Y Pwyllgor Iechyd a Gofal Cymdeithasol

Health and Social Care Committee

08/02/2024

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

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

Y rhai eraill a oedd yn bresennol

Others in Attendance

Calum Higgins Cymdeithas Siartredig Ffisiotherapi
Chartered Society of Physiotherapy
Dai Davies Coleg Brenhinol y Therapyddion Galwedigaethol
Royal College of Occupational Therapists
Dr Hilary Williams Coleg Brenhinol y Meddygon
Royal College of Physicians
Dr Rowena Christmas Coleg Brenhinol y Meddygon Teulu Cymru
Royal College of General Practitioners Wales
Lisa Turnbull Coleg Nyrsio Brenhinol
Royal College of Nursing

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Angharad Lewis Ymchwilydd
Researcher
Claire Morris Ail Glerc
Second Clerk
Lowri Jones Dirprwy Glerc
Deputy Clerk
Philippa Watkins Ymchwilydd
Researcher
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 09:30.

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

The meeting began at 09:30.

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

Croeso, pawb. Welcome to the Health and Social Care Committee this morning. I move to item 1, and we have apologies from Jack Sargeant this morning. We are operating this morning both virtually and here on the Senedd estate, so some of our witnesses and Members are joining us virtually this morning. As always, we operate in both Cymraeg and English as well. If there are any declarations, please say now. No.

2. Cefnogi pobl sydd â chyflyrau cronig: sesiwn dystiolaeth gyda chynrychiolwyr gofal sylfaenol a gofal eilaidd
2. Supporting people with chronic conditions: evidence session with primary and secondary care representatives

In that case, I move to item 2, and this is in regard to our piece of work on supporting people with chronic conditions, and an evidence session this morning with primary and secondary care representatives. I thank our witnesses for being with us this morning, so perhaps I could just ask the witnesses to introduce themselves for the public record first.

I'm Rowena Christmas. I'm a GP in a small practice in Monmouthshire, and I'm chair of the Royal College of General Practitioners Cymru Wales.

Lisa Turnbull, and I'm from the Royal College of Nursing in Wales, the head of policy.

I'm Dr Hilary Williams. I'm the lead for the Royal College of Physicians in Wales and an oncologist practising at Velindre. Unfortunately, we've got a clinic crisis this morning with staff off, so I'm going to be here for half an hour or so, if that's okay.

Well, no, we understand if there are pressures, so thank you for being with us. Can I just check, Dr Hilary, that the Welsh translation is okay for you? If I could ask the translators to say something.

[TRANSLATION: 'Testing interpretation. Testing. One, two. If you can hear that, can you give us a thumbs up?']

Could you hear that?

No, okay. We'll probably just need to—. Is there a breakout room of some sort we can take Dr Hilary to? We'll try and help with this. We did a test earlier on, unfortunately, but I'm just conscious that you won't hear any questions in Wales, Dr Hilary. Okay, right. So, if I can perhaps ask the witnesses to start with: can you define what 'person-centred care' means, or how do you define that? Dr Christmas.

Yes. I guess 'person-centred care' is what we try very much to achieve in primary care, in general practice. So, the doctor has got their expertise as from their medical degree and their further training, but you see the patient as the expert in their own condition. So, you're two experts trying to meet common ground. And that enables us to have a sort of more holistic approach; we can see the patient as a person within their environment, looking at their social factors and their environmental factors. And we know that if we can get this right, involve family and friends and carers, get the whole picture, that's going to decrease costs for the NHS, which is important, but equally, it's going to significantly increase patient satisfaction, and we're going to get a better outcome in the long run, so it's a good thing.

Okay, thank you. Any other definitions from Dr Hilary or Lisa Turnbull?

Just to add: I think it's useful to say from the perspective of nursing as a profession, that kind of holistic approach to examining the person and the environment, and caring for the person, I think is quite central to the nursing tradition, because nursing is about caring for a person, as opposed to specific interventions. So, it does fit quite naturally, that approach, I think, with the clinical approach of nursing as a profession. I think that's worth mentioning, and I think possibly also the fact that if you then take those principles from the individual clinician-patient relationship, it's also about designing the services to make sure that they obviously facilitate that approach.

So, for you, what are the key challenges in terms of delivering patient-centred care, and how do you overcome some of those challenges?

I think that what I would say initially—and I think it's very relevant to this inquiry—is that the national health service, historically, I would say, and still to a certain extent, is set up to treat specific conditions, often specific conditions maybe that are regarded as or expected to be temporary, that can be cured in an intervention—so, I mean like a 'let's fix a broken leg' type thing. Whereas, the whole nature of what we're discussing here, people with chronic conditions, it's effectively life. Very few people are not going to fall within this category, actually, during the course of their lifespan, so this is about caring for people. So, I suppose what I would say the barriers to that are are probably the barriers that we will explore in further questions, which are about caring for people holistically over a span of their life, rather than intervening, doing something, prescribing something, getting out.

09:35

Could I add something there?

Yes. I'll come to you next, Dr Williams, yes. Dr Christmas.

One of the things that makes person-centred care much easier is if you've got some continuity of care, if you've built up a relationship with patients. So, if I've got somebody and I'm trying to manage their heart failure, but I've seen them six months earlier and we've discussed their diabetes in detail, you keep that knowledge in your head, and also you know that their granny is not very well and they're having to look after them and travel to Cardiff three times a week—all of that information becomes incredibly important in how you manage the patient, and it develops a trust. Patients with longer term relationships with their doctors are more likely to follow advice. They're more likely to challenge their doctor if they disagree. They're more likely to take their medication. That overarching leads to much less likely to need emergency services, much less likely to be referred to hospital or be admitted. So, again, it decreases costs, keeps care closer to home, gives the patient the outcome that works for them and their family. So, relationship-based care is absolutely key to managing chronic conditions well.

I'll come back to you in a second. I'll bring in Dr Williams as well, but I just wanted to add to that question, Dr Williams, as well, in terms of what I've already asked. Of course, in 2015, the Welsh Government brought in the individual care plans—. I'll come back to you as well on this, Dr Christmas, but if I could perhaps ask you to perhaps comment on that as well, Dr Williams, in terms of whether those individual care plans have actually seen an improvement in terms of the relationship and communication between healthcare professionals and the patient.

I think it's a very real issue, isn't it, and absolutely supporting what Dr Christmas—Rowena—said, I think there is a problem in that we are too distant between primary and secondary care, and, actually, if you think of the patient at the heart of that, they are going often between different systems, particularly with cancer or a complication that does require hospital care. I think there was a good point made in the HIW report this year, that people are sort of falling between the gaps, and something so basic as a discharge summary, or what I'd call a discharge summary, which is a letter written by, often, the doctors when someone leaves hospital, it bears no relation to what a clinician in the community might need. So, I think our digital services are letting us down there, but we are probably far too distant in terms of our acute and community care. I think we do work in different places, and I do think it does mean patients are falling between the gaps. I'm not aware of the treatment plan. It may be something that perhaps is a little bit more nursing led. But there is a bit of a tendency, I think—. For something like cancer, we almost take over their care, which is probably not ideal, because then they miss out on the strength of having a good GP relationship, and I would say, if GPs can provide continuity of care, I absolutely agree with Rowena; they absolutely hold the reins and support that patient to make some much wiser decisions. Once people are in secondary care, they often get pushed down quite a rapid journey of lots and lots of tests, lots of complicated things, and that may not always be looking at the whole person when that happens, I'd say.

Okay, that's helpful. Dr Christmas, do you want to come in on that last point about the individual care plans?

Yes, I mean, just talking about what Hilary said, it's amazing how often you see a patient and you talk about a condition and talk about what might happen in hospital and then ask, 'What do you want?', and frequently they don't want the very expensive investigations or the tests. People who are more frail and towards the end, they will tell you, 'Actually, what I want is—' and it's much less. So, if you can take the time to find out what people want for themselves, and some people do want a lot more, and that's fine—we can arrange that as well—but, without that continuity, you never really find out what matters to the patient. Now, the tricky thing in primary care, unfortunately, is that relationship-based care is becoming less; it's almost becoming a privilege, when you're lucky enough to be in a practice that has it. The shortage of GPs, which has been getting progressively worse, and is really acute now, means that access—. And of course, you can only provide a quality service if patients can see a doctor or a healthcare professional. Access is very important, but the drive for access over and above everything else is just knocking continuity out, and I so often say to my patients, 'There are five doctors in my practice now; we used to be just two. Yes, if you have to see a doctor the same day, of course, see whoever is available, but, actually, you're so much better if you can just hold on and see me or see one of my colleagues, because we've had this conversation now; we don't have to have that conversation again. We'll deepen our understanding of what's going on.' So, we've got to push away from access being the absolute holy grail; it isn't. Continuity and understanding the patient in their lives, in their conditions, that's the holy grail, but access is important too.

09:40

No, understood. I'm going to bring Gareth Davies in, if that's all right, because I'm just conscious of time as well. Gareth.

Thank you very much, Chair, and good morning everybody. I want to cover managing multiple chronic conditions, if I may, and healthcare, as we've heard many times over the years, operates in silos, traditionally. How can we improve communication and collaboration, to be improved between the different parts of the healthcare system to manage the care of those with multiple chronic conditions? That's a question to Dr Williams.

It's such an important question, Gareth, and I've sort of been pondering this, actually. The most obvious thing is to empower the patient, isn't it? And if they knew absolutely everything that's going on—. And, actually, my sister's got chronic conditions, and she's very well informed, but I think we're still not very good at that. And there is a downside, I think, if—. You know, there's talk about everyone in England having some sort of app with all their information on; a lot of our patients in Wales don't have that sort of digital capacity, so it does worry me, if we go down a very digital route for that, that we actually won't support the people with the most need. But I do think that it is actually giving the patient the information they need, and I was thinking more about—. Because we know, with lung cancer, 50 per cent of the patients that die in hospital, they're spending 25 per cent of their life in the last three months of life in hospital, and that's probably not their choice, and they've probably got multiple conditions. But we've really got to up the capacity to give them an ability to make decisions, so I think it is switching away from quite a medicalised approach to empowering our patients. It's not an easy thing to do, but—

Yes. That's good to hear from a patient perspective, about empowering patients, and I fully agree with that. But, in terms of specialities and different healthcare professions, how can that be done within the workforce? You mentioned digital as well. Is there a silver bullet to solving that within the workforce? Is it digital, or is it just better relationships?

I think better digital would really help. I think the renal teams have a good summary. So, I was looking after a patient that had renal failure and cancer, and, within 24 hours, we were able to make a joint decision; he was a very straightforward chap, and actually had very good support. And their records were good; I think ours were perhaps less clear to them. But I think we do have to be really clear that the information, that it's there, so that I can access and understand what's going on. And how to contact that health professional is incredibly important, I think. But it has to be in an understandable way, and there has to be an across-Wales way. It is a bit of a holy grail at the moment, but I'm sure there are better ways of doing it. I think being able to access the GP systems I find very helpful, to be able to look at what medications and things they are on, but, the more we can do that, the more we are going to be able to work across specialities.

But also we recognise that we need to develop clinicians that have that skill set and retain them in Wales, and something I'm very interested is what the skill set of a generalist in a rural hospital is, and I think there are people that definitely want to train in that, but we will need to support them for that training and empower them to say stay in Wales doing what they enjoy doing, because I think some of the doctors in Hywel Dda, for example, are really excellent at that, but they are quite small numbers of people to deliver that care.

09:45

And we hear as a committee—most recently from Public Health Wales and others across the period of this Senedd—of pockets of excellent service in different minutiae of Wales, possibly. How can we best learn from good practice and spread that good practice around further, so that we are learning positive lessons, and we can learn off each other, so that we can create that all-Wales system that you speak about?

We've probably been relatively successful in what I call acute oncology, which I'm involved in, and that's been very much bringing solutions from the shop floor rather than imposing them from above. But also I think we have to be realistic that, in Wales, we are a smaller country and we are trying to do an awful lot, and I think we have to perhaps be a bit bolder and say, 'These are the things that are really going to make a difference in the next three years. Let's really empower our staff and deliver on those', rather than doing too many things, because I think we're trying to do an awful lot. And I think it is focusing on those things that really deliver on the ground. What I see a lot of is very good policy that doesn't get delivered, and too much policy that doesn't get delivered, and I think we have to stop writing documents and actually deliver what we know are some of the solutions, and really—. And there's a bit of devil in the detail there around the delivery as well. I think you have to work quite hard on the delivery, not just on writing the plan.

Thanks. Just finally to Dr Williams, could you expand a little bit more on the patient booklet, or the red book, found in paediatrics, as you referred to in the paper, just to give us some more information on the details of that?

Yes. Sorry, I'm not a paediatrician. I think it happens in maternity health, and I think there is very much an aim that people have their own information with them, and we're probably a little bit slower in parts of Wales than we should be. I'm sorry; I don't actually know about the red book per se, but I think the principle is, and it's done in lots of different things now, that the patient holds the information about their own health decisions. I think one of the problems is getting that information in a way that it makes sense to people but also acts as a medical note, and there's a bit of a conflict there, I think.

Gareth, the other witnesses wanted to come in as well. Do you want me to bring them in now? Or do you want to pose any other questions you've got and then I'll come to Lisa and Dr Christmas?

No, feel free to introduce the other witnesses—yes.

Did you have any other questions, Gareth, on your side?

Well, ask that now, then, and then I'll ask them to expand on other points as well.

Okay. Thank you, Chair. Your written paper says that the standard 10-minute GP appointment is insufficient to build meaningful relationships, particularly with patients with the multiple chronic conditions we've spoken about. What changes do we need, as the number of people with chronic conditions rises, and how healthcare services can rise to the challenge of growing complexity and their patients' needs?

I think we need to give ourselves more time with patients. We've gone up to 15 minutes in my practice with each patient, and even that's quite tight. So, with endless amounts of money and endless amounts of doctors it would be easy; we would have half an hour with each patient. But that's not realistic. So, I think what we need to do is have the GPs with more time with the highly complex patients, and then develop our primary care multidisciplinary teams, with our excellent nurse practitioners, paramedics and practice-based pharmacists seeing other patients. Everybody needs to be working at the top of their ability, but with enough time to do that work and enough time to supervise the multidisciplinary team as well. But we will definitely provide a more quality service if we've got the time to do it.

Can I just ask, Gareth, if you don't mind—Joyce wants to just come in?

Just on that point, we're seeing more and more a hub, a medical hub, where different disciplines exist within that. First of all, do they ease the situation you describe and allow a GP to have more time, and, if they do, or if they don't, how could they?

I think, overall, they do. When I became a GP 20 plus years ago, I did all the smears, I did lots of minor illness. I haven't done a smear for years, because our nurses are brilliant at that—highly capable. So, you definitely can delegate work and train appropriately. Where it becomes difficult is when there's a lot of supervision to be done and there's not really enough time for that supervision. Then it becomes very stressful and, potentially, becomes less safe for patients. So, you absolutely have to recognise that, when, for example, a physician associate is working in a practice, they need to be seeing a specific scope of practice patient and they need to be supervised by a GP. Every patient needs to have a discussion and a hot review afterwards. I know, for me, I can see four patients, and that's one level of stress or anxiety. If I'm supervising someone else to see four patients, that's actually a bit harder, so you need to have that protected time to do a good-quality service there.

09:50

Yes, please. If I can just refer to the point about people working in silos, people with multiple conditions, bringing that together—if we can just go back to that point. I would like to go back to the point that Dr Christmas made earlier about that relationship of care. I think what's central there is somebody is leading the person's care and has responsibility for doing that co-ordination and bringing that together. That has, traditionally in the past, been the GP role. It has also been a community nursing role, it has been the role of the district nurse. It can also be a specialist nurse, because if we're talking about chronic conditions, we're also talking, in nursing, about consultant nurses and nurse specialists who may be providing that continuity of care and, crucially, have the responsibility to co-ordinate that and outreach to others.

If you don't have that individual, that clinician doing that role, you're either putting the burden on the patient and saying, 'You co-ordinate', which, quite frankly, is an enormous burden to put on somebody who is clearly already—otherwise they wouldn't be there—having a chronic condition, or you're just relying on happenstance. And, yes, things can assist in that. Good digital systems can assist, because clinicians can see what's going on. But once it's everybody's business, it's nobody’s business, in a way. So, there is something there about the patient having a relationship with somebody who is overseeing that care for them. So, I think bringing and emphasising that role back—and, as I said before, that could be a plethora of appropriate people, depending on the situation—is important. 

The second thing I'd really like to emphasise, and I think it's the answer to some of the questions that have been raised so far, is once you're already in the system, making that system work is an important question for the committee to answer. What I'm concerned about is people who are not, if you like, in the system, and this comes back to this whole access to primary care. I do think that access to primary care is in a bit of a crisis point, actually, in Wales, and I do think it's something that the committee might want to focus specifically on. Because it is extremely difficult, if not impossible, to get, in some places, an appointment with not even just a GP, but perhaps someone else in the surgery, such as paramedic or nurse, et cetera. It can be very difficult to get in. And then, of course, there's the pressure on time, the person's skill set that you're seeing—all of those things might impact on the ability to actually determine the actual future, the care plan, the holistic approach that we've talked about. So, there is something about access to primary care and that access point.

The third point—sorry, I will be quiet then; I appreciate the pressure of time—I just wanted to make is the very important point about discharge being an issue and the lack of communication between primary and secondary care. That's very important, that almost breakdown in communication between primary care that's led by the GP and the hospital. But there's also an equally significant breakdown of communication with the community nursing team, who are often, post operation, post hospital, providing that care. That lack of information on patients discharged into the responsibility of that team, and people in that team scrambling then to try and put stuff together, is extremely important. So, I just emphasise that triangle, actually, of care in the home, primary care, and perhaps the consultant in the acute hospital.

09:55

Thank you, Lisa. I think some Members might want to pick up on some of those points in their questions later on as well, actually. Can I just check with Dr Williams—? Can translation just say something, please, to make sure Dr Williams can hear?

[TRANSLATION: 'Testing interpretation. If you can hear that, can you give me a thumbs up? Thank you.']

Can you hear that? There we are. Thank you, Dr Williams. Mabon ap Gwynfor.

Diolch yn fawr iawn, Gadeirydd. Dwi eisiau jest holi cwestiynau'n seiliedig ar iechyd meddwl yn gysylltiedig â chyflyrau cronig. Rydyn ni wedi clywed fel tystiolaeth bod yna ddim digon o gymorth iechyd meddwl ar gael i bobl sydd yn byw gyda chyflyrau cronig, felly pa gamau ydych chi'n meddwl dylid eu cymryd er mwyn gwella'r cymorth iechyd meddwl ar gyfer y grŵp yma o bobl?

Thank you very much, Chair. I wanted to ask a few questions on mental health in relation to chronic conditions. We've heard evidence that not enough mental health support is available for people living with chronic conditions, so what action do you think could be taken to improve mental health support for this group of people?

Is there anybody who would like to take that question? Lisa Turnbull.

I'll start by saying that I think this goes back to my point about what services are available in primary care. Because I think—again, going back to my point—almost the category of people living with chronic conditions is the population. Again, if you're wanting to access that for the first time, that does depend on what services the GP—and I say 'the GP', but the GP surgery, as such—has access to, can refer you to, like counselling and so forth, what might be appropriate. So, if we're talking particularly around low-level, medium to minor conditions like moderate depression, anxiety, that kind of thing, resilience, all of those kinds of areas, there's a lot that can be done in that primary care service portion. If we're talking about specialist mental health services that are specific, we have, jointly with other royal colleges, raised attention of the fact to the health committee previously that there needs to be an investment in the workforce, because we don't have enough of the workforce in there with those high-level skills, I think, to really appropriately support the population that need it. The consequence of that is very long waiting times, not being able to access that type of service. So, I'm highlighting workforce issues, but they're almost two types of workforce issues that I think are relevant in this scenario. So, that would be my starting point.

I think many, many people with chronic illnesses have, as you say, low-grade mental health problems, and perhaps they're not even mental health problems; perhaps it's loneliness or difficulty accessing services, difficulty with transport. Often, chronic illnesses will reduce your financial ability. So, something called social prescribing, which is where you improve the infrastructure in communities to create a healthy environment, will make a huge difference. I read last night that 30 per cent of patients who visit their GP are coming with a social reason. So, that's using our skill set in a way that—. You know, somebody else could probably do that better. But the RCGP tracker survey last year showed that only 26 per cent of GPs have access to a social prescribing link worker. These people know where to signpost people to. Often there are a huge number of brilliant things going on in communities.

A social prescribing link worker. They have different names, but that's what we tend to call them. You'd refer a patient to them, and they would then have a host—. And it doesn't matter whether they've got loneliness, anxiety, or they're struggling to pay their gas bill. The social prescribing link worker will have a resource to direct them to. It's absolutely brilliant, really.

Diolch. Difyr iawn. Dwi'n meddwl yn fanna am rywun sydd efo cyflwr cronig ac yn medru disgyn i mewn i gyflwr afiechyd meddwl oherwydd y rhestr aros, oherwydd eu bod nhw'n methu â chael triniaeth ac yn y blaen, ond ar yr un pryd mae gennym ni bobl sydd efo cyflwr iechyd meddwl hirdymor sydd, oherwydd y cyflwr iechyd meddwl hirdymor, yn medru disgyn i mewn i gael cyflwr iechyd corfforol cronig. Felly, o ran yr ail garfan yna wedyn, a oes yna ddigon yn cael ei wneud ar gyfer y garfan yna o bobl?

Thank you. That's very interesting. I'm thinking there about someone who has a chronic condition and how they can fall into mental health difficulties due to the waiting lists and not being able to access treatment et cetera, and at the same time we have people who have long-term mental health issues that, due to that long-term mental health issue, can fall into suffering from a physical, chronic condition. So, in terms of that second cohort, is there enough being done for that cohort of people?

No. I think people with significant mental health problems will develop chronic illnesses perhaps 20 or even 30 years earlier than the population who don't have serious mental health problems, and that's partly because of the medication they're prescribed—that often increases their cardiovascular risk, it makes them more likely to be overweight or obese. They often really struggle with motivation, so they're not getting out of the house and going for a walk, they're not meeting with people, they're lonely, they're isolated. Often, they don't come to the doctor to present with symptoms; they're more likely to live on their own, so they haven't got a wife or a husband or a son saying, 'Get to the doctor, Dad'. We know that people in that situation—. We bring them into the surgery once a year, if we possibly can, so that we can do all of those checks. But sometimes, we send letter after letter after letter and they ignore them, because that's part of their illness, rather than who they are. So, this is a huge problem and, yes, something that we could do with doing better at, I think.

10:00

I'd like to specifically mention here, actually—I think it's appropriate—learning disability. Again, we've referred a specific paper that we've produced on this to the committee. There is a shortage of learning disability nurses in Wales. The learning disability nurse is classically the empowerer and the co-ordinator of person-centred care for the person with learning disabilities. It's the person who will take on that role that you've described, of ensuring that the individual has access to the kind of support services that might prevent a physical condition, or prevent it from worsening. Because people with learning disabilities—and the statistics show this—are very vulnerable, as you've described, to developing physical chronic conditions. So, I think that's a very pertinent group to mention at this point.

I think there are a few things to consider here. I actually think that we're getting better at treating people with cancer—we're getting much better at treating people with mental health issues. I think the medical profession and the nursing profession are writing people off a lot less. I think some people with mental ill health and anxiety, et cetera, are absolutely brilliant at looking after their own conditions. I've been really impressed. When people have that ability to say, 'Well, I'm on these drugs, I know what to do with them, I know who to reach out to if I'm unstable', it's so reassuring when I'm giving them cancer treatment. Not everyone can be like that, but when they can be empowered and supported and know they've got their community psychiatric nurse if things go wrong, it's so much easier.

I think the other thing that really strikes me—I cover south Newport—is that we have a lot of patients, sadly, who fall into that category, but there are probably bits of Wales that don't, and I do think we've got to consider the deprivation in the areas. I know quite a lot of Wales does have more issues around this. Actually, staff need a bit more time. But if we get it right, it can be successfully negotiated. But it is about having that right support and right expertise, and it definitely takes a little bit longer, but I would say I think we're improving.

To me, it's also just not taking away the control from the patient ever. I think the more we take over everything, the more dependent we make people—. That might be very simplistic, but I do think it's really important that we empower. And I think the social prescribing and knowing how to look after yourself can be a real game changer there. There's lots of evidence that, if we support people in the right way and with the right people, with things like social prescribing and looking after themselves, it can be very powerful. It doesn't work for everyone, but even if you get a number or a percentage of people looking after their own health, the long-term impact of that can be brilliant.

Un terfynol, os caf fi, Gadeirydd. Rydyn ni wedi derbyn tystiolaeth am effeithlonrwydd presgripsiynau cymdeithasol a NERS, y cynllun cenedlaethol i atgyfeirio cleifion i wneud ymarfer corff, o ran hybu iechyd a llesiant meddwl i bobl sy'n byw gyda chyflyrau cronig. Felly, oes gan y cynlluniau hyn gapasiti, ydych chi'n meddwl, i ateb y galw? Ydyn nhw'n gwneud yr hyn sy'n ofynnol ohonyn nhw, neu a ddylen nhw wneud mwy?

I have one final question, if that's okay, Chair. We've received evidence about the effectiveness of both social prescribing and the national exercise referral scheme in promoting mental health and well-being for people living with chronic conditions. Do these schemes have enough capacity, do you think, to meet demand? Are they doing what's required of them, or should they do more?

I think the broad point I would make about social prescribing—and that specific scheme, as you say, is very well regarded—and the link system that you described is it relies on those community activities being present. So, if you don't have the community choirs or art classes or exercise schemes or any of this activity going on in the community, then obviously it continuously reduces the options to be able to offer the individual. So, therefore, I think this ties into the broader issue of public funding and being able to see benefits holistically, so that, while some might say, 'Well, that's an arts and culture issue', 'That's about public transport', well, actually, they all have a fairly significant impact on health. Because if you cannot get to the leisure centre—or if there isn't a leisure centre, for that matter—if you can't get somewhere via transport, or because the pavement hasn't been gritted, or there are no dropped kerbs, or there are no public toilets available, then you can't do the exercise in the park, or whatever it is that's helping your mental health, or your physical activity, or whatever it is. So, I think there is a broader point here about how we assess and understand the impact on health, on the NHS, of some of these broader community activities.

10:05

Thank you. Right, before I move on, I know, Dr Williams, if you do disappear—you mentioned you had to go early—we'll understand. So, no problem at all. Joyce Watson.

I'm just going to bring one other thing into the whole question, and it's a sudden change in a person's well-being, through maybe a stroke, a severe heart attack, or the onset of Parkinson's and being diagnosed with what, effectively, is a long-term, life-changing event, and the advice then, holistic advice, that they would need going forward, particularly in the area of mental health and well-being. How well served are those people—you will know many more than I will know—that suffer a sudden change from the person they were the day before?

For instance, on the people having a sudden heart attack, we've got a cardiac rehabilitation service, and the evidence for the people who attend and go to every session, for how well they do afterwards, is really strong. So, we're quite well supported in that. That's an area of improvement, really, along with the fact that far fewer people are having heart attacks at all now, because we are managing chronic illness better. There are some good news stories here.

Parkinson's disease: we've got long waits for neurology, that's really tricky. We're advised to refer to a neurologist before initiating treatment, but, frankly, that very rarely happens because people are really suffering, so that's tricky. But we do have really excellent Parkinson's specialist nurses who will visit people at home. They're that point of contact that Lisa was talking about before, so the patients feel very safe with their Parkinson's specialist nurse that they can phone up and talk to. So, we have got good things in place for that, but there's always room for more.

I'd like to come in here specifically on the point about the specialist nurse. Because as probably Members of the Senedd in this room will know, if you ask the question, 'How many specialist nurses are there in Wales?', you will receive the answer, 'That information is not held centrally.' And this, I think, illustrates profoundly the problem that we have with specialist nurses. Because, where they exist, they are excellent. Now, if that nurse gets another job, or retires, who replaces that person? And then the entire service actually can collapse, and this is even more the truth when we're talking about the very rare nurse consultant posts. We've never had—. Before the Assembly was established, there was a survey done to see how many consultant nurses were needed in Wales, and the answer at that time came back as 52. To my knowledge, we've never reached that point, even now.

What we have been calling for is a national postgraduate, post-registration commissioning strategy for nursing. Because in order to become a specialist nurse, in order to become a nurse consultant, obviously, you need to undertake more education, more training, more experience, and so forth—these are very specialist posts, obviously. So, that is paid for and commissioned by the Welsh Government, by public money. But at the moment, there's quite a random approach to this. Whereas what we are saying is, what we need to do is we actually need to look at the population and say, 'This is how many we need, let's do some succession planning for providing the education, so that, in five years' time, we will have those people and we can provide those excellent services to the people who need them.' That's opposed to the situation we have now, which is, 'We happen to have an excellent nurse here, so we can have an excellent service', or, 'Oh, sorry, we don't happen to have anyone here, so we can't provide that excellent service.' So, I think there's a critical point here about planning the number of specialist nurses, who've often provided exactly what you describe—the advice on management, practical, emotional advice on how to change one's life, adapt one's life, and flourish in one's life while having this chronic condition in the situation you describe. 

10:10

We most certainly can. 

Please. So, I'm going to move on to inequalities. We know, and you've already mentioned it, that certain areas are more likely to experience multiple chronic conditions, particularly in their good health, because of where they live or who they are. So, what role can, and do healthcare services play in helping to address some of those inequalities?

Well, the problem we've got—

I'm probably going to need to leave in a second. It's just—[Inaudible]—and I think in answer to this as well, I think what we really need to do—. I do worry that the education of Health Education and Improvement Wales, which is our education body, is falling a little behind Health Education England here, in that what HEE are doing is projecting what the healthcare needs of their population are going to be in the future, based on Office for National Statistics data. And I think we're all beginning to understand that the rural communities, which are a big issue for Wales, and the older population is growing and growing. I think, exactly as the previous speaker said, we need to start planning our workforce based on that future need, not on this ad hoc basis. I think we need to be much braver about that, and probably not overcomplicate it, but we need the staff working in rural communities to do exactly all the things that we're talking about.

That would be a huge recommendation from me: plan much more ahead, so that we don't—. We have got some great pockets of care and there's probably more in Cardiff than elsewhere, just because that's where your population is, not because of the quality of the staff, and that's what I think we need to do for the future is to start predicting and understanding. And the older co-morbid population is absolutely what we need to plan for. So, a really useful session. I'm really sorry, I'm going to have to leave now, but thanks for your time.

I understand your pressures. Thank you, Dr Williams. All the best. Thank you. Dr Christmas. 

Yes. Unfortunately, the inverse care law that Julian Tudor Hart talked about is alive and well in Wales. We know that people in deprived areas will develop more chronic conditions, they will develop them earlier, they'll tend to be more severe, and that's partly because, in deprived areas, people are more likely to be overweight, they're more likely to smoke or drink or have mental health problems. And just those places where you need the really excellent staff, you're less likely to have a specialist nurse.

I was in surgery yesterday. A specialist nursing in chronic obstructive pulmonary disease phoned me up and said, 'I'm really worried about such and such patient. Her oxygen saturations are dropping a bit, she's going to end up in hospital, I'm worried about it, so shall we do x, y and z?' I said, 'Absolutely brilliant.' She's now on x, y and z and she's much less likely to end up acutely unwell and in hospital. If that person was living in the Valleys, she's less likely to have a specialist nurse who would go and see her at home. And so, the pressure on those areas increases and she's more likely to end up in hospital. 

So, if we can invest in the community, more specialist nurses in the communities where people are less well, we are much more likely to empower them to stay well and stay at home. And health literacy is really, really important. I read a statistic that 43 per cent of adults, if you give them written information about their health, won't understand it, and that number goes up to 64 per cent if that information includes numbers as well as words. So, we can do that better. We can provide them with information that's more understandable, or we can prescribe them with—. We can give them people who will help to explain it to them, and that doesn't need to be a trained medic, that can be a lower paid person who has the time to sit and explain information to them.

So, there's a lot we can do to try and help people to help themselves to stay at home and stay in the communities, because nobody really wants to be in hospital, apart from the people who've got a planned operation, and we want to be able to get them in for their operations.

10:15

Yes, I would definitely, absolutely echo all of that. I think it is about planning. We know where certain geographical areas or certain vulnerable populations are in Wales, so we should be planning services around the population as opposed to the ad hoc way we've done this in the past.

I think in terms of the public health thing as well, it's also about investment in other areas. Take, for example, the role of the school nurse—potentially hugely valuable in that kind of health literacy at an early age. So, there are certain public health nursing roles that are not about treating individuals, but are about assisting in the situation that prevents illness and prevents these conditions from worsening, and helps manage those conditions. 

So, there is something there about that approach, but absolutely critical is the investment in primary care and the investment in community care in that neighbourhood. That is community nursing, pharmacy, mental health, GPs, all of that.

And talking about children, I appreciate this is chronic illnesses, but gracious me, the number of children who are overweight and obese and are developing diabetes and other problems associated with that is just shocking. And yet, if I've got an adult who's overweight, I've got services to refer them to: they can go to the exercise referral scheme, they've got weight management services. Kids, there's a real lack of anywhere to—. The poor parents will come in, anxious, and beyond telling them to go to the swimming pool, which is often closed, or to go and join a junior parkrun, which is brilliant, but—. There are things we can do, but, again, they need to have Sunday morning off to go, they need the transport to be able to take them. It's very tricky, and we need to be looking at children to optimise their health to prevent this problem. These poor kids who are unwell now, they're going to be very unwell and unhealthy middle-aged people. 

But there's also another specific group, and that's the black, Asian and minority ethnic group, with known factors of health issues that they will perhaps present with. How do we help and support those not to fall into being chronically ill? How well are they supported, and how should we support them, beyond anything else that you've said?

I think we learnt a lot during COVID, when that group of people were less likely to come forward for vaccination. We had people going into their mosques, or the places where they go, and increasing their health literacy there, so trying to capture them because they were less likely to present. So, it's building on that, building on that knowledge that we learnt during the pandemic to improve things now. Because you're right: they're a vulnerable group, and they're perhaps less likely to present at the doctor's surgery or come for annual checks than other people.

I would completely support that, absolutely. I think I would add as well there's something—again, going back to my point—about community infrastructure that benefits the community. And that community geographically could happen to be predominantly Asian or black, but would benefit that community. So, I suppose it's a question of—. It's difficult because if you overgeneralise, you can actually miss the point. It may be, with certain communities, that they are more inclined to have that disadvantage, because of factors like, for example, lack of investment in transport, lack of health facilities or lack of access to primary care. So, it may be an intervention like that that can actually prevent these kinds of disadvantages from emerging. So, I think, looking at transport and looking at the actual location of health and leisure facilities is really important. 

Going back to the point about encouraging physical activity in children, for example, if you don't have access to a playing field or recreational area that is safe for the child to go to, particularly if it's by themselves, so it's about crossing roads, then where are they getting that physical activity? If the curriculum is so squished that there is no room for physical activity and that kind of thing, then all of those things are reducing the opportunities available for people to access. So, I think that thinking about it in that way can also be extremely helpful.

10:20

Thank you. I'm going to ask a question now about primary prevention. Many of you have actually touched on this morning about empowering and educating patients, social prescribing in relation to health literacy, and the Royal College of General Practitioners, in written evidence, have said that you need the time and resources to promote well-being, rather than treating sick people. So, last year our committee commissioned a report on health literacy, which was written by Dr Emily Marchant and Professor Tom Crick. And it does show that evidence states that patients who have greater levels of health literacy are less likely to rely on health services. Therefore, the more knowledge a population has, the more time is freed up for GPs. You've touched on a number of ways this morning of how that can help, and I also just wanted to know your views, really, on the peer-support groups that are out there, which are often run at the moment by third sector groups. It seems to be that funding is being sucked away from those. And you also mentioned the social prescribing links—we call them community navigators, in my community. They're called the best kept secret, because if you can find one, brilliant, but most people can't. So, I was just wondering what your thoughts are, really, on those peer-support groups that are out there, if there's enough of a link to them, and if you see the benefits of them.

I think they are, when available, absolutely hugely valuable, but they're not routinely available. If any of us are going through a difficult experience and you meet someone else who has gone through the same thing, or is going through it, just sharing those vulnerabilities, sharing tips and ideas is incredibly important, incredibly useful. It does feel like we're missing an enormous trick here. The idea of having group consultations for people with high blood pressure, where you can talk about a low-salt diet, more exercise, cutting down on smoking—. I've been in a room where people will—you step back and they start talking to each other, moaning about how hard it is to give up smoking, 'But I tried this', or, 'That Champix is really good.' You know, allow people to be experts in their lives and share that. People come away—there's a hubbub of enthusiasm and positivity. Of course, you're also then addressing loneliness and isolation. There are wins throughout doing this.

I often think that we should be getting our patient representative group on to this, but, of course—. I get into surgery—and I'm sure you're the same—I'm in surgery at 7.30 a.m.; I get home about 20:30 at night, rung out and exhausted, and there just isn't the time in the day for these quite time-consuming quality improvement things to be set up. It was good in COVID, we had all these volunteers just doing amazing things. I can remember thinking that we've got to harness this, and then, of course, life got back to normal and busyness happened. There are opportunities in communities to set up expert groups of patients who will gain themselves from sharing their knowledge and their expertise. There's nothing more empowering or that makes you feel good about life than helping other people. 

I couldn't agree more. I think peer groups are absolutely incredible—the work that they do. What I would say is that there is, as identified, a cost there, but there is an administration issue of who is setting these up—

Technology's fantastic in this regard, because, actually, this can address issues of isolation and loneliness, because it means that people don't necessarily have to travel physically to have the support of that peer group; they can just log on and have that discussion. It's also an opportunity—. And often as well, this could be the specialist nurse, or nurse, or therapist leading this type of group—perhaps 'leading' is the wrong word, but potentially contributing when the group wants to. But it can be very helpful in terms of addressing misinformation.

One of the other areas, of course, that's important to flag when we're discussing health literacy is the fact that we have a situation now where long-standing approaches to understanding what science is, and understanding the authority of science and the spread of misinformation is very difficult. So, having a support group where people can collectively say, 'This is the latest suggestion online, what do you think?'—having someone there who's able to say, 'Well, actually, this is the evidence one way or the other', can be an incredibly timely intervention into that community.

10:25

I agree. Thank you very much. As we're short on time, I'm going to skip over now to secondary and tertiary prevention, specifically looking at older people. So, as we know, older people are more at risk of chronic conditions and experiencing frailty. Some of the written evidence highlights the role of frailty nurses. So, would you be able to give us some evidence on what impact frailty nurses are having in supporting older people with chronic conditions, and whether they're accessible to older people throughout Wales right now?

Well, I think that they're doing an absolutely fantastic and amazing job, and incredibly important. However, I suppose what I would say is that this is a new name, it's not a new specialism. Looking after and empowering people who are frail, older people who are frail, is a key component of nursing.

One of the things we've identified in our community nursing paper is that part of this comes back to what we would call a bit of a neglect of that community nursing important strand of the NHS. A lot of the funding is being funnelled now through these regional partnership boards and involves bids for new things. So, very often, the core community nursing service is engaged in rebadging itself, or rejigging itself in order to access these new pools of funding, whereas, actually, what could be more useful in some respects would be increasing the core funding of the community nursing team and the amount of people and the level of skills that they have access to, and that would include frailty nursing, exactly as you describe, which is really important and has a huge impact. 

I think it's also worth saying that, if you're talking about frail older people with chronic conditions, if they're in their own home, they will be receiving packages, potentially, of support. What we're seeing is, as pressure comes on funding, a difficulty to access that support, but also a stripping of the skill base from that support. So, what you end up with is a task-based situation. It's like, 'Right, this person is going into this person's house to do this task, and then they're going out again.' Whereas, actually, if you have the system of the community nurse, a senior level district nurse, or a senior community nurse, they're going in and assessing the need and thinking, 'I need to refer them to here', or, 'This has happened', or, 'What's the situation with the heating in this room', or, 'Actually, we need an occupational therapist in here and some aids.' Where is that holistic assessment of what's going on and the co-ordination of care, as opposed to, 'Right, we've found out this person needs a task done', so somebody will go in for 15 minutes every Wednesday and do the task? So, what happens then is, when there's a crisis, it's GP, out of hours. What are we going are we going to do? We're going to get into the hospital and blah blah blah, and the system, basically, is not helpful for that individual, and it's certainly not helpful for the system as a whole. 

The other point is, in residential care, which is the other potential place where you might find that population, again, there's a stripping out of the nursing expertise, because, 'Do you need actual specialist nursing care?' 'No, you don't.' So, if you don't need specialist nursing care, how are you seeing a nurse? Whereas, if there was nurse present, they'd be doing that assessment, that holistic care. So, one of the things we've often said is that there needs to be, in commissioning services, residential services, not this sharp distinction between, 'Do you need some kind of medical care? In which case we'll get it for you', and, 'What is your health need?', for the population as a whole. Those are the answers to that question. The first question: absolutely, yes, frailty nurses are marvellous and it would be great to have them, but I think there's a wider point about how that service is provided, planned for and delivered to that community.

I think that's key. We have got an ageing population, and because we're doing very well, our ageing population are living with chronic illnesses because they're not dying from them. What I see is just how guilty our ageing population often feel. Instead of celebrating the fact that they're elderly and they're doing well with their conditions, they just feel so guilty that they're such a burden on their family, or society or their GP. That's just dreadful, dreadful that they're in that situation. So, we really do need to do better. And I think that you're right: good-quality holistic nursing and care makes all the difference. Rush in, 10 minutes to heat up your meal in the microwave, dump it on your lap and rush out again—and it's not the carer's fault. They've got unbelievable pressures on them, and they're not terribly well paid. But it does add to that, 'I feel guilty. I'm just a terrible burden to society' feeling that older, more frail people have.

10:30

Thank you for sharing that. You're right. Thank you, and thank you, Chair.

We are over time, but are there any key recommendations you can bullet point to us, in terms of our discussion this morning in supporting people with chronic conditions, that you think that we should be considering to make to the Welsh Government?

For me, the way to look after people with chronic conditions best is at home, so invest in the community. And I can't emphasise that enough. And the whole of community service—so, district nurses, primary care, GPs, and our whole teams. We want to keep people with chronic conditions out of hospital. They are far better for that. And if you ask them, that's what they want as well. But for us to do that well and effectively, so that people don't just survive at home, they flourish at home, we need more time and resources to do that.

And is there—and I understand that point completely—anything Government can do that doesn't cost anything—

Get a plan in for how you're commissioning. Because you're commissioning postgraduate, post-registration nursing—the Welsh Government is doing that anyway. There is a budget that exists for it, it's happening—the only thing that we are calling for is for that to be planned better. That would be my point on that. The other thing I would add to that—I couldn't agree more with absolutely everything the speaker's just said. I think access to primary care is an issue here. 

And continuity—try and find a way to incentivise continuity of care. Put it into nursing and medical student curriculums, so that we're teaching it from the get-go. Make it as important as access, and you will see demand on secondary care fall.

Okay. Thank you, both, for your time. I know you've provided some papers previously as well, which has helped our discussion this morning as well. So, thank you, both, for being with us this morning. Diolch yn fawr iawn.

Thank you.

Gohiriwyd y cyfarfod rhwng 10:33 a 10:44.

The meeting adjourned between 10:33 and 10:44.

10:40
3. Cefnogi pobl sydd â chyflyrau cronig: sesiwn dystiolaeth gyda gweithwyr proffesiynol perthynol i iechyd
3. Supporting people with chronic conditions: evidence session with Allied Health Professionals

Welcome back to the Health and Social Care Committee. I move to item 3 with regard to our work on supporting people with chronic conditions. We've got an evidence session now, for the next hour, with allied health professionals. I'll just ask the witnesses to introduce themselves, please.

Thank you, Chair. I'm Calum Higgins, I'm the policy and public affairs manager for the Chartered Society of Physiotherapy in Wales.

I'm Dai Davies, I'm an occupational therapist and I'm the professional practice lead for the Royal College of Occupational Therapists here in Wales.

Lovely. Thank you, both, for being with us. The first set of questions is from Gareth Davies.

Thank you, Chair. Good morning, everybody. What role can AHPs play in delivering person-centred care for people with chronic conditions? That's to both of you.

10:45

Well, a vital role, to be perfectly honest. We have an AHP framework in Wales that directs our vital role in relation to getting a healthier population. AHPs—so, occupational therapists, physios, podiatrists, dieticians—are the forefront of making sure people with multiple conditions can live their lives the best they can. We're all experts at person-centred care, self-management, rehabilitation. We've got a range of evidence-based interventions that have been proven to support the people of Wales.

It would be good if we were utilised more correctly and seen by patients sooner in the journey. That would be in primary care and social care—occupational therapists, physiotherapists. Our mental health patients need access to AHPs. But we are the one profession, or professions, that actually manage multiple conditions in relation to how someone lives their life. It's an evidence-based approach. 

Following on from everything that Dai has said, which we completely agree with, the AHPs really specialise in a holistic, round look at someone's health. Sometimes, we overmedicalise, probably, in the NHS, and in providing services, we look at the medical viewpoint, whereas AHPs bring a multidisciplinary look at someone's life, how they can carry on living as healthily as possible with whatever condition they have, or multiple conditions, as we're seeing increasingly. They look at the person and what they can achieve and what they want from their health and their lifestyle, rather than maybe just simply treating something that's been diagnosed. It's more about how can you live with that.

As Dai says, we probably put that at the end of the journey, very often, in health provision, and maybe we need to look at putting it at the beginning of a patient's journey, having prehab before someone goes in for treatment, speaking to OTs, physios, speech and language therapists earlier on in the journey so that we, maybe, avoid some of those hospital admissions that we see, and allow people to live longer, healthier lives.

Thank you very much. Your evidence and panels earlier today and in the past have alluded to the need for people to be cared for at home and in the local community, and, if possible, to stay out of hospital. So, can you provide specific examples of the way in which AHPs collaborate with primary care in order to provide support for people living with chronic conditions in their homes and local communities?

That's a brilliant question. We're always looking for case studies to be able to present. We have a video at the minute that's on Twitter, online—or X as it's called now—about the Carmarthenshire First programme, which is a community rehab programme run by Hywel Dda in Carmarthenshire, really about keeping people out of hospital, avoiding those admissions that could be avoided if people were treated outside of hospital and given that care and follow-up. That is collaborative, it's out of one of the local authority buildings, so they can speak to the local authority staff about any issues that are raised and also liaise with primary care. What we see, though, is that that kind of programme isn't rolled out consistently across Wales. It's something that the Welsh Government prioritises, something that all the professions agree with, but there really is an inconsistency in delivery. That's a great programme and a great example— 

'Pilotitis' is what we call it. I'm sure you're aware, and other people will have said it: pilots are run, funding is a little bit inconsistent, and when that funding runs out, people take the learning but it doesn't really go anywhere nationally, in my opinion, and it doesn't get, then, from the top down, spread out across all health boards. Just as an example there, it's a Carmarthenshire programme, it's not even a Hywel Dda-wide programme. So, before we talk about all of Wales, it's not even consistently delivered across one health board.

Thanks. Who's to blame for that, then? Is it health boards? Is it the Government? Is it more of a national-level or strategic issue? What's the—

I don't mind answering it. I think everyone's well meaning, everyone wants to share their learning, but it's just that nobody has taken responsibility at a central point to be the people to collect that and share it and be accountable for that. Maybe the NHS executive is the new way forward for that. That's what I would say, but I don't know if Dai has got any thoughts. 

10:50

The audit office brings it up. There's just been an evaluation of the Social Services and Well-being (Wales) Act 2014 and there's been mention of the disconnect between the 'What matters?' conversations and, actually, the delivery. Obviously, the parliamentary review said that the NHS executive was an important part, so it's about time that got started. And it would be interesting to see how it liaises with the social care office that has come in as well. There's a definite disconnect about what policy says—that is the social services and well-being Act, the Well-being of Future Generations (Wales) Act 2015 and 'A Healthier Wales'—and delivery. The health boards and the local councils, with the regional partnership boards, need scrutiny in relation to that delivery, because we've been in a bit of a death circle at the moment, where people go to hospital, people get discharged from hospital, people go back to hospital. There needs to be a block. Everyone says that and all the evidence is there. So, the governance arrangements really need to make sure that this happens. Again, there are loads of arrangements there, but there is just not enough connection between the different parts—

It's just the fragmentedness of that. Regional partnership boards are an excellent idea—all of them getting together—but there's no statutory footing to them and each individual part of that regional partnership board obviously reports back to their governance arrangements, so—

Some governance arrangements relating to the regional partnership boards so that they can be judged against those, to be perfectly honest. That's ultimately it.

Yes, I think a stronger line of accountability to the Welsh Government where the boards need to report back and be held to something. We often see guidance and there's some great work that we'll probably get on to in discussion that is positive, but I'm not sure they're being held to it and what the accountability is at a higher level nationally.

Just one final one, thank you. Are there any other key barriers to delivering PCC for AHPs and what steps should be taken to overcome these? Are they logistical issues, maybe some stories on the ground, if you like, on the front line of care? Are there any logistical or practical barriers to delivering that?

I know you might have heard this, but it's the funding again—what Calum talked about earlier. Lots of services providing rehabilitation should be core funded, but somehow, they're repackaged into this transformation stuff and they get integrated care funding. But they're not transformational, they're proven interventions. They are transformational for the people, but they kept on getting funded in these small blocks of funding that only last two or three years.

The reporting arrangements are all different. I've had occupational therapy in one service where half the service is funded by one fund, the other half is funded by another fund, and they've got different reporting mechanisms, but they're doing the same things. Health boards need to fund proper rehabilitation as core. It exasperates our members. And, again, funding is everything. We know there isn't much money, but if the NHS wants to stop the ambulances at the front door and have a healthier population, rehabilitation at primary care and community services shouldn't be short-term funding, it should be part of core funding. 

Yes, I'd agree. It probably stems from a cultural issue around the parity of esteem given to these services. Nobody really questions the need for nurses and doctors, but it's much harder on the ground to convince funders to fund a rehab service. It has to be packaged as something innovative and new and transformational. Actually, it's not; it's really basic and should be core funded. By having to package it as transformational, the funding becomes temporary and then disappears after a while. So, yes, it's really difficult for the managers on the ground. 

Can I add another suggestion? The visibility of the population needs assessment, in relation to workforce, isn't there. Our managers will do a population needs and workforce plan and that seems to get lost in the ether. There needs to be more clarity on how we workforce plan in relation to population health needs, rather than how we plan in relation to finance and process. Our managers get hugely frustrated. They'll identify a population need, they'll develop an evidence-based workforce service development and then it gets lost in the ether. So, there needs to be connection about how our workers on the ground are planning and where that goes, because all health boards and local authorities should be assessing population health needs. It's part of the policy. There's a massive disconnect between what our innovative occupational therapists and physios do on the ground and actually what's delivered. 

10:55

Diolch, Cadeirydd, a diolch i Dai a Calum am y dystiolaeth hyd yma. Mae'n wirioneddol ddiddorol ac yn agoriad llygaid. Dwi eisiau cyffwrdd ychydig ar iechyd meddwl, os caf i, ac mae gen i gwestiwn yn benodol i Dai i gychwyn. Mae papur y coleg rydych chi wedi ei gyflwyno yn nodi bod mynediad at gymorth adsefydlu ar gyfer anghenion iechyd meddwl yn brin. Ydych chi'n gallu ymhelaethu ar y gwaith yma, os gwelwch yn dda? Beth sydd angen ei wneud er mwyn gwella cymorth adsefydlu ar gyfer anghenion iechyd meddwl?

Thank you, Chair, and thank you to Dai and Calum for the evidence. It is very interesting and an eye-opener, in fact. I want to touch on mental health, if I may, and I've a specific question for Dai first of all. The college's paper notes that access to rehabilitation support for mental health is particularly lacking. Can you elaborate on this, please? What needs to be done to improve rehabilitation support for mental health needs?

That's a great question. That was my clinical background before I became a policy officer. I was an occupational therapist in forensic and community mental health. The main thing that needs to happen with mental health patients is—. Literally, I was the only person delivering therapy to my patients. There are hardly any dieticians, speech and language therapists, physiotherapists that actually work within mental health services. And considering the well-known problems for people who have mental health problems—10 to 15 years below the normal life expectancy, massive issues with obesity, isolation—there's a massive lack of equity between mental health patients and patients who have physical health problems.

We advocate, and our members advocate, quite significantly through the mental health strategy that, actually, mental health patients have access to physio and speech and language therapists, which is really, really important. And also our occupational therapists who work in physical health are dually trained. So, we could deliver mental health interventions—if you've had a stroke, or if you have Parkinson's. The trouble is the system moves our therapist away from that intervention. It's all very process driven, it's all very risk averse, 'Let's get them in and get them out'. So, actually, there are two points: there are not enough AHPs within mental health services; and, actually, in physical services, the AHPs are directed for this very physical-related, 'Get people out of the system', and really not concerned about—. If you've had a stroke, that is a massive transition, and you need mental health support if you've got mental health problems and stuff.

So, again, its inequity; there's massive inequity. And, again, this is well-known, because when we do have services—. In north Wales, there's a classic example, where we've got OTs in GP practices who are seeing mental health patients, so people with mental health problems, before they even get into the service. They work with the third sector, they refer them to physio and speech and language therapists. I worked in the prisons, and one of the big factors is that the boys there really struggled with communication needs. So, they can't actually access the therapy. So, if they had speech and language therapy before accessing that therapy with OTs and psychology, it would be an amazing achievement. So, the evidence is absolutely there, we just need to do it. 

Diolch yn fawr iawn, Dai, am hynny. Mae yna dystiolaeth rydyn ni wedi ei derbyn hefyd am effeithiolrwydd cynlluniau fel presgripsiynu cymdeithasol neu'r rhaglen NERS, y cynllun cenedlaethol i atgyfeirio cleifion i wneud ymarfer corff. Oes gan weithwyr proffesiynol perthynol i iechyd ran i'w chwarae wrth gyflwyno cynlluniau fel hyn? Pa gamau y gellir eu cymryd er mwyn sicrhau eu bod nhw'n cyrraedd y rhai sydd eu hangen nhw fwyaf?

Thank you very much, Dai, for that. We have received evidence also on the effectiveness of schemes like social prescribing, or the NERS programme, the national exercise referral scheme. Do allied health professionals have a role to play in delivering schemes like these? And what action do you think could be taken in order to ensure that they reach those who need them most?

Diolch am y cwestiwn. Jest i gyfeirio nôl at beth ddywedodd Dai hefyd, mae iechyd meddyliol a bod yn actif ynghlwm â'i gilydd. Felly, mae gweithio mewn MDTs, lle mae gennych chi OTs, ffisios a phobl sy'n arbenigo mewn iechyd meddwl yn cydweithio gyda phobl sy'n arbenigo mewn bod yn actif, yn rili bwysig. A dyna beth rŷn ni'n ei weld gyda phobl yn aros ar restrau gwahanol—aros ar restr ffisio a wedyn aros ar restr iechyd meddwl. Maen nhw'n dod at y gwasanaethau ar amseroedd gwahanol, dŷn nhw ddim yn eu cael nhw ar yr un pryd, ac efallai byddai e'n fwy effeithiol i gael y timoedd at ei gilydd a bod cleifion ddim yn aros ar sawl rhestr ar yr un pryd.

Ond nôl i'r cwestiwn amboutu NERS a rheini, mae'r rhaglenni wedi gweithio'n eithaf da yn y gorffennol, ond beth rŷn ni'n gweld yw pobl yn dechrau rhaglenni a ddim yn eu gorffen nhw. Ac mae cadw pobl mewn rhaglen swyddogol fel yna yn anodd iawn i'r staff ar y coalface, fel maen nhw'n ei ddweud. So, beth fyddaf i'n awgrymu, rili, yw ein bod ni'n mynd at, fel roeddwn i'n ei ddweud, person-centred holistic care, dŷn ni'n gwneud rhywbeth mwy unigryw i bob glaf, siarad â nhw am beth maen nhw ei eisiau, a ddim yn eu rhoi nhw mewn bocs lle mae un rhaglen yn mynd i weithio i bawb, achos dyw e ddim mewn realiti. So, mae'n rhaid canolbwyntio ar y cleifion unigol, rwy'n credu.

Thank you for the question. Just to refer back to what Dai said also, mental health and being active are one. So, working in multidisciplinary teams, where you have OTs, physios and those with expertise in mental health working collaboratively with those who work on people becoming active, is really important. And that's what we see with people on different waiting lists—they're on a waiting list for physio and then they're on a waiting list for mental health. They come to the services at different times, they don't get the treatment at the same time, and perhaps it would be useful if teams came together and patients weren't waiting on different lists at the same time.

So, to refer back to the question about NERS, the programmes have worked quite well in the past, but what we've seen is that people start programmes and they don't finish them. So, keeping people in a formal programme like that, it can be very difficult for staff at the coalface, as they say. So, I would suggest that we go towards this person-centred holistic care and that we provide something more unique for every patient, so that we discuss with them what they need, and that we don't put them in a box where one programme is going to work for everyone, because it's not in reality. So, we need to focus on the patients as individuals, I think.

11:00

Yes, I can talk about social prescribing. Fair play to the Welsh Government, they got us involved in the task and finish group—and, obviously, the Minister for mental health. So, we were really involved in the social prescribing framework and the sort of governance arrangements. We are really supportive of it, but it's not a medical intervention, it's a social intervention, and that's really important. So, again, I've talked to the north Wales mental health services; they're working quite a lot with social prescribers in relation to that. The important thing is that we want to ensure that when problems become such that you need to see a registered professional, the social prescribers have the training and the governance arrangements to be able to move that on. Because they're not there to treat people, they're there to socially prescribe. So, there are some concerns around that. They're not another registered professional—that's our job—but they are an amazing service to get people out and about and physically active and stuff. So, we'd encourage it, but not at the expense of registered professionals. But that's one good thing about the Welsh Government, and, obviously, the Minister's been really keen to get us involved and we'd like to thank her for that.

Diolch am hynny. Os caf i orffen efo un cwestiwn, os gwelwch yn dda, Gadeirydd, oes gan y rhai sydd yn ddioddef o afiechyd meddwl difrifol fynediad digonol, ydych chi'n meddwl, at wasanaethau sy'n cael eu darparu gan weithwyr proffesiynol perthynol iechyd? Pa gamau ydych chi'n meddwl sydd angen eu cymryd er mwyn gwella'r cymorth ar gyfer pobl sydd ag afiechyd meddwl a'r mynediad tuag at weithwyr proffesiynol yn eich meysydd chi?

Thank you for that. If I can conclude with one further question, Chair, in terms of those with severe mental illness, do they have sufficient access, do you think, to the services provided by allied health professionals? What actions do you think should be taken in order to improve the support for people with severe mental illness and access to allied health professionals in your areas?

'No', is the answer. So, the mental health workforce plan has a number of AHP pathfinders in there—so, it would be great if the committee could emphasise the importance of them developing, and then, if they are proven to work well with the AHP transformation, that they are mainstreamed. It can't be good that if you've got dementia, say, the only therapy you can access is OT and maybe a bit of psychology. We've got some fantastic early intervention memory services, but, again, that is in, like, two parts of Wales. So, at the very first start of your journey to dementia, actually, there's an intervention there that can slow down your deterioration and keep you at home and healthy and active, but there are only two parts of Wales where that happens.

And then we've got our forensic services. Just walk on a forensic ward and just see the general levels of obesity on a forensic ward because of the medication and stuff like that. It is scandalous. We should have dieticians there; we should have physiotherapists there. They know about this, because it's in the mental health workforce plan. It needs to be implemented, and we need to treat people with chronic mental health a lot, lot better in Wales than we do.

Ie, dwi'n cytuno â sylwadau Dai. A jest nôl at y pwynt, rili, ar hyn o bryd, mae'r gwasanaethau iechyd meddwl rili ar wahân i'r gwasanaethau bod yn actif, a rili mae'r ddau ynghlwm, ac ni ddylai unrhyw ddrws fod ar gau i rywun sydd eisiau cael cyngor iechyd meddwl, ac efallai bod eisiau codi mwy o ymwybyddiaeth yn y gweithlu ar y cyfan a chael mwy o bobl sydd wedi cael eu hyfforddi fel rhywun sy'n gallu rhoi cymorth cyntaf iechyd meddwl i dreial osgoi pobl yn aros am amseroedd mawr i gael yr help yna.

Yes, I agree with Dai's comments. And I'd just refer back to the point, really, that, at the moment, the mental health services are very separate from the being active services and they should be entwined, and no door should be closed to someone who is seeking mental health advice, and perhaps we need to raise more awareness in the workforce and have more people who have been trained as first aiders in mental health in order to try to avoid people waiting to get that help.

My questions are to the Royal College of Occupational Therapists. In your paper, you do mention social factors impacting people's ability to engage in prevention and self-management activities, and then going on to health inequalities. So, what particular social factors have you identified, and what do we need to do to help?

11:05

Yes. So, housing is the big one. So, our occupational therapists obviously work in the local council, and housing is a major issue. So, they are the main people who see people with chronic conditions. You phone your council, you're struggling to get up and down your stairs, you're struggling to get on and off the toilet and do the everyday life stuff, and then you're on a waiting list in a council because of the significant factors.

Funding to adaptation budgets is hugely problematic at the moment. The Welsh Government have done some good things, like removing the means test for adaptations, but they didn't give money with it. So, we've got an increase in the waiting list now, because we've got people who traditionally wouldn't have come into the services, because they would have paid for them, who have come into the service, which is a good thing, but then there's a massive lag in waiting list times, and it is a massive preventative strategy with chronic illness. You fall over and end up in A&E, you're in a world of pain, aren't you, you're stuck in an ambulance, you're stuck in hospital, you deteriorate. So, I think the system needs to look at occupational therapists in social care as a massive preventative progress, and they need the resources to be able to develop that. Obviously, tenure, in relation to housing, is a massive problem, in relation to the private sector; the different housing associations and how they fund it, that's a major issue. 

And then employment is another thing. It's well documented that if you keep people in good work, and good work is the primary factor, people are healthier and stuff. And if you think about it now, AHPs, or physios and occupational therapists, can actually do fit notes now, so they don't have to go to the GP to get a fit note. So, the way do we fit notes, it'd be slightly different. It'd be recommendations of how you can maintain fitness, how you get back to fitness, and that would be a proper relationship. So, we're seeing small pilots in relation to that, and we've got evidence, when we've done that—. In Pembrokeshire, we've got, actually, quite decent evidence that was published about how OTs and physios can support people staying in work. 

And in relation, then, to mental health and dementia, we've got some excellent examples—the Cynon Valley is another one—where the OTs and the third sector actually worked with shops in Mountain Ash and talked about being dementia-friendly services and stuff.

So, those are the three big ones for us—housing, getting people and maintaining people in work, and supporting the community to develop more friendly services, so people can get out and about and do stuff. 

The other thing, of course, is that people living in deprived areas are more likely to have multiple health issues, and the health disparities become pretty obvious, let's be honest. So, what action can we do to help in those circumstances? And that's to both of you. 

Yes, so, it is encouraging health boards to have innovative ways for referrals and identifying people. So, I'll give an example of one in Swansea bay, which is a children's service, because, again, if you access children really, really quickly, they don't become chronically unwell. So, our service in Swansea, which was OT and physio, was really, really innovative. They started mapping out the schools from deprived areas that they weren't getting referrals from, and then built a relationship with those schools to develop a relationship. You've got—. Sometimes, when we try and reach out to people, we give them a number, we give them an app and stuff, but that doesn't work, and the evidence suggests it doesn't work. We've got to actively seek out underprivileged communities. So, it's not good enough just to say, 'Here's a phone number, here's a television campaign'; it's encouraging health boards, local councils and Public Health Wales to actively identify where it is and develop interventions to improve that. 

Yes, I agree with Dai, there. In the CSP, we've moved to using equity rather than equality as our measure. So, we have a new equity, diversity and belonging plan. That really means not just providing equality in terms of putting out, as you said, a number there—anyone can access it, anyone can ring—but looking at the outcomes, who's actually accessing the services. And that's a great example that we discussed around going out and being active, looking at who's not accessing the services, looking at the deprived areas, realising there's a relationship and being proactive in going out there and doing it. And I think that just takes leadership at quite a local level, if not at local health board level anyway, and having a lead on that, someone who's willing to make those decisions and put resource into it.

11:10

Can I just add? A number of royal colleges have come together and we've sent information to Welsh Government, and we think it's a cross-department issue; it's not a health issue primarily. All Ministers should have this in their portfolio, because the social determinants of health, it's like 5 per cent is the health service that makes sure you're well; it's all the rest, housing—

It's environment.

Environment. All Ministers should have that in their portfolio.

Did you say you've said that to—? Sorry, just repeat that last bit again.

Yes. We've come together as part of the NHS Confederation and we've got—

Yes. We've sent them a report, which we can give you.

I'm not sure.

We're not leading on it; it's Lowri from the physicians, who's fantastic at policy. She's leading on it.

We endorsed the paper collectively.

Yes. So, we'll contact you.

Okay. Well, I suppose it would be useful—if there is some decision or a response from the Government, it would be useful to know that.

Can I just ask one more question? In terms of access to food, which we're going to talk about, the projection going forward with diabetes and other health-related issues that then become chronic, do you look at all at foodbanks, or do you have any link-up between what's available to people when they're really struggling—that's why I mentioned foodbanks, or food larders—and the difference that they might help make through the access of the people who are most in need not becoming chronically ill in the future?

I think this is the importance of integrating health and local authority social care services. If you're dealing with things separately, you're going to have the health professionals going in and doing one thing but not making the right referrals to foodbanks and the right services for people's holistic needs. So, I don't think there's enough of that done; it seems to be in its infancy. It's talked about a lot, but I don't think, on the ground, really, that link-up has been made.

When I was a mental health practitioner, I used the foodbank in Bridgend quite a bit. They're an absolutely vital service, and, with social prescribing, you can't prescribe anything socially if there's nothing to socially prescribe to, so they desperately need secure funding. Obviously, the dieticians who are a part of the AHPs are a massive factor, and they should be a massive factor in the NHS, but a big part of it, mind you, is just policy around food. Obviously, again, that's outside our remit, but increasingly our members are telling us that they're seeing really unhealthy people now. It's older unhealthy people, so it needs to be looked at, what people consume, how they consume it and so forth. But the Trussell Trust and stuff are invaluable; I know members use them quite significantly, unfortunately.

Are there any examples that you can give, any further examples that you can give, within your sector that demonstrate new ways of working in terms of prevention?

Yes. So, obviously, we can speak to our dieticians in relation to food. Just an example, there's a Bevan example up in north Wales where OTs have worked with victims of domestic abuse, which is amazing. It's amazing, but, when you've been a victim of abuse, you lose loads of your skills because of cohesion and stuff, so our OTs there are doing stuff like cooking skills and shopping skills and management skills because people who have had years and years of abuse get deskilled, unfortunately. So, there's an excellent example there of that. There are excellent examples in Powys where the OTs are connected to the schools and supporting the children, developing skills with our neurodiverse children and stuff. I can give you countless examples. Again, they just—

11:15

In Powys, then, why does that—? Are you suggesting that only happens in Powys, or it happens more in Powys? So, if that's a good example, what's the blockage in that taking place elsewhere?

Yes. It's hugely frustrating, Chair, it really is. And it's frustrating to our members. It's that block, again, about—. And it shouldn't be, so this is why—

This, I think—us opening this up, recommendations from you, recommendations—

That they're core funded. It's as simple as that, really. But, I mean, if it's proven to work, it's proven to work, and policy suggests that that's the way we should move them down. Sorry for being colloquial, but it's a no-brainer, isn't it, really?

If it's a no-brainer, if the Minister was sat here, what would the Minister say, do you think, in terms of why the Minister is not core funding these areas?

So, I think there is some work that's been done that is a step forward. So, you've got these quality statements for each area, condition-specific quality statements that have been rolled out now across Wales that we should be adhering to. We've got rehab standards that should be adhered to by every health board. What I'd say to the Minister, if she was sat here, I'd say, 'Welsh Government need to needs to be making sure that that is enforced, that that is being delivered at a local level.' Because the right things have been done, there's a national—

It's early days yet, I think, to know, but I'm not sure who's checking and I'm not sure if there's real follow-up. It's assumed, I think, that everyone takes the standards and cracks on and does the work.

That's, again, a political question, really. Is it enforced through accountability at health board level? Should the health board members be the ones who are accountable for it, like any other aspect of health board activity? It's a difficult question, but I'd say that it's very early days in this new framework we have, but there are things to do.

Are there any other—my original question—examples of where good work is been done to prioritise prevention? Are there any other examples that you could point to? There are lots, are there?

In general, I think there are some good examples, particularly in Cardiff, if we're talking about diet. We have waiting lists for orthopaedic surgery that are quite high—a lot of that is weight-management related. So, there is really good work already ongoing where, if you go in, initially, and it's identified you have a problem with your knee or your hip or something that can be managed through weight, we are getting the waiting list down to the bare bones of what they can be by offering that weight management and diet advice quite early on, and prehab, before someone has the operation to, in some cases, actually get them to avoid needing an operation in the end. So, that is done. A really good example, I'd say, is Cardiff, of doing that, particularly when the pandemic finished. They really went for that.

I think that's probably one of the positives. I think, generally, that is the kind of service you will get at a fairly consistent level in Wales, across most health that boards I can think of.

Pulmonary rehab is an interesting one. We had a fantastic service—OT, physio-led service in Swansea bay, where we were delivering a pulmonary rehab in the community, which is really good. They've merged with Cwm Taf now, and there are real struggles to develop that service in Cwm Taf. So, you've got excellent services for Bridgend and not-so-great services for Cwm Taf, and that is an evidence-based, award-winning service that should be spread out, and they can't spread it out in the one health board. It's exasperating to our members when that happens. But, again, pulmonary rehab is a major problem in Wales. Lots of people have chronic obstructive pulmonary disease, lots of breathing problems—there are evidence-based interventions that should really be upscaled.

Any other examples at all? I'm liking this question.

Again, cancer rehab in Velindre, OTs and physios within neuro cancer.

They do loads of preventative therapy when people have got neuro cancer, brain sort of stuff, so, again, its early intervention. The earlier you get in, and the evidence, in relation to this, with patients—the sooner they see a rehab professional, the better their outcomes are. That's absolutely seen in evidence throughout the world, that is. So, it's that—. As soon as someone's admitted or seen a professional, as quickly as they can see a rehab professional, there's evidence, then, to suggest you get fewer hospital admissions and the person is able to live their life better. That's the issue. 

11:20

Is something happening—? Is there a particular programme or pilot that's running there? 

Another award-winning service, which is really good. We've got Stay well@home in Cwm Taf, and in Swansea, OTs and physios—OTs with a connection to Rhondda Cynon Taf, keeping people out of hospital. If it wasn't for them, God knows how busy they would be. Just look at the Bevan exemplars. The Bevan Commission has loads of exemplars and lots of them are AHP exemplars. 

Yes. You mentioned a few prehab ones there. I think Welsh Government has been quite good at emphasising the need for prehab because it does have a—. We talk about rehab after the operation, and that's kind of now in people's minds as something they expect, but the preparation for an operation makes a massive difference to people's outcomes at the end. The complications are reduced. And Dai's mentioned there a couple of examples that I think work really well, and it has helped bring waiting lists down, or to be less high than they would be otherwise. 

Are there any pilots or projects such as you just outlined that have taken place that haven't been that successful? 

I don't know. I'd just say a lot of them are very similar and they're not—. We've learnt it already in some cases, and you think, actually, it's clearly to have access—. Access to funding was the reason it was done that way. 

There are lots of different projects and pilots that are taking place, and there are examples of where it's working well and where it's working really well. Who's analysing so that the very best projects and pilots—? Who's doing the work on that to think, 'This is something we need to be running right across Wales'? Who's doing that work? 

Yes, so there's a group going on. They're reviewing the regional integration fund at the moment, so there are lots of communities of practice and there's research by Swansea University. And their plan is to look at the five best models in the next five years.  

So, they've got communities of practice on each of the six goals areas. I know we're involved in that and some of our members and stuff. They're actually great, do you know what I mean? But, again, it's almost like you're re-proving something that's already proven, so why don't we just get on and do it, to be perfectly honest? 

There have been some really good appointments in Healthcare Inspectorate Wales and in Welsh Government, key APs, members of ours who are now leading on rehab nationally, leading on learning. These are recent appointments in the last couple of years, and we're starting to see the fruition of that, again, with national standards in place. So, I think those are steps forward, and hopefully those people, more appointments and larger teams in these organisations, particularly HIW and Welsh Government itself, can really push that national learning. I think that's where it should be, from my point of view. 

And just a positive thing—I don't mean to be negative—there are loads of good services happening, brilliant. Actually, we are quite a forerunner in Britain in relation to primary care. We've got lots of OTs and physios, and lots of our colleagues from England, Scotland and Northern Ireland are looking at our models in Wales. What Welsh Government's got to do is make sure their models are permanent, because we are a bit of an envy of the rest of the UK in relation to OT delivery in GP surgeries. It's very small and not every area of Wales has got it, but that is a really positive thing about Wales, about our GPs. 

Thank you very much. Just to check, Chair, am I doing primary and—? Sections 11 and 12, or just 12? 

I think I've covered my areas, so cover the secondary and tertiary prevention, please, yes. 

Excellent. Okay, thank you very much. Right, so I'm going to ask some questions now about secondary and tertiary prevention. So, to start with, and we heard this this morning in our evidence session, older people are more at risk of chronic conditions and experiencing frailty. How do you think that services should be designed to support older people to maximise quality of life and build resilience? Are you aware of any examples of best service? Just to say, we heard from Dr Christmas as well this morning, and she was saying that what she's finding is that older people she sees are feeling very guilty because they feel like they're a burden, and it's not so much—. In a way, it should be more like a celebration that they are living longer and better with chronic conditions, but maybe that kind of wraparound service isn't there. Your thoughts on that.

11:25

So, it's that 'no wrong door' principle, I think, is what we go back to. Patients shouldn't feel guilty, whether they're going to see their healthcare professional, or however they present to the service. But we've been traditionally based around hospitals as a model, people get referred for an appointment out of hospital, and it takes a lot out of people's personal life to go and do that. It's all a big event, and it's quite intensive for staffing, and quite costly. Really, the future is in that community provision, so having services wrapped around in the community so people feel that it's not as big a deal, really, as going into hospital. If you're going into the leisure centre where there happens to be a multidisciplinary team, the social services and local authority services are there, and you can deal with everything at once, I think the guilt that the patient might feel will be lessened. It's more centred to them, it's in their community, and I think we’ve talked about the right to rehab as a principle. People should feel that they have that right and not feel guilty about asking for those services.

Monmouthshire integrated services is an excellent example—the connection between Aneurin Bevan and Monmouthshire council. Their services are based on that ‘what matters’ conversation, which is in statute—it’s the cornerstone of the Social Services and Well-being (Wales) Act 2014. So, if you base your service around that, it is about co-production, understanding what the person needs, and having that conversation. There are issues there, though. Where our members have those ‘what matters’ conversations, our members do work on the edge, and there are often arguments with resource about what we deliver. I know Monmouthshire got inspected, and it was a bit of a criticism of, actually, the OTs, and how they delivered the services, because our legislation in relation to housing is very, very rigid, and predates the Assembly. Someone’s quality of life is not just getting on and off the toilet and on and off the bed; it’s to do with stuff like, if you love gardening, it’s being able to go to the garden, and do your gardening, and they try to do interventions that get people out and about, which they’ve been criticised for. But if you keep getting people out and about, that reduces muscle wastage, it improves mental health, so the policy, the legislation, says, the ‘what matters’ conversation—the reality is still quite rigid, and our members really, really fight against that.

I was speaking to someone from one of our community resource teams yesterday in south Wales, and they do get really frustrated that they can’t actually have their ‘what matters’ conversations, which, again, really isn’t great. There’s a very risk-averse culture in some health boards where they just about get that person to hospital, and make sure they’re safe in and out of bed, and that is it. So, there needs to be—. Again, there’s been a review by Swansea University about how we implement the social services and well-being Act, and there are some really good recommendations there that we should enact—fantastic legislation, not so good on delivery at the moment, unfortunately.

Yes, that's come through a number of times, but thank you for raising that. And then a question to you, Mr Davies, is—your paper says that children and young people are presenting with more complex physical, learning and mental health needs, in part due to delayed support and recognition, and missed opportunities during the pandemic. Could you expand on this and what action should be taken to prevent these difficulties escalating?

At the very start, when you're a premature baby, and you go into the special need maternity unit, you should have access to occupational therapy, physiotherapy, and speech and language therapy. In England most babies have access to that now, and the evidence is spectacular about how OTs help the parents manage their children, and that reduction of stress on that child reduces longer term intervention markedly. So, every special baby unit in Wales should have AHP involvement. Again, we brought this up with the relevant people, and they all admit it, but then they tell us there's no money for it. So, a bit of respect for the professions that can deliver, okay? So, can we have that?

Flying Start—again, speech and language therapy can do some fantastic things in Flying Start for communication. Again, it's in policy, there should be a speech and language therapist, and there isn't. They haven't had any uptake in speech and language therapy, so that's another thing that you can look at.

Our connection to schools are, again—. I'm not sick of talking about pilots, but we've got a good pilot in Neath Port Talbot. We've got an occupational therapist who works with Neath Port Talbot council, and he's working with the teachers in all of the schools in Neath Port Talbot and training them in neurodiverse interventions, because that's a big part of what—. We know we're not going to be able to have an OT in every school; the model needs to be OTs and physiotherapists working with schools, and getting the teachers to help. I talked about this in another committee, actually, because the children's committee are doing an investigation into disability as well, so, I think, maybe have a look at that as well; we've got lots of evidence in relation to that.

But, schools and teachers need access to OTs, and one of the big problems with schools at the moment is that they're getting rid of lots of the teaching assistants. When we work with schools, teaching assistants are a massive ally to us; they deliver lots of the interventions in schools, and that's been hugely problematic as schools reduce the budget and are taking away teaching assistants. But, again, there's loads of evidence about, actually, intervening early being such an important thing. So, OTs helping kids—. Some kids didn't hold a pen for two years, which is the way it is; my children have had issues because of that too. Getting OTs to work with schools is such a good model, and, again, it happens in one council; it should happen in all councils.

11:30

Okay, thank you. Also, I went to visit the Cerebral Palsy Cymru head office in Cardiff a couple of weeks ago, and, again, they do a lot of early intervention work. Do you know much about that and the outcomes from that as well?

We've been working together on, really, the shortage of the neonatal allied health professionals needed to deal with that as early on as possible. As Dai said, in England, they've pumped money into addressing that issue specifically from a national level. You know, the system is different in Wales, in that the health boards are independent, and there's a bit of a discussion around how you mandate something, but the principle, I think, is that we do need that money pumped in early into that early intervention, particularly around conditions like cerebral palsy, because the outcomes—. If you get in early, the evidence is that you can resolve a lot of issues, it costs less money for the NHS and it gives somebody a better quality of life. Early on is a no-brainer. 

What would really help us, as a royal college, is just data. So, if you put in a freedom of information request to ask how many children's OTs there are, you won't get an answer; it'll just be the OTs. So, if you could identify where our children's OTs were, that would help us. Obviously, we have a good connection with them, but for workforce planning, if we had that difference of, actually, 'These are the OTs who work in stroke care, these are the OTs who work in children's care', that would help planning. We're just a big blob at the moment. You've heard this countless times about data, but data is such a massive issue. We could plan better, then.

It absolutely is. Well, to be honest, one of the things that Cerebral Palsy Cymru have raised is that they can't actually access the data, because all of the health boards have different data sets, to tell you how many children in Wales have it and are being treated with it.

But it does bring me on to my question, which I asked earlier on in a previous session as well, around the third sector and peer support groups. It does seem like a lot of the services that were in hospitals in particular, but also in the community, that were providing—. I've got a dementia hub where I am, I've got free classes for people with Parkinson's to go and do exercise—lots of these kinds of things. That funding seems to be being sucked away as well, and I was just wondering what your thoughts are on that and what the relationship is between what you're doing and the third sector and organisations.

OT mental health is a major issue, it really is. When I was in practice, I relied on Mind, Gofal and Hafal and all of those. They help the statutory services; they used to send people off for welfare checks with Mind and stuff. Obviously, we connect with the third sector quite a bit in the policy world; with the Welsh NHS Confederation, they've got a social care and a third sector group, and we work quite closely. The relationship with Care & Repair is something special in certain areas, but that funding needs to be—. They really do support the statutory services. But, again, about social prescribing, there's nothing to prescribe if there's nothing there to prescribe to. They are invaluable for us in occupational therapy and we'll always advocate for the third sector.

Yes, I agree completely. We've worked closely with the third sector. The Right to Rehab campaign we've had in Wales is a mixture of professional bodies and the third sector providing their advice to us from a policy perspective. But I'd say the CSP—. I work particularly closely with Versus Arthritis. If I had to give anybody a shout out, their knowledge about orthopaedics, when we had the orthopaedic waiting lists post pandemic, and how they want to offer peer-to-peer support, their helpline, that is invaluable for patients, and physiotherapists on the ground were making referrals to those services. Without them, it makes the life of a professional practitioner in the NHS much more difficult.

11:35

You have a 'what matters' conversation, that could be it. We want fewer people seeing us, if you know what I mean. If we could have time at the start of the journey, if we could see them really early and have that 'what matters' conversation, we might have to intervene here and there, but then we can go, 'Here's a social prescriber, go and see Care & Repair, go and see that.' That would be a good way of working. But, too often, they don't have time when they first see them, and then the next time they see them they're in need, because they've fallen over or they've had a massive breakdown.

Exactly; it's acute. I agree. Thank you very much, and thank you, Chair. 

As we draw our session to an end, are there any key recommendations—? Obviously there are quite a few that have been brought forward during the course of this session, but are there any key recommendations you think we should be making to the Welsh Government?

I have a couple. So, regional partnership boards, we've discussed. I think there should be somebody on that board who is appointed for rehab, with responsibility for integrating and making sure that rehab is seen as an important issue across local authorities and health, and be in charge of that integration. So, the need for voices and leadership at that sort of level is a common theme, I think, across Wales.

You've got health and you've got people representing health, they tend to be nursing or medical, and you've got people from the local authorities, who are looking at social care, and while the board itself might be integrated, they're still separate voices a lot of the time. So, I think, someone who works in the service that needs to be integrated, with that responsibility for rehab, would be probably a key one. I think that would be something I'd recommend.

We've mentioned the national accountability through the NHS exec. Something similar: who's responsible for rehab nationally on the NHS executive once it's set up and fully going? So, some clarity on that.

I think it would be a good idea if we had a rehab lead in every hospital to deliver those standards that have been put in place last year, so there's someone in charge of making sure—. Because we have discharge leads, you said to me, Dai. There's a discharge lead in every hospital, but there's no rehab lead. I know they're connected, but somebody with responsibility for delivering rehab in the hospital and then making sure that it's integrated into the community would be something I'd recommend.