn fawr, Cadeirydd. Minister, I've just been looking in front of me here at the 'Later Life in the United Kingdom 2019' fact sheet from Age UK, and it states in their report that over half of older people—I think it's 54 per cent—have at least two chronic conditions or more; obviously, those living with one, that's a significantly higher percentage. Therefore, I was just wondering what specific measures is your department implementing to address the increased demand and strain on healthcare services resulting from the ageing population, including people living with chronic conditions.

We're very aware that we are confronting a very different demographic from what we've seen in the past, and what we're talking about is perhaps far more complex cases and, as you suggest, multimorbidities. So, actually, we're doing a huge amount of work in this area just to try and ensure that we're putting the right kind of support in place. All of this is actually set out very clearly in 'A Healthier Wales'. This has not come as a surprise; this is something that we foresaw. And if you looked at the health projections that we had a debate on in early September, looking at the chances of how many people are going to have cancer in future, how many people are going to be living with strokes in future, increases in the number of people with diabetes—all of these really complicate the picture. And what we've got is a population—. Some things should be celebrated—an ageing population. When Nye Bevan established the NHS in 1948, generally, you stopped working at 65 and you died at 66. So, we're in a very different situation. It's a success story. The problem is that people are living longer but with poorer health, and so we're going to have to change our approach to how we do health in Wales. And we are trying to do that. We need to shift the emphasis into the community, so people need to be cared for in the community, as part of what we're trying to do there, through introducing things like the Further Faster programme, giving that support within the community. But also we need to think about training, making sure that we have, perhaps, more generalists who are able to deal with multimorbidities. So, specialists—at the moment, people tend to just really dig down deep in different specialist areas. I don't know, Alex, is there anything you'd like to add?

Thank you, Minister. I think there's the relationship around urgent and routine as well, and that tension that exists, particularly when you think about general practice and management of long-term conditions, and how we've made changes around 111, '111 press 2', urgent primary care centres, to try to deal with some of that urgent space and demand, such that general practice can then manage the long-term conditions, have that relationship with the patients, the continuity of care, which leads to better outcomes, and working with the Royal College of General Practitioners on their views around continuity of care, to really make sure we've got that balance right between access for urgent patients, where they need it, through various routes, as I just touched on, and then having that ongoing relationship with your GP or a member of their team for those longer term conditions, to make sure they're managed effectively.

Thank you, both. If I can perhaps ask the Deputy Minister for Social Services around dementia care. In the same report I have in front of me, it refers to research from the Alzheimer's Society that says an estimated over 1 million people in the UK will have dementia by 2025, and that's to rise to over 2 million by 2051. This is obviously a growing issue, one that we take seriously and should take seriously. Given the growing demand, I'm just wondering how you are working and collaborating across Government with other departments to address some of the challenges we see, particularly with dementia care.

Thank you, Jack. Lynne actually deals with the dementia plans, so I'll hand over to Lynne.

My apologies. I'll address it to the Minister for—

Thank you, Jack, and you are right to highlight the very worrying figures relating to a potential rise in numbers of people living with dementia. Obviously, in Wales, we have our dementia action plan, which was reviewed as part of the pandemic, and a companion plan was delivered. We're currently waiting for the evaluation of the dementia action plan, and we're expecting to receive an interim report by the end of this calendar year and then the full report next year—it was, unfortunately, affected by the pandemic. We have prioritised funding for dementia services; we allocate £12 million to regional partnership boards, and all of them have got plans in place to support people living with dementia. All of them have leads in place, and there is also regular scrutiny of that work, which is undertaken through the relationships that we have with the RPBs. I think there is more work to be done in terms of reducing the risk factors for living with dementia, and that is a public health issue. Obviously, we're doing lots of work through our 'Healthy Weight: Healthy Wales' delivery plan, things like reducing the rates of diabetes—that also has links to dementia. But these aren't short-term measures, obviously, and we will be working to have a new plan in due course when we've had a chance to consider the evaluation.

10:20

Thank you for that. That's all from me, Chair. Just to say, I think we'd be interested in seeing the response to the evaluation as well, when that comes through. Thank you.

Thank you, Jack. Sorry, Sarah, I know you wanted to come in on an earlier question, on section 4. Did you want to come in now on this one?

Yes. Thank you very much, Chair. I just wanted to ask, in terms of eating disorder services, Deputy Minister, I understand that the Welsh Health Specialised Services Committee is looking at commissioning in-patient beds for adults with eating disorders in Wales, and also with the Cheshire and Wirral Partnership NHS Foundation Trust about patients in north Wales and north Powys. And this of course is a very welcome development. But I just wanted to ask as well—Beat Eating Disorders charity and other stakeholders are asking if the Welsh Government will publish an early intervention service model/framework, with timescales for achieving the vision of the Welsh eating disorder service review from 2018, so that everyone affected can access effective help quickly. Diolch.

Well, it's quite a difficult thing to answer briefly, Russell.

So, if I can say, in relation to the beds, as you say, Sarah, the Welsh Health Specialised Services Committee are considering the need for in-patient beds on a long-term basis, as part of the work that they're doing on their specialist strategy. But I'm also very pleased to tell you that we have secured some interim beds in Wales, and I'm actually going to see them tomorrow, in Ebbw Vale, so there will be in-patient beds available for people living with eating disorders in Wales. In terms of the Tan review, what I can say is that we have worked very hard, invested a lot of extra money, to make sure that health boards are meeting the National Institute for Health and Care Excellence guidance on eating disorders, and that includes meeting the four-week waiting time, and also a commitment to early intervention. We've got a new clinical lead in place, and there's a clinical network beneath her, and we are looking at early intervention, including looking at some new programmes, which we have looked at in England. So, that work is very much happening with pace. We've made good progress on waiting times for children with eating disorders, and also there is nobody waiting—there is no waiting list currently for adults with eating disorders in Wales. So, I'm really pleased with the progress that we're making. And we also fund early intervention through things like Beat, and that work will be continuing.

Thank you, Joyce. Sorry—thank you, Lynne. We've got two sections left that I want try and cover before 10:30, so it leaves about two and a half minutes for each; it's a bit of a struggle. So, I've got Joyce on a section, then Jack. We've got to try and finish both by 10:30, so apologies. Joyce Watson.

Health inequalities: has the Minister considered the need for the redistribution of resources in the areas where people are finding, particular communities are finding, access to care, and therefore the outcomes, not being so good for them? And I'll wrap it up into the second question, that we would need data and analysis in order to inform us about those disparities. What actions are you taking—? So, it's a twofold question. Let's have the data and the analysis so that we can give greater access to those people who currently aren't having it.

10:25

Great. Thanks very much. What we do is we set out a planning framework. So, at the beginning of the year we say, 'Right, these are the things we really want you to focus on, health boards.' So, last year, because of the kinds of pressures that we were under, we limited that to six areas that we wanted them to focus on. So, I set the strategic vision, but it's up to the health boards themselves to do that local analysis, and don't forget that this was something that was built into the Social Services and Well-being Act (Wales) 2014, where they had to make a population needs assessment, working with local authorities. Obviously, now we have the data from the census that can also be built into that.

We're very aware of the inverse care law and the fact that, actually, the people who need the support most may be furthest away or not able to access in quite the same way—you represent a rural area and you'll know that you're more likely to have issues in terms of accessing—and they're more likely to die prematurely. So, we need to make sure that we take those kinds of things into account, so that when we're making those financial assessments of things, rurality, deprivation, all of those things, actually come into that formula.

Just in terms of the data, we do have a health inequalities data group, and we continue to increase the number of breakdowns by different kinds of groups in terms of people with protected characteristics and things—deprivation, geography. So, we are doing that on a more granular basis all of the time, but it is up to the health boards themselves to do that local analysis.

So, would it be possible to see some of that data, so that we can scrutinise? And if we're going to scrutinise the health boards, that would help us to understand it. 

So, they publish the population needs assessment, so it would be very easy for your committee to get hold of that. 

That's good. And when can we expect, Minister, the publication of the health impact assessment regulations set out in the Public Health (Wales) Act 2017?  

I'm hoping that will be done by the end of this year. So, we'll start the consultation on that by the end of this year, which is—. You know, this is groundbreaking stuff. This is world-leading stuff. So, every time a new policy development will happen across Government, across the public sector, they're going to have to think through what is the health impact of this. This is revolutionary stuff. The World Health Organization are very, very excited about what we're doing here, so we're hoping that that consultation will start by the end of this calendar year.  

Calendar year—by the end of next month. There we are. Thank you. Jack Sargeant. 

Diolch, Cadeirydd. Does the health Minister maintain a risk register of potential public health threats and, if so, what are those threats? 

So, what we've got is a national security risk assessment, and that's done generally via the UK Government and they take that overview of risks in terms of major emergencies that could impact on the UK. They tend to look at around two years ahead. So, the kinds of things that they are looking at at the moment are, obviously, the risk of a new pandemic. They also look at human and plant disease, and they give a score: 1 is minor, 5 is catastrophic. So, obviously, we're still concerned about a new variant of COVID-19 emerging, and the disruption that could have on health services. We're keeping in regular contact with them and, obviously, the civil contingencies group across Welsh Government is all over this as well. 

And will that then—? You'll receive that as health Minister and your department receive that, and you share that with Cabinet colleagues in—? 

So, it's generally the civil contingencies group that leads on those areas, but the health group will be receiving those national security risk assessments on a regular basis. 

Thank you, and noting what the Chair said, I will just ask one final question to the Deputy Minister. I'll try and get the right Deputy Minister—I think it's the Deputy Minister for mental health again. Just how effective was the Welsh Government substance misuse strategy and delivery plan for 2019-2022, and whether or not it met its intended targets, and whether you have any plans to develop a new delivery plan or successor strategy.

10:30

Thank you, Jack. Well, we refreshed the substance misuse plan as well during the pandemic, and that is still a live plan that we're currently working on. You'll be aware that the focus within the plan is very much on a harm reduction, public health approach to substance misuse. We're currently investing £67 million in our substance misuse agenda this financial year, and that will increase to over £69 million next year. That money goes out to area planning boards, and they commission, then, local services. But that work is very closely overseen by Welsh Government officials, and they're also required to provide key performance indicators on how they are doing.

But actually, I'm very proud, really, of the work that we've been doing on substance misuse in Wales. We've protected that funding. We've got a really good partnership approach being taken forward through our area planning boards, which is about to be modelled in England as well. So, that work continues apace, really. We're currently implementing our existing plan. 

Thank you. And England and Scotland have published their women's health plans. When can we expect a women's health plan to be published in Wales?

This is now an NHS health plan, so this is not going quite as quickly as I’d hoped. But what we are doing is we’re in a situation now where we’ve got the quality statement that’s been delivered already, and progress has been made with the establishment of the women’s health network. We’ve recruited, or we’re in the process of recruiting, two key posts in terms of the clinical lead and a network manager, and those appointments are anticipated for December. But we’re not waiting for that. There’s actually quite a lot of work being done in the background. We’ve got a transitional senior leadership group, which is preparing documentation ready for the establishment of that network. So, quite a lot of work is being done, but I’m hoping that things will pick up the pace once we’ve got that network manager and clinical lead in place, as I say, in December.

So, the plan is an NHS plan. I can't determine what they're going to do, because it's their plan—it's the NHS plan. I do the quality statement, they do the delivery.

Okay. Have you asked them about when they expect their plan to be available?

The clinical lead is just about to be appointed and the network manager is currently in place. But it's not like we haven't been doing anything. We've been doing a huge amount of work on endometriosis, for example, doing a lot more work in relation to working with Llais and Fair Treatment for the Women of Wales—working with them. So there's been a lot of work being done, and also across the three nations we've been doing work together on things like the menopause and abortion as well. 

I appreciate you said you're disappointed with the slowness of the plan coming forward, but in a nutshell, why has there been a delay?

It just takes time to get the right people in the right place. We have appointed within the Welsh Government somebody to lead on this, but we did need the NHS to get that clinical leadership in place.

So, when do you envisage that Wales will have a women's health plan?

I'll have to wait until that clinical lead and the network manager have been appointed, because they have to own this plan. Because if they own it, they're more likely to deliver it.

Okay. I want to take a break, but we haven't got a lot of time, unless somebody's really pressing for a break, so we'll take a two-minute pause, if that's all right. I appreciate some Ministers have got to—. Did you want a quick break? Do Members want a very quick break? Okay. We'll take a very quick four or five-minute break, and that gives us time to help the officials change around appropriately. Thank you. 

10:40

Gohiriwyd y cyfarfod rhwng 10:35 a 10:40.

The meeting adjourned between 10:35 and 10:40.

Welcome back. Just to say that Jeremy Griffith, director of operations, and Albert Heaney, chief social care officer—sorry; I got that right, did I, Albert? 

You did indeed. Thank you.

They have now joined the table as well. Gareth Davies.

Thank you very much, Chair. In our last general scrutiny session, we asked for figures on the current number of care staff vacancies and the forecast for the winter, and we were concerned about the lack of up-to-date data available to accurately assess the scale of the problem. Has that situation improved now that we're embarking on the winter period? 

Yes. We've got much more solid data now, since we last had that discussion. We have a monthly check-up in terms of the vacancies and where people are placed, and this is much more specific, much more refined than before, so we get those details on a monthly basis. Also, I'm sure that you're aware that we're setting up a national office and one of the real main functions of the national office will be to ensure that we have even more refined data and information in order to plan the social care workforce. I know you appreciate that it is difficult, in some ways, to do this, because there are 1,000 independent providers in the social care field, so it's not only the local authorities, obviously, it's this mass of independent providers. So, trying to get to grips with the data is not easy, but we have made a lot of progress.

But they are all governed by Care Inspectorate Wales, so there is a universal approach to solving some of those problems with the independent sector, isn't there?

Oh, yes. Care Inspectorate Wales—all the independent sector has to be registered through Care Inspectorate Wales, so there is a universal way of looking at what standards are there, yes. 

And do you have any data? You mentioned having a data stream—are you able to share some of the figures and what we're looking at in terms of vacancies?

I think it's probably best—it's quite detailed—if we write to you about the detail. I'm quite happy to do that, yes. We've got quite a lot of data.

Okay. That would be helpful. Thank you very much. Staff are expected to leave the sector within the next 12 months and 44 per cent in the next five years. Obviously, we talk a lot about recruitment and retention, so what sort of priorities do you have in terms of looking at that problem and trying to retain and recruit people into the sector, obviously to make it more attractive for people to come into and show that it can be a rewarding career?

Well, you're absolutely right, it is a very rewarding career, and I know that you'll speak to people in the sector and they really love it and really appreciate it. But there are issues that we have to address in terms of retention and recruitment, which is absolutely crucial. The pay issue is very crucial. I mean, what we want to do is professionalise the workforce and get them recognised for the great work that they do and obviously pay is one of those things. So, we have set up a real living wage. Last year, we put £43 million into that, and this year we put £70 million in an uplift to keep pace with the real living wage. But people are still attracted, we are told, by jobs in retail and jobs in other sectors where, possibly, they are able to earn more. So, longer term, we would like to see better pay rates. There's also the issue of terms and conditions, and we work very closely with the social care fair work forum, who are looking at terms and conditions and also at pay progression. We've consulted on that over the summer. So, we feel it's really important that the workforce is registered, and we've been in the process of registering all the workers in social care, and it's trying, as I say, to boost their value in terms of the public. 

We have the We Care Wales campaign, which is very wide-ranging, where there are—I'm sure you've probably seen them—lots of television adverts and lots of ways of trying to reach people, and that has had a wide range of interaction with the public. The feedback is that, yes, there is more understanding and respect for what social care is. We're keen to expand that now, as well, to highlight the fact that there are not many men working in social care. It is mainly a women's occupation, and we'd really like to see more men coming into social care, and older people in terms of the workforce. So, there are not enough people there; I think if we could attract more older people, who I think would really be great at the job, and more men, that would be a good way, as well, of improving the workforce.

10:45

Obviously, your comments are very welcome, and we supported the increase in the real living wage, but why, then, are Unison Wales still saying that there's urgent need for negotiation on pay and terms and conditions, in their words, to

'stave off an exodus of care workers'?

They are friends, really, Unison, so why are they still saying that in light of the real living wage increase?

I think, basically, they'd like more. They supported us bringing in the real living wage, we are friends and they really supported us, but I think they think it would be better to have higher wages and to be more in parallel with the health service. I think that's one of the big issues, the disparity between what you earn in the health service and what you earn in social care.

Would you support in the future, then, a parallel between health and social care pay, because I think it was estimated in the last Welsh Government budget that it would cost an additional £9 million to bring social care pay up to NHS pay scales? So, would that be something that you might be able to consider in the future?

The difference between somebody who's working in social care as a care assistant and somebody working in the NHS as a care assistant, I think, is £3,000 in terms of pay at the moment. I would like to see that brought down, but, obviously, we're in a very difficult financial situation, as we've discussed at length in this meeting this morning. So, I can't see when that could be done, but, yes, I think they're doing very much the same job, and in order to bring real parity and esteem to the social care sector, they should be treated in the same way as in the NHS. 

Moving to unpaid carers, and in the Deputy Minister's words, Association of Directors of Social Services Cymru's rapid review found a lack of awareness or recognition of unpaid carers' rights, and raised concerns about the low numbers of carers' assessments and support plans, and you describe that as a significant and enduring issue. So, in light of that, are you able to tell us more about the active steps that you plan to take and will that be on a national basis?

I think this is important information from the ADSS, and we are taking very seriously what they're recommending. We've got a ministerial advisory group, a very important group, consisting of people with lived experiences of care, and we're asking them to analyse what those recommendations are and to see how we can take them forward. But, obviously, the lack of carers' needs assessments is pretty crucial, and you need social workers to do that, and that has been a difficulty. So, we are quietly optimistic that the number of social workers is growing, because we have brought in the social work bursaries now, £10 million over three years, and at the beginning of this September there was an increase in the number of social workers who were applying to go on a course, and there's also the increase in the in-work training, and that development of social workers who are already employed in local authorities and train within the local authority to become social workers. So, I'm optimistic that we will get more social workers there, because that's what we need to carry out more of these assessments, because it's the carers' needs assessments that are crucial. But it's also important that carers recognise that they are carers in order to request the assessments.

Of course, the other side of this is that access to care and pressures through the winter, through financial—more and more is being asked of families and relatives to take on the duties of being an unpaid carer, and they, effectively, are plugging a gap in services that they might have elsewhere found. So, are you able to offer them some support?

10:50

Yes. The first point to make is that the vast majority of carers are doing it because they want to do it, and I think we all pay tribute to what they do. But we are putting in measures of support, some of it financial, and some of it supportive of them and the lives that carers want to lead—their life alongside caring. So, we’ve got the carers support fund, a three-year fund, which is to help carers with basic importance necessities, and I think we've had £4.5 million put into that and 24,000 unpaid carers have availed themselves of that fund to help them with necessities. And you don’t have to be a registered carer, you don’t have to receive carers allowance in order to get that money, and that has proved very important and has identified some people who are unpaid carers who we didn’t know about before.

And then, very importantly, we have set up a short break scheme, because helping carers go through the winter and just having a break, I think, is one of the absolute key things to keep them going. And so we’ve put in £9 million over three years in order for carers to have the sort of break that they personally want. It could be a range of things they’d like to do. I know some people wanted to have evening classes—art classes, actually—and putting in support for that. We’re also working with the hospitality industry to try and see if there are opportunities of using some of the accommodation out of season in order to help carers have a break, because, sometimes, they want a break with the person they’re caring with. Scotland have got a very good scheme, a ‘respitality scheme’ they call it, so that’s another way of doing it.

So, the short break scheme is the support we’re giving—very important—and then another key area where the Minister for health and I work very closely together is the discharge from hospital bit, because, obviously, discharging to an unpaid carer is very important, and we’ve allocated £1 million this year through the regional integration fund to local health boards, and that is when the person being cared for is admitted to or discharged from hospital, to try and make sure that it goes as smoothly as possible and the information is there, because one of the things, when I first met carers when I took on this job, was they said they felt they had a lack of information and a lack of support on those crucial times in-between hospitals. So, that’s being done as well.

And, of course, the other group in this field are child carers, and I’m assuming—and I know there’s been work in this field to help—that there is a continuation of work to help those who are children caring for, very often, their adult parents.

Yes, the young unpaid carers. Yes, that’s a very important area of our work, and this summer, in August, we had a three-day festival, a young carers festival, in Builth Wells, which was absolutely tremendous. I went down to visit and spent some time there and it was really so good to see these young people enjoying themselves. There was a huge range of activities and they were so pleased to be with other people who are in the same position as them. That’s the second year we’ve done that, and I just think it’s absolutely crucial for young unpaid carers to have a good time and to relax a bit from the duties that they have. And then the other thing we’ve had is the young carers ID card, where we’ve put the money in in order for each local authority to develop a card, which means that—. Some local authorities put benefits onto those cards, but, with others, it just identifies you if you’re going into the chemist, for example, and you don’t have to go through again why you are picking up the prescriptions, and it can help you in school. So, that has proved very popular, but we’re making an assessment of that now to see how it’s working.

10:55

Okay. So, when will we be able to see that assessment? There's an awful lot of pressure on young people and it's been identified over the years—and I'm really pleased about the card—in being continually asked why they're not in school on time, why they're not—? And, of course, anything after school is probably not accessible to them either, because they're going home, and that's going to impact on their mental health and well-being. So, when can we expect to see the results of that review?

Well, when I was at Builth Wells in the summer, I had a meeting with people from the local authorities, and the local authorities have, as I say, taken over now the funding of the cards. So, I've asked for that to be reviewed now to see how it's actually going so that we can keep track on how it's going. So, that is ongoing, basically. 

Thank you. If I could just ask the Deputy Minister, in the Government's written response, you talk about £10 million over the next three years invested in the social worker bursary. In your response, Deputy Minister, you talk about being confident that the increased offer of support will help to draw more students into taking up social care work as a career. So, I'm just interested in that confidence that you have and what evidence you have to back up that level of confidence.

Well, the numbers have increased. In September, the numbers actually increased. I don't know whether you've got the figures, Albert.

I don't have the figures in front of me, Minister, but I think, at the time, when we were looking at it in September, we had around about—. I think it was from about 154—but we will provide the actual figures—and it had gone up to around about, at that time, 215. I think, subsequently, in terms of follow through, it's around about the 194 mark. So, we've already seen an increase in the bursaries coming through in terms of uptake, so that's good news. And then, alongside that, the Minister referenced the 'grow your own' scheme, because I think this is a dual, twin-track process of bringing more students through, supporting them, but also then supporting the workforce to grow, and that's important to see the career pathways within social care.

I suppose the question is in the context of not the numbers increasing now, but your response now to increased numbers in the future. But your answer is that you're on the right trajectory, so you're confident that those numbers will increase further.

Absolutely, and there's work going on behind the scenes, for the committee to be aware, looking at the universities, the cohorts, how many signed up, to actually go underneath that top layer to understand who dropped off, and it seems that most universities have increased in terms of their uptake this year. For those universities where it hasn't quite matched the initial expectation, there are further considerations and dialogue taking place, Chair.

Thank you, and also in your response as well, Deputy Minister, you talked about improving pay by investing a further £70 million this financial year to ensure that all social care workers continue to get paid the real living wage, but, I suppose, it's about how confident you feel that that £70 million is actually reaching that objective.

I think we're confident that, in the vast majority of cases, it is. We have had isolated examples given to us where there's been a complaint that it hasn't reached and we have followed all those up, but those have been very small numbers and, on the whole, the evidence shows that it is reaching the people.

So, you're confident that that £70 million is reaching social care workers in their pay packets.

Yes, okay, thank you. We've got half an hour left of committee. There are a couple of general questions at the end, but there's a significant number of questions now around NHS waiting times, and, of course, the context of these questions is the first two recovery targets of no-one waiting more than a year for their first out-patient appointment by the end of 2022 and the elimination of the number of people waiting longer than two years in most specialties being achieved by 2023. So, we're all aware that those two targets that you set were not achieved. So, following the revision of the first two recovery targets, which you extended by a year, Minister, could you provide us with an update on the current trajectory in terms of health boards being on course to meet the revised targets?

11:00

So, as you said, we had a number of targets. One of them was that nobody should be waiting for longer than a year for their first out-patient appointment. What we have seen is a reduction of almost 50 per cent by the end of August 2023, compared to August 2022. So, it's not an insignificant number, but it's unlikely that we're going to reach that target by the end of 2023. I think it's probably worth emphasising that England doesn't have a target on out-patient appointments. But, in relation to the two-year targets, we have seen consistently improvements in relation to this. It's now 61 per cent lower than when we first set out the target.

I think it's probably worth emphasising that, for those waiting for two years, 90 per cent of them were waiting in the seven areas that we thought that we would be challenged in already. Those are general surgery; ear, nose and throat; urology; ophthalmology; gynaecology; oral surgery; and trauma and orthopaedics. So, we knew we would be challenged on those seven specific areas. We have a number of pathways where the two-year waiting lists have been cleared entirely. But what we have done now is we've set out some additional milestones just to make sure we keep up the pace within the health boards. So, we're expecting 97 per cent of those open pathways to be waiting less than two years by December 2023, and 99 per cent of those waiting less than two years by March 2024. Those are not insignificant numbers. So, what we are talking about is 1 per cent by the end of this financial year waiting for more than two years.

Thank you, Minister. There is also a recovery target to eliminate the number of people waiting longer than one year to start treatment in most specialities by the spring of 2025. So, are health boards on course to achieve this target, do you believe?

We think that, for most specialities, they will be able to hit that target. I think there are a few of those specialist areas that I set out, like orthopaedic surgery, but we are putting a lot of investment and a lot of support in place to try to drive significant improvements in relation to things like orthopaedics, and you'll have seen that we've got a new facility developed in Neath Port Talbot, for example, which is a surgical hub there. We've seen huge improvements in terms of productivity rates in the surgical hub in Abergele. So, we're trying to get health boards to work more regionally to share out, because some are doing better than others. So, there'll be some, for example, that have real issues in relation to, for example, spinal surgery, which comes under orthopaedics, which is very, very highly specialised stuff, and sometimes it takes a whole day to do the operation. And, as you can imagine, as health boards, they want to see their waiting lists come down. Well, if it takes you a whole day to do an operation where you could be getting five knee joints done in that day, it makes a difference. So, we are trying to tell them, 'No, listen, we understand, but you've got to get the longest waiters done. Enough; you need to focus on those.' So, we are trying to put that support in, where possible. I don't know, Jeremy, if there's anything to add on that.

Well, I'll just come back with a final question and we'll bring in Jeremy then, if that's all right. There were over 760,000 patient pathways waiting to start treatment in August this year. That's the highest level on record. So, I suppose I'm just trying to understand why the performance in reducing waiting times has worsened, despite the significant focus placed on it.

So, what you're talking about are the overall numbers now—

—rather than the longest waiters. It's partly because, actually, the number of people coming onto the waiting lists has increased massively. So, if you look at the past 12 months, you'll see a 14 per cent increase on the numbers coming in compared to the 12 months before that. So, the numbers coming onto the lists, we're getting them off, but more of them are coming onto the lists—14 per cent more than the speed at which we're able to bring them down.

11:05

I'm trying to understand, then—. Because, when you're setting targets, you would have no doubt envisaged that more people would be coming onto the list.

Sure. Yes. Yes, but I don't think any of us envisaged a 14 per cent increase. I think the other thing just to bear in mind is that, whilst our waiting lists are going up—and they have gone up by 1.9 per cent in Wales over the past year—they've gone up by 10.7 per cent in England in the past year. So, that overall number is still going up, but it's not going up as fast as it is in England.

I can see Hywel Dda have said that achieving the target to reduce two-year waits by March 2024 will require additional resources beyond the currently available levels. So, what would be your response to that?

So, we give £170 million—so, we've earmarked £170 million to bring down these waiting lists; we held back £50 million of that. So, I think Hywel Dda were waiting to hear how much of that £50 million they would be getting. So, they've now been allocated an amount from that £50 million to try and help clear those longest waits. But it's not all about money; some of it is about efficiency working. So, we've brought a lot of the GIRFT teams in—Getting It Right First Time teams—who are all about efficiency, getting it right, making sure people turn up on time, making sure they start and finish on time, making sure all of the right people are in the room at the same time; just speeding up the process. So, we've got these GIRFT teams that have come in now across Wales into different disciplines to speed up the process. That's what's happened in Abergele—we've seen a huge turnaround in what's happening there—now they're coming into different places, including—. The next one they're really focused on is Swansea and Hywel Dda.

We're really short for time, but I'll bring Mabon in, and, if Jeremy wanted to make a quick comment afterwards, that's fine as well. Mabon.

Jest yn sydyn iawn ar hynny, dwi'n trio deall. Mae'r dystiolaeth dwi'n ei derbyn gan gleifion yn dangos bod pobl yn aros dros flwyddyn, ddywedwn ni, am driniaeth orthopedig. Mae'r byrddau iechyd wedi comisiynu cwmnïau preifat allanol i wneud y gwaith er mwyn lleihau'r rhestrau aros. Felly, yn sydyn iawn, mae'r rhestrau aros wedi mynd yn llai oherwydd bod y niferoedd oedd ar y rhestr yna wedi mynd i'r cwmnïau preifat, ond yr hyn rydyn ni'n ei glywed rŵan ydy bod y cwmnïau preifat yna yn rhoi'r cleifion yna yn ôl i'r byrddau iechyd, gan ddweud eu bod nhw'n methu gwneud y gwaith achos bod y bwrdd iechyd yn methu eu talu nhw, achos does yna ddim digon o arian yn y system i dalu am y driniaeth. Felly, hwyrach bod y niferodd ar y rhestrau aros wedi disgyn yn ddiweddar, ond ydyn ni'n hyderus bod y rhestrau aros yna yn mynd i aros yn isel, neu ydyn nhw'n mynd i gynyddu oherwydd does yna ddim digon o arian yn y system i dalu'r cwmnïau allanol i wneud y gwaith?

Just very quickly on that, I'm trying to understand. The evidence that I receive from patients shows that people are waiting for more than a year, for example, for orthopaedic treatment. The health boards have commissioned private external firms to do that work in order to reduce the waiting lists. So, suddenly, the waiting lists have shortened because the numbers on that list have gone to these private firms, but what we hear now is that those private companies are giving those patients back to the health board, saying that they can't do the work because the health board can't pay them, because there's not enough money in the system to pay for that treatment. So, maybe the numbers on the waiting lists have fallen recently, but are we confident that those waiting lists are going to stay low, or are they going to increase because there's not enough money in the system to fund those external companies to do the work?

Wel, dwi yn poeni bod y ffaith does dim arian gyda ni i dalu yn allanol yn mynd i fod yn fwy anodd, ac mae hynny'n bryder mawr inni. Dwi'n meddwl bod pawb yn deall, os yw'n mynd i helpu cael pobl off y rhestrau aros—. Rydyn ni, yn amlwg, yn awyddus, os ydyn ni'n gallu, i gadw'r bobl yma tu fewn i'n system ni, ond os gallwn ni gymryd tipyn bach o bwysau off, mae'n ocê i fynd â nhw i'r sector breifat yn y tymor byr. Ond mae hwnna'n rhywbeth lle bydd yn sialens yn y dyfodol, achos dyw'r arian ddim yma. Ond dwi ddim yn meddwl eu bod nhw'n mynd off y rhestrau aros oni bai eu bod nhw wedi cael y driniaeth.

Well, I am concerned that the fact that we have no money to pay external people will be more difficult, and that's a big concern of ours. I think everybody understands that if it's going to help get people off the waiting lists—. Clearly, we're keen, if we can, to keep these people in our system, but if we can take some of the pressure off the system, then it's acceptable to go to the private sector in the short term. But that's something where there will be a challenge in the future, because the money isn't there. But I don't think they're taken off the waiting lists unless they've been treated.

Jeremy, would you like to—?

Yes, that's right. They would remain on the waiting list until the treatment happened and then the pathway would close down. They wouldn't be taken off the waiting list; they would remain on there.

Thank you. Thank you, Minister. Sarah Murphy. I don't know if it's possible to try and keep your time to around about three minutes, if that's all right, Sarah.

Thank you very much, Chair. I'm going to try to compress some of the questions that we have around diagnostic testing and therapy interventions. So, the recovery target is to increase the speed of diagnostic testing and reporting to eight weeks and 14 weeks for therapy interventions by spring 2024. It would be very good to have your insight into how you think it's going in terms of reaching those targets and particularly, as well, what the reasons are behind the challenges and extended waiting times in audiology and endoscopy. Thank you.

Thanks very much. Well, you'll be aware that we've produced a national diagnostic plan, and that is supported by a national diagnostic board, and so there's a lot of focus on diagnostics, because that's partly where there's a little bit of a bottleneck at the moment. Some of the reason for that bottleneck is because far more people are being sent for diagnostic tests, and that's a good thing in the sense that the earlier we catch people, in particular in relation to cancer diagnostics, the better. But the number of people coming through is significantly higher than what we've had. The good news is that we are treating a lot more people than before. But what we are trying to do is to get far more people sent directly to tests, and we have invested quite a lot in equipment already, but obviously you'll be aware that one of the things we're trying to do is to get health boards to work regionally a lot better together, and one of those is the development of the facility in Cwm Taf Morgannwg in the Llantrisant area, where we will be getting people to work together across three health boards.

11:10

Diolch. Thank you very much, Minister. I'll hand back to you, Chair, so that we can get through the rest of the questions this morning.

Yes. Thanks ever so much. We probably did have some more questions in that area, but we'll probably take them up in writing if that's all right, Minister. 

Thanks, Chair. We want to move to cancer waiting times in the short period we have. I'm conscious we've rehearsed quite a lot of this in our inquiry on gynaecological cancers, so I'll try and stick to just a couple of points. Firstly, Welsh Government and the NHS executive have introduced a national cancer intervention focused on the worst-performing areas and sites. What is the expectation of that intervention as to how it can improve the cancer position?

What we've done is we've got this NHS executive that has brought together the stakeholders and the experts who are looking at those three particularly challenged areas, and you as a committee, obviously, have done a huge amount of work, in particular in relation to gynaecology. What they've done is they've held these workshops where they've worked out, 'Right, what is it that you need to do to drive performance in these areas?' We're trying to do that in a whole range of areas: triage, diagnostics, digital intelligence, treatment capacity, standardisation of best practice—so there's a lot of variance across the whole of Wales—workforce, person-centred care. So, there's a whole load of things where we're trying to speed up the process. What we've got, though, is a lot more people coming onto the system, so the referrals in relation to cancer have gone up by 8 per cent, compared to the previous 12 months. So, you can prepare, but an 8 per cent increase is quite a significant additional amount. Jeremy, is there anything you could add to that?

Yes. I think the key aspect—it links back to the diagnostic question—is that standardising the pathway is going to be where the greatest gain is, but the focus on the diagnostic parts of that pathway is where our biggest challenge is, particularly around endoscopy as well, so it does link in with the previous question.

I think the other aspect that we've seen big growth in as well is urology. We've seen public campaigns, so it's a good thing people are coming forward, and early diagnosis, but we are starting to target now the resources that are going into the diagnostic stages, because that's where we feel we'll have greater gain. Cancer isn't separate to planned care capacity. Cancer capacity, as required, will take from planned care, because of the urgency there, so there is an evaluation between what the Minister mentioned on our GIRFT efficiency programme and then our cancer improvement programme as well, clinically led and driven consistently amongst the system.

Thank you both for that. Can I just touch on briefly, then, Chair, the rapid diagnostic centres and the planned extension of them and the expanding of the availability of them? Do all GP practices in Wales have access to one of these centres? Is there a strategy in place to ensure the effectiveness of improving the healthcare systems? I'm not sure if Jeremy or the Minister—.

Yes. So, in our diagnostic strategy, there are a number of initiatives or processes we'll need to put in place. We definitely need to put in the rapid diagnostic centres and the centres that have multiple assessments for diagnostics—the Minister mentioned Llantrisant there. Then, the focus then on community diagnostics. We've already got within our clusters practices that do more than routine bloods. So, our accelerated cluster plans are how our primary care clusters come together and develop those, but there is access to diagnostics now, particularly in the specialities within the health boards, but we're moving much more to a regional approach, because that's the only way we'll deal with the demand. So, Llantrisant business park is one example; there'll be further examples as we move through the diagnostics strategy. 

11:15

But we're confident that my GP would have one—access to a centre—and Mabon's would have the same.

That's the ambition in the diagnostics strategy, but it is sort of based on the population need and the demand through the system. 

Thank you, Chair. We've mentioned surgical hubs to a degree, and I've certainly seen the impact of Abergele—it's not in my constituency, but my constituents do use Abergele Hospital quite a lot. But segregating emergency and planned care, do you see that as a way to reduce waiting times in the long term?

Well, the difficulty is when you get massive, massive pressure at A&E and they need those beds urgently, then it does tend to squeeze out planned care. So, that does cause a problem, so we recognise that there's definitely a significant role for surgical hubs, and that's why we already had some in place, like Abergele, which has been there for a long time, but we've developed far more now. We've got ophthalmology in Cardiff, we've got Hywel Dda, where we've developed another surgical hub there. So, there are a lot more coming on line. I think Jeremy can give you a few more examples, but the key thing to remember here is that, when there is an urgent case, it does knock out the planned care. So, that's always the danger. 

If you have a big population, and Cardiff is big for Wales, but it's not big relative to the rest of the United Kingdom, you are able to separate them out a bit more, because you've got two hospitals quite near each other. It's far more difficult to do that in an area where there's actually one hospital. So, we are in a very, very different place from where you're at in England, where you've got big population centres. And I think it's just worth while just remembering that. 

The other thing that we're urging them to do is to do a lot more day cases—so, get the job done in a day and send people home. And we're able to do that. There have been some great examples in Ysbyty Gwynedd recently, for example, where they're doing knee surgery—robotic knee surgery—getting it all done in a day, off they go back home. Cancer—people being treated for breast cancer, done in a day. And so we've got to do a lot more of that—get them into hospital and get them out the same day. 

I might need one of those robotic surgeries for knees one day, being a runner. [Laughter.]

But what strategies are you putting in place to mitigate seasonal pressures on paediatric care, given that it's such an important sector? Obviously, winter pressures, we know, have an effect on other areas in care, so what are you doing to mitigate those potential issues, so it doesn't affect paediatric care?

So, as part of the winter plans, obviously health boards have got to come forward with what their plans are in relation to things like paediatric care as well. But I think it's just worth noting that every single health board have to come up with their plan at the beginning of April. So, we don't wait until October and then start to panic in Wales; we ask them to set out what is their winter plan in April and start to work towards delivering that, and that includes children. 

And, just finally, during Christmas and the new year period, local authority services tend to close for a couple of weeks over that time, leading to disruption in patient flow, discharges, that sort of thing. So, what steps are you taking to address that issue and minimise its impact on healthcare services, thinking about that reality?

So, there's a huge amount of preparation and work that is done for that Christmas period. So, Jeremy, would you like to just elaborate on that?

Yes, as colleagues will know, that's a very pressurised period for a number of concurrent risks, and we're monitoring the concurrent risks all the time—respiratory, for example, as you mentioned there. But, for that period in particular, I know that the six goals of urgent and emergency care boards, which are health and social care, are across every single health board. They do develop quite a forensic, detailed plan around which managers are on, which clinicians are on, which social workers are on, and opening hours for nearly every single service. They're quite detailed templates, which they complete and are desk instructions then for those working during those periods. So, there is cover for all services throughout the period. It is reduced, as it would be on bank holidays—it's similar to weekends—but they do go into that to put the detail in and then put also the additionality in as well.

11:20

I support everything Jeremy just stated and, although local authorities do have different patterns around opening and closing social care, the actual social services side of local authorities continues to work over the Christmas period and new year.

Obviously, just finally, if I may. Obviously, during that Christmas and new year period, people tend to go out more, there are more alcohol-related incidents happening, which results in more pressures on emergency care. Are there plans in place for that reality? And do you have communications with local police services and local authorities to try and mitigate that reality as well?

I know that in the three health boards that have got the biggest footfall, I guess, of these activities, they certainly put in services that are more within the locality of where the festivities are happening. So, they work with the police and they work with local authorities for that.

I think some of this as well is about our winter messaging. So, we're focusing at the moment very much on keeping well for winter, but there will be messaging as we go into the festive period and the public health around enjoying it, but enjoying it responsibly. That's really important as well. But for where they expect bigger footfall, organisations do plan to know how to deal with those issues.

There's also then, obviously, the equivalent in terms of the emergency departments as well. They will look at the pressure coming in to the system and plan pressure, and the access into the system and look to proactively put on resources for those pressurised periods.

I'm going to talk about the seven exceptionally challenging specialities, and you've talked about improvements in some areas, and that's, of course, welcome when we're talking about the two-year waiting time,