National Assembly for Wales

Good morning. Welcome to the Health and Social Care Committee meeting today. Thank you all for attending. Can I just note that the meeting is bilingual and there is simultaneous translation from Welsh to English available? Can I ask Members, are there any declarations of interest? No. Okay. If anybody finds one on the way through the meeting, please declare it and we will record that.

So, our main item today is to continue with our—. Well, actually, to take our first formal evidence session to help inform our inquiry into the future of general practice in Wales. I'm really pleased to have such distinguished guests with us today. And perhaps I could ask you all to introduce yourselves for the record. Perhaps, Rowena, would you like to—?

Hello. Yes. I'm Rowena Christmas, I'm a general practitioner from Monmouthshire and I'm chair of the Royal College of General Practitioners Cymru Wales.

Thank you.

Hi. I'm Tom Kneale. I'm a GP in Ruthin in north Wales, and I've also recently been the chair of the RCGP in north Wales. I'm also a senior clinical lecturer in the north Wales medical school.

Thank you.

I'm Gareth Oelmann. I'm a GP in Cwmbran, Gwent, and chair of the General Practitioners Committee Wales.

Thank you, Gareth.

I'm Ian Harris, I'm a GP in Brackla in Bridgend, and I'm deputy chair of GPC Wales.

Great. Thank you so much for your time. I know how busy a people you are, and to give up a morning like this is quite a big ask for you; I know that. But it's so fundamental, hearing from practitioners like yourselves, to help us shape our inquiry and to get under the nuts and bolts of things a little bit more, really. And, hopefully, this will be beneficial—. Well, it will be very beneficial for us, but hopefully it will be beneficial for you to be able to share some of your thinking. We have about an hour and a half, if that's still okay for you. We've got several questions, but, you know, not too many. Please don't feel that you all need to speak on the same question, but if you feel that there are points that you might want to add some extra value to, please do so, and I'll bring you in whenever needed.

I'll kick off, really. We've got several sections we want to focus on. I wanted to really kick off by looking at funding and contracts because I know that's a real issue. And I suppose if I could start by trying to understand what steps we could take to increase investment in general practice in Wales, especially in the light of the sustained pressure on secondary care, and I just wondered how this could be achieved. How could we achieve that further investment into our general practice in a way that supports rather than compromises acute care services? Anybody like to have a go? Yes, Gareth.

Maybe contractually, it probably falls to me to start things off, and it's a very important question; I think it's the nub of general practice and the future. You will all have seen the Save our Surgeries campaign, where we've laid out and laid bare some of the history of funding from NHS Wales. Of course, we understand that it's a limited pot, a devolved pot, that over recent years has seen a decline in the proportion of funding into general practice. And I'll say 'general practice', and I suppose there's the general medical services contract within general practice as a whole, but the funding into general practice has gone from previously being 8.7 per cent down to, at last estimate, about 6.01 per cent. That's not much of an estimate, that's quite accurate, isn't it? But that's where we're at now. So, that's the proportion of NHS Wales spend that has been dedicated to general practice.

And then we need to consider what the value that the patients and the taxpayers in Wales are getting from that; the volume of work that flows through what I would say is the bedrock of the NHS, the foundation stone, et cetera. That decline in the proportion of funding has come at the detriment of practice viability, sustainability, and you'll all have seen the figures within the last 10 years of how 100 practices have returned their contracts, et cetera. There are many reasons for that, and we've outlined many of those over recent times, but it all comes down to—I'll get it off my chest early—workforce, workload and well-being.

If we can see that the workforce is decreasing, the workload is going up, becoming more complicated, more complex, there's a transfer of a shift left of workload, then the resource needs to follow the cost. What we can see quite clearly from the graph over time is that the prioritisation, the political prioritisation, has, for lots of reasons, moved the other way with regard to the funding and the resource. If we could see a return to previous funding quanta, amounts, proportions of the NHS Wales spend, the prioritisation back towards general practice and what it can do, then I think we would start to see a more sustainable general practice, and a general practice that could provide services close to home and services that the patients need in a timely fashion. I'll stop there, otherwise I could go on for the remaining hour and a half, I suppose.

That's good. Ian and then Rowena.

I'd just like to add to that that there needs to be a policy decision here. You spoke about the pressure on acute services. They're very real and we see them day to day in our conversations with patients, having to apologise to our patients on behalf of the NHS a lot of the time for the care they're receiving and the delays in treatment. We believe that general practice can be part of the solution to that, but certainly we can't do more with less. Over the years, we've been asked to do more and more and more with a reducing proportion of the NHS spend. Our view is that there needs to be a policy decision to invest in the preventive agenda and invest in general practice, because we feel that will offload the acute sector as well. If people are healthier and we can maintain their health in the community, we're less likely to put that pressure on the acute care sector. 

So, the preventative agenda is suffering now. 

Absolutely.

It's diminishing, is it? Rowena.

I'm just going to echo what the guys have said. We can do even more than we do. At the moment, we're seeing 90 per cent of patient contact in primary care, but we're firefighting all of the time because of that budget being reduced all the time. If we had a little bit more of that sliver of the budget, we'd be doing more preventive work. We'd be able to offer probably better continuity of care. If you see the same GP regularly, you're much less likely to be referred to secondary care. You're much less likely to present as an emergency at the hospital. So, a little bit more for us will take the pressure off secondary care.

What's interesting—. I'm chair of the Academy of Medical Royal Colleges Wales, and I say this to a table like this full of consultants from secondary care: we need more of the proportion of the budget. Those consultants sit around the table, nodding their heads and acknowledging that what we're asking for is right, and they can see that it will take the pressure off them. So, we've only got one pot of money. We need to be courageous with it, take it away from the bottomless pit of the hospitals and just put a little bit more towards us in primary care, and you will see the difference. You will see the pressure being relieved from secondary care.

Thank you, Rowena. Lesley, do you want come in?

Yes, thank you. Rowena, we hear this a lot: with the number of appointments in primary care and the number of appointments in secondary care, the budget is completely the opposite. It used to be 90 per cent and 10 per cent. I think it's increased now to about 93 per cent, or would you say it's higher than that even?

It feels higher.

It feels higher. I hear what you're saying about consultants nodding their heads. So, what do you think is the real barrier to not reversing that funding pot to fit the way that people access the health service?

Is it fear of the narrative? The headlines show ambulances queued up outside hospitals. That's the sort of thing that makes the headlines, whereas the quiet, saving lives in slow motion that we do in primary care is much less headline grabbing and perhaps less appealing to people who are desperately trying to get the approval of their voters. 

So, on the reverse side of that, in accident and emergency departments, I believe, certainly—unfortunately, I've had a couple of visits to A&E with a relative—there are people who should go to the GP. The relative I took should have gone to the GP. I couldn't get her into the GP, so we had no choice but to go to A&E. She ended up being admitted, so it was probably the right thing in that case. But so many people there should see their GP, so I don't understand why the health boards don't accept that that budget needs to be reversed.

Lesley, you've talked about barriers, or you've asked about barriers, and I think that, strategically, the primary care voice at a health board level, I think, is lacking. There's probably, because of the lack of voice, a blind spot across the health boards with regard to the need to have a shift, to be bold, as Rowena said, moving funding, de-prioritising, changing the priority, changing the strategy. And I suppose in looking for short-term wins, having to balance budgets by the end of the year, there's always—. It's like Welsh rugby looking for the next win, isn't it? Let's not worry about the next five years and the preventative agenda or the next election; let's focus on the budget, let's deal with the problem that is apparent now. I think we've seen an example of this with regard to the funding that has flowed from the Treasury budget last autumn, and the changes in national insurance, et cetera, and the prioritisation of that money into waiting list initiatives, funding for waiting lists, when actually a small proportion of that money, even if it was 6 per cent of that money—I'm asking for 8.7 per cent, I'm asking for 11 per cent, et cetera, as an aspiration—that's a small quantum but would make an enormous difference when you look at the proportion of NHS Wales spend.

So, maybe there are barriers at health board level, maybe there are political barriers, and with regard to imperatives, prioritisation of the pot, and what can be done with that money. So, I think the barriers are at lots of different levels.

Thank you. 

So, primary care you don't feel has a strong enough voice around the health board table. Should we be recommending something to strengthen that? 

I'd go further, Peter, if I'm being honest. I think it's on a wider level. It's a policy decision that the focus is on the shiny bit of the healthcare service, if you like—the hospital end—and that isn't just at health board level; I believe it's a policy decision at governmental level currently that needs to change. We're making that argument, but it's trying to turn around a supertanker, because the direction of travel with funding and policy over the years has been to relatively de-fund general practice and primary care in favour of other sectors. I think you could probably make the same case about social care, couldn't you? So, they're less shiny and enticing areas of healthcare. You don't have fantastic new innovations and new drugs and interventions. But they're so vital to the health of the nation that they tend to be denuded in favour of those other areas. So, it isn't just at health board level, but it definitely is at health board level as well.

Thank you for that. Just for your observations, if we want to get more money into primary care—and I absolutely agree; I've met practices where the preventative agenda is getting eroded and services that were offered before can no longer be offered—where do you think we should perhaps be disinvesting in—this is such a challenging question for you—to be able to divert more money into primary care or into GP contracts or whatever? Is there something obvious that the system recognises could change?

I think there needs to be a planned strategy for moving the funding streams. I recognise it can't just happen overnight without robbing Peter to pay Paul and creating issues in another sector, so there needs to be a strategy, there needs to be a plan. But we talk about the preventative agenda; I suppose obesity, diabetes, diabetes from obesity, and what have you. We're not going to see immediate gains by the end of the next session if there is that strategic shift, but it is, as I say, looking forward and being strategic about moving that money to the preventative agenda: health promotion, weight management, obesity management. I think it's very topical, and I don't want to go down the nuance of weight loss drugs and injections, et cetera, but we do know that the National Institute for Health and Care Excellence has recommended—and England have taken that on board—but Welsh Government have decided to await a further review and a further review, et cetera, with regard to the prioritisation.

So, it's that sort of example. I'm not saying that's the only focus that we would have or the only option, et cetera, but moving that creates—I'll use that as the example—something that's close to home, something that's governed, something that's safe, something that's linked with the holistic care, the continuity of care, that general practice provides. And I think that that's some of the benefits that Rowena is making of how general practice can deliver on these agendas over time. But it is a strategy, not a short-term win and a fix.

Can I bring Rowena in? And then I'll come back to Ian.

I think there are probably many areas where you could safely take money out of secondary care without having a catastrophic impact on the well-being of patients. Just, for instance, patients waiting for operations. There's an initiative where nurses from the hospitals will phone the patients and encourage them to optimise their weight or optimise their blood pressure or stop smoking—really useful, healthy things. The idea is that it's preventative healthcare and also to make them healthier for their operation. But actually, the patients don't know the nurse who's calling, the nurse doesn't know the patients, they're often not there. Whereas, just from my perspective, if you put that money into my practice for my patients waiting for an operation and my bossy Scottish nurse, Simone, got on the phone and spoke to them, I think the outcomes would probably be better and we would be able to do more with that money and follow those patients up. You would just catch them at that moment of thinking they might give up smoking and then we'll take that forward with other preventive work. Because GPs and their teams know their patients, they can really make a difference when you get that key opportunity.

That's a good point. Ian, do you want to come in on this?

I was going to make the point that in some respects, it isn't so much a case of where do you defund, it's where do you put your funding. Because we've seen recently with the focus on waiting lists—which is very real and very necessary—that hundreds of millions of pounds have been allocated to waiting list management. What you find is that secondary care will increase activity and, in a very expensive way, reduce those waiting lists, whereas, actually, there are initiatives that you could invest in at general practice level that would have a very real effect on bringing waiting lists down.

There are lots of people on waiting lists who are almost stranded on waiting lists. I know of a family member who wanted to come off a waiting list, but couldn't find a way to come off. And that person stays on that waiting list, lengthening the time somebody else needs to get to their necessary treatment. There are initiatives that you could fund in general practice that would help to reduce those waiting lists and bring treatment forward for those who really do need it.

That's almost like magical thinking at a health board level, because that's not the way they function. They're allocated pots of money and they will spend it on the bits of the system that they're used to spending it on. There isn't any policy decision being made, even at national level, to say, 'We direct this funding here because we think this is where it's going to have the most impact on the system and for patients.'

And, as I said, social care probably are in the same boat as us in that, in that they're not going to get the focus they deserve, even though if you look at hospital length of stay, a lot of that is based around the inability to access care out of hospital. So people need to start thinking about the 'why' and then directing the funding to 'where'.

Thank you for that. We've spent a bit of time on that, but I think it's a fundamental strand. Obviously, linked to that, we hear—. I've heard a lot about it; I never even knew what the Carr-Hill formula was until recently, and I'm hearing more and more about it. I just wondered what your positions are on Carr-Hill and what changes you think perhaps could be considered to make it more effective. And also, we're hearing a lot about it, but what discussions are actually going on with the Government to help them see that it might need changing?

Again, we recognise that the funding formula is only part of the funding question, because we actually need to look at the quantum of the pot. Because what the funding formula does is allocate the total amount et cetera. I will keep on coming back to increasing the total pot et cetera, because there are many elements of the Carr-Hill formula that distribute the funding through the global sum on a weighted list size reflecting age, sex, illness, local costs et cetera.

We recognise that there are elements within the funding formula that are outdated. This was a formula created in the 1990s, based upon data from the 1990s et cetera, with regard to mortality rates and some of the demography, and of course, we all know that Wales has changed. And so, there does need to be a reflection. There are elements within the Carr-Hill formula that were tinkered with from the original academic proposals, for political decisions, during negotiations back in—. Well, you can all work out who was in charge in 2004 at a UK level. So, there are elements that aren't reflected and not addressed well.

You'll have heard from Deep End practices about deprivation. You'll have heard from practices in more rural areas that it doesn't reflect the changes in morbidity, mortality, illness within their areas—rural practices, multi-site practices. So, there are elements there. One of your direct questions is what is happening through our current contract negotiations, which are ongoing. Part of the mandate is to look at a review of the funding allocations, and I would like to say, if it was easy to fix we would have done it, et cetera. So, there are complexities. I go back to the original point about the quantum, because a funding allocation formula, by its very nature, is a zero-sum game.

Yes. It's how you share it out.

It's how it's shared out—how it's shared out equitably, fairly, but if we make any changes to that or any recommendations, then it has to be done on an evidenced, modelled, reviewed basis. If we just make simple, quick-fix changes, there will be losers as much as there are winners, and that will equally defund other practices, destabilise other practices, and one thing at a national level that we cannot afford to do is to have unintended consequences. 

You're making those messages clear to the Government. Are the Government listening and are they recognising all the sensitivities around it? Will we see an improved formula that recognises all of the elements? Because I know there have been concerns about how does it match population growth around a practice and things like that.

I wouldn't like to predict the outcome of negotiations in this room, unless anybody has got something that they'd like to tell me, but actually the call is to have a review, and we know that in Scotland, a number of years ago, they underwent a fundamental root-and-branch review et cetera, and I think the first stage before committing to a changed formula is that there needs to be a review et cetera. There is a commitment across all sides of the tripartite table. It sounds very lopsided, doesn't it, a three-sided table, but there is a commitment for a review in real time, and I think everybody is absolutely aligned to that—to the need for that. We know that there are equally calls in England for a review of the Carr-Hill formula, so whether that needs to be a multination review, reflecting the fact that we are devolved in Wales and have different elements. So, 'yes' is the answer.

Thank you for that. Did you want to come in?

Could I add just briefly? There is a lot of clamour around Carr-Hill and around allocation formulas, and it is understandable—the formula is out of date and we would like to review it—but when you start hearing, 'The formula doesn't work for me' in an urban practice with a young population, when you're hearing that it doesn't work for you in an ageing population in a retirement seaside town, when you hear it doesn't work in a rural multi-site practice, what you're starting to hear is, 'Well, perhaps it isn't the formula; perhaps it's the quantum'. So, it's ripe for review and we need to make sure that it does work for the twenty-first century, but if you're just going to move the deckchairs around on the Titanic with that formula, you're going to do more harm than good.

The formula can only be tinkered with to create more fairness, but the quantum is the key message—we get that, yes. Okay, I'm going to move on—

Can I just come back to one point, though, Peter? In the fundamental review of the formula, what we need to look at potentially is something that allocates funding upon need, not workload. Because what Carr-Hill actually did was look at workload and proxy markers et cetera, but if we take deprivation as an example in areas—and we know that there are plenty of areas in Wales that are deprived, and practices that work in those deprived areas—then you can give more funding, but we need to actually look at the fundamentals of thinking about the inverse care law. I've got experts on the inverse care law sitting next to me, but we need to look at the need et cetera, because we could actually unearth a lot of unmet needs. So, we can put funding into areas, but maybe we need to look at targeted schemes that can actually focus upon deprivation, which sit outside of the Carr-Hill formula, so that we can actually address some of the local nuances and the local needs. We might not be able to address that with a national formula, but there are elements that need to be addressed.

Thanks for that. That was really helpful.

Can I ask a question—

Oh yes, sorry, Joyce.

—on that point you've just made? Couldn't those decisions be made by the local health board currently?

Is that a rhetorical question, Joyce, or do you want me to—? 

No, it's a genuine question. If you have recognised need in the way you've just described, do you need to change your whole formula, or do you need to look at the funding at the local level?

I think that the answer is 'both'. Health boards are given an allocation, and it goes back to the previous question about the voice of general practice, the accountability et cetera, and the prioritisation of where that quantum is spent. And if the needs of that locality are that there needs to be more preventative work—more work at a local level, get into the grass roots—then the health boards have an opportunity to do that under current regulations and directions, yes.

It is hard to measure need, though. You could take a single patient from an affluent practice who's had a private Bupa medical that's thrown up something on an ECG recording that isn't of great concern, but it results in him having three appointments with his GP because he wants to understand it, have more tests. None of that's actually changing his outcomes, but it's work for the GP. Whereas your patient from a much more deprived area who's got cardiovascular disease that's unrecognised, because he's getting some chest pain, but doesn't go to the doctors, because he hasn't got time and can't get an appointment, because they're so overworked in that practice—you would measure the practice that has had three appointments for the wealthier person with little health pathology as having more work than the deprived practice. So, it's incredibly difficult to pull these challenges out. The GP in the more affluent practice is still needing to see that patient who's asking for an appointment, and you wouldn't say, 'Oh, I can't see you because I think that's probably just a private test that hasn't shown anything significant'. So, it is difficult. It's not a straightforward problem that the health board can just fix, I don't think, easily.

Okay, thanks for that. Just exploring contracts, at the moment you've got annual contracts. Is that the best model to support long-term planning, or should we be looking to move to multi-year contracts? Would that be more helpful, and how would we get there?

I guess what you're alluding to is the ability to plan services based on the timescales in which we're agreeing contracts currently, and I think we'd all recognise that you can't do that based on the timescales in which we have been agreeing contracts. Multi-year contracts are quite seductive because they give you that ability to plan on a longer term basis, but they do have their drawbacks as well, based on things like unforeseen circumstances, unexpected costs and changes in the landscape that happen during that period. So as long as you're allowing for those to happen, I don't think we would be averse to having a cycle that allowed you to plan on a longer term basis.

The real problem with annual contracts is the fact that we agreed last year's contract in January 2025 for something that began in April 2024. How can you deliver anything for 2024-25 in that timescale? We would assert that the negotiations should be happening and complete before April each financial year, if they're on an annual basis, and this is something we've pushed for recurrently. The argument tends to be that there's a conflation between the announcement by the Review Body on Doctors and Dentists Remuneration and then the funding envelope and then we can't start discussions until that point. We would argue very clearly that that's a false argument, that you can decouple contractual negotiations and what general practice is resourced to do from that discussion over GP and staff pay, and look at that in a separate element, because it just gets in the way of us delivering services.

Yes, yes. Sorry, did you—

Can I just add to that? If the decoupling of pay awards for GPs and for our staff—. And I think that's what we can't ignore here, and I go back to my third 'w' about 'well-being': it doesn't do anything for the morale of those who are within our employ to not be seeing a pay award that their peers, equivalents, in the rest of the NHS are already seeing, et cetera. So, a decoupling of pay for GPs and staff expenses. Annual contract negotiations are problematic, as Ian said, because just like a fixed rate mortgage, then you are beholden to the vagaries of inflation with regard to expenses and unforeseen circumstances, et cetera. So, we've seen a five-year deal in England that left practices contractually at a 2 per cent increase year on year, which created their own problems. So, we wouldn't look to try and replicate multi-year contractual deals, but a multi-year funding strategy is a much more nuanced way to address some of the issues, to move the resource restoration argument and shifting left, and resources following the cost, et cetera. So, a strategy for multi-year sort of funding elements, but maybe not a multi-year contractual deal, which is going to come—. But decoupling all of those elements would enable that, and actually one of the barriers—. Ian's talked about the delays in having a contractual deal, but within—. I've just talked about the pay element of it, but even when one looks at this year's mandate, the tripartite mandate that we would be negotiating, then we can't actually deliver anything because of the big-bang approach to contract negotiations, et cetera. So, there should be lots more business as usual, which would fit within a funding strategy that allows work to go on throughout the year, not reliant upon an all-or-nothing agreement.

Thank you for that. I'll bring Rowena in, and then I'll bring you in, Ian.

Just very quickly, Ian, you mentioned the time lapse; is that usual? Does that happen year on year?

Unfortunately, they always start late, and like I said—again, I'll say the words 'policy decision' again—it's always a policy decision that the negotiations can't start until DDRB has been announced, and as we know, DDRB doesn't announce in advance of the financial year, so you're always on the back foot and we're always working in arrears. And then, when you end up with difficult years like we had last year, where we didn't end up agreeing until after we'd had a referendum rejecting the initial deal that the Welsh Government had put to us, that you end up with the weird situation that you agree it in January, it takes another couple of months to be put in statute through directions, it takes time to go through the statement of fees and entitlements to end up at practice level, so practices were getting the funding in February/March for a deal that began in April. And when is the next deal due to start? The next month. It doesn't make any sense. And I think we have to get away from that sort of thinking if we're going to plan on a better cycle in Wales. As Gareth said, multi-year contracts are potentially problematic, but strategies that allow you to fund and plan services better would be most welcome.

Thank you. Rowena.

Yes, just speaking as a GP partner who's not part of the contract negotiations, it's incredibly difficult to plan. And, for well-being, we took on a GP this year for a 12-month contract, because we didn't know what the outcome of the contract negotiations would be. That's not great for that GP; it's not great for the patients that she sees regularly; it's not great for us in terms of knowing what's going to be happening. So, it's really tricky, I think. 

I'd say it's exceptionally difficult, as a working GP, to predict what services I can provide within my practice, if I don't know what funding is coming in. We don't know whether we can replace our boiler; we don't know if we can afford another salaried GP, and this is an exceptionally difficult circumstance to work in, day in, day out.

Yes. Okay, thanks. A last quick question from me then as I'm conscious that we've used quite a lot of time up on this section: I just wanted to look briefly at cluster funding and what mechanisms might be in place to assess the impact of primary care cluster funding. How could we strengthen that cluster performance by creating more accountability or whatever? I don't know if you have any views on cluster funding. Tom.

I've been a deputy cluster lead before, and it's an exceptionally rewarding job, but it was very difficult to get forward funding, even for successful cluster projects. So, your concept is to provide funding for us to create innovative projects and then to get forward funding after that, but what we find is that the forward funding just isn't forthcoming. We've got data and evidence for really good cluster projects, for example, care home advanced nurse practitioners, and we just can't get the forward funding. So, if that could be freed up, and again, recognition of GP leadership is part of that within health boards, I think. So, if we could do that, that would be fantastic.

Yes, thank you, Tom. Ian.

It feels like groundhog day to me, because I sat in an inquiry similar to this in the Senedd in 2017, where Phil White and I gave evidence, saying exactly the same thing. Unfortunately, we've seen no improvement in that, and if anything, the processes of trying to release funding for initiatives are even more clogged than they were back in the day, and what we're seeing is there's probably more health board interference in that. It feels to me that the cluster project is completely encased in concrete at the minute and going nowhere. And unless that changes and unless the thinking process and the freedom to innovate and to mainstream successful things are enabled very quickly, I think we're almost at a point where the enthusiasm for engaging with clusters is gone.

Okay. Thanks. Rowena.

Yes, I'd agree with that. I can think of so many projects that have been really exciting and have gone well, and then the funding hasn't been continued, that the GP leaders, who are behind them, become really demoralised and cynical and fed up. And you lose all of the positivity and the quest for improvement when you get that response, so it's quite damaging.

Yes. Thanks, that's really helpful. It sounds like it's a good model, but without sustainability, it's being wasted or lost.

Could I just expand upon your question of evaluation and appropriate evaluation of funding, et cetera? I would also add to your question that you could equally ask the same question about urgent primary care centres and the funding and the value. And I'm on record in the national primary care board in asking for the evaluation, and there is little. It's public money and there should be evaluations of the projects before. On the floor of the Senedd, people are willing to stand up and say, 'This is the way we save primary care'; without any evaluation, it's a very difficult claim to substantiate.

Yes. Thank you. I'm going to move us on now, and, Joyce, would you like to—?

I will. I'm going to ask about models of practice, and to compare the independent contractor model for general practice in Wales with the health board managed practices, and for your thinking about value for money and patient outcomes, because, ultimately, that's what we're talking about.

Can I come in on that? It's very hard to get the data on health board managed practices, but the BMA undertook a freedom of information request through all the health boards a few years ago to look at the direct and indirect costs of running managed practices. The baseline level that we found was that a health board managed practice costs at least 30 per cent more to run per capita than a GMS contracted practice.

We don't have any in our area. I'm in Cwm Taf. Tom would probably have more lived experience being in north Wales, where there is a much bigger proliferation of health board managed practices. So, the services available and the lived experience of living next door to or being a patient in that practice, I'll defer to Tom on that, because he's probably more of an expert if I'm being honest.

But what we do know is that the reports that we get back are that the services tend not to be as all encompassing as they are in a GMS contracted practice. The continuity isn't as real, because clearly what you've got is health boards bringing in staff, and generally you will find salaried and locum staff will be more mobile, so you're unlikely to have the same GP in a managed practice as you would—. I've been in my own practice for 25 years, and that's my long-term investment in my patients and my area. You're less likely to get that with a managed practice by definition, because you're not in charge of that practice, you're not running that practice, you're not invested in that practice.

So, we would always argue that, on a value-for-money basis, investing in the GMS contract would be a far better way of funding patient care in the medium and long term particularly. Clearly, there are instances where a practice folds, and unfortunately far too many of those over the last 10 to 15 years, and the health board has to step in to continue those services in those areas, but we would still argue that clearly there's good evidence that value for money means that health board managed practices are a last resort, not a way of trying to run general practice.

Coming from north Wales where there are a significant number of managed practices, again, I don't think they've been effectively evaluated yet, and I think that should be something that the Government calls for and undertakes. I feel that there can sometimes be a lack of ownership, because within the GMS contract they're my patients, I live in the same area as them, I have to get it right and if I don't, I'll hear about it at the school gates. I don't necessarily think that happens within that managed environment. You see your patients, you leave the building, job done, really, so that value is lost.

I do think they're probably significantly more expensive to run and, from what I've seen on the ground, it's very person dependent on who's working there, what the outcomes are like, which I suppose you could say is the same for everywhere, but the feedback we get is that the running and experience there isn't as good for patients. Possibly I don't think it works very well, if I'm honest.

So, in terms of the answer I've been given about evaluating it, because you're going on the evidence you've got because of lack of evaluation, I'm assuming, from what you've told me, why is the evaluation not in place, I suppose, is the obvious question.

There are a number of questions you asked, and I'll go back to your first question, then I'll come on to your second one. You talked about the difference or asked about the difference between the independent contracting general practice model and a managed practice model. I know that through our written evidence we alluded to a paper that was forthcoming, which I'm sure you've been sent, which is a BMA document on the value of a GP. It's not that I commend you to read it, but I think it's an excellent academic piece of work that actually looks at the value of continuity, holistic care, the value of the independent contracting GP model.

I would also go back to the fact that there is a reason why these practices are managed. The health boards have responsibility for the care, but it’s because, for many reasons, those contracts in those various localities have been handed back because the independent contracting model has failed the partners. And I think that one of the main reasons for that is the lack of funding. The nub of it comes back to the funding and the funding models, the ability to actually provide the care that is required. There are staff—. I'm sure we'll come on to issues about the underemployment and unemployment of GPs, but we do feel that there is a trained staff, a workforce, that's able to take on these additional roles if the funding was there.

We are coming on to that. I'm going to ask about that later.

Sorry. So, there are lots of issues and complexities within that, but I do think that the direct question you asked about the value of the independent contracting model compared to the managed practice—. The evaluation, the financial evaluation, is one thing, but I think the quantitative experience of the patients is another element of evaluation that needs to be done—the services that are being provided, the timeliness et cetera—as a comparison.

Can I bring Rowena in and then I'll come back to you, Ian?

I was just going to explain the difference in model, and why managed practices probably cost more. They can cost more. If they haven't got a doctor in that day, the health board has to do something, so they'll spend whatever they have to spend on a locum, whereas I've got a doctor who's going to be off sick for six weeks having a knee operation; I've only got a finite amount of money, I'm going to come in and cover her sessions—you know, the buck stops with me and my partners, and that's what we signed up to and that's what we do. You can see that that offers the patient the continuity of care of a doctor who's already in their practice, rather than a locum that's costing a lot more and doesn't know them, so it does create quality. It also creates a great deal of pressure and well-being problems and stress for the independent contractor practices, but overall I think the patients and the taxpayer get a better outcome from that. If we can invest in that and pick up practices before they hand their contracts back and become managed practices, overall the taxpayer will get a better deal from that and the patients will as well.

Ian.

Yes. Just to come back to Joyce's point on evaluation, we'd like to know why there hasn't been an evaluation as well. Because once the contract's gone back—and it costs 30 per cent more for a health board to run—returning that practice then to GMS is incredibly difficult, because you have services that are up and running with existing staffing that the health board may have augmented, and, then, when a practice comes in, it has to TUPE those people across and has increased running costs. The key to this has to be stopping that practice getting to managed status in the first place. You don't know what you've got until it's gone, to paraphrase Joni Mitchell, I guess, because once it's gone over to being managed it's incredibly difficult to turn the clock back and get it back into what we would deem general practice should be, which is that GMS contract-run practice, really.

My next question—. I live in west Wales and I cover most of Wales, so I know quite a bit about contracts not being renewed and people retiring and no-one wanting to come in, and the nub of it, very often, is GPs retiring or single practices. So, there's an obvious question that comes from that and that is: how do we encourage younger people, particularly doctors in this case, to take on those practices, especially—and I'm going to speak for my area—in rural areas? You'll have plenty of that too. 

I'm going to speak on experience. I joined my practice and all the partners there qualified in the year I was born, so I had a couple of years, which was lovely, and then they gradually all retired. So, we struggled for years trying to recruit in a rural area, so it was exceptionally hard. Within the north Wales medical school, we're embedding students now for a year in general practice, so they come out with a positive view of general practice and experience and understanding of that. I think that helps because they then want to work in general practice, particularly in rural areas. I think that's just one model that we're using in north Wales to help with that. Within the college, we are doing a pathway to partnership, where young GPs are taught, through a series of days, about the partnership model, which I think helps when they come into GMS. Then there's also a network for later career GPs to keep them going in GMS practices, which I think helps as well.

Can I add to that? I think the other thing it needs to be is—. Being a GP is the best job in the world and the worst job in the world, usually at the same time. The thing that makes it the worst job in the world is the attritional nature of the pressure that you feel to deliver services when you don't have the resource. So, it needs to be a sustainable future for you to enter into that practice.

When I joined my practice in 2001 as a partner, I never thought I'd see the day where we would potentially be thinking about handing back a contract at some stage in the future. It just wasn't an option. I think a lot of the practices that have folded over the last 10 years would have been in the same position. So, it needs to be a sustainable contractual future, and it needs to be an enjoyable and rewarding job. Now, the patient-facing element of it certainly is, day to day. It isn't any different to when I first set foot as a trainee in 1997, or whenever it was, but what has changed is the attritional environment that we're seeing. That's why people don't feel able to commit their full futures to general practice as partners at the minute in the same number that they were.

I think they'll come back. I think if we can get back to the core function of general practice, as that long-term investment in your area and in the patients that you see day to day, it's such a rewarding job. They will come back. 'If you build it, they will come', I think is the advice. But there needs to be a focus on it, on a policy and contractual basis, to make it worthwhile.

We're in a unique environment with underemployment at the minute. We have lots of trained GPs who can't find work, which is a bizarre thing to say when we're telling you that we're under such pressure, but people can't afford to employ people to do the job, and there are people who can't get work as GPs. That's a Kafkaesque situation that we've ended up in. Bizarrely, though, that gives us an opportunity now to invest now to bring more people in, to make it more sustainable, and encourage more people with us. So, there's a real watershed moment here for this.

Rowena.

Yes. About 10 years ago, the big worry with not having enough GPs was about GPs retiring at the end of their careers. Now, the big worry with retention is GPs in the first five years post qualification. They're burning out really early. You can see the tragedy of that for each individual GP, but also for the taxpayer that supported them through. As Ian says, if you—. We had a day recently when nobody was on holiday, nobody was off sick, we were seeing 25 patient contacts and the extra bits of work, and we had a bit of time. We had time to discuss interesting cases, or to have a chat in the waiting room with a patient. It was a wonderful, wonderful day, a beautiful job, and that's how it used to be. That was absolutely—. I've been here 25 years, like Ian. That's how general practice was when I first became a GP—you just had a bit of time to pick up the phone and say, 'How are you after that operation?', or, 'Are you okay, having had your baby?', knowing that she had really bad postnatal depression with her first baby. That extra bit of time to do a quality job makes you feel like a good GP, like you're doing the job that you're trained to do. We've lost that a bit, and that's why we need that extra resource to give us the time to do the wonderful job that makes a difference to all of our patients.

And that is so valued by the patient and the resident, because lots of us feel that we're losing that now. We hear it in our in-trays most weeks. Thank you for that. Joyce.

We've talked a lot already about the strategic representation within health boards, but also national policy forums. So, without restating—because I'm watching the clock; I know what's going to happen—what you've already said, is there something else you'd like to add?

I do think it's so important to recognise that GPs are natural leaders, and that is under-represented. We have talked about this a little bit. Our patients recognise, I think, that—they come to us every day for really important life decisions—but, for some reason, other people don't recognise that. And I think, because of the nature of GMS, we're used to making important decisions quickly and easily. So, I think there's an untapped body of GP leadership there that should be tapped into to help with that. 

Thank you. Lesley.

Thank you. I want to look at workforce sustainability and planning. Obviously, we've touched on that. It was a point you made, Ian, around doctors not being able to find work within general practice. I've spoken to some GPs in my own constituency of Wrexham and I was shocked at how many could not get work, when I know, obviously, the patient demand and the demand for GPs. One locum I spoke to was working in the emergency department because he couldn't; I think he did two sessions in this particular surgery. So, are you seeing that trend? Is it increasing?

Yes, it's frightening at the minute. I saw a piece of work that had been done in Bangor, I think, where of 10 or so trainees coming off the scheme as qualified GPs in August, or what have you, maybe only one of them had found work. We see it with trainees who, particularly, don't have resident status, actually. We bring people over to train them as GPs. They come on visas to train. They need five years to train and to be working in the UK to have indefinite leave to remain. They get to the end of their scheme and they don't have a job lined up. If they don't have a job, they can't get a visa sponsor. If they don't get a visa sponsor, they're getting deported. As I said, it is Kafkaesque at the minute. We're sitting here saying that we don't have enough GPs per capita—we're about 700 short compared to the Organisation for Economic Co-operation and Development average—yet we've got all these trained GPs who can't get work because we can't afford to employ them, because we're running completely at that line at the minute where our practices are viable or unviable above and below it. So, we really do have to think about do we want to lose a cohort of GPs in this process as well, a generation of GPs that we've trained, who are excellent GPs—we would employ the majority of them in a heartbeat—and we're seeing them struggle and struggle and struggle to find work. That is largely an economic issue because of the way that general practice has been funded and the contractual position that we're in. That has to change sharpish.

Can I just expand upon that, Lesley? I think the important point not to lose here is that if we're saying there's a surplus of GPs, you are also going to hear me say, 'I want more training numbers for GPs' et cetera. We've seen in the last year a capping upon the 160, whereas, previously, Welsh Government had taken the funding further than that. Ian has just mentioned the shortfall of safe working. I think what we can't lose track of is the need to create safe levels of working—that's safe for the GP and the practitioner, and that's safe for the patients, et cetera. So, we have a shortfall. We have a group of trained GPs that are underemployed, unemployed, et cetera. But I also strongly believe that we need to train more GPs et cetera, because we have a deficit. There is a reliance upon there to actually have the funding to actually employ them, and that's where it comes back to, et cetera. If we want more out of general practice, if there is a value of the GP, if there's an economic value, if there's a value for the patient, continuity, all of those things that we've just discussed, then we can't say, 'Okay, there's the workforce, we don't need to train more.' We are short of GPs. We are short of funding to employ those GPs, and that comes back to the nub.

Rowena.

Yes, absolutely echoing that, we can see what's happening to the population in Wales. They're getting older, they're getting fatter, they're becoming less healthy, living with more chronic conditions, living with more medications. They desperately need a generalist approach to looking after them, and that is general practice. If we don't do that now, we're going to be absolutely lost in a decade. At the moment, our fantastic GPs—. Our training programmes are so good here in Wales, they are being delightedly snapped up by Australia, New Zealand, Canada—all places where the GPs are emigrating and having more income. They are better paid, they have got a much better work-life balance, they have got fewer patients to see. It is understandable that we are losing these absolutely fantastic people, but they do not actually want to go. They want to stay and work in Wales. They are just struggling to find the work.

The other issue is estates as well. We want to expand practices, but the fact is that there isn’t the estate to do that in its current form. I'd love to have the funding for more doctors, and if I had more doctors I'd love to be able to have more rooms to put them in, but that just doesn't exist, and that's across my cluster, really.

Okay. Just before we move off this, just the point you mentioned, Ian, about visas. So, obviously the previous UK Government changed the visas. Are we still seeing issues around visas? 

We are, just because you need a sponsor. So, if you don't have a substantive post, it's quite difficult to get yourself a sponsor. That might be made worse shortly if that five-year period for indefinite leave to remain extends to 10, so we're really keen that that doesn't happen, particularly for doctors as a specific group. But, yes, it's still an issue. I've got a trainee in my own practice who's facing up to that currently when the term of her training ends and there's that uncertainty that makes you think, ‘Well, do I really need this?’ You see the adverts from Australia, New Zealand, Canada and you think, ‘Well, hang on a minute, I've travelled to Wales to train’, and that's a big investment from the NHS to train them. They'll have been paid throughout the time they've been here training. The training practice has been resourced. You're creating this workforce that's ripe to deliver care for your patients and then you're losing them. It just doesn't make any sense on a planning basis to any of us.

So, it is still an issue. Welsh Government have done their best to try and alleviate that by trying to offset the cost of sponsorship, but ultimately it's the Home Office that needs to make a decision here, that this is a group of professionals that are here to deliver care for our patients, and they need to be exempted from these rules because otherwise it's the population of Wales and the UK that suffers.

I think I know what you're going to say to this, but just put money aside—and I know it's really difficult: what do you think we can do? I remember a few years ago we had a campaign to attract GPs to Wales. That work-life balance was one of the things that we were giving as a real selling point. What more do you think we can do to make doctors want to stay in Wales, apart from money? There might not be an answer to that, but—. 

This is the ‘Train. Work. Live.’ programme, which we've rather sadly had to term ‘Train. Work. Leave.’ I think the attraction of coming to Wales to work is there. It's a marvellous place to live and work. The problem is that you have to give people a career at the end of it that keeps them here. I don't think there's an issue trying to sell the environment, or potentially what the work could be like. It's just that the financial environment doesn't allow you to recruit people, and once they get there the attritional nature of the job is making people leave early. It's hard not to draw a line between the reduction in the proportion of NHS funding from 8.7 per cent 15 years ago down to 6 per cent now and that drift in what's happening to general practice. The definition of insanity is trying to do the same thing over and over again expecting a different outcome, isn't it? The little initiatives and pots of money and, ‘We'll do this and they'll come’, are one thing. What you really need is a sustainable general practice at the base of it, and if you do that I've no doubt that these issues will evaporate.

Can I bring Mabon in, please? And I'll come back to Rowena.

It's a good one. I'll defer to my college colleagues, probably. The numbers are insufficient to reach that 700 OECD gap that we've got, particularly with the 160 that are in training now. Like I said, the numbers have been as high as 210, I believe, on an annual basis, and that's an intake of 210 each year. But that has to replace people leaving the profession at the other end of their careers and, as we've heard, retention is not just—. The other end of your career isn't necessarily when you're 65 and beyond. I heard a horrifying statistic a few years ago that the average age that a female GP leaves general practice is 36, I think, from memory. Clearly, there are a lot of reasons why people leave, but certainly that 700 gap seems to be growing. It doesn't seem to be reducing. So, if we're to close that gap, not only do we need to use the workforce that's currently there that's underemployed, but we need to continue to train more and more people.

And remember, to get to that 700 gap, that's just to deliver services that you're currently delivering. We've got a safe working limit advice of around 25 contacts a day, because after that, you start to get decision fatigue and it starts to become more dangerous for patients and for professionals. If you want to deliver better care again, you need to increase that ratio and reduce that number of contacts a day, so that you can do better, if you like. And we're nowhere near that.

Rowena, do you want to come in on that? 

I apologise. I need that question translated to English please, because my headphones didn't work.

Oh, didn't they? Oh, right.

Sorry, Mabon. Can anyone do that?

It didn't work just now. 

I just got a beautiful Welsh question that I didn't fully understand. 

As you're just getting the new equipment, I was just asking, Rowena, about the numbers being trained in Wales, and whether the numbers are sufficient looking forward to the needs of Wales in the immediate future. Are we training enough GPs in Wales?

Sorry, before Rowena answers the question, Mabon, can I just clarify, because I wasn't sure whether it was the translation or maybe your second bite of the cherry was a little bit clearer? I think we need to—. There are two separate strategies we need to concentrate on. One is postgraduate training, one is undergraduate training. And Tom earlier on talked about the attractiveness of local students staying in Wales, being trained in Wales at undergraduate level, equally at postgraduate level. And maybe there are two strands, maybe it's the same answer, et cetera, but I wasn't quite clear from your question whether or not you were talking about undergraduate training or postgraduate training, or both.

And equally, I think that there are many benefits of retaining local talent, particularly just referencing the question about rural areas, and those who are more likely to stay in those rural areas—those who have got that attachment to the rural areas. So, you can use innate attachment, as in, 'That's where I was born and brought up', or you can place people in programmes through directed, targeted schemes to those rural areas, et cetera.  

Mabon, do you want to come back? 

Simply both. 

Okay, right, good. Sorry, Tom. 

I think it's a difficult question to answer. I know at the moment our numbers are capped. So, we've got 160 instead of 200, I think. That's not what we need. We need the 200 at the very, very least. Just looking at populations and where we're going, we're trying very hard to have this left shift that we talk about, where patients are cared for in the community, out of a hospital setting, where they possibly can be. That's going to need a lot more GPs, practice nurses, health visitors, district nurses, healthcare assistants in the community. So, my answer is 'no'; we haven't got enough and we will need more.

But, equally, I have trained GPs coming with great frustration, saying, 'I've been sold a dud; I've had 10 years of my life training to be a GP and now there are no jobs for me. Somebody should have looked at the workforce planning and not trained me, or trained me to do something different', but that's not the case: we do need those doctors, those GPs.

Tom.

The evidence, certainly from an undergraduate, suggests that two thirds who train in an area will stay within 50 miles of that area. So, I think it's important if we want to retain GPs and doctors in an area that we increase undergraduate numbers to make up with everything that Rowena's alluded to.

There are 100 medical students a year in Bangor now, which is going to be a great help.

It'll make a fantastic difference. The other thing is that how GPs work now is slightly changing. So, when GPs become GPs now, often they expect perhaps to spend a third of their time doing something different, and that's changed over the last 10 or 15 years. So, there's again another untapped resource that can help deliver care much closer to home, which is happening as we speak, really. So, I think it's important that we try and foster that through everything we've touched upon with funding, really.

Lesley, do you want to—

If I could just add one thing to that.

Oh, sorry.

We're not having difficulty recruiting people to training schemes at the minute either—they're oversubscribed. So, it's clear that there's still an appetite from young doctors to become GPs and train as GPs. So, this is where there's a real tragedy that, as Rowena said, they're desperate to be GPs, they get to that point where they've trained and, suddenly, there's no career for them at the end of it. So, there needs to be some joined-up thinking on that. But it does suggest that the future for recruitment and retention in general practice is there if people can make the job less attritional and make the economics of employing GPs and retaining GPs attractive for practices.

I think you raised a really important point there, Tom, about the north Wales medical school. So, it's probably a bit early to evaluate. Do you think the health board—? Do you think Betsi's engaged with trying to keep those undergraduates in—? You talk about that two thirds and the 50 mile radius. Do you think the health board is—? Because I think we need to start now, don't we, to make sure that those students trained in Bangor stay in north Wales?

I think that it's very early days, and they're making an attempt to engage with it. I think there are further steps to be made, if that makes sense, in doing so. It's very difficult when everyone's firefighting. Just touching upon the GP side of things, I mentioned earlier that we're going to expand and students can spend a whole year in general practice. We had a real worry that we wouldn't find practices to do that, but actually we've got more than enough practices, so it can happen. And I think it's the same with secondary care as well. It absolutely can happen, and I'm sure it will happen, but it is early days.

So, who does that? Who makes sure you've got enough placements?

At the moment—. I'm not grey yet—

That's your job, is it? [Laughter.]

—but part of the responsibility for—. One of my roles is that, yes.

Okay. Carry on, can I?

Yes, please.

Okay. Thank you. This is a question mainly to Gareth—sorry, Gareth. We're hearing reports of a bottleneck in specialty training pathways. I wonder if you could expand a bit more on that, and the impact you think that has, and what action you think all the partners in relation to that should be looking at.

I think that the bottleneck, as described, is actually post certificate of completion of training, so post the completion of the training. I suppose, as we've talked about already, it's actually having a job, a sustainable job to move into, et cetera. So, the gap and the differential is the element that we need to bridge. It does come back down to the fact—and I know it seems to—that whenever somebody turns to me, I say, 'You need to give more money into the system', but, actually, the unemployment, underemployment element, that's the bottleneck. We're training people, but practices don't have the resource to give jobs that are substantive, ongoing and fulfilling.

Are we talking about the gap between foundation training and specialist training as well? That's fair enough. It's a particular issue in medicine generally, I would say, at the minute, with the offer that we're seeing for resident doctors, especially going from their foundation years into specialist training, and we're losing a cohort of people because of that. This is where that intake per year of specialist trained GPs is so important, because there's an opportunity to recruit more into the scheme for doing that. Like I said, at the end of the day, you're creating a conveyor belt, where people fall off at the other end if you're not careful. And that's where this sort of—. The workforce planning—. I know Health Education and Improvement Wales have been involved in doing a workforce plan, but there have been previous workforce plans. Again, I think there's a lot of short-term thinking involved in all of this. It's, 'How many can we train, because how much is our pot of money?', not, 'How many do we need?', and then, 'What do we do about them once we've trained them?' So, we need more joined-up thinking in the system as a whole. But, certainly, we do see that there is an impact on the bottleneck for specialist training, particularly where people go through two years of foundation training, are looking to get a training post, and there isn't one available. So, their natural response—. You know, if I was 25 again, I'd probably go off to Australia for a year, but a lot of them never come back. So, again, this is where that coherent workforce plan is so important.

Sorry—

Apologies, Lesley. We've obviously got a bottle that's got two necks: one at input and one at output.

Yes. Just on that—

I'm just conscious of time—

Sorry.

It's all right, Lesley. Can we just—?

Just on that point, Ian, about that joined-up thinking, so you obviously have got quite a few partners who need to come together to join up, including Government. Is there anything specific you would say that they need to do around that?

I'm going to defer to what Gareth said: a lot of it is about funding. If you don't put the posts in place—. As Tom has said, the training places are there, the people who are prepared to train them are there, the people who are prepared to employ them are there, at the other end of it. It's just that the financials at the minute don't make any sense, and that always, always, comes back to that 6 per cent of the NHS funding share that's there. You can't do more with less.

Does anybody want to add anything on workforce planning for GPs? What's not been said?

I think it's about—. As much as we don't want it to be, I think it's about the funding.

It is about funding. Yes, okay. Gareth, the words you used, the three Ws: the workforce, the workload and the well-being. And, again, is there anything you want to add around burn-out? I think those three points obviously really cover why GPs are leaving early. You mentioned 36. Is there anything any of you would like to add to that?

A little anecdote, if I can. I heard a GP at a conference say, 'I don't need any more resilience training, I just need a job that doesn't make me ill', and I thought that was really, really powerful. If you have enough GPs, that's the workforce element, then you can deliver a more realistic workload that means that people don't burn out, so their well-being isn't affected. The three are so interlinked. But, ultimately, we didn't see the same—. When I started in general practice, we didn't see burn-out in anything like the same levels as we do now.  So, 25—I'm showing my age—30 years ago was the first time I started to set foot in general practice. It was tough, it was hard work, but they didn't seem to have anything like the same level of burn-out, because we didn't have any of the obstacles and the attritional stuff that we get in today's age.

What we do in general practice has changed completely. What I did in 2000 is totally different from what I do in 2025. But I feel the pressure of it every day that I do it now, in a way that I didn't. And that's not just because I'm older. I think it's because the nature of the work has changed and the environment that we operate in has changed, and I think that can't be underestimated. I really feel we risk losing general practice altogether if we don't turn this ship around very quickly.

We talked about the need for evidence and evaluation—. I will be really quick, Peter. We have a BMA workforce well-being survey, which we run annually, and lots of that data was in our written evidence. It does talk about the morale and the effects of morale and the burn-out, and the intention of practitioners in the next number of years to actually leave the profession, and that's a stark warning. But I won't go all the way through the figures in the interests of time here.

Rowena, do you want to add to that?

Yes. I think so much of it is about having the time to look after our patients properly, and we lack that, so we feel exhausted. We spend an awful lot of time apologising for how long they waited to see us, and stuff that's outside our control we feel very guilty about. But there's something about patient expectation that's changed dramatically in the 25 years that I've been a GP. In a lot of consultations, people are unhappy that you can't prescribe Mounjaro, for instance, the weight-loss drug, people thinking—. Whereas 25 years ago people accepted the limitations of the NHS and the service you were trying to provide, people are less able to accept that. There are a lot more complaints now. I know, from supporting other GPs, complaints are incredibly demoralising for a very stressed professional. Sometimes they're vexatious and they just take up a lot of time. Sometimes GPs are so hard-pressed that they do make mistakes, human errors, and all of that whittles at people's strength and demoralises them. So, that's all part of it.

Society has changed a lot, hasn't it, in that 25 years, as you've just said. Did you want to add anything, Tom?

Just very briefly. We're working in a pressurised environment. You touched upon taking a relative to A&E. Now if I send someone to hospital, I don't know what the outcome is going to be for them. It's so difficult for them. So, that has an impact on my decision making. And I think that interface between primary and secondary care has become more difficult in a post-pandemic era, and I think that understanding has slightly drifted as well between what general practice can do and should do and what's going on in secondary care. I think if we can improve that understanding between the two, I hope that things would get better for patient outcome.

Okay, thank you. Can I just ask one final question?

Yes, one final one and then we'll go to digital.

I just wanted to know your position on the use of physician associates. I have to say, I had never heard of them. A constituent contacted me about two months ago on the back of the Leng review that the UK Government had undertaken, and you may have seen that the Welsh Government put out a written statement about a month ago, I think, around the Leng review. So, I delved into physician associates and I was just wondering if you have particular views. Rowena?

My practice couldn't afford to employ a physician's associate because they need to be supervised by a GP, so it just wouldn't make financial sense for us to employ a physician's associate—now assistant. I'd probably employ a practice nurse or a nurse practitioner or a practice-based pharmacist or another GP.

So, if money were no object, you would employ one?

No.

No, you wouldn't.

It's about the cohort of patients we see, Lesley. In general practice, you see what we call undifferentiated presentations. So, patients come to you and they're not all potential bowel cancers, they're not all potential asthma. They come to you and it's a blank page. You don't know until they've walked in your room what you're seeing. Now, that's a special skill set that doesn't really lend itself to PAs.

So, I think the royal college have a position statement, as do the BMA, that, actually, we don't feel that PAs have an effective role in general practice as things stand because of the limitations of what they do and the fact they need supervision. You know, we could all have PAs in our surgery, but what we would be doing is supervising what they did a lot of the time, and, unfortunately, I'm doing what I'm doing. So, it actually makes more sense for me, as an employing GP, to employ somebody who can do that without supervision. So, I'd rather, if I had the money, which I don't, employ a GP.

Okay.

Well, that was a good, clear message, I think, on that.

Very, yes.

I'm going to move this on. We've only got 10 minutes left. Can I invite Mabon to come in, please? And can we just make sure that these are all working okay?

Yes, good, Mabon.

Diolch, Mabon. I hold the digital brief for GPC Wales, so I do a lot of the digital stuff. I mean, in fairness, general practice has been pretty at the vanguard of digital working in the NHS since the year dot. So, before I started in general practice, we always had computers from the 1990s onwards, really, doing lots of functions. We'd love to be further on. There are lots of developments in the world of artificial intelligence and various other things that are coming down the line that we need to probably embrace as safely as we can; there are upsides and downsides to both of those.

We'd love the digital infrastructure in NHS Wales to enable us even more. In some respects, again, I hate to say it, there's a funding issue in that, because, clearly, you know, it takes investment to end up with effective digital solutions, if you like. So, you know, there's an element in there around enabling practices to have digital solutions. But if we're being honest, we've probably embraced things at a faster pace than the NHS allows us to. We've got lots of patient messaging apps, ways that you can make your own appointment, and there are various things for patients to view their own records and other things.

One of the things that holds us back, I think, is that NHS Wales wants everything to go via one solution or one route, via the NHS Wales app, which tends to be a little further back than we would like things to be. So, we would like there to be more of an ecosystem digitally where you could bolt things onto the app, or embrace what people have already done within their practice, and perhaps enable it more by small aliquots of funding that would allow them to deliver services better and more efficiently, because I don't think there's a practice in Wales at the minute that doesn't use some of these things and could live without them now.

Gareth.

Digitally, I suppose, with electronic prescribing, we're a little bit late in coming to the party compared to England, but we certainly see the advantages. We advocate for electronic prescribing, and are very grateful for the investment that has been put in that area. But we would strive for universality of the electronic prescribing, and there are certain gaps within that, and cost elements that are pertinent to dispensing practices particularly, and the need for additional funding streams for the software for those dispensing practices that we represent as well. We all know that the majority of dispensing practices are rural practices, and we need to ensure that we're sustaining the viability of rural practices, many of which do depend upon their dispensing incomes. So, we're very happy that Welsh Government have also committed to having a review of dispensing in Wales. I know that's not your question, but it is pertinent with regard to the electronic prescribing element and the strive for universality in that area. Thanks.

Not 100 per cent. They are designed, if you like, to talk to one another. They can be quite clunky and actually add to your workload when you do try and communicate. The other issue, I guess, is that you'd think the digital landscape within NHS Wales was homogenous. It isn't because there are a lot of differences between each health board system as well. That means that something that works for me in CTM might not work for Gareth in Aneurin Bevan, or that we might be talking to different systems. Again, we talked about joined-up thinking in workforce planning. We'd like to think about joined-up thinking in digital planning as well. I know Digital Health and Care Wales are quite hot in their 'once for Wales' approach, and I think we'd probably support that. But what we also find is that I think that solutions in general practice tend to go faster than the secondary care solutions, partially because of the way we function. We can innovate. If you ask me to do something on a Monday morning, I'm probably halfway to doing it by the Tuesday afternoon, whereas I don't think health boards are that agile. We're often frustrated at the pace of change and frustrated at how things can work across an interface. But, then, I spend half my life frustrated as a GP, I think it's fair to say.

Gareth.

Mabon, I don't think Peter's going to allow us time to go into this in depth, but, actually, the interface of sharing of data is a very important question that does need bottoming out. GPs are the data controllers for the data that we hold and face personal liabilities for any breaches in that data. It's going to be a very quick answer to a very long question and a long-standing question from me, which is that we do require legislative reform to support safe digital access for the patients and transfer of that data from one sector to another.

Mabon, do you want to get one more question in? I'm going to push our barriers by a minute.

I have to say, personally, I do have confidence in DHCW. There are people within that organisation who are very responsive to general practice's needs, and are certainly in listening mode. Whether they can do everything that we want them to do with the budget they’ve got is another thing, and whether they can deliver everything, particularly over that pan-health-board landscape that I spoke about earlier as well, is another thing.

I think they’ve got an unenviable job in trying to deal with the digital landscape in Wales generally, because they’re dealing with health boards separately, and there are competing needs. Certainly, I would again advocate for more funding towards general practice technology, because I think you get more bang for your buck in that area, and a little bit more devolution of the solution to the ground level, and using DHCW to enable that, rather than looking for that centralised solution.

But, in general, I don’t think you’ll hear the same grumbles from general practice about DHCW in quite the same way you’ll hear it at a health board level. If there are single initiatives that they don’t like, people will grumble very clearly about it, but, in general, I think we find them more reactive to general practice needs than how the health boards might respond.

Gareth, then Rowena. 

I’m just going to focus on the NHS Wales app. Obviously, DHCW have been tasked with delivering a universal system, but my plea is that, in creating that system, it doesn’t take us backwards. It needs to take us forwards. Because of lack of funding into digital strategies, practices have needed to go down their own pathway, and have funded their own digital tools, which are far in advance with regard to two-way conversations with patients—text messages, photographs, videos, et cetera. My fear is that mandating practices to all move onto a universal app could be retrograde and not as responsive to the needs of general practice as what is already being bought by the practices themselves. We cannot go backwards to be seen to be going forwards.  

From my perspective, DHCW will fix my computer when I phone them up, and they do that very quickly. So, they are doing a good enough job, I’d say. The digital landscape is an exciting one and quite a challenging one for general practice at the moment. There’s a wealth of stuff that’s coming in with AI that looks like it might really make our lives and our care for patients a bit easier. At the moment, it’s not regulated, so we need to catch up with what’s going on across Wales, and ensure that it’s safe and regulated and is doing a good job.

I’m afraid we’ve gone over time, and we’ve used too much of your time as well. Thank you so much for what you’ve contributed today. We have still several sections of questions we would like to ask. Thank you for providing your written evidence as well. If there are some key points we wish to flag up, can we do that in writing afterwards? Thank you. 

There will be a transcript available for you, and if you want to alter anything where you feel we’ve got things wrong, please feel free to feed back. Thanks again for your time; I really do appreciate it. This is a really fundamental inquiry we’re doing, and the people of Wales want us to do this. We need to do this. So, thank you once again.  

Members, we’ll move on to item 3, and that’s papers to note. You’ll see there are a few there. I don’t know if you want me to go through them individually. Are you content to accept them en bloc? You are. Thank you very much.

Just before we do move to item 4, to move into private session, it was remiss of me at the beginning of the meeting not to record apologies for John Griffiths and James Evans. Can we make sure that's on the record as well?

With that, can I resolve to exclude the public from the remainder of this meeting? Are you all in favour of that? You are. Thank you.