National Assembly for Wales

Good morning. 

Diolch, Cadeirydd. Before I start, can I please ask you to convey our thanks to the front-line staff in local authorities for the tremendous work they've been doing in the episodes of lockdown, because I know they're facing some of the hardest tasks ahead of us, either with social care or other tasks they're doing because they are key workers and making sure we are able to manage our lives as normally as possible in these circumstances? So, please convey our thanks to them. 

But, clearly, there are also questions of financial issues that local authorities are facing. I've been informed that, clearly, local authorities across Wales are losing on income—let alone any expenditures, but on income—£33 million a month, effectively. And you're facing very serious challenges being able to deliver additional services. So, how are you seeing in particular the financial agenda to help local authorities, as they need to deliver greater social care needs during this time? 

Okay. Would you like me to go first?

Yes, kick off, Andrew.

Okay. Thanks. If I outline, first of all, the pressures in terms of increased cost pressures and the loss of income, even with the savings we have been able to make with reduced services in some areas, we've calculated over a three-month period, so, for the first three months of what's happening now, that our total budget deficit will be in the region of £173 million across Wales. That's loss of income and increased cost pressures after taking savings off. Now, Welsh Government has put in place quite substantial funding so far around us bidding in on a claims basis for increased cost pressures. So, for example, in the first month of claims, I think over £5 million was paid out for the first month. While claims were small, that's largely because we claim the funding back once we've paid out. So, I understand that this month's claims, which, actually, I think are going in today to Welsh Government, will be many times that figure. My own local authority is probably putting in for about four times as much increased cost pressures this month compared to last month, and I'm sure next month's will increase even further. 

So, in terms of cost pressures, we do have a mechanism in place to meet the new cost pressures. The issue for us will be the lost income—as you say, the substantial loss of income—because while we've been discussing the first three months based on our best modelling we can do across the 22 authorities, there are going to be some areas that will continue to have cost pressures and loss of income for many, many months. So, if I give you an example of leisure services across local authorities, that will cost millions of pounds of lost income every month that they stay closed, and the real prospect is they won't be opening for many, many months yet. So, we are trying to manage the budgets very carefully. 

The additional funding that's been put forward for social care in particular is welcome, because the cost pressures are significant in terms of where we've had to accommodate initially an influx of additional people as quickly as possible out of hospital, before this started to take hold. In addition, we've had the problems with our own staff going down with COVID-19 or similar symptoms, which has meant that they've had to isolate, or, if they have a family member that they live with who has symptoms, they've had to self-isolate. So, that has meant we've had to bring in substantial extra resources in terms of human resources to cover these positions, and it will be mirrored in the independent sector. So, the costs, they are substantial to say the least. 

Councillor David.

Thanks, Chair. So, in particular, the pressures have been acute in the social services sector, because, of course, our settings, particularly settings for older people, have not been accepting new residents to protect existing residents. In addition to that—so, potentially there's a loss of income for independent providers around that—most of those settings, if not all of those settings, have had to recruit additional, or take on additional, staff or staff hours because, as Councillor Morgan has said, there's been a very high level of sickness due to the virus, and a need for additional care. And, as Members will know, because you've heard evidence from us previously, and I know you've certainly focused on this challenge to the sector that was there before the crisis, and that's the fragile nature of the social care sector in Wales that, even before the pandemic, was facing some really tough challenges. 

Great. Thank you. Back to David Rees.

Okay. Clearly, that's an important aspect and the financial pressures are going to be huge in the months ahead of us. We heard last week from Care Forum Wales about £40 million that had been allocated by the Welsh Government, but they indicated to us in evidence last week that they were struggling to actually get clarification as to how that funding would be distributed to the sector. Have you got any sort of update as to how that funding will be distributed, and what guidance do you now have to distribute that £40 million?

Andrew.

I have to say, unless Huw can update me on if there's been developments this week, I haven't seen guidance on that funding yet. However, every local authority has been asked to have discussions with the independent care sector on understanding what the pressures are. In many cases, it is where there are vacant spaces, which obviously is loss of income. In addition to that, they have had the pressure of additional staffing costs, as I've already mentioned, because people have either been off ill, or people are in the shielding programme as well, who have had to self-isolate.

The one area we've been able to help so far—cover all costs for—and that's personal protective equipment. So, while the independent sector initially—and obviously it's got its own responsibility to provide PPE—. Very early on, once we started to get it—[Inaudible.]—Welsh Government, it was also agreed that we would pass PPE on to those care sectors, because they were struggling to get PPE. But, in terms of actually a fixed formula, I'm not aware—unless it's developed this week—of a mechanism that is currently in place to get the funding out to those sectors. But every council has been asked now to discuss with every single independent home in their borough around what are the needs and what are the problems, and I think that is being collated now by the 22 authorities.

Councillor David.

Before you answer, is there a possibility then that, after those discussions as to their needs, you could actually end up with a recognition that £40 million is not enough, because they come back and the figures are, across the authorities, far more than £40 million?

Okay. Councillor David.

I think it's fair to say that the overall pressures will be more than £45 million. And, if they're not already, then they continue to increase by the day. We'll get you the latest information as soon as possible about where we are in terms of establishing the exact costs, because that's been a request—that, instead of just coming up with an estimate, we arrive at actual costs for each provider across Wales. So, that's taking some time to put together, but we're putting that together very quickly.

Good. Angela's got a supplementary, and then we'll come back to you, David.

[Interruption.] Sorry, it's a new muting system.

It's so much better when I can hear you, Angela. [Laughter.]

Thank you. You're in a rare minority there, then. [Laughter.] I just wanted to say that the leaders of social services that I've spoken to in my constituency basically have said that the £40 million—their share of the £40 million—has pretty much already been spent, even before it has arrived on the doorstep, because of the enormous costs of PPE and trying to put into place support for care homes—and not just care homes, of course, but actually dealing with people who had to come out of hospital really quickly, to empty the hospitals, and then trying to place them into either the community setting or support them in their own homes. And I just wondered if perhaps you could expand on that, because it was sort of like, 'Yes, lovely to have, but actually it's already gone, so we don't have it to go forward and make the plans going forward.' And that bit about emptying the hospitals really rapidly of people really did resonate with me.

Councillor Huw David, you're the health and social care lead.

So, you're right, that won't be—£45 million won't be enough. Welsh Government has recognised that, and they have indicated that this is an initial payment, and we anticipate that those costs will continue to rise. Because one problem we recognise is that there is now an unmet demand out there that we will want to meet, because lots of people are caring for family at home currently, and we think that will change in the coming months. And that will have an impact on overall costs.

Back to David Rees.

Thanks, Chair. In that sense then, clearly, because that—[Inaudible.]—financial issues and we understand the pressures now facing you, have you had discussions also with the care sector as to what their financial positions are? Because I'm aware that many are struggling and the fallback, effectively, will be local authorities. Are you in a situation as to predict or actually provide an estimate as to the needs your authorities may have if those care homes fail? Clearly, because that—[Inaudible.]—financial issues and we understand the pressures now facing you, have you had discussions also with the care sector as to what their financial positions are? Because I'm aware that many are struggling and the fallback, effectively, will be local authorities. Are you in a situation as to predict or actually provide an estimate as to the needs your authorities may have if those care homes fail?

Andrew. 

Can I just clarify, just to be clear how the fund is working? I don't think we should look at them in isolation. For example, all the funding allocations that have been announced by Ministers, whether it's free school meals, additional support for local authority costs, care sectors, all of that money has been put into—. It's a COVID-19 fund, as it's described to us, and it's all on a claims basis. So, we are very much—. It all has to be evidenced, so if, this month, my authority, for example, was to say 'Well, we've got the evidence that says that care homes need x amount of support in our area and this is the reason why', we then can submit that as part of our claim as eligible, and then we work with that care sector, the independent sector, to support them.

But one thing I would say is that all the figures that we're talking about are the figures that we have worked out, as 22 local authorities of the WLGA, for the first three months. All these sums we're talking about—the loss of income, the additional cost pressures, social care money—these are the first three months' worth, and I have to say the first three months is fast coming to an end. We are now into the last month, in effect—only a few weeks away from the end of the 13-week period—and we are already now starting in the WLGA to look at what the costs will be for the next three months. We're hoping the cost pressures will reduce and we're hoping the loss of income will reduce so that the gap narrows, but there will be a further substantial gap for the coming three months. So, everything we're talking about so far is only what's been allocated based on our estimates for three months.

Okay. David. 

But do those estimates include, as you say, the increased likelihood, increased costs, of social care? Because you will have some individuals coming out of hospital who have gone through COVID-19, but will need additional support and, therefore, additional care. There'll be others—homes that might need support in the short term in particular, or the local authority has to take over some responsibilities for those homes. Have you included those costs in your next set of calculations? 

Not at present, because, as I said, the 22 authorities are gathering the evidence now from the independent sector on their cost pressures for that to be fed in. So, the £40 million, I would see it as an initial payment, an initial allocation to the fund, to get us through the here and now while we gather all that information. Because I honestly couldn't tell you today what the gap is when we include all the independent care sector in addition to local authority costs. So, that's why we've got the 22 authorities now working with those homes to establish what are the genuine cost pressures. Because what we don't want to be doing is funding independent care homes to the full occupation level where, maybe, there's obviously a profit margin in there. What we need to do in the short term is make sure that they don't go under and that they remain viable. So, it's getting the balance right and that is something that's being reviewed at present. 

And you've had discussions with the Welsh Government, obviously, to look at the—I wouldn't say the word 'guarantee'—but the future funding and reassurances that the costs you're going to be facing as a consequence of COVID-19 will be there if needed. 

Every week, at some point—it's been as many as three or four times a week—we're joined, as 22 leaders across Wales, we have meetings between ourselves, WLGA officials and Welsh Government Ministers. Julie James joins us at every opportunity, but also we've had Vaughan Gething, Julie Morgan, Rebecca Evans and others. So, we talk through the individual areas of concern, whether it's been the free school meals allocation, whether it's been the social care pressures, so the Ministers then have heard it directly from the 22 leaders and our officers. They then have been able to help inform those decisions and the announcements Ministers are making, and that's where there's continued announcements of funding being allocated to the COVID fund, based on the ongoing discussions we're having.  

Okay. 

Okay. Turning now to matters on testing and PPE, I've got questions from Angela and Rhun. Angela to start. 

Thank you very much indeed. I just wanted to run past the whole testing issue, not just obviously within the local authority and your direct staff, but within care homes. I've got some specific questions, but I just wondered if you'd like to just give us a quick overview as to how you believe that testing is happening now, how well it is. And what do you think we need to put in place to ensure that it can really work well going forward? 

Who wants to kick off there? 

I'm happy to.

Andrew. Yes, go on.

So, in terms of testing of staff first of all, that has greatly picked up and improved over the last probably two to three weeks from the initial—. It was a slow response in terms of us getting results back, et cetera, and being able to book staff in. At first, there were allocations, there were certain numbers. I believe one of the numbers at first was that we could put forward 15 staff a day. But because there was capacity and the full number of tests weren't being used, the Minister removed that cap, and at that point said to us that we could put forward as many as we wanted from both our staff, but also from the independent care sector. Clearly, that's home care and nursing homes, et cetera. So, that part has been improving steadily.

In terms of care home testing, firstly, I would say that Public Health Wales have been quite helpful in terms of their engagement with local authorities where we've had outbreaks in homes around infection control and how we managed that. And they've been carrying out initial testing to confirm if somebody who's had suspected symptoms has been confirmed as COVID positive.

What has been announced now around the testing of all care homes is going to be a substantial piece of work. I had a discussion earlier this week with my own health board and the same health board as Councillor Huw David is in. We had a discussion with the chief executive where they will now be in a process of testing over 80 care homes in Cwm Taf Morgannwg, and putting in place a fortnightly testing regime. Now, to put that into context, that is thousands of tests a fortnight, because there are over 80 care and residential homes. In addition to that, it's not just the clients in those homes, there will be all the staff and, of course, several shifts of staff as well. So, we are talking thousands of tests.

There are programmes being put together I understand now across all of the health boards. And I understand—I think the Minister, when I spoke to the Minister for Health and Social Services yesterday, said that I think it's today that health boards have to submit their plans based on how they plan to carry out the testing, and the frequency of testing in all care homes. That was a discussion we had yesterday with the Minister.

Okay. Angela, back to some detail.

Thank you very much indeed for that, because that's really helped with some of the clarity on it, because I'm having approaches from care homes that appreciate that the Minister has now made the new ruling that everyone in a care home should be tested, but they're being really clear—. The answers I'm getting back as well from some local authorities have made it very clear—and I'm just reading the e-mails now—that there will be a priority system for testing and that the first care homes that will be tested will be ones that already have COVID. 

Now, the argument that care homes are putting to me is you already know that you've got a pool of infection in that particular care home, so surely, the priority should be to start testing as well, as fast as possible, the ones who are asymptomatic, especially as they're the people who are the most nervous and reluctant to bring in people from hospital in case they bring COVID in with them. I just wondered if you could expand on that, because what I'm being told by local officials in local councils is that there will be a priority system, but it will be dedicated first of all to those people who've already got the test.

And I also wondered if you could give me your view on what you might think about care homes feeling happier and more reassured if they could ensure that the people who were coming back in to them, from either the community or from hospital, had had two tests prior to them coming in. Now, I've been approached by Care Forum Wales on this issue and by some of the very large care homes that have been put under immense pressure to take four or five people at a time from a hospital setting, and what they're saying is that one test isn't enough, because we know that you can test negative but actually still carry it.

Andrew Morgan.

Could I say on that one—and I'm sure that Councillor David would agree—that if there's an opportunity for people to be tested twice before they're discharged, because you're right, on occasion, there is a false-negative on the test, then I would say, absolutely, I think all council leaders would welcome that if there was an opportunity for people to be tested twice.

But, what I would say is that I think nearly all local authorities, and certainly with the independent sector, we've been overly cautious because of, obviously, the experiences we've had, sadly, with deaths in our homes, where, even when somebody is tested and comes out of a home, in the vast majority of cases—and officers in the WLGA and I discussed this yesterday with the older people's commissioner—wherever possible, those people, when they come into a home, are almost treated as though, for seven days, they are positive anyway. This has been the case now for a number of weeks where we're being overly cautious, where we're trying to—I don't want to use the word 'isolate' these individuals, but it is, in a way, isolating them to keep them away from the rest of the clients in these homes. Even if they've had a test that says they're negative, to be cautious, there are additional measures in place. Because, I have to say, staff are extremely anxious about it getting into the homes, because the staff see the clients like family members and obviously, they've been devastated by some of the really sad losses that we've had.

So, I would welcome, certainly, the double testing if that was possible, but again, it comes down to being timely. So, we need the tests done in a timely manner, but in particular the results back, and that's where we've had some difficulty, is actually in the delay in getting the results back. It's vastly improved, but at some points, we've been waiting as long as four days for test results.  

Yes. And I wonder—.

Okay. Angela.

Has anybody discussed in much detail with you the use of, perhaps, field hospitals as a step down so that you might come out of hospital into one of the field hospitals in a special area made appropriate for an older person who's then going to go into a care home, where they might then be there for a week or two in that isolation, or semi isolation? Because, of course, as you will know, a lot of the older care homes are small and it's very difficult to have that ability to pull apart some of their cohort to keep them away from the rest of the home.

Not myself. Perhaps Councillor David can answer, but I haven't had any direct discussions on that, sorry.

Okay. Councillor David. 

Yes. So, already we are using local facilities as step-down facilities that were opened up as part of the response to COVID-19. They were specifically opened up for that purpose of providing step-down facilities and they've been very effective, certainly in the Cwm Taf Morgannwg health board area. And I know that, in other parts of Wales, that's also been part of the response, but I think we'll see increasing use of that type of facility, and certainly, I think if the field hospitals aren't going to be used as they were originally intended, they could be remodeled and used for that type of purpose, potentially.

Great. Angela.

Could I ask both of you probably my final—? I want to talk about test and trace quickly, but my final, sort of, point on all of this bit, the current situation: do you have a sense that all of the health boards are on the same page as the county councils throughout the whole of Wales? I know you can probably only speak to your specific areas, but in your WLGA role, do you have a sense that, actually, we're all moving in the same direction, or are there some areas in Wales that are being slightly more left behind?

Councillor Morgan.

Can I just say that that's a very good question and that's something we actually discussed? We had several meetings last week on it and at the end of the week before in preparing for test and trace because, obviously, the health boards are working with us and Public Health Wales. So, what I would say, the concern I expressed was that perhaps, maybe, not everybody was moving at the same pace on this and we had a discussion with the health Minister and Public Health Wales to pull it all together so that, by the end of last week, we were in a good position to then on Monday this week, launch the pilot in a few areas in Wales around test and trace, ready now to learn over this week and next week, ahead of the launch across Wales by the start of next month.

But what I would say—this isn't a direct criticism of the health boards—but what I would say is that I think there was either a different understanding on some areas, but also perhaps a different pace of doing what we needed. So, by having everybody together, we had, I think, Andrew Goodall from the NHS was on the call, there were a number of us there from Public Health Wales, local authorities and the health sector, and basically saying, 'Look now, this is where we've got to get to. Are we all on the same page here? Is everybody actually understanding our roles and responsibilities on this?'. And since then, we've had some progress, I think, over the last two weeks—some good progress. 

Okay. Last question, Angela, before we move on to Rhun.

Yes. I just wanted to expand—and I'm sure that Rhun will then pick it up more—on the test and trace, because you talk about perhaps not everybody is working at the same pace, and as a committee, I think it's fair to say that we might have some reservations of the capacity within Public Health Wales to deliver test and trace. Do you think you could just give us an overview of that and an overview of the ability to recruit the individuals to the programme, and will we really be able to deliver it in time? Is there that capacity and experience from the people that you're negotiating with in other organisations to be able to deliver this? I mean, I have to say that the two county councils that I deal with—Pembrokeshire and Carmarthenshire—their officers have been absolutely stellar in moving all the programmes forward, but I'm not sure how well that's reflected across the whole of Wales.

Councillor Morgan.

So, on the test and trace, I and Chris Llewelyn, as the chief executive of the WLGA, have been leading on this with the local authorities. So, in terms first of all about recruiting, each health board area, because obviously—. The testing is going to be operating in a health board area and then these sub-cluster areas below that, with trace teams. So, we're trying to make sure that everybody has established what numbers of staff are going to be needed, based on the estimates and projections from Public Health Wales and the Welsh Government.

Initially, if I speak for the Cwm Taf Morgannwg area, where Merthyr, RCT and Bridgend have worked from this, initially we won't be recruiting any staff because we have significant numbers of staff who are shielding at home at present, who obviously can do a lot of the work from home, using telephones, because all of this is contacting by telephone and discussing with people and questioning. There will then be our environmental health officers. There's been additional training, so some staff are being redeployed within local authorities where services are currently suspended. So, we're confident, we think, and there has been discussion across local authorities.

I think, from now, we're confident we have the staff available, so we don't need to recruit significant numbers of staff, so that isn't an issue right now. Where that becomes an issue is going forward. If the current stages of lockdown are lifted more and more, and if we get to the stage of more council services being reintroduced, then there is a conflict there, because we won't be able to use those same staff for tracing if we're expecting them to reopen services. So, where we'll have to backfill staff, there will be significant costs, and we've had discussions with the Welsh Government about that to make them aware that this is a multimillion pound, ongoing task, where, at some point, funding will have to come available.

The shielding element—the staff who are shielding—again, it depends how long they're shielding for. If the current three months of shielding, which ends in June, is extended by another three months, that means hundreds of staff—in my authority, it's about 600 staff—that are shielding. Of that 600 staff, a large number would be available then to do the tracing from home using telephones. So, we are working all this through, but in terms of actually the—. As to the advice that's coming from Public Health Wales, Welsh Government is taking the lead on it, and the case officer who is leading on it has been very positive; I've had several discussions with her.

The one area that we need to make sure that we're really on top of, which is partly why we've had the discussions with the Minister over the last week, is the testing, and in particular the timely response of the testing. So, we're reasonably confident that—. I know, last week, in the meeting, there was over 2,000 a day capacity, and it's ramping up to 5,000. I understand that, by the end of the month, we'll have 10,000 test capacity in Wales and we can call on another 10,000 test capacity from the English system. So, I understand, and the briefing I had was, that we'll have up to 20,000 tests available a day by next month.

Now, what that means is, if we are doing testing, we need the results back quickly, because if we are to trace the individuals that that person's had contact with, while the individual is supposed to isolate until the results come back, I have to say that, in some poor communities, where people can't afford to take three, four, five days off waiting, and if they think, 'Well, I only had mild symptoms; I don't think I had it', by day three they may decide to go back to work, or they may decide to carry on with what they do. So, we need to make sure those test results come back, because, otherwise, our tracing job of maybe tracking and tracing five, six, seven individuals could become tracing 30 or 40 individuals, and the whole system then would fail. So, that's where we are in terms of the conversations.

Moving on to Rhun now.

Good morning to you. Are you confident that you know who you're looking to to give you that confidence, you know, that the system is there, the back-up is there, for you to run test-and-trace in an effective way?

Well, each of the local health board areas now have got these sub-groups set up. So, for example, in the three authorities of Bridgend, Merthyr and RCT, my head of public health, the director, is leading on it, working with the other directors in the other two authorities. They are then working with the heads of public health in the local health boards. So, there's a team set up, working this through every day—they have conference calls. The feedback I'm having is that everything is in place, everything is—. We're confident, but the one part that we can't control is that test—the actual test being done in a timely way and the result coming back. We have to rely on others for that, and that's the part that we need to make sure we have absolute confidence in. 

In terms of your role in local government, has it been clear throughout the process what it is that you were being asked to deliver in terms of test-and-trace?

Do you want me to answer, again?

Yes.

Yes, go on.

I think that the trace element is quite clear. I think we're well suited to doing that. I think, when we've had discussions with local authorities, a number of leaders have expressed the view that we have environmental health officers set up and we are used to doing elements of this, for example, with food poisoning outbreaks and other issues we've had in the past—so, when we've had E.coli. So, we are used to doing this tracing element, but I think everybody has to understand that this is on a scale that's never been done before—what we expect them to do. So, that is why we are really pleased that we were able to say to Welsh Government to have these two weeks of piloting, because I'm sure it's not going to be A1 on day one. So, we need these two weeks to find out is the scripting right, what are the issues, what is the feedback we're getting from these people when we ring them, are they responding in the way we expect? So, we will need to learn from that. 

And you've mentioned that you have passed the message to Government that you will more than likely need additional resources at some point to deliver this in terms of additional funding as well. What kind of response are you getting from Welsh Government now on that issue? 

I have to say, in fairness, I, on a Wednesday morning, join, as you're probably aware, the Cabinet, as part of the COVID-19 group that they've established, and the First Minister asked me to join that for the WLGA from week one. Every week, I take the opportunity to raise the issue of more funding and various areas of cost pressure. I've raised test and tracing over the last probably three or four weeks, saying that initially the cost would be very small to us because we can use various staff, but it is going to ramp up substantially. And I have to say, in fairness, the First Minister, the Minister for Housing and Local Government and the Minister for Health and Social Services, I think they all recognise, and we've had various correspondence where they absolutely understand, there will be a cost implication both in terms of staff and financial impact.

But, at present, I suppose the difficulty is we don't know ourselves yet what the cost is going to be, because if, for example, the shielding was extended by three months, in my authority I could say, 'Well, I could probably manage not to recruit anybody for three months.' If the shielding ended, I'd have to find 300 staff. So, it is difficult for us to quantum, but we've put a marker down to say that we know, at some point, if this goes on for maybe a 12-month or more—the test and tracing—there will be a cost to us.

We haven't got time to go into PPE in detail, but I think we just need to get an overview from you of where you think we're at currently. Clearly, we've gone through problems of critical shortages in various areas. Where are we here now on 21 May and, looking forward, are you confident that you will have enough PPE delivered to you from central stocks to cope with the relaxing of restrictions and the additional PPE that you'll need for that, and the flexibility to use PPE in whatever way you think is necessary, not just with, say, social care staff, but also with others at, I don't know, recycling centres and so on? 

Councillor Huw David.

Thanks, Chair. So, initially, all Members will be aware that there were significant concerns about the limited availability of PPE. That has been addressed. We saw the new guidance back at the start of April, which led to a big increase in the demand and use of PPE. We've now got a stable supply from Welsh Government, and we are able to meet the current needs. We are, of course, very cautious, because if restrictions continue to be lifted and there's a demand for PPE in other sectors of society, then that may have an impact on the overall total supply, and I know that, with Welsh Government, we are looking at opportunities to secure future supplies from here in Wales. 

On that question of flexibility in particular, one council leader suggested to me that the message coming from the Welsh Government was that PPE supplied from central stores, or central stocks, should only be used for social care staff—for care workers. That was of concern, because they could see that they will need PPE for all sorts of things, moving forward. Is that a worry?

Could I just say that that was initially the position, but that hasn't been the position for a number of weeks? So, initially, for example, as Councillor David said now, we had difficulties with PPE. As far as I'm aware, no local authority has run out of PPE. First of all, I think we should make that clear. But, what we did come down to is, literally, within perhaps hours of PPE being available, where we had to get emergency deliveries to us and then out to the private and independent care sector as well.

But, initially, I suppose because of the guidance on PPE and everybody was, obviously, very concerned, PPE, I have to say, I think in some authorities would be used, probably, more outside the guidance, which did strain PPE deliveries. But, since then, we've had clear guidance where we should and shouldn't use it. If local authorities can source their own PPE over and above that, then, of course, they're entirely entitled to do that and some are doing it and they can use it where they want.

The Welsh Government has a twice-weekly return system. Now, initially it was once a week, but we asked for it to be twice weekly to be more robust. I believe, if I'm correct, the current days of delivery to local authorities are a Monday and a Thursday. So, we have a delivery twice a week to the central stores, where they are then distributed between a number of local authorities. Local authorities then do a daily return back to the Welsh Government so that they can keep tracking every single day how much PPE we have got.

If there's an increase—. So, for example, in a care home at that time, you only wore a mask and the full PPE if you had somebody who was either positive or suspected of having symptoms. If they didn't have symptoms, then you didn't. If nobody in the home had a symptom, you didn't need a mask. Now, it's changed to that all staff will wear masks all of the time. Therefore, the demand on PPE has changed.

There is a robust system in place. I would say, now, and for the last two weeks I've raised with leaders on a conference call and I've updated the COVID group on a Wednesday morning, that, at present, I've had no complaints on PPE for the last couple of weeks. Initially, I think it was around understanding exactly who needed it and making sure we had those. Ideally, every council leader would like to say to their staff, 'We've got a store of a week's or two weeks' worth of PPE'. Unfortunately, at best we had a day's supply of PPE, and that's why it was critical to make sure we kept getting those supplies.

Of course, care homes—the independent sector, who, previously, would have looked after their own PPE—were struggling. As their supplies were being exhausted because the Governments were buying all of the PPE, we then had to turn to supporting them as well. So, it does have to incrementally step up, but I think it's stable at present and I'm not aware of any feedback, and certainly in the call that we had yesterday with council leaders across Wales there were no concerns raised yesterday.

Thank you, Chair. Good morning. I just want to turn, first of all, to the impact of the pandemic on the social care workforce. First of all, can you just elaborate on some of the challenges there? Also, do you have any estimates of the percentages of the social care workforce throughout Wales who are shielding or self-isolating at any time?

Sounds like one for the social care lead—Councillor Huw David.

Thanks, Chair. I think the impact has been profound on our workforce. Clearly, they're experiencing a very difficult period, particularly with the loss of life that we've seen. We will get you the figures on the current level of staff absence in social services—we will get that to the committee.

PPE was, obviously, an issue initially, but that has been addressed. We also are keen to ensure that the staff are provided with as much emotional support as we can provide. The recent announcement of £500 extra payment for all social care workers in Wales was important recognition for a workforce that has often felt undervalued and overlooked for many years. So, that was a real boost. It's also been really encouraging to see the wider public recognition at last for the sector and the fantastic work that is undertaken by the front-line workers.

Jayne.

Thank you. Thank you very much for that. Can you give your assessment on the new temporary modifications to the Social Services and Well-being (Wales) Act 2014 and how is that going to impact on services and those who need it?

Councillor David.

So, obviously, it's still new. We were part of the co-production of those regulations, and I think they've been broadly welcomed by the sector. What we can do is we can keep the committee informed about how those regulations are being implemented on the ground, but broadly speaking they've been positively welcomed. 

Okay. Jayne.

Are there concerns about prioritising of care in some local authorities?

Councillor David.

Currently, the feedback that we're having is that care continues to be provided to the people that need it. So, certainly, for example, in Bridgend, we have not reduced care packages, we've not withdrawn care from people, and every local authority in Wales has taken the same approach, together with our partners in the independent sector, to continue, and that approach is to continue to provide that care to people.

Can I just add—?

Go on, then—Councillor Morgan.

Just to say, I know that there was concern with some of the changes made, but at the time, when we were first being asked to prepare for the onset of the pandemic, our modelling across local government was showing that we could expect potentially over 20 per cent of our staff off at any one time—and it doesn't have to be an even spread of 20 per cent, we could have had 40 per cent off in social care and 10 per cent in recycling et cetera. So, we had to prepare for a 20 per cent reduction.

So, every local authority looked at plans for how we could reduce care packages, how we could concentrate on the most vulnerable, and how we could redeploy people, ultimately, to residential homes where those people didn't have anybody else to rely on, no family or friends or neighbours. So, there were lots of plans put in place, and I know there would have been a lot of concern around those plans, but they were done for absolutely the right reasons, but thankfully, as far as I'm aware, no local authority had to introduce those plans. But that's quite clearly what the changing of the guidance and the regs was for.

Excellent. Jayne.

Thank you for that. How do you feel about and how confident are you about the voluntary support and how that's available in local authorities, just in case they need to fill some gaps in care and support services? Are you monitoring that throughout each local authority?

Councillor David.

Sorry, when you say 'voluntary sector', do you mean providing social care, Jayne?

Yes.

Yes. So, it's not something we're considering at the moment because, as Councillor Morgan explained, we were preparing for the very worst-case scenario where we'd have very high staff absences. So, we're continuing, for example, to recruit. Every day, we're calling for more social care staff to be recruited in Bridgend so that we are ready if there is a second wave. We've brought people out of retirement, for example, just as they did in the NHS. So, at the moment, we're confident we can meet those needs through the workforce that we have brought together with the independent sector.

Great, that's really helpful. And just finally from me—you've touched on it, around the role of unpaid carers, who are having increased caring responsibilities, and, obviously, a lot of those people are not able to access respite services that they had been before—how are you planning to support unpaid carers throughout this time?

Councillor David.

One initiative, for example, that we've undertaken in Bridgend is that we've launched a 24/7 hotline, a helpline, for carers because we recognise that, potentially, they're under huge pressure at the moment. We're in regular contact with carers as well—carers that are known to us. One of the difficulties, of course, is that we estimate that most carers are unknown to social services, particularly young carers. So, that is, again, an area where we are trying to reach out to as many of our carers as we possibly can. And I know that Assembly Members and Welsh Government are really helpful in that regard, because we do have concerns about carers and about the support they can access.

I'm sure most of you will have seen the reports yesterday of young carers that have a real problem, for example, just undertaking the shopping because people don't see them as young carers, do they? They just see them as children and young people. The carers card has made a difference there, and we are doing more work, again, with Welsh Government around promoting the role of the carers card.

Thank you. Thanks, Chair.

In the final few minutes, the final sections on shielding and exit strategy, and our shielding queen is Lynne Neagle. [Laughter.]

Thank you, Chair—I think. [Laughter.] Just before I ask my question, I would like to place on record my thanks to my own local authority, who have been absolutely outstanding on shielding, and I honestly don't know where we would have been without them, in all honesty.

Can I ask you what you think have been the issues with the shielding system, how you feel it's been working, and whether there are any things you think should have been changed, really?

Councillor Morgan.

Could I say, first of all, I should place on record, I think, thanks to all the local authorities? Because I was called to an urgent meeting in the First Minister's office, with several other officials, on the Wednesday, ahead of the Prime Minister's announcement on the weekend, so we were only given three days' notice that the shielding exercise was to be announced. At that point, when I attended the meeting, because it was on various things with COVID, they said that, in Wales, there could be around 100,000 people who would be shielded; they would need support services from local authorities, third sector—[Inaudible.]—from WCVA. And I have to say that, when I came back and had to brief the other 21 leaders in Wales of what I'd just been asked that all local authorities prepared for, I have to say, the response was fantastic.

I think that, initially, clearly, doing something on this scale, where we are supporting around 100,000 people, is huge. The fact that we had to have the data sets, then, over the following week—they came through in tranches. So, the people who are shielding who are quite happy to have a family member, a friend et cetera, or a neighbour look after them and get them their shopping—all of those people should have, by now, all been telephoned at least once. Some get telephoned once a week, just to check their okay and that they have had support services.

The food-box scheme—we were up and running probably within about 10 days after the shielding. Because, of course, we had to get the list, and then you had to ring thousands of people to see who actually wanted the box. Initially, they didn't cover—because, obviously, these are emergency packages, and initially they didn't cover for people's preferences or for dietary restraints, so local authorities have been going over and above, then, supporting individuals. And I think that's being done in every local authority, where they've provided additional services over and above.

I know in my local authority, no different from many other local authorities, we're even providing dog walkers. So, elderly people who've got dogs in their houses, they can't go out to walk them—we're doing dog walking for them. You name it, I think local authorities have stepped up to it.

The volunteer response, I have to say, has been fantastic. Each local authority asked about recruiting. My own authority had about 1,200 volunteers. We've probably only used a third of them to date, because we have so many staff as well, who are volunteering because they were either told to stay home, because services were shut down, and they couldn't work from home.

So, across local authorities, I think the response on the shielding exercise, while if we'd had maybe a few weeks' notice—of course, I appreciate now these things move very quickly. But if we'd had a few weeks' notice, I'm sure we could have planned better, but the speed of things when the Prime Minister had to make the announcement and the Welsh Government followed suit with the shielding—I think that in the space of three, four, five days, local authorities went over and above. I have to commend all senior officers in local authorities, because I was getting updates well into the night off other local authorities on what they were doing and how they were preparing. So, I hope that if nothing else, this has shown, actually, local government can step up when it's asked to do so.

Absolutely.

Lynne.

Yes, absolutely. I totally agree. I think local government has been absolutely outstanding in response to this crisis. One of the issues I raised very regularly in the early weeks with Welsh Government was my concerns, though, that too much pressure, I felt, was being put on local government to deliver, especially because of the difficulties getting online shopping slots. Now, to be fair, local government has totally stepped up, and I haven't seen any cases where people have been left stranded, but do you think anything could have been done differently to put less pressure on local government?

With more time to plan, certainly we would have done things differently, I'm sure, but what I would say is that in the initial, say, 10 days, we were asked to do everything from provide free school meals to thousands—in my own authority, 8,600 pupils are on free school meals. Local authorities stepped up with emergency childcare hubs. We were working on the shielding exercise, we were dealing with sourcing our own PPE and providing support to the independent sector. You would not want to ever plan to have to do all these exercises in the same 10 days.

But I think that's where—the vast majority of our staff live in their own council areas. The reason my senior officers and those on the front line, I think, have gone over and above is because it's their communities. Actually, across Wales and in local government, we would have planned things differently, but I don't think we could have done much more or much better under the circumstances. I think the time constraints we were given to work—at the end of the day, we know this was about, in some cases, supporting individuals, or in some cases it could mean a difference of life and death.

Absolutely.

Okay. And finally, Lynne.

Yes, absolutely, and honestly, my hat's off to you all on this. Can I just ask then about exit strategy? Are there any lessons you think from what we've had so far? Are there any messages to Welsh Government? I made the point in Plenary yesterday I think co-production with local government is crucial. Are there any key messages for Welsh Government on how we best handle this exit strategy?

Councillor Morgan.

Can I just say on that—and Councillor David will come in now—that what we are doing is we're discussing each element of the lockdown? So, as the Government is suggesting looking at certain areas, they're obviously looking at the modelling about what that means for the R value, because every little bit of loosening of the restraints means the R value could change. Obviously, it's clearly for them and for the advisers to advise on what that impact will be, and then we are giving our views.

So, for example, on council services, we are clear that certain services, even if the Government was to say they could reopen tomorrow—we simply couldn't do it because we have so many staff shielding or potentially off with symptoms. So, it's having those conversations in advance.

Going forward, I'm pleased that they've asked local government to have an involvement in the recovery phase, in particular, the economic recovery, because while everybody is focusing right now on the here and now, the health and well-being of people, if we are to get the economy going when it's safe to do so, then my firm view is we will need a major stimulus economic package, and local government could help drive some of that with the private sector. So, we are having those discussions, but they are at an early stage.

Final word, Councillor Huw David.

Thanks, Chair. I think the lessons for Welsh Government would be: continue that really close engagement that we've had between leaders and Ministers, which is unparalleled in the UK. So, it's not happening in Scotland, Northern Ireland and England, as we're being told by colleagues, in the way it's happening in Wales. Look, we're not getting everything right, but I think that co-production is absolutely vital, about how we exit this successfully. And then, as Councillor Morgan has said, we've got a huge piece of work to do now around economic and societal recovery, and that will need to be rooted in local communities, because the needs and economies are different across Wales, and we know that local authorities just through their spending power alone are huge players in the local economy. We've got to make sure that those recovery plans are based around local communities and their needs. 

Thank you.

Good morning, everybody, and thank you first of all for the written evidence that you've provided us with this morning. First of all, I'd just like to ask about the differing levels of response to the pandemic. Obviously, both health boards are in a slightly different situation, so I just wonder if you could outline first of all the immediate response that you had to the pandemic.

Who wants to kick off? Naturally, we don't need six answers to every question. Shall we kick off with Aneurin Bevan? Who wants to kick off there?

Thank you. I'll bring Sarah in, if that's okay. 

Thank you. If committee members have got our written evidence in front of you, on page 3 you'll see there's a graph of our critical care bed usage. If I could ask you to look at that, because it does tell the story for Aneurin Bevan.

Our first patient was admitted to intensive care and tested positive on 11 March, and was picked up when the surveillance broadened to include people who hadn't travelled. What has become evident subsequently is that the virus had established itself in the community in Gwent by that first week in March. At the time, testing was only based on a travel history, and we only had our first positive on 8 March. But, once we started testing people on admission to hospital who had respiratory disease, you'll see the graph that unfolded pretty quickly for us.

We found ourselves responding to the virus at an early stage of the outbreak in the UK as a whole. You'll see that our critical care usage rose extremely steeply and, at the peak, we had 49 patients in critical care, our normal maximum being 28. So the important thing is that we did cope, but we coped by moving—[Inaudible.]—capacity plans by remobilising our workforce. We have a lovely story about orthopaedic junior doctors working in intensive care, and many other staff who were redeployed from other areas. We also benefited from urgent deliveries of equipment, including ventilators. In the event, it was the consumables that really stretched our capacity—the supply chain keeping up with, in particular, the number of patients who had kidney failure and needed renal filtration. We can talk about that a bit more if you'd like to.

So, the story for us is that it did peak within our surge capacity, but it was important that the lockdown was quickly effective for us. And one of the successes, or one of the good news stories in Gwent, is the way the public responded. We put out messages early on about what was happening, and our local resilience forum partners aided us amazingly in terms of helping to spread that information, and it was an enormous collective effort. I think while national policy provides the context, actually the local response is probably one of the things that we've really learned, response—

Excellent. Obviously, we're starting off with the overviews here now. We'll drill down to the details later. So, the overview from Betsi Cadwaladr. Who wants to kick off there? Simon Dean. 

[Inaudible]—comments. So, the course of the pandemic has been different in north Wales from south-east Wales. We both started, I think, from the same point, which was to plan for potentially a massive number of cases hitting us in a very short time. I'm sure colleagues in Aneurin Bevan did very similar things. So, we built capacity in primary care; we changed our models to provide protected primary care capacity through local assessment centres. We changed our general dental services to provide protected access for urgent general dental care; the same in optometry with an eye care pathway; and we changed our pharmaceutical services as well. So, a lot of work in the out-of-hospital setting. 

We freed up capacity in our acute hospital settings through suspending non-urgent care in line with Welsh Government guidance from 23 March. We created a lot of surge capacity in addition to the normal levels that we would have had through a normal winter period, and embarked on a programme of building three temporary hospitals. Aneurin Bevan colleagues mentioned this: a massive effort from our workforce, and I do want to pay tribute to the efforts that people have put in that have really gone above and beyond in very exceptional circumstances.  

So, just to give a little flavour, we trained 1,863 staff through a back-to-the-floor pathway, delivered through just under 4,200 sessions. Very different models of care in place, and a very strong partnership ethos. So, for us it's been all about preparation. The presentation of the pandemic has been different for us than it has been for colleagues in Aneurin Bevan, but in terms of an overview, it's been all about preparing for a very significant peak.

Great. Jayne Bryant.

Thank you, Chair. That was very helpful. I was just wondering about the issue of the differing levels and the time difference in the pandemic and how it manifested itself in different parts of Wales. Were Aneurin Bevan able to learn as you were going along what was happening, and were you able to share that experience with other parts of Wales and other health boards such as Betsi, so that they were able to understand that?

Aneurin Bevan. Judith. 

I'll come in here, thank you. Yes, we absolutely were from the very first week. The director general of Welsh Government set up calls for the whole of Wales three times a week, and we were able to share through those not only what was happening in terms of the number of cases, how many needed oxygen versus how many needed critical care, but we were also able to share some of the things that we'd found in terms of particular issues around ventilators and the number of patients who needed haemofiltration. So, there was a lot of sharing that went on, and it included other things like the workforce issues, how we'd organised the protecting of staff, how we were providing well-being support, the sorts of issues that were being raised, some of them very practical, and we were able to share that on an ongoing basis. Hopefully, that was helpful to other health boards in terms of preparing them for some of those. 

Great. Jayne. 

Thank you. What changes have you made to governance management joint-working arrangements in terms of managing the outbreak?

I don't know if Ann wants to talk about board governance, and then we can pick up general governance issues. 

There we are. Ann Lloyd.

Yes, thank you, Chair. Obviously, in the light of the escalation of the pandemic in the Aneurin Bevan health board area, we asked all the board secretaries in Wales to collectively provide a view on safe assurance and governance methodologies during a pandemic. As a consequence of the very helpful guidance that they provided to us, our board discussed whether or not we should step down our usual arrangements for board meetings and sub-committee meetings and really concentrate on the very, very important parts of quality and patient safety and the assurance through the audit committee.

So, what we did was—we had four options presented to us to look at how do we run a board meeting. The most extreme of which was that there should be no board meeting and chair's action should only be taken. Well, I rejected that, on the grounds of openness and a necessity to really discus some of these issues. 

So, our first board meeting after lockdown was held with a quorum only and we published the notes of the meeting within 12 hours, and then, the full board meetings two days later.FootnoteLink However, subsequently, we had a board meeting yesterday, we held it virtually, and Wales Audit Office and internal audit and the community health council also joined. It meant that every time we feel that we're coming out of this surge we can re-establish a normal board governance. 

In order to protect the assurance processes in the organisation, we continued to hold the quality and patient safety committee and the audit committee, to which all independent members were invited, even if they weren't members, because I really needed to ensure that they understood and felt able to ask questions in respect of those very important topics. We also put in other governance requirements that Judith and I meet formally twice a week, but, quite frankly, we're on the phone most of the time, and I meet with my vice-chair five times a week. Because if anything happens to me, he has to take over so he's got to know what I'm thinking.

We've had daily briefings to all staff from the executive team and they have also gone to the board, and that has proved to be very, very useful indeed, because we could track the process of this epidemic, and also put into place lots of testing questions around 'So, what else are we doing?' and 'What support do we need?'. As the chair of the chairmen, I've held fortnightly meetings with chairs so that we could share best practice and also learn from each other and, again, like the chief executives, what were the lessons learnt and how did we respond to it. 

I have had regular briefings with the leaders of the local authorities to keep them up to speed and I have been able to feed back—[Inaudible.].FootnoteLink And I have met every single one of my independent members fortnightly to enable them to ensure that we can manage this and we keep it under constant review. 

Okay, thank you. Judith or Sarah Aitken do you want to add to that before we move on to Betsi Cadwaladr?

Yes, just to say, internally within the health board, clearly, we set up our command structures very quickly. We had them in outline actually in February, but implemented them and adjusted them going through March. So, internally in the health board, those structures worked very well, and we had external support from South Wales Fire and Rescue Service, which came in just to give us some critical review and some suggestions about how that might be more effective, which we implemented.

I think the only other thing to mention—and Sarah did touch on it—is the superb work of the local resilience forum through the strategic co-ordinating group and the support we've had from all other public services across the Gwent area. It has been absolutely superb and I just wanted to put on record my thanks to them all, because they've been amazing.

Excellent. And from a Betsi Cadwaladr point of view—shall we have Mark Polin to start, and then perhaps Dr Chris Stockport? Mark Polin.

Very similar to what Ann described. We followed the maintaining good governance framework too. There are some slight differences. Clearly, the key requirement has been to afford the executives the opportunity in which to operate to respond to what has been a complex, fast-changing emergency, whilst at the same time ensure that board is doing its job in terms of governance. And I think we've got the balance right there.

One of the key points with assurance to start with was for the board to be clear about what the command structure was that the executive would put in place to gain the assurance that that was operating effectively and that the right decisions were being escalated to the board, and so on and so forth.

So, there are other mechanisms that we've put in place, slightly different to Ann's. There is a board briefing every fortnight; it is a detailed board briefing. In the intervening weeks, there is a cabinet as I call it—a quorum—that comes together to ensure that urgent business can be progressed and, at the same time, the progress around COVID is monitored through that forum too.

But fundamentally, it's about talking to each other. So, Simon and I are in regular contact. I'm sat here with Chris now. I quite often come across to the command centre to speak to him about what's going on, as do colleagues. So, I feel that's worked.

The vice chair continues to discharge her responsibilities, particularly around primary and mental health, and she receives regular briefings from the mental health and primary leads too. So, I'll stop there, if I may, Chair.

Good, and seamlessly to Dr Chris Stockport, then. Chris.

Okay, thank you, Chair. Just to add to Mark's comments, we established a clear command structure right from the very beginning of this. So, on 6 March, we established a command governance structure that followed through bronze, silver and gold, and was very tightly linked in with our LRF. And I'd have to say exactly as Judith has said, the support that we've had from our LRF colleagues has been absolutely exemplary all the way through this, both in terms of helping us from a strategic perspective, but actually also coming in and helping us with some of that command governance. So, we've had support from North Wales Police in helping us to establish some of the processes that would follow through the command structure.

We have daily briefings that include all of our key decisions that had been made and clear decision logs, which are shared with cabinet members and with our exec teams, and daily meetings between myself and the chief exec, and as Mark has just outlined, also with himself. And then, a COVID exec team that meets three times a week so that we're able to discharge an executive function. That's more focussed towards COVID during these particularly hot weeks, and then is able to feed through into the board processes that Mark has just outlined.

Great. Jayne Bryant.

Thank you. Just finally, Chair, how confident are you that you've had, all along this process, access to the necessary advice, including modelling, that's needed? And, do you feel that your voices are being heard at a Welsh level?

Right, Aneurin Bevan first, then. Judith. Mute.

Yes, thanks. So, yes, we've had various iterations of modelling, I have to say, through the course of the pandemic. In some ways, we were fortunate in that, because the curve hit us first, we had our lived experience to help us work out, from a practical level, where we were on that curve, and to help us make assessments on how compliant the population were being to the lockdown measures. So, that helped us adjust our plan. So, yes, the modelling has been there, it's been frequent.

What we probably do need now is to help us with further modelling as to what might happen from here on in, because, clearly, we're trying to get back to some more routine working, if that's possible in a COVID situation. Clearly, understanding what might happen will be really helpful. But, yes, we've had good access to modelling, good ability to ask questions about the modelling, and good ability to make suggestions and ask questions of Welsh Government as well.

Excellent. And for Betsi Cadwaladr, who is the modelling supremo? Chris Stockport?

Okay, thank you. Yes. So, as Judith has just said, excellent support all the way through in terms of access and in terms of support and in terms of help of understanding the modelling that has been received. I would have to say that we have received lots of modelling, and sometimes, there is a tendency for people to become transfixed around specific numbers, and that has sometimes been a little bit of a distraction, which we've worked through within the organisation and with partners.

We've been in a slightly different position to Aneurin Bevan in that our curve has been different, and so, to some extent, some of the modelling data has not fitted for us in quite the same way, but we have supplemented that with the lived experience that Aneurin Bevan have had and other areas that have been a little way ahead of us, including some of the international data so that we're able to fit our experiences alongside the experiences of other people. 

Okay. In addition, Simon Dean.

Thank you. Perhaps I should declare, of course, that I'm seconded from Welsh Government, but I would like to just amplify Judith's point about the dialogue with Welsh Government colleagues; it has not just been about sharing their view of the numbers, it's been seeking advice from the NHS on impacts on the NHS—the things that are of concern to us as things have developed. So, I believe that it's been a really productive two-way street and that we've been able to influence actions that Government might be considering alongside understanding the modelling, which is always going to be changing to take account of the lived experience.

Great, thank you. Jayne.

Thank you, Chair. 

Right. Moving on, then, to PPE and testing issues. Rhun ap Iorwerth.

Thank you. I think the issue with PPE was the quantity that was needed very quickly and the need to put in place a supply chain that could manage that quantity from sourcing it at Government level through to distributing it to every single frontline worker. The military have been incredibly helpful in terms of understanding that end-to-end supply chain, and in terms of the hospital, we have always had sufficient PPE in our hospitals and we've now got good flow through to every ward. At the beginning, there were incidents where wards may not have been aware of how it was distributed, but we always had it. In the community, I think most supply chains at the beginning were—. They needed to be set up; they weren't necessarily all there at the very start. They are now there and the PPE is flowing through to all parts of the community system in the Gwent area from the regular conversation we have about it at the local resilience forum meetings.

Okay, yes. Much of a similar story, I guess, to what Sarah's just explained. Right at the beginning, there were some issues in terms of community and primary care speed of supply and we intervened by supporting primary care with a small pack for each practice from our own supplies until the supply chain, which comes through the shared services partnership for primary care, kicked in properly.

Since then, we have, through the LRF, had a strong relationship with partners in terms of mutual support and there were experiences where we've shared PPE with care homes, with primary care, and with other NHS providers. So, that's worked really well for us. I think it's fair to say that, in those first few weeks, there were some anxious moments where people were worried whether or not certain pieces of PPE would run out before they were replenished. We haven't actually had any experiences of that, but have had a few close encounters where it has required us to move equipment around very quickly. As a consequence to that, we set up within the first few weeks a PPE cell and took in support from our military liaison colleagues in terms of help to distribute equipment more quickly and to move it around north Wales, and that's worked well. I'd say that, at the moment, we're in a position where our PPE supplies are more predictable. Certainly, looking at the stocks that we're holding at the moment, we have stocks across all of our equipment.

Okay. Angela's got a supplementary before I come back to Rhun.

I will get the hang of this system eventually. Both of your answers were really interesting—thank you. However, it is still worth noting that, as far as the British Medical Association are concerned, in Wales, 67 per cent of their doctors do not feel fully protected. And that's obviously across all aspects of the health board. So, I was quite interested when I was reading the evidence from Aneurin Bevan that talked about it—and you, Chris, have just reinforced the fact that you believe that there's a lot of PPE out there. It does just still seem that the people on the front line don't share that view, and I wondered if perhaps you might care to elaborate on why there is that difference in views. 

Chris.

Okay. Well, I guess, firstly, there will be some professional disagreement in terms of what the right PPE is against the national guidance, and that will in part have influenced some of those views. I can be absolutely clear that, in terms of the recommended PPE coming out from our public health experts, we have at all times had that in supply.

Very early on, there were some questions in terms of some of the supply, which very quickly gathered legs in terms of people feeling that it was more of an issue than perhaps it was. I guess the example I would call out for that is the provision of visors for aerosol-generating procedures. One of the things that we did was work with Bangor University in a collaborative and we sourced our own locally, which actually brought some of those clinicians along to recognise that, actually, those supplies are available and it is possible to obtain the right equipment in the right place.

Lynne Neagle's got a supplementary.

Thank you, Chair. I just wanted to ask a brief question about processes when companies were coming forward offering their help with PPE. I was very grateful to Judith Paget for her help with one of my local companies. But I'd be keen to know if you felt that, on a Wales-wide basis, we'd been sufficiently responsive to those offers of help.

Excellent question. Judith Paget, perhaps.

Thank you. I think, yes, you're right, Lynne; I think in the early weeks—and, actually, it's still happening now—we became inundated with offers of support, which was fantastic. Everybody wanted to help, which was really great to see. Our job in the health board, really, was to link with the shared services partnership, who did a phenomenal piece of work to make sure we all had enough PPE but, clearly, we needed to make sure that any new offers were put through a process to make sure that the standard of the PPE that was being offered was the right standard, because we wouldn't want people to be spending a lot of time and money creating PPE that then was not suitable for use in any of our circumstances.

So, I think that did take a little while to get sorted, and it did feel a little bit clunky to start with. And I don't think that was down to anybody's fault at all; I just think it was the volume of people who were offering to help from across Wales, and the process. There is learning for us all on that, but we did manage to get people through the system and get some of those offers taken up, which was really great to see.

My supplementary was asked by Angela there, really, about the experience on the front line perhaps not matching what the official line is. I was going to quote from the RCN survey, rather than the BMA. Maybe we could get a response from Aneurin Bevan on that, actually: how do you still ensure that not only do front-line staff—not only are they safe according to the guidelines that you are given, but also they feel they are safe when they, you know, want to make sure they have the highest level of protection possible in their minds, which sometimes goes beyond what's in the guidelines? 

I think our infection control team, and our executive lead for PPE, who was Rhiannon Jones, our directive of nursing, spent a lot of time making sure that our distribution systems around PPE were working really well, but also that they provided interpretations of the guidance in visual format, which then could be displayed on wards in clinical areas, so that people understood how the guidance was.

One of the things we did have was that the infection control guidance on the use of PPE did change very frequently during the pandemic. So, keeping people updated and making sure that everybody was clear about the current guidance on PPE was an enormous task for our infection control team. We had to move people into that team, and also then supplement it with staff from our health and safety team, who were helping with fit testing. So, I think it's about regular contact, regular awareness, regular engagement. We met regularly—well, weekly—with the RCN, the trade union partnership members and the BMA, to keep them updated on what was happening to get feedback from them if there were any issues. And I can honestly say, through the whole of the pandemic, PPE availability in our health board area has not been an issue, but making sure that people were aware about the level of PPE required in different circumstances and what the guidance is has been a very big task for us—it's one we have done, but it's been a big task. 

There was concern of course, certainly at one point, that changes to guidance were being driven by what was in the stores, and I remember, for example, when guidance changed on the use of—what would usually be single-use PPE could then suddenly become okay for sessional use. You're nodding, Dr Stockport—do you recognise that that was a problem in the minds of staff that felt that their safety was being compromised at that stage, and how is that being addressed by this point in Betsi Cadwaladr?

Chris.

So, I recognise that those were observations made by some of my clinical colleagues at the time. It's not for me to comment upon Public Health England and Wales guidance in terms of PPE, but what I can absolutely say is never did a situation arise where we were varying our use of single-use PPE. That situation simply didn't occur. Had we had seen some of the numbers that were perhaps projected for coronavirus in the very early days and continued to have trouble with the supply chain, perhaps we would have been in a different space, but certainly that has never occurred. And in terms of noise from clinicians, certainly in north Wales, I have not had a single complaint from a clinician in north Wales to say they've been unable to obtain PPE. Sometimes there's been some confusion about where that PPE might be, or what the correct PPE is, and certainly what Judith has said in terms of posters and videos and the visuals has been very helpful for us in terms of explaining to people that actually a surgical mask is the appropriate mask, not an FFP3 mask, for example. That's been very helpful in terms of allaying some of those fears, but we've certainly not got close to being in a space where we've been reusing equipment. 

Rhun.

The concern is pretty current, though. You'll know that I, as a local Senedd Member, will have written to the health board in the past couple of weeks with concerns in parts of Ysbyty Gwynedd about, 'Have there been changes in guidance, and are we being compromised?'

I'll move onto testing, if I can. We remember the frustrations in the very early days of the pandemic about clinical staff not being able to be tested. Perhaps you could comment on the problems that were caused for you, as health boards, at that time, and bring us up to date on your feelings about the testing system and its ability to fulfil your needs to test your staff.

We're happy to come in, so if Sarah—

Yes, crack on.

Thank you.

As part of our response to what was unfolding in Gwent, I had a conversation with Public Health Wales about testing our staff. We actually started testing our staff from 14 March and were able to test those staff who were symptomatic working in parts of the health board where we knew they had been exposed to patients with respiratory disease. So, for us, we were actually able to test staff from the very early stages. 

I think, in the early stages, that additional testing was part of trying to understand what was actually happening in Gwent and whether—. The question was asked whether we were just testing more people. I think, when you look at the graph, it's obvious that it wasn't about testing—it was about actual spread in the community. So, we tested staff right from the beginning, and it's been a very important part of controlling the spread of the infection in the hospital—knowing that our staff are positive, they are self-isolating, and then understanding where they may have got it from and being able to control that infection. In terms of where we are today and how we control things from here, that is an important area of focus for us for the future.

And there are certainly no shortages of capacity from your perspective as a health board—if you want somebody tested, they can be tested and that is it.

And that's been the case for some time.

Yes, okay. And in Betsi Cadwaladr.

I'll pick that up. Yes, in the very early days, we had significantly less testing capacity than we do now. I think it's fair to say that we got off to a slightly shaky start in terms of the procedures and the policies—everything was moving quickly when we were trying to establish occupational health processes that were suitably accessible, given the geography and those sorts of factors. But I think that we made progress with that pretty quickly and found ourselves in a position where we were able to meet the requirements, certainly for NHS staff testing, at that point.

As the criteria for key workers has broadened, so too has the testing capacity, both in terms of our ability to physically do the tests and the ability of the labs to be able to process those tests in a timely way. That's been particularly helped with the recent availability of testing in north Wales, which has only been in recent weeks. So, we're now in a position where, from a staff-testing point of view, we are testing more staff, including the staff of our partners and other key workers, without any limitation in terms of our current capacity.

On that timeliness, Mark Polin, how much more difficult did it make it for you, as a health board covering the north of Wales, that you were facing 72-hour delays in getting test results back from a lab hundreds of miles away?

Well, it was clearly not ideal, but it was the situation as it stood at the time. We were doing our very best to explain that to our staff in particular, and to other essential workers. As Chris has already highlighted, we're glad to now see the lab capacity here in the north. It is not what was projected at this point, so we will expect to see that improve, and hopefully significantly, because that will help us see the turn around of tests far quicker than 72 hours.

What was the Government's response when you were politely—I was going to say 'screaming at them', but politely raising your voice at them to tell them, 'We need that capacity here in the north in order to get our test results back quicker'?

I think they were responding, as Public Health Wales were, to a fast-moving situation themselves. To be clear, the pressure was in the south, in the south-east. So, it wasn't just on the subject of testing that there was a variance occurring in terms of what was going on across Wales, but it's difficult to argue against that when the operational pressure is arising in a different part of Wales, as it was at that time. What we are keen to ensure now is that the testing capability here increases, because we may yet need it, of course, based on the modelling that we're seeing and the fact that we are clearly running behind the other areas of Wales.

So, the same applies to PPE, we would want to know that the supply moving forward is resilient, because we may not be there yet—and that's always been a concern in the north. Because our colleagues in the south were seeing it earlier, we were concerned that things either might run out or be prioritised differently and then there might be an impact on us up here. We haven't seen that, but it could have happened. Of course, that will always be a concern.

Simon Dean, on this point.

Just to add, if I may, whilst it is the case that some test results were taking longer than we would like, that isn't the norm. Many test responses were coming back much sooner. On the question of the lab in north Wales, the issue was about the sourcing of equipment. So, equipment was purchased, if I recall correctly, from South Korea. So, there was a delivery issue, it wasn't something that could have been brought into play sooner. It was entirely linked with the availability of the right equipment in the lab. It was Public Health Wales ordering it and it was at the mercies of the supply chain. So, they had ordered it as quickly as possible, but it wouldn't have been possible to increase local testing capacity more quickly for that reason.

Okay, Rhun.

On the 72 hours, I'll make the point that we were always told that test results were generally taking 48 to 72 hours to come back in north Wales—that these weren't outliers. Do you want to comment on that, Simon Dean?

I guess—I don't offer this as a flippant comment, but there's a difference between 72 hours and 48 to 72 hours. So, some tests did take a longer period than we would have liked, but that is the case for—. Obviously, the sooner we get test results back, the happier we all are, including the person who's waiting for the result.

Yes. As a local Member, for the record, I was told by people at all levels within the health board that this was a major problem over the past few weeks. Maybe with hindsight you're more relaxed about it by now. Fine, I'll come back with some other questions later, Chair.

Diolch yn fawr. Shall we move on now to the impact of COVID-19 on service delivery? I've got questions from David Rees and also from Lynne Neagle. So, David Rees to start.

Diolch, Cadeirydd. Obviously, we saw some services being suspended and we saw the ways in which those services that are still operational are being delivered differently. What lessons are you learning from the changes to delivery of services? And as a consequence of this—. I don't want to go too much into the reintroduction of services, but as a consequence of this, do you foresee some of these changes being longer term and perhaps permanent?

Okay, who wants to kick off? Judith?

Yes, thank you. I think this is the time to pay tribute to the staff of the health board who actually worked phenomenally in those early weeks to redesign the framework for how care should be delivered, and relocated themselves, redeployed, thought very differently about how we could continue to provide as much care as possible in a safe environment for patients.

So, some of the things that we did were actually to think through some of the models that we've been designing as part of our work on the Clinical Futures programme. You'll know we've got a new hospital planning to be opened next March, and we've been doing a lot of work with our clinical teams about how do we deliver more care closer to home, how do we site services in a single way, how do we prevent patients having to travel to hospital when they don't need to. So, really, we used the pandemic as our opportunity to bring forward some of those changes and to test it out.

So, things like virtual out-patients and virtual consultations became the norm. Thousands—I think it was 26,000 virtual out-patient consultations—happened during April and March. We set up pre-hospital streaming so that we could talk to ambulances and GPs before patients were conveyed to hospital about which hospital would it be most appropriate for them to be conveyed to. We set up single points of access. So, we moved emergency surgery and emergency trauma down to Nevill Hall so that junior doctors could be freed up to support critical care at Nevill Hall. We moved haematology services to Ysbyty Ystrad Fawr. And we worked very collaboratively in primary care. So, our neighbourhood care networks, or clusters, worked very collaboratively about how they maintain access to general practice—are they using technology, but how do they work together to provide support to their patients who were, potentially, COVID positive?

So, I think, moving forward, a lot of those changes will stay. Whether they'll stay in the short term, whether we might need to, for instance, move some things back to Neville Hall before we move into the Grange university hospital is still part of our planning at the moment. But, absolutely, it's shown us how things can be different. And also, the amount of home working that we've done, the use of technology—not only has it saved travel time, it saves the environment, and it's actually saved us quite a lot of money as well. So, there are some really positive things in that too.

And from Betsi Cadwaladr, Simon Dean.

Thank you, Chair. I'd echo everything that Judith has said—[Inaudible.]—changes throughout the whole of the system, from primary care, through out-patients, through the way in which we manage our emergency departments. So, very much the sort of things that Judith has just been describing. And, similarly, we will be wanting to make sure that we are putting in place those things on a sustainable basis, particularly, I think, being in a particularly interesting time from a technical point of view, proving that video consultations can be done safely, to the benefit of patients and staff; it can be a very efficient way of working. So, many lessons to learn, and we will be embedding new ways of working as we move forward.

Indeed. I'm conscious that we've lost Ann Lloyd again. But before we lose anybody else, Mark Polin.

I think it would be remiss of us not to just comment on the innovation that our staff have demonstrated in this time, because they've led many of the service changes. I was speaking to a GP the other day who was insistent that they wouldn't return to past practice because what they were doing now was so good. And also, to commend the public, who've actually responded to those service changes and been very resilient in doing so. It's never easy for anybody to change their behaviour, but our patients and our communities have, and that's been really, really helpful in managing the COVID situation.

Have there been any problems you've experienced? Because everything we try, obviously sometimes there are drawbacks. Are there any drawbacks, you would say—'Actually, we don't want to do that again'?

Who wants this one? Dr Sarah Aitken.

I think the short answer is 'no'. I think—

Fine. That'll do. That'll be fine. I'm conscious of the time.

We like short answers.

A slightly longer answer is that we had—[Inaudible.]. We have done two years' worth of planning to move into the Grange university hospital, and what we've done is implement plans that we had already developed.

Can I add something, if that's okay? It's just that I was talking to some GP colleagues earlier this week and they were saying that about 90 per cent of their consultations at the moment are happening via virtual means, and they did wonder whether we've got the balance right and, actually, we might need to adjust that a little bit. So, they definitely want to make continued use of virtual consultation, but whether it's a 90/10 split is something that they probably can think about again.

Okay. David.

Yes, okay, I accept that. What about the relationship between health and social care services? Has that changed? Because, clearly, there is a huge difference. People have been moving into the care sector, we've seen problems in the care sector, and highlighting those issues. Have the management and partnership between the health services and social care services changed in any way?

I mean, my view is that we had a very strong partnership with our five local authorities before this, and it's just continued during this. We've been problem solving together, finding solutions together, and it's just been a continuation of positive partnership working.

And up north—Simon.

I would echo that. Six local authorities, differences in detail, but very effective working relationships. This has provided us with an opportunity to strengthen the whole system working and to work across boundaries, and I think some very effective work has been going on and will be built on from here.

And just one final point from me, then. We heard of the situation with medicines last week—supply of medicines. Have there been any issues that were perhaps unexpected—[Inaudible.]—to cause you some difficulties that you hadn't anticipated? You know, other additional pressure points coming in.

Judith.

Yes, we can come in. Sarah.

Yes. So, when I was describing our experience earlier and the peak of our critical care demand, the thing that was limiting us expanding further was the supply of intensive care medicines and the renal filtration fluids. So, the supply of medicines was a limiting factor in terms of how far we could have surged. In terms of supply now, there have been a number of changes made safely but allow for more agile use of medicines that have been put in place as part of the response to the pandemic. I'm not aware of any local issues in Gwent at this time.

Simon Dean.

So, a comment that relates back to an earlier point—we were watching with interest Aneurin Bevan's experiences, particularly around renal filtration and the concerns that they were experiencing. That hasn't manifested itself in north Wales. One area that has been a challenge is oxygen supply, particularly for our temporary hospitals, where we need the big fixed plants, which are not readily available across the UK. Again, everyone has been chasing a limited supply. We have sourced supply now, but that was a concern given the prevalence of the use of oxygen in the management of people with COVID-19.

Okay. David, happy?

Yes. Interesting.

Lynne Neagle.

Thank you, Chair. I wanted to ask about mental health. The health Minister has been very clear that he expects mental health to be a continued priority for health boards during this COVID crisis, and I just wanted to ask for your assurances, really, that both health boards are continuing to provide access to mental health services, and to ask you whether there are any issues in relation to that you think should be brought to the committee's attention.

Okay. Judith, first, then.

So, no issues, as such. I think the experiences of our mental health, learning disability and child adolescent mental health services team are similar to the ones we've just described. They moved very quickly to provide online materials, they've provided a lot of virtual consultations, they've kept in touch with service users through other means and they've found successes in that in areas where they probably were sceptical about whether or not virtual consultations would work. They've translated things that were face to face, so some of the road to well-being sessions that you know we run across Gwent—they moved those into virtual sessions, and they've proven to be very successful. The feedback from service users is incredibly positive, so there is something about how we keep some of that going forward, as well. So, similar comments, really, about the real opportunity this has given to find new ways of engaging with service users and families, and the positive feedback we've had as a result of that.

Okay, and Betsi Cadwaladr—Simon Dean.

Thank you. Generally speaking, I'd echo the comments that Judith has made. Lots of pressure in those services, but effective mechanisms put in place. Members will be aware of recent press coverage of some problems in access to primary care mental health services in parts of north Wales. That was a misinterpretation of Welsh Government guidance that was applied by parts of the organisation, by teams working under significant pressure. That was an error that should not have occurred. We are making arrangements to contact all of the patients who were discharged from the service that shouldn't have been. It was more about not being able to take so many new referrals; it shouldn't have been about discharging people currently in contact with the service. So, teams are currently working on contacting all the patients affected and making sure that their needs are being met, and there will be a process over the next few days to do that. So, that's perhaps the one issue that I'm aware of within mental health services for which I'd like to apologise to any of our residents who were affected.

Lynne.

Thank you, that's very helpful.

Rhun ap Iorwerth had a question.

I was going to raise that issue, and I'm grateful to the chief executive for explaining that that was indeed a mistake, it shouldn't have happened. I wonder if you could give us an idea of how many people you think may have been affected, either in Flintshire, where this letter was sent out, or elsewhere across Betsi Cadwaladr, and whether this may have happened in other mental or physical health areas within your control in Betsi Cadwaladr. 

I don't have a precise number to offer to you. I have a sense that it may be in the order of 200 to 300 people, but the team are working through the precise number at the moment. I'm not aware of any other similar examples in any other aspects of our services, whether physical or mental health care—that certainly would not be my expectation. We have had the guidance from Welsh Government. People have worked incredibly hard at a very, very fast pace. This occurred right at the beginning of the pandemic, when things were up in the air. It was a mistake. It shouldn't have happened. I would like to repeat my apologies to any patients who were affected by it, but I am not aware of similar issues elsewhere in our services. 

Thank you. Just briefly again on mental health, that has been cleared up, but of course it's not just the maintaining of what we had that we'll need; we need a ramping up of support for people suffering mental health problems. There's been an under-investment anyway for a long time. This pandemic and the pressures that come with it are causing more mental health problems. Are you putting plans in place to increase investment and to be able to reach out to more people who are vulnerable?

Simon Dean. 

I think that's a really, really important point, Rhun. The way that I look at this is that, over the last two months, we've focused on responding to a potential tsunami of COVID cases, and that's dominated the focus. We're now in a marathon, not a sprint. We're at the stage of starting to be able to think more broadly, because we have the plans in place, which we may still need, to address a very significant upswing in COVID cases, depending on what happens with broader societal measures. But we do now have a bit more space. We're thinking much more broadly, and certainly one of the things that we're concerned about—and I know my chief exec colleagues are as well, because we've talked about it—is the, if you like, hidden risks associated with, for example, lockdown. So, the child safeguarding referrals—we're aware of that, and potential domestic violence, et cetera. So, we have to broaden our focus. Mental health consequences of the pandemic, of the stresses and strains of working in it, of the economic impact, are going to be a major concern for us all. 

Okay, and Dr Sarah Aitken. 

Being a public health doctor, there's a distinction between the mental well-being of the population and service users of mental health services, and I think, building on Simon's point, the impact on the population's mental well-being is going to be considerable. In Gwent, through our regional partnership board with social care, we already had a programme that we were rolling out that was about population well-being, and we are building on that. An important thing people can do for their well-being is physical activity outdoors. So, I think that part of the lockdown measures, and the encouragement to people to go outside and exercise, is an important part of promoting well-being, and it's my own observation that there do seem to be a lot more people out doing that. So, I think the point about vulnerable populations is really important, but, for the general population, I think that's a way they can protect their well-being. 

Okay. Judith Paget. 

I just wanted to add a different dimension to the conversation, which is about the well-being, mental health and well-being, of our staff as well, who've been through the pandemic and will continue to be, some of them, affected by it. We've put a lot of emphasis on mental health and well-being for our staff as we went through the last few weeks, but we've also now taken time, learning from what's happened across the world, from those people who are ahead of us in the pandemic, what the long-term residual impact on staff could be. So, paying close attention to that as well is going to be really important. 

Okay. We need to move on to the next area, which is service and capacity planning, and I'm looking to Angela Burns. 

Yes, thank you very much for that. We've spent a lot of this committee looking back and evaluating what did and didn't happen in various areas. I'd actually, just now, like to look forward and I'd like to ask you to start with: given the situation where we are now, and given that we have been fortunate enough not to have seen the enormous pressure on our NHS that we saw in other countries, how are you planning to move forward and what are you doing about planning for the potential second or third spike scenario, the peaks and troughs? And have you done any modelling as to whether, in your particular areas, you think that your peaks may be substantially higher, or are they going to be more like waves that will gradually diminish? I've a load of other questions to ask, but I just want to start with that, to set the scene about how you're looking forward. 

Who wants to kick off? 

Sarah will come in on that. 

Go on.

I think the point about future waves is a very important one. We know, every winter, that we have a lot of respiratory disease that puts the NHS under strain normally and, if you add COVID-19 to that mix, I think that it would be prudent to plan for a higher rate of respiratory disease for this coming winter. Therefore, we are planning on that basis. Judith will just explain in more detail about what that planning is.  

Go on, Judith. 

So, we took the first draft of an operational plan to our board yesterday, and we're doing significant work—. Hold on. Hold on. Sorry, we've got a note coming up on our screen. Can you still hear me? 

You're doing fine. Carry on. 

So, to look at how we can—. Because we've been maintaining essential and many of our cancer and other services and what it's practical and possible to do. So, we do have a very detailed plan around, if we needed to surge again, how we would do that. And we're also looking at whether or not it is at all feasible and practical for us to open the Grange University Hospital earlier than March 2021. So, there's a huge amount of work happening at the moment around that planning. Clearly, the plans to ease lockdown and how that's going to move forward will be critical to that, because we'll need to model in when those surges might happen. But, other than that, yes, thinking ahead is definitely where we're at now—so, learning from the things that we've done and how they can be reflected for the future, and then what autumn and winter might bring us.  

And similarly in the north?

This is—. Sorry, can I just follow up on that for a second? Judith, I know that this is going to be a really difficult question to answer, no doubt, and I will ask the same of Simon later, but, if you could look at your experience to date, what would be the couple of absolutely key lessons that you would like to take forward in terms of being able to manage exiting this pandemic eventually, and, indeed, having an ace up our sleeve for any other scenario like this that may come along in future?

So, we won't have another experience like we've just had, because, clearly, we were at the very early stages of the pandemic, we had community spread very early in this curve, and so there are lots of things that we've put in place now that we only had to put in place once; we won't need to repeat that. So, for any future curves, we do feel better prepared. I think the thing that's worrying us most is this combination of a flu season and a COVID season. So, I think, thinking ahead how we move through the summer now through to the winter, and then actually prepare ourselves, using all the things that we've just learnt from the last eight weeks to make sure we're able to mobilise and operationalise those in our system to make sure that we cope with that—. And I mean equipment—I mean places, equipment and staff. They are the three things that we have to get aligned in order to have a really comprehensive and sensible response. 

Simon Dean.

Okay. In the interests of time, I would absolutely echo everything that Judith has said about approaches. We're doing exactly the same in north Wales. Perhaps just a question to add: I think we're going to have to not only build in the innovations that we've made over the last couple of months as permanent ways of working, but we're going to have to get used to a system that has to live with COVID within it, and that's going to have major implications for the way in which we use our facilities. So, my answer to your question, Angela, about what would be the two things that I would want to see: one would be not to run the system so hot, because there's little headroom. We're going to have to have social distancing within our hospitals. How can we cope and provide care for people with COVID-19 alongside people without COVID-19 who are coming in for a planned procedure? We need to keep them safe, so how do we create the right architecture in our system so that we can manage a system that is going to have the COVID within it for—well, I'm not a doctor, but it seems to me for a long, long time. 

And the second point that I'd perhaps make in answer to your question is it's all about the people. It's all about the staff. I think the staff have shown tremendous resilience, creativity, innovation and we've got to make sure that we unleash that potential for the long term. Staff have been incredibly flexible; people are doing very, very different roles very willingly, there's a huge amount of training and support that we need to provide. So, if we could do those two things and build in some of the new ways of working, I think we will find that we have more resilience in our system, not just within the hospital setting but within primary care as well. So, we have to have a bit of headroom in the system, and we have to be able to make sure that our staff are resilient, flexible and feel supported. 

Okay. Angela. 

Thank you for that and, of course, I think that the NHS has done what the NHS does best, which is, in a crisis, it steps up to the plate and beyond, and we're all very, very grateful for that, and to each and every member of staff who's taken part in that, whether they are the most experienced consultant or whether they are the newest and most junior member of the team who's given up their training to take part in it. 

But staff—that is the issue. So, I've heard interesting ideas coming from different health boards about perhaps redeploying field hospitals, about creating green zones there so that we can pick up on elective surgery, so we can restart some of the cancer programmes that have been put into abeyance, because, whilst I did hear and I do agree that there have been massive changes to how the public have used the NHS and how they're accessing services, we all know that there are also people out there who are unwell, who are in need of treatment, who are not coming forward for that treatment either because they're scared because they don't want to get COVID, or because, actually, they're trying to show real respect for the NHS and not over-use the service and think, 'Well, I'll just put up with that pain in my chest'. We need those people now to come back.

But if you've got the staff that you've currently redeployed into the front line going back to their normal day jobs, and then we have that pressure in the winter of the normal flu season, the bronchiolitis in the kids, the slips and falls among our elderly people, plus still ongoing COVID, we can't magic staff out of it. So, I just wondered what planning you're already doing into how you're going to be able to fill in those gaps. I think, Judith, you said it was people, places and there was one third thing, but that's what we need. But, of course, the people take a long time to grow. As we've shown with our field hospitals, we can actually chuck those up in days, and really well done for that, but the people issue really worried me and I'd like to have a bit more of a conversation, if possible, with both of you on that aspect. 

Shall I come in? 

Judith. 

So, you're absolutely right, because what we've got to try and do is to make sure that we've got the workforce with the right skills at the right grade to deliver our plan, whatever that plan might look like going forward. And that's a plan for normal—whatever normal is—NHS work now, as well as the potential to keep capacity for potentially COVID-positive patients. So, we've tried to align our workforce requirements with that surge plan that we've put in place, and we went out to recruit and ask for people to come forward to work as part of the pandemic response in our area. And 2,000 people came forward, of whom we've already offered contracts to 792 individuals and others. And they're coming in on a phased basis. So, this will include registered nurses, healthcare support workers, facilities staff. We've had doctors, et cetera. We've also had volunteers to support some of the effort, and we've also had staff redeployed, who, clearly, will go back to their usual work at some point. 

But we've also had nurses who wouldn't be normally in front-line roles, or in different roles, clinical roles, who've taken on new clinical skills training. We've had other staff who've come forward for training. We've had huge amounts of support from retired staff who've come back, some of whom have retired early and have now decided they actually would like to come back to work. So, we've worked quite hard at trying to align that plan, and making sure that we are in a position to bring on staff as we need them. 

It's still a challenge—there are still certain clinical staff. And we could definitely do with more registered nurses. But we have a plan that we are trying to make sure fits the places and the equipment and the people, so that, if we do need to deploy the whole plan as we go through a further peak or through winter, then we have already started giving some thought to that. 

Okay. I've got Rhun ap Iorwerth on a supplementary. I'll come back to you then, Angela. Rhun. 

Yes, just some questions about cancer services really, and how you plan in both health boards to build back up to pre-pandemic levels of cancer services, and for you to give us an idea of what proportion of, say, chemotherapy and radiotherapy you have been able to deliver throughout this period of pandemic, given the enormous pressures that you have faced.

Okay. Where shall we go first? Sarah, go on.

I'm happy to start. I think it's building on that last point about patients with symptoms at home coming forward. And an important part of what we're planning is how do we provide quick access to a clinical opinion, which can be on a telephone or virtually, followed up by the diagnostic test that actually gives people the definitive diagnosis quickly, because a lot of the out-patient activity is for people to get the diagnosis. So, we have been managing to maintain that with all the virtual work.

In terms of people who are already waiting for treatment, we have managed to maintain all of the normal cancer services that we provide. Some of the services that you've just referred to are provided by other health boards for us. And we're working through, for those that we've had to slow down, how we can build them back up again. But it's back to the point made earlier about working differently. We've got to focus on: the point is a quick diagnosis, reassurance for the vast majority, because most people don't have cancer, and access to treatment quickly for those who do. And the same—

Dr Chris Stockport from Betsi on that point—cancer services. 

Yes, very similar to what Sarah's just said, actually—whilst we have been doing less cancer activity, we've also been seeing less referrals coming in. But we've also been spending time thinking about how we might want to manage this as we move forwards. So, as well as looking at our COVID pathways, we've been looking at some of our cancer pathways, and how they might look when we get further into normal business. That includes things like more one-stop-type experiences. It also means implementing a system such as Consultant Connect, which we've recently deployed, which, as Sarah has just said, means that we can get much quicker initial opinions about things and get people into pathways much more quickly.

Going back to Rhun's question in terms of chemotherapy and radiotherapy, I don't have the exact numbers to hand, but this has been a real challenge for us, because, whilst we have protected space in order to be able to continue to deliver chemotherapy and radiotherapy, we've had to take very careful decisions, with individual patients—it's most definitely a conversation to have with individuals—in terms of whether doing those interventions, at this point of time, is right or not, because of the impact it has upon their immunosuppression as they then go back out into their communities. 

Okay. Have you made any assessment on cancer mortality rates or anything like that or are the timescales too tight to have been able to do that?

The timescales have been tight. We certainly will have some data that I'm happy to share with you later, but I don't have any of that to hand.

Okay. Sarah Aitken.

Yes. We have been working with the ONS to look at the all-cause mortality in our community, because we were concerned about the reduction in attendances at emergency departments. And we've seen a small increase in deaths in the community, but actually not a parallel increase, and we're working through whether there may have been some health benefits, in particular from the reduction in air pollution. So, I think that—. So, we are working through that data with ONS at the moment, but, as has been said at the national level by the scientists, the measure is going to be all-cause mortality age-standardised and that is going to be the measure that will tell us, in terms of the population as a whole, what has happened to mortality.

Okay. Back to Angela to wrap this session up.

Okay. I've got two questions. The first is: are you doing—? Obviously you're doing, yourselves, capacity planning and all the rest of it. What are you basing that on—what modelling are you using? Are you taking Welsh Government modelling and then flexing it to fit your particular circumstances? Because, of course, as we've already heard throughout this session, what has happened, for example, in Betsi, has been quite different to the experiences that you've gone through in the southern, south-eastern corner of Wales, where you were really hammered hard and hammered early.

Yes, we're taking two of the Welsh-Government-provided modelling scenarios and then adjusting it based on our lived experience. And we've also developed an escalation framework at which we can monitor on a daily basis where we are against those—so, increases in new attendances, increases in admissions to ITU, et cetera. So, we've got a model and we've got a way of measuring where we are against it.

Okay. And then Simon Dean.

Yes, very similar in north Wales. The only thing that I would add is that, of course, the model is based on a set of assumptions about the context and particularly about lockdown and social isolation measures. As those change, then the modelling will change. So, the planning—. Back to an earlier question, I think the phrase we've been using to describe our approach to planning for the future across Wales—the 'business as normal', if I can put it that way—is 'progressing, but cautious'. So, we're going to have to plan in very short cycles. So, some of the pictures that were in newspapers and in the media over the last few days about beaches in other parts of the UK, where social distancing didn't appear to be a strong feature—that could have significant implications. It may not, but it might have significant implications for the presentation of the pandemic, which then would change the modelling. So—[Inaudible.]—of things changing.

Thank you for that, because I think, as a committee, we've heard evidence over the last few weeks that hasn't necessarily filled us with confidence on some of our modelling ability and what I'm seeking reassurance from health boards on is that, as our R number changes, even in 0.5 of increments, the model will then also change. So, if we suddenly find ourselves at 1.1, 1.5 or down at 0.7, there are a whole series of different models. We've had the impression before from some organisations that there's a static model, and that's it, and I want to see that flex and—.

Simon.

I think the approach that we've taken, and it's the same with other colleagues, is to build capacity into our system. Ten weeks ago, we were looking at—this week, actually, would have been the first of our peak weeks, so we were planning capacity for a huge volume of COVID cases. So, we have those plans in place and we're able to scale up towards the use of that capacity as circumstances dictate, and I think that's what Judith was saying about the escalation plan in Aneurin Bevan—so, having the capacity to cope with very high numbers of cases. Thankfully, we don't have to use it currently, but we need to know that we can bring it into play quite quickly, which is why, as we do more planned surgery, for example, we have to do that in a way that we could stop pretty quickly should the need arise to switch our capacity—

Okay. Dr Sarah Aitken.

I was going to add that the upside of having lived through the experience in Aneurin Bevan is that we could see in our data that it was starting to increase, and we have already put into practice the measures that we would need to take. We wouldn't wish to live through it again, but we do have that added confidence of having done it once.

Thank you. I've got one final question, and it's to Aneurin Bevan, because it was in your evidence. We’d like to leave on a cheerful note. Could you just expand a little bit on your 11 national clinical COVID-19 trials, just to sort of just give us an overview of what's happening?

Thank you—thank you for that opportunity. Our research and development team, who are a very small team, were incredibly proactive from the very beginning. So, these research protocols existed in anticipation of a pandemic, and they implemented them and joined the trial quickly. So, we have joined all of those significant trials and are now benefiting from the early results.

One trial has already reported, which was 17,000 patients in the United Kingdom and the description of COVID in those patients and what the outcome measures are. That's enabled us to then look at our own outcome measures and have a view about how we're doing. And I'm pleased to report that our outcome measures are actually, across the piste, better than that average.

So, being part of those trials and generating the evidence, and then being able to learn from it, has been a very positive experience. We also have a number of clinicians who've started up—. They're evaluating the service changes—so, relevant to earlier questions—and looking at the benefits from those as well. And our primary care doctors have looked at a series of 100 patients who were admitted to see what we can learn from those. And, yesterday, I had the update from our intensive care doctors who are looking at their patients as well.

So, that culture of learning as we go, applying it, evaluating, has just come through across the organisation, and thank you for the opportunity to tell you about that.

Excellent stuff.

Interesting. Thank you.

A little point from Simon, then we go to Lynne Neagle. Simon Dean.

A quick point. Certainly, the equivalent response from a north Wales perspective would be that we've got four studies currently under way, five in set-up stage, and eight more in the earlier stages of development. So, the learning and the research is critically important for us all to participate in.

Excellent. The much-anticipated final part of this session is supporting the recovery stage, and Lynne Neagle has some expertise in this area. Lynne.

Thank you, Chair. I only wanted to ask the one question, really, because we have covered quite a lot of this. I just wanted to ask, in terms of the recovery, if there is anything else you think that Welsh Government could be doing to assist health boards.

I also, if the Chair will indulge me, wanted to say 'thank you' to both health boards, but, from my point of view, especially to Aneurin Bevan health board, which is the area I represent. I was so fearful when we saw the start of the pandemic there, and I just wanted to place on record my thanks for the immense effort that has taken place from front-line staff, right up to the leadership of the organisation. Thank you so much.

So, you can take this as a cue for some final remarks. Shall we kick off with Aneurin Bevan, then?

Yes. Thank you, and thank you, Lynne. Yes, I think the response from the organisation, from the staff, has been overwhelming, but the response from the community and the people living in our area has been equally overwhelming as well. It's been a difficult experience, but there have been so many positives that have come out of it.

I think the one thing that is left with me, really, and the thing that I think we need to work on nationally, is how do we support our staff now as they recover from their experiences through this as well. We ask a lot of our staff, and there may be further peaks in the pandemic, and there most definitely, probably, will be a difficult winter ahead, so I think how we focus our collective efforts to support the well-being of the health and care staff, wherever they are, is going to be a really important one for all of us, I think.

Okay. And closing remarks, Simon Dean and perhaps Mark Polin to wrap things up. Simon Dean.

Thank you, Chair. I'm going to echo comments from Judith there. I think there's something about the opportunities for positive change that come from the experience and the learning, and absolutely through the innovation of our staff. I think there's something about strength in relationships across the system, and the reason I say that is because whilst the NHS needs to recover, then so does the whole of society. There are massive impacts on the economy, on social care, on partner agencies. So, I think that strength in relationships will stand us in good stead. We had our first meeting of our multi-agency recovery group yesterday and a multi-agency response is absolutely critical to recovery, and I'm sure that Welsh Government will be thinking along those lines as well.

Okay. Mark Polin to wrap up.

I'll just echo the last point first of all, Chair. I think that not just the health board but partners have stepped up in the response to the emergency. There's lots that we can learn from that, particularly in terms of how we manage the relationships, communication and work together.

I think the other thing for me from a Welsh Government perspective is we need to be clear about the frameworks that we're going to be working to moving forward, be they in terms of performance or be they in terms of finance, for example. The sooner we get clarity around that the better, because how we move forward together is, of course, going to rely to a high degree on those frameworks and the operating parameters that we need to perform to.

Thank you. We seem to have lost Ann Lloyd again. Lynne, did you want to just wrap things up from your point of view?

I think that's fine, thank you. I think those are helpful points and I'm really glad to hear the messages about taking the positives going forward as well, and thank you all again.

You came back just in time for some closing remarks, Ann. Sorry—you've got about a minute to say something nice about the whole situation. Ann.

Thank you. We've had an unprecedented challenge in Aneurin Bevan, as you have heard today. However, I think that my first responsibility is to pay a real tribute to the magnificent effort that has been made by our staff who have shown real, unwavering commitment to the care of our patients at all times and in some very, very difficult circumstances. I am very grateful indeed, as is the whole of the board, for the work that's been undertaken by the executives and the LRF and our partners and the command structures that we established, in whom we had absolute confidence although we have interrogated them a lot. I think they've intelligently steered our organisation through this pandemic and are steering us now, as agreed by the board, through the next stage.

I think it's been really good to see the changes in practice that have come about that we've been trying to achieve for years, and clinicians have willingly adopted new practices that have been good for patients, and we're evaluating all of those, and everybody's been so committed. The board has been really impressed by the work and the achievements of all of them and our working with partners, and their real dedication to achieving a really good outcome for people and managing our staff really well in very hard circumstances. So, I think that's all I have to say.