National Assembly for Wales

Croeso, bawb. Bore da. Welcome to the Health and Social Care Committee this morning. As always, we're operating the committee bilingually, both in Cymraeg and in English. There are apologies this morning from Lesley Griffiths. I'd also like to take this opportunity to thank Sam Rowlands for his contribution to the committee. He's now moved on to other areas. I welcome James Evans, who joins the committee from today. Welcome, James. If there are any declarations of interest, please state them now. 

In that case, I move to item 2. We have the Ministers in this morning. I'd like to introduce Jeremy Miles, the Cabinet Secretary for Health and Social Care, and Dawn Bowden, the Minister for Children and Social Care. I was wondering if the officials want to introduce themselves as well for the public record, if that's all right. Shall I start on my left? Sioned.

I'm Sioned Rees, director of public health protection. 

Albert Heaney, Chief Social Care Officer for Wales.

Good morning. I'm Alex Slade. I'm director of primary care, mental health and early years. 

Bore da. Hywel Jones, director of finance.

Good morning. Nick Wood, deputy chief executive, NHS Wales. 

Sorry, Nick, you're squeezed off the end of the table. I should have just checked as well that the interpretation works. So, if I can just ask for the test on that. If you can just put your finger up so I can see that you can hear. Good. Is that okay, Alex, as well? You heard okay. Thank you. Is there anything, Cabinet Secretary, that you would like to say at the opening of the meeting at all?

No, I'm very happy to get under way, Chair.

Lovely. Thank you. With that, Cabinet Secretary, you've allocated an additional £435 million to the health budget for the next financial year. That sounds a large sum of money. But how much of that is being eaten into by inflationary pressures and other areas? How much of it is additional income, if you like, for the health service?

Certainly, Chair. Obviously, it is a significant sum of money. There's £435 million, as you say, of resource funding, of revenue funding, and then it's also worth noting there's £175 million extra of capital funding as well. The scale of the increase is, obviously, reflecting the priority that the Government attaches to health and social care and, in particular, in light of the First Minister’s priorities following the summer listening exercise. The £435 million is allocated to the main expenditure group, so not all of that will go on the NHS itself, so to speak.

In terms of what has been allocated to health, to the NHS, as you say in your question, a significant proportion of that is around ensuring the sustainability of the service in its fundamentals, and recognising, as you say, the pressure both from cost inflation and also from increased demand. So, in a sense, that is the starting point, isn’t it, for where you look at what you need to provide for next year before you look at the additional things that you would wish to do or change. You’ve obviously got to make sure that you’ve provided for that, so that the service is able to continue. I would say, if you look strictly at that element, it’s probably got an additional £150 million of that overall figure, but then there are also allocations for the planned care programme, so £170 million of that sits in the budget as well.

So, that’s the element that is there for inflation and for demand pressure. There’s obviously a provision, as well, in relation to pay for next year, which is clearly a significant element. Obviously, I’m sure we’ll come on to talk about this about some point, but, obviously, the figures aren’t agreed for next year yet because we haven’t had the recommendations, haven’t had the negotiations, but there’s an allocation for that, clearly, as well in the MEG.

And then, in addition to that, there are provisions in the budget that are not related to demand, not related specifically to inflation, but are things that support the Government’s policy in terms of transforming services and so on, which I’m very happy to go into if that would be helpful.

Yes, perhaps we can touch on that, because, I suppose, part of the question is how much this is going to meet, in a way, those pressures that are beyond your control—

Sure.

—inflationary pressures. So, how much of that additional £455 million do you envisage will be used to bring forward your transformation programme and what you need to change in the longer term?     

Sure. Well, there’s probably around £65 million of that which relates to new levels of investment, or new initiatives in relation to the childcare offer, workforce training, digital investments, the focus on women’s health, additional provision that we’ve made for hospices.

I think, if you were to look at where the transformation of services is underpinned, if you like, in the budget next year, some of those will be in the capital allocations, as you’d expect them to be. So, in addition to the, if you like, business-as-usual requirements of the capital budget for digital, which is around kit and ensuring that we have modern equipment for the digital programme that we have, then there is funding for additional diagnostic equipment, which will have a bearing on increasing our productivity. There are specific capital projects in there that are designed to improve productivity. There is an additional fund of around £30 million for digital projects, and all of those, in a sense, have a bearing on performance overall. We may come on to talk about digital, but it’s an area where, I think, if you’re seeking, as we obviously are, to improve the level of performance across the NHS generally, you have to have a level of digital investment to underpin that, and that has been the challenge over recent years, quite bluntly.

When you’re making allocations to different service areas, and you just talked about the £30 million for digital transformation, I think you said—

Yes. 

—how do you arrive at that figure? How do you know how much is required to deliver the outcomes that you want? What’s the process for that?

Well, some of it is—. There is a range of ways in which one does that. So, for example, in the capital space, we will have identified what the interventions are that we are asking, for example, Digital Health and Care Wales, to take forward for us. We will cost individual elements of those programmes and we will fund that accordingly where the funding is available. So, there are specific things that are project led, which have a business case, for example, and then we’ll be able to evaluate that.

Sure. So, capital projects are, effectively, easier to determine than perhaps some of the revenue projects.  

The same argument applies to revenue as well, because there's a revenue element to many of those projects. But some of it is—. You look at it from the other perspective. So, this year, we've had an increase in our capital budget, and so one of the judgments I reached was to say, 'Well, I think we need to be putting as much of that additional funding into diagnostic equipment,' for example, and so the case then isn't necessarily a business case for a particular piece of kit. It's a, 'Let's create a fund that we can then allocate during the course of the year on diagnostic equipment.' So, there's a range of ways in which you can do it, Chair.

And how do you evaluate that? So, for future years' budgets, you're making sure that, in terms of how you've allocated a budget and the £30 million or whatever it is—the £3 million to women's health or £30 million for digital—. How do you check the progress of that funding throughout the year to make sure that it is the correct level and it is not an overspend or it's not sufficient funding to meet the outcomes that you want?

Sure. Well, I mean, it depends, doesn't it? Much of the budget in health specifically is, essentially, delegated to local health boards. Obviously, there are some central elements, clearly—quite a number, obviously. We have a planning process, which sits, as you know, alongside the allocations process, and this year we were able to bring the guidance that we provide to the system together, so that the system was able to look at both our planning requirements and our allocations as a whole at the same point in time, which I hope is helpful. But, over the next few months, there will be a detailed dialogue, effectively, between health boards and us where they will present plans that respond to the planning guidance, and we will either ascertain whether we think those plans are adequate or not, and there have been, as you will obviously know, many examples where we have said, 'Well, we can't support that plan over three years because we don't think it's sufficient.' So, there's a planning process and, critically—and, again, this is really the planning framework—I hope the committee will have seen that we've tried to be very, very specific this year about the key things against which we'll evaluate performance, and have been very specific about our expectations of interventions the health board should put in place that will deliver those, so we will be able to measure outcomes against a very clear framework of expectations.

Sure. Okay. Thank you, Cabinet Secretary. Joyce Watson.

Good morning, everybody. I want to move on to policy and priorities. You've already said that a lot of the spending on the priorities is in line with the priorities of the First Minister. So, in what ways particularly has it influenced planned spending for the coming year, and are there any further in-year investments anticipated to progress those particular key priorities?

Well, we have sought to reflect the priorities that the First Minister set out in the budget. So, for example, the women's health plan is a critical part of the First Minister's priority. So, there are two dimensions to that. There's an allocation, for example, specifically for the establishment of women's hubs within the health plan, which we think is an important part of how we deliver aspects of the plan. So, there is a specific allocation of £3 million, which is largely the cost of establishing those hubs. There is some extra in there, but that's essentially what that £3 million is allocated for. But then, you could make the argument that the entire health budget, given that women make up 51 per cent of the population, is or should be skewed towards supporting women's health.

Then there is funding in relation to waiting lists. So, the provision in relation to that, currently, will only be able to be finalised exactly at the end of the current process that we've gone through in relation to spending the £50 million that has gone into the system since the autumn. So, what I would expect to see as we move into next year is that the profile of waiting times moves from being something that is a system-wide challenge to one that is more likely to be particular specialities in particular areas—particular geographies, particular health boards. So, rather than a system-wide challenge, our expectation is that the investment this year will have reduced the backlog across the system sufficient to get demand and provision into a better balance across most of the service. So, the funding for that next year is likely to be much more specifically allocated than it has needed to be this year. It had to be more broadly based this year. So, there will be funding for that next year, but, today, we don't have the output of the £50 million for this year yet. So, we've made an initial allocation, really, of just £20 million at this point, but taken together with the planned care programme of £70 million and the transformation funding of £15 million, we would look at how that is spent overall in a way that helps us to continue to drive down waiting times, which is, obviously, the First Minister's top priority.

Yes. So, in light of what you've just said, are you going to commit to publishing the update on that progress on a regular basis?

Yes, so in terms of the figures that are available, we already publish—and you will see next week—on a monthly basis waiting times overall. We've now provided that information on, I think, a more useful basis, where it breaks it down more accessibly at a health board level. So, we publish that on a monthly basis anyway. We also publish on a monthly basis the figures for delayed discharges from hospital. So, that data is currently available, but, obviously, I'm happy to update the committee and the Senedd in other ways if they're useful, as well.

So, have you made provision for additional funding to support 'A Healthier Wales'?

Well, 'A Healthier Wales' is the overall strategy of the Government in relation to health, so I would make the argument that, in a sense, the entire budget is there to deliver 'A Healthier Wales'. I guess there might be some specifics that you could point to in relation to—. There's a strong theme, isn't there, in 'A Healthier Wales' around prevention, and there is a range of ways in which we've provided specifically for preventative work. But I would say that the entire budget, really, is there to support 'A Healthier Wales'.

Because one of the areas, and we've done a lot of work on it, is obesity, particularly childhood obesity, and the growing escalation, really, within communities, and then the long-term impact of that on the social care and health budgets.

Yes. And the budget for—. As you say, in relation to obesity, we've maintained the budget for that at the level it's been for this year. What the committee, I think, can expect to see there is probably a rebalancing of how that is spent. All of the evidence that we have tells us that where countries have been most effective in being able to change behaviour or change the rate at which obesity is increasing, which is really where the successes have been rather than in reversing obesity, unfortunately—

Joyce, do you mind if I bring Mabon in and come back to you, if that's all right with you, Joyce?

Diolch.

Thank you. Joyce.

I want to go on to social care reform, and the UK Government has recently announced its plans for a new commission on social care reform, with paying for care reform not being reported on until 2028. The King’s Fund have raised expressions that that is too late and that there's an urgent situation ongoing now. So, if you could share your thoughts on that move and timescale, and whether that will affect the development of a national care service in Wales? 

Thank you, Joyce, for that question. And you’re absolutely right: the review that’s been commissioned in England, I think, is long overdue. I mean, we’ve been waiting for this for a long time. And I think there was some disappointment in some areas that the second phase of that work—the work of the commission—isn’t really going to hit the ground until 2028, so, there’s going to be quite a bit of a lead-in time for that.

What I would say—. From the discussions that I’ve had with UK Government Ministers, what we’ve been saying is that there is an awful lot of overlap between the work that they’re going to be doing through the work on social care reform in England with what we’re already doing. And interestingly enough, UK Ministers are really quite interested in hearing what we’ve been doing, because we’re ahead of the game on this.

So, you’ll be aware that we published our plans for a national care service in 2021, and that came out of some work we did through the co-operation agreement with Plaid Cymru. We established an expert group to look at the areas that would need to be developed in order to deliver a national care service for Wales. And those plans are still ahead—we set that out into three phases. The first phase of that plan, that implementation plan for a national care service in Wales, is where we’re at now. And we’ve looked at commissioning research into what a national care service could look like, how it would be funded—all of the mechanisms that would be needed to deliver that. And that work is going on and is going ahead at pace. We’re expecting the first report from that research in spring of this year, aren’t we? And that will then inform the next phase of work that we do.

But I think it’s important to say that within the work that they’re doing in England, it’s primarily targeted at adult social care, and the changes that we’re making in Wales is across adult and children’s social care. And we’ve made it very clear to the UK Government that anything that they do in this space, if we were to work in co-operation with them and deliver on some of the same areas, it would have to be across adult and children's social care; we don’t separate the two out. There are different reasons why they do that in England; it sits in different departments in England and so on.

And one of the other aspects of the discussions that we’ve had around the work that’s going on on the social care reforms in England is the Employment Rights Bill, which sits alongside it, which is the introduction of the fair pay agreement for adult social care. Now, again, we’ve had conversations with UK Government Ministers and we have said that we absolutely want to be part of the fair pay agreement. I'm almost certain, Chair, that we're going to come on to be discussing workforce issues at some point in social care. And we see this as a key element of the work that we're doing in the delivery of a national care service, to have a workforce agreement that will mean that we can have that fair pay arrangement. We know that that is a significant problem in social care. Again, the fair pay agreement elements in England apply to the adult social care only, not to children's social care, and we've made it very clear that, if we're going to implement the fair pay agreement in Wales, it has to be across children and adult social care.

So, those discussions are going on and they've been very positive, and I'm very keen to see that we continue to work on that. But I think what is important from our perspective is that we're doing the work now. We're already three years into our implementation programme for the establishment of a national care service. The driver behind that is the national office, which we established and we launched in April of last year, and I think it might be useful if Albert came in and said a bit about the national office, because he heads the national office, and how that is driving the work on the delivery of the national care service.

Yes, thank you very much, Minister. Good morning, committee members. Just to say, I think that work that the Minister's just described around the co-operation agreement, the expert group, leading to the 10-year implementation plan that was published in December 2023 is really very important, because that is driving the work of the new National Office for Care and Support. The national office was set up in April of last year. It's a small office, but very active, and one of the things that I'm particularly pleased about on behalf of the Minister is that one of the first pieces of work has been establishing the national framework for commissioning of care and support in Wales, and that covers local authorities, social care and also our health partners.

Importantly, within the national framework, we have a code, and the code requires commissioners to support employers to support and improve status, but, in essence, the short version is to really sustain care and support that's built on fair work and fair pricing. Importantly, the code will be refreshed every two years, so, as we learn and develop, we can actually amend and resolve.

And then, just to say, obviously, the national office has been at the beginning stage, I think, of what a national care service would mean for Wales, and, as part of that, we have established, with expertise, a stakeholder strategic advisory group, and already that group is giving us their insights and their thoughts about what a national care service could mean for Wales.

And then, just to conclude, the national office is very active at the moment, but also has initiated new engagement around establishing a best practice and continuous improvement forum, bringing together local authorities so we can make sure we share best practice and actually implement it going forward. Diolch yn fawr.

Okay. I'll keep on this, and then I'll come back to something. So, in light of all of that, what is the Welsh Government doing to ensure that the funding for health and social care are integrated efficiently, and allocated efficiently? Because we know, all of us, that, very often, the delays and the obstacles for patient flow co-exist between health and social services.

Do you want to—?

Yes, so I'll kick off on that, if I may, then perhaps you'll want to come in. The challenge, the obvious challenge, in the system is that we have separate budgets, clearly, for health and for social care. I don't mean within the MEG; social care is really driven through the revenue support grant for local authorities, as you will obviously appreciate. So, the challenge then, and the task, is to ensure that local authorities and health boards can work together in a way where those boundaries, as we will all want them to be, are more porous and less of a factor. Clearly, the regional partnership boards have a role to play in that, partly about changing behaviours and encouraging ways of working that are collaborative and joined up as ways of working, but also significant sums of money are invested through the regional partnership boards. So, the regional integration fund is the largest of those, at about just under £150 million, but there are also other funds. So, the housing with care fund, the integration and rebalancing capital fund, these are all significant sums of money. We've published a report recently that shows how that more integrated way of funding the relationship between health boards and care providers specifically I think is bearing fruit, and there's a report that we published a few weeks ago that the committee may have seen.

I think the most vivid example recently of making sure that there is better joint working so that budgets can be spent in that more integrated, purposeful way has been around the 50-day challenge work that has been going on at the end of last year, where that was supported by about £19 million-worth of funding around reablement and to support GPs to work in care homes and other interventions. I think that is demonstrating already that that more integrated way of working, a kind of 'what works' approach, very much focused on the experience of the patient, is bearing fruit.

So, we know, for example—. You might recall—I'm sure colleagues will remember—we tasked regions with identifying the 25 per cent of patients who'd been waiting longest to be discharged from hospital and who were ready to go, if you like, and develop a plan specifically for those. So, I'm pleased to say that most of those were, in fact, discharged during the month of December. For those who haven't, I think it's about 80 per cent of them now have an agreed discharge plan. So, I think you can absolutely see the benefits of regional joint working and how budgets can be pooled to deliver some of that.

That's good. Thank you. I'm going to come back to the funding, and you quite rightly said that there's a lot of money, there's looking at pay, but you haven't had all those agreements in place yet. There are a number of agreements, for example, like the general dental service, the general medical service, pharmacy contracts, and they recur every single year. So, are you happy, even though those haven't been negotiated, necessarily, yet, that you've got sufficient funds in readiness for those negotiations?

Yes, two things on that. Firstly, we've made it clear, as you would expect, to the health service that we will provide the additional funding for the additional element of those negotiations for next year. So, that's where it sits from a budgeting point of view. So, we've retained that element to satisfy those negotiations. As I mentioned earlier, we haven't done the negotiations, we haven't had the recommendations, but I'm satisfied that we've made sufficient provision for us to be able to negotiate those arrangements or respond to those recommendations appropriately.

Okay.

Thank you, Joyce. Cabinet Secretary, if I could just ask some questions around health boards' financial positions, so, as I have understood it, there's £220 million of deficit that's been reported that health boards are in deficit by the end of this financial year. You've stepped in with £112 million of additional funding and you're expecting the health boards to meet the savings in terms of the difference I've just outlined. Is that correct? I just want to check my understanding is correct of that position.

I may bring Hywel in on some of the detail of this, if I may, but the planned position, as you say, was that there would be a combined deficit across the system of £220 million. I'm tasked with delivering a balanced MEG, regardless of what the deficits are in the system. So, we have to make provision centrally to meet that outcome, and, therefore, what we need to find centrally is in fact the full £220 million, so that that figure is invested to balance the budget. So, I've made provision in my budget for that £220 million.

In this financial year.

Yes.

Yes, of course. Yes. Okay. So, help me to understand, then, because you're asking the health boards to make the savings to match the difference, but you've already allocated that money, even though you've asked them to make savings to the additional—whatever the difference is between £220 million and £112 million.

So, the allocation I have is to balance the MEG, right?

Yes.

So, there's a deficit in the system, which I have to cover in the MEG, so that the MEG is balanced. And then there is, as it were, a separate question of what that means for cash that health boards have access to in order to spend, which is looking at it from the other perspective. You're right to say that there are savings expectations, which health boards will have to deliver in order to get to the level of outturn at the end of the year that they have committed to doing.

Sure. Okay. So, most years, most health boards end up in a deficit position, and that can't be a sustainable position, so I assume you agree with that. So, is there enough funding that you've allocated in your 2025-26 budget to ensure that, in your position, health boards should bring forward a balanced budget next year?

Well, some health boards will not be able to get to a balanced budget next year, but we will have set them a figure that they will need to deliver in order to have met the plans that they have been set, effectively. And that varies from health board to health board, because each of them has a different financial profile, as you will appreciate. I may ask Hywel to explain how this works in practice, because it's reasonably technical. I think the committee would find that helpful.

Yes.

Okay, thank you. So, I think it's probably important context for the committee to put a join-up to the last financial year as well, in the context that we had very significant allocations within the financial year and set control totals for each health board, which then informed our approach this year. So, we don't have a specific approach or intent to hold back funding on a long-term basis. As the Cabinet Secretary has outlined, we've got a need to ensure a MEG that's balanced, health boards that deliver the plans that they themselves set out, and an equitable approach, effectively, so we're not rewarding failure. And equally, for those who are balancing financially, such as Cwm Taf health board, that they're not disincentivised by delivering on the expectation that's set out.

So, in the last financial year, we received significant additional funding, we set an equitable framework and a target control total in place by health board, and we held savings to offset the deficit at that point in time. Now, some of those savings were non-recurrent, so, at the start of this financial year, we set out significant additional funding to the NHS and a very clear set of planning expectations, which included an expectation that if health boards were unable to deliver a balanced financial plan, they sought to maintain their outturn position from the previous year, and we sought to maintain an offset against that deficit within the MEG. So, the £220 million you described at that point in time and the funding we retained in the MEG, that's absolutely right.

What we've done in year is allocate some of that additional funding to health boards in recognition of some of the pressures they face. So, that £112 million you referred to, £50 million of that was for general pressures that are persistent across all boards, in particular around continuing healthcare and prescribing, and then the £62 million was specifically for three health boards in particular—Aneurin Bevan, Hywel Dda and Powys—for reasons I could go into if you want to explore those, and we've reset new target control totals, in effect, which equate to £85 million.

In terms of next year, which is your question, what we've retained within the MEG as it stands is sufficient cover for the control totals that we've set the boards. So, that £85 million, we will have cover for. We're asking health boards to develop and deliver plans within available resources. They have a statutory requirement to deliver a balanced plan; if they're unable to do so, our expectation is that they develop plans to maintain and achieve that target control total.

Sure. Okay. Thank you, Hywel. I appreciate that. James Evans.

Yes. My interest is on balanced plans. Obviously, that means, sometimes, a reduction in service as well, a reduction in what patients can expect, because if health boards haven't got the money they can't deliver it. And the First Minister's priorities are mental health, women's health, driving down waiting lists and cancer services. If a health board can't find a balanced position next year, they are going to have to make cuts to services, aren't they? We have already seen that with Powys, and what's been proposed there with pausing some elective surgery. So, I am just interested in the deficit. You have to balance your MEG, and health boards are going to have to find money. I just wonder how that is going to impact on the First Minister’s priorities in those service areas.  

I can see why you ask the question. It's obviously a fair question to ask. I, myself, wouldn’t put it in quite those terms. Obviously, we have set the allocations, as Hywel has just explained; we have set the planning framework, which has our expectations of the system; and we have identified the very most important priorities, which the committee will have seen.

So, the other element of the planning guidance is the enabling actions, as we have called them, which is a list of about 30 things, off the top of my head, that are current expectations of the health service and that are all being implemented, to some extent, in most of the health boards. So, there is nothing in there that is new. There is no new level of obligation. They are things that all health boards should be doing anyway, and there is a level of quite significant variation in the system about whether they are being done.

The reason that I am emphasising that is that an awful lot of those are in the space of delivering services in ways that we know are the most effective ways to deliver them, both in terms of patient outcome but also in terms of cost-effective outcomes, and that are delivered variably at the moment. So, we had this debate in the Senedd yesterday, to some extent.

So, I wouldn’t put it in the binary way in which you are putting it, though it’s obviously a fair challenge. I would say that we absolutely know that there are ways of delivering particular pathways, ways of operating, theatre optimisation, high-volume clinics, particular pathways, and there is extremely clear evidence that these are both effective for patient outcomes and value for money, and we are expecting them to be implemented this year. That would, I think, help to square the circle, really, in the way that you are putting it to me.

But that's pace, isn't it? These things can be delivered, but there is pace behind how quickly they can be delivered, though, isn't there? With digital services, for example, it's how quick they can be delivered. If there isn't the money in the system to be push these things to happen at pace, it's not going to—. It's an invest to save, isn't it, in a way?

No, not necessarily. If you have an opportunity to go through that table, you will see that there is a very wide range of different approaches. Some of it is digital, and therefore there is a lead-in time. Some of it isn't in that space at all. We know that some of the elements in there specifically require some practices to be deprioritised, where we know that they don't lead to the best patient outcomes or the most effective financial outcomes. So, I think the committee might find it interesting to go through the detail of that, because I think that that will support both better outcomes and better financial planning.

Joyce, you wanted to come in.

Diolch. You have got a lot of investment up front. It's pretty significant investment in modernising the health service in the way that it delivers. I'm assuming that there has been link-up between that and also the fact that some health boards could be performing more efficiently, not just financially, but for the patient as well. So, it would be interesting to see some evidence between those two, linking, because there is a clear link. It's upgrading outdated equipment, for example. So, people might have to travel, and there's a cost to that to the health board, by commissioning it elsewhere, if they had that equipment available to them. Also, it's about not everybody having all of the equipment in every place, but making a pathway—you talked about pathways—efficiently where that is possible.

Yes. Most of these things, as you say in your question, are very well evidenced. So, the twin challenges that we try and negotiate are: the overall funding pressure, which is obvious, and the points that I made earlier about the investment in diagnostic equipment, for example, and the capital investment in that, but there are also ways in which services can be differently delivered. For example, we are clear that some services are better delivered on a regional basis. That isn't actually about the availability of equipment; it's often about the concentration of expertise from a clinical perspective.

But a very good example of where those two things come together, I think, is you'll know that we are developing a future health park in Llantrisant, which is a regional diagnostic and elective surgery proposition that will serve the south-east of Wales. These things take time to implement. In the meantime, they've had mobile MRI and CT scanners on site. So, that isn't about the availability of equipment, it's about having a regional delivery of a service, and that's made it possible for waiting times to be reduced quite significantly in the diagnostic space. So, I think it's a mix of investment, on the one hand, but also imaginative configuration of how services are delivered, and that's very often at a regional level.

Okay.

Thank you, Joyce. Alex, did you want to come in?

Just to add to the Cabinet Secretary's example, if you take child and adolescent mental health services performance as an example around that, we've not specifically said, 'There's an increase in CAMHS investment', but through the work of the strategic programme for mental health, working with health boards, we've focused on variation in the system and having a consistent framework about what the service model and pathway for individuals look like, and that's then led to efficiencies in the system, such that, on an all-Wales basis now, we're at a 93 per cent referral to assessment position against the 80 per cent target. So, we've seen improvements through having consistency across health boards, and that hasn't been about, 'We've focused on budget.' It is a ministerial priority and it features in the planning framework, but that is about having a consistent approach across Wales. And there are more, but CAMHS is a good example given that that's worked effectively over the last 12 months.

Thank you, Alex. In terms of revenues, Cabinet Secretary, how much additional funding in this financial year was sourced from reserves to cover the deficits that we talked about? And how much, in your draft budget for 2025-26, addresses the risk of further reliance, I suppose, on using reserves?

So, from the point of view of reserves, none of it has been funded using reserves. I mentioned earlier that we'd made provision in the MEG, so the MEG can balance, and that's what those figures are. They're not to draw on the reserves, they are a provision in the budget in order for the MEG to balance.

Okay, that's understood. Thank you. In terms of the real challenges that we've spoken about, and you've spoken about, in terms of the strain on NHS services, what discussions have you had with health boards about the potential of deprioritising some areas? What specific areas have been identified so far to you from health boards, and to what extent do you agree with their suggestions, because, clearly, there's got to be some deprioritising to balance the budgets that we've spoken about?

Yes. Well I, in the letter that I sent before Christmas, have said that I recognise, just as you've said, that if you're going to focus in on—. Just to say, as you will obviously know, there are dozens of priorities that we set the health service that go way beyond the 15 or so that I particularly highlighted. These are complex organisations with access to very, very significant budgets and complex population health needs—that's the backdrop. But I do accept that, when you're specifically highlighting the priorities that you will most regularly focus on in terms of performance, then there's an element of deprioritisation that happens elsewhere in the system. I should say that that happens anyway. In a complex organisation where there are more demands than there are resources, clearly the system will make its own judgments, and I feel it's important that the Government gives a direction on what we think are the things that need to be prioritised amongst those.

I've also said, as part of that process, that, firstly, I recognise there will be some things that will be deprioritised, and I want to have a live ongoing conversation with chairs and chief executives over the coming months about what that looks like in practice. So, I've invited those conversations and I expect people to be bringing those choices and challenges into those discussions.

Alongside that, I think, as well as the deprioritisation, there is something important about ways of working and the system's entitlement, I think, to look to us to be very clear and consistent in our demands of the system. So, this year, as I mentioned earlier, we've been able to bring together the planning framework and the allocation letters at the same time, which is, I think, great from a planning point of view. Next year, we'll go a step further: we'll bring the planning guidance, the performance guidance and the quality guidance into one integrated approach. So, there's a kind of a streamlining of the ways of working, if you like, which I think is quite a significant benefit to the system. And I've also said, alongside a conversation about what might need to be deprioritised, I want to have that conversation about an ongoing streamlining of the way we make demands of the system. Do we ask for data in ways that are duplicative? Are there things that we ask for that we don't really do anything with when we get? Those sorts of judgments we need to test ourselves with, really.

So, what areas have chairs already discussed with you about deprioritising certain areas?

They haven't come to me yet with those, but I'm starting the new year's cycle of meetings from next week onwards, so I'm assuming they'll be part of those.

Okay. And in terms of this financial year, because we're talking about the next financial year, but in terms of this financial year, surely those discussions would have taken place prior to now, in terms of them balancing this year's budget, in terms of discussions with you about what they may need to deprioritise?

Well, they will have predated me, Chair, personally, given the time point in the year at which I came into post. But, at the start of the year, or in advance of the year, they will have obviously been in the same planning process, responding to last year's cycle of guidance, and that will have fed through into the integrated medium-term plan discussion. So, that will have been baked in in advance of the year, really.

Okay. So, there's been some discussion around Powys health board's deficit position. The First Minister this week made a very clear statement that it's unreasonable for Welsh patients to be told that they need to wait longer than their English counterparts. So, how will this budget for 2025-26 ensure that health boards are funded to buy English capacity based on English waiting times rather than the much longer Welsh waiting times here in Wales? 

Well, there's a range of whether they're much longer, Chair. I think that's a value judgment. It's not quite as clear cut as you suggest. But the point is a valid point to make, obviously. We delegate budgets to health boards and they are required to commission services within their budget envelope. That is not a surprising or unreasonable expectation of any health board, and that is absolutely what we expect all health boards to do. There are some health boards that, by virtue of geography, do that more than others, obviously. But there are also, as you know, commissioning arrangements generally that operate on a national level and which also engage NHS providers across our border, and they're all baked into the budget allocations that we make. So, for example, in the case of Powys, as you will know, we made specific provision in this financial year for increased cost implications of surgery across the border. We've committed to providing that funding to recognise that increased cost. So, there's an upfront element that is baked into the allocation, and then, where there is a change that happens in the course of a year, as there was last year, we're able to recognise that specifically.

Okay. And then—. James, do you want to come in on this point?

Yes, just out of interest, Cabinet Secretary, because of the way the budget allocations work, I'm just interested because, obviously, the English NHS charge the Welsh NHS for operations. What part does the Welsh NHS executive play in that as well, to make sure that, actually, Wales is getting good value for money off English health providers as well, because surely those are conversations that should be happening in the budget-setting process, so Welsh Government can understand exactly how much, say, Powys or Betsi Cadwaladr—people who do commission services on both sides of the border—have, so they can project exactly how much those figures are going to cost our health boards?

On the detail of that, I might ask Hywel to come in for me.

Yes, thank you. Ultimately, it's a health board responsibility, and the NHS executive and we, actually, work closely with health boards in terms of understanding the planning assumptions that they make and monitoring that on a robust basis throughout the year. So, again, if you took Powys as an example, one of the particular challenges for Powys this year, from my perspective, is they outturned last year at a £12 million deficit. We provided significant additional funding. Their plan this year was a £22.9 million deficit, which is clearly challenged, and the health board has been escalated in intervention terms, and they've got challenges to delivering that position in-year. And one of the challenges within that is—we were very clear on the planning assumptions that Powys have set—that they have challenges in delivering the plan that they themselves have set out. So, that's an in-year challenge in terms of how we manage that particular set of circumstances and pressures that have materialised in-year. In terms of the wider interaction with England, all health boards will have contracts with their English providers. They're all very robust and transparent. That information and value-for-money test is part of local health board arrangements, and we also have interactions between Welsh Government officials and English officials in terms of planning guidance and expectation at a macro level across the system.

So, the Welsh NHS executive wouldn't get involved in any of the cost element of how much it costs to do an orthopaedic operation back and forth. 

No, they wouldn't. So, the NHS executive hold a lot of costing data in those terms. So, we've got a good understanding of the cost of services, cost of patient treatments. So, there are instances where health boards would seek to access some of that information and data in terms of informing some of their planning choices and decisions, but the NHS executive wouldn't have a direct role in terms of those relationships.

Can I have one more? Just as a point to the Cabinet Secretary, I know health boards have got their own independent commissioning models, but, on the value-for-money element, would it probably be a wider policy matter, more value for money, if the Welsh NHS executive was managing that negotiation on behalf of the other health boards, because negotiating as a big collective together is easier than bargaining as individual health boards on their own, for example, where, say, English NHS trusts could be charging different health boards across Wales completely different charges for operations, and because, if it was done centrally, it would be one cost, so it would be easier to project, going forward.

Bigger buying power. 

Bigger buying power, yes. 

Well, that is one possible advantage, I agree. I don't think it necessarily results in that outcome, but I absolutely accept that it's a possible outcome. As you know, some commissioning happens on a Wales-wide basis anyway through the newly constituted joint commissioning committee, so there is existing practice where capacity is negotiated at a national level. I suppose one of the challenges—although it may well not be insurmountable—is how you get the level of granularity about the operational requirements of a particular health board versus the capacity in another. So, I think the operations of a health board are very much at that level in the way our system is configured. So, there are some, I could imagine, challenges in that space, but what you're describing isn't without precedent in the system.

Yes, okay. 

Thank you. Joyce. 

One of the areas where there is significant pressure is orthopaedics, and the need to improve the outcomes is significant. I know we've got an ageing population, but not all people who need orthopaedic treatment are out of the workforce, and then there's a cost more widely. So, I'm quite interested—and I can't remember your areas of priorities—to know whether orthopaedics features in those. Of course, the other side of delay in orthopaedics is that people's ability to live a full life diminishes quite quickly, whether that's their mental ability or whether it leads also to further medical problems, and then the cost goes up exponentially. So, I suppose the first question in terms of the budget is: is there a budget line particularly focusing on an area where we know that there's a high-end need, which is orthopaedics, and is it in your priorities, because I can't remember?

It absolutely is because it's historically been one of the largest areas of waiting lists for us, as it is in many other places as well. And, as you say, people are waiting in pain for too long, aren't they, so it's a big challenge? So, the way our budget is structured is that the funding that is provided for orthopaedic intervention will be allocated by the health board from the budget that we provide to them. But, in the enabling actions that you will see for the planning guidance that I issued before Christmas, there are specific and very detailed requirements about performance against pathways for orthopaedics and, in particular, ways of working that reflect the Getting It Right First Time recommendations, which is the efficiency advisers, if you like, if I can use that term, in the system, about how to expedite orthopaedic surgery. So, there are very specific requirements that I expect to be delivered by the service this year. Many parts of the service are already doing that, but it isn't sufficiently consistent.

One of the points I was touching on earlier is where regional working can make a big difference, and we know—and the royal colleges are very strongly of this view as well—that orthopaedics is one of those areas that benefit from regionalised high-volume, low-complex surgery. So, that's the reason we have the Llandudno orthopaedic unit currently being built in north Wales—£30 million-worth of investment. It's one of the reasons why we directed Swansea Bay health board and Hywel Dda health board to work jointly around orthopaedics. We've got a unit in Neath Port Talbot, which has doubled the capacity of that hospital to do orthopaedic work, and I touched earlier on the development in Llantrisant. A significant component of the elective surgery offer—if I can put it like that—in that unit, when it's developed, will be around elective orthopaedic surgery. So, I essentially accept what you're saying.

Nick, did you still want to come in?

It was a point around the tariff of procedures, which, in some respects, also links to this point and the point the Cabinet Secretary's making. So, commissioning of services, both in England and in Wales, is based upon a price tariff, which is nationally published by NHS England, which avoids, then, the smaller provider, if you like, or the smaller commissioner being at a disadvantage when negotiating a contract. We've used that tariff in Wales a number of times and, in terms of orthopaedics currently, we've used that tariff to purchase additional capacity, recognising the difficulties that we've had with orthopaedics over the last, probably, seven or eight years in terms of waiting times. Of the, I think, about 22,000 additional procedures that will happen in the last two quarters of the current year, around about a third to 40 per cent are in orthopaedics, many of which have been procured from other providers, at a tariff that is set nationally, which is the price that everybody then pays for that particular procedure.

Okay. Thanks. Did you have a question to come back on that, James?

Just on orthopaedics, if that's okay. So, when the orthopaedics centre is open in Llandudno, and these others across the country, because we know that if you go to a certain doctor's surgery, you've got to go to a certain health board area and that's where you're going to be treated, and so if there is capacity, say, in that centre in north Wales, and patients in south Wales can't get seen, will there be an offer for them to go to where there's capacity in north Wales rather than being stuck in a certain part of Wales, when they could be seen somewhere else quicker?

Well, there's an element of that in the system already, and I think one of the opportunities, if you like, in having more regional working in the future is an ability to do that in the longer term. We absolutely aren't there yet, because the capacity isn't there in the system. But you could imagine, where you have very efficient regional delivery of some of these services, that that might be an option. So, for example, in the south-east, there's a new cataract facility at Nevill Hall Hospital, which is a regional cataract facility. That's been able to increase the capacity very significantly. When that has reached a level of throughput that we understand and which is predictable, and when we've got to grips with the combined waiting lists, which will be feeding in to that, you absolutely could imagine a situation where, if there's capacity there, that becomes available more broadly. We aren't in that position at the moment, but I think, in the longer term, you could imagine it, certainly.

We're struggling a bit for time, but Hywel wanted to come in, and I've got one last question on health boards' financial situation, and then we'll move on. Hywel.

It was just a broader point to the Member's question around orthopaedics. We've heard a lot this morning, and you'll see it's a common feature in what we've set out in the planning framework, a much stronger theme around—whether it's the 35 enabling actions, the CAMHS example that Alex gave earlier, the 50-day challenge—a real focus on the highest value, high-impact interventions across the system, and how you strengthen the implementation of those consistently, which may also result in consideration of what's then of lower value, to the choices conversation you were referring to earlier, Chair. So, if you take orthopaedics again as an example, one of the 35 enabling actions is the implementation of the high-value, high-impact pathway for knee and hip arthroplasty, where the national clinical lead in Wales has set out, 'This is what good looks like, by stage of pathway in this particular area', and that's the delivery expectation that we then put on health boards in that respect.

Thank you, Hywel. One last question on the health boards' positions from me. Of course, we're aware of Powys health board's position because it had to make that decision in a board meeting, so it's a public position, but, of course, other health boards in Wales are not in the same position as Powys. Are you aware of the practice that Powys health board were suggesting in terms of asking health providers to delay treatment for financial reasons? Are you aware of that practice happening in any other health boards in Wales, where health boards are, within their own health board area—because the provider is also within the health board area—seeking to delay treatment for financial reasons, even though there's capacity there within that health board?

I'm not aware of that, and I would be surprised if that were the case, because it would assume a material level of unused capacity in the health service in Wales, which I don't think is the experience, generally speaking. I think, in the longer term, though, Chair—. For example, we don't have significant amounts of activity on the weekends in the health service in Wales. I think there's a legitimate discussion to be had about whether, in the longer term, we need to move towards that. That would create extra capacity. One of the reasons we aren't in the position to do that now is obviously partly to do with funding. So, you could look at it from that perspective, but I think you were making a more specific point about current levels of activity, and I'm not aware of that being a challenge elsewhere.

The headline there is that there is no extra capacity within the Welsh NHS, so the waiting lists are as they are for capacity reasons, not financial reasons, apart from the Powys situation. 

Well, the waiting lists are where they are for a range of different reasons, Chair. So—

But not financial. That's what I'm digging into.

I'm not following the question, I'm afraid.

The point I'm getting to is that the point that you're making, Cabinet Secretary, is that there's no spare capacity within the NHS—that's the point you just made. There is capacity in other parts of the NHS, outside of Wales, clearly—we know that from the discussions that Powys health board are having. So, is there scope for using further capacity within the NHS across the border in England to help reduce your waiting lists?

We've had these very live discussions in the context of how we invest the £50 million into speeding up treatment. Obviously, we've commissioned activity from the independent sector, from the private sector, and also from across the border. Our understanding is that we've basically used up the capacity that exists in the system, so I don't think that is, at the moment, the challenge. The existence of extra capacity that's not being used, as it were, is absolutely not the situation that we're in.

Okay. I could go on, but I'm going to stop it there because of time. James Evans.

Thank you. My questions will be to the Minister for Social Services, to give you a rest, Jeremy, for 10 minutes. Minister, considering the ongoing financial pressures on public services, which were outlined in the Government's draft budget, you talked about the national care service earlier, so I'm just wondering what funding mechanisms are being considered to make sure it's financially sustainable in the long term without compromising the quality of care and placing extra burdens on the taxpayer as well.

Specifically on the national care service, or social care in general?

The national care service.

What I was saying in answer to the earlier question in terms of the national care service is that the first phase of the implementation is to undertake some research around fee methodology and funding, and how we would actually fund a national care service. What I omitted to say when I answered my earlier question, of course, is that, depending on how things develop with the work of the commission in England and the funding mechanisms that may change for social care in England, that may well result in an additional funding envelope for us in Wales to be able to help our modelling around that.

It's very much a part of the process towards that national care service that we undertake this research to look at, against the backdrop of severely challenging financial times, how we would move towards, within our 10-year window, delivering a national care service that is free at the point of need. That is very, very ambitious. We don't underestimate that at all. I don't think there are any of our local authority colleagues that don't share our ambition in this area. We've seen and heard nothing thus far that is moving us away from taking that direction. We know that social care, as it stands at the moment, is really not sustainable. To do nothing with social care is not an option. So, we have the progress towards the national care service that I've talked about. I’ll ask Albert to say a little bit more about the commissioned research around that and what it is that we're looking at.

We're also looking at the wider structure of social care. Social care is about more than residential homes. It's about more than just children's services. For some people, it's about how we support their day-to-day living. We've tried very hard in this year's budget settlement to provide local authorities, who primarily are responsible for funding social care—. We can have a conversation in a moment, if you like, about the difference between the social care element of local authority budgets and what we're doing from the health and social care MEG, because they are different.

It is perhaps a difficult situation to be in as a Minister that has lead policy responsibility in a significant area like social care, but I actually don't have the financial responsibility for local government—that sits with the Cabinet Secretary for Local Government. I can absolutely assure you that she is having regular conversations with local authority leaders about how we drive forward the social care agenda. We set the policy directives for social care. Local authorities are signed up to those priorities with us, and that covers a whole range of issues, through the transformation of children's care through to the development of a national care service, and everything in between—domiciliary care and so on.

Albert, do you want to say a little bit more about the research that we've commissioned about how we might move towards funding the national care service?

Thank you, Minister. Just before I do that, I think it's important to make a comment on the Minister’s statement about that 'do nothing' position. When we step back and we look at the information around demographic changes taking place, the committee will be very aware of the older population, aged 65 plus, and it’s going to be really important for us as a nation that, as we age, we age well, and that people need to live longer in periods of good health. That's going to be absolutely crucial to us, because, without that change, then all the funding and issues will be in the heavy end, and we've got to change that.

In terms of the research, I'll just mention a couple of pieces of research that are currently important. One is that larger research commission that relates to paying for care and the future funding. It's absolutely key to determining the next steps for the national care service development. And that's going to look at what elements of investment are required, thinking about the commissions around preventative services, that earlier point I was making, because that's going to be absolutely crucial to us. And it also will incorporate, it will not surprise you, a charging regime as well, which was one of the points that you made.

And just to say, there's another piece of research, just to complete the package, and that's about the feasibility piece to consider a national fee methodology approach in Wales for care home placement, which is absolutely critical to the care of our especially older people and people in need. This will look at a single-fee national methodology. It’ll probably, in a sense—. Let me correct that. It'll probably end up with a range of fees because of the different needs, but it will have a national fee methodology to it, so you'll cover the core elements, and we'll be advised on that. And that will really then enable us to support the commissioning processes that we have mentioned earlier in this meeting. Thank you.

That was very comprehensive. Thank you very much, Albert.

You did mention, Cabinet Secretary, the link with local government, and it is intrinsically linked together, between health and social care and local government. The Association of Directors of Social Services in Wales and the Welsh Local Government Association projected a £223 million shortfall in social services funding for 2025-26 due to rising costs and demand. And they did warn that, without additional funding, the quality of services that local authorities could deliver would be detrimented, as they’re struggling to balance budgets as it is.

So, I’m just interested in how the Welsh Government plans to address this significant funding gap, because the NHS Confederation in Wales also emphasised the importance of resource allocations between health and the social care sector. So, I’d just be interested in how you intend to bridge this gap.

The Cabinet Secretary talked earlier on about how we’re trying to address that from an integration point of view, and there are very specific correlations between how we fund health and social care together on the integration agenda. But not everything in social care, again, is necessarily linked to the integration or the pathways of care delays and so on. But the determinants of health sit very much within social care.

We’re more than well aware of the pressures on local government, as I say. Although the Cabinet Secretary for local government meets with local government leaders on a regular basis, so do we, so do I. I meet with our social care leads. The Cabinet Secretary and I meet with both health and local government leads together, to talk around the integration agenda and how we can upscale good practice to ensure that we get greater efficiency of practice not just on a regional basis, but a national basis.

One of the things we identified very early on is that we find very good pockets of good practice, which are delivering significant outcomes, whether it’s reducing waiting lists, whether it’s doing significant work around children’s services and promoting the preventative agenda, preventing children going into care and so on, and we see really good things happening in one area, but not such good things happening in the other area. And part of the work that we’re doing with local authorities is saying, 'How do we roll out that good practice so that we see those benefits across the country?' And I think that’s probably key to some of the things that we’re talking about here around financial pressures—looking at more commonality, more consistency around the way that things are delivered.

All of the pressures in local government, of course, are not just around social care. They are significant in social care, and social care accounts for around 40 per cent of their budget—30 or 40 per cent of the budget—and about 40 per cent, I think, is education. So, it’s not an insignificant element of their budget. What we have done—and, as I say, I’m not the Cabinet Secretary for local government—this year is provided a significant uplift for local authorities. They’ve seen an increase of some £253 million on their budget from 2024-25. But it is very much for them to determine how that is spent. But within that spend, of course they have to be cognisant of their legal requirements in social care, the policy requirements coming out of the Welsh Government, and all their regulatory obligations. So, they will have to take into account, from that, things like the elimination programme and the move towards establishing their own provision for children’s services, or third sector provision and so on.

We understand those challenges. We are funding it to the extent that we can at present. And when the opportunity presents us—and it does present us in-year, as well as when we’re going through the budget setting process—to support social care additionally to the budget, then we do that. An example of that is that in-year this year we’ve provided additional money for reablement, which is significant in the preventative agenda, I would have to say, and we’ve provided a significant amount of additional funding towards supporting domiciliary care services in local authorities.

That was on the back of, you might recall, local authorities wanting to raise the cap of how much they can charge people for domiciliary care services. We took the view that that would not be an appropriate thing to do. We know that, in the middle of a cost-of-living crisis, to be asking some of the most vulnerable people, particularly people with disabilities, to be paying for their domiciliary care was not the way forward. So, what we have done is provided more funding for local authorities, for domicilary care, to enable them not to have to put their domicilary care charges up, and we think that was the right thing to do, and we've given a commitment on that, going forward as well. So, that's a very roundabout way, James, of saying, that when the opportunity presents itself to us, then we do look at the Government priorities in the delivery of social care and sustainability of social care, and we place additional funding there when we can.

Going back to the point I made earlier and what Albert was alluding to, I do have a paper that I'm in the process of finalising at the moment that we're going to take to Cabinet, looking at the future of social care, on the basis that we acknowledge that the 'do nothing' approach is not an option, that we do have to look at the future sustainability of social care, and we will hopefully be setting up some kind of structural review on that, about how maybe more regional working might deliver better outcomes, might make the system more sustainable, might make the funding models more attractive, because we're very conscious that we have 22 local authorities doing things in 22 different ways, and sometimes that is not the best way to deliver efficiency across the system.

Do you want to come in, Mabon?

Well, it depends what you mean by 'focusing on local government'. Social care is a local government service, so focusing on local government delivering social care is clearly important. We can't change or modernise or restructure local government—. Sorry, I shouldn't say that, that we'd restructure local government. [Laughter.] Without restructuring—

Do you think local government should be restructured?

Well, you know, local government is not my responsibility in Government—

No, no, but do you think it should be?

—and it wouldn't be appropriate for me to sit here and talk about my personal views on another Minister's portfolio area, but what I am responsible for is social care and ensuring that we have the right policy mechanisms in place to deliver the best outcomes for people using our social care services. And I think, in conversation with our local authority colleagues, they would accept and agree with us that the current system and the current situation are not sustainable going forward. So, it would be irresponsible of us as a Government not to accept that, take that on board, and look at what we can do to make social care more viable in a general sense, sitting alongside what we're trying to do with the delivery of a national care service, and how we can make the social care sector more sustainable. It is about funding—of course it's about funding—but it's not just about funding.

James, are you happy for John to come in and then I'll come back to you?

Just as a practical example of where there's real pressure on social care in the way that it works with the NHS, delayed transfers of care are a real issue, aren't they, in terms of the pressure on accident and emergency and the ambulance services. In terms of your portfolio, how much of your effort, how much of the new ways of working and budgetary allocations, will get to grips with that problem, which has been such a thorny, long-standing problem and is very much still with us?

It absolutely has, and I think it goes back to what the Cabinet Secretary was talking about earlier on, you know, the 50-day challenge and the work around delayed transfers of care. There is very much joint working. One can't happen without the other. That is absolutely clear, and that is why I'm saying that through the in-year additional financial allocation process, there was a significant amount of additional funding put into the local government element of that around reablement and domicilary care, because one of the ways in which we can help the flow through hospitals is through ensuring that we've got the capacity in the community, through social care, that people can come out of hospital in a timely fashion, with a tailored package of care to suit them. Now, most people get the social care that they need. Some people have to wait longer for that, and the longer waits for that is what is impacting on waiting times in hospitals and delayed transfers in hospitals.

So, we're absolutely working on that as a joint policy objective, if you like. And one of the things that we want to do as part of that process is to make sure that, where we can avoid people going into hospital in the first place that we should absolutely invest in that. And that means—. It goes back to James's point about the preventative agenda. There is a lot that can be done in the reablement field to adapt homes, to provide help and support for people to live at home safely without them having the need to go into hospital. If we can do that more effectively, we take the pressures off the hospital services as well.

So, we absolutely know what needs to be done. Funding, of course, is always a challenge, as is having the workforce to deliver all of this. And I can talk to you in a moment, if you want me to, about the workforce and what we're trying to do in that area, because we know that we have significant workforce challenges. We know what needs to be done, and quite often our inability to be able to deliver exactly what needs to be done in the community is about our inability to have a fully—what's the word I'm looking for? Not 'fully funded'; it's not about funding. It's about capacity. That's the word I'm looking for. Having the full staffing capacity to deliver what we need. 

James.

Lovely. Before I move on to staff, I just want to touch on—. You mentioned the 22 local authorities and that there shouldn't be 22 different ways of doing things differently, but sometimes there are. Rural councils have individual issues, don't they, with delivering social care over rural areas. It's extremely different to delivering it here in Cardiff, for example, with the time it takes to get between different—I hate using the word 'clients'—between different people and the rest. I'm just interested, within the budget setting process that you have, given that you're not the Cabinet Secretary for local government, I respect that, but where does the rural element come into the thinking around funding for social care? Because delivering it is very different in, say, Gwynedd, for example—I won't say 'Powys'; we've talked a lot about Powys—than delivering it in Newport or Cardiff.

So, what you're talking about is the local government funding formula—

I could be.

—which is delivered through the revenue support grant, of course, and there is a formula that takes into account rurality, it takes into account population growth or the reductions in populations. It's why we tend to see local government allocations fluctuate from time to time. I know in my own area, when I was first elected, I was hauled over the coals by the leader of Merthyr council because their budgets had been cut, but actually what had happened was that the population had dropped significantly, and so the funding formula takes account of that, but it also takes account of deprivation, it takes account of rurality and so on. So, that is taken account of already in the way in which the local government funding is allocated through the RSG.

How does it directly correlate to the thinking within your department, though, about how you deliver social care and the funding for social care in rural areas? Now, it was funded through the RSG, but I'm just interested in how you, in your directorate, focus on funding rural councils directly. 

Well, rural councils, as I say, primarily—. I think that it is important to say that the majority of social care funding is through the RSG. We provide grant funding to support particular Government priorities, and that's primarily through regional partnership boards, the integration fund and so on. So, the regional partnership boards themselves would be those bodies that would look at, on a regional basis, what is the best way to deliver a particular service, whether it is social care or any of the other services that they look to allocate grants towards. And that is on a regional basis. So, that's not directed from Welsh Government; that's very deliberately done through the regional partnership boards because they know their areas and their services better than we do, sat here in Cardiff. 

Okay. I'll move on to staffing now, Minister. One of the things we all know is that there's a lack of social care staff across Wales, but actually the data that we can have to look at the vacancies within social care across Wales is patchy, to say the least. The last available data on vacancy numbers was back in 2022, and the previous Deputy Minister in this portfolio said that she'd provide more up-to-date data, but that hasn't come yet. So, I'm just wondering when Welsh Government are going to provide that data on vacancy numbers in the social care sector across Wales.

Well, we will be publishing shortly, and I understand—

How long is 'shortly'?

I'll ask Albert to say a bit more about this in a moment. And I am conscious that my predecessor did give a commitment on progress on data, and we have been making progress on that through the establishment of the national office, and Albert heads the national office, so I'll ask him to say a bit more about that.

It is quite difficult, because, particularly in social care, 80 per cent of social care providers are in the private and independent sectors, so gathering data from bodies that you're not directly responsible for is difficult and is challenging, but, Albert, do you want to say a bit about the—

You'll just have to be brief. It might be that we'll have to perhaps have some information in writing because I'm just conscious that we're struggling with time—

We will write to you.

I would appreciate that.

We can do that.

That would help.

Can we do that, Albert?

We can—

Did you want to say something briefly, Albert?

—but I'll go with the brief version rather than the long way around—

Please, yes, that's fine.

Absolutely right, the data for 2023 is going to be published in February 2025. Two comments to make: one is that that will just show, moving from 2022, a 9 per cent vacancy rate to a 6 per cent vacancy rate, mostly because the workforce has grown, local authorities are providing 1,000 people, dom care, more, that increase compared to where we were this time last year. So, we're seeing changes taking place.

And then, finally, the Deputy Minister did take forward action. We have really substantially strengthened some of the data. It still needs further refinement; it needs further improvement, but it's a beginning. We have a social care checkpoint collection point with local authorities, and really importantly, Chair, that begins to address—. At the moment, that's not published data, but there is work behind the scenes trying to move that forward into a future published arena, which you would get then like you would some of the NHS data. Diolch yn fawr.

Do you have any final pressing questions? If we break about 11:05 a.m. for 10 minutes, we should be on time. 

Right. I've one very quick question, Chair, and it's on workforce again. A survey that was done showed that only 35 per cent of social care staff are content with how much they're getting paid, with 25 per cent of social care staff thinking of leaving the sector. While introducing the living wage was a positive, Care Forum Wales reports that it's just not enough to compete against other employers. As I mentioned in the debate yesterday, people can earn more money working in supermarkets than what they can in the social care sector. It is becoming extremely difficult for social care providers to pay that, especially with the national insurance contributions going on top as well. So, I'm just interested, from the Government, in what steps you're taking to ensure that providers can pay people properly.

And also, wider than that, what steps are you taking to make sure that our social care staff have actually got career progression as well? So, if you want to get people into the sector, some of those people could make fantastic nurses in our NHS, and how do you push those people through? So, if you can round that off, Minister, I'd be grateful. Thank you.

Yes, I mean, that latter point that you made there is really important and that very much is part of our workforce strategy for social care. So, we've been working on this for some considerable time. We, annually, were providing Social Care Wales with around £32 million to support recruitment, retention, to support improvements within the social care sector.

We've got a pay and progression framework, and progression is an important part of that—it's about enabling people to come into the social care sector and see social care as a career. It's why we've professionalised the workforce in social care. And so, whereas I understand and accept the argument that they could get paid the same working in Tesco—and by the way, we absolutely need people working in Tesco, because if we don't have people working in Tesco, we can't go and get our weekly shop—there is a difference about what we're offering. We're offering people not just a job, earning a wage, we're actually offering them the potential of a career, which could start as a social care worker and could progress, because of the support that we have through things like the social work bursary. People can work their way through and take on more senior positions and even become professionally qualified social workers through the processes that we've put in place through Social Care Wales. And you may or may not have noticed that I issued a statement yesterday about the social care partnership that we've now developed for the independent and third sector, about developing some kind of frameworks around all of that as well.

What I would say is that I am concerned to hear that the money that we are putting in for the real living wage—and we've done that for three years running now—. It's part of the core funding for local government, so it goes through the rates support grant, but it is absolutely part of the global figure that we provide to local authorities is to pay the real living wage—that's the difference between the living wage and the real living wage; that's what we are funding—to local authorities, and that should be used for those independent and third sector organisations from where social care is commissioned, and if that is not happening, I would be very concerned about that. I think we're doing a review of the real living wage at the moment, and we're looking at that, and whether in fact the money that we are providing to local authorities is actually reaching the people it was intended to reach, and that is social care workers, whether they are in the independent or the private sector. Local authority workers it doesn't apply to so much, because they will get it anyway through their employment with local authority. So, we're doing an awful lot in that, and I think the work that we're doing with the UK Government now on the employment Bill and the implementation of a fair pay agreement is going to put us in a far stronger position, I hope, going forward, in terms of what will be underpinned by a legal requirement to have an agreement to not pay below a certain rate under the fair pay agreement.

[Inaudible.]

If you do, it means that we're having a shorter break. Yes, we're having a shorter break. Joyce.

I'm going to ask for written information.

We've got a seven-minute break, so whatever time this takes, we've got a shorter break. We've got to be back at 11:15. Joyce.

Ten million pounds: there was an increase for the social work bursary over three years, from 2021-22, which means it could come to an end now in 2025. We'll have it as written, because of time. So, the obvious question is: is it going to be maintained, and if we could have that in writing?

One word answer?

Yes, one word. Good.

Yes.

There we are.

In that case, we'll keep to the break. Right, we'll break for just under 10 minutes. We're back just after 11:15. Thank you.

Welcome back to the Health and Social Care Committee. We continue now with scrutiny of the Welsh Government's draft budget. Mabon ap Gwynfor.

Do you want me to cover that? Sorry, I get feedback if I've got the headphones still on, so excuse me, Mabon. I think the starting point we're talking about—. Is it one in 10 people now identify themselves as carers? That was from the last census, so it's a huge issue for us, and I think it's probably worth, for the record, saying how appreciative we are of what unpaid carers do. They're worth billions to the economy in terms of the care that they provide.

So, just to set out briefly what we've done and what our thinking, going forward, is, we've set out, as you quite rightly said, Mabon, the carers support fund and the short break scheme, and all of that together was about £42 million between 2022 and 2025. I think it's important to say, from the point of view of the carers themselves,—and I've had several conversations with carers' groups and individual carers—about the impact that those funds have had on their lives. They're not huge amounts of money, but you don't necessarily need huge amounts of money to alleviate some of the issues that unpaid carers are dealing with. The short break scheme, in particular, is a scheme that is very flexible. It enables unpaid carers to say themselves what they need in terms of a break from caring. So, it could be something as simple as having a night out in the theatre, or it could be a weekend break, or it could be going to the spa, or it could be a whole range of things, not high value, but making a significant difference to the individual carer.

The carers support fund is particularly for those unpaid carers that find themselves in financial difficulties, and it's an emergency fund, almost, to do things like, you know, if the freezer's broken down, it will replace the freezer. It's those kinds of things. And, again, talking to carers themselves, the impact that that has had on their lives is quite significant—

Sorry.

I suppose the reason I was setting that out was to set the context and to say that, because of all of that, we're taking that on board and saying how significant we know that is. Although I can't give you an absolute today, what I am saying is that we are currently looking to extend those schemes, but I'll be making an announcement on that shortly, because we're still doing the workings-out on that. But it is my intention that, if we can, we are extending those schemes, because of the benefits that they clearly deliver.

They will be funds that will be maintained. Obviously, the amount that's going to be contained within those funds has to take all of that into account, because they have to be able to support people—so, they have to be able to provide the short break, they have to be able to provide a new freezer or whatever it is. It's taking that on board. But I think it's also important to say that those funds that we provide are really over and above what is already out there and what is already being delivered by local authorities, by health boards, by third sector providers, and so on. So, this is supplementing lots of other schemes that are out there as well that are provided by public and third sector bodies. And, of course, we've seen the UK announcements on carers allowance and the right to unpaid leave, and so on, which are all, again, very positive developments in terms of the support for carers. I think it's also important just to highlight the work that we're doing very specifically with young carers, and the provision of the young carers' ID cards so that schools can then recognise pupils as unpaid carers—again, I've been to schools and spoken to young carers—and the challenges that that presents them in their daily lives at school. And having a young carers' ID card does something as simple as alerting the school to that and giving those kids a little bit more time to put their homework in, or needing time off to take a parent to the doctor, or whatever, whereas, without that, it's more complicated. And we're also hoping that that scheme helps—well, it does help—with things like picking up parents' drugs and so on.

So, quite a lot is going on in that area and quite a lot, as I say, is being delivered by us, funded by us, but also being funded by other organisations. And a significant amount of these schemes are delivered through the regional integration fund and through regional partnership boards, as well. So, yes, there's much going on.

'At Tenovus Cancer Care, we deliver essential services for people affected by cancer including counselling, nurse-led support, and benefits advice. This is provided free of charge, exclusively to the NHS'—

'Sadly, a third of those we support are end-of-life, facing their most difficult days.

Diolch yn fawr iawn.

Thank you. James Evans.

Diolch. Cabinet Secretary, I just want to talk about waiting times, if I can. There has been an increase in funding provided by the Welsh Government to address waiting times. However they've not decreased across certain disciplines, such as fertility treatment and other areas. So I was interested: when the funding was allocated, was it based on a comprehensive needs assessment across all specialities? And if so, what factors contribute to the underestimation of the scale of the challenges in reducing waiting times, not just in orthopaedics but across other areas as well?

Which funding are you referring to?

The funding you provided to reduce waiting times. 

So do you mean the most recent funding?

The most recent. The £50 million.

Okay. That is obviously not the totality of the funding that the health service draws on to grapple with waiting times. So, if you look at the pattern, for example, over the last two years, you'll have seen in the longest waits a progressive reduction. They're probably now at about 65 per cent less than they were two and a half years ago, and that's the product of the investment we made—the £170 million planned care investment and some of the transformation funding as well. So, you can see the impact of that across the system.

The additional funding that we made available at the end of last year was in recognition that there was more demand coming into the system so that the trajectory that we were on had plateaued and was going back up because more people were presenting with urgent needs, more people were presenting for cancer treatment, for example, which as you know is a challenging set of services that we provide. So that's the rationale for the additional funding going in, and it absolutely has been targeted to those areas, both geographically and areas of treatment that have been most stubbornly challenging to reduce.

We were very clear that we would only fund on the basis of specific plans that health boards themselves were committing to delivering. So, there was obviously a process of discussion between my officials and health boards to test those plans, frankly, and to validate them and get under the skin of them a little. And so they're based on plans that are being monitored weekly, actually, and they're a mix of capacity in the NHS, insourcing where providers outside the NHS provide the service in, for example, NHS operating theatres, and then also independent private providers as well. So that's all been quantified, contracted, and is being delivered at the moment.

I'm interested in that money. Everybody talks about the waiting times, don't they, in orthopaedic care and also for cancers; they’re the big areas. But there are also other areas I'd touch on—fertility, for example. There are long waits on fertility treatment. And I'm just interested, Cabinet Secretary, that we talk a lot about these other disciplines. Is there a risk sometimes that perhaps those other areas could slip behind on waiting times because they're not perhaps given the focus of, say, what orthopaedics and cancers have, but those areas as well can change people's lives and have a direct correlation to how people live as well. So, I’d be interested to know what assessments you do around that to make sure that those other specialities don't start to slip behind as the clear focus would be, ‘Right, we need to get orthopaedics and cancers done' and other people just get forgotten about in a way.

No, that really isn't the plan. Basically, the test was: where are the waits that are longer than two years? So, the plans that have been presented to us and which we are funding are across a much, much wider range of specialisms than the two or three that you mentioned. So, ear, nose and throat, general surgery, ophthalmology, and a range of others as well. So, I think it's a much more balanced plan than that. And the test has been where can we reduce the longest waits fastest, because we know that the longest waits are those that compel people, I suppose, from their point of view to make choices to go privately and so on. We don't want to see people having to make that choice. So that's the rationale for that decision.

There is, frankly, in a sense, a balance to be struck. Clearly, clinical urgency is the critical, critical judgment, isn't it? And you balance that against long waits. But you will and others will challenge me in the Chamber about the size of the waiting lists. So, there are judgments to be made about how you allocate that funding, but the thrust of it is on reducing the two-year waits.

So, funding for the recovery, it is conditional, isn't it, some of the money you're putting in to reduce the longest waits. I'm interested in what enforceable consequences there are for health boards that don't get rid of those long waits. So, you've put that extra money into them and they still have persistently high waiting lists across various specialities. And I'm wondering then how does the Government intervene if they don't act on those plans. You could have chucked £5 million or £10 million at a health board and it's still carrying on. I'd be interested to know what the Welsh Government would plan to do then to intervene directly to say, 'Well, we've given you the money, you're not doing anything about it, and this is the consequence of not doing that.'

There are two aspects to that. So, take, for example, the funding that you just asked me about, the £50 million fund. We were crystal clear at the start of that process—frankly, because the plans we were funding were health board-backed plans—so we said that, if health boards were not delivering to the plans that they were committing to do, we would stop the funding and reallocate it to other health boards that had the capacity to do more than they had in their plan. So, it's been absolutely clear from the start that that funding would not be simply available in a general sense; it's available for a specific plan at a health board level, and if that plan is not met we will reallocate it. We're not in that position, because health boards are following through on what they agreed to do, but that is an absolutely clear understanding in the system, and we would have other things that we could spend that money on in other ways on waiting lists, if that were to arise. So, the money can be used productively on waiting lists in either scenario. 

The second means of doing that—and I think in the longer term the more productive relationship, if I can put it like that—is the funding is there in this financial year to do two things; firstly, to reduce the backlog and then get demand and capacity into better balance generally. But also to create a little bit of extra space so that we can ask health boards to put in place new ways of working. We know that if you do—we were talking earlier—orthopaedics in a particular way, if you do the high volume, low complexity clinics, that is the better way of delivering, for example, orthopaedics, or much of it, into the future. So, we want to get there. If we can make that transition—. The faster we can make that transition, the more sustainable the provision of that service is going to be. 

So, there is capacity for some of that in this year's funding. Most of it'll be, frankly, on backlog. So, linked with that, you'll have seen in the allocation in the planning framework that we've been very specific about what we expect the system to do—we're talking about orthopaedics but there are lots of other things in there as well—to put in place those new ways of working: theatre optimisation; different shift patterns; the rate at which you do particular joints over the course of an operating day. We expect those to be delivered. They're already requirements of the system and they're delivered in a very variable way. If we can get the system to do that, then the profile starts to look different, in terms of waiting times, hopefully reasonably soon. So, there are two ways of doing it. 

What if the system doesn't start delivering on those—? Like you say, theatre optimisation, doing things differently, shift patterns. If health boards are, say, reluctant to do some of that, what power do you have then to say, 'Well, you're going to do this; I'm going to make you do it' because you are the Cabinet Secretary for health and you're asking them to do something. If they don't do it, I'd be interested to know what powers you have to make them do it. 

The way our system is structured is that, obviously, we set the strategy and funding and then the operational aspects are delivered locally, for reasons that we all absolutely understand, obviously. But there are circumstances in which Ministers have powers to direct, and I've said—. One would generally want to use those sparingly, for obvious reasons, but I've said that I think there's a challenge in the system in delivering regional solutions where the regional solution is the clear answer. I think that's challenging for lots of reasons—some of them are good, some of them aren't so good—and I've been very clear to say that where we feel there are regional solutions that are the way forward and they are not being delivered, if you like, organically, then I will use powers of direction to make them happen. 

So, I think you've got to choose the context carefully. This is generally not because people simply don't want to do it; these are complex things to deliver and a direction is a blunt instrument, isn't it? There are judgments around it, but there are backstop powers.

On waiting times generally, we know that the NHS does use private sector involvement, sometimes, to get waiting lists down. I'm just interested in the draft budget what the breakdown and proportion of the spend is going to be in the MEG to use private sector involvement to get waiting lists down.

I can tell you what they are for this year; we won't have broken that down for next year, because the plans for next year would be based on the performance in this year, so that isn't a piece of work that could have been done yet. But in this year, the run rate—and Nick will tell me if I'm misremembering these—for the NHS, generally, is about 6,500 procedures a week. Part of the funding this year is used to increase the capacity of the NHS itself by doing more activity in the evening and on weekends. We will all have heard of people having MRI scans in the evening, and all those positive things that we want to see. And then, in addition to that, to the activity in the public NHS, there are about 22,000 extra treatments that we are commissioning, and about 12,000 of those, I think, are from the independent private sector. So, that's the broad picture in terms of the contribution in this year's budget.

This is my final question, Chair, if that's okay. I'm just wondering, generally, across Government, how concerned the Welsh Government are about having the two-tiered health system here in Wales—those who are able to pay to go private, not using the NHS and bypassing NHS waiting lists in certain specialities. We've heard of a lot of people, for orthopaedic care and certain types of treatments, putting them all on credit cards, which they can't really afford to pay back, or people going abroad to clinics over in the EU, perhaps, where they're not as reputable as what we have here, although some of them are very good. But they're going away to get treatment done. I'm just interested, across the Welsh Government, how much of a concern that is for Government—people putting themselves, sometimes, in debt, trying to get their operations done, because they just physically can't wait any longer. 

Obviously, it's the last thing I want to see. Clearly, I do not want people to be feeling they have to make that choice. None of us would want that, obviously. In terms of the context for what you just said, which is why I was checking for the figures here, our understanding, our analysis, is that the proportion of people who are self-funding in the way that you are describing—so, in whatever way, paying for it themselves, either through insurance or through paying on a unit basis in the way that you were describing—is less than 1 per cent of the population. I don't actually want anybody to be in that position, but that's the kind of scale of the numbers that we're talking about. And crucially, the sorts of things that people, generally, are making that choice to do, within that 1 per cent, are the areas that we are targeting in terms of the longest waits in our most recent initiatives—so, ophthalmology, diagnostics, orthopaedics. So, we've constructed the focus of our investment very much on removing the sense of pressure that some people may feel to take the route that you said.

Thank you.

Mabon ap Gwynfor.

Does anybody have the—? Do you have the information, Alex?

Thank you. On the eyecare digitisation, alongside a mix of schemes around digital, there is advice pending to go to the Cabinet Secretary around DHCW's remit and their financial plans for the next year. So, it's a live discussion at the moment around the eyecare scheme, amidst others, but once the Cabinet Secretary has reached a decision on that, that will then be communicated to the system. 

Thank you. James, if it's a very short question.

It is. It's just about capital investment in hospitals. I've been contacted by leagues of friends and different things from a number of hospitals. They've got a lot of money to spend in hospitals, but they keep getting pushback from, say, the estate department saying, 'We don't physically have the staff available to man the new kit that you want to put into hospitals.' So, I'm just interested, from the Welsh Government's perspective, how can you help with that system? If you've got organisations that want to invest in our hospitals to make them better with new kit, and health boards are pushing back saying, 'We can't have that because we can't man them', how can the Welsh Government facilitate some of that investment to actually reach our hospitals?

It's going to have to be a short answer. 

I'm not sure I understood the question exactly. What are they saying is the issue?

I'll write to you about it. 

Please do. 

Thank you, both. John Griffiths. 

Diolch, Cadeirydd. This is on urgent and emergency care, Cabinet Secretary. How much has been invested in the national programme, and could you say something about the specific metrics and timelines to achieving the six goals?

Yes, certainly. I had a very productive discussion, actually, yesterday with the six goals team to have a clear sense of where we are with the programme, and I think that there is very good progress. The budget for next year is around £28 million. About £18 million or £19 million of that will go to health boards for them to invest in meeting the objectives that we set them, and then the roughly £10 million that is left is kept at a national level for us to commission various interventions and changes in the system. So, that's roughly how it breaks down. I would say as well that the funding specifically for the six goals is one element of this, but you could make the case easily that a large part of the regional integration fund, for example, contributes significantly to removing pressure on emergency departments in particular. So, there's a much broader envelope.

You asked me about how we monitor and how we evaluate what's happening on the ground. The six goals programme has, obviously, six goals, and it sets out requirements of the system. You will also have seen in the much-referenced planning framework, which I issued before Christmas, some very specific requirements there as well. So, the first requirement in the list is putting in place a community falls service, which we know makes a huge difference to the level of presentation at emergency departments. What I was told in the discussion that we had yesterday in relation to the performance of the six goals programme overall is that most health boards now have in place urgent primary care centres. They see about 10,000 people a month, and they are able to resolve the challenges that people present with without hospital admission in about 85 to 90 per cent of the cases, so that is a successful programme. We want to see more of that.

The same-day emergency care centres is another requirement of the six goals programme. They're in place in a number of hospitals across Wales. They see similar levels of people with similar levels of resolution without hospital admission, so we are confident that we are on the right track, and we can see that in the metrics. So, I touched earlier on the discharge from hospital in December: 57 per cent of those who been waiting longest have been discharged; 80 per cent of those who are the longest waiters who weren't discharged have in place a discharge plan. So, I think it's working well. Obviously, we want to see that continuing and building out.

Okay, thank you for that. Moving on to NHS workforce issues, we touched on pay earlier. Could you say a little bit about the UK Government pay settlement proposals for the forthcoming financial year, and how Welsh Government will juggle that balance between fair pay and financial sustainability?

Certainly. So, the UK Government, as you will know, has provided its remit to the pay review bodies and they are saying that they're expecting a pay bill increase, if I can put it in those terms, of 2.8 per cent. That's the figure that they have set. They have stipulated that as the affordability level from their point of view. We take a slightly different approach in Wales, so I have remitted both PRBs in Wales, and we don't provide an affordability figure for the decision that they take. We obviously have a conversation with the sector in light of their recommendation. So, we're awaiting the outcome of the PRB reports and their recommendations at the moment. Obviously, we look at those in light of the budget provision that we made earlier. Clearly, in Wales, we do all of the work in this space in social partnership and with that commitment to fair pay, and on that basis, we've made assumptions in our MEG. In a sense, the UK Government's recommendation is a matter for the UK Government. That's the approach that we will take in Wales.

Yes, okay. Thanks for that. Workforce training: could you clarify for the committee, Cabinet Secretary, whether the increase in funding for workforce training will both address the shortfall from the current financial year, but also lead to a genuine expansion of training places?

Yes, so I think the correlation between budget and the availability of places isn't a perfect correlation year on year, because there is quite a lot of scope for juggling the mix of provision that you commission within that envelope, and so I would not say there is a linear relationship, really. So, for example, last year, as you say, the funding was flat, but we in fact were able, in practice, to commission a higher number of nurse training places in 2024-25 than were actually filled the year before. So, we're committing to the same level of budget this year, but obviously the profile of what's commissioned within that may look different, and it may be higher or lower because it's basically demand led, essentially, or system-need led, if I can put it like that.

Yes, I see. Okay, if we move on to agency staff, this is something that's been an issue in the NHS for ever and a day, I guess, and getting those rates of use of agency staff down is a big help to the health board's budgets, isn't it? So, in terms of how you work with health boards on this, do you have strategies in place to reduce that reliance on agency staff, and do you track progress?

Yes, we do both. So, again, one of the mandatory requirements of this year's planning guidance is to implement the agency staffing frameworks that we have. So, we published last year an agency workforce reduction programme and a framework to control that, which health boards are required to implement. I think this is one of those areas that is a slightly unsung success, if I can put it in those terms, because we have a thing called the value and sustainability board, which is a Welsh Government-led national board, and they're tasked with devising interventions that meet two tests: one is effective patient outcomes, and the second is effective value for money. So, a lot of the things you'll see in the planning guidance are basically the products of that process. We know there's a good evidence base, and we are requiring the system to do them.

One of those very good examples is agency staff. So, if you look at the figures from 2022-23 on to this year, in very broad terms, you will see a halving of the agency bill. That isn't really given much airtime, but it's quite a significant success, I think. Clearly, there's much more to do, obviously there is, but there is a metric, there's a mechanism for doing it, we evaluate it and it's currently working.

I certainly know from a visit to one of my local hospitals to meet the health board the other week that they've made quite a lot of progress—

Have they? That's good.

—on that front, which is good to see. On managing risks and challenges, finally from me, we heard a little bit earlier about your intervention powers, Cabinet Secretary. Could you tell committee what is the current escalation status of health boards, and how has that status influenced Welsh Government spending plans for the next financial year? 

Certainly. So, as the committee will know, each health board is in some level of escalation. Betsi Cadwaladr is at level 5, which is the highest level, and that's across the organisation. Hywel Dda is at level 4 across the organisation. In Swansea bay, certain parts of the health board are in escalation. So, for performance outcomes and finance and planning, Swansea bay is at level 4, and for maternity and neonatal services, it's at level 3. In Aneurin Bevan, they're at level 4 for finance and planning, and level 3 for performance and outcomes, specifically in relation to urgent and emergency at the Grange, which colleagues will know is under a particular challenge at the moment. Powys is at level 4 for finance and planning, as we know; Cwm Taf at level 4 for performance and outcomes, and level 3 for CAMHS and finance and planning. And then Cardiff and Vale is at level 3 for finance and planning. So, that's the picture generally.

Each of those levels of intervention, as you know, will have a plan and a set of requirements, and, clearly, the higher up you are in escalation, the closer the scrutiny and intervention from the Government, which colleagues will know. I'll ask Hywel, maybe, to talk about Betsi specifically, because the way we funded them this year and next year has a very specific bearing on their level of escalation, because it's, obviously, at the very highest end.

Mabon, can I just ask, did you want to come in on a very specific point?

John.

Sorry, I thought you were going to come on, Cabinet Secretary, or your official, to that relationship between the degree of escalation and the funding implications.

Yes. If I come back to what we've done in year and the in-year funding that we've allocated, in doing so and in resetting control totals and the expectation, which also followed through in terms of next year's plan, we've set stronger prospective conditions for those organisations. The Cabinet Secretary referenced Betsi in particular, so the committee will be familiar with the £82 million funding support that Betsi receive. We've strengthened the conditions on the two component parts, so the £40 million, colleagues will be familiar with, is conditional on the organisation developing a balanced financial plan going forward, and the £42 million that supports transformation and performance is conditional on escalation status, in effect, and a strengthening of the alignment of the use of that resource and the requirements for the organisation to achieve de-escalation.

On a broader point, the escalation status of bodies hasn't directly influenced the allocation mechanisms we've set for next year because of the consistent and equitable approach that I've set out in line with our allocation formulas, and so on. What we are doing through the action plan work that the Cabinet Secretary has described is considering the actions in place and the effectiveness of those by organisations, and we will do that over the forthcoming months, coming through the planning process, and if further support or actions are required in terms of delivering the expectations set out.

Okay. Diolch yn fawr. Planning and preparedness, Cabinet Secretary. We know that winter pressures have been very considerable and are very considerable again this year, in terms of flu, COVID and indeed other viruses and similar problems. To what extent does the budget for next year build in provision for those, in a way, and possible unexpected events such as, perish the thought, further flu pandemics?

Well, the budget for that is delegated to health boards. So, the budget itself doesn't illustrate that, but the planning process that goes with it is designed to identify that and make sure that we've tested it with health boards. So, when the boards put together their draft integrated medium-term plans, their IMTPs, they are expected, as part of that, to match demand with capacity and take account, in light of that, of seasonal issues—pressures in winter in particular. And then there's a level of national support that goes into that. We've talked about the six goals programme already, but in terms of winter pressures, there's a national cycle of planning that goes with that as well. So, we knew from last year that there were pressures on ambulance services, so this year we put in more resources, they've put in more clinicians. So, that happens at a national level, but we expect health boards then to plan as well, and share those plans with us at a local level.

Okay. Diolch yn fawr. Finally from me, then, Cadeirydd, in terms of COVID-19—again, I'm sure this will be a matter of the way you work with health boards in terms of the funding that they generally receive. Are you confident that the health boards will meet conditions tied to some of the recurrent funding, including health protection, PPE and the long COVID programme, Adferiad? How confident can we be that those particular matters will be addressed by health boards through the funding available?

There are two lines of funding on this, some is a health board level fund and some is a national level fund. So, the national funding, we've increased the central emergency budget, for example, quite significantly, and we have provision in the budget to deal with the recommendations made by—you talked about COVID-19 specifically, and the budget for that. In terms of the funding that health boards are tasked with investing, there is a very, very comprehensive architecture of monitoring around these things, so I think it's a six-monthly report and a set of meetings and then that sits alongside the existing quality, performance and delivery architecture that we've got. So, there's a very, very clear line of sight on that.

Okay. Diolch yn fawr.

A very quick question, Mabon.

Are there any pressing final questions? Joyce Watson.

Yes, but I’d also like a note on workforce planning, as that links into budgets and to training, and to workforce management, returning to the workforce, to post-lifetime events, and a lot of good work was done in COVID to speed those processes up, or even to take note of them. And it’s critically important, if you’re talking about reductions, which are welcome, in agency staff, then you have to backfill them. They’re not just agency staff; they’re staff. So, I won’t delay on that.

What I do want to ask is about the mental health ring fence in the draft budget, and it’s over £820 million, but the 2025 health board allocations letter puts it at £830.6 million. There’s obviously a difference there. Can you clarify the ring fence value and outline the steps to address the unavoidable costs and growing demand, and any efficiency savings that might be reinvested in the pressures to improve those services?

Yes. So, on the reconciliation of the figure, the final figure for the allocation is £830 million. I think, when we submitted the evidence paper, that was still a moving figure. So, it’s just a question of timing. That is now a final figure of £830 million as the floor, basically. And the reason I say 'floor is because, actually, what we require is that that funding can be reinvested in the way that you’re talking about the savings and efficiencies. So, having that floor in place encourages that level of reinvestment, and then that helps with efficiencies, as I say, and the savings overall.

And the other important thing is the women’s health plan.

Yes. 

Three million pounds have been allocated for that plan for the next year. Is it going to be sufficient to meet the actions set out in it? And, as this is stated as a ministerial top priority—I do remember one of them—is that allocation adequate, because it represents a relatively small portion of overall health spending?

Yes, but it isn’t the only spending that’s spent on women’s health, as committee will obviously know. The health boards are tasked with meeting the needs of their local population. In most parts of Wales, the population is 51 per cent plus women, so that is, actually, where the health plan will be delivered in practice. What the £3 million is there to do is, essentially, to fund the establishment of the women’s health hubs in each health board area in Wales. That’s got a specific cost implication, which his above and beyond the operations of the health service in a customary sense, so that’s where that figure comes from.

Okay. Right. We are—

We are over.

—out of time. But, if I can be really cheeky, which I’m going to be, we looked at capital spending, and it was very focused on hard hospital structures. The majority of people, we all know, don’t actually go to hospital for their care, and we’ve invested—the Welsh Government’s invested—quite heavily in other facilities. And I would be particularly interested, and I’m sure my colleagues will be, in having a breakdown on some of those facilities, which we haven’t got time to draw out now, and I know some of them have been in my area and they are delivering significant change.

Can I just say I think that’s a really important point, because we do fall into the trap, if I can put it like that, of thinking that the services are always provided through hospitals? Absolutely they are not, and nor should they be, and we want to see more provided in the community. So, the integration and rebalancing capital fund is a good example of how services are being funded through capital projects in the community. So, I'm very happy to break that down and provide the information.

Thank you. Can I thank the Cabinet Secretary and the Minister for attending today, and officials? Diolch yn fawr iawn. I appreciate your time.

Diolch yn fawr.

I move to item 3. There are several papers to note: correspondence from the Petitions Committee regarding health-related matters; correspondence from the Welsh Government regarding the Welsh Ambulance Services University NHS Trust and the Health and Social Care (Wales) Bill; correspondence from Tenovus Cancer Care regarding the proposed increase in employer NI contributions; and requests from Senedd Members for committee inquiries, which I know we'll discuss at a later date when we're discussing our forward work programme. Are Members content to note those papers? Fine.

We move to item 4. I propose, in accordance with Standing Order 17.42, that the committee resolves to exclude the public from the remainder of today's meeting, if Members are content. Thank you. Diolch yn fawr iawn. In that case, our public sessions comes to an end, and we'll now move forward in private.