National Assembly for Wales

Thank you, colleagues, and thanks for the opportunity to discuss this issue with you. My job as chief medical officer, really, has three roles. One is to provide advice to Ministers, the other is to be the medical director of the NHS and the third is to be an advocate on behalf of the health of the population. Those are my three main duties and they persist through the coronavirus work, really. So, really, what I've been trying to do during this epidemic, this pandemic that we're facing here in Wales, in common with the rest of the world, is to provide the best advice that I can to Ministers so that effective decision making can occur within Welsh Government, and we can make the best decisions in very difficult circumstances on behalf of the population.

The second responsibility around being the medical director of the NHS has involved me in those discussions about reconfiguring the NHS, about liaising with directors of public health and with medical directors and chief executives, and thinking about how we can meet the challenges that coronavirus has posed to the health system.

In terms of providing that advice, and also understanding how the virus has been affecting Wales, a really key part of my job has been to look across the borders into the other nations in the UK and beyond into other nations around the world to try to understand what is happening there. We have very deep and, I would say, effective co-ordination across the four chief medical officers in the UK—my colleagues in England, Northern Ireland and Scotland meet on a very regular basis. And that really helps in terms of getting some consistency of advice, and in terms of understanding what is happening elsewhere. So those have been, really, what my main duties, I would say, have been.

Okay. Rob.

Hi. I hope you can hear me okay. So, my role as chief scientific advisor for health is to provide scientific opinion, and to be able to deconvolute complex scientific information to inform policy making. In normal peacetime, I provide this role. I'm also policy sponsor for the diagnostic programmes outside of coronavirus, so that would include imaging and pathology and genomics, and other areas.

With regard to coronavirus specifically, I interact with the Scientific Advisory Group for Emergencies group as an active member; I have been doing so since early February. I join SAGE meetings twice weekly. Early in the outbreak, both the CMO and I identified a need for our own technical advisory group to interpret the scientific information that was flowing from SAGE and its relevant sub-groups. We formed a technical advisory group that's composed of experts from universities, Public Health Wales and within Welsh Government, and that group sits three times a week. The principal objective of that group is to reduce direct and indirect harm arising from coronavirus, and we work to provide advice to the NHS in Wales, to our local resilience forum, and our strategic co-ordination group. So we really do work hand in glove with our colleagues and counterparts from around the UK—

If I could just stop you there for a second, that doesn't mean that there's a Welsh SAGE. And in Scotland, for example, the First Minister took the decision to set up a new scientific advisory panel. What's the difference between that that we're seeing happening in Scotland and what's going on in Wales?

In my mind, there's no difference. We have a technical advisory group that is interpreting the scientific and technical outputs of SAGE into a Welsh context. That group meets three times a week. There are very active conversations, and it's an excellent forum for debate and forecasting what we think the future might look like, interpreting the models, and providing that information to our decision makers, to inform debate and policy development.

Okay. Rhun.

Thank you. Back to Dr Atherton before my colleagues come in, what weaknesses have you found that have meant that you've had to change maybe lines of command or operational structures over the past few weeks, in terms of, I don't know, the need for you to be able to be more proactive, the need for you to have better access to some decisions, and so on?

I think it's fair to say that the command and control arrangements within the Welsh Government have evolved over the last four months during which we've been dealing with the coronavirus epidemic. We—

Sorry, Frank, can you speak a little louder? You're a little bit quiet on my input. I know it's valuable, and you don't like thrusting yourself forward as a forceful personality, but sometimes it might be worthwhile. Diolch.

My apologies, Chair. I will try to speak louder. What I was saying, Chair, and colleagues, was that the command and control arrangements for managing this epidemic over the last four months have really evolved, as one might expect. Initially, it was seen—if you think back to early January—as purely a health issue, and we managed it accordingly. We had, of course, a good starting point, in that we have, in Wales, as across the UK, a pandemic flu plan, which was the start of our arrangements for command and control co-ordination. 

As the epidemic emerged, it became clear that this affected all parts of society and so, the arrangements that we have for managing the outbreak, managing any incident, through the activation of our emergency control arrangements did take place. And so, it moved from being a purely health-focused issue to a much more co-ordinated cross-Government issue. And that was right and proper.

Okay. Rhun, do you want to come back before we move on? No. Okay, David Rees.

Diolch, Cadeirydd. Can I just go back to the question of science? As we know, the First Minister in Wales, the Prime Minister and other Ministers across all Governments have been continually saying that their decisions are being driven by the science, and therefore, it's important for us to understand how that science comes to the advice it gives to Government. Now, Dr Orford, you've indicated that you participate in SAGE and that there's a Welsh technical advisory group, effectively. Regarding SAGE in the first instance, when you say that you participate, now, we understand that perhaps participation is that you submit written questions prior to them, but you're not allowed to actually actively speak within those meetings. Can you confirm whether you are able to speak and take part actively in those meetings, or not?

I am an active member of SAGE and I do speak regularly. I'm the chair of our technical advisory group and I must say there are very good conversations in SAGE and I'm very grateful for the forum that SAGE provides and that enables that scientific debate, which is unrestricted and is a very good structure to have in place, and I'm very glad that we're active participants in that forum.

Thank you for that. It's very important for us to have that clarification. And you said that the technical advice group meets three times a week and SAGE about twice a week. Do you meet as a group before the SAGE meeting so that you take forward the group's consideration of questions and issues that you wish to raise with SAGE? And then, do you have discussions following those meetings to disseminate the answers you get to be able to give advice to the Welsh Government?

Absolutely. So, we're meeting on the different days of SAGE so that we can anticipate what's coming forward and also the outputs of SAGE and help contextualise those for Wales, for Ministers in Wales and for policy makers in Wales. So, so far, it's proved quite an effective way of operating, where we constantly—[Inaudible.]—and we constantly look at our membership and look at the challenges ahead as we move through this epidemic forward. So, we'll need to continue to do that.

And clearly, the science, technically, should be the same, because science is science as we know, but the circumstances and the context in which you may want to get advice may be different. And, therefore, as a consequence of the science being the same, but the context being different, are you coming up with a different set of advice for Welsh Government, based on what SAGE may be giving, because clearly, the emphasis of the pandemic in England has been around London and the south-east, whereas in Wales, it's been around the south-east of Wales and there are different implications as to how that will be addressed. Are you, therefore, giving slightly different advice based upon the context?

We do have to think about our local demographic and also the differences in some of the outbreaks, whether that's in the south-east or the south-west, as well as thinking about that at a national level and the granularity in our advice. I think, it's fair to say that we've been broadly consistent with the SAGE outputs and our advice. As you say, the science is the science, but it's about contextualising that for a Welsh population.

And do you use the SAGE modelling or do you have your own modelling?

We use several different models. We absolutely use the Imperial College and Warwick models and the London School of Hygiene and Tropical Medicine model and we also reflect that in our own observations. So, locally, we'll look at ICU capacity and ICU occupancy deaths and hospital admissions, and other surveillance systems that we have in Wales, such that we're using what we have available and that are well-proven and well-trodden in Wales. So, I feel very confident that we have very good advice with excellent access to experts in Wales, and we have very well-formed mature relationships and networks in place to enable those conversations to be free flowing in Wales. It's quite positive.

Okay, David. 

One quick question. Do you have access to the data that SAGE has? And are you confident in the data you receive for your contexts? Because, clearly, we've seen some lack of data coming through from Public Health Wales. Are you confident you're getting all the data you need in Wales? 

Absolutely. 

Okay. Happy, David? 

Yes. 

Diolch, Chair. Good morning. You've mentioned, Dr Atherton, this morning, that a key part has been looking across the border and further afield to try to understand the scientific evidence. Can you perhaps say a bit more about the international scene that you're setting, the scientific evidence coming through that? There must be so much information coming through internationally, and how's that contributing to what we're hearing in Wales? 

Yes. So, through a variety of routes we've had bilateral discussions with a number of countries to try to understand how the epidemic is unfolding in other parts of the world and to see what we can learn from those countries. So, from my recollection, I've had discussions with colleagues in South Korea, recently in Germany and in Sweden most recently. And those are invaluable, because every country has a slightly different perspective and slightly different response and so that's important. I think what matters in Wales, and one thing that I have flagged with my colleagues in Public Health Wales, is that the bilateral relationships are really useful, but we need a more systematic approach to understanding what is happening across other countries.

The Welsh Government does have a way of trying to look at the different restrictions that have been put in place in other countries and what impact that is having. But I feel we need to have a better, if you like, scientific view of understanding exactly what's going on. It's an issue I've raised with chief medical officers and also with Public Health Wales, and they are currently looking at how we can systematise that. We do have some extremely good links through Public Health Wales, in fact, not least through an organisation called IANPHI, the International Association of National Public Health Institutes, of which Public Health Wales is a member, and that is an effective route. We also have some links, of course, with the WHO, but I would like to see us having a stronger, more systematic way of understanding what is happening across the world.

Okay. Jayne. 

Thank you. In terms of what's happening in Wales, are we feeding into all the data and making sure that the Welsh examples and the experiences here are learnt as well, across not just the UK then, but across the world as well? 

Yes, indeed, that's a really important point. It's one that—. Again, that's why I have these conversations, so that we can show what's happening in Wales, so we can talk about the issues and challenges that we face, but also the successes we do have here. So, very much, it's a two-way street, yes. 

Thank you. 

Okay. Rob. 

So, there's some fantastic work going on in Welsh Government. Our office for science are working with our colleagues in international offices, understanding what's happening in different countries and feeding that back to us, and they're constantly reviewing that and feeding that back to our technical advisory group. 

As well as sharing information, Public Health Wales in a specific example, the pathogen genomics unit—absolutely amazing staff there—I think they're third in the world in uploading pathogen genomics sequences for people to analyse and for us to use that information to look at disease spread. So, there's an enormous amount of sharing. Many of our—. Pretty much all of our experts have their own informal and formal networks that they play into, so there's quite a healthy environment of sharing in science, as there always has been, and it's important that we learn from others and not reinvent the wheel here in Wales. And we're observing good practice and bringing that into our own practice and being iterative, and I think that's the nature of science, it's both iterative and peer review. 

Thank you, Chair. I had a couple of questions about shielding for Dr Atherton. Dr Atherton, there have been challenges, as you know, with the shielding letters. I suppose that's not surprising given the scale of the challenge involved. I wanted to ask first of all about what your role was in relation to how GPs are handling shielding enquiries because I am still finding that there is an inconsistent approach between GP practices in terms of how they're handling it. Some GPs are dealing very readily with patients, but I've also had other GP practices where patients have been told, 'Well, this is a matter for the Welsh Assembly', which is, of course, wrong on both counts, really. So, can you just explain what your role has been in terms of managing that whole shielding process at a local level?

From what I said at the beginning, my first role in this was to work with the other chief medical officers across the UK to identify shielding as a potential measure for mitigating the impacts, not on the transmission of the virus you understand, but on the deaths and disability that might accrue from people who are particularly vulnerable being infected with the virus. So, at a policy level, there was a discussion there. Wales of course chose, quite rightly in my opinion, to go with the rest of the UK and to initiate a shielding process.

It was then slightly differently managed. There is a difference between agreeing on broad strategy and then having variants in operational detail. In Wales, we took the line that we didn't really want to put an additional burden onto general practitioners who were already really struggling with workload, so we took a rather centralised approach of identifying through our information systems those patients who we agreed at a UK level were those patients groups. So, we used our IT systems to identify them and write directly from Welsh Government as opposed to through GPs.

We always recognised, and thank you for acknowledging the point, that it was a complex system put in place very quickly, and we always acknowledged it would not be perfect. Our ambition, as I recall, was to get it 85 to 90 per cent right and then to learn as we go, and that's really what we've done. As you well know, there was a problem that came to light around old addresses being on some of the databases. That was corrected, so some people got letters later than others.

There is, of course, a lot of debate by different organisations—let's say patient representative groups—who sometimes feel that the patients they represent should be included in the shielding group, or indeed not included. It's worked both ways. So, there's been a lot of discussion and we've tried to maintain, again, a four-nation approach to that, which has been partially successful. There is now a group on which Wales is represented that works across the UK. So, as we get new requests in from these patient groups, we have somewhere where we can sift those.

With regard to the GP issue, I've talked quite regularly with the British Medical Association and the Royal College of General Practitioners about this, and as I say, we tried not to put a burden on to GPs, but we always recognised that there would probably be some patients who might slip through the net and who might be in those vulnerable groups but didn't get a letter, and there's always been a facility for them, of course, to go to their GPs and to make the point, and GPs do have the ability to issue a letter on our behalf for those patients who may have slipped through the net. But by and large, we've not been asking GPs to lead this for the simple reason that they have other priorities to discharge.

Okay. Thank you. In terms of the—. You referred to the patient groups and the lobbying, and I do recognise that that has been a particular challenge, but can I just ask: are there now different patients classed as shielding in England as opposed to Wales? To give you an example, the issue of splenectomies—and I'm sorry if I haven't said that correctly—apparently that has been added in England, but is not on the list in Wales, and something like that then, you've got a patient group that is clearly communicating across the UK and that is causing problems. So, can you just clarify whether the list of actual shielded patients is the same in England and Wales, and maybe say something about splenectomy, because in Wales splenectomy is classed as an at-risk condition rather than extremely vulnerable?

Yes. I think there may be some variations that have emerged over time. I don't know the detail of splenectomy in England, of how that's being managed, but there have been a few groups like that that have argued that they should be included. The basic principle was that we were trying to include groups of patients who were particularly at risk and there has been, I think, some lack of understanding, I would say, in some areas about the difference between the most vulnerable group, the shielded group, and the groups who are particularly vulnerable groups, which essentially is anybody who's eligible for a flu vaccine and people who are elderly. That group, of course, is advised to be particularly rigorous about their social distancing but are not in the shielded group.

Splenectomy: I haven't been approached directly by any group representing splenectomy, but that's an example of why we tried—and perhaps we didn't do it early enough—but why we tried to create a structure across the four nations so we could have consistency. There have been a few other cases where, for example, patients on renal dialysis were not originally included and we had quite significant interaction with renal societies who were arguing that they should be included, and then, rather than being dealt with on a single country basis, that was referred to this panel, which made a decision and then a recommendation came to the CMOs and that was agreed that they should be included. The question of splenectomy has not, to my knowledge, come back to that group of chief medical officers. So, I'm a little bit surprised, if I'm honest, to hear that England has gone down that approach and it's something I will go and check up with my colleagues. 

Okay. Lynne.

Thank you, yes. An example, it is, really, of how not having a consistent approach can cause difficulties for patients. Thank you.

Well, thank you for a rather loaded question. I have to say, I don't regard our testing as a failure in any sense. We were very—. We got on to testing in Wales very early and one of the successes that Jayne Bryant was mentioning earlier was that we did have the ability to, because of our skilful laboratory staff—we have some very talented virologists there—develop testing early in Wales, much earlier than other nations. So, at a time when, really, all the testing was being centralised on Porton Down, we managed in Wales to get testing on board and, of course, we have over time increased our testing capacity, as you know.

Just on the numbers, I have consistently advised Ministers, the media and everybody who I speak to that it's not the numbers that matter but how we use the tests that matter, and we have been very consistent in Wales about our approach to testing and what the purpose of our testing is, and the first priority has always been to support patients to make sure that patients coming through our system are tested where they need to be. The second priority has always been to look after our health and social care staff and—

Can I just stop you there for a second? Who got it so wildly wrong that you suggested you might need 9,000 a day by the end of April?

Dr Orford?

Yes, I can come in. So, initially, when we put the testing plan together, we estimated what that need was. That need has not been modelled. None of the big numbers have been modelled, but they're starting to be modelled, and I agree with Frank that testing is important, that you use that information into action. Coronavirus—this SARS-CoV-2 virus—is interesting in that people could be infectious before they're symptomatic. The best way to undertake surveillance is for you to know yourself if you're symptomatic or not, and then for you to take actions that if you've got a testing infrastructure in place and it takes 24 hours, then you could have been in isolation for 24 hours with symptoms. So, the utility of testing, really, is to use that information to inform action, and if that action is providing the right care pathway, or patient management, that's really important if it's to enable people to come back to work earlier. You'll only come back to work if you're negative and if you're not symptomatic with other diseases. So, the utility of testing is around the action at the end of it, and so it's important to say that this is a clinical pathway. I think a lot has been said about other ways in which we can test, but we've got a very robust procedure in Wales. We've got very good IT architecture in Wales, and we're operationalising a plan based on the targets that we've set ourselves, and we haven't dropped our targets. We are working towards—

You have dropped your targets. The target was to be testing 9,000 a day by the end of April. I'm happy for you to say, 'We were way out. We didn't need anything like that and we've learnt as we've gone along.' But we were told that we'd be testing 9,000 a day by now, so my calculation suggests we would have done 200,000-plus tests in Wales. If you're saying that doesn't matter at all and not a single life has been lost because you were 10 times out in your estimation of how many tests you should be doing now, that's fine, but—.

As I say, that was our forecast that we were aiming for. We haven't cropped our ambitions in terms of the number of tests that we're doing, but—

So, you'd still like to be doing 9,000 tests a day now?

So, we're not publishing the number of tests that we're aiming for, but the internal numbers are significant—

You did about 700—well, the Welsh Government conducted—Public Health Wales—700 to 800 tests on a few days last week. Fewer than 700 tests, I think, one day. That's quite a way off 9,000 tests a day.

And either side, I think it was 1,200 tests and 1,300 tests, again, using those tests—

Compared with 9,000. What I'm trying to get at, and maybe you can tell me it's not important, but, to me, it sounds as if we are falling way, way behind where we were told we'd need to be, and if you're saying, 'We were really wrong. We don't need 9,000 tests a day or anything like it,'—

So, when we made that plan, I think I made the forecast back in early March and, of course, we're at the end of April now. If you reflect backwards, the reasonable worst-case scenarios that we'd forecast for unmitigated access of this virus into the community was significant. The control measures that we've put in place have suppressed the epidemic significantly in Wales and across the rest of the UK. And so, some of the forecasts were based on potential numbers that we might be seeing coming through the door at hospitals each day, and that's been a success story that perhaps we haven't considered. The might of the public in observing those social distancing measures has suppressed the epidemic so significantly that we're not getting the anticipated flow. So, with everything that we plan, in any planning, we expect the best but we prepare for the worst. So, we prepared for very large numbers of people coming into the NHS, and you can see that in the infrastructure that's been brought online.

What we see, of course, is that in countries where they did decide, 'No, do you know what, we are going to keep on with these very high daily tests numbers, and we're going to go through the stringent social distancing measures', they've managed to keep mortality rates lower, and an obvious question to ask is could things have been done differently up to now, and can things be done differently from here on in?

Chair, I wonder if I could just continue with what I was trying to say? I will come back to the point about what other countries have done. Our approach in Wales, as Rob has rightly said, is focusing on the patients. We had to plan for a significantly higher number of patients than we've seen. That represents a success in the NHS—that we have not exceeded our capacity—and that's a positive thing. We don't believe in testing for testing's sake; we have to test for a purpose.

I've talked about the patients, the health and social care staff and that we need to keep things moving. Key workers are another area where, obviously, we have increased testing, and, as our testing does further increase, we can expand that group.

The fourth area really, really importantly is around better surveillance so that we can understand where the disease is, how it's moving around and using possibly a track-and-trace. Now, just to answer, before colleagues come back in, the question about other countries, Germany is often cited as the place—and I had a lengthy discussion with my colleagues in Germany about this—. Germany was in the fortunate position that they had, before the coronavirus broke upon the world—this coronavirus—a world expert in coronavirus who'd been researching this for 20-30 years. They also had a network of public health laboratories—300 of them around the country, around Germany, the federalised state as it is—which were able to do that. So, they were in a much better position and they had a chemical industry that was able to produce the reagents.

They were in a very different position, and, of course, there's been a lot of comparison with Germany. One of the things that we do learn and share when we have these calls is that every country's trajectory is different, but we don't know what the end point of any country is as yet. It's interesting that Germany and Sweden—both countries I have spoken to recently—have the same kinds of issues that we’re seeing, for example, in the care home sector. I'm sure we'll come on to discuss that. So, we're not alone in experiencing these problems, but we do have different trajectories.

We could go on and on. We'll have plenty of opportunity to ask these questions again. But, I just think, we take decisions here in Wales—like the decision not to test in care homes, for example. These are decisions that are taken and they have an effect. I've been reading a report this morning from the Centers for Disease Control and Prevention in the United States, looking at how pre-symptomatic testing is really, really important in care homes, because of the sheer speed that COVID-19 can spread through care homes. Now, you've taken a decision in Wales not to pursue testing in care homes. These have an impact, and maybe you’d like to comment on that, briefly.

Our approach to care homes is a really important question because hospitals and care homes—closed settings, generally—are places where the virus does transmit and transmits easily. That's not that surprising, because the flu virus every year affects care homes. We do have, of course, in the care home sector, a well-trodden approach to dealing with respiratory outbreaks and, at the start of the epidemic, of course, we applied those. That involved testing groups of patients when the disease was—[Inaudible.] A typical approach to managing an outbreak of respiratory infection in a care home involves testing up to five patients. Once you know it's in a care home, it's in a care home, and anyone who is symptomatic should be treated as though they are positive, and that was our initial approach.

We did move from that because the virus is different to flu, as we well know. So, we did move from that to an approach where we now test every symptomatic patient—sorry, resident—in a care home, and we test symptomatic staff, as well. That was a change we made relatively recently. We continue to look at what's happening. I know there's a lot of comparison across the border because, without any notice that came to the Welsh Government, there was a policy decision made in England to use testing capacity to test asymptomatic people in care homes. We continue to review the evidence on that, including the papers you mentioned. It's very easy to pick one paper; it's better to look at the body of evidence. We continue to look at what's best to protect residents in care homes.

One thing I have to say before we move on, though, is that testing is important—it absolutely is—but there are fundamentally other things we need to do in care homes, and are doing in care homes, to protect the residents there, who are indeed among the most vulnerable in society.

Basic hygiene is really important. I know we don't like to talk about it because it's such a basic thing, but it really is important, and strengthening that is a process. We've made sure that infection control teams in local health boards are activated and available to provide that support.

When we have outbreaks in care homes, it's really important that people go in and work with the staff, work with the teams there, to help them to develop ways of cohorting patients, of managing patients, of making sure there's infection control. Local authorities and environmental health officers have been absolutely key in that and they've stepped up magnificently and they are continuing to do that.

We've also moved from a position where initially we were asking EHOs—environmental health officers—in local authorities to just look at places where we do have outbreaks in care homes to really looking at every care home to make sure that they have those systems robustly in place.

These are the things that we need to have in place, the bread and butter, the basic things. We need to manage infection control as well as—and I do not underplay the importance of testing—as well as testing. Our testing policy has evolved, it continues to evolve and it will evolve, based on science. Our testing policy at the moment is more akin to what Scotland is doing than what England is doing, but we do need to understand the implications and the rationale behind the changes that were made in England. We don't fully have that information. My colleagues are trying to look across the border to get that kind of information.

Thank you very much, Chair. I just did want to ask one quick question on the testing that Rhun raised. Given that this virus is so new to the world and we know very little about it, although obviously our knowledge is gaining all the time, I haven't understood why we didn't test people more, whether they're care homes or not, on a basis to find out, even if somebody—. Say I develop a temperature and I develop a cough and the advice is to stay at home until I feel better, but, if I feel much worse, then to call for help. But if I had that and I was staying at home but I was tested so it was doubly sure that I had it, wouldn't you as scientists then be able to trace how this virus is working, how it's spreading, and learn so much more about it? So, on a basic sort of trying to understand the enemy, I don't quite understand why we haven't made some of those other choices.

And when you talk about well-trodden paths for care homes that you've used for other things such as influenza, my understanding again is that we knew right from the very beginning that this virus had the ability unchecked to infect seven people at every one instance—one person could infect seven. I think flu is one person could infect two. So, again—as I say, this is my understanding—because of these differences, I'm just puzzled as to why we didn't pick up that testing differently or do the science differently.

Who wants to take that? Dr Atherton?

I can start, and then Rob may want to come in. They're very good questions, Angela, and in terms of—. What your first point made is—. You speak absolutely to surveillance and the need to use the capacity that we're building to get better surveillance and better understanding of the enemy, as you describe it. If you think back to the early days, remember we had a containment phase where we did try to identify every case and then managed to contact those cases. Once we moved beyond a limited number, that was impossible to manage on that basis in the UK, partly for human resource issues, but partly, of course, because at that time we did not have the capacity even that we have now. So, it would have been impossible for every symptomatic person to be tested.

In fact—we came out of flu season, of course—there was a little bit of a time window when we had mixed infections, with some people having flu and some people having coronavirus. But by the time we got into mid to late March, we were into a period where flu had more or less gone away and, for anybody who was symptomatic, the best thing was to just assume that you were positive and manage yourself in that way. As you know, we did put in place testing for people who absolutely needed to get back to work quickly, particularly critical front-line staff working in accident and emergency departments and intensive care units, for example. The point that you make also speaks to the need to get better surveillance, and that's the third priority that I mention when I talk about our testing priorities. It really is important that we protect some of our testing capacity, which will never be unlimited, but we protect some of it, so we can understand the virus and we can start to get out of the lockdown situation that we're in. Because if we don't have effective surveillance, if we don't understand the R0, the transmissibility that you referred to, Angela, we will not be able to unlock the measures with which the public are becoming tired, let's be honest. So, we need that surveillance to help us get out of the predicament that we're currently in. Rob may wish to add to that.

Okay. Dr Orford.

Thank you. Just to come back to the scenario that you suggested, that if you had symptoms of coronavirus, if you were tested, I'd be interested to understand the difference in your actions—that if you are symptomatic, that you would isolate away from your family for seven days. And if you were with the family, then 14 days as your household. We know that's a really effective control measure. We know that's effective because we're seeing the R value coming down, the incidence decreasing. So, adding testing on top of that wouldn't have really made much difference to you and it wouldn't have made much difference to how we would have managed the epidemic.

We have very well-trodden surveillance strategies in place because we do have upper respiratory tract infections, we do have circulating flu and other more infectious diseases—our infrastructure is well versed in doing that. We use measures like hospital admissions, ICU beds and calls to 111. Recently, we've introduced a really interesting application called the ZOE tracker app that enables people themselves to upload their symptoms, and the read-out from that is very, very sensitive. We've got over 100,000 people in Wales using that app, and we use the outputs to look at the incidence in the population. So, that's a far more direct and more timely read-out than you can get from testing, unless I stood in front of you with a point-of-care testing device.

However, we are developing more testing for us to have a better understanding of what R is today and tomorrow and then introduce that into our models, so we can understand the infection and the epidemic and how that's evolving. If we weren't able to measure that, and, previously, we wouldn't have been able to put the brakes on in the way that we did and stop the NHS from being topped out and then the fatalities from increasing—. So, some of the narrative in the media would speak to that we haven't got surveillance systems in place when we do. We can do better when we have more tests, and we will. But to think that we haven't got anything and we're in the blind I think is not correct. Unfortunately, that's my—

I just want to talk very briefly about the exit strategy, and, in fact, we obviously need to release people, free up businesses, ensure we don't go above R1, and restore the health services, of course, that have all been stopped or been put on hold temporarily whilst we try to prepare our NHS and our social care. But I think what I'm seeking, and what I have yet to have, is reassurance as to how the modelling is being prepared to go forward. Now, of course, absolutely, I know you're doing modelling, you're the guys with the knowledge, but we need comfort; we need to know that it's being looked at in the absolute round and not just in a purely physical 'we don't want people to get this'.

So, my question—and, again, I appreciate you've got surveillance strategies in place, but we haven't been sharp over the last couple of weeks in data collection, in the public—and I'm a member of the public, first and foremost—having confidence that we know where it is, we know how many people have got it, we know who's dying of it. Because I know that a lot of the death certificates are saying 'died with COVID', but that's different to 'dying of COVID'. So, it's finding out all of that, and knowing that, actually, there are some really top-class people who are building a modelling system that is looking at Wales and the population of Wales and our particular issues, our particular mortalities, our particular issues with obesity or with smoking and all the other things that might put us more at risk. But it's modelling a system that also does have equality at the heart of it, so that we don't end up saying to older citizens, 'Tough luck, you get locked up for a lot longer, you can't come out until Christmas.' So, can you just give us some feel for that?

And you talked earlier, Rob, about the SAGE group and your own technical advisory groups—are those minutes able to be—? I know the SAGE group minutes aren't published, of course—that's one of the great cries from everyone. But is there no more concrete information that you can start giving out to the people of Wales, because I do believe—and I think one of you made the point that we were all getting a bit fed up, I know I certainly am, of lockdown—that transparency, bringing people with you, is key to winning any battle, is it not?

Frank to kick off or—?

Shall I kick off, and then—[Inaudible.]—later on? Thank you very much, Angela, for those questions. Just in terms of the lockdown situation and the way that we try to navigate our way out of this, it's really important that we understand that we are not out of the woods. What we aimed to do when we put in place the intense social restriction measures, Chair, that are now in place in Wales, as there are in other countries—. What we tried to do was we tried to reduce the transmission of the virus so that our NHS did not become overwhelmed, and that's been successful. That has absolutely been successful, because we've brought NHS capacity in a way that has never been done before, and we've managed to not overtop our NHS. That is a fantastic achievement that we've done. But the sting in the tail is that to completely suppress transmission—and the risk, of course, is that if we lift the measures, we will get a second, possibly a third or more waves, we will resume transmission, and that's something that we have to somehow avoid.

You also speak to the rounder picture, and it's really important we do that and that we don't just look at the immediate numbers of deaths. We have to get better at knowing those numbers and articulating those numbers, I absolutely agree with you, but there is something about understanding the hidden harm in what we're doing as well. You've probably heard Chris Whitty and me talk about the four harms that come from coronavirus—[Inaudible.]—the indirect deaths if we do overtop our NHS and run out of capacity, which we've avoided so far on this. But there are also the harms due to people not accessing healthcare, and we know that, for example, ambulance conveyances have been down about 25 per cent, A&E attendance is down about 50 per cent, so people are not coming in. Even cancer services, although we've tried very hard to get the message to the public that the NHS remains open for essential services like cancer—even some of those services haven't seen the throughput, the new presentations that we would expect. So, we have to get that going and we have to get better at quantifying, measuring those harms as well. And, of course, the fourth harm is the harm due to the economic situation that we find ourselves in. So, we need to get better in our modelling at incorporating all of those—[Inaudible.]

Rob may wish to comment on the SAGE issue—the question of transparency, I think—

Okay—

But also, Rob, could I ask you when you comment on that: could you also just talk about the development of these apps and the apps for contact tracing, the apps for being able to book tests going forward, because, of course, these are going to be absolutely vital, are they not, in being able to move us forward?

Yes, sure. I'll start with the SAGE process and then I'll finish with the apps—

Can we make it a concise answer, Rob, because we really have to finish on time?

So, in answer to the modelling question, there are comprehensive conversations around different models. We share those models in Wales, we have a national modelling forum, which is a sub-group of the technical advisory group, and modelling outputs are shared with NHS Wales planners, they're shared with local resilience forums and SCGs. Our intention is to be more transparent. We're dealing with this one-in-100 year incident. We will, invariably, share this information with absolutely nothing to hide in the information that we have been processing.

R, we think, is under one, which is good, because it means infections are lowering. In part, the epidemic's being driven by the hospitals and the care homes and the community, so there are three different types of epidemic happening out there. We don't have a lot of headroom. If we switch things round significantly we will go back into growth again, and we will have to think about the NHS capacity. There is no easy out, there is no easy answer. This is going to be a hard-fought battle and we will need to feel our way forwards, working with colleagues at a UK level and internationally to find the best ways. However, the control measures that we currently have in place—social distancing, good hand hygiene, isolation if you're symptomatic—are very, very effective, and that's why they've been employed. So, we need to carefully find our way forward and use our surveillance systems to be able to measure our way out of this.

Things like contact tracing will be important. Invariably, apps like the ZOE symptom tracker app, and other apps that are being developed, would be a part of the solution, but there is no magic bullet, there is no silver bullet to this problem. The contribution from the public will be invaluable now and going forward. We know that the compliance with the current control measures is good. It's not great, but it's good, and that's helping reduce the epidemic in Wales.

Angela. 

I just wanted to say that I absolutely understand that not overwhelming NHS capacity is a key priority—but I did say is 'a' key priority, in that, going forward, can it really be our only raison d'être if actually what we then do is take away the rest of our society? That we are unable to keep our economy going and do all the other things that we as human beings have pulled together as our network?

If I can just reflect on Frank's point that there are both direct and indirect harms, and our aim is to reduce direct and indirect harms for coronavirus, so we won't exclude one—we have to consider them all in our actions.

Yes, I wanted to ask about the exit strategy, please. How confident are you that the indicators are moving in the right direction? What can we learn from the international evidence to enable us to move out of this lockdown situation?

And that has to be brief, I'm afraid, Frank.

Yes. I'm very confident that, as Rob said, the reproductive rate is less than one. The lockdown measures are working, there is no doubt in my mind about that. We've moved from a doubling time of the virus, and those indicators we've been looking at around hospital admissions, ICU admissions and deaths into a reduction—a halving rate. The doubling time has—[Inaudible.]

Sorry, my sound is dropping out now. Frank, you broke up a little bit, if you can hear me. I think Frank was saying we absolutely need to use our surveillance systems to understand when the right time is for us to act. We need to learn from others. We need to work to the evidence that we've got available and the scientific advice, and the interpretation of that advice, to inform our policies going forward.

Thank you, colleagues. I think my conclusion, really, is that we're not out of this yet, and we have a long way to go. This virus has many surprises and they pop up almost on a daily basis. I'm very grateful to the public of Wales for doing what they've done, which is to help us to contain the infection. Getting out of this predicament is extraordinarily difficult. It's one that we don't do alone. We do this in concert with our colleagues around the rest of the UK, and we need to continue learning from others. The virus is not finished with us yet. We continue to adapt our strategy and our approaches. I'm very grateful as well to everybody who's working in the NHS. People are working flat out, and in Welsh Government and across other sectors, to try to manage this. It really is an extraordinary effort by everybody, and I'm very grateful, not least to the people of Wales for what they're doing.

Diolch, Cadeirydd. Good morning, Minister. 

Good morning. 

To start, we've heard from the chief science officer, clearly, regarding the issue of SAGE, and it's been clarified that now there's a Welsh technical advisory group, effectively responding to what SAGE is discussing, but also feeding into SAGE. I suppose I'm asking: can you confirm that you are listening to the Welsh technical advisory group, rather than SAGE, effectively, because they are putting in context the advice or information coming from SAGE into a Welsh context? So, can you confirm you are taking the advice of the Welsh technical advisory group more than SAGE?

Can you also highlight as to whether you are now satisfied that the structures that are in place for leadership throughout this process are now developed and you're comfortable with what they are as of now?

I'll answer your question, but just can I—? Oh, that's very echoey. Can I just ask, in terms of the structures of leadership, whether you're talking about leadership in terms of scientific advice, or more general leadership across the service? I don't want to answer a different question— 

Well, let's do both. 

Okay, right. I shouldn't have asked, really, should I? [Laughter.] On the technical advisory group that we have here in Wales, it's co-chaired by chief scientific adviser on health, and I speak with the chief scientific adviser on health and the chief medical officer on a regular basis; I've just come from a conversation with them now, just a few minutes ago. So, there's a regular conversation with them and advice into the Government at several points in the week, and they're regularly looking at the different data that is available within Wales, together with the messaging and the advice from SAGE and what that then means for policy choices and practical choices we have to make here.

So, yes, it's a regular conversation with the chief scientific adviser on health. And, to be fair, in normal times I would have had submissions that might have had his name on it and advice he'd have given remotely, but I would probably physically have met him in formal update meetings no more than four times in a year. It's not unusual for me to see him four times in a week at present, and that's been the way for the last few months. So, there's a much, much greater level of activity and engagement, as you would expect. 

On leadership, we're looking again to make sure the technical advisory group has got the right people around it and on it, and I've got some advice for me to look at that, to make sure it's still doing what we need it to do for us here in Wales. Within the wider service, I think that the response of our leadership has been remarkable. If you just go back to a few weeks ago, to the very sobering and difficult committee meeting that we had when I was speaking remotely for the first time a few months ago—and I say 'difficult' because the subject matter was difficult—we were expecting the possibility of a reasonable worst-case scenario at that point of more than 20,000 deaths, and the very real prospect that individual burials may not be possible.

To go from that to where we are now really is remarkable and it has not happened by accident; it's happened both because the public have behaved so responsibly to the social distancing measures and the rules we've put in place, but also the way that our health and care service has responded has been remarkable as well. And I think our leadership but also our staff at all levels deserve tremendous credit for that, and that's the reason why so many lives have been saved in Wales, compared to what could have happened. But it still doesn't take away from the fact that we know that already more than 1,000 lives have been lost because of COVID-19.

David. 

Yes, just one final point on this particular topic. You just mentioned that you've got some advice as to whether the group needs to be changed depending on what you need—your words were 'what we need'. Is there any change in the Welsh Government's request or desire for the type of information it wants from this new technical group to what it was before? Are you simply saying, 'We are moving forward, so there may be, looking at the future, an exit address that we need to look at', or are you simply saying, 'Well, they've always been there, they've always given us advice, that's the advice I want to continue to have'. I'm just asking as to why you think there's a need to change in that case. 

No, it's about, in all of this, we're constantly checking and rechecking the evidence we have, and the make-up of the mechanism where we're getting that advice. So, it's a time, while we're still in lockdown, to look at what we need now and in the future to make sure that the terms are right and if we need to add in any additional voices of expertise or not. So, it's the sort of review that I think that, in a different context, you'd be asking me why haven't we reviewed what we need and why don't we look to learn from what's happened with the progress of the pandemic here in Wales. So, I don't want to set any hares running to say there's been a problem; it's really about the proactive review of what we're doing and why to make sure it's still fit for purpose for the advice that Ministers will need to make choices for the people of Wales. 

Okay. 

Thank you, Chair. Good morning, Minister. 

Good morning. 

Can you outline your assessment of the testing policy and how you've seen it change in Wales? 

Well, we've seen the testing policy continue to develop, both through the course of the pandemic, as our capacity has changed, but also needing to have testing as part of a wider, worked-up plan. So, you'll know that we moved from, in the very initial stage, when there were a handful of cases, following up with contacts around those people and, in particular, the concern about people travelling into the country. Then, when we reached the stage of more widespread community transmission, that profile changed, and we've now, for some weeks now, been focusing and prioritising our resources to understand who was coming in to our health and care system, and, in particular, to give staff the confidence to go back to work if they are symptomatic. Now, as we move into the next phase, ahead of coming out of lockdown, we'll need to see testing as part of a wider public surveillance approach. And this comes back to the point of having capacity to do that, but to see testing not as an end in itself, but to see testing as part of that wider approach to understand, if we are seeing, post lockdown being phased out, a further community outbreak, and what that looks like.

So, there are different purposes for testing, and part of that is also because the current test we have just tells you if you have it at that point in time. It doesn't tell you if you're likely to get coronavirus tomorrow, or in three days' time—it tells you at that point in time do you have coronavirus. The antibody test will be much more useful in telling us if people have had coronavirus in the past and recovered from it, and what the state of that is. We do, though, also need to understand the level of protection that may or may not give. So, it's part of a changing and complex picture, but the continued focus is on making sure that critical workers get tested, so they can return to the workplace. And, of course, we've had a particular focus around care homes as well. But the testing regime itself isn't what makes care homes safe or not—that's actually about the way that people are treated and cared for—but it can help us to understand the level of a coronavirus outbreak in one of those localised settings.

Jayne.

Thank you. Are you satisfied with the number of tests taken up at the moment and the capacity available, and that those eligible are taking them up? And how could that be improved?

Okay. So, on capacity and take-up, we're still committed to increasing our capacity. Because, as I've said, we know we're going to need a larger infrastructure, both in terms of the daily number of tests that can take place, but that infrastructure will also develop how easy it is for people to get tests, whether that's home testing, whether that's mobile testing, as well as the drive-through centres that are being created.

Then, in terms of the take-up, you know that, following the review that I ordered a couple of weeks ago, I was concerned that we had a number of our critical workers, especially through health and social care, who were reporting that they weren't getting tests and they were self-isolating at home when they could potentially be going back to work. And that was definitely a driver in the review that I ordered. We're now in a position where the feedback we're getting from lots of our players—and I spoke with a number of them on Monday—from emergency services, to people in health and social care, was that there's now a much-improved position on people getting quick access to testing and that the capacity that we have will match the need we have for those critical workers.

I still want to see an efficient process that makes proper use of the testing that we have, so I still want to see uptake, but I do then need to get that sense check of: have we tested everyone who we need to test, and, if that's the case, what's the next useful stage at which we could deploy our current testing resource? But, even if we get ahead of the need for testing now, when we're in lockdown, as I've said, we will still need to increase our capacity. So, we could end up having many thousands more tests available, but not need to take them while we're in lockdown—we'll need to test that infrastructure in itself, to make sure it is fit for purpose if we're going to phase our way through and out of lockdown. It's been much easier to put the country into lockdown than it will be to take it out.

Okay. Jayne.

To expand your idea a bit, what would that bigger testing infrastructure look like? Is that home testings and—?

Yes. So, that's both home testing—we've got some testing of tests about home testing being done now—that's also mobile testing, that's drive-through testing, and it's also some of our community-testing teams that are already going out and testing people in their own homes as well. So, there's a self-test; that's also a part of what we're looking at too. We're also, as I said, looking at the ease of the process, because, when I ordered the testing review, there was far too much anecdotal evidence for me that there were, in some parts of the country, too many steps for people to go from being symptomatic, asking for a test, and then having to sign out a number of forms, having a number of authorisations. So, we took that seriously, and I'm really pleased to say that the reports we now have back are that that's significantly improved, because that was holding up people getting tested. And I'm also interested in how quickly people get their test back. At the moment, the great majority of people get their test back within 24 hours, well over 90 per cent get their test back within 48 hours. But we're also now looking at the ability to have text results sent back to people, which should again further speed up the process, because all of these things matter.

Okay. Can I finally just check—? You've touched on the issue of care homes and we've heard the older people's commissioner who's called for more testing for residents and staff in care homes, and also, we just heard from the chief medical officer around the change in policy in England. Were you aware of that change of policy and given advanced notice of that? Also, could you perhaps outline your response to the concerns that people have who are working in care homes, particularly through this incredibly difficult time?

Well, on changes in testing and policy in England, we haven’t had acres of notice about that. There hasn't been a discussion before those policy changes have effectively been determined and then made. So, no, we don’t really have notice about the way that the policy is changing in England. And this is difficult, isn't it, because we make policy choices for ourselves here in Wales. When I decided to end standard activity in the national health service, I spoke to each of the health Ministers in the UK at Cabinet level, and I told them what we were about to do. That hasn't always been the case in every choice, and that's partly because it's a fast-moving picture.

On testing, we haven't had those discussions in advance of the significant changes in testing policy made in England, but the UK Government in this instance are responsible for England, not for the UK. The challenge is that that obviously affects the public discourse around testing. I don’t understand the rationale in terms of how it keeps the public safer and how it saves more lives for the way that testing policy has been changed in England, but I'm not responsible for those policy choices.

You've heard from the chief medical officer about our position on care home testing, and the challenge here is that the evidence picture does develop, and so, I said on more than one occasion that if the evidence base changes, then I'll be happy to change my position, and I know that there's a review of that evidence around care home testing. But I think it's really important to be clear that just testing every care home resident doesn’t automatically make them safer, because as I say, the test tells you whether you have coronavirus at the point in time when the test was undertaken, not whether you could get it the next day, and actually, that point about how you keep people safe is actually about how we help care homes in the way that they're operating. And the points about infection control, the points about the precautionary approach to the way that we're using PPE now across the health and social care sector, they are actually more important in terms of the choices that are made to keep people alive.

So, I understand the way that some people are concerned because Ministers are concerned about the outcomes for people in care homes too, but there still isn't an evidence base that widespread testing for every individual, whether asymptomatic or symptomatic, is the right thing to do. But we are looking at that evidence, and each day, there could be something new that changes the view on how Ministers need to make choices. So, I don’t want to get trapped into saying that there's a hard and fast choice that will never change, because—[Inaudible.]—in the picture.

I think you're adding two and two and coming up with seven, to be fair, because when it comes to testing in the care home sector, the advice and the guidance on PPE usage has already come to the point where, following a statement made about widespread community transmission, the guidance on PPE, if you like, in the different tables, was already at the point where a precautionary approach was supposed to have been being used, and that has led to a significant increase in the take-up of PPE in Wales and in every other UK country.

The testing regime itself where England are looking to test even more care homes residents, whether symptomatic or not, doesn't necessarily mean that more PPE is going to be used at all. It's a matter for England to determine those policy choices. I think that, in each of the choices we make, it's always helpful to have UK-wide discussions so that we understand not just the public relations part, the communications part of it, which matters in terms of the confidence the public have, but actually in the thinking and the rationale and the evidence behind it as well.

So, that's why, for example, we did something different on announcing that we weren't coming out of lockdown. Ahead of a COBRA meeting, there were some—not to use the pun too broadly—but some antibodies in the UK Government about the fact that we did that. We did that because we don't just have powers, we have responsibilities here and we weren't in a position to have a four-nation conversation in a sensible way about it beforehand, because COBRA wasn't meeting on a regular enough timetable. So, we ourselves have made choices ahead of other parts of the UK in some parts of the coronavirus pandemic, and we may well do so again in the future. But I know that the chief medical officer remains keen to make sure that there's a continued conversation between him and his counterparts on the evidence base that underpins all the choices and what that does in very practical terms about public expectations here in Wales.

I just wanted to go back quickly to the testing in care homes, because we are told by the science that 30 per cent of the population will be asymptomatic, in other words, they will have COVID-19, they will not show any sign of it, they won't feel particularly unwell, and as we're now learning from people who have it, actually, although the cough and the high temperature are one of the keys, not everybody follows exactly that pattern. Some people have upset tummies, and people have different ways of displaying the symptoms.

So, coming back to specifically care homes where we know our most vulnerable reside and the people whose physical resistance to illness is going to be probably lower than the average population, and given that they're all contained in a small area and therefore transmission is much harder to control, and given that asymptomatic nature of the coronavirus, I would have thought that that, in and of itself, would have dictated that we might consider testing everybody who is not only in a care home, but those who come in and out.

And the other thing that concerns me whenever we talk about testing is that people always seem to think of it as a one action, whereas, we could actually be in a situation where we need to see people tested on a regular basis, particularly in, say, a care home. If we manage to get a care home that's finally COVID-free, you might want to test everybody who goes into it before they go into it to make sure that for that day, there is that—. Surely, that's the only way we're going to be able to stop these pools of infection developing.

I think there are a couple of things that come under the points that are made. The advice that I've had doesn't quite say that 30 per cent is the real figure for asymptomatic transmission or acquisition. Part of the difficulty is that there isn't certainty about that. I was just talking earlier this morning with the chief scientific advisor on health about some of the studies that he's seen looking at what is the level of asymptomatic transmission, and that's uncertain. It's part of the reason why I've always had that very significant and important caveat that if the evidence changes, we may need to change our position. And, certainly, if the evidence of asymptomatic transmission shifting got firmed up, then that could lead to a different set of policy choices. So, I absolutely hold open the possibility that we may need to move, because if that evidence base changes, that obviously has potential consequences.

I think your point about the regularity of testing is an important one because if, for the sake of argument, we have 10,000 tests a day in Wales—we've got, what, 20,000 people-ish in residential care, lots more people receiving domiciliary care—[Interruption.] Sorry, I think it's 20,000 beds with the occupancy. All of our testing capacity across the whole country could go into testing that sector and not test all of it. And if there's going to be utility to it, you're right: what do you do if you're doing this not because there's an evidence base of people who are affected—? But if you want to do that on a regular basis—. And then, what do you do about people who are in hospital, again, in a closed environment? What do you do about people who receive domiciliary care—again, many of whom will be at risk—and all their staff? And actually, that isn't the approach that we're looking to scale up and do, because I don't see another country that's taken that prospective approach, and just testing the whole population on a regular basis, every couple of days, retesting people, whether they're symptomatic or not. And it's then—[Inaudible.]—what's the purpose and the utility of the test result, when, at the moment, it just tells you whether you have coronavirus at the point in time at which you had the test?

The rationale and the logic around if there are hotspots in a care home may change; the rationale and the logic around asymptomatic testing may change, and that's why I'm looking for that advice that keeps coming back to me and that we review each day, to understand how that informs our policy choice. And at this point in time, the evidence doesn't support a policy choice to test everybody and anybody who works in a care home, but the evidence about what to do in different parts of that sector may change and I'd need to see that evidence to base any choice that I make on for the country.

Okay. Rhun, I'll come back to you.

Just briefly, one key phrase yesterday, I think used by the First Minister, was 'to test everybody in care homes isn't the best use of capacity now'. Now, I come to the conclusion that you don't have enough capacity, but perhaps you could, for example, do sample testing within care homes in order to be able to perhaps try to spot some outbreaks before they get to that point where even asymptomatic or presymptomatic COVID-19 can't cause really deep problems within care homes.

I just think your point that this is about capacity is just wrong, because as I said, if we had—

I know you think that—

—if we had 10,000 tests a day, and we were to test the care home sector, we couldn't test the whole sector in a day. And if we're saying that that's the measure to try to give people comfort or certainty or safety, I think that's losing sight of the facts about what the test actually does. And so, if we get to having 10,000 tests a day in Wales, that will be a big meaty, chunky amount of testing and that may allow us to move out of lockdown and to have the appropriate amount of testing for a community surveillance approach. And yet, we're now talking about burning up all of that testing and much more, if we test everyone in a care home environment. And it does matter that we use the resources we have to us in a way that makes sense and is actually all driven towards a best-evidence approach to how we save the maximum number of lives. That is absolutely where we are, and as I said, the evidence about whether we need to test in different settings on a different basis, that's constantly being reviewed, and as I said, if that evidence changes, then the Government won't be afraid to say, 'If the evidence has changed, we're making a different decision now.'

Okay, back to Rhun, and then Jayne.

So, are you saying that if we had 10,000 tests a day today, that would be great?

No, I'm saying that if we had 10,000 tests a day today, then we would still not be able to test the entire care home sector in a day. We need to understand what—

Would it be a good thing if we had 10,000 tests a day today?

Please let me answer the question. If you do 10,000 tests in a day,  what do you do with the information that comes from that? What comfort does that give people? What does it tell them about how they behave the next day? Because actually, the bigger challenges about how to keep people safe are about good hygiene standards. They're about making sure that people have appropriate PPE to keep themselves and the people they care for safe. And actually, the testing isn't part of doing that, so I think there's a real danger that people see testing as a marker for safety or how we value people. We absolutely value every citizen of the country, and every single death figure that gets announced isn't just a tragedy for that person, but it really does affect Ministers and decision makers, so there's certainly no element of wantonness or callousness in decision-making choices. It simply comes back to what is the right choice to make to save the maximum number of lives and how is testing a part of that, rather than the only means to determining and understanding how we make the right sort of choices to keep people well and alive.

I don't doubt for a second that you're trying your best and you're trying to save lives. What we're asking is: can your best be better? And that's why we're pushing you on a number of things and the basic question I asked there was: would 10,000 tests a day be useful in trying to limit the number of deaths that are happening still in Wales, tragically every day?

Well, that comes back to the point about what the value of each test is and how we deploy the tests that tell you if you have coronavirus on that day. And actually, that bigger testing infrastructure is more important for deploying in a public health surveillance role, so that it's going to be really important as we're looking to phase out of lockdown. Now, England are testing people because they've got the capacity to test people rather than saying there's a specific rationale that underpins why they're choosing different groups and how that information will help the health service in England, or the social care system, to care for people and what that means in terms of saving lives. I'm really keen that we have an approach that is based on evidence, and an evidence base that is changing, which is why I'm not afraid to change position if the evidence changes, because I think that being stubborn about this is entirely the wrong thing. That's actually about trying to save your own position rather than actually trying to do the right thing for the country.

Okay, we need to move on. Jayne Bryant.

Thank you, Chair. Just finally, who's monitoring or how can we—? How are you supporting individual care homes, perhaps, who are going through such a difficult time where there perhaps has been an outbreak, or how can we do that better in the coming weeks and months ahead?

Well, funnily enough, there's active work going on with that with the inspectorate; with representative bodies within the sector; with advice from officials here. There's specific advice and guidance from Public Health Wales about operating in a care home environment at present now, and you would have heard the chief medical officer say, on a number on occasions, that he's really concerned about the care home sector, partly because of what we're seeing happen in Italy and Spain and the awful images of people who were abandoned, but actually the reality that we know that, in that closed environment, a number of people have died in large numbers. So, it's very high on our worry list about what might happen. That advice and guidance has been issued and we'll look at it again, because I'm always interested, if there's more learning about how we help the care home sector, how we support them, then I'd want to be able to do it. I think Andrew may be able to come up with some specifics on this for you, Jayne.

Thank you, Minister.

Minister, I mean, alongside the national mechanisms you've outlined there, both with guidance and, of course, the role of the inspectorate, I think it's also worth emphasising that, right from the outset, in terms of looking at the capacity, we've wanted to make sure that care homes aren't seen as an extension of the hospital environment. So, our approach has been to try it and ensure that we have had an integrated approach for the system. That's why, on areas like PPE, we had started that mechanism to make sure that it was ensuring that there was a distribution of supply out into the care sector environment and working with local authorities. We've also been really keen to make sure, and this has been reaffirmed by health boards, that when there are any outbreaks or concerns happening, that the health boards themselves have a role to reach out to the care homes themselves. I've seen examples of staffing arrangements being underpinned and supported; training and practice arrangements being put in place; and, of course, Public Health Wales continue to have an active role in any outbreak management. So, whilst I know the number of care home involved causes concerns, the professional advice can still be accessed when it’s required.

Thank you. Minister, I just wanted to talk about the exit strategy. I know we touched on it very briefly in Plenary yesterday, but I wanted to understand just a little bit more about the planning and modelling that Wales is undertaking to hopefully look towards a future when we can start coming out of lockdown in whatever way that may be. Could you just give us an overview of how you're going about it in Government, in terms of who you're pulling together to do this modelling? I know that you've talked about the pillars, or the First Minister talked about the pillars in the recovery plan, but within the health services, and you've talked about the criteria, but much more about how you're doing a risk assessment about how we could come out of lockdown. I've got a number of questions on that, so if I just start with that. So, sort of a scene setting—that would be really helpful.

Well, this is a whole-Government effort, and so you've heard from the different aspects of this, both about what recovery looks like and the group that the Counsel General is chairing, to give advice to the Government on what recovery could look like. There's then the practical points about how to determine how we come out of lockdown, and then what might be the first steps. I know that in your sister committee, chaired by comrade Neagle, the education Minister yesterday was talking about the fact that in terms of schools, there would be a phased approach there and you wouldn't see all school years returning all at the same time. So, there's individual work in individual portfolios about what could make sense there, and that’s being drawn together through the Government—work that the First Minister obviously has oversight of following the document we published on a path through lockdown, the sort of principles we'd want to apply.

I do think it matters that we set out the sort of tests we’d apply to that, the sort of information we'd want to see as well. Because I think that's part of an engaged and intelligent and mature debate we want with the public. Because I said earlier in response to some of Jayne Bryant's questions, I made the point it's much easier to go into lockdown than to come out. We're seeing that in other countries around the rest of the world. Once you start to have people circulating more freely, the coronavirus reservoir isn't gone, and there's a real challenge that even with continued social distancing we may see a further upturn.

So, we've got to balance a number of competing interests, because there's harm from COVID-19 from direct mortality, there's harm for those people who are not coming into our healthcare system in the way that they should do, there's real economic harm being done as well. Balancing those different things isn't straightforward, but they're part of the architecture that we're trying to review. In many ways, having a Government team of a dozen or so Ministers means that it's possible for us all to be engaged in the same conversation at the same time and to bring together the work of our different departments.

Thank you for that. So, moving this forward, we understand that we've got to do it in the round and that there are many different strands that have to be pulled together. To come out of it successfully, we're obviously going to have to continue with surveillance, and you've already mentioned that and we've talked about the development of apps. Can you just give us an overview of where we are with the development of a contact tracing application? Because one of the concerns I have, which I have raised before but I'm not sure I've had a response because I think you were going to look at it, is the fact that I know that, for example, in Hywel Dda there's an app being developed, and I understand the Welsh Government's developing an app and there's obviously going to be a UK-wide app. Surely, we don't want to be in a position where we're asking individuals to download multiple apps on their telephones in order to be able to know where they've been if they happen to come into touch with someone with COVID. So, there has to be uniformity. So, are there any plans for bringing this all together and where is that responsibility sitting?

There are a couple of different things there. First, on the symptom tracker pilot, we're already publicising and we've been encouraging people to download the app. When it comes to the wider point, the UK Government are testing for England something in the Isle of Wight—that's their plan—and we're looking at whether we can have a similar system here in Wales and in Scotland too, as part of the conversation I had with other Cabinet Ministers for health at the start of this week.

So, we are looking at what would make a difference and make sense for people. And, actually, it matters probably more for us in Wales than in other UK countries because we have a more porous border with England in terms of work and travel. And so, if we're phasing out of lockdown, then understanding how and where people are moving would make a difference to us. So, that is work that is still being drawn together, because we will need to make choices about whether we have a specific app for Wales or whether we have a common app that works for Wales, England, Scotland and maybe Northern Ireland too, although they have their own challenges about that.

So, that is still very much an open conversation between officials in the Governments. And it was helpful that Matt Hancock made clear that he wanted his officials to be open with both the Welsh and the Scottish Government officials about the development of the app that they had. Because if that technology worked, and it worked for our health and care system, then you could obviously see advantages in having a common platform, but we do need to make sure that it works for us here in Wales. And as you've mentioned before in our regular briefings through the week, there is work ongoing in this area in different parts of Wales as well.

Okay, Angela.

So, the need for that common platform is really important, and I just wonder if Welsh Government needs to really begin to talk to all those other people who are working on apps, to either tell them not to or to draw them into the national effort, rather than having lots and lots of little bits of development going on all over the place, and that is a real concern of mine. 

Moving forward on the exit strategy, has Welsh Government got plans, or have you got any further thoughts that you can share with us over as we begin to come out of lockdown? Let me rephrase that question. I think concerns have been raised with me substantially by different organisations and individuals that there may be inequality to lockdown release, and that older people, who are often fitter and younger mentally and physically than perhaps some of us here, are going to be asked to stay at home, and there's a concern that there may be a degree of ageism creeping into this. So, will you be looking at issues like that? Will you be looking at, as now more research is coming out, that men seem to suffer more than women; that people who are larger seem to suffer more than people who are slimmer; that, obviously, people of black, Asian or minority ethnic backgrounds seem to suffer more than other people? We don't want to have any of these artificial divides in society, so who's looking at the societal impact of any lockdown decision to exit?

Well, that's part of our decision-making framework about what we do, because I know that the Brexit Party representative, who spoke in the Chamber yesterday, was making light of the reference to social and economic equality, whereas, actually, it really matters. It matters about the healthcare inequalities that we know exist already; it matters about the potential differential impact on choices, and to make sure that we're not making choices that exacerbate divides or provide an element of discrimination.

We're looking at risk for different people and how we manage that risk, and the risk of not just having coronavirus, but then the potential impact upon that person. Now, that underpins the rationale for the shielded group of people because we've looked at the risks for those individuals. And in moving out of lockdown, we need to keep on looking at individual and community groups and what the risk factors are for them in either staying in a more protected state, because that comes with consequences too, or, indeed, for allowing more people more freedom, whether that's about work or moving around. So, that is very much within our framework for decision making, and I'm happy to give that assurance. And those are active considerations that Ministers have raised in our own discussions about the sort of choices that we could make and the differential impact on different groups of people in the country.

And how will you be engaging with the people of Wales? Because this whole process, surely, will only be successful if we are really transparent with people and take them on the journey with us. And how will you be engaging, not just within your Government sphere, but with, actually, just ordinary people out on the street, particularly those who may be asked to shield for longer, to see what their view is and about their choices and their decision-making capability?

Well, that's why we published the framework document to try to help inform that public debate; to publicly expose the sort of considerations we're taking into account, the sort of concerns we have and how that would inform our choices. Now, if we're getting closer to lockdown ending, we then want to give notice, again, of the rather more specific things we'd be considering. And again, that's why I refer back to the education Minister's evidence yesterday in the Children, Young People and Education Committee, because that's something very practical that you can understand about these different choices, and even there, you've got to give notice to parents and to teachers for different arrangements to understand what that means. So, we'd need to have that very engaged conversation around each and any proposal, and the difficulty with that is, at the moment, we don't have a set of hard and fast proposals because the evidence isn't there to do that.

We do have principles and a framework that we want people to engage with, but as we come up with further, more concrete proposals about what might happen, not the final decisions, as it were, but then we want people to engage in, 'Well, what does this look like?' and to understand for different sectors and stakeholders, including the public, what would be the impact of doing this. And because we've never had to do this before, we're going to need to trial this in real time. We're going to need to make choices to understand the evidence of the actual behaviour of people, if we change the position we're in now. And then it's not only on the economy, on people's health, but, of course, what that means in terms of the service's ability to cope if we do see an upturn in coronavirus, because turning lockdown back on after we've come out of it could actually be much more damaging than staying in for a briefer period of time to get those things right. So, it's not a simple question and answer. I'm not suggesting you're saying it is, but those are real complexities that we have to grapple with.

Thank you, Chair. I've also got a question on the exit strategy. Are you going to come back on that?

Yes.

Okay. I was going to ask, when we were talking about testing, about the prison service. I've had a number of constituents working within the prison service who've raised a range of concerns with me about testing, PPE, general problems with social distancing. Clearly, prison healthcare is devolved, the prison service isn't. Without exception, they've all been afraid to raise their concerns with the prison service management. We've had the death of a prison officer, tragically, in Usk. Can I just ask what you are doing and what discussions are taking place to ensure that the public health measures we are promoting so hard in Wales are being adopted by a non-devolved service in the prison service?

Well, as you identify, there are some challenges here. Julie James has been leading on the conversation with the prison service, and she's been engaging with UK-wide Ministers in some of the sub-committees that are meeting whilst COBRA isn't meeting with the UK Government.

There has been a challenge that I hope is now going to be resolved about information on what's happening within the prison estate, because we weren't being made aware of some of what was happening within the prison estate with inmates and staff. We've had a prison officer pass away, we've also had an older prisoner pass away as well, and those are important for us, because one of the points that I made when I was engaged in that sub-committee, together with Julie James, was that, whilst the service is not devolved, if we're talking about early prisoner release, then almost all of those people will have care and support needs and many of them will have healthcare needs as part of that care and support, and we need to make sure that, now, more than ever, that information flow to help support those people is undertaken properly, because they are potentially not just a risk to themselves but to other people who they may be coming into contact with. And, of course, we want to make sure we save the lives of people across the country, including on the prison estate, and many of these people have a range of healthcare needs going into prison, if not acquired whilst they're in prison.

So, it's certainly not a matter we're giving up on, and it is a part of an active conversation with the UK Government to try to make sure we're sharing information to meet the varying responsibilities we have for the people working and living in the prison estate. I know Andrew Goodall wants to come in on a specific point here as well.

Andrew Goodall.

Just to reinforce what the Minister says, we are able to make sure that the healthcare conversations and responsibilities are actioned, so health boards who are overseeing the prisons are able to ensure that they can give the appropriate advice and make sure that that is part of a broader response, in line with how we take things forward in NHS Wales. Secondly, just to say that, in respect of, for example, PPE guidance and advice, Public Health Wales is working alongside Public Health England to make sure that there is consistent advice that is available that's appropriate for those environments. So, clearly, we'd want to have that assurance within Wales, but it's perfectly appropriate that we actually work across the borders to make sure that is something consistent. And, thirdly, there are opportunities to speak to colleagues—as the Minister said, there are opportunities on the ministerial side. I was speaking to the director of the prison service in the UK just last week, where we were just sharing our own professional thoughts on what needed to happen next in order to give those assurances and make sure that there was a connection on the Welsh side as well.

Good. Lynne.

Okay. On the exit strategy now, is it?

Yes.

On Tuesday, the cross-party group on suicide prevention met to discuss the suicide risk in the pandemic, and one of the issues we talked about was how the exit strategy could really impact on mental health, for the reasons that Angela Burns has described. I feel like we've made progress in Wales in recent years in terms of delivering, or moving towards delivering, parity between mental and physical health, but, obviously, in recent weeks, the focus has been very much on physical health, with the pandemic. What assurances can you offer that mental health will be a key consideration in developing the exit strategy, but also, vitally, that those experts that we've got in Wales, people like Professor Ann John, will be fully involved in those deliberations so that they can fully inform them?

Well, I'm really concerned about the mental health impacts during lockdown, as well as what happens coming out of lockdown, both for people who are living in closed environments—. Some families get on by not seeing lots of each other. It's not a trivial point. The concern—it's a physical health issue, but the domestic abuse upswing is a real challenge. As you then come out of lockdown, then how people behave will make a difference to the physical health of the rest of the country.

But I'm really concerned about our staff. Because even though we haven't seen the scale that, at one point, we were potentially facing at this point in time, it's not easy for our staff across health and social care in going into work and doing what they're doing, and I am genuinely worried about the wider impact on the public of being in lockdown and then coming out. For all of us who are living through this, this is extraordinary, at whatever point in life we are. In some ways, though—. Understanding the impact on our children is something that really bothers me, not just because I'm a parent of a primary school age child who's finding it very difficult in not seeing his friends. He knows that there's a virus that is stopping this from happening, but it's hard to then tell what that then means for him, his classmates and others around the country, and in particular those children who we were already concerned about before the pandemic started as well. So, there's a range of real worry points about how we support vulnerable people, and it is often their mental health, not their physical health, that is a point of concern to us. I certainly don't want to lose the expertise of any of the people who are part of the national effort we've made to make real progress on mental health provision and the unfinished point about the parity of esteem between physical and mental health.

Okay. Andrew Goodall.

Just to pick up on the health professionals support—so, the Minister had agreed an extra package of support, recognising the environment that our NHS staff are working in, and we've built on experiences that are hosted by Cardiff University to make sure that that is now available. Whilst that's just one example, we do need to make sure that there is a package of broader support, keeping an eye on staff who are really working in exceptional and difficult circumstances, and we can't take that for granted.

Just on the broader concern about mental health, whilst on 13 March the Minister had indicated, with the support of the system, a need to step away from routine activities, we've also wanted to make sure that people have interpreted that appropriately and correctly. Clearly, there is still an ongoing need to make sure of, as a minimum, the emergency and urgent access that's required for mental health. But, clearly, the fact that we've been able to maintain primary care operating as normally as possible, although with precautions, means that there should be access points still for those that need to enter perhaps at that lower level, within primary care. I did write out, however, to the service, which was on 14 April, just picking up that perhaps there were some concerns about some of the access points for mental health, just to make it really clear that we have that ongoing expectation to make sure that the NHS was discharging those responsibilities.

Okay, Lynne. Right. We're going to cover PPE next, and we'll come back. There are still questions on exit, because I've got one as well. David Rees—PPE to start off with.

Diolch, Cadeirydd. Minister, before we go on to PPE, I've got a question on testing, because I missed the opportunities on testing. At the start of this process, we were testing those patients who were symptomatic in hospitals. Then we went to front-line staff in hospitals, then we've included care staff and care patients, and you are going to expand, obviously, then to emergency services as well. Are you also going to look at expanding that into the volunteers who have been working in the community to help many people who are self-isolating so that, if they come down with symptoms, they can also be supported through testing? But the question would be: how do they then apply for testing, if that's the situation? Because, clearly, the process is quite—as you say, it has been long winded. It's getting better, but, if we are going to expand the testing to other people and other groups, how are you going to manage the applications and the process for applying to have a test?

Well, the focus is on critical workers, as you know, at present, and people within our health and care system being cared for. We are trialling and phasing out the roll-out of a web-based system for people to make bookings, and, if we're getting into wider population testing, or testing and tracing, then that technology should make sense in terms of how we make that an easier use for members of the public.

Okay. David.

Yes, okay. I just wanted to raise that concern, because it's been brought to my attention by various community groups in my area. On PPE, clearly we've had some concerns on PPE. I appreciate very much that there's been a delivery this week from Cambodia, and I understand that there's one scheduled from China this week, of PPE. It's good to see that we're getting—. The information I get from my health board is that they are adequately stocked at this point in time for up to about four or five days. But do you now believe that there is sufficient PPE to be able to deliver beyond four or five days, because, if we're stocked for four or five days, what happens in a week's time if we don't get those deliveries? Are there sufficient stocks—? Because you're using a huge amount of your reserves. Are there sufficient stocks now available to actually continue with the PPE deliveries for both healthcare and social care, because we're now moving into the very important area of social care support as well?

Well, look, this is an area where we have made real progress over the last few weeks, but it's not something that I am in any way complacent about or see as a done deal. It's still my No. 1 anxiety about keeping staff safe. The flight that came in from Cambodia this week is really welcome. That provides a good stock of gowns for us—fluid-resistant gowns—here in Wales. That was one of the real shortage items.

As I've said in public, we've received mutual aid from Scotland and England; we've provided mutual aid to England and Northern Ireland on masks, on face protectors, and I think that we're going to provide mutual aid to England on fluid-resistant gowns, because they've got real issues there as well. It's part of the reality of the world market that we're in. So, we're both looking at how we pursue our own lines of procurement that don't compete with a UK-wide approach, and Wales and Scotland in particular have been able to do that. We've been co-operating in doing that as well, as well as making sure that the UK-wide arrangements deliver their population share for Wales. Again, it was a subject that I raised with other Cabinet Ministers for health in our call earlier this week. And it is really important that we carry on with that international effort in procurement, with a collaborative approach here in Wales and across the UK—collaboration between health and social care, and between the four nations.

That also comes alongside what we're doing to manufacture PPE, because we've had more companies that are coming online making items, from the early stage about hand sanitiser and eye protection equipment—we've got quite a number of Welsh firms doing that now. Penderyn, famously, is making hand sanitiser now—as opposed to the other product that the CMO advises us to take in moderation to having effective hand sanitisers. Others are producing that too. The Royal Mint and Rototherm and others are producing face protectors. It now looks like we're going to get some of the clothes from Alexandra and the work that they're doing in Wales with Welsh companies in manufacturing scrubs. We should be self-sufficient, I think, on scrubs this week. And we're also then looking at the potential for fluid-resistant gowns to be produced here as well.

It comes back to this point—not just on what we have now, because I'm certainly not sanguine or blasé about it at all—the world we have where procurement is more difficult and more expensive, and actually manufacturing more of that ourselves, because none of us expects coronavirus to disappear suddenly within a period of a couple of weeks, so we're going to be here for a long time. We're going to use PPE at a much greater rate across health and social care for a long time, so for a long time we'll need to both procure and manufacture our own PPE in different measures, and we then need to think, as we come towards the end of this extraordinary period of time, of what the balance should be for the future in having a robust and sustainable approach to PPE provision that involves the balancing of international procurement and then home provision and home manufacture. That may mean that we need to think again about what we're prepared to pay for and the price of it—not just foundational economy points here, but to accept that we should pay more to make sure we've got a supply that, if we were to get anywhere close to this again, we could flex upwards, rather than being completely reliant, in the early stages at least, on international contract provision that, as we know, other countries ended up dispensing with to protect their own citizens. 

Andrew Goodall.

Using the mechanisms the Minister has outlined, it's really important to make sure that we continue to have confidence in the replenishment, and I know there have been some visible examples of that over the last few days. We've distributed about 71 million items now; inevitably, this changes every couple of days. We've got about 44 million items in our central stores, but we have over 150 million items that are on order at the moment. That just shows the scale of the replenishment that needs to happen.

I was just going to make the point that we do need to balance the national availability of supplies and items alongside the local position. Whilst you might have a health board saying that they have four to five days' supply and that they will have confidence in that, it doesn't necessarily mean that it's a shortage item at the national level. What we're trying to make sure is that local organisations don't simply build up their own local stores over many weeks. We obviously have to distribute where we see the pressures and the problems, and I think that has come together very well over recent weeks, because, of course, we have had to look at a much broader distribution chain. Whatever we've done historically through our central stores out to hospital sites, predominately, to extend it to all of those of sectors, from GPs to pharmacists to some dental areas, right through to local authorities and even individual care homes, has been of a very different scale than the system was actually set up for.

One thing I would say is that we have been able to absolutely take advantage of the fact that we have a national shared service in Wales of NHS supplies, and I think that they have stretched their responsibilities but done a really professional job to make sure that that has been delivered. But there's been a lot of learning that we've had to undertake as well. 

David Rees, then Rhun.

Can I ask—? Clearly you've identified these number of items of PPE, and I appreciate the local manufacturers, all the firms in my constituency—those companies doing scrubs and those specifically doing hand sanitiser. There are local businesses helping services here. But are you confident you understand the need and demand, because I read last week of the number of items a hospital in England would want per week? Do we know how many each of our hospitals want per week? Do we know how many each of care homes need per week? Do we know many domiciliary care needs per week? In other words, do we have an accurate picture of what is actually needed per week to meet the guidelines, and to make sure that everyone is safe?

It's broadly 'yes', David, because before the PPE guidance was changed and then after it was changed, we were in a much more difficult position in terms of being able to predict more accurately what was needed and where. And then it became very clear that the Government, through the national health service, would need to provide PPE to the social care sector, because their supply lines had collapsed, they weren't able to provide PPE. And whilst it's legally the employer's responsibility to provide PPE to their workers, if we'd said, 'We're not helping social care', then we could all predict in a few easy steps what would have happened to businesses in that sector and to workers in that sector who'd have been left unprotected. So, we stepped in, and that is the measure of the extraordinary times that we're in to provide free, state-provided personal protective equipment to a largely independent sector business. 

Now, in terms of our confidence around the future, I think this is part of the point that Andrew Goodall made that NHS shared services have really demonstrated their value of being a national strategic purchaser in the way we've been able to work within our system, to make sure those items go out to local authorities to distribute into the social care system, but also to get out right across the national health service. We've done a remarkable job to date. We have enough PPE within our system. We understand more about the usage rates. I've got more confidence now than I would have had a week ago, but I always have to add the caveat that because the position is always changing, we may find ourselves in a few weeks' time facing a different position, either of a shortage item because we're still reliant, for example, on the manufacture of millions of masks coming from other parts of the world—.

So, I wouldn't want to be over-confident about the supply for the future, but for now we have a much better understanding of what our health and social care system needs, how we are going to go about getting it and how we're trying to do that, but there are risks in every part of it. So, it's certainly not a comfortable position to be in as a Minister with oversight and responsibility for the whole system, and I'm grateful for the work that Lee Waters, the Deputy Minister for the economy, has done on this in shifting some of his time to have regular contact on PPE provision and acquisition. But my discomfort is because I understand very well what this means for our staff who are working on the front line in caring for people across Wales. 

Okay. David, finally, or moving on? 

Can I come back if Rhun wants to ask a question now? 

You can come back later, yes. Rhun. 

Just very quick, really, on what you just said then, Minister, about masks being one particular problem. Are we developing our manufacturing capacity around masks as well? 

Yes. For all of our items, we've had a huge response—over 1,000 companies have said they're interested in helping the NHS, and a number of those are being taken forward. Those include people who are looking at the real shortage items, including masks, and we have got businesses that are looking at the manufacture of that. And if we get to the point of having agreement on the numbers we need, then obviously we'll be telling the public about that. 

And I know we passed on ideas about building up with bringing in equipment from the Basque Country, and that kind of thing.

Just very quickly, we've heard some really good things from you and the NHS chief executive there. We're clearly in a better place in terms of manufacturing now than we were a few weeks ago. I think, Mr Goodall, you're right to say that distribution schedules are very important too. But let me just ask this: do you already, through sort of gritted teeth, ask yourself how much better off we would have been had we acted on the advice of the Cygnus report, and that kind of thing, or is that for the inevitable inquiry that's to come after this?

We regularly ask ourselves, not just about what we've done previously, but we're asking about what can we do better today and tomorrow. There's bound to be an inquiry. We make choices on the information we have today, rather than the information we wished we'd had. But we're in a much better position than we would have been, and I'm always happy to learn lessons. Because, as I say, we're in this for a long time to come. In this area in particular, I think, people need to think about another year's worth of activity, because until we get to the other side of a vaccine, and understanding how people are going to be kept safe, we're going to be using a lot of PPE as a regular matter of course—it's not just a few weeks ahead in the future.

And just as a reminder, one of the key recommendations out of emergency planning testing arrangements was to have a pandemic store available, and we have actually been able to deploy that. Obviously, we had to work on the replenishment of that supply, but that was part of giving us the flexibility in the system, even at the time when we were trying to apply the guidance. The one aspect that we have to reflect on is that that was about anticipation of a flu pandemic, and obviously a coronavirus pandemic is something different. Therefore, there has needed to be an adjustment around some of the, for example, PPE requirements.

No, that's okay. I'll come back with some of the exit strategy stuff later, if I can.

Sorry, Chair, I did want to come back on PPE. [Inaudible.]—the numbers, because we are—we've talked very much about hospital settings, GP practices, community nurses, district nurses. They're the ones we've always associated. Of course, we're now into care homes, we have funeral directors requesting PPE, we have domiciliary care, we have hospices who are struggling, and mental health units that are struggling. I know of a case where there's only one face mask in a mental health hospital where there is a COVID patient. And so there are challenges, and there are more and more coming on board that are requiring PPE. And I appreciate the Minister saying that they're helping out the independent sector very much, and that's very much appreciated, but the independent sector are also having difficulties—huge difficulties—in sourcing PPE outside of that support, because (a) a lot is going into the NHS or the—[Inaudible.]—areas anyway, but (b) the costs are actually increasing dramatically in the private sector for them, so they're finding challenges in being able to actually secure their own needs. So, that's why I think it's important that we have confirmation that the Government is fully aware of the need and the size of the need, so that, as time goes on, we're able to deliver those PPEs to those units.

That sets out the challenge that we understand—that it's a moving picture. We know that the cost has gone up for the Government to acquire these items, we know the cost has gone up for people in the independent sector; some people simply can't get it now. And that's why we're acting pragmatically and doing the right thing from a values point of view in looking after people in different parts of the health and social care field. And again, in each of those units, in each of those positions that you referred to, we'd want to understand what that picture looks like, what contact they're having with their local suppliers, what contact they're having with local resilience fora, who are actually holding the ring on some of this, and they regularly discuss across each of the four of those a position on PPE provision within the health and social care sector, but to remind ourselves that the pandemic stock that Dr Goodall referred to has been really important in getting us through in the deployment of that. Without that, I think we would have had a gap that would have been pretty terrible for our staff and the public that they're serving. We used over 40 per cent of that stock to go into social care. So, we've used the resources we've had, within the Government, within the public sector, to make our whole system more stable, and we'll need to carry on behaving that way for some time to come.

And finally, if we actually go down into a situation where we ease the lockdown but the Government decides—as Scotland is basically saying—that masks should be, perhaps, a means that can be used in public, or maybe on public transport, are we going to be in a position where the Welsh Government will be able to supply such masks, or are you going to be expecting the public to supply themselves? And if so, with the increasing costs and sourcing, how do you think that's going to be achieved?

Well, I think this is a really difficult area. I don't know if you've asked the chief medical officer about this before, but the advice in Scotland isn't compulsory and certainly it's really clear that they're not looking at medical-grade masks, and I don't think that the Welsh Government is going to provide free masks to the public, unless there's a really strong evidence base that that's the right thing to do. But the starting point is that if you're symptomatic, then you shouldn't be out in public. You shouldn't be going to the supermarket, coughing on other people or on produce.

We also do, though, need to think this through and think carefully about what it means if the Government endorse advice, not a message that, 'Well there's no harm in wearing a scarf over your face', because the evidence isn't that you need a particular medical-grade mask, and we're generally worried about competition for medical-grade masks that people will need to provide health and care. But if someone is going in on a bus or to do their shopping, and they don't wear a mask, I'm concerned about what the reaction of other people will be, and I'm especially concerned about what the reaction of other people will be, say for the sake of argument, to someone who looks like me, who is going around on a bus or doing their shopping, not wearing a mask—I'm aware of the opportunities for other, deep-rooted prejudices to be justified on a different basis.

We've got to think this through really carefully, because if the Government endorses advice that says that people should wear a mask or consider wearing a mask, that I think has a pretty direct consequence. And I'm not sure we understand—at the moment I've not had advice from our chief medical officer that it's the right thing to do, but remember the starting point is: if you're symptomatic and you haven't been tested, you should be self-isolating—you shouldn't be going out. If you've been tested and you're positive, you definitely shouldn't be going out. So, we shouldn't have people going into the public sphere who are symptomatic. I feel that, taking the 'it does no harm' approach, you can put a scarf in front of your own face. That certainly doesn't require the Welsh Government to spend money to provide those masks free to the public. We have a large enough financial challenge on our hands in providing extraordinary amounts of PPE and other costs we have in propping up local authorities and the extraordinary cost pressures they have. I don't think we're going to be able to provide every member of the public with a free set of face masks each week, unless we get some pretty clear advice from the chief medical officer that that is the right thing to do and that will provide us then with a very different challenge.

We're only looking at household isolation because you'll understand that if someone is symptomatic in particular, then there's always the chance that they've already passed it on to members of their own household, and you've then got to understand the utility of then trying to take that person out of that household to move them somewhere else. So, if you, effectively, have large quarantine centres, whether they're a hotel or a new facility being created, I'd need to be persuaded, and I'd say that I'm pretty sceptical that that's the right thing to do, both in the use of our resources, but the use of our resources for the purpose of saving more lives.

You know that, for example, some NHS staff are living in different facilities, so they're not going back to their homes, because they're either worried about passing on potentially something to their family or they're worried about having a symptomatic individual in their family and if they go back, they may then end up taking that back into the workplace. So, steps are already being taken there, but that's about how households are behaving. I'm not yet at the point where I've got evidence in front of me that says that the state should intervene to require or provide an opportunity for people to leave their house, so, effectively, go to a larger, quarantine centre. But as I say—as I regularly say—if the evidence changes, then I'll shift my position, but that's not where the current evidence directs me to make a choice for the country.

Rhun.

And as I've done throughout, I'll pass on anything that I find to you—it’s just some material from Italy in particular that I've been reading where multi-generational living seems to be causing a particular problem there.

And secondly, Chair, I hope this is an appropriate time to ask this—it's about the return to a new normal and the need for a continuation of NHS services, in particular, Andrew Goodall, perhaps, on cancer services. When will we get an indication of the road map, if you like, back to what might be seen as normal delivery of cancer services and, for example, the need for a provision of green or clean treatment regional sites, perhaps in order to be able to bring that capacity back up to normal? We know what the problems are with diagnosis and getting people to see their doctors. I'm grateful for the messages we've heard over the past 24 hours on, 'Please, please continue to go and see your doctors', but on continuation and return to normal in terms of treatment.

Andrew Goodall.

I've asked the system to do this, to have a plan for the future, to look at urgent care needs, and you'll recall that in Dr Goodall's press conference a couple of weeks ago he made the point that the NHS remains open for business. He's written to the service to make clear that urgent referrals should still be taking place, especially in the field of cancer. But in terms of the planning, we're looking for planning [Inaudible.] to run through about what turning on larger areas of the NHS activity could look like in both urgent care and also in the non-urgent care that's been paused where there's discomfort or harm being caused to people who are waiting for treatment that we would otherwise have provided.

I don't know, Dr Goodall, if you'd like to add to that.

Andrew Goodall.

We are tracking the underlying numbers in the system, and whilst we gave guidance back on 13 March to follow, it's been really important to track that through. We're still concerned at this stage that we're seeing a drop in our A&E attendances—around 50 per cent of what we would expect. Current numbers would say we're about a third down on our emergency admissions. We know that GPs are seeing about 20 to 25 per cent fewer patients in here, and we are seeing some evidence of drop-off in some of the cancer referrals into the system, which we do need to be concerned about. We’re just trying to make sure whether that translates into those patients that need the active treatment for cancer. It may be something where patients, if you like, those who are worried, have filtered out a little bit at this stage. So, I'm worried that some of that is about anxiety of patients coming into the system, so as we look to recover and offer work, I think we have to demonstrate our confidence about the environment that we're offering.

But as the Minister was saying, we have got our own views on what a policy can look like to take this forward and we are working with the NHS, as we did with the original announcements back on 13 March. There have been some provisional proposals about what stepping forward could look like. But I don’t think it’s going to be as straightforward as just flicking a switch and normality happening; I think we're going to have to be quite progressive and cautious about our approach going forward. If we start work on a whole series of different fronts, we’re just going to have to understand the dynamics about that, and we have to keep an eye on the underlying community transmission rate and make sure that what the NHS doesn’t do is contribute to those broader concerns about lockdown at this stage.

Having said that, we are making sure also that there is a real professional basis to how we would take these services forward. We've focused a lot on ethical frameworks, we want to make sure that there is a consent process in place for patients so that there's some real understanding. And even yesterday, there was a conversation happening with the Royal College of Surgeons and also with the Cancer Network about the opportunity to make sure that we can, through a cancer lens, create COVID-19 areas distinct from non-COVID-19 areas to give an element of protection as well.

We also, obviously, have the opportunity to recalibrate our system because we have some available capacity now, of course, because we were able to manage at least this first peak, through some of the mechanisms we'd put in place for field hospitals, and I think they will become quite an important way in which what we don't do is overwhelm the system as we take these steps forward at this stage. So, we deploy capacity appropriately.

So, Minister, you're expecting some advice, not least through the course of this week into the weekend, and then, hopefully, we can make some further judgments next week. What I would say is that there is already authorisation within the system, though, to be able to make progress, given some available capacity in the areas that we originally highlighted. So, to make sure that we can get our urgent workstreams back on line and absolutely to ensure that emergencies are able to be accommodated within the system.

Thank you.

Great. We've reached that time in every committee where there's a need to be agile, and we've got some well-known authorities on agility, and I'm looking at them in front of me here. So, foremost amongst them is Lynne Neagle on service delivery issues. If we can have a brief spot of that, please. Thank you.

Thank you, Chair. I know that you're in front of the Children, Young People and Education Committee next week, Minister, but I did just want to ask you for your response to the news that the NSPCC has said that there's been a 20 per cent increase in calls to its child protection helpline since the lockdown.

Well, obviously, I'm concerned, and as I said in earlier answers, we're really concerned about the picture with and for vulnerable children. In a previous statement to the Assembly, I made clear that safeguarding remains everyone's business, but we want people to be raising concerns if they have them about vulnerable children or adults, and I'm concerned that that may not have been taking place, bearing in mind the need they already knew existed within Wales before going into lockdown. So, it is a matter of concern to me and it's not something that I'm particularly sanguine about at all. It is something that I and other Ministers are really bothered about.

Lynne.

Thank you. Can I just ask about social care, then, and the capacity issues in social care that have arisen as a result of the pandemic, and also about the financial sustainability of the sector? We've had reports that care homes are in danger of going bust. How confident are you that the social care sector is going to be resilient enough, not just to take us through this, but into the rehabilitation and all the issues ahead?

Well, we've been concerned for some time about the sustainability of all parts of the sector and the future of the sector was always likely to look different to the one we have today. That's partly about how we want to have a managed transition, though, where the position we're in now may accelerate or cause bigger problems for us. So, I am concerned about individual reports, local authorities have raised issues and, indeed, the most significant body, Care Forum Wales, have obviously raised concerns about the future of the sector too.

So, we are looking at how the £40 million I've already announced can support adult social care. We're looking at how business support can support some of those business too. I'm looking to have a more intelligent way of providing some of that support on a localised basis. So, it's work that our officials are doing together with the WLGA and Care Forum Wales to look at how that could be done.

In times past, before coronavirus, if a care home was going to go under, it's possible that a local authority could have stepped in to maintain it, particularly if there was a need for that care to continue. We may well see that being more of a pattern, but we're looking still at what sort of sector we want for the future, with good terms and conditions for our staff, with good-quality care being provided for residents, and how we have an approach that is based on quality, and that requires all of us to consider how much we're prepared to pay for that care to be provided, and at the end of this, I certainly hope that we don't return to the old way and the old normal. I want to see a new settlement for social care, moving forward in the future.

Okay. Lynne.

Just one final question from me. Overnight, it was reported that NHS in England had looked into introducing new risk assessments for black and minority ethnic members of staff because of the concerns about the rising incidents in some of the staff and also the higher death rate. Are there such discussions going on in Wales? 

Yes is the straight answer. It was raised with me again today in my conversation with trade unions, and it's something that I'm asking for an update on about the work that I've already set in train to look at these issues, not just for BAME staff but for black, Asian and minority ethnic communities as well. Because we're just as concerned and we've had an insight into some of the work that England are doing, so I want to be in a position to provide a public statement on it in the near future.

Great. David, have you got any questions that haven't been covered on service delivery issues? 

No. I wanted to raise the issue about cancer, but Dr Goodall actually answered the question earlier on the cancer treatments. 

Okay, right. We'll move on because time is short, as I may have intimated previously. Angela, I know that you're capable of some extremely succinct questions. Now is the time for one of them, on data.

Wow, Chair, I've never been accused of that before. We've obviously had a real issue with data just recently, particularly with the two health boards that had inaccurate data reporting of people who had died. I don't want to rehearse that particular argument. What I am concerned about, though, is how strong our data collection and management is at this very vital time. And I want to raise, for example, one thing that I've noticed in that if you look at the ONS provisional figures for deaths in care homes in Wales, you will see that Aneurin Bevan health board has some of the highest overall figures of COVID-19 in hospitals than anywhere else in Wales and we know this. It has a lower amount of care home deaths registered than for example Cardiff and Vale next door or Cwm Taf, and I'm not expecting you to know the answers to why that may be, although if you obviously have it, it would be great to listen to it, but when you see those kinds of oddities occurring and when we know that we've had that issue with health boards—. And another example quickly here: Swansea. They don't, for example, hold any corporate records of their collection of numbers of front-line staff who've been tested. So, obviously, some people are doing it some ways, other organisations aren't doing it at all. How confident are you? We've got the data; is anybody actually reviewing the whole piece, because we're just seeing more and more of these oddities occur?

Yes. Following the issues at the end of last week on death data, we've also had a review of that, and the chief statistician has been really helpful in providing some oversight and some rigour into that to try to make sure that we are comparing like with like.

It's a similar position in terms of care home sector data. So, we're looking at having some specific reports for Wales in the future. I've asked for and agreed for that to happen within the next few weeks. You'll get a regular weekly update on that picture. You'll get something from the provision of Welsh Government stats and that'll be married up with the Office for National Statistics reports as well. And we're looking at data now in a different way to the way we collected data in the past, because we're asking some slightly different questions. So, of course I recognise, Angela, that it's about wanting to understand what does the data tell us, can we rely on the data, is it consistent, are we collecting the same data in different parts of the country, and what does that then do in terms of informing us about the picture and the answers we should have to the challenge that we face. And I know that Dr Goodall will have something to say on this as well.

Dr Goodall.

I think we have data being used in different ways. There are some of the existing data sources that we obviously use to oversee our system. We've had to introduce exceptional arrangements, not least around surveillance approaches and obviously, we rely, for example, on the process that is already in place. So, actually, in the information and data we have available, the ONS data will be the most accurate, because it's based on the registration of deaths process, for example. But what we do need to do is to make sure that we're able to make sense of the different purposes of the data that we have available, and it's absolutely right, as the Minister said, using the chief statistician role within Welsh Government to help to oversee these areas, and to actually understand some of the variance across Wales—that's going to be really important for us and to deploy that, then, as part of the tactical and technical decisions that we make.

So, somebody is actually looking at, for example, why Aneurin Bevan's got more people in hospital who've died of COVID, but hardly anybody in care homes, and yet it's a picture that's quite different to the neighbouring health board. Those things are being flagged up.

Yes, they are.

That's great, thank you. My last question, very quickly, again, was the ONS data. It is obviously a register of deaths, and this is people who've died of COVID, or with COVID symptoms. Is that actually split out at all, so that you can tell the difference? Because of course, that may have a material impact in analysis, going forward.

Yes. So, in analysis going forward, we should be able to tell where COVID is mentioned as a factor on the death certificate or the factor. And it's part of the issue about the death certificate reviews and what that looks like, so the figure that ONS provide is a broader figure for where COVID is mentioned as a factor within it. I think that's probably a more accurate figure for us to use and I don't want to try to splice that down to try and dismiss ones where it's a factor, rather than the only factor on the death certificate. I think that's really important, because in all of this, we're likely, still, with our official figures to have an underestimate, and it's important that we recognise that in the way that we then understand the impact of COVID-19 and what that tells us about the future.

Thank you.

I think it's a deliberate snub actually, Chair.

Yes, really sensitive [Laughter.]

We've usually got some willing volunteers to fill in the gap. David Rees.

Thank you, Chair. Because Lynne's not here, I'll ask the question. The capacity that's been created as a consequence to the field hospitals across Wales: clearly most of those field hospitals have been built into leisure centres or halls or rugby stadiums and at some point, they will have to be reverted back to their original use. But are we going to be able to use that capacity for other purposes in the shorter term, so that we can get services in our hospitals delivering other things as we reduce the COVID-19 patients in the hospitals? Now, I appreciate that we are possibly still awaiting a second peak that may come, so we need to be very careful. But what is the thinking behind the use of those field hospitals for other purposes?

So, there are two things that I think perhaps are helpful to set out. The first is that, yes, in the scenario planning about turning on the NHS for more activity, then the use of field hospitals is part of that, for step-down care and provision. So, that's part of what I'm expecting to come into the advice that Dr Goodall referred to, about how we could make use of some of that capacity, and that goes into my second one about some of that capacity. You will have seen, in a number of broadsheet publications, briefing from different parts of the UK Government about a debate apparently between running the NHS hot, where it's relatively full, and running the NHS with much more capacity in terms of coming out of lockdown. For me, it's really important that we maintain a proper amount of capacity within our critical care, but also within the field hospital sector as well, because, as I said earlier, until we get the other side of a vaccine, we're going to have a coronavirus reservoir that will affect the way that PPE is provided, the costs of it, how we manufacture it, what we're prepared to decide, but will also affect the capacity you need to have in case there is a further spike. Because we can't accurately predict that all will be well in January or in December or in September; we don't know that now. So, we're going to need to maintain that infrastructure until we have much greater certainty about that.

Now, having built the field hospitals themselves, having everything in place, that cost has essentially been incurred. The bigger challenge, though, is if we need to staff them up, where the regular costs coming in with staffing would obviously be significant as well. So, in making use of the capacity, we've got to think about the use of our staff resource. We've then got to think about that point about, from a policy point of view, it can't be the right thing to run the NHS hot and full and then to go out of lockdown, because any further upswing in coronavirus could have the sort of consequences we've worked so hard to avoid, and we've seen what an overtopped healthcare system looks like in northern Italy, and I do not want that here in Wales.

Briefly, on end-of-life care, which, sadly, is having to be offered to more people than we would like at this current time, money has been made available by UK Government for end-of-life care—some £200 million. Can you confirm the latest position on whether there will be a consequential for Wales from this, how much consequential that would be, given that we'd expect there to be a consequential, and whether that is intended to go to end-of-life care and hospices in Wales?

I'm not aware of the direct detail on what that looks like. There's a finance Ministers' meeting later on this afternoon, so we may then get more details, and we'll then need to make choices about that, because we do know that we're going to have more end-of-life care. We've seen from the latest ONS figures that we have more than expected deaths through the last few weeks, and we don't expect that position is suddenly going to disappear. So, we know this is a very real factor for all of us about what we do. Whether there is a consequential or not, we're going to need to have an answer.