National Assembly for Wales

Diolch, Cadeirydd. Good morning, all. We've obviously seen the reports and our report indicated that there was an issue with PPE at the beginning of the pandemic. Now, that process got better and people were able to access PPE better as the time went on. So, I want to look forward a little bit now and to simply ask the question: do you believe that you have sufficient resource availability and access to those resources for the future to sustain the use of PPE and also to build up your reserves that you've used, because the First Minister, if I remember right, yesterday mentioned that 91 million items had been used? Now, that's a lot to replace. You've got to not just find out what you need now for the current circumstances, because we are using more PPE now as a consequence of the normal practice today, but we also have to start building up our reserves as well. So, are you confident, Minister, that you actually have in place the systems to do both?

I'm happy to respond to the points. I think, just as a point of clarity at the start, the figure used yesterday, the 92 million items, that's just the amount that we've provided for social care. We've actually issued over 215 million items in total, but that does show that well over 40 per cent of that has gone to social care. That's part of the support that we've provided through the pandemic to the social care system. I haven't seen the up-to-date figures on the cost—I think it's about £30 million or so. The cost of that could be more. I need to check the figures on how much that means in cash terms that we've provided to social care for PPE.

That gives an idea of the scale of the exercise, and, of course, I was open with Members and the public about the fact that we were down to, at one point, on fluid-resistant gowns, less than a week's supply, so it was difficult but we never ran out, but it was incredibly pressured, and difficult. We're now in a position, though, where we have not just a range of items in stock—we have, I think, 108 million items in stock—but we have over 670 million items on order. So, this is part of what we're trying to do, to do exactly as you suggest. We're already in a position where we're looking to restock what we have, to have a reserve moving forward, and we have to then balance what we're doing in terms of procuring items from overseas, whilst the market isn't constrained, to then make sure we're in a better position for the future, as well as continuing to work with Welsh manufacturers to make sure that we have not just alternative routes of supply that have an economic benefit for Welsh manufacturers here, but, actually, there's a point about resilience for the future as well, because as you'll recall, the PPE market got very, very constrained really quite quickly and all of our previous arrangements that had a range of just-in-time contracts, well, actually, they weren't fulfilled, because other countries made other choices about the goods they either held or manufactured, and that's why we are looking to restock. It means we need to look again at the amount of storage that we have. We may need to spend more on having places to store the items we're going to need to build up, and then we need to make sure that we have the ability to fund all of that as well. So, the PPE consequentials that I've still not quite finalised with the UK Government do need to be resolved, because there's a significant amount of money that has already been spent and will need to be spent to make sure we're in the position we should be for the autumn and the winter. I can see that Dr Goodall wants to come in.

Andrew Goodall.

To add to the Minister, just two reflections from me, Chair. Firstly, I would just say that we did have an advantage that we did have the pandemic stores available. So, in terms of that real pressure that happened at the outset—as the Minister said, there were moments when things were very tight—the fact that we were able to deploy aspects of the PPE supplies that we actually had within our pandemic store, actually targeting the NHS, of course, but making sure that that was also available for our immediate extension into the social care arena, that was just a really important part. It's going to be essential that—. As we look forward on our order supplies, I think an aspect of replenishment of that stock, as well as just ensuring that the pipelines are in place, is really important.

The second thing I thought I would say was that I just wanted to give real credit to NHS Wales Shared Services Partnership because of the way in which they picked up a much broader set of responsibilities. They are inward facing to the NHS, and they've tended to have a distribution process out to hospital settings through regional distribution centres, and if you can imagine how they've had to completely change that over the last 16, 17 weeks to ensure that the whole supply chain works out even to the level of individual providers, albeit working with the good offices of local governments as well, I think that they have really stepped up in this very difficult environment and we've been able to genuinely use some expertise, of course, just around the procurement process as well.

Okay. David Rees.

Minister, in your answer, you highlighted the benefits from the Welsh businesses being able to produce some of the materials for you. What are you doing with your Cabinet colleagues in the economy department to ensure that those businesses can continue to deliver? If we're in a situation where a second wave comes, because there's a lot of talk about the possibility of a very difficult winter ahead of us, and we find ourselves again in a situation where we would need to restock quickly, are you now looking at using more Welsh businesses and supporting more Welsh businesses to actually produce the PPE so your supply chain becomes more local rather than having to go international?

We're looking at exactly that blend of what we're going to want to maintain, in terms of the businesses that have been repurposed. There was a really significant response from Welsh businesses to the call from the Welsh Government to help manufacture items of PPE, and not just the famous stories of alcohol distilleries that went on to produce hand sanitiser, but a wide range of items that are now being produced. And that is some of the work we're actively doing to understand what the balance is that we'll need in our international procurement supplies—because, as I say, we saw those get very tightened and compromised at the start of the pandemic—and what we can and should have manufactured here to provide that additional resilience and capacity. And it all goes into the point that Andrew Goodall has made that we have a distribution system that has held up well under all of that pressure and been able to expand.

You may recall that, in the early months, the early weeks of the pandemic, there were voices in local government that were sharply critical of some of those services and didn't have full confidence—people wanted to procure their own PPE. And, actually the NHS shared services method has been shown to be robust and reliable; it's required real agility on their part and it's a real success story, and, actually, that model and some of the—. You may find in other smaller countries within the UK—certainly England are looking to have to replicate a different central model that they didn't have. So, we've been really robust and I'm very proud of the response. And that does go into this work now with procurement colleagues in the economy team on understanding how we want Welsh business to continue to support and maintain that ability to manufacture PPE. We certainly don't want to see people turn that off and then find that we get to December, for the sake of argument, and need to call on those people again without the ability to have those manufacturing lines already up and running for us. So, it's a really significant economic endeavour as well.

David.

Thank you for that. Let's go back to the situation with social care and dentists, for example, which require now more use of PPE as a consequence of the pandemic, and the Welsh Government has supported the social care sector during this period of time. What are your plans going ahead? Will you continue to support the social care sector with the provision of PPE?

Yes, as I say, it's a significant financial transfer to social care to make sure that we're providing all of those PPE items, as well, of course, as the assurance that social care have that there are robust supply lines. And, as I say, over 40 per cent of the items that we've distributed through the pandemic have gone to social care, so it's a really significant endeavour and there's a continuing commitment to do so. Now, as I've said before, in normal times, the independent sector in particular have their own responsibilities, as the employer of those staff, to provide PPE—that's the legal position—but we've actually made sure they've been able to do so with the free provision of PPE items, and that contrasts with the position across Offa's Dyke, where English providers still have to pay for that. We don't have any plans to change that but there is a real issue, as I said before, with the consequential from the UK Government. It's been discussed, there's in principle agreement, but we really do need to get that over the line, because these are really, really significant financial transactions that we've already undertaken, and we'll need, as I've said before, to carry on acquiring PPE at this heightened rate for a significant period of time into the future. 

When it comes to other areas, not just dentistry, but pharmacy and other parts of primary care too, including optometry, we are working with NHS contractors on what to do. So, shared services again; having asked them to supply social care, we now have asked them to make sure there are supply lines available for wider primary care services as well. So, there is PPE provision that, at an earlier stage, went into pharmacy; we're now providing more supplies for dentistry as well as dentistry is reopening. So, we really are looking at making sure that our whole system can continue to function in a new normal where PPE use is going to be much higher for some time to come. And, of course, in dentistry and a range of those other areas, because you can't physically distance yourself in providing that care—and optometry have to be really close to some and we know that transmission can take place through the eye as well—these are areas where there are obvious risks for the patient and the practitioner, and it's why we are making sure that those PPE supply lines are available. It puts more strain and pressure on what we need to do, but thus far I've been very proud of the response that our wider system has managed to provide to keep both staff and the public safe.

I appreciate that and I appreciate you've mentioned the additional pressures that this places upon you in doing so, to ensure that those are delivered. But the one group we haven't yet talked about is the third sector. Are you also going to give the same support to the third sector organisations that require PPE as they undertake their duties to help people in this difficult time?

Well, it depends which part of the third sector we're talking about, as opposed to anything and everything in the third sector. But there are parts of the third sector that are regular parts of the way we deliver health and social care, and much of that relationship takes place with local government. And as we've just been describing, we've been providing, not just direct to social care providers, but actually through local government—that's how we are providing social care with stores, so the joint equipment stores that local government run, and they've got direct relationships with a range of the third sector providers they work with and there are direct relationships between health boards and third sectors that are running commissioned services. So, we expect those relationships to work through those organisations rather than the Government trying to directly supply individual third sector suppliers—that would not be a sensible position for us to get into, and the supply lines in the distribution system we've created, I think, would fall over if we tried to do that. But with our main—

Minister, I accept that, and I understand that the delivery would be through, more likely, the local authority. The question, I suppose, that I'm asking is: how are you ensuring—what kind of audit are you undertaking to ensure that those organisations are receiving it and that you're satisfied that it is being delivered by the local authorities?

We haven't had people come to us to say that there is a problem. It is about people working with their local relationships. It can't be the case that if people think that there's an issue that they automatically escalate it to the Government. We're providing lots of the financial support—we're providing support to NHS shared services to make sure that the national distribution systems work.

There is responsibility within our health and social care system for those regular partnerships to work as partners, because they're not just fora for people to go along and have a cup of tea with each other—they're areas to work through problems and challenges, whether that's in direct relationships that people have with either the health board or, indeed, the local authority, or, indeed, the regional partnership arrangements that exist. There are plenty of avenues for a joined-up conversation. I would expect those to take place.

I don't expect the Government to have to go in and do an audit on individual third sector organisations, because, honestly, what we have already had to do in an extraordinary environment, to go in and try to micromanage other parts of the system would require extra energy and effort, and would divert us from what we really need to do on making central, national and strategic choices.

As I say, I've not had, in the meetings—. I had a recent meeting with the third sector, together with the Deputy Minister—PPE supply was not raised with us as an issue of concern. If there are individual concerns, as I say, they should take them up with their partners locally and regionally in the first instance. If there is a bigger strategic issue, I would expect us to be sighted of it. If there is, then, obviously, we'll consider what the Government needs to do at that strategic, national level.

Okay.

Well, actually, we have Government-to-Government relationships that have worked well through the pandemic. It's meant that at various points in time we've had some supply of mutual aid from England, Scotland and Northern Ireland. On the net figure, though, we've actually provided more mutual aid—slightly more mutual aid to Scotland and Northern Ireland, but significantly more mutual aid to England. We've provided more than 10 million items net to England.

When it comes to the supply that should exist, there is no agreement in place that says that suppliers should be prevented from supplying into other parts of the UK. If individual businesses are making choices, then that is the choice of that individual business and it's not a directive that we have signed up to, authorised or agreed.

Our own information, though, is that our supplies that we are providing have not been compromised, and there's no prospect of that in the future from the mutual aid agreements we have in place. My real concern, as I say, is getting over the line the consequentials for the, I think, £9 billion that's initially been spent in England and the additional moneys that have been announced as well.

It's worth looking at the flow, I think, of PPE. You mentioned that there was a net flow out of Wales. In total, Wales has received 1.4 million pieces of PPE and shared out nearly 15 million pieces of PPE. So, we, little old Wales, have shared out more 10 ten times as much PPE as we have received. We could say, 'That's good—we're an altruistic country and we're happy to share', but it strikes me as being odd that the system turned out to be as imbalanced as that. Does it strike you as odd?

Rather than it being odd, what I think it does show is it shows how successful we've been relative to other parts of the UK. We were glad to help Scotland and Northern Ireland. Northern Ireland had short-term issues we helped them with, but they've also assisted us, and again they've very much been a team player in helping other parts of the UK. We received mutual aid from Scotland on arranging masks early on, and we've returned the mutual aid we've received as well. So, it's always been the case that mutual aid has been returned.

Really, it's the English system that has had some really significant challenges in organising themselves to have, if you like, the central arrangements we have within Wales that have stood up to the extreme stress and pressure of this pandemic. And we've been able to not just meet Wales's needs but to help England with some of their challenges. And when it comes to it, I think that is a success story for Wales.

We've been able to assist other UK nations without compromising our supply and that, I think, deals with David Rees's points from earlier about the robustness and the confidence we should have, because it's proven to be successful. But we need to maintain those relationships with other UK countries, not only because they may want to call on our help in the future, but, of course, it's entirely possible that we may want to call on other countries as we did at the start of the pandemic for assistance from them. And that's why, in particular, our relationships with Scotland and Northern Ireland have been very easy and free-flowing, and I've been happy to sign off requests from the English system when they've needed our help.

Thank you for that; it's a very fair response, I think. I can see that you agree that it is rather unexpected, perhaps, that the flow would have been quite the way it happened between Wales and England.

I will go on, Chair, then, to testing and TTP. I'll start with testing itself, perhaps. We had a new testing strategy yesterday. Explain again, if you can, why it is not automatically beneficial to seek to use our capacity as much as possible for testing—not in a random way, not in a scatter-gun way, but at least to try to identify and focus on groups that are at highest risk, and to test as many people as we can in order to identify outbreaks as early as we can, because that's not the approach.

Well, I think that's a rather mixed presentation. Actually, part of that I agree with and part I simply don't. Let's try to get through it in a way that I think is as helpful as possible. So, we are looking to try to identify where we need to deploy our testing resources for that purpose, to identify where there are infections, to identify where there are possible outbreaks, and to have testing there that makes sense. And that's the approach we set out in the strategy. What we're not going to do is to try to set an approach that says we want to maximise the use of tests as an end in itself, and that's the distinction that I'm trying to make.

So, the testing numbers that we currently have are driven by where we really do need to test people, where we've got committed programmes of regular testing, the testing we're still doing around the incident in south Wales, and the two outbreaks in north Wales, and then the testing we're encouraging people to undertake if they have symptoms. So, that's the way we're driving that testing, and the strategy sets out that there could be other risk profiles—and we're talking about the antigen test here that tests if you have coronavirus—where we're looking at how we deploy those tests in the future.

So, if, for the sake of argument, we had a situation as we saw in the English Marches where you've had fruit pickers, vegetable pickers, who live in accommodation on site and they've got an outbreak there, we'd do what we've done here already. We'd look at what we needed to do with a small handful of cases in a cluster—that's how we described the Merthyr incident at the outset, a cluster of cases, and we then went and deployed our testing resources to test people on an asymptomatic basis, and we then discovered people who were recovering, and historic rates of infection, as well as people who were asymptomatic. And that's largely been contained because we were able to use the intelligence we had from our testing system and the test, trace and protect system we have to go on and test on a wider basis.

We'll use that risk base and intelligence-led approach to how we actually use our testing resources, rather than deciding on a broad programme of asymptomatic testing because we have the depth and capacity to do so, because, actually, that in itself isn't a sensible way to behave when prevalence is low. It's part of the point that not just I'm making but, as I said, the Royal College of Pathologists and others make as well. Because the test we have is very accurate: 98 per cent plus accurate. That does mean, though, if you test 100 people who don't have coronavirus, you'll still potentially get two people coming back with false positive results, and you're then going to ask those people to isolate. And that's why just testing asymptomatically on its own isn't necessarily the right thing to do, and, in fact, the scientific advice that we've had from our technical advisory group that I published yesterday reinforces that. It's their consensus position that we shouldn't undertake widespread asymptomatic testing just to use the capacity. It has to be intelligence led and a risk-based approach.

So, in identifying risk, you're now looking for, if you like, signs of prevalence of the virus within a sector or a geographic area, or a factory or whatever it might be, rather than considering a particular sector to be an at-risk sector. For example, I've had correspondence over the past week about domiciliary care in particular, and people—both carers and those receiving care—believing that they are an at-risk group and asking, 'Why don't domiciliary carers get tested so that they can know as early as possible if they have contracted the virus and that the people they've caring for can know that, those with the virus are being kept away from them?' Why don't you do standard, routine testing of domiciliary carers?

Well, again, that would be in direct contradiction of the up-to-date scientific advice that we've had that was published yesterday. And we either want to take the science seriously or we just want to throw it over the side and say that we'll do what seems right, regardless of the evidence. That just isn't an approach that I'm prepared to take in discharging my responsibilities for the country.

There's a difference between the antigen test to test if you have it and, of course, the antibody test. And we are looking at having domiciliary care workers in the next roll-out of antibody testing to look at where coronavirus has actually spread to date and what that then means in terms of the intelligence that we'll then have about future areas of testing. So, that's adding to our knowledge and understanding. And, again, if there are any individual circumstances where people do test positive with the thousands of tests that we do every day for members of the public who have symptoms, that then allows us to look at clusters of cases, and that's exactly what we did, for example, in a school in Barry, where we had two positive cases and we then went out and we tested a wider group of people. That's what we're able to do. 

But the problem is what we have learnt about asymptomatic transmission of the virus. I think, Andrew Goodall, you wanted to come in there as well.

The Minister had started to draw it in. I was going to comment on still the underlying concerns that we need to make sure that the proper infection control and protective mechanisms are actually undertaken. So, it's just to keep ensuring that we retain the behaviour that we require across the system to ensure safety for both practitioners and, of course, for those who are there visiting in communities.

I think, as the Minister was making the point about antibody testing, one of the worries there is almost that people may feel that it's a process for declaring immunity. Now, we haven't got the evidence that demonstrates that yet; it's still continuing to be assessed on an international basis. But people also need to be concerned that, irrespective of, perhaps, some comfort from knowing that kind of output, they still need to have all of the appropriate mechanisms in place. And, of course, this is a virus that still is transmitted from surfaces, so it's still quite possible, even if you've had coronavirus, that you could be in an environment where you could still pass it on to other colleagues, for example, or indeed into a home environment if you were visiting, as well. So, I just wanted to make the point about emphasising the safety and protective measures that are taken.

Okay. If I can move to the need for rapid return and processing of tests, we know that the stats have been moving in the wrong direction over recent weeks in terms of more tests taking longer than 24 hours to be returned. It's a concern. Are you confident that this is something that is being addressed? And what evidence do you have to show that we are on the right track now, because you yourself say, Minister, that we need tests back as quickly as possible?

Yes. It's certainly not a matter that I'm sanguine about or in any way complacent. I'm somewhat frustrated that we haven't seen more improvement to date, and I was explaining yesterday, and we set out in the testing strategy as well the different ways that the tests come in and the different points to improve what happens. There's a point about people getting a test and that's now quick and easy for members of the public, but also, as I say, if we have incidents or outbreaks, we'll move testing resources to make it even easier for people to get tested.

There's then the point about getting the sample to the lab; we've already done a range of things to look at that as well. There was some real frustration that a handful of samples at the end of one day were potentially being left and not being taken to a lab and so you'd automatically build in an overnight delay in those samples getting to a lab to be tested. So, we've had to look at that and really do something more about improving the courier service and about the frequency of it.

And there is then the point about the efficiency within the lab as well, and that's one of the things where the person we've brought in to give some more grip to this, has already had conversations with Public Health Wales about efficiencies within labs. And there's also an issue about clinicians' expectations as well, when we need to bus through some of the challenges and say, 'Actually, we don't need all this testing done as quickly as possible for one part of the health side purposes' and, yet, actually, for contact tracing, it is really important to have a much quicker turnaround. So, we've got to get through some of the clinical expectations as well as the efficiency of the labs.

And to deal with that efficiency in the labs, as I said yesterday, we're going to have to look at the resource level we have in. That includes not just money, but the people and the ability to make sure that the theoretical and the practical capacity that we have to run those labs isn't something that we do in extremis for a sustained period of a few weeks or months, but, actually, something where we may well need to have going through the winter, with more symptoms, even those that aren't really going to be coronavirus, but more coronavirus-like symptoms, where we're going to need a much more regular testing platform. So, over the summer, we're going to need to have not just a plan in place, but we're going to need to demonstrate that much greater efficiency and the ability to maintain that efficiency with much greater demand coming into the system.

So, that's, if you like, the range of factors we're already looking at, and I certainly expect us to see us moving forward in the summer. Because whilst our contact tracing figures are actually really good in the numbers of people that we're getting to, we do need to get to more people at a quicker rate of time. The starting point is that efficiency, really, in the lab space. That's what I'm most concerned about because, actually, I think it's easier then in terms of getting results from the lab to people. That often happens very, very quickly, and that data flow then takes place automatically into our contact tracing teams.

One of the approaches that you're going to take is to work with the UK Government on setting up a lighthouse laboratory in Wales—you've announced that. You will have heard Sir David King of Independent SAGE, and his colleagues from Independent SAGE, raising real questions about how effective lighthouse laboratories are.

I've been reading a report this morning from the Institute of Biomedical Science raising real questions about how lighthouse is working in England and that it'll compound the data connectivity problems. It actually praises the fact that, in Wales, we haven't gone down the lighthouse route and have done more in-house, and that it's been much more effective in terms of sharing data and getting tests back quickly and that kind of thing. That worries me and many other people that you're thinking of changing tack and moving towards a system about which there are some very serious questions being asked.

Well, as I say, you'll remember it wasn't that long ago that I was being criticised for not taking part in the UK testing programme. We didn't take part exactly because of the data transfer issues. And we're now in a position where we're seeing that data flow into our system electronically each day, and that's been really important for us. It's why, from the weekend just gone, we've been able to present a report for the daily testing figures, including lighthouse labs and NHS Wales labs, and it also means that information is flowing into our patient record systems. That's available for clinicians as well, and that's been really, really important, because otherwise, we'd have had figures—. And at one point, people were obsessed rather more about the figures rather than the purpose, but we wouldn't have understood what that meant for individuals; we couldn't have shared that information with our healthcare system, and it wouldn't have assisted us in contact tracing.

We have now resolved that; it has taken some time to get there, but that's why we're able to make greater use of lighthouse labs. And that then means the NHS Wales capacity that we have is capacity we're going to be able to use in different ways when we know we're going to need to make use of that through the autumn and the winter. If we didn't do that, we'd compromise the capacity that we have.

Now it's, as ever, a balanced and a pragmatic choice about achieving that overall objective. I don't think it would be sensible to say that we should not make use of lighthouse labs. It's about how we make use of that capacity to add to our overall capacity. And, equally, the convenience for members of the public, in particular the drive-through testing services that we've created with the UK Government, and they are part of the infrastructure we want to see carry on. And the investment of a lighthouse lab in Wales will provide some economic benefit as well as a closer relationship with one of the labs.

And you've seen that there are advantages from that in Scotland, for example, where they had an early lighthouse lab created in Scotland. And if you asked my Cabinet counterpart Jeane Freeman, I think she'd say that having a lighthouse lab in Scotland is a good thing and they have a positive relationship with it, but that is not a substitute for the NHS capacity that we have created and expanded, and that we need to see not just maintained—the expansion we have—but, actually, to make it more efficient, so we have a whole package that helps to protect people here in Wales.

Well, it is a replacement in some ways, because you've switched to lighthouse in some centres, you have changed what was done at other laboratories to lighthouse, so it literally is a replacement in many ways.

No, we've still maintained all of that capacity that we had, so we haven't given up NHS Wales capacity, we've actually freed up NHS Wales capacity by making greater use of lighthouse labs, and that was a deliberate choice that I made, because what I would not have done is I would not have said, 'Well, let's turn off NHS Wales lab capacity and move into lighthouse.' We've maintained and, in fact, we have expanded NHS Wales lab capacity, and we've been able to do so to give us greater capacity and flexibility overall by making use of the lighthouse labs. It's a UK programme, it's partnered, so it's been funded through UK sources, and that means we have our resources and an ability to look at funding alternative ways of maintaining that NHS Wales capacity.

So, it's a balance. I still think it's the right balance, it's pragmatic, and, as I say, it's all about how we keep Wales safe by making use of those alternative sources of testing now that we have got confidence that that information is flowing into our system. So, we haven't had the challenges that the Mayor of Leicester set out, where they weren't sighted on what was happening within what they call pillar 2 testing in England, the lighthouse labs. We've had that information coming into our system, so contact tracing teams in Anglesey, in Wrexham, in Merthyr and the Cwm Taf Morgannwg area have been able to see that information from those lighthouse labs. That's the position we were in previously, when I didn't take part in the UK programme; that was my choice again, because we would have been blind to those test results. We're in a better position as a result of the work we've done with the UK Government. It has taken time, but we're in a better place for it.

But financial reasons are behind, partly, the shift to lighthouse. I've had people telling me within the public health arena in Wales this is being driven by the need to save money, and they're worried about that. It's something you have to consider, of course—

Well, no, we're not taking on lighthouse labs to save money. It does mean we can use resources in a different way. That's not the same as saying that this is effectively a cost-cutting exercise. It's a different way to use resources from the UK programme that means that other resources we have are freed up, and, as I say, we haven't reduced any of our NHS Wales lab capacity as a result of moving over some of the work into lighthouse labs. It actually means we can make different use of the pressured NHS resources that we have. Despite all the money we're spending, the Welsh Government has real financial pressures because of the extra money we're having to spend, and, frankly, a lot of it is less efficient in other terms. I'm sure we'll go on later to talk about non-COVID activity, but because of the other measures we're having to take, we're not able to see as many people in other forms of treatment, so there are real financial pressures across the system. The lighthouse labs use means we're able to deploy those resources in a different way, including in the extra investment we're making in not just lab capacity, but our broader test and trace system.

Finally from me, this is really a question for Julie James, the Minister for local government, so I won't dwell on it too long, but how confident are you as the Minister for health given the hat that you're wearing in relation to tracing that the resources are going to be available to local government to deliver the vital tracing, the second 't' that makes the first 't' in TTP worth while? 

Well, that is a question for me, as opposed to Julie, because we're working with local government, and it's been a real feature of where we've got to. I really think that the health and local government relationship at the start of the pandemic was broadly good, but with some real points of pressure and difficulty. We had sharp and difficult conversations on a number of points. That's because we were open and honest with each other across all of the varying political leaderships, and I had some difficult conversations with local government leaders. But, actually, we've seen a real improvement in the very practical relationships between local government and not just the officer side of local government, but the political leadership as well, and there's real credit to every single political leadership within local government, in particular the role of Andrew Morgan as the leader of the Welsh Local Government Association and Huw David as the health spokesperson, in the way we've worked with them. That's why we have a public service able to test, trace and protect.

So, we do have local government-employed teams. We have secured investment that means we're going to spend £45 million on our contact tracing teams, and that will mean we'll have an employed workforce of contact tracers, very different to the model they have in England, and those teams are still working alongside our NHS in a real partnership. That's all happened within a matter of just a few months, and so it does show that, in the necessity of what we had to do, those relationships have improved—not just held up, they've improved—and we are all benefiting as a result. So, local government have resources till the end of the year, about £45 million, but we may need to change and revise that again, because as ever, we're still learning as we're doing, and we're still looking at what may happen in the autumn and the winter, and as we get closer to it, we may need to look again at what we're doing. But we've made a significant financial commitment as a Government to invest in contact tracing, and those resources are going to be made available to local government. And as I say, I'm really proud and grateful for the work that local government have done with our health service to keep people in Wales safe.

Andrew Goodall.

I've been really pleased to see how those relationships, as the Minister said, have settled down, because rather than have a national system trying to stretch out, we've been able to create a national framework, but then have that real local infrastructure in place. I think the thing that was striking was at the point when, of course, there was a need to deal with the outbreaks that occurred in those food and factory outlets, actually, the really important part of the response was the mutual aid that came from across Wales, because we'd invested in those local facilities. So, seeing colleagues in south Wales, for example, ensure that support was provided to north Wales, and that we were able to deploy the mobile testing units—that was a very unique and distinctive response for Wales with the system that we've actually established.

Diolch, Cadeirydd.

David Rees, before we leave testing.

Before we leave this particular point, one of the highlights we put in the report was the need to have trained contact tracers, because their ability to discuss with certain people was more of a delicate and different approach. But I also am aware that, in my own local authority, they are reducing the numbers, because the numbers are low at this point in time in our area, and therefore they're probably redeploying to other aspects. Are you ensuring that all the contact tracers that you are going to be funding are going to be trained to be able to deal with the situation, so that they can approach the individuals carefully and sensitively, and they're actually able to get the best out of that discussion, and not the worst?

Actually we've had praise from local government for the training materials that have been provided to contact tracers, and I think the situation you're describing in your own local authority is one that I recognise in others, where, as some local government functions are coming back on stream, the people who have been redeployed from the existing local government work are going to return to other areas of work. That’s why we're investing the £45 million in having an employed workforce for contact tracing, and of course training and support for those people is an essential part of what we need to do to equip them to do their job. It then means that if we do have a surge in demand, and we need to actually increase capacity beyond that, the people who have been redeployed into contract tracing at this point in time return to their jobs. They're effectively part of our surge capacity—a group of people who are already trained, already having experience of contact tracing, who can be redeployed back from their other jobs in local government to contact tracing if we need to. But the point of investing in that employed workforce is to make sure there is a more stable workforce who don't have other jobs to go back to, but also they'll have that training and support to allow them to do their job. Again, it's not just a public service point of view or an ideological preference point of view, it's actually worked in practice, and that's why I'm really proud of the very good figures we have on positive follow-up. Because actually, since 21 June, we've got to 90 per cent of contacts, and that's a really high level of achievement, and it's only happened because of the way we've deliberately chosen to work together.

Thank you, Chair. Good morning. I just wanted to talk about a subject that I know is very dear to all of our hearts, which is how we look at the rest of the NHS. So, I think the NHS has been absolutely stellar in the way that it has dealt with the coronavirus pandemic in terms of the staff, the way that organisations have tried to step up to the plate and to deliver that sort of protection. Of course, that's come at an enormous cost, as I'm sure you all recognise, to the rest of the NHS, where everything essentially has been put on hold. I have a series of questions on this, and my first one is: do you have a clear, Wales-wide picture of the scale of the challenge, the scale of the non-delivery of alternative services, from community all the way through to major operations?

The simple answer is 'yes'. I don't know if it might make sense, Chair, for Andrew Goodall to run through some of the numbers, but we have ideas about the delays in over-36-week waiters for elected care, impacts on cancer, impacts on primary care with the numbers on reductions in appointments that we'd expect at this point in the year. So, there are lots and lots of figures that are available that we've provided at various points. It may be helpful for Dr Goodall to run through some of those for you now, to give an idea of what we do understand about the scale of the impact that's taken place. 

We love figures in this committee. Andrew Goodall. 

First of all, could I just thank the Senedd Member as well for her comments about the NHS and just the extraordinary circumstances we've been in? I think it's absolutely a credit to our staff across health and social care in the way that they have stepped up and responded. These are not normal circumstances at all. I think everybody has tried to really focus on the protection of the Welsh population in all of the decisions that have taken place. 

Clearly, our concerns in the very immediate response were about the harm that could be caused because of COVID-19 itself, and we've embedded an approach to harm both in the approach of Welsh Government to lockdown, but it's actually been embedded in our operating framework. And we were responding back in March to a series of scenarios that were suggesting to us that we were going to see upwards of 28,000 Welsh deaths, that we might see an additional 120,000 hospital admissions and having to plan from that perspective. 

I just wanted to make the point that in stepping away from routine activities, which was a decision that the Minister took, that was very much a shared sense of the need to prepare for the NHS system, which had come very strongly from the NHS itself, even though it was endorsed as a Welsh Government approach, and that did give us time for the preparation. But we've had to shift the focus, having ensured the system wasn't overwhelmed by COVID-19, then ensuring that we didn't cause other harms simply by not being able to respond professionally and appropriately, to needing to understand the harm that is across our system, and in the different settings, as the Member has said. 

So, we do understand that there has been an impact in terms of numbers coming through. We are worried that we have seen drops, for example, in A&E attendances, which have been as high as a 60 per cent drop, particularly through March and April, although that has recovered, and over recent weeks a more normal level of A&E attendance has been seen across Wales, certainly in some of our individual sites. 

Cancer referrals have been a worry. So, I would have two comments on this in terms of how we are maintaining that, because it was an essential service. First of all, there was a very visible drop in referrals into the system for cancer that occurred through March and April—up to about 70 per cent at times. Interestingly, having put a focus on essential services, actually, we were able to maintain a very good level of cancer activity throughout the early period of weeks. So, in fact, our treatment activity in March, for example, was actually higher than we would normally have expected because the system was able to respond to patients who were already on the waiting list, and that was maintained, actually, in April, where again we were able to maintain a high level.

But, clearly, if we're not receiving cancer referrals from within the new system, we do need to make sure that, through GPs and through individuals within the community spotting symptoms, they do feel that they can access our services. In order to restore some normality to that, I'm pleased to say that our national screening programmes have again been restarting just over these recent weeks. 

I think waiting lists are a concern, because, clearly, we had to make decisions to focus on the front door of the emergency admissions and the protection of both staff and patients with COVID-19. So, we have seen an impact in terms of the length of time that patients are waiting who are already on our waiting lists. We have seen a reduction in our out-patient referrals coming in from GPs. That has been a much more noticeable drop; even at this stage, we're probably seeing those numbers 50 per cent down from what we would normally expect. But the waiting list itself in size terms, perhaps to my surprise, has actually reduced a little in total numbers. I think that's probably because we've maintained a level of activity whilst referrals have dropped off. But my main concern is that, clearly, what we've seen is a shift of those that have waited longest.

And as we've focused on harm, it will be inevitable as we restore our services that we are still going to have to make sure that patients are seen more about their clinical priority and their urgency in the first instance, rather than just simply taking patients at the end of the list. Having said that, I think it would be important to recognise that we can't allow the NHS to just return to some of its old delivery models, some of which feel as though they've probably been the basis of the NHS since 1948. With the way that we've seen outpatient services transform—virtual attendances, alternative pathways and settings—one of the ways in which we'll be able to see patients and restore them won't be about necessarily walking into hospital sites in the same way. It'll be about us taking advantage of the technology and the change in practice that has actually occurred at the moment.

In community settings, whilst I think GP and primary care has been very resilient through the process and, obviously, they—both pharmacists and GP practices—have stayed open throughout all of that period of time, they have also seen a drop-off in their activity. They've done much more virtual and face-to-face contacts and through telephone triage et cetera, and maintaining the opportunity to make sure that people don't again walk into physical buildings at this stage. But we've seen a drop of about 30 to 35 per cent in GP attendances and activity, which has still stayed roughly about that level over these recent weeks. So, as part of our quarter 2 operating framework, we have been putting our focus on particular areas to try to restore more. That means that some of the more routine activities, and it would include examples like the taking of smear test, for example, or some of the routine injections—vitamin B12 et cetera—that will be taken, can actually be restored, because whilst they may not be urgent on the one hand, they are an important part of the treatment regime to actually keep patients safe within communities.

We've also maintained services in different areas. So, areas like dental services—we have maintained dental services to be open, obviously focused on urgency with a lot telephone contact happening. We've made sure that urgent patients can be seen within the dental community. But whilst it is such a routine part of our day-to-day healthcare lives—going to the dentist—it is, actually, one of the riskier procedures that is undertaken, just because it's an aerosol-generating procedure and, obviously, there is a lot of spray that takes place as people go to the dentist. So, the cautious approach needs to be maintained in that as we restore it.

So, I just wanted to reassure you. I could give you a series of examples. I'm happy to share some of the operational data that we have, but there will be some pinch points that we do have worries about, and at the moment, I will want to ensure—and to give the Minister the support—that we're able to target areas like diagnostics, like endoscopy, and I know the committee had previous reviews on these areas. They have been particularly affected by these recent weeks by stepping away from routine activities, but also simply because of the way you now have to safely discharge those kinds of treatments because of the environment that they are carried out in.

And the final comment that I would make, in terms of how we restore—and I'm happy to respond and clarify any issues—is just recognising that the NHS is going to have to continue to operate with an environment that will be very different from the previous environment. So, when, ultimately, patients do need to go into a hospital environment for treatment or for an operation, they will find designated zones, they will find green areas that we're trying to keep more COVID-free, they will find themselves going into environments where staff are wearing PPE, for example. And one of the implications for that, for example, in a theatre environment, is there will be fewer patients going through theatre lists, because you will have staff who are operating in full PPE in order to provide safety for themselves, but, of course, more importantly, to provide safety to the patients who they are discharging and caring for.

Okay. Angela.

Thank you for that. That was a very comprehensive overview, and I do appreciate it, and I don't underestimate the difficulty of being able to run the NHS looking after COVID and the NHS looking after everybody else, and I know that both David Rees and Lynne Neagle want to come in on specific areas of cancer and mental health, so I won't particularly talk about them. I just want to talk about the overall picture.

So, you talk about waiting lists that might have gone down, but we heard evidence—I'd be interested to have your take on it. So, Swansea Bay University Health Board, they've said that their referral to treatment numbers over 36 weeks had gone from being 1,676 people in June 2019 to over 11,000 in June 2020. Now, we may all understand the reasons why, but my question is: how on earth are they going to be able to catch up with that, especially as we're all saying, 'Oh, woe is us, winter is coming' and we could well have another coronavirus spike and we're going to have all our normal winter pressures like seasonal flu and all the rest of it?

And the chief executive of Hywel Dda said that having to deal with the coronavirus pandemic had actually set their waiting times and lists back some five years to where they used to be. They'd made great strides, and all of that's gone. Now, given we can't just increase our staffing overnight—. I do appreciate that we do have the extra beds available through the Nightingale hospitals, but we can't magic up extra staff. I'm sure you wish you could at times. Have you plans for how we might be able to manage that sort of situation?

Indeed, and I'd wish to clarify—as I said earlier, I was surprised that, in total terms, the waiting list hadn't changed numbers. I was expecting the overall waiting list to have increased, but I was very clear that we had seen a deterioration in the number of patients who had been waiting longer within that process. And certainly on the back of just NHS operational data, we will be seeing, by the end of May, our figures probably close to around 60,000 patients waiting over 36 weeks. That's not validated data, that's just simply from our NHS operational data, and that would tie very much into what individual organisations were advising you when they were giving their own evidence.

I think Hywel Dda is a really good example, because I do think as an organisation—and you'll know this as a local Member—the way in which they were able to target their waiting times and to reduce them on an ongoing basis over a three- to four-year period of time to get to the position where they had no patients waiting over 36 weeks at the end of last March was a real credit, I think, to the approach that they took, and they will have seen those slip materially. I have a confidence that the system, both in a non-COVID environment, but also recognising that we have to recognise we operate with COVID as a reality for us, will find a way of restoring these areas, because we will be wanting to discharge our responsibility for patients. It's why I was saying earlier that we need to hold on to some of the transformation agenda—that there are alternative ways in which patients could be treated.

But in terms of the outlook—and the Minister will know how I've advised him as well—I think, having taken three to four years of us seeing an improvement in waiting times and making progress and having investment going into the system, to recover to the same level with waiting lists that have got worse rather than better, therefore, just simply in this last three months, will take us some considerable time.

So, I think we need to think very differently. We need to ensure that any patients that can respond to alternative pathways we can promote them through that way. We will have to make sure that we're able to look at the need for surgery and make sure that we can operate and invest, to some extent, in what we need to do, but I personally would be saying that this could well take us another three to four years to recover as well, and I would hope that we would do it sooner than that, with some of the understanding that we have, but it could well be quite a long haul. The Minister will know that I've given him valuable advice on previous occasions as well that I'm afraid that the deterioration will have put us back, I'm afraid, two or three years as a minimum.

David Rees, at this point. I'll come back to you then, Angela. 

Just a very quick point: I'm not surprised that the waiting lists haven't increased in size, but, obviously, they've increased in waits, because what we've been told very often is that people have been not presenting themselves for further referral, therefore the referrals haven't increased. For example, cancer referrals have drastically reduced by about 60, 70 per cent. So, waiting lists not increasing is not a surprise to me, but what the question, I suppose, is: we expect, therefore, that they will increase because those referrals will start coming in now, so how are you going to manage that additional influx of people who will come onto the waiting lists?

So, again, two reflections on this. The first one, just in respect of cancer referrals—it remains a concern to us to ensure that we give the advice into the system that, if people have concerns, if they have symptoms, they should be looking to access the care that they need and we have to be in a position to respond to it.

Some of the cancer waiting lists across Wales, if you like, the backlog of patients who may be within our system, they were able to clear some of those patients. We've probably now just about returned to the number of patients who were waiting to access into the system to about where we were pre-March. And just to reassure you that, just certainly on our latest weekly figures, we've actually seen, really, a return to a normal level of cancer referral now into the system.

I was actually chairing a cancer summit just last Wednesday afternoon virtually, with all of the respective clinical teams and leads across all of Wales and the respective health organisations, and it was very clear to me that they had taken a really professional approach to the way in which they have tried to maintain cancer activity throughout the COVID response.

One of the worries for cancer particularly—and it'll be a factor for both operations and also access to treatments like chemotherapy—is that inevitably patients will have some of their immunity compromised by some of the treatment regimes, and I know that there was a very fine balance in judgment often taking place with individual patients across Wales, about the judgment of coming into a COVID environment, where there would be higher risks, possibly, for the operation taking place. We do know that there are individuals who have made judgments to defer or possibly to seek alternative treatment regimes in the short term.

So, at least the numbers at this stage have returned and restored. It's why I highlighted earlier, though, that I'm worried that we have to make sure that we tackle areas like endoscopy and the way in which those waiting lists have particularly grown over these recent weeks, because they are so fundamental to that cancer journey.

On out-patient activity more generally and out-patient referrals, even at this stage, we are seeing the numbers coming in being much lower than we would expect. So, actually, our out-patient referrals in Wales are probably around 50 per cent of the level that we would normally see. Now, not all of those are for urgent reasons, and there might well be still some underlying messages that we need to give to patients that the NHS is open and available when people need it, and we need to reinforce some of the messages that we've been giving out over these recent weeks. I think, however, for some specialties, it may well just be a sign that we've been successful in some of the alternative mechanisms that are in place.

Perhaps if I could finally just take the opportunity to make another comment, which is not about out-patient referrals and planned care, we still need to have some understanding about some of the reasons for seeing drops in activity around emergency admissions, and whilst some of those are of concern, about people not accessing emergency and urgent care that is required, it's quite interesting looking at the reduced number of admissions that we're seeing in areas like heart attacks, for example—also for respiratory admissions. We've actually seen much lower levels of air pollution, for example, over these recent weeks, and it's interesting when you start to track it with some of the activity going on within areas. And there was a useful study this week that was just looking at English figures, just suggesting, actually, a real fall-off in the number of heart attack admissions in England, for example.

So, whilst there is harm that we need to look for in the system, it's quite interesting also to use a bit of a different lens—that some of the normal admissions haven't come in, because, actually, our society and our environment have actually changed as well.

Good. Angela.

Thank you for that, but I do want to bring you back to out-patients, and how we handle out-patients. I understand that not every out-patient appointment is an urgent one, but I just want to give you just one example, which was a response to a written question to the Minister: so, we've got 116,000, just over 116,000, patient pathways waiting for an out-patient appointment who are people who are suffering from R1 definition of sight loss, which means that, if they don't have that out-patient appointment, they could very easily lose their sight, which would obviously cause not only enormous tragedy for them, but, again, that sort of pressure on the NHS going forward and on social care and all the rest of it, or they could have significant harm. So, if we've already got 116,000 people waiting, of which 42 per cent are already waiting longer than they should have waited—so, well past their appointment date—and they're classed in that—. And that's just one example, and I'm sure you will know better than I that, throughout out-patients, there'll be other disciplines where there are people who you have to look at on a regular basis, to check up on them, to make sure that they're not in danger of further harm. I just don't have any sense of clarity on how we're actually really going to manage that backlog. If we've got that backlog in just one area in out-patients, then, you know, all the other areas—.

And may I just also finally bring into play community services? Later on, we're going to talk about how we carry forward the gains that we've made in terms of transformation and all the rest of it, but community services: there's been absolute cancellation across community services pretty much on physiotherapy, occupational and speech therapy, chiropody, mental health services. And a lot of these are hands-on services, particularly for older people, particularly for vulnerable groups, new mothers, people with disabilities and so on and so forth, and we're holding them all at arm's length because of COVID, and they're people that can't, perhaps, be so easily treated. You certainly can't be treated in terms of physiotherapy terribly well, I wouldn't have thought, through a Zoom meeting or whatever.

I understand GPs have been able to pick up this and to triage people and to allay people's concerns, and that's great, and we need to hang onto that. But, ultimately, if you're providing chiropody services to an elderly person stuck at home, who is unable to go anywhere, that person's got to be able to go back out and look after that person. So, how are we going to be able to get that sense of normality back, and when do you think that might be able to happen?

So, first of all, I don't think we're looking to defer those issues. So, resetting activity is different from recovering activity, if I could put it in that way. So, that, for me, is part of a restoration of a more normal approach and an expectation that we can actually discharge those safely, particularly when there are lower rates of community transmission, but, secondly, when we actually have the opportunity to ensure that the protection is there for those staff that go into those areas. So, for physiotherapy services, which are being undertaken in the community, for the examples like you said there around podiatry and chiropody, we are expecting within our quarter 2 plans for those to be examples of services that are being restored. Now, it may not remove some of the waiting list issues that we've been talking about, but really important and visible signs, I think, that normality is there, and I would expect that they can be discharged safely, because staff can wear the appropriate PPE to go into that environment and ensure that they are acting in a safe way for themselves and actually for somebody in their home environment as well. That does apply to community services, which we've looked to clarify through the quarter 2 operating framework in particular. So, whilst we are being cautious about what we're looking to step up, it does come with an expectation that we see change in a range of different settings that we've stepped away from, particularly in the middle of the immediate response as well. 

In respect of your examples on the out-patient list, I am also concerned about the need to ensure that patients are able to access the care that they require—both those being referred into the system, but those, clearly, that have ongoing contact and regimes. I do think that not all of the patients that you are describing have to have the same style of contact that they have had in the past, and I think there are opportunities to deal with some of these issues virtually.

I've been really pleased in working with optometrists to actually see some of the response around COVID-19 allowing us to ensure the alternative settings, and using optometrists' skills and experience—which has been done across Wales, but perhaps not to the scale that we've been seeing. That has been definitely an outcome that we've wanted to do, and, some of the patients who need that routine eye care monitoring, it can be done with optometrists rather than having to come in and be within a specialist ophthalmology centre, for example.

But we also need to make sure that we are targeting those particular measures and outcomes in out-patients that are of greatest concern. So, again, in the first stages, the eye care pathway, which was set up particularly for the reasons that you've outlined and we were making progress on, cardiac services in particular, also around cancer services, as I've been highlighting—all of those are important areas to go through. I'm very happy, perhaps, if it helps, to drop a note through to the committee, and, even if we just look at it through the eyes of eye care, just to give you an example of the level of activity and changes that are taking place across Wales to deal with both the backlog and the patients that will be continually coming into the system—if that helps, to just give a bit more detail as well further to today.

Thank you. Angela.

I've just got one more question, Chair, which is one of those 'how long is a piece of string?' ones, Andrew. So, let us assume that, with luck and a following wind, COVID stays quite quiet and we're able, over quarter 2, quarter 3, to start up all of these services and to start normal NHS as well as COVID NHS in a more sort of meaningful way. If we do have a spike of COVID in the winter, and we have our normal winter pressures and bronchiolitis and seasonal flu and all the rest of it, would you anticipate, and have you anticipated and are you anticipating that you might have to close all those services back down again and go back to where we've been in February/March? Because, of course, we're talking about the impact on service delivery, and, having got the engine firing up again, if we've suddenly got to stop it all—. I'm assuming the answer to this is probably going to be (a) yes, but you don't know how much, how long, et cetera. But is there thinking going around all of that and about how that might then have an impact going into next year, so that in February, March, April, those waiting lists will have doubled yet again—if that makes sense?

So, my first response is that I think we have learnt a lot about how we can respond to the virus. So, our initial response back in March was because we just simply needed to ensure that we were taking safe and protective actions for the Welsh population, and we knew less, clearly, about the virus and the way in which we could manage and contain it. We obviously know that we can deploy our normal infection control approaches and we've learnt more about that, and things like the availability of PPE helps us to go forward.

I think my framing of it is that I think we have to recognise that the NHS now has to operate not just to assume that there is no community transmission, but it has to work in a way that actually recognises that COVID-19 is part of our reality, and, as we look forward, to have the opportunity to make sure that we continue to be able to maintain as many services as possible in as many settings. Having said that, it really does depend, because when is the trigger for when the system would be overwhelmed and we would cause more harm by not stepping away from some of our routine activities within the system? And I think that is a judgment call that is necessary. Our own preparations for what we need to do before the winter, despite the look to resetting of activities quarter by quarter, and including into the winter, is that we absolutely need to assume that there will be a second peak, a second wave, and that we should expect that peak to be similar to, if not worse than, our experience, I'm afraid, in March and April. We've done our own assessment of what we think we need, just in terms of providing capacity across the system in Wales—that's learning a little bit about the last 16 weeks or so and applying a realistic check on what we think we need, based on our original plans. So, whilst we may not need as many beds through things like field hospital provision as we were originally intending with that first wave, based on what we know now, we will still need to have that level of extra contingency in the system to respond.

You may well have seen the Academy of Medical Sciences report that came out just this week. Our assessment in Wales is no different. We will go through our own workings in a Welsh context of what that looks like, but that also shows that, irrespective of the peak happening, although we would hope to mitigate it, it would probably be much more sustained through the winter period, at a higher level—exactly what you're saying—because in the winter the virus will act in a more difficult manner. In the cold, more contained, with more people being indoors, the transmission is likely to be higher, and we are going to have, whether it's local lockdowns or local outbreaks—. I think this will translate into something that will feel much more significant through the winter months, I'm afraid. I am reflecting a little bit on some of the international experience that we're seeing at the moment, including most visibly at the moment the experience over in Melbourne, where they've had to go into lockdown again for another six weeks. So, we will professionally prepare. We have to make sure that we can respond to some of the assessment of the worst-case scenarios, of course, but we have learnt an awful lot, I would say, over the last 16, 17 weeks, to maintain as much as we can for as long as possible.

Thank you.

Good. I'm conscious of the intensity of the questioning. Before we go into a short break, Lynne Neagle on mental health issues—Lynne.

Thank you, Chair. Andrew, when you came to the committee before, you told the committee that you had issued instructions to health boards to continue mental health work, and that was very welcome indeed. However, as a committee we've been told that that hasn't happened in practice. We had the Royal College of General Practitioners telling us that, basically, they didn't feel that people had been getting what they were entitled to under the Measure. Of course, the Measure wasn't modified by the emergency legislation.

The committee I chair was told that child psychologists had been prepared for reprioritisation, which is very worrying, because I'm struggling to even understand how you could redeploy a child psychologist to deal with a physical health emergency, really. So, I'd just like you to comment, really, on whether you feel that what you asked for has been delivered on the ground and to what extent. 

Andrew.

It was really important that we did not only focus on the physical health side. So, in terms of the operating frameworks, but also the direction that we have given to the NHS within the COVID-19 response, we did ensure that mental health was clarified as an area that was defined as an essential service. Now, clearly, there are different aspects of delivery that we see at those different levels. In a COVID-19 response, there will be, inevitably, a focus on the higher and more specialist areas, perhaps, than some of the more routine activities right through. So, I think the system will have struggled to maintain all levels of activity in all settings, in the context that COVID-19 absolutely had an impact on all of the different delivery models for our services across Wales.

If I look at some of the more significant access points for mental health, and look at the crisis teams access, for example, I was describing earlier that we saw cancer referrals drop down by around 70 per cent at the peak, although they've recovered. But, on the mental health crisis team referrals, whilst there was a dip, it was only around 10 per cent, which did show that there was a resilient level of ongoing response. Although it's a concern that that had dropped off, it was actually retained at a much higher, or more normal, level of expectation in there at this stage.

I do think that we have tried to focus on some of the alternative access points using technology, cognitive behavioural therapy, et cetera. Whilst I think that would have satisfied some of the needs, because people could've accessed them online, I'm not sure that that would have been an appropriate response for a number of individuals who would've needed to access care, whether that was through adult services or through children's services, as well. 

We still wanted to make sure that the referrals are still able to be discharged. Of course, on the gateway approach with mental health, primary care has remained available. So, I respect the Royal College of GPs—the points that they made—but, of course, there is also a primary care gateway that we've wanted to maintain through this to make sure that we continue to discharge that access. The GP focus for care has not simply been on physical health either; it's also been about making sure that mental health is one of those areas of support.

So, alongside some investment decisions that the Minister made to try to maintain services, I think our intentions have remained really clear throughout all of this. I think we've seen some recovery of mental health, certainly over these more recent weeks, as we have with other services, but I've had to write out on a couple of occasions to the service to make clear my particular concerns about mental health and maintaining that at this stage. So, I think our intentions have always been very clear. I think, unfortunately, there has been inconsistency across Wales, and maybe some of the lower level points of access have been more of a concern to me as I look back on these recent weeks as well. So, I have the NHS executive board next week, and we'll be picking up an ongoing conversation about where do individual health boards across Wales feel they are on their mental health services and outlook, and I will make sure that I have an opportunity to see whether I have recognised any improvement in that position from what you've described. Having said that, if there are any individual examples that you've got that would allow me to track them through the system, not least with individual organisations, it's often helpful to do it through the eye of an individual experience than it is perhaps just on the overall description.

Okay, thank you. So, is it your intention, then, at this NHS executive meeting to sort of maybe have a plan to actually monitor this going forward? Because what the evidence we've had suggests to me is that it does need some individual monitoring of health board activity, really.

Yes, we've actually had a particular mental health monitoring approach in place throughout the whole of these 16 weeks—a mental health dashboard that's allowed us to understand some of the individual differences. Some of the data, obviously, comes through more retrospectively than operationally on the day, so I think we're having to look a little bit over our shoulder about the experiences that are there. But what I'm hoping to do next week is to ask whether some of the information that we've seen on that dashboard does match up with some of the practice. And it has allowed us to facilitate, through the mental health network in Wales, ongoing conversations with some of the different organisations, as well. 

What I'm minded to do, having had such a good experience doing the cancer summit last week, is that there may well be an opportunity to do something very similar on the mental health side where I can actually speak a bit more directly to some of the mental health teams across Wales. But I'm very happy, again, to see whether there's a way in which I could give you a feel for some of the data that we've actually seen on that dashboard and whether it underpins the concerns that you've described. 

Thank you. Chair, with your indulgence, if I could just ask about memory clinics, because memory clinics were suspended and I understand there is a big waiting list now, and a lot of staff who support memory clinic work apparently were redeployed. A dementia diagnosis—. It's important to have the diagnosis, but also it can have a really big impact on mental health if you haven't got a diagnosis and you don't know what's happening. Is that something that you can give some focus to as well?

Yes, I can pick up on that. Again, if I could just look back to March and April, I can only really try to personally describe just the sheer intensity of the circumstances at that time, for myself, the team, the Welsh Government, the NHS generally, and of course staff, as we were responding to something that we had never experienced before. A once in a century global pandemic clearly turns the system upside down, and inevitably there will have been an impact for needing staff to be deployed simply to be a response to the coronavirus. As I said earlier, we were having to plan for a scenario of seeing possibly an extra 100,000 hospital admissions coming into the Welsh system, and wanting to ensure that we didn't overwhelm it. Having said that, we're at a different point at this stage, with lower levels of community transmission, and it's important in the transition to pick up on these areas. So, I will look into the memory clinic issue that you've raised and make sure that I respond to that.

What I would say also is that we're having to ensure that we do focus, obviously, on dementia patients who are more generally in our care. I think one of the concerns that we've had, clearly, with an essential need to protect people and to remove hospital visiting in the normal way—I've had my own descriptions back to me—is the impact that that does have, of course, for patients who are within our system because it's not maintaining the normal regime or the normal contact, not least with loved ones and family as well. So, we're also needing to see how we can adapt to that kind of environment, because we know that they would have been very difficult personal circumstances, of course, for the individual patients, but also for their family members as well. So, I could extend it also to maybe give some further reassurances about our particular focus on dementia right across the system.

Thank you. I think that would be very helpful, and you've kind of answered one of the questions from my next section on social care, really, because the impact on people living with dementia has been massive, really, and there has been a real harm to people living with dementia who've had contact cut off with loved ones. So, I would be grateful if you could look at that. 

I'd be happy to.

I think we'll break now. I'm conscious David Rees has a question outstanding, so we'll break for 10 minutes until 11:00, and then David Rees will kick off then. Okay, so back in 10. Diolch yn fawr.

Diolch, Cadeirydd. I just wanted to raise a point again about cancer services. I know that Andrew Goodall, in earlier evidence, talked about the work in cancer services, and he also mentioned endoscopy as being an issue. I'm also deeply concerned that some of the evidence we've received is that the diagnostics have been very challenged during this period of time, and diagnostic waiting times have gone up, as well. So, I suppose I want to try and be reassured that the diagnostic agenda is going to be something that is going to be focused upon so that we can reduce the number of people waiting over eight weeks for diagnostic work.

Also, in relation to cancer, we had a cancer cross-party group on Tuesday and one of the issues that was raised was the deeply worrying situation of the third sector organisations that support these services and patients, and that, I think, as they would put it, they were the mortar to the bricks of the NHS services, and, without the mortar, the fragility was there. And so, I want to ask the Minister as to how he's going to manage to ensure that those sectors and organisations are supported, because many of them have relied upon the public, through other means, and their financial input has obviously been hit dramatically through the pandemic. So, they're going to be facing very difficult times. So, what's the Minister going to do to support those organisations as well?

Well, part of the real difficulty in our response to the pandemic has been that we've had real cost pressures all across the whole system, and that includes, as I said earlier, the parts of the voluntary sector that are part of the way that we deliver healthcare in Wales. So, in a range of areas, we've not just looked at what they want and what they need, but there are regular conversations with our officials. And in the hospice sector, we've got money. There's more information across my desk and there are active conversations with the sector to make sure that we do support them as well as we can. To be fair, they've recognised that these are generally extraordinary times that we're in, but, like I say, that regular conversation has not finished. We'll look to continue to have that with them, and we've already provided an availability of around £6 million and we'll have more money that we're looking to examine how we can provide to make sure that the sector is still able to fulfil the function that we know is of real value to people right across the whole service. And you'll see that not just in cancer, but in a wide range of other areas too.

We were talking about mental health earlier. The Mental Health Wales alliance—I met them just a few weeks ago. We've had a talk with them on what they're able to do. They're having weekly conversations with us about issues in the service and what we can do to support each other. So, this isn't a flipped picture; it'll continue to move and to shift. We need to think about how we're able to do that, given the constraints that we face as well.

And can I ask from the diagnostic agenda?

Yes. On the diagnostic agenda, you'll have heard that, on a range of areas—we've heard from Dr Goodall earlier that on both diagnostics and endoscopy, we know that it's a really significant feature for us. And, again, there's efficiency challenge again as well. Because the ways of working will be different, so it'll affect our throughput in a range of areas too. So, there are very real challenges. But, for example, we continue to make investment choices, both before where we are—what do we think about investment choices investing in new forms of diagnostic equipment that would improve not just accuracy but efficiency too? So, you can expect to see ongoing choices made. But there's no getting away from the fact we've got not just, as you identified earlier, the challenges of those people who are already in the system, but those who have not come into the system because they're concerned; we expect to see demand increase over the coming weeks and months. So, this isn't going to be easy or comfortable, I'm afraid.

Andrew Goodall.

Just to build on the Minister's comments, one of the constraints for diagnostic areas, in all the overall areas, is, on the one hand, we have some really fantastic examples of both equipment and facilities and environment, but we also have some difficult environments across Wales. What we have to do more than anything is ensure that when we are providing the diagnostic care, it is done safely. So, there's quite a number of important protections that are taking place to make those environments as safe as possible for the practitioners and for the patients. And you may well have seen some of these facilities and environments across Wales. You know, they tend to be more contained environments, they're quite limited in the space that's available—that, obviously, affects throughput, as the Minister was describing.

And I was also, Chair, just going to comment, just to reassure you, that when the cancer summit took place last week, I was really pleased that we had representatives of the Wales Cancer Alliance there. So, it wasn't just about me only talking to the NHS, although it is, fundamentally, about that, it was actually an opportunity to make sure it was a more holistic discussion about all of those that are providing care in this area.

Thank you, Chair. Can I start by asking about the decision to modify local authorities' care and support duties, which was done, obviously, as part of the emergency arrangements at the start of the pandemic? It wasn't done for children, which was a huge relief, but can you just explain again for the record why that decision was taken in relation to adult social care, please?

Right. Thank you very much, Lynne, for that question, and good morning, everybody. The arrangements that were made when the Coronavirus Act 2020 came in were agreed by the Senedd, and it does give the Senedd significant powers. It does give the power to withdraw or limit somebody's care or support; it does impact on daily personal activities for individuals. And so, the powers that were given to us were wide. I know that this has caused concern amongst service users, but we've worked very closely with those service users, and, in fact, the restriction on the services has not really been as great as anybody feared.

Lynne.

Okay, thank you. I mean, you haven't really explained, though, what the rationale was for doing that for adults when you took a decision to protect children—as welcome as that was to protect children. What was the rationale for doing that for adults?

Well, as you know, when the pandemic started, we were in a crisis situation, and we were uncertain about whether we would be able to cope with these services that we were delivering, and, in particular, the packages of care that would be delivered to so many of, particularly, our older and disabled population. So, in that debate, we decided that it was best to introduce these powers in case they were needed to be used. So, it was a precautionary step in order to see how we would cope as we were going through the pandemic.

Albert Heaney wants to come in at this point. Sorry, Lynne, we'll come back to you now. Albert.

Thank you very much, Chair. Just to respond to support, in relation to what the Minister has said, and to add that, at the time that this coronavirus Act was co-ordinated, we were really working on a number of modelling assumptions that showed a potential wave coming our way around coronavirus. So, the preparation needed to take place back at that stage in March, and, of course, for committee to be aware this was a piece of legislation that was worked across all of the four Governments, so it wasn't something that was seen to be in isolation. I think, as the Minister quite rightly explained, there was a lot of anxiety at the time in some quarters, but, through good discussion and also, I think, really good dialogue and monitoring—so, the Minister's had in place a number of forums where she has been able to follow through with the political leadership and have those discussions, and also her officials have a number of forums, for example weekly conversations with directors of social services. We have continued to monitor. We have a weekly data capture that comes in and the Minister, myself and others do go through that in some detail.

Okay. Lynne.

Thank you. Minister, you said that the powers haven't really been used by local authorities. Can you flesh that out a bit, really? Have no local authorities used those powers? Can you give us a flavour of what exactly is happening on the ground, because this committee has been told that this has actually had a huge impact on people who need care and support at home?

Well, as Albert said when he spoke then, we have engaged very closely with the sector and the people who have actually been affected by these proposals. I went to the disability equality forum on two occasions to directly engage with representatives and users of the services, and so I was very aware of their fears and their concerns about what might happen. But we were very pleased that we were able to get them to actively participate in the guidance for any of these measures, and they were very involved in that process and were very pleased at the results.

We asked at all those forums for examples of people who'd had care packages withdrawn, for example, and where there were concerns, and we were not able to identify many cases. As Albert also said, we do have this check-in checklist of seeing where local authorities are, and I understand that of 23,000 packages of care, 460 have either been reduced or withdrawn, and for many reasons, those have been withdrawn because the families no longer wanted the packages of care, because they were concerned about people coming into the house and were worried that infection would be brought into the house. So, I do know that some people have withdrawn themselves from care packages, but, as I say, out of 23,000, 460 were altered in some way. We have found it difficult to get actual examples of people who have suffered because of the withdrawal of care packages.

So, we absolutely share your concern about not wanting to affect anybody, and that has been the message to local authorities: that these powers are there and only to be used in extreme situations where you have to switch resources to a more life-saving situation, but it hasn't happened. On the whole, things have carried on in the way that they were before.

Okay, Lynne?

I've got to say that that wasn't what we were told at the dementia cross-party group last week, so I'd be surprised if there weren't examples of real problems that have been caused by this out there. But when do you plan, then, to reverse this modification? Obviously, we're through the worst of this phase of the pandemic; are you planning to reverse that modification now, or is this going to stay in place for the whole of the winter ahead?

Well, it is obviously constantly reviewed, and it will be reviewed as part of the First Minister's recovery programme. So, it will be reviewed. It is under constant review. But just to say, in terms of the dementia group that you had, and the examples that came forward, it has been hard, as I say, for us to identify the hardship that has been suffered, and there is constant contact with the social services department, and Albert Heaney is speaking to the directors every week. I'm having a lot of contact, and, as I say, I attended those two forums. So, there is an awful lot of contact going on, because, obviously, we are very concerned to do what we can to ensure that people do not suffer.

Thank you. Just before I move on to talk about the funding, I'd like to ask about young carers. You'll have seen, I'm sure, that the Carers Trust this week published a report on the impact of the pandemic on young carers, and it makes very sobering reading, really: 37 per cent of children who are young carers have said that their mental health has been really badly impacted by the pandemic. I won't read you some of the quotes from children in Wales in the report because we haven't got time, but I'd like to ask you specifically what you've been doing to monitor the impact of the pandemic on young carers, especially in the light of that modification that we've just discussed. 

Yes, we have been working very closely with the carers forums, and we are aware of the strain that this has put on young carers, and we have tried to do as much as we possibly can in terms of working with carers, in particular young carers. We are considering whether there is more that we can do at this stage. 

The First Minister and I met with carers to have a face-to-face discussion about the experiences that they were actually having, and that did bring it absolutely home to me, the difficulties that all carers were having. But in terms, particularly, of young carers, we are very aware that young carers are vulnerable learners, and it's been very important to recognise their need to balance schoolwork and home life so that their own health and well-being does not suffer. Meic, of course, the national young people's support service, has been available to assist young people, and we also launched our young person's mental health toolkit on Hwb.

But the carers ministerial advisory group will be specifically looking to see what more we can do. As you know, we announced £50,000 to Carers Wales to increase psychological support for unpaid carers, and we hope that that will help provide help with peer support. In terms of working with the pharmacies, we've worked with the pharmacies in order to make it easier for young carers and carers to collect prescriptions in terms of identification letters. Of course, there was £24 million given to the third sector in order to help to support carers—some of that would go towards carers.

So, I accept that they've had a really difficult time during this period, and we are looking to see what more we can do to help, but certainly, the surveys that you've referred to do highlight the issues that young carers have coped with.

Okay. Lynne.

Thank you. And, of course, £50,000 for mental health support for carers equates to roughly 13p per carer in Wales. I mean, I've raised that with you previously, so I think definitely there needs to be more of a focus on this. 

Can I ask about funding, then? There's been no clarification given to local authorities on funding for the next three months. Now, we've heard the health Minister today say how wonderful local government has been, and I totally agree. But would you agree, then, that we do need to provide that certainty to local government about funding, going forward, for social care?

Yes, I'd certainly echo what the health Minister said, and what you're saying—that local government have been fantastic, and it's been a really great working partnership between local government and national Government. So, I really would like to pay tribute to them. But, as you know, our immediate response was to give local authorities up to £40 million to meet the additional day-to-day costs arising from COVID-19 that adult social care providers were experiencing. And so, that was the first thing that we did. That £40 million was intended to deal with the additional costs: the increased staffing costs, the greater infection control, the higher food prices and all the issues that were being coped with in adult social care.

So, by the end of May, over £20 million of this funding had been provided by local authorities to meet the additional COVID-19 related costs, and we are now planning for the July/August/September period, and there have been discussions with local government, so they are aware of what the plans are. Ministers have agreed further funding of £22 million, which is in the process of being worked out at the moment, so it will be formally announced soon, and that will cover the next period. And, of course, the nature of what it's needed for has changed over the period, and one of the issues that now has to be addressed is the issue of voids, because many care homes are saying how difficult it is to actually cope with the reduced income from voids. So, that is one of the areas that is going to be addressed by this next section of funding. 

And you'll be aware that the committee has made a call for three to six months' worth of funding to be announced so that the sector has got the stability to plan, really. And mindful of what Dr Goodall said about the winter that we've got ahead of us, I think that makes that even more important, really, rather than announcing pots of money here, there and everywhere. What plans have you made to actually put social care funding on a sustainable footing now to get us through this winter? 

Certainly, this additional money that we have now agreed and will shortly be announced will be for a three-month period, which will take us up to the end of September. We'll have to look during that period to plan ahead for what is going to happen after that period. So, there is three months' stability, but of course we do have the much longer term issue of funding for social care generally, which was an issue that existed before this COVID-19 emergency happened and which, of course, we have been trying to plan for what we can do in order to improve the long-term funding for social care. 

Lynne, okay? 

I think that was Albert indicating. 

Oh, Albert, yes, sorry.

Oh, Albert. 

Thank you, Chair. Thank you, Members. Just to really add to what the Minister was saying, the funding that's been put in place, the hardship funding, has run from the middle of March and will now run up until the end of September, and the total of that hardship fund for social care itself, excluding some of the funding considerations for the national health service, is in excess of £62 million. Combine that, then, with PPE, I think that gives confidence to the sector and confidence to local authority partners in relation to the funding commitment from Welsh Government. 

But there are other aspects that we need to consider as well during the winter preparation. I think over the last few months, we've spoken less perhaps around regional partnership boards. Additional money did go to regional partnership boards to facilitate and help them around discharge and the appropriate arrangements for discharge. So, as we move into winter, one of the vehicles and one of the areas that we really see a bringing together is that health and social care world has been integrating and delivering new models of care. So, I think in response to local government demand, that will be critical to us as well. Thank you.  

Thank you. Just a couple of final questions from me, then. Both staff and residents in care homes have experienced major trauma, really, over the last few months. What plans does the Welsh Government have to put in place support to get them through this? 

I absolutely agree that they have experienced significant trauma. One of the big issues of trauma that the residents have experienced is the lack of contact with their family and friends, and I think that has been a very difficult situation to cope with. The care homes' own managers had to take a quick decision that they had to close the homes down to as many outside visitors as possible, and this has meant that care home residents have suffered significant trauma, I would say, by not having that contact.

So, that is why we have now moved on to the stage where Albert Heaney wrote to all the care homes to say that outdoor visiting could be arranged, and the Government has given guidance on how those meetings would actually take place. So, that has been opened up now, and we are now in the process of discussing how we can open up care homes for indoor visits, because it's not always possible, obviously, to meet outdoors. And that discussion is actually happening now.

I do feel very strongly about it, that people should have that contact with their loved ones, but, obviously, we have to balance it with the risk of bringing the infection into the home. So, that's what we're trying to do now, and we are consulting for scientific advice on how we can actually do that, and I think that this is a very important next step. Albert may wish to say something about this, because he's been directly involved in that. But that is one of the ways that I think we want to address that part of the trauma that residents have suffered from.

And, obviously, for the staff, again it will mean—. I do want to use the opportunity to pay tribute to the care home staff who've gone the extra mile and have done fantastically well in terms of caring for the residents, but I think may be left with deep scars by the experience that they have actually been through, particularly ones where there have been significant losses of life.

Then I do think it's important to remember that nearly 70 per cent of the care homes did not have COVID-19, but, obviously, for the ones where they did and there were deaths, I think it's important to remember that care homes, unlike hospitals, are a family—it's somebody's home, it's where they live—and so I think that loss has been very profound.

So, we are aware of the needs of the care home workers and the need to offer them any help and support that they do need, and I know we are in the process of discussing with the Samaritans about providing a special support service, a support line specifically including care home workers. So, I think that's very important. And I do think it's important as well, because we all know that this is a low-paid workforce that hasn't always had the recognition that it should have, that we are recognising that by giving the £500 as a one-off recognition of their work, to all the people involved in front-line care. So, we are doing what we can to boost the care workforce, but it is a long-term issue, because the status of the workforce, I think, was there before all this happened.

Albert, do you want to add anything to this, because you've been directly involved with some of this trauma?

Thank you, Minister. I think the Minister has given an extensive response, but just to add a few comments to that—a few reflections. I think the first one is that both social care and NHS staff have been exemplary on the front line during this particular crisis, and they've had to deal with circumstances that are not their day-to-day working environments.

So, as part of our response, working together with employers, providers and local government, we have identified, as part of our action plan, six really important themes. Those themes range from infection prevention and control to PPE, but they also extend to the well-being of both staff and residents. So, as the Minister has outlined, responding, supporting and going forward is going to be critical to our action plan as well. And just to finish on the actual action plan, there is a review that's currently taking place, a rapid review, so that we can clearly continue to develop and learn and put the right policy measures in place. Thank you.

Okay. Lynne.

Thank you. Finally from me then, ONS statistics have shown residential and home-care workers dying at double the rate of the general population from COVID-19. Has the Government done any work to determine what the reasons for that might be and to militate against them?

Yes. I mean, these figures have occurred from the ONS and we are planning to look into them in more detail to find out some more details about them. Our figures as we know them in Wales in terms of social care staff mortalities are, as far as we know, very low. We're only aware of fewer than 20 who have died in Wales, and those are based on the definition of occupation on the death certificate, so we don't even know if they were actually in work, but it is obviously an absolute tragedy however many there actually were. So, what we will do is work with the ONS and with the UK Government to look into this in more depth. Obviously, we know that the jobs that they're in do make them very vulnerable and it's absolutely our duty to protect the workers in those situations as much as we possibly can. So, we're going to have an in-depth look at why this has happened.

I'm going to start off with a question that I asked the chief executives of health boards last week, which is: what's changed? Why could you not effect the transformational change that we've been driving for for the past decade as easily as you've managed to effect this extraordinary change in the last three months? What barriers were removed? What changes were made? What enabling of the health boards happened?

I think it's a range of things. We had very clear direction, but not only the direction; what really changed was a system-wide recognition that we needed to do things very differently, very quickly. I went to a partnership forum meeting where the trade union side, including the BMA, said, 'All bets are off. Everything else needs to be put to one side while we deal with COVID and we've got to act quickly for this to happen.' And in the way that we normally discuss and try to deliver change, you've got to bring lots of people with you and it's often painful, difficult and takes lots and lots of time. We haven't had the luxury of that time, as everyone in the system has recognised, including system leaders at every level from chief execs to medical directors, nurse directors and people who are leaders amongst peers at a much more ground level. And as we were reflecting earlier, that recognition has also come with our colleagues in social care and the third sector as partners.

So, it's really been a significant and rapid cultural change that has allowed us to deliver this much change this quickly. Apart from anything, it's reinforced the agenda that 'A Healthier Wales' set out and it's reinforced that we are aiming in the right direction. We've achieved an awful lot more of it much more quickly, and as you've heard earlier, we need to keep hold of some of the gains that we've made. What we cannot do is go back to systems that we recognise needed reform. We could give any number of examples, but out-patients being a very, very obvious one that Dr Goodall referred to earlier.

Angela. 

So, given that and your comment that because of the common purpose that change was able to be effected, are you therefore saying that over the last decade—? Since 'A Healthier Wales' came out and we had the parliamentary review, we all had a common goal, we all knew which direction we were going in, there was a very clear direction of travel, and yet still it was becoming very, very difficult to implement that transformation. So, how confident are you that the people who should have been doing it before and obviously were not doing it at sufficient pace—and you've talked about two particular organisations who said, 'All bets are off'—how do we stop them or how will you stop them falling back into the old ways where everything becomes too difficult and there have to be a million meetings to make one single decision? How will you be able to keep that culture, because three months is not actually very long to embed a new way of working?

Well, we're talking about cultural change, aren't we, and human behaviour? And, you know, you can't get over the fact—

 That's what I just asked you.

Exactly. You can't get over the fact that, when you're used to working in a certain way and you don't see the same necessity and the very immediate need that this pandemic has created, then that change takes much more time. And I don't think we should try to say that that isn't the position that we were in. What we are definitely already looking at, in terms of some of the lesson learning that is taking place and our planning for the autumn and the winter, is how we keep hold of things that have worked, what do we think has worked, what do we think didn't work that we need to improve on, and how we regather the preparations for the next peak. Because within the service—you know, the comments that Dr Goodall made earlier, about the potential for a different peak and potentially a longer one—well, people within the service have already understood that and the public debate is catching up.

So, I don't think we're going to lose the moment that we are in any time soon because the necessity to behave and the necessity to act has absolutely not gone away. We have a window now, in the summer, to do things to get ready for what, I'm afraid, as I've rightly said before, could very well be a very difficult winter.

Andrew Goodall, before we come back to you, Angela.

Just to comment briefly, it's been an unusual mix of, on the one hand, finding a way of empowering front-line staff and organisations to be able to pursue the right outcomes very quickly and with urgency, and, clearly, we've had examples of things happening in hours and days as decision making that normally would take us many months and even years at a time. But at the same time—and that's why I said there's been a balance—there have been the areas that we have really grabbed nationally and that we have directed and set an expectation for compliance. And, I think, if we'd not got that mix right, this would have been quite a different experience, because just kind of banging the table on a set of national issues wouldn't have been the right mechanism.

So, we do need to make sure that we adopt those characteristics, going forward. And, certainly, irrespective of the learning in the system, there will inevitably—and this will be something that applies more broadly across Welsh Government—be areas that we need to think about and change because, actually, we've had to adapt our own agility around decision making within the system as well.

Angela.

One of the comments or, I mean—.The comments back from the chiefs of the health boards had a theme about them, and the theme was about a lightening of the governance, about being trusted and about them feeling able to trust—you know, cascading that trust throughout the organisation—which was hard for us to hear, because we like to think that these organisations, you know, are using those kinds of methodologies. But it's obviously ramped it up. There was also the comment about the meetings being focused and that there were fewer meetings. So, this newly acquired ability to think fast and to trust the people below you to get on and do that job, how do you think you'll be able to embed that, going forward, so that we don't lose that, but without, obviously, of course, losing proper and fair scrutiny and governance without micromanaging everybody to the nth degree?

Well, that's part of the difficulty in the balance, isn't it, Angela? We regularly have committee reports that encourage us or demand that the Government micromanages parts of the service and sets new performance measures and new expectations. And if we end up doing that, then that acts in the opposite direction of the way we've had to behave up to this point in time. So, as ever, it is a balance, and it's not an exact science, unfortunately. But one of the things that has helped has been the fact that our structures have held up as being the right sort of structures in place. Now, we haven't had to unpick and radically redesign the big structural points in the way that we've provided the system. I mean, we talked about shared services earlier—again, something that was there already; we've been able to use that. And we've already had the structures in the way we've had social partnership and other arrangements as well.

We've then had people who have really stepped up to the plate at every level, and maintaining some of that balance, moving forward, will not be straightforward, because, as ever, there'll be some people who want to go back to saying, 'Actually, I now want you to have a longer period of consultation before you need to implement something'. Because, normally, we wouldn't have created field hospitals in the way that we did, at the speed that we did; that would have taken many years of examining business cases, of the scrutiny we would've needed to go through. Think about the Velindre project. That's taken many years to get to the point of having the business case, the selection of the site and going forward. Well, we did something of the same scale in terms of the financial spend in every health board around the country overall, and this is on all sides—clinicians, trade unions, stakeholders and the public. So, the balance, I think, is the difficult part of this, Angela. It's so much easier to ask the question about needing to maintain this going forward, to then, actually, still manage and bring along the way that people are prepared to behave willingly in recognising the real imperatives for speed of decision making and action, when we then have a bit more comfort in being able to take more time and the way that, as I say, there's an odd relationship. The tension is between the demand to be able to crawl all over everything and the competing demand we sometimes get, to say, 'You need to give people their head and trust them. After all, they're the experts, not you as politicians.'

And, of course, Minister, I'm sure you will recall that, in the parliamentary review, that was one of the real themes, about letting people have their head. A lot of the witnesses that come before committee reports—. There have been many committee reports that have also drawn the other side of the balance that you refer to, which is, actually, there is so much that does happen on a small level, which is what we have seen during this pandemic, that's worked really well in particular areas, and yet it gets squashed when the big guns come in, when normal business starts. Those small green shoots of difference, of real cultural change, of transformation get squashed, and my questions are all about how you can preserve that and help that go forward.

I'm going to expand the question slightly, in saying: how can we continue to take the public with us? You mentioned the public a little bit earlier. Now, one of the health chiefs—I think it was Swansea; no, it was Cwm Taf—said that already they were seeing A&E back up at 80 per cent, which indicates that people are slowly falling back to perhaps more of the old ways. Now, I don't know whether they were rightly there, wrongly there, or whatever, but we know that our emergency departments have been an area that have been under significant pressure, and we'd like to make those changes. I noted with interest that Cardiff and Vale are saying, 'Phone ahead, book an appointment.' Clever, clever ways; it happens in Denmark. We can look at all of these things, but we've got to take the public along, so all of it is absolutely about that cultural change, and what I'm really trying to understand from you is how you think you'll be able to preserve and protect that, because we know the things that have worked really well that are tangible that you're going to want to keep, like the changes to IT, like Attend Anywhere, those kinds of things. They're easy, because they're really touchable, tangible. It's the intangibles that have made such a difference and how we keep those.

Well, I think that we obviously have a responsibility, and I've got a responsibility in terms of the choices I make and the expectations that I set within the system. But it isn't quite as simple as me expecting people to carry on behaving this way and that it'll happen. That's why it's about leadership at all levels. That's peers and people who lead teams on the ground, about common expectations of people in the team you work in and all through.

If you think about the example of Cardiff and Vale and the pilot that they're trialling, actually, we're seeing quite a lot of change taking place in emergency departments, because, with the clinical leadership we have from Jo Mower, working with people in every emergency department, we've actually gathered something together that's a pretty significant change, actually. And that's, I think, going to be advanced because we'll have to. Again, the necessity is still there, but, equally, we think we'll actually end up ultimately with a better way of doing standard business as well post COVID. So, the pilot in Cardiff and Vale, I'm really interested in it and I'd like to see something like that rolled out across the rest of the country. And we then have not just those small areas where we regularly have awards, where we recognise in the NHS Wales awards and others as well what you would describe as green shoots and smaller projects—well, actually, we need to pick up and grab more of those to see those influencing across the system. Whereas, if we get to a post-COVID world, I think we'll find our ability to simply say, 'Here are 10 things you have to do—'. Well, people are willing to accept an element of central direction now and to go along with it willingly, and also, on a local level, people are able to go along and say, 'We already think we have a way to do this, let's get on and do it.' That can-do attitude is the most important part, and yet, as politicians, we introduce other difficulties, don't we?

So, on big service change, that's really difficult. Service change that doesn't involve a hospital is almost always easier to implement than changing the mission of a hospital, and that's not just in your part of the world where we recognise that; it's an issue right across the whole country. But we need to be able to deliver some of that big, visible service change as well as the things that people may not notice but will happen alongside them, and I still think there's an element of almost catching up with public expectation. So, I'm still very much in the position of wanting more change to happen at a faster pace, but there's a real challenge in how we continue to keep our staff and the public with us, because that public demand and expectation can be a really important tension, and yet the loudest voices are often those that are in opposition to changing any way in which the world has worked for the last 70 years.

Andrew Goodall.

I think the public can be very hesitant, with perhaps a lack of confidence in the alternative services, and I think what we've had over these recent weeks is people having to actually live and experience the alternative services rather than just the concept. So it's really interesting, just on the digital experience of the virtual consultation, seeing a 95 per cent-plus satisfaction level with patients who've been through that process. Obviously, that's an appropriate cohort of patients to go through that mechanism.

The second comment I would make is just that—and maybe it's to the core of your question—the public have responded in an extraordinary way to support the lockdown mechanisms for society, and I think that creates a different balance of the relationship here. It's a bit of a moment for us to utilise, because that understanding of protecting the NHS and social care and making these alternative choices, including being so compliant, I think is something to really build on, and I think it's a reminder to us that, within 'A Healthier Wales', of course, the co-production aspect and really getting alongside the public and individual patients passing through our system was a core component. I think we have lived and breathed that in these extraordinary times, and I would genuinely like to build on that and make sure that we're doing that on an ongoing basis as part of the way we behave and work.

Last question, Angela.

I absolutely agree with you on that, Andrew. I do think that this pandemic has made people realise—it's the old saying—you use it well or lose it. When we become overly familiar with something, it's very easy to forget the value and importance, and to just treat it like a bit of furniture rather than the quite special thing it is, and I do see that, and that's why we're really keen as a committee to see how those gains are kept and moved forward.

Now, 'A Healthier Wales', as you say, sets out an enormous transformation programme, and it is all about driving consistency and equity throughout the whole of the NHS, in all areas. What impact do you think the pandemic has had on holding back that programme, and how do you think you'll be able to try to bring that forward and to get that traction that we need? And the last bit of my question, Chair, is on the areas where you really identify projects and pilots that could work well, such as the book ahead for an A&E appointment at Cardiff and Vale. Is there going to be some kind of taskforce or group that will just simply collate all those ideas, monitor them and watch them and help them to spread them out? Because, again, that's one of the areas where we've not been so great in the past—making sure that if something works really well in Cardiff, it can also work incredibly well in Betsi, or down in Hywel Dda.

If I say a couple of things, then I'm sure Dr Goodall will want to come in as well with some of those practical points about how we're looking to drive system transformation, which of course was started with 'A Healthier Wales'. The process of getting to a healthier Wales, of gathering people together and then providing some money, which was actually an important factor in helping to deliver some of that cultural change—. We were then, before the pandemic, getting to the point of wanting to assess the success or otherwise of those transformation projects, and then to get into the wider roll-out from the regional partnerships that have put them together, to say, 'How do we transfer this across the country?' And the pandemic has done two opposing things, I guess, and we are looking at these. One is that, in some areas, we've had to interrupt normal ways of working, so some of the transformation projects were looking at improving normal ways of working in areas that have been paused.

Yet, actually, the broader agenda of transformation has been advanced by the pandemic, as I think you recognised earlier. We've seen lots of change take place, and actually our partners in health and social care in the third sector have recognised that 'A Healthier Wales' is still very much alive and well and what we recognise we really need to do, not just for COVID, but for the post-COVID world as well. So, through the summer we'll be looking again at where we are on the actions in 'A Healthier Wales', and that will sit alongside the lesson-learning that I've recognised that we're going to do over the summer, to look back and say, 'What has worked well? What can we improve?' and to enable us to then set out, going into the autumn, an, if you like, autumn and winter plan that will say, 'Here are things we've learnt, here are things we got right, here are things we need to improve on, and this is what we're going to do about them', and that will then set a framework for us to behave through the autumn and the winter, and that will definitely have to take account of the review we need to do on where we are on the different parts of 'A Healthier Wales' and to honestly set out, 'These are the things that have been paused or have been slowed down, and here are the reasons why. These are the things that we have advanced and are really taking forward.' And I think that you'll find a level of honesty. In many big transformation projects, you'll find the things that have not worked as we would have wanted them to and envisaged them, even with the best evidence and the best people looking at them a couple of years ago to where we are now. But I still think, at the end of it, you're going to see an agenda that is very much intact and will be really important to drive in the future. 

Okay. Andrew Goodall. 

Just very briefly, if I could share very openly with you that, back in March/April, 'A Healthier Wales' wasn't first and foremost in the response, it was simply to make sure the system—

Of course not. 

—was not overwhelmed. We were going to make the Welsh population safe and we were going to look to mitigate as much as possible those hospital admissions and deaths in Wales. But in this transition period at the moment, and looking back, absolutely, as the Minister said, 'A Healthier Wales' has come to life. People have absolutely used all of the principles and the settings that we've described in there, and many of the successful models that we've introduced in Wales are absolutely in line and, in fact, have been fast-tracked through the process. So, it's interesting, not having pressed the button necessarily with the 'A Healthier Wales' concept, that we've ended up bringing forward the strategy and it still has been very real for us. 

And, yes, we are going through a process to try not to do this bureaucratically, collating the examples and the outcomes in all of the settings in all sorts of different fora, even some of the more public commentary from organisations like the Bevan Commission. The trick on it is going to be not to just celebrate it as great practice, but to pull out those that we then standardise and make the national model for Wales, like if we follow through on the 'phone first' mechanism across Wales, which will be our underlying intention, and the way in which we implemented a GP system that was able to deal with virtual consultations within three and a half weeks, when it would normally have taken us probably about seven years. 

Yes—well, more than seven years, actually, but anyway. Three and a half weeks. Anyway, we need to move on as time is marching on. Jayne Bryant has been very patient and you've got some questions to start with on workforce—Jayne.

Yes, thank you, Chair, and good morning. As has been said today, the staff in our health and social care services have been absolutely amazing and outstanding throughout this, and we've talked this morning—the Deputy Minister talked about the trauma for social care staff and how that's impacted there, and I just want to bring up the issue of potential burn-out and potential stress on staff in our NHS. Do you think there's sufficient support available at the moment for staff to be able to cope and to come out of this, and also going into what we think will be a very difficult winter? 

Look, we've recognised this from the outset and through the pandemic, that we've called on our staff, who have responded magnificently, but we can't expect them to carry on doing as much as they've done with the scale and the volume of challenge they have had to face without there being support. So, we've provided more support for NHS staff. We're working with the Samaritans and others to look to have more support available, not just within secondary and primary care but also in the social care sector as well. So, we're looking at what that looks like in terms of providing support through the remaining period of the pandemic. 

In your part of the world, of course, we've heard, not just in the last week or so, the interview that David Hepburn did, describing his experiences, but Ami Jones as well and also Tim Rogerson have all spoken publicly and, I think, very powerfully about the impact on them and the whole team of people they work with in the here and now. Ami Jones in particular described experiences about her time on active service in the forces and the fact that some of this will have a longer tail, and that's one of the things we're going to have to get used to. We're going to need to support our workforce for years to come, because not everyone will have a point of realisation or a point of impact from the work they're doing now in the immediate period, and it's often the case that that takes some time to manifest itself. So, the measures now are not just a point about helping staff through and then we can breathe a sigh of relief in a year or two and then say it's all over; there's a much longer term support we're going to need to have in place.

So, the way that our whole service behaves and that point about, if you like, compassionate leadership, will be more important in the future as well as, if you like, the practical support mechanisms and occupational health support, mental health support and well-being support we're going to need to provide for a much longer period of time. It again goes back to, I think, Angela's point about cultural change. That's going to be an essential feature for the future to care for our staff and look after them—people at the middle and the end of their careers, as well as those people who will start their career, and the pandemic experience will be an important part of the way that they see health and care services, because they've had to live and work through this experience, whether as students or as new entrants on the register. 

Okay. Jayne. 

Thank you. Just talking about the additional and returning staff, when you put a call out for those people to come back into the service, how do you feel that that has been, and do you think they were used effectively throughout the pandemic?

It's part of the lesson learning that I think we need to do through the summer, because we could run through the figures, but, actually, it's not just the figures, it's actually about how useful were they both in them feeling that they've been able to contribute, but also the impact on the pre-existing teams already and how they have viewed those people, whether they are people returning to work across health and social care, or whether they are people who have stepped up from their time as students, so those that have accelerated their time to qualification through working through the last part of their curriculum, and those who are returning to study, because we wanted to protect their time and the qualifications they're still pursuing as well. And we may be looking again at calling on those people to return back, depending on what happens through the autumn and the winter. 

So, my starting point is that I think we have made effective use of the commitment that those people have shown in wanting to return, and we need to know what that means for the future in both assessing what's happened now and what we may need to ask people to do. It is a request—we can't demand people do it—either to stay on the register or to come back onto the temporary register at some point in the future. 

Okay. Jayne. 

I'm just wondering if you've looked at alternatives. Lots of people were putting themselves forward to come back, but they might not have been able to go back right on to the front line of what they used to do, maybe, but perhaps they could be, instead of being put to one side and being told, 'You're not able to help us at this moment'—perhaps there are other ways of looking at those retiring or returning staff, and how they could support and help the workforce, which might not be in their traditional role. 

Well, that's absolutely the way that we've looked at it. So, for example, if you have people who are retired and potentially in an at-risk group either from an age or a healthcare condition point of view, you wouldn't necessarily be putting those people into front-line roles. But those people are being redeployed in thinking about other ways  they could help, and because we're doing more things remotely—experienced clinicians returning to practice may not be able to sit face-to-face directly in a room as someone in that capacity, but, actually, they can be really useful in terms of some of the triage and support elements as well. That's been really important in health and social care to think about that experience, and how that really does add value, even if it's not in the way that those people have worked in their careers before retirement and return.

We need to think again, as I said in the point about learning lessons, about how we want to ask people to behave if we do see a future peak or a spike, and what that means about making effective use of the time and the commitment, but also the real skills that those people have to offer. 

Okay. Jayne. 

I'd just like to ask you now about field hospitals and the capacity in those field hospitals, and what use we should be making of that capacity. Obviously, it's different perhaps in Aneurin Bevan health board, where we have the potential opening of the Grange, but perhaps you could comment on the future use of those and perhaps also touch on the Grange, actually, and how you see that accelerating. 

If I could deal with field hospitals first, and, again, at the end of this, Dr Goodall may want to come in on some more detail of the arrangements that we're looking at, we've had a review that's come in. I've not got through all of that with the advice that will come, but it's a look at this balance of the areas where we've managed to decommission a couple of field hospitals. So, the one at the Vale resort has been decommissioned, because we're looking again at the realistic planning scenario of what we think we're going to need to have and to maintain, and that's difficult because we're either going to mothball or standby some of those, but there's a difference between having those then available to stand back up again and what that then means in terms of capacity to continue running.

And there are difficult practical challenges here as well. Again, there's the really positive response from those other providers and businesses, whether it's the most visible one, being, obviously, the Principality Stadium here in Cardiff, but other businesses too, from the theatre in north Wales that many of us have been to for conferences, and Bluestone in west Wales as well. So, we've got a range of other concerns, when, actually, from an NHS and social care point of view, in terms of caring for the public if there's going to be a future rise, we're going to be thinking about, 'What can we move around?', 'What do we need to maintain?', and to make sure there's a real state of preparedness and readiness. And the Grange, because we've been able to deliver that project on time and on budget and there are options for us to bring forward the opening—well, in a normal winter, we'd be seriously considering whether we want to bring forward the opening of the Grange anyway. So, rather than the way that, for example, the Gwent and Nevill Hall have different pressures because of the way they're designed, whereas if we have a new facility to take on board some of that activity, we'll want to seriously think, in a normal winter, 'Well, if we can, why wouldn't we?'—well, actually, with the challenges we know that we're likely to face in the winter, it's an even bigger consideration. That's to the credit of not just the people who have built that facility, but the way that the health board has worked with them, and the way the staff are planned, because lots of staff planning, getting those service models ready—it doesn't happen because a chief exec clicks their fingers and says, 'Make it so.' It takes a lot of engagement and work alongside people. So, that's a very real option for us because of the way that they've worked and behaved, whether that is as a fully functioning site or whether that is as an extended or expanded field hospital site for the way in which we will potentially want to make use of that significant facility for the future.

Okay. Andrew Goodall, briefly. 

Yes, just again to go back to the original scenario planning, it was an exceptional response to establish these in days, really. I mean, I'm still looking back wondering how on earth the NHS in Wales was able to discharge that so consistently across Wales, and our original scenario planning was to actually have to need the beds that we put into the system. It was an expected peak that had come through all of the UK modelling and that we'd translated into Wales, and I think people often forget that it's the actions and the preparation that took place alongside the real impact of how the public reacted—to stay in lockdown for such a protracted time—was why we didn't see the hospital admissions nor the deaths that were expected across the UK. And, again, the academy report that came out this week just reinforced that fact about the lives saved and therefore the hospital admissions avoided within the process. So, I'd just like to remind ourselves about that.

And, secondly, the actual period of time that we were originally promoting these field hospitals for—and, again, based on the knowledge at the time—was to expect a peak that would be overcome and perhaps to have a period of around 12 to 16 weeks where we maybe would need to use them as a contingency and then, if you like, come out the other side and look to reset the system. Now, again, we know much more now: we know that COVID is now with us for a much longer term outlook and, therefore, the plans have to alter and adapt accordingly. So, we already know that we can look to reduce the number of beds that field hospitals provided. My own view is that their strength should be that they're there as a contingency to step into, but there may be some exceptions where some residual use can be made of them. They are structures that are temporary, therefore they can be utilised in an emergency situation for a public health emergency, but the normal mechanisms don't apply then, so there will be fire regulations, inevitably, and you wouldn't want to have them being used simply as if they are a normal hospital environment.

So, we will be looking for them to be a key part of our winter plans; we will need to reduce and mitigate. And as the Minister has said, the time that we have now allows us to make, perhaps, some different judgments because some of these facilities themselves will need to be restored, but we also need to look at some of the value-for-money choices that we need to make, because we now have some time with us rather than the days that we had to make those original decisions on as well. But I think it is a really successful outcome of the way in which the system came together cohesively. And I am pleased that the model that we promoted in Wales was actually more about step-down and rehabilitation and recovery, because it was felt that that was more where the underlying need was, perhaps rather than the critical care side, which is obviously where other choices were made in the UK.

Okay. Moving on, Jayne.

Just finally, Chair, just on recovery, really, and rehabilitation services. There's a great scheme in my own area at the velodrome—Aneurin Bevan health board in partnership with Newport Live—doing some exercise classes for those people who were in hospital seriously ill and some even on the verge of dying from COVID: they're doing 90-minute sessions in the velodrome. It just shows that some of the people taking part—somebody was a former taekwondo champion who's only 30 years old, so it's showing how it can impact on many people who are quite fit or very fit. And I'm just wondering about those services, really, because it's so important that they're there as soon as possible, because of the impact on those patients who have been seriously ill, long-term, and I just want to know that, and have some assurances, that they will be—you know, this is an example, but perhaps could be spread out across Wales to ensure that people are able to get up and moving as quickly as possible with those support services in place.

The chief therapies adviser has issued a revised AHP framework and in particular focusing on rehabilitation. As Dr Goodall was saying, we've already looked at our field hospitals as being areas for rehabilitation, but that also includes in that broadest mix the prehabilitation work that we piloted within parts of Wales as we look to have non-COVID activity, and that's about people being fit to receive and benefit from treatment as well. So it's really important for both parts: the prehabilitation, the work we're already doing and the conversations that are not quite complete yet about how significant a role that will play, as well as rehabilitation. There are then workforce implications for that as well, making sure that we have the right staff able to do that, and how you have both those people that are registered and their assistants making sure that you're providing practical support for people. So, what you see in Newport or the velodrome is something that we expect to see consistently in each health board area, and it's again about encouraging the public to take up those opportunities, which could make a big difference for them individually as well as their future care needs and the sort of money and investment we're going to need to make to keep people well in the future.

Andrew Goodall.

You're muted, Andrew.

A lot of our focus clearly has been having to report some very difficult figures in the public domain, from positive tests through to patients in hospital, through to critical care around that and of course, sadly, deaths across Wales that have happened. I've always tried to remind people, however, about the individuals who've come through the system and have actually managed to be able to be discharged. So, over 9,000 patients have been discharged who've been in a hospital for a COVID-related admission. And even today, we have 485 patients in our hospitals across Wales. Half of those are actually there for reasons of recovery, because they will be long-stay patients needing to be rehabilitated and to work it through. And I think it's well over 500 patients who actually stayed in our critical care units across Wales also. So, we're still learning about this virus and there will inevitably be both international and domestic evidence that we have about the way in which we need to treat them, but some of these patients are going to really need long-term care for some time, particularly out in the home and the community environment.

Okay, Jayne?

Yes, thanks.

Lynne, did you have any questions here on—? Or have you already covered it earlier?

[Inaudible.]—about the mental health money and I think someone else is picking that up, aren't they? Or am I meant to be doing that?

No, we'll come onto financial considerations now, so that's David Rees.

Thank you, Chair. Before we go on to financial considerations, can I come back to the field hospital issue? I understand everything that's been said there, but in the previous Assembly your predecessor, Minister, came before the health committee then and very often used to say to us that 'If we had beds, we would fill them', so it was about the capacity of the beds. Now, in fact, what we've seen here is that we have spare capacity and they're not filled; the field hospitals are empty. Is it going to change our thinking about the way in which spare capacity will now become available, because, as you say, if the Grange comes online, there will be more spare capacity now in Nevill Hall and Royal Gwent? Is it changing the Welsh Government's thinking about how to use spare capacity, and not to simply get rid of it?

I think we're asking different questions, though, aren't we, with respect? Because the way that we're going to need to behave and to look after people when we've got a global pandemic and we saw that if we hadn't increased capacity, in particular in critical care, then we'd have been overwhelmed in the first wave of coronavirus, and how we plan to make use of capacity now is very different to running a healthcare system in non-COVID times as well. So, we still need to, again, obviously think about the evidence and the balance of our overall capacity; the types of beds that are available; and how we use—picking up on where we left Jayne Bryant's questions about rehabilitation: in the past, people were in a different position within hospitals, a different sort of approach. We now want people to be up and active much more quickly, so actually we won't need beds in the way we used to use them in the past. So, it's still about understanding what's the best way to do that and the level of resilience we need within our system for not just winter pressures, but for the year-round activities. So, as practice changes, we'll need to continue to consider what is the right mix of beds for us to have in our system, the right different types of beds as well as overall capacity. But I don't think we should bank on the expanded capacity we've delivered with field hospitals, and it was a success story that we didn't need to use them because the first wave, the first peak wasn't as significant or as sustained as it could have been because of a range of steps taken, not just by us in the Government and the health service, but most importantly by the public themselves.

David.

Okay, but it's important because we cleared out the hospitals basically to create the capacity and it's important we talk about that we have seen a lot of closures of small, community hospitals and beds being removed as a consequence and, as you say, rehabilitation, that's where some people could go for rehabilitation and used to go for rehabilitation. So, it is important that perhaps the Welsh Government rethinks its consideration of how that capacity would be used in the future. I'll leave it at that because I think it's a discussion we could have more thoroughly.

If I go to the financial implications in relation to this, we had the health boards before us last week and, as an example, Swansea Bay in my area highlighted that they believe that they have already spent £100 million on the pandemic at this point in time. In May, Cwm Taf indicated that they would have spent £51.5 million on this. I appreciate that the first supplementary budget has given an extra £140 million reallocated funding and, on top of that, you've cleared the historic debt. The historic debt is not actually going to be affecting the day-to-day running; it's going to mean more of—. As we were told last week, you haven't got to look over your shoulder for this historic debt any more; it's not affecting the day-to-day running. How are you going to ensure that health boards don't end up with another historic debt as a consequence of the pandemic?

Well, that comes back to what happens in the rest of the pandemic and the crisis that is still not completed about the sorts of investment choices that are made, not just by the Welsh Government, but across the UK. It's then, of course, about the ability of our whole system to live within its means. You'll recall questions that Angela Burns has asked, but others too, about wanting to make sure that health and care services didn't need to think about financial considerations in front of doing the right thing to prepare for COVID, and to make sure that people that have done the right thing to keep people well and safe weren't then going to suffer a financial penalty for it when it comes to the long-running challenge we'll have on rebalancing and returning NHS activity to the sorts of levels and efficiency that we want to see in terms of the time that people wait for treatment as well.

So, it isn't as simple as saying, 'I can ensure this happens by giving a simple answer now', because we'll have a very different challenge to face in the post-COVID world, as Andrew Goodall has set out, and potentially we'll have a whole Senedd term or more where we'll need to still be recovering the position we'll find ourselves in at the end of the pandemic. So, I think the broader points about, of course we want to see a system that lives within its means, to have financial discipline, but to still make choices about transforming services as we'll need to for the future, but I don't want to try to give a glib or simplistic answer that says that that is something that we will manage without difficulty or without challenge, but it's the regular challenge that we always have in the chair that I sit in and in the chief exec's hot seat as well, about how we manage to do that across the NHS and what we then do if organisations can't live within their means.

Okay. David. You're muted.

Does that mean that the intermediate health plans, which you have suspended temporarily, will need to be relooked at, as to how they will work and what they will represent in the future? Because if we are talking about a five-year period of time, that's going to be quite a dramatic change in one sense.

Well, of course we're going to need to reset how the planning framework supports the real world that the national health service and its partners are operating in. It would be absolutely crazy to reintroduce performance measures that we know would be utterly unachievable for years to come and a planning framework that was looking at the pre-COVID world. We've got to set a sense of a realistic expectation: what does improvement look like; how do we get that and how does the planning framework support that, rather than having a fantasy approach that would just mean that we'd be setting organisations up to fail?

That's not the approach that we should take, but of course we'll need to revise the approach that we are taking now. In fact, the frameworks throughout quarter 1 and quarter 2 and the plan we'll have for autumn and winter will help to reset some of that, about what we expect people to do when we go back to having three-year plans. We'll need to say, 'Well, how does that take forward the position we'll find ourselves in when we get through COVID?' That's why the work we're doing over the summer is important, of course, for the six months ahead of us, but it's also important in terms of resetting a new normal for our whole health and care system to work together for the future.

Okay. Andrew Goodall.

I think it's really important to say that we've not abandoned planning. We've not abandoned the plans as such, but, yes, of course, the context has changed. I think that some of the response that has been possible over these recent weeks is because of the progress that we have made on planning over recent years, so I think we can build on that.

It is important that organisations will need to recast where they stand now against a number of the areas. One of the things I want to ensure that focus is on, and this will come through in advice to the Minister, is that we absolutely capture the quality and outcomes of our system, in line with 'A Healthier Wales'. It's not just about us continuing to focus on all of the old, perhaps traditional measures as well, otherwise we'll never end up translating or converting the way in which we act and behave.

But, I've been reassured by at least seeing the quarter 1 and quarter 2 plans. We were reviewing the quarter 2 plans through last week, having received them. We've moved everybody from asking about three years into just a three-month period of time, but deliberately quarter 2 plans were about stretching the thinking into the winter, as the Minister has outlined. I hope what we won't lose if we can restore the 'A Healthier Wales' framework is the fact that this is also about ensuring that we're on a pathway to the longer term, and not just about what the next few weeks ahead of us look like. 

Okay. David, briefly.

Yes, briefly. Obviously, it's been raised—mental health has been raised very much today. I just want reassurance on two things: one, that the money that has been ring-fenced for mental health will not be diverted to other services that are facing challenges as well; and, two, that the future planning and spending plans for the Welsh Government will reflect the increasing need for mental health, because the pandemic will definitely have an impact upon that.

Yes, we haven't taken money out of mental health services; it's about how we've redeployed it within mental health services to deal with the reality of where we are, and that's what we're looking to do. So, we're certainly not looking to reduce the amount that we spend on mental health services. As we look at our overall picture, we'll need to think about whether we need to do more, whether that's on tier 0 or tier 1 services, or, indeed, the way that we've looked at more significant spend for more significant interventions where there's a higher level of need.

So, it's an unfinished conversation, as we look to plan for what recovery looks like for both physical health and mental health, and looking to have a proper plan to take that forward as well. Again, that's part of the work that we're going to look to do over the summer and the autumn, so we don't just think about recovery in the sense of getting back on top of waiting times and wanting to see people go back to work. Actually, the mental health recovery we'll need to undertake is a really significant factor within that as well.

I've got Lynne Neagle with a supplementary. I'll come back to you then, David.

I think what the committee is worried about, Minister, is that £7 million that has come from the mental health transformation pot. I don't think anyone is arguing that we don't need more expenditure to tackle COVID-related mental health issues, but that doesn't negate the need to continue with the transformation journey that we're on. I think what we're looking for is some assurances that any COVID-related mental health spend will be additional to that.

The reality is that we're having to move around money in every part of the service to cope with where we are. We're looking at what that means in terms of the ability to carry on with those transformation projects, because sometimes they're the same people, so we can't expect them to do all of that work and to do extra—[Inaudible.] It's about how we manage and marshal our resources.

We're not rolling back on the need to transform. In fact, again, it's an area that shows the need to transform the way we deliver services. That was the conversation I've had with not just officials, but the mental health alliance as well, and the recognition that this will raise mental health up the agenda, I think, rather than see it fall back, because I think we'll have more need across the country—need and demand within our system. I've said that it will absolutely reinforce the need to transform the way we deliver services, including at the more early intervention and preventative end, as well as people with more significant mental health concerns.

David.

No, that's me finished, Chair. Thank you.

Right, well, in rugby union international terms, we're in the red zone at the end of the game now, so the next forward pass and the game's up.

Okay. On face coverings in particular, the First Minister explained yesterday why he was still rejecting calls for more widespread use of face coverings, including in shops, for example, as a mandatory measure, but it is to become mandatory on public transport. Could you just give us an explanation of why Welsh Government is taking the line that it currently is on face coverings?

Well, to be fair, I have answered this in press conferences, and the First Minister answered this in the Chamber yesterday. On face coverings on public transport, there's a challenge about cross-border services, bus and rail in particular, and whether we want to have a system where you're potentially requiring people to adopt different regimes on the same journey when they cross the border and whether it would be tenable to have a different system for those cross-border services and other services that we run on public transport in the rest of the country.

So, you don't think—

And, as the First Minister said, that's a point about simplicity and communication, and that underpins the move that we've announced and the First Minister answered questions on in the Chamber yesterday.

Fine. So, you don't necessarily think face coverings are beneficial; you're just doing it because it's easier.

Well, it's not helpful to try to put words into my mouth about it, Rhun—

That's what you said, though.

No, it isn't. What we've actually said is we've published the advice from the chief medical officer pointing out the extent to which they can be used and what they mean in terms of this position and the situation you're in.

Face coverings are at the bottom end of activity to try to protect people. We've set this out many times before. So, social distancing, that's the most effective thing in terms of people doing that, and good hand hygiene. Face coverings are not a substitute for that. But, in some situations, if more people are using public transport, for example, as we expect will happen moving forward, then effective social distancing isn't possible, and that's why there's advice and recommendations as opposed to mandation about the use of face coverings.

We'll continue to review the evidence, though—the evidence and the advice we'll receive—and then Ministers will need to make choices about it. But you'll also have heard on a regular number of occasions the view of the chief medical officer and the advice he's given to the Government, importantly not only about wearing masks but safely putting them on, the safe wearing of those masks so they're actually effective if you're wearing them, and then also about taking them off as well. Because otherwise, if you're taking them on and off all the time or having them underneath your nose or below your mouth, then actually, potentially, if you have got coronavirus, you're shedding it and spreading it around.

So, there are real challenges about the behaviour in mask wearing, about safe wearing of those masks, and safe disposal and removal of them, as well as, of course, the point about behaviour, because there is some observation that some people wearing masks are then undertaking riskier behaviour, and the way that that in itself isn't helpful.

So, it isn't a straightforward silver bullet, but we'll continue to review the evidence about it. And, as I say, if the evidence changes or if the position of behaviour changes, then we may do something different. For example, a local lockdown in Wales—it may end up that one of the measures is we may ask people to wear masks going about their business and going into shops.

And I'll send you the link to a study from Italy that says that behaviour changes for the better when people are wearing masks. So, I fully admit that there are conflicting pieces of scientific research, but there are research pieces that go completely in the different direction of saying that people are more willy-nilly when they are wearing masks. I'll finish there. Thank you, Chair.