National Assembly for Wales

Good morning, and welcome to the Health and Social Care Committee this morning. It's really good to see you all this morning. We have Members in the committee room, Joyce Watson and myself, and colleagues who are coming in online, Mabon, Lesley Griffiths, John Griffiths and Altaf Hussain, who is standing in for James Evans today. Thank you, Altaf. Just to note that the meeting is bilingual and there is simultaneous translation from Welsh to English. Can I ask Members if there are any declarations of interest, before we start? No. I don't see any. If you find something as we go through the meeting, please declare it. It was remiss of me: I'm Peter Fox as well, I'm the Chair of the committee. So, welcome.

We are pursuing our inquiry into general practice in Wales. We've had several sessions, and I'm really pleased to have before us today people from the Chartered Society of Physiotherapy and the Royal College of Occupational Therapists. Welcome. Can I ask you to introduce yourselves, please? Nia. 

Thank you. My name is Nia Boughton. I'm a consultant nurse for primary care. I have over 25 years' experience working in the primary care field and I'm here representing the Royal College of Nursing.

I'm Calum Higgins. I'm the policy and public affairs manager for Wales for the Chartered Society of Physiotherapy.

And I'm Kim Willis. I'm a clinical lead occupational therapist who works in west Wales in primary care.

Great. Thank you so much for making time. It is a really important inquiry that we're finding extremely interesting. So, thanks for making the time for us. We have several questions that we'll try to work through. We've got about an hour and a quarter. We'll try to work through them and, if we don't cover them all, perhaps we can follow up with you, if you're okay with that.

Perhaps I'll kick off, if I may. I want to look at the roles of nurses and allied professionals within this whole remit. I just wondered what you think might be the key enablers and barriers to fully utilising the skills and expertise of nurses and other allied professionals in general practice and primary care more broadly, particularly in managing long-term conditions and supporting preventative care.

Don't feel that you all have to speak on everything, but if you want to, please just indicate and we'll bring you in. Who'd like to start on that?

Do you want me to start? Please jump in. The enablers and barriers to the utilisation of nurses and allied health professionals in terms of long-term conditions and the preventative agenda is probably one of my favourite subjects to speak about, so by all means, rein me in. Nurses in particular, I think, are naturally very holistic. Our degrees are in health, so we have a particular interest in well-being and prevention and the optimisation of health outside of the traditional medicalised pathways. So, we are better at linking all the determinants that ultimately give healthier outcomes and a way of activating health improvement behaviours within individuals, which often is lacking in a traditional medicalised system that we work within at the moment. And I think one of the barriers that we've got, in particular with the way that primary care is constructed, and has historically been constructed, is that it is an illness system—that we wait for the onset of symptoms before we try to intervene, and often those symptoms are fairly well progressed, and then we manage symptoms rather than the root cause of illness.

The general medical services contract that configures and covers about 97 per cent of primary care operation in Wales is based upon a funding system that promotes that model of work, so it's very difficult for us to make the change for workforce diversification. And I would argue, with the case of need, the population need currently, and the projections around long-term conditions in particular—. So, we know now that we're expected to see the amount of patients with four or more long-term conditions double over the next decade, so the way in which we manage and support those patients needs to be very different to what we've got now, but the traditional GMS contract doesn't allow the employment of additional nurses and allied health professionals to provide that. So, for example, last year, Health Education and Improvement Wales only trained about 2 per cent of new practice nurses to work within Wales, against the backdrop of just over 1,000 practice nurses who work in Wales. So, 2 per cent additional training is in no way sufficient for us to continue the much, much-needed work in this arena.

Thank you for that, because I was quite surprised, reading some of the briefing notes, that there was only 1,000.

Yes, I know.

I was really, really surprised on that, and if you're going to address a preventative agenda—.

Yes, it's not really sufficient. Within the briefing notes, the 1,000 that's referred to are nurses that work within the context of primary care within a GP surgery, if you like, whereas, actually, for us in the Royal College of Nursing, we would consider primary care nursing much broader than that, into community nursing, into prisons, school nursing et cetera. So, it is a broader church than perhaps that 1,000 refers to, but, still, we need many, many more.

Yes. Thank you. Anybody else? Calum.

Yes, just to agree with what Nia's said, and to add on a couple of points, really. So, for AHP it's a newer arena. So, traditionally, it's been in secondary care where physios would be providing most of their services. That move into primary care is exactly what Nia said about preventative and keeping people healthy, rather than treating illness as an afterthought—a sickness service rather than a health service is a phrase that comes up quite often. 

That focus is something that's changed more recently. And the barrier there is that lack of clarity, I think, as to the purpose of AHPs and physiotherapists in primary care. If we can get that culture change, and that clarity that it's to keep people healthy, prevent them from being ill, in primary care and general practice, I think we'd have a far more successful model. 

So, yes, we've got newer roles. I mentioned in the written evidence about first-contact practitioners, which physiotherapists have led on. That means that they could be the first point of contact for a patient, and they can refer to other services if needed; they're advanced practitioners. I know my colleagues here have worked with physiotherapists who are trained to that level. And that's something that we've learnt in pockets in Wales, but it's not standardised across the board to maximise effectiveness. So, that's another barrier—learning something and repeating it across Wales. 

Yes, thanks, Calum. Kim. 

Well, I’m not a policy maker, I've come to talk to you about what it is like on the ground, really. So, that’s my bread and butter—working in that primary care sector. So, very fortunately in Pembrokeshire, we actually pioneered some of this stuff in Wales, when it came to having OTs directly working within GP practices. And what started off as a cluster-funded project grew and expanded. I think, looking at a barrier around that is—. There was a shift from when we were cluster-funded, and therefore, working purely for the practices and becoming really embedded—GPs knew who we were, we were in their surgeries, knowing the populations, being very specific on what we did—to being back under health board remit and control, I suppose.

So, one of the barriers around that is that uncertainty sometimes of where that resource is. So, we know as occupational therapists—we're very holistic; I'd say we're one of the most holistic. We're trained in physical health, mental health, across health and social care. We look at barriers to function in everyday life, bearing in mind what someone's condition is, regardless of what their condition or conditions are, because, obviously, we're seeing more and more comorbidities—looking at someone enabling to stay in their own home and doing the things that they need and want to be able to do. I think one of the challenges we have as OTs, more generally, is the lack of understanding from other healthcare professionals what it is we actually do. We're really poor at defining ourselves, and I think part of that is, because of that broad spectrum I just mentioned of where we can work, it's very hard to say, 'This is what we do for everybody.' I can tell you what I do for Mrs Jones or what I do for whoever, but it's a challenging thing to define. But certainly within primary care what we've found, as it's expanded, is that we are part of that workplace and we are picking up people, patients, within our service in primary care that would never meet the criteria for any other service in our region. 

So, this I think is a really important point, because going back to that preventative work we're talking about, we see the walking well, we see working-age people who want to get back into work. There's an emerging role in doing fit notes and things; I know that physios are also part of that conversation. So, we are seeing people who are working or who are able to get about, able to go to the shops, able to live a life, but they're just on that cusp of tipping into something happening, and it doesn't take very many things to go wrong before someone's well-being and their independence and the way that they live their life alters through their own well-being and their own health, as well as factors around them—environmental factors as well.

Thank you for that. That was really helpful. Actually talking of barriers, and I suppose some of the things you've described there, Kim, are they some of the barriers that stop the collaboration between the various professional—? And if they are, are there any sorts of strategies being thought out about how you can sort of break down some of those barriers, so that that collective can come together and some of the parts also?

Well, I think the fact that we're all managed separately is an issue. We're not under one umbrella, so I'm through an OT management structure, but not managed at all by the GP practices, although I'm there and I'm embedded within that work and get to know those populations, and have built a lot of relationships and networking to become part of that. We work closely with our physiotherapy colleagues, but we do a very different role. So, as OTs we don't have clinic rooms, for example; estates is a big issue, there isn't space for us to really work from the surgeries. And actually, one of the remits when we set up the project was to get patients away from the surgeries, so most of our work is actually in the patients' homes. So, we don't see our other colleagues directly all the time, so although there's that collective MDT working and we meet within that MDT, and I always go into the surgeries to do that collaboration, it's still a little bit siloed from different MDT members, but also even within our own profession. Where I work, we've got OTs that—. There are just so many ways that you have access to an occupational therapist, it's a minefield, and GPs don't know, and they say, 'Kim, I've got this person, what do you think?' And then part of my role is to navigate some of that system, because that system is all about transferring care all the time, which we know is costly and timely.

Ok, thank you.

I think what you're asking about here is how we integrate care and not have kind of silos and the risk of duplication, and I think that's exactly what we've got at the moment. Part of the issue is for us to fully integrate care. You almost need the GP practices to be embracing workforce diversification. There are pockets of good practice around this, but generally, they're not able to do that at the moment because the funding stream doesn't allow them. So, where you've got this tested and you've got some front-runners, you'll see practices substituting a traditional medical role for either an advanced nursing role like mine or physiotherapist or OT, but then becomes the enormous pressure to work in a medicalised way because of the demand on the system.

So, they're trying to compete with this overwhelming amount of urgent care presenting every day, recognising that they need to work in a more preventative way, but being powerless, if you like, to employ the workforce model that they require to enable them to offer that difference in service provision. It's really frustrating, but true integration would come from this being an employed cluster or employed practice-led model, and additional funds will need to be made available to stop that from purely being a medical substitution, if we really want to get into a population preventative health-focused service offer.

And most practices realise all this, they would love to do all this, but the money is stopping them.

Absolutely, yes.

What we've found with funding is that transformation funding has been made available, there have been great pilot projects that have gone forward, and then once that funding comes to an end—I think someone's already mentioned this—there's then an argument between health boards and GP clusters as to who carries on that work, because it's been temporary funding. Everyone has benefited, the patient in particular, patients love it, and the visibility of AHPs in primary care is being seen to work. We're trying to share that practice across Wales, but the sustainable funding isn't being picked up by the health board in particular, where the majority of the funding lies.

That's really helpful, thank you. So, what do you think the Welsh Government and health boards could do to better support the integration of yourselves and your members into the multidisciplinary teams, and not just tokenistically, but actually to make sure you're included as part of that overall structure and treated with parity and things?

I think if you speak to any clinician who works in primary care, they will tell you our absolute frustration at the fixation around secondary care services. Two thirds of care is delivered out within primary and community services, but yet health boards are directed to focus on the performance of secondary care, and the bulk of the funds goes into secondary care. There needs to be an absolute refocus on this urgently. If we are to significantly impact on the health inequalities in Wales, if we are really committed to working towards a prevention and population health-focused service, then we've got to stop directing all the attention and all the moneys into secondary care. That would allow us to build the sort of diversified workforce model that you see before you today. Any practice that has an advanced nurse or any form of nursing, a physio and an OT within it will have much more beneficial outcomes for the patients, but yet this is not a common workforce model across Wales.

Are there leadership issues that are stopping some of this from happening?

I think there's some of that, absolutely, because leadership often originates out of a secondary care setting, and therefore that's where their focus is. They don't necessarily understand the mechanics and workings of the primary care set-up, and also, lots of what we're talking about is longitudinal in nature, so it's tricky from a performance and short-term investment process to demonstrate what hasn't happened. So, by the intervention of Kim or Calum or myself, actually how do you show that that person hasn't gone on to develop a long-term condition or hasn't fallen out of the work system? It's really tricky, and that needs measuring over decades, often. The issue with the way that health boards are structured now, and the funding streams in particular, means that there is a fixation on very short-term metrics and performance management, and that dial needs to be shifted.

Yes.

Can I—? Kim, do you want to—?

Sorry. I agree with everything Nia has said, and I think it is really clear out in the workforce that there has always tended to be and still remains that secondary care focus. Going back to what I was saying around cluster funding versus health board funding, that's one of those, again, question marks and barriers, because at any point you're dragged out of that really good proactive stuff that you're doing that's difficult to measure in that short-term way to plug a gap or to firefight. Eventually everyone becomes firefighters, working in accident and emergency, preventing admission to hospital, and that all seems to have always been the metric of success. Have you stopped somebody going into hospital? Well, sometimes, people have to go into hospital for an x-ray, they have to go in for a blood test, they have to go in for a consult, but I think it's quite shortsighted to think that the best way is to go down that end. We work very much—. I'd say we are very upstream in what we do. We're very fortunate, at the moment, to be able to be allowed to do that work. We keep quite a lot of data, and our data does show that, in terms of the before and after when someone goes into a GP, into the practice, before they get seen by an OT, versus after, our data almost unanimously says that that reduces. So, we're saving GP time, and that was always one of the very initial drivers for what we're doing, was, 'Well, can you save GP time?' But as time has gone on and as the project has expanded, we're now being recognised as adding value in our own right, as an AHP, adding something different. So, we're not doing medical model stuff; we're doing function, we're doing the other bits that the GPs don't know what to do with. So, I think it's important to note that. I agree that that focus needs to come straight back into primary care.

I was just going to mention from a policy perspective, there are strategies already in place. There's a workforce plan for primary care, there's a draft service specification for musculoskeletal in primary care in the works right now. As you said about leadership, centrally, Welsh Government has a role, I think, to make sure that health boards deliver on those plans. It's great to have them in place, but if we want to see actual improvement, it needs to be measured somewhere to see the investment in primary care and for central Government to have that role of pushing it across Wales consistently.

Okay. Thanks for that. I'll go to my last question. How would you see—? What are the current barriers to expanding the use of independent prescribers such as nurses or physiotherapists in general practice? And what steps ought to be taken if we're going to maximise the potential of that?

I am an independent prescriber. It's a really interesting question, because there absolutely is a need for independent prescribing, and I'll come back to the training requirements, which I think is one of the barriers, in a moment. But this comes back, again, to us recognising the values of our professions in their own right, and not necessarily funnelling us down a very medicalised way of working. Sometimes the opportunity to prescribe is a double-edged sword, because part of the problem with the system at the moment is that it's easier to prescribe, it's easier to medicalise and to give a tablet for that than it really is to work to the root cause of ill health. So, I just want the idea of independent prescribing to be tempered by that understanding, really.

In terms of it as a postgraduate qualification for each of our professional groups, it's a Master's level qualification. It takes about six months, it involves 90 hours of supervised practice, and for each of us in particular, we have different pots of money that remunerate GP practices and other colleagues to provide that supervision. Now, part of my concern is that, as nurses, if we are reliant on doctors to train in that domain, then you are deflecting doctors away from front-line practice, but also you're training nurses in a very medicalised way. So, I think that needs to be recognised.

Also the funds that we have available to us as nurses to incentivise doctors—and rightly incentivise, because they often have to employ additional locum staff to free up the capacity to train in this environment—is significantly lower than for other professional groups. So, pharmacists, for example, have up to £3,000 that they can pay an individual GP practice to train them in independent prescribing, but we have the equivalent of £300. Therefore, if you're a GP practice and you think you'd like to train in this area, you're going to train a pharmacist over and above a nurse, despite the fact that the nurse may return more in terms of the input within that community or cluster.

That's a really interesting point. Anything further?

Just to say, our members would say it's the peer support out there. With any advanced practice skill, having peers that you know about and can network with, and other AHPs to talk to, is invaluable for making sure that you're confident with your skills and you've just got someone to talk to. Often, in the current system, we've got individuals out there who don't feel that supported or visible within the practices they're working in. So, that's the key barrier, really, for them.

Yes. Thanks for capturing that. Okay. Thanks for that session. Can I move on to Lesley, please? 

Thanks very much, Peter. I was going to ask you around workforce planning, et cetera, but I was fascinated to hear you say, Nia, you think it should be an illness system, because I'd always thought it should be the national ill health service. You three absolutely represent part of the health service that can be so proactive in keeping people healthy. So, it's quite depressing, particularly from you, Kim, to hear that people don't know what occupational therapists do within the NHS and how siloed it is. So, I think that is something that we really need to take up with the Welsh Government.

As I say, I want to look at workforce planning and obviously training and education and recruitment. So, I wonder if you can give us your views on what more needs to be done to make sure there's far more alignment between the health boards, the education providers, and obviously policy makers as well.

So, I should mention, I'm also vice-chair of the AHPF, so that's the Allied Health Professions Federation in Wales. That's the collection of all the AHPs together, their policy officers working together. We've put a manifesto together, and we call for a workforce strategy in the next Welsh Government to be formed for AHPs, because there isn't a national AHP workforce strategy. It's to give us that long-term thinking across all settings, including primary care, for us to plan our training, the needs of the population, and how many AHPs we need to have this holistic health service that Lesley just mentioned, that keeps people healthy rather than treating illnesses as the after product of people becoming unhealthy. So, yes, that long-term strategic thinking is what we're calling for as a collective.

Yes, very similar in many ways, actually. I should declare too that I am chair of the all-Wales primary care lead nurse network. We've also not long produced a paper calling for investment for up to four times the number of primary care nurses that are currently employed. And we are having conversations with Health Education and Improvement Wales colleagues around a pipeline for primary care nurses that takes from postgraduate into enhanced and then onwards to advanced and consultant level, that picks up the public health and population health focus that we're describing here today.

The issue that we've got is that to train people really well, you need to have capacity in the system. And the reality is that, as we've said already, 1,000 nurses is in no way enough capacity to deliver direct care, never mind to carve time out to train people well. And in the area in which I work currently, they have paused training any advanced primary care nurses because they don't feel there are the jobs for them to go into, and is it reasonable to invest in training when people then can't secure employment? And that comes back to my first point that there has to be a financial incentive for primary care teams to diversify their workforce. Otherwise, we can invest in education all we want, but there won't be the posts for these people to be employed within.

Yes, thank you. 

So, from an occupational therapy perspective, we don't train specifically in primary care. There aren't specific areas that you do and then you go, 'I can work in primary care now.' It's the approach that you're taking and the area of work that you're in, but the work can be very similar, it's just further upstream in the patient's ill health or journey really.

From our perspective, there is certainly a lack of progression clinically for people. So, thinking about having that incentive, we don't really have advanced practitioners. There are very few. There are a couple in specialist services; there aren't any in primary care. We also don't have that element for first contact practitioner within occupational therapy that they have within physio, and we don't have those advanced roles like you would have with physio and nursing. If you're going to progress your career within occupational therapy, you have to slide into management, once you get past being a senior clinician, and that's the only route. So, you do hit a wall and a ceiling, I should say, quite quickly.

And in terms of workforce planning, I think, again, the challenge comes with where health boards decide to put that resource, because it isn't specific to primary care, they could put you anywhere. And also because of the pressures for cost savings—. So, for example, we've lost a member of staff recently, and they're not being replaced, so that's fewer people in primary care. And that's the reality when services are mixed in one big pot as opposed to, I suppose, protected, like they might have been under cluster funding, and within that GP arena, you've got that risk that they sit under the same cost pressures as the whole department and the whole region, really. And that's the reality of it.

Absolutely. Apologies, I don't know if it's the same for physiotherapy or OT, but just to flag a particular issue within nursing is that an undergraduate nurse training pathway currently is undertaken almost entirely within a secondary care setting. You might, if you're fortunate, get a very short three-week placement out in primary care, but otherwise you would not know at all what primary care nursing is about.

We've said this before, but really we'd love to invert that model so that people train predominantly out in primary and community, and then did in-reach into secondary, but to do that, we need to have investment in the training environment out in primary care to support it.

Can I just add as well that we have lots of students coming to us? We've got one with us at the moment, so there's a rolling programme of having students come through, even within primary care. There's an expectation that all the teams across our county will have students and have that rolling programme. And more recently we've had students coming through from Swansea, since they've got that programme up and running. So, we are seeing the students coming through and we do have them with us in primary care as well. So, there is that education model, but, again, it is alongside your everyday work, as it is with most of us, really. That student is sort of an add-on, and you're training them as they go on the placements.

Lesley.

Thanks, yes. If I wanted to know how many nurses or AHPs are working in primary care across Wales, would I be able to find that data really easily?

Yes. I think the RCN did a survey last year that shows we've got 1,027 nurses working in GP practices in Wales. About 97 per cent of those are employed through a general medical services scheme, so are not necessarily on 'Agenda for Change' contracts, but the Royal College of Nursing does have that information.

Okay, and is it the same for physio and occupational health?

Yes, we can get the occupational therapists. I don't have the figure with me. [Interruption.] No, it's okay. I don't have the figure on me, but I can absolutely get you that figure, but it isn't very many.

Yes, similar to physio.

Yes, okay. Does that feed into hospital training? I suppose it's going back to what Nia was saying that if there isn't the capacity in the system, it doesn't matter if you train 5,000 nurses to work in primary care, because if there isn't the funding to employ them, then it's not there. But do you think that data is fed into your training?

Do you mean, Lesley, in terms of, 'Actually, we've got 1,000 now, we'd like 4,000; how are we planning on accommodating the numbers to do that?', in terms of the conversations, or do you mean more so within the health service workforce planning and the integrated medium-term plan process?

Yes, the latter. The workforce planning.

The IMTP process. Yes. I think, when I'm involved in this, again, it predominantly has much more of a secondary care focus, and some of the legislation around the safe staffing Act and levels within secondary care almost demands more of an attention and focus around that in secondary care, to the detriment of primary and community services sometimes.

We have a particular issue within nursing too, aside from not necessarily having the numbers, but 60 per cent of our workforce are aged over 48. Only 5 per cent of our workforce is under 30, and if we're only training 2 per cent, we are also walking straight into an absolute crisis in this field over and above what we're describing here today. So, that sort of demographic data along with the actual numbers is fed into the health board IMTPs, but often because of the issue between the health boards as commissioners of primary care, rather than the contract holders of GMS—I know we've got some managed primary care providers—their ability to influence the number of posts that are created is still very limited.

Yes, I'd agree with that. And just to say, I think the IMTP process feels more budget driven than need-of-the-population driven.

Yes.

Yes.

And that's what we need to look at long term is where we are going to be in 10 years' time; what will people need in terms of the health system to deliver for them. The IMTP process is based on how much money you have to deliver how many posts, and that's not the same thing. It's really important, I think, that we recognise that.

Of course, the percentage of money being spent in GPs has dropped as a percentage of the total, hasn't it, over the last period, which is actually exacerbating the situation. Sorry, Lesley.

No, no. So, do you think there are enough training places to fill what you think is needed in primary care? Just take aside the funding at the moment: if funding wasn't an issue, do you think we are training enough people? I guess, with what you were just saying, Nia, about the age profile, I think I know your answer.

No. No, we're not. And we're not clear in terms of the overall workforce strategy. We're still very much pathway dependent—that a GP practice will have a workforce model that's medically dominant, and then will have a nurse, a physio and an OT, if you're lucky. Whereas, actually, what I think we're trying to get across here today is actually what modern patient need is, and what the forecast tells us the need will look like, is really to invert that model. It should be predominantly nursing and AHP led with some medical elements to it, and to deliver that would just need an absolute whole-scale investment in training.

Just on that point, and I absolutely agree with you, do you not think there would need to be a huge education with patients as well? 

Yes. That's a slightly different point, but, again, I think that's exactly the space that myself and my colleagues here today work in. That health activation, rather than the learned helplessness that comes out of a very biomedical model that we've got now is not helpful around health optimisation. So, we would all absolutely say that a key part of our roles is working with patients to understand their strengths and to activate those positive health behaviours within them that give the long-term health outcomes and quality of life that they deserve—far, far more beneficial than just being able to prescribe a tablet.

So, at the moment, would you say the training and the workforce planning that's done is far more focused on secondary needs rather than primary care needs?

Yes, absolutely. Yes.

Okay. Just a last question from me, Peter, because I'm conscious of time: what role do pay conditions and professional development opportunity play in retaining nurses and allied health professionals in general practice? And again, do these factors compare with other NHS settings?

I think that's a really good question. Any nurses or AHP, regardless of where they work, do these types of roles because they are hugely rewarding, and we're very privileged in the positions that we hold in our communities. But, ultimately, we are expert professionals in our own right, and we have to draw down a remuneration that makes it reasonable to work and be retained within these roles. And we have a significant issue with that at the moment. Like I've alluded to, 97 per cent of primary care nurses are employed within GMS. Over 80 per cent of those have reported to the Royal College of Nursing that their employer has not talked to them about a pay uplift, and over 80 per cent again feel that they are worse off financially than they were five years ago. And that is, of course, going to have a massively detrimental effect on our ability to both recruit new primary care nurses and to retain the experience that we absolutely must do.

Thank you, Lesley. Joyce, Lesley has moved into some of your areas, but did you want to pick up?

I want to look at the distribution. We've talked about the numbers, but we need to talk about the distribution as well of those training places and workforce demands, particularly underserved areas. So, if you—. That is my question: how is that working? 

Well, certainly from my point of view, I think we're very lucky that we had this project and it was pioneering, and now we've got a clinical lead OT that covers each of the practices. But, because of geographically where we are, we are spread over massive patches. In my patch, it can take an hour and a half to get from one side to the other in the car in the day. So, in terms of that distribution within the county, we're very fortunate that we've got it all covered there. But, interestingly, some of the most deprived areas that I work in have the least number of referrals to me, which speaks for itself in some ways. And I would say part of that is to do with the way that people reach out for support themselves, but also part of it's going to be about the surgeries themselves. Each surgery is like a mini business in its own right and they all work differently, and we've learnt, you know, ‘In this patch I work like this, and in this one I work like this’, because that's how the GPs want to do it, and some are tougher nuts to crack than others, but we know that the demand is there. I'd like to see us, certainly—and we are doing a bit of work in this risk stratification stuff to get the patient referrals in from those areas—identifying them ourselves, because I would argue all of us could benefit from a physiotherapy consult to decide how we're sitting, how we're moving and how to prevent problems later on down the line, and I would argue the same for occupational therapy. So, the work is there, but, in terms of distribution, it depends on the uptake, and us as OTs rely on the referrals as opposed to generating our own, because we're not first-contact practitioners. 

I'm really pleased that you've asked this question, because for us as nurses this is our space. We know there is a massive unmet need agenda, and part of that is down to the traditional structure of primary care, and accessing a primary care appointment is incredibly difficult. Some of it is around health literacy, and it's understanding that, actually, I've got concerning symptoms or I'm worried about my health. Some of it is being able to relate to your healthcare professional, and I think nurses in particular relate to patients in their communities in a very different way to what they might do with a medic or a different profession, and that gives us an opportunity to lever outcomes in a different way. But if we're, again, really committed to addressing health inequalities and where our life expectancy variances are really very stark in some parts of our most deprived wards, then we've got to think about a different way of delivering services that isn't based on an 8 a.m. till 6.30 p.m., and you must ring this number or you must come at 8 o'clock. We need to be working with these patients in a different way.

Primary care is the rarest of professions, which allows you to work with people from cradle to grave. You work in a very multigenerational way. You are supporting families, not just individuals, but families, and communities as a whole, and that needs time, investment, and time to care is a particular issue. The whole of primary care is predicated on a 10 or 15-minute appointment, a sort of speed-dating philosophy, if you like, which worked fine when it was an illness system, as it was designed 50 years ago, but that's not the type of presentation that we're dealing with now. We need longer appointments to spend with those that need us the most, that need us to advocate for them in a very different way to other parts of our community.

What about—? I live in your area, so you don't have to tell me about driving one end to the other and the time, but the point here really is about distribution. For those people who need it, are those professionals readily available equally? That's what we're trying to get to. 

From, I think, a policy perspective it's clear that we're not meeting everyone's needs. We've run a campaign collectively called the Right to Rehab campaign, and the key message there is that rehab services, or prehab, if someone's preparing to have an operation—physiotherapists, OTs in particular will be involved in those services—equity of distribution of those services and access to those services is key. Having them available is very different to actually delivering to people who need them. You have to make an active choice in the service design. And there are great examples where services have gone out and looked for those communities that are underserved across Wales, but we're not probably learning across Wales and consistently delivering that from the learning in pockets that we have had a great service deliver something to a community that really needed it. So, I'd say there are great examples out there, but it's really inconsistent. 

Okay, and it's the same question again: the availability of quality training placements, and all your professions—you've part answered that, but is it equal, I suppose, is the question I'm trying to find the answers to.

The reason we ask this is we've got a lot of evidence saying that where you train, you stay. So, if you can't train, you're not going to be there.

I think one way of improving that would be apprenticeships as a model of training. So, the traditional university route, there are geographic restrictions to that, really—you have to go somewhere to train in university, whereas an apprenticeship model, where people stay in the community, train in that community, work at the same time, they're probably more likely to stay. Particularly in rural areas, I think that's an idea to make sure there's more training capacity and opportunities for people.

Yes, I'd agree completely; we have got an apprentice route within nursing, which is successful. And, of course, it's not just about the initial training; it's the pathway then, the postgraduate pathway, which retains that experience and expertise within the communities too. So, there is the piece around the undergraduate learning needs, but also postgraduate needs that need to be considered too.

Okay. And we know that there's an evolving general practice; we know that general practice isn't what it used to be. So, are the pathways meeting that, and particularly the advanced practice roles—and you say that you are one of those—and also the multidisciplinary team working, because those are the keys, aren't they?

That's the future, absolutely. A multiprofessional approach, a team around a patient and the family is absolutely the way forward, for sure. Advanced practice roles—again, touching on what we've said already—those career progression pathways that allow people to incrementally increase their skills, to be able to deliver much more of what's traditionally been delivered in a secondary care setting, and supporting that shift-left agenda, which I haven't touched much on this morning, but it absolutely could do, it's so important that we build that in too.

But just again, a plea: for us within nursing, our advanced practice pathways are really supported by medical substitution—so, in primary care, that's come from a place of, 'We haven't been able to employ a GP, so we'll employ an advanced practitioner, but we'll still want them to work in a very medicalised way.' That workforce diversification has to come from a place of wanting to progress a population health focused primary care system.

Can I just add briefly as well?

Yes, please, Kim.

In west Wales, we do struggle with recruitment, as a rule, getting people to come as far west, and we don't always find the same model of where you train, you stay. Unfortunately, that isn't always the case, although it is improving, with having Swansea—the training programme based there. But we do struggle across the board with any profession, and I think one of the challenges, certainly within occupational therapy, that I see, is that a new initiative will come up, a new bit of money, a new post will come up, and everyone just goes for that, so you're always robbing Peter to pay Paul. The staff just move about—within the health board, because that's where the work is, but you're always leaving a gap somewhere. So, we do struggle that far west with recruitment, but we do offer lots of training.

Okay. Thanks, Joyce. John, I'm not sure if there's a question there you'd like to come in on?

Diolch yn fawr, Cadeirydd. I think much of what I was going to ask has been covered, Chair. Perhaps I could just ask if there's anything else our witnesses might want to say in terms of how general practice can be made a more attractive and sustainable career option for early career professionals and allied health professionals in general practice, particularly with regard to those rural, underserved areas that we've already heard about.

I would say, actually, that, if the posts were there, they would likely be filled. I think they are attractive posts. As I say, we're very fortunate to have as many posts as we do within west Wales. It's just whether that's where they allocate the funding at that time. So, if money became available, would it be in primary care or would it go to stopping someone going into hospital, would it be somebody in A&E, would it be somebody firefighting somewhere? So, I think, again, the challenge is—. If the posts were there, I think they would be attractive posts in primary care for occupational therapy, without a shadow of a doubt, because we're able to do bits of OT that we train for that we just do not get the opportunity for, when, in secondary care, it's all about getting somebody out, and in community it's all about preventing them from going in, but in a different stream, in a different way. We can use the things that we train to do, which is very attractive as therapists, but, again, it will leave a gap somewhere else always because it's just getting the numbers and making west Wales attractive. The health board do put quite a bit of emphasis on trying to sell that part of the world, but it remains a challenge.

I think there are two things for us, within nursing. The postgraduate pathway, I've mentioned that a couple of times, but I think that's fundamental. Every nurse will describe a professional curiosity to you. They will want to progress. So, having the opportunity to do that consistently. At the moment, sometimes, it's right place, right time—it's a bit of a lottery whether you're allowed access into enhanced-level working and on to advanced. I'm currently the only consultant nurse for primary care in Wales, which is a travesty. So, there's something for me about formulating the pathway to make that attractive. But more than anything, these roles are rooted in the communities where nurses and AHPs often live themselves. That's brilliant because there's a vested interest in wanting to improve health outcomes. But if individuals can't feel that they've got the time to do their job properly, then they will, (a), not apply in the first place, or, (b), definitely not stay. So, there's something around the time to care that is so fundamental not just to the better health outcomes, but in terms of the professionals being able to draw down a sense of a job well done.

Yes. That career progression, as you said, Nia, I think is important. So, the early start to a career post in primary care, that person will want to think, 'I can progress in primary care in the future and there's a clear pathway', which probably doesn't exist at the minute. It's not very clear if you're a physio, as an example—how do you train to become an advanced practitioner in primary care? Where's the funding for that?

And then also connected is the funding for the posts themselves. When I said they're at risk earlier because it's temporary money, the easiest thing to do is to go back into secondary care and think, 'That's where it's safe, because I know my job will be secure.' If we can get over those barriers, people will stay in primary care for much longer as a career because they know they can progress.

Clearly, that workforce strategy you were talking about earlier, it's got to address all those things, hasn't it? It's not just identifying what jobs we need where, but it's how do you retain as well and make it attractive.

Absolutely, yes.

Anything further, John?

No. That's fine. Thank you, Chair.

Thanks for that. Perhaps we can move on to Mabon. It might be in Welsh.

I can tell you how we do it. With us, we have access to the records. The GPs have allowed us to have access to the patient notes, so we're able to input directly onto there, which saves a lot of time, and it means that it's real time. So, when we see somebody, we're able to pop on there that we've been to see them, give a brief summary, and then we attach our full documentation towards the end of our intervention. But we spend a lot of time inputting into systems. We keep stringent data. We also have access to the health board's digital network as well, so we can do a lot of our looking up of patient records from a secondary care perspective. But having that alignment across the two is very helpful, and we've found that to make the biggest difference, really, when it comes to information sharing, it's having access. Without that, it would be much more clunky.

I've got the benefit of a foot in both camps, I guess. I actively practice in primary care, so I utilise the EMIS system, and our newly launched EMIS community system that enables us to input directly into the primary medical record when we’re out undertaking homes visits or working with vulnerable parts of the community. The system is clunky, but it is a thousand times better than what they’ve got in secondary care, which is still predominantly paper based. So, it’s good, but it’s not as good as it could be, I guess, is the short answer.

And we’ve talked quite a lot about the challenges today, but, actually, one of the enablers to much of what we’ve discussed is embracing technology and AI. And there’s so much more opportunity, particularly when we think about some of the unmet need. And part of that comes from a place of people just not being able to access traditional entry routes into primary care. So, by having opportunities to harness the NHS app, for example, to book appointments, and to receive consultations digitally, in your place of work, in your lunch break, for example, that would make such a difference to many people who just can’t attend during that 8.30 a.m. to 6 p.m. period.

I think the other thing with technology is what it offers us with diagnostics too. So, we always talk lots in terms of the systems functions of it, which is great and needs to be progressed, but technology and AI is revolutionising healthcare at a speed of knots, which is quite tricky for us to keep up with. But, actually, what that’s doing is creating time in the diagnostic space. And that, if we bat really clever here, allows us to reprocess that into relational care, and it’s the relational care piece that AI can never revolutionise for us. And that’s the magic fairy dust that we’re describing here today, that when you get that right for patients and communities, it really does realise better health outcomes. So, it's how we can embrace technology and AI to take over the diagnostic bits and improve that diagnostic acumen that then allows us to reinvest that back within the relational models of care for primary care.

Mabon. 

We have absolutely embraced telemedicine, and COVID kind of forced that upon us, actually. But there is still so much more that could be done with this. And, in many ways, there’s been a pulling back from the position that we got to over COVID with telemedicine, because, sometimes, it’s not very popular publicly to say you offer a digital consultation as opposed to a direct face-to-face. But the reality is that, for an awful lot of working people, actually, a digital consultation, at least in the first instance, is a much easier way to access primary healthcare.

Where I don’t think we’re doing enough with this is at the other end of the age spectrum, and we haven’t talked much this morning around frailty, pre-frailty, out-of-hospital solutions. Primary care could be doing an awful lot more in this space. Telemedicine and monitoring software is available, and is tested, and used in pockets, I guess, across Wales, but not consistently used, and not consistently upscaled to a point that could really revolutionise the traditional secondary care pathways.

Yes, I’d just agree with that. I think, during COVID, secondary care definitely accelerated telemedicine to as much of the wider public as possible for physiotherapy. Primary care is probably more varied, and probably relies on the relationship with the GP and the rest of the practice, and how they operate internally in that GP cluster or practice, as to how confident all the staff there are in using it. So, yes, it’s more prevalent in secondary care. There are good projects and examples across Wales, but, as Nia’s just said, it's not very consistent.

There are a few strands to what you're asking there. All three of them have a responsibility—absolutely they do. But, again, the investment in technology in this space is expensive, so for individual practices to invest in that, they've really got to demonstrate how they'll have return on their investment, and sometimes that's difficult to do because what you're getting into is the unmet need space, and that's not necessarily in the practice financial incentive, or there isn't financial incentive for the practices to perhaps chase that down.

I think, where we're talking about the 'shift left' agenda and maintaining frail, vulnerable patients at home as an alternative to a hospital admission, or expediting timely discharge out of a secondary care setting, then actually that investment has to be driven by the health board itself, and that is a struggle, because there often aren't pots of money to purchase and oversee some of this technology. And then it's not just about the technology, of course; it's the staff and the workforce model that wraps around that technology to deliver that care closer to home. So, it is quite a substantial investment that's required, and often when we talk about 'shift left' and we talk about moving services out of secondary into primary care, there is a perception that you can just switch off the funding stream in secondary care, redivert that money into primary care and then that service will pop up in primary care and everything will be fine, but it isn't as simple as that. You need to have two funding streams to allow that model to be established, to allow the technology to embed, to allow time for the staff to become competent in using that technology, so that's where we struggle. It's that, often, there isn't a dual funding stream to support some of that investment.

Can I just add to that, as well? I liked what you said in that bit about the fairy dust, because, actually, that's the bit that isn't technology. Within occupational therapy, we do use digital platforms like Attend Anywhere, even offering Microsoft Teams appointments with people. They are, like Nia said, more often taken up by the working-age or younger population, who have ready access to this and it makes it more convenient for them. I think having that approach where it hasn't got to be one or the other, but that mix, makes it rich, and then you're meeting people's needs where they're at. So, a lot of what I do is in people's homes. So, depending on the intervention that I'm delivering, some of that can be done online, but the majority is in people's homes, and that fairy dust bit of that is the bit that technology won't be able to replace. But there are certain aspects of the work that can be digitalised.

Thank you.

Yes, that's exactly right. It can't just be, 'Right, we're investing on Monday, so we can therefore flick the switch that has the funding stream into secondary care on Monday.' This type of technology—revolutionary technology—takes time to embed, and also is dependent on a workforce model wrapped around it, and a workforce working in, perhaps, a very different way to which they've been traditionally utilised. That has a lead-in time. So, often, when we look at pots of money that are there to pump prime technological intervention, for example, they are just focused on the very immediate costs of purchasing the technology and don't take into account the wider workforce strategy and the training and development needs around it.

Mabon, could you lead us into estates, please?

John, would you like to come in?

Thank you. Diolch yn fawr, Mabon. I’m very happy to do that, yes. We’d be interested, I think, as a committee in your view on the quality and suitability of the general practice estate in supporting your multidisciplinary team working. What are the barriers in terms of physical infrastructure that need to be addressed if we’re going to move to this more integrated model of care?

The primary care estate is generally in a very poor state. It’s generally limited in terms of capacity and space. It's sometimes lacking in its ability to access some of the technological advances that we've talked about today, too, ease of access and parking—all the considerations, really, that we need to think about when we're looking to build services for the future. So, generally, there needs to be significant investment in considering the primary care estate of the future and we need to look to make these integrated health hubs. So, whereas at the moment we have individual GP practices, if you like, and sometimes we have a number of these scattered throughout our towns and our cities, a much more comprehensive integrated approach to delivery of the services here is required. The estate needs to reflect that and it needs to have the capacity and scope to continue to extend but also to encompass the technology, and the ability to work remotely and work in a very different way to the traditional models that we've got at the moment also needs to be considered and built in.

I completely agree. What my members have fed back in recent years is that it's a parity of esteem issue. If you haven't got the same facilities as the GP in the practice, the same sort of room set-up, as an AHP practicing there, you're seen as an afterthought by the patients as well. You need to be integrated into the structure of the building, the plan of how your patients will come into the GP surgery and see you as a professional equal to the others there. Throughout COVID, people were asked to leave GP surgeries because things would be done on the telephone, and getting back in after COVID into GP surgeries is quite difficult for a lot of professionals. I think that, now, if we're going to plan forward, as Nia said, these health hubs where we think of the AHP services from the beginning and integrate them into the plan for a new building, it will be key in how patients view that service and see its importance.

I would agree. It is ad hoc for me as a practitioner going into the practices that I work in as to whether I'll have space to work. I've sat in the reception before now or have sat behind an admin person answering a phone because there's just nowhere for us to work. And again that is viewed by the patients as well. So I think that's the message, really.

Thank you for that. We're running close to the end of time. I'd like to bring Altaf in to wind up this session. 

Thank you, Chair. I'm grateful. It’s a very interesting session. Could I ask one small question about the digital infrastructure? We did talk about the GDPR, the training that people should have when they are dealing with data. But coming to my question, it is about the primary and secondary care interface. Given that the use of generic and tick-box referral systems and administrative-led triage processes can create long waiting lists and risk patient harm, particularly for urgent cases like cancer, what fundamental systemic and communication reforms are required between primary and secondary care?

That is a big question.

To establish accountability, a clinically led patient pathway.

There are lots of elements to this, and you're right. It starts with supporting patients to come forward and recognise when they need help with their health early on, so that we're not seeing patients present with symptoms so far progressed that you are limited in the interventions you can make in primary care and therefore forced down a route of having to refer. As with everything, all roads lead back to prevention, early intervention and optimisation—of course they do—but where you are faced with a patient that you need to refer, there is a piece of work ongoing in Wales at the moment around standardisation of community health pathways that help primary care clinicians make sure that they've got the right diagnostic tests and that they've made the right considerations in respect of the referrals, so that the referrals that are going through are of a high quality.

When it reaches secondary care, of course, you're quite right, and it's not uncommon that we see patients unfortunately with quite worrisome symptoms waiting for quite lengthy periods for the further investigation that they require or an intervention from the secondary care system, and part of that is of course the overwhelm within secondary care. Part of that is the distraction from planned preventative care that happens when the unscheduled care side of work is unbalanced and overtakes some of that. Of course, this is a system thing. We've got to get the unscheduled care agenda right, and that links back to what I was saying around technology and the shift left and ways to work that prevent hospital admissions and accelerate more timely discharge.

But there's also something around being clear around what really does need to be delivered within a secondary care space, and a lot of what goes on currently is because of historic practice and because we haven't got the right infrastructure within primary and community care to accommodate some of this. So, if we invest properly with primary and community services and we get this integrated infrastructure right, then we are so well placed to really dig into what has been the traditional stronghold of secondary care and think about what we can repatriate back into primary and community services. It's a big undertaking. It trips off the tongue quite easily, doesn't it, but there is quite a bit to it.

I agree. I don't know about your colleagues and whether they have something to say. But I know, for instance, a GP cannot order a blood test, they cannot order an x-ray, they don't have access to ultrasound. And to then ask for occupational health, or asking for physio, or asking for other areas—how can he decide that? But let's hear from your other colleagues.

Kim, would you like to come in?

I was just going to say that forms do cause delay. When you're referring to somebody, it's delaying patient care, it's time and things like that. We were discussing only this morning some of the referral forms that people need between primary and secondary care. I can speak from our point of view in the OT department; we don't require a form. That's why GPs will come to us, and that's how we've slotted in so well. It's because we just need a very small ditty of what's going on and an NHS number and we're away, and we do what we do. So, from that point of view it doesn't cause that delay in treatment with transferring people from all different places. But we do a lot of work with taking people from secondary care into primary care, from a therapy perspective. But I'm not sure that's necessarily joint thinking across the MDT all the time.

I think it's just important, as well, to recognise that the patient is the expert, a lot of the time, in their own care, and so we have self-referral where patients go direct to physio and there's a form to fill out on the health board website and that's it, to get straight to physio. It doesn't take up the GP's time at all. So, modernising the ways a patient can go, using technology, to the right professional, the right place, the right time for them is really key.

I agree with that, because these are all generic forms and no two patients are alike. Let me come to the last question. To what extent are the specific roles and contributions of the multidisciplinary teams, including nurses, physiotherapists, occupational therapists and pharmacists, understood by general practitioners, GP practice staff and the wider public?

Furthermore, to widen out this question, what targeted strategies are required within both primary care and public health campaigns to enhance awareness, improve appropriate patient signposting, and ensure the effective and safe utilisation of the MDT while maintaining the ultimate clinical accountability of the GP, because he is accountable?

That's another huge question and we haven't got too much time to answer it.

Sorry for that.

No, thank you, Altaf. Perhaps the three of you can have a stab at that quickly, and we'll have to wind up.

It's a good question. Just to add, we are all professionally accountable in our own rights. Our roles are misunderstood, and I think historically over the last few years, they've been marketed almost as a second best: 'You'd like to see a GP, but the GP's full, so here, make do with either a nurse, a physio or an OT instead.' Whereas actually we would absolutely argue that we're probably the best person for you to see over and above a medic. So, there's something around the narrative that we put out that is important here. I don't know if you'd agree.

I think all the royal colleges and professional bodies have done their bit of work to try and educate the public about their professions individually. There's probably a bit more of a holistic project to do the MDT as a whole. The Welsh Government are doing some work, as I said, around specifications and explaining the MDTs to the wider health service, including GPs, so they understand what services are available that they could have in their GP practice. So, it's something I think that's being worked on and definitely something that can be improved.

I'd agree. It's a bit of a trickle effect, unfortunately. The GPs see what we do, and when they see what we do, they understand what we do, and then it grows from there, and that's how it's been. There is a challenge with that global messaging, about what is it that we would do, and why would you see us first. But patients do self-refer to us once they've seen us once. We're finding a lot of people come back to us: 'Ah, it's not the GP I need to go to for this. Kim will be able to help me with this' and they'll come back to me that way. So, that's a way of trying to bypass some of that GP time, and it's working really well.

Thank you so much for capturing that so succinctly. I think there's a key message there about communication, and that you should not be seen as Cinderella until you come forward and people learn—people should know. So, there's some work to do for all of us in that regard. Can I thank you so much? It's been a fascinating session, really interesting and helpful for what we're doing. There will be a transcript available for you to check over, just to check you're comfortable with everything that's been said. Can I just thank you once again for all your time? I really do appreciate it. Thank you.

Members, we will be going into a short break for a quarter of an hour in a second.

Welcome back to the Health and Social Care Committee. It's been an interesting day already as we pursue our inquiry into general practice in Wales. We're on our second evidence session today, and it's a great pleasure to welcome colleagues from the Royal Pharmaceutical Society and Community Pharmacy Wales. Could I ask you perhaps to introduce yourselves? Could I start with Liz?

Hi, I'm Liz Hallett. I'm representing the Welsh board for the Royal Pharmaceutical Society, and I have a background in primary care and have been a practice pharmacist in the past. 

Thanks.

Hi, I'm Helen Davies. I'm also an RPS member and a Welsh board representative here today, representing primary care. I also work in a GP practice. 

Thank you.

Good morning. My name is Dai Williams, I'm a community pharmacist in the Rhondda and I sit on the board of CPW. 

Thank you, Dai.

Hi, I'm Steve Simmons. I'm a pharmacist. I've worked most of my life in community pharmacy until joining Community Pharmacy Wales, and I'm a member of the Community Pharmacy Wales executive team. 

Great, thank you very much, and welcome again. We've got a few questions to ask you in turn, and perhaps I can kick off if that's okay. It's looking at the role of pharmacists. I just wondered what are the key enablers and barriers to maximising the contribution of pharmacists in general practice, particularly in managing those long-term conditions and supporting the preventative care agenda. Would anybody like to kick off on that? Don't feel that you all have to come in, but you're very welcome to. 

I think, as pharmacists, we are the experts in medication, so our wider multidisciplinary team recognising that fact, that that's where our strengths lie, because there we can support with the polypharmacy, reducing that deprescribing. Many of us are independent prescribers now, so with that individual skill set as well to be able to make those autonomous decisions. So, those are the key enablers. We're also medicine safety experts, so assessing the risks of those medications, helping prevent those hospital admissions by that deprescribing, but having everyone be aware of what our scope is. We are not instead of GPs, we are in addition to GPs. We work best as part of that multidisciplinary team, so I think that's one of the key enablers is people knowing what a pharmacist does, and the public being aware of what a pharmacist's role is. 

I'd agree with that point, if I can come in there, because I think public awareness of our unique selling point is key, but also our colleagues' awareness of what we can do as well. So, we are not just replacing GPs, as Liz said, we are adding value in terms of medicines expertise. But, for me, working within the Rhondda valley, which is where I work at the moment, we've got pockets of deprivation as well, and it's a real absolute pleasure to be able to have that longer term relationship with a patient, really optimising medications to try to reduce admissions. That long-term relationship is key. We work closely with our community pharmacy partners where we can really try to manage those conditions, and whilst you're there with that patient, you develop a relationship and you can counsel them more on a prevention agenda, because there's a limit to what we can achieve with medicines alone. I think it's key, trying to get behaviour change involved as well. So, key enablers really are making sure people are aware, the public and professionals, about what we can offer. We're not just substitutes for GPs, but offer expertise in medicines as well. 

Dai.

It's a difficult question, isn't it? As medicine's evolving, no-one can know everything. The whole world is starting to revolve around multidisciplinary teams. As Helen said, the skills that pharmacists have, some of them are complementary to GPs, some are different to GPs. The system operates better when that team can communicate better together, working well to achieve the same outcomes. The barriers are the biggest issue.

Funding is always an issue and digital interoperability is an issue. We've got electronic transfer for prescriptions at the moment between GPs and community pharmacies, which is great. I'm a prescriber, so I sit in my community pharmacy, seeing patients that the GP has referred in to me. I can access the summary care record, so I can get access into the GP record and see a summary of where they are, but I don't get to see everything. I don't get to see pathology laboratory results or letters from hospitals. I don't get read-and-write access to the GP's records. So, there's a danger that the information that I'm getting isn't complete to allow me to make a decision, and I can't then write directly back into that GP record, so there's a chance that, when I communicate that back, it gets lost in the wad of documents that they have sitting there. So, read-and-write access would be a massive bonus.

That's a really helpful point, Dai. Steve, anything?

I don't think I can really add much more to that because my colleague is a practising colleague. But the role of community pharmacy is obviously changing dramatically. We started off being suppliers of medicines and dispensers and now, under Welsh Government arrangements, we've extended our range into far more clinical service provision. So, we're looking after common ailments, we're looking after prescribing for other conditions, we have a public health role, we take on all sorts of things. But, to me, it's about people not places. I think if there's anything that's a barrier it's thinking of places: 'This happens in a GP practice'; 'This happens in a community pharmacy'. To me, I want to reach a stage where an independent prescribing pharmacist working in a GP surgery, or a nurse working two rooms up in the GP practice, is part of primary care, no different to an independent prescriber working in a consultation room in a community pharmacy a couple of miles away. And in these days of digital connectivity and interoperability, we really should be thinking more and more about primary care.

Yes. That's a really good first point. Yes, come back in, Helen, please, yes.

I was going to talk a bit more about some of the barriers we face as well in terms of operating those key issues. Working in a GP practice, we can only survive with the volume of work, I think, because there's a lot of work coming up from every kind of specialty in secondary care whilst trying to maintain chronic disease management, and whilst we are the right people to do it on the ground because we are in the patient's community and we are easily accessible, thinking about where I work, actually, some people would probably struggle to travel to some of their appointments further afield. So, we are in the right geographical area, but we are limited, sometimes, by physical room space in GP practices and things like that. So, I would love to set up an extra clinic and do a polypharmacy deprescribing clinic whilst looking at the chronic disease management, but I am limited to where there's enough room availability. That can vary depending on the type of building that your GP practice is in; the newer ones tend to be a little bit better for that.

Some of the digital infrastructure, our systems don't always talk to each other, and I wonder why not, in this day and age. As David was saying, that can become an issue because if certain changes are then lost in translation, that comes with a risk, then, doesn't it, really.

Definitely.

Well, that's really important, interesting stuff, because I know how much work that you, on the pharmacy side of things, have been doing to be able to put more into the primary care system. I've met with your colleagues as well, and I've seen what great work they're trying to do in moving forward. And I heard some of that about the physical buildings. I just wonder how can pharmacy be more strategically embedded in the NHS service planning and transformation programmes, so that you can actually give all of that you've got now to give.

I think we need protected learning time, because there's an infinite amount of things that we can do, supporting with deprescribing and preventative health medication, but especially as we're getting newly qualified pharmacists who will be IPs coming out, we need to support those pharmacists throughout their whole career. So, in their early years, giving them the support and mentorship, but also, with those advanced pharmacists, enabling them to continue to expand their scopes of practice. But we also need to bear in mind that we can only do so much in a working day; the workforce pressures are immense. So, I do think we need to be looking at workforce pressures and the harm that can cause to the profession, for the whole multidisciplinary team in GP practices, not just pharmacists.

Yes. Dai.

It's quite interesting. You asked how we can embed pharmacists into the system. Helen just pointed out that space in a GP surgery is sometimes at a premium. I work in the Rhondda, and there are 10 GP practices in the Rhondda cluster, 14 buildings, because some of them have branch surgeries, but there are 10 GP practices. There are 27 community pharmacists. The community pharmacy contract has independent prescribing built into it. That's 27 consulting rooms spaced all over the Rhondda, not just in the GP surgeries. The question is a very relevant one: how can we embed that? 

And how can we use what you've got?

It's there, isn't it? It's there. This is general practice we're talking about, but primary care is the whole issue. I get patients sent to me from a GP, I end up sending them to the optometrists, then they send them back to me with a prescription. It's about using the expertise of all those primary care contractors: the optometrists, the dentists, the community pharmacies and the GPs, pharmacists, advanced nurse practitioners. They've all got a part to play and we can't afford to let any of those skills go missing.

No. That's really powerful. Helen, and then I'll come to Steve. 

I would agree. Prudent healthcare is key. You have to use everyone's skill sets and look at the patient's journey across the whole pathway. Where can they add most value? Where is the space to operate this? But, for me, the key thing is links. But your original question was about how do we embed pharmacists into the strategy overall, a big part of that for me is workforce planning, in terms of getting our grass-roots pharmacy trainees out into practice, out into primary care working, so that we can see the benefits: we're growing our own expertise as we're going along; the profession is visible, they can see what we add. And for me, then, the key thing there is protected time for learning and, actually, interprofessional education, because I learn a hell of a lot from my colleagues in other professions, but we give the same back. So, if we can embed those structures with Health Education and Improvement Wales and funding as well, that would be key.

I'll bring Steve in, and then I'll come to you, Altaf. I'll just bring Steve in.

I think we're at a stage where we really need to think strategically about how we're going to use pharmacy, particularly in community pharmacy. We've got—I looked it up—about 1,600 full-time equivalent GPs. In nine months' time, the first of the universities are going to be releasing pharmacists who are independent prescribers. So, within about five years' time, I'd be very surprised if at least 600 pharmacies across Wales didn't have a full-time independent prescriber in there. Now, that is a 30 per cent to 40 per cent increase in prescribing capacity within primary care. We can either let it grow organically or we can really think strategically about what needs to happen where, so that we can make sure that this new workforce, and it's going to be a huge workforce, is going to be utilised properly.

Yes. Altaf, would you like to come in?

Yes. Just a quick point about—. Each general practice surgery has a prescribing clerk. Are they pharmacists or are they, I don't know, clerks?

They're not normally pharmacists. Well, they're not pharmacists. They're normally trained individuals and there are training programmes that enable them to be upskilled to become that. There are some moves that some pharmacy technicians are slightly taking on the role of a prescription clerk, but, generally, prescription clerks were not pharmacy professionals, no.

They could be replaced by the pharmacists. 

You wouldn't want to be doing that. The pharmacist would have a higher level of medical expertise than you would need for a prescription clerk. Prescription clerks add great value and have a great remit and a role, but it's not the role of a pharmacist to be a prescription clerk. 

So, in my practice, we work extremely closely with our prescribing clerks, because they make sure the processes run safely and that everything is on time, whereas we add the value then in terms of the expertise, like, 'Actually, it's all well and good getting that prescription ready, but as a pharmacist, I don't think they need that prescription anymore, so book them in for a consultation with me so I can have that conversation.' Add to that, then, our pharmacy technicians, they can support a lot of the work we do by making sure the necessary blood monitoring is done, and they're professionals in their own right who can support. So, yes, there's a role for all of us, but prescribing clerks are not clinical in any way and so can't add that value.

Thanks for that for clarity. Thank you, Altaf. We've heard a lot already about how we could probably improve things, but what's your assessment of the current relationship between general practice and community pharmacy?

How long is a piece of string? It depends on relationships. I've worked in the Rhondda for 40 years. I get on really well with all my GP practices. The system works despite the system, and that's always the problem, isn't it? The system shouldn't rely on relationships. The processes should be embedded so it's not left to chance.

Yes, that's good.

Yes, I'd agree with that. Actually, the GP practice I work in is just up the road from where David works, so that works well for us because we've got that relationship, but that doesn't mean it's going to be reproducible across the patch, and that's what we need. We need systems that are reproducible and just work, and simple things, sometimes, like having open communication channels between community pharmacists and GP practices, aren't always that easy, you know. So, things like using Microsoft Teams, it's making sure you've got the right infrastructure so we can talk to each other more easily and things to solve issues and so on. It just helps. So, we just need to make sure those communication channels are easy for us all.

Yes. Sorry, Joyce, would you like to come in?

I just want to dig a little bit deeper. We talked about relationships, but there are sometimes tensions, and there's a two-way referral system that hasn't been mentioned. So, a lot of people will go to you, maybe, to have their blood pressure—let's use that one—checked, and you know that they really need to go and see their GP. So, you would, I assume, refer them, because it's this two-way referral that I wanted to draw out, and the tension is about vaccinations, maybe. I'm just asking the question. Lots and lots of pharmacists, probably most now, will administer vaccinations, and it's a paid-for service, and GPs will also administer vaccinations in a paid-for service. Are you finding any tensions between that, because you quite rightly said it's about the people, not the system?

That's a really easy one to answer, isn't it? If you develop a service that has remuneration attached to it, and the practices find that they are struggling financially, then they're going to chase that revenue, aren't they? They've got bills to pay. So, the best way to get rid of that tension is to make sure that primary care is funded properly in the first place. If you get the core funding right, then people are not fighting over the bits that make them survive. That's about core funding, and that's a bigger question.

We have less tension now with flu vaccinations than we did, as it's becoming more custom and practice. I still don't like some of the conversations I hear and I don't like some of the posts I see from my GP colleagues and my pharmacy colleagues, but they're under pressure financially. What do you expect them to do? You give them a contract, and say, 'This is what you're going to get paid, and within that contract there's a lump of money for doing vaccinations. If you don't do the vaccinations, you don't access our funding.' So, the system creates that tension, and, yes, change it. Change that system so it doesn't.

Steve.

If I can just build on Dai's point there, it's about thinking through the tensions that do occur, and a lot of tensions occur, for instance, with repeat medication. It's the usual sort of thing: who orders it, who's responsible for it, where does it sit? So, often the system itself creates the problems, the tensions within it, and this is where we're saying, 'Okay, so who should do what in primary care?' A good example of that is repeat medication. So, we've currently got someone whose expertise is in diagnosis—a GP—and puts me right as a patient, and then says to me, 'Okay, Steve, you're fairly stable, so I shouldn't really need to see you for a year, and I'll fix an appointment to see you.' But each month now, I want this to and fro about—. [Correction: But each month currently, I have to go through this to and fro.] You need to get an ordinary, [Correction: 'need to go and order'] a monthly prescription. You need to order that prescription. You need to pick it up from the pharmacy.' Some systems work, some systems don't work. Here we are. We've invested heavily in electronic prescribing and an electronic prescription service. What I would expect the GP to be able to do is to say, 'Right, Steve, you can pick up your medicine from the pharmacy now.' Ting. 'Give Steve this medicine for 12 months at an interval that works between you and the patient. I won't be seeing the patient unless you refer the patient back to me.' So, we need to get rid of this monthly chase of prescriptions. It used to be green pieces of paper whizzing all over Wales, but now it's still going to be digital messaging. So, we've got to think about how we make this system a lot smoother, a lot simpler, and who does what within the system. As far as I'm concerned, repeat medication for stable patients shouldn't belong anywhere near a GP surgery. What are we bogging them down with that sort of workload for?

Thanks, Steve. Helen, and then I'll bring Liz in.

I would agree, for the stable patients, that, actually, those batch-prescribing approaches are useful because it takes the workload off everyone and the patient. It can sometimes go wrong when we have to make changes or if you've got complex regimes that are not suitable. So, it's not suitable for everyone. And I think the process, for me, that's where we get this collaborative conversation. We actually work with our community pharmacy partners to identify people they think would be useful—'You come back to us and we'll set that up.' That releases the GP pharmacist to do more of the complex cases. So, for example, if I wanted to spend my time reducing somebody on high-risk pain medication, that's not suitable for batch prescribing, but it means, because I've released the stable patients to you guys, I can spend my time doing that. 

I think processes are there sometimes to trip us up, and you are right that they can cause a problem with tensions, but it comes down to then actually planning services and having those conversations with every stakeholder around the table. What's right for the patient? What's their journey? Which part of the pathway is going to be easier for them? And, for me, when you're talking about things like having your blood pressure checked, we need to make sure the pathways are in place so that there is somewhere that you can refer somebody if you find something that goes wrong. 

Liz.

And I think, once again, back to that patient education, with regard to ordering their medication, they don't need to order all their medication every single time, so only ordering what they need. That will free up resources and it will free up manpower in community pharmacy, because there's nothing more disheartening than dispensing something that isn't actually needed and then it goes straight into waste. We know there are huge amounts of medication waste. I think it's really important for that key message to go out to patients that, yes, it is on your prescription, yes, you can have it when you need it, but do only order it when you do need it. And have conversations, if you can't take that medication, with your community pharmacist and with your primary care pharmacy team as well.

Okay. I'll move us on. John, can I bring you in?

Thanks very much for coming in to give evidence to committee today. You've touched on funding a few times already and, obviously, that's always vital. We'd be interested in your views on how sustainable the current funding model is for pharmacy services in general practice and primary care, and what changes you  would suggest to move to a more effective long-term planning system and service delivery.

Between 2013 and 2016, Mark Drakeford was health Minister. He had a 'shift left' policy: prudent healthcare—only do what only you can do, more people treated in primary care, fewer people in secondary care. And that's fine, but the funding has to follow that. If there's more work being done in primary care, then the funding has got to support that work. We're in a situation—I don't want to get drawn into a contract discussion—where primary care is not sustainable with the level of funding that you have at the moment. There are issues with social care and how that integrates with it. That's complex, I accept that. But if you want primary care to deliver more, you've got to pay more for it. It's as simple as that. Where does that money come from? That's a discussion you have to have. 

We have a clinical service in community pharmacy where, four years ago, we had 30,000 registrations on common ailments. There are now 300,000. The budget was £28 million last year. They think it's going to be £38 million, all from within that global sum. Nothing over and above inflation has gone in for this year. That is not sustainable. I've got colleagues on burn-out. I've got independent contractors working 12 hours a day. They put their life into running a pharmacy and they're working 12 hours a day because they can't get the work done, because there's no finance to bring other people in to help them. And chucking more money at it on its own won't help. It's about deciding what is your policy for primary care. What do you want primary care to deliver? Who are the players in primary care? How are they going to work together, and how are we going to fund it? It's a massive issue, but you've got to look at the whole system of primary care, not just bits of it.

I would agree with that, in that it’s a whole-system approach. So, if a new service is being developed and it starts in secondary care with the specialties, there has to be a thought process about how that funding transfers. I am not just talking about the funding to deliver, but the funding to actually pay for the prescribing as well. All of these things are in-built.

But, for me, some of the issues—. If you take the fact that having a pharmacist in a GP practice is adding lots of medicines expertise and making it safer dealing with those chronic diseases, we cannot actually do that sustainably or consistently because a lot of practices cannot afford to employ GPs because of numerous issues and so on, because of the model, I guess. If we’ve used cluster funding in the past, for example, that varies from place to place, so what you have then is a bit of a postcode variation in the pharmacy support. You can’t really build a service on that because you don’t know whether it’s long term. If you did want pharmacist expertise within a GP practice, and I definitely think there's a place for it, there would probably need to be more of a permanent funding solution.

And there will always be those practices that won’t be able to afford their own pharmacist, so how do we support them to have this vital service, this vital person in their role to provide that medicine safety? Especially in rural areas, in single-handed GP practices, realistically, we need to work out how we are going to support those practices to enable them to have a pharmacist as well.

Thank you. Good point. John.

Okay. Helen, when you spoke about clusters and funding for clusters, we know that it is quite short term, isn't it, that funding, which also should lead, and hopefully does lead, to transformation to some extent. What is the impact of the short-term nature of that funding on the ability of the pharmacy teams to actually plan and deliver consistent and sustainable services? What changes would you like to highlight to committee today as being necessary to overcome the problems that are involved in that system? 

For me, I think, because of the short term nature of it, I appreciate the premise where it is meant to be that you test something and it brings with it transformation, but where does the funding then come to continue that? It is just not there anywhere. If you then put that funding into people, which is often what we need, and expertise—so, pharmacists, for example—you can see what can be delivered in terms of medication reviews, yet we know that is going to be fleeting. You end up trying to select project-based work, which is short term. Actually, if you have just put a project in and you have spent your time delivering sustainable inhalers, doing respiratory reviews, to make sure we are increasing our decarbonisation and we are addressing those things, that cannot then continue when the funding ends. So, it is just that, whilst it is good to test things, it needs to be a constant thing, because you cannot rely on a service that you know is going to be fleeting. I don't know if I have answered your question very well there, sorry.

I think you have. It’s about the impact, isn't it? You’ve described that quite well, I think.

Okay. Thank you. 

Dai.

I've been heavily involved with the Rhondda cluster over the last seven or eight years, and, picking up on Helen's point, cluster funding should be about proof of concept. It should be about allowing someone to develop a system with minimal risk to their practice to see if it works. Half the Rhondda cluster budget is now spent on cluster pharmacists, and that has been going on for about six years. That’s not what the funding was designed for, but the practices now realise they cannot do without those pharmacists. With the safety they bring to the process, the practice will not operate without them. So, that now limits the other proof of concepts we can explore, because now you’ve educated the GPs on the vital role pharmacists play and they realise they cannot do without them. So, I do not have an answer to that, I am afraid.

Unfortunately, the answer probably is more funding. We understand there is not an infinite pot, but I think, as services move down from secondary care to primary care, the money should follow, but that is not easy to fix, because you cannot just suddenly say, 'Secondary care, you won’t prescribe that and have that pot of money; we're now moving it to primary care', because that would not work either. It is how we follow those services, as well.

That example you gave there, Dai, demonstrates very clearly that, actually, looking at new models, investing in that, is worth it, because that one was proved very quickly. 

Yes.

Sorry, John—anything?

No, I think that's fine, unless any of our witnesses want to add anything, Chair.

Okay. Thank you, John. Let's move on to workforce, and Lesley.

Thanks very much, Chair, and good morning, everyone. Dai's just referred to burnout and 12-hour days et cetera, but I wonder if there are any other challenges that you think are there for recruiting and, importantly, retaining pharmacists in both general practice and community pharmacy settings.

Shall I come in there, if that's okay? Yes. So, as Dai has said, burnout is a real issue. There's a lot of good will out there, I think, and that comes with our roles. We care for our patients and care for the population, so we will go above and beyond. It can't carry on like that for ever, I guess, but, you know—. I think, for me, if I was to recruit pharmacists to a GP practice, particularly where I live—. Obviously, there's a lot of travelling for a lot of people to go up to the top of the Rhondda Valley, that sometimes is a bit of an issue in that you can't recruit because of those—. It's making that attractive, I suppose. But also it's making sure they feel that they are in a secure role, because, if funding is temporary, there's a worry, then, that they might think—. People have got mortgages and bills to pay, they might think, 'Well, I'm not going to risk taking a role in a practice that I'll probably love, because I'm having a massive impact on this patient, but I can't rely on that long term.' And also it's making sure you are integrated in a team and you feel valued and that your skill set is realised. So, obviously, it's making sure patients understand what value we can add, and making sure we're embedded into the MDT early on, really.

I think it's looking at the whole structure of the GP practice as well, making sure that the rest of the team aren't understaffed and underfunded, because that just builds stress, and then, obviously, that impacts on everyone, the whole team. It's utilising our skills where they're best placed as well, given that job satisfaction. So, if you're working long, long hours with admin-like roles or things like that, then, actually, that's not making the best use of your skills. So, it's getting that—. We like patients, we're here for patients, and that's the thing that brings you joy, and that impact you have on patients is the key to everything that, as a pharmacy professional, we feel.

It's introducing those pharmacy technicians into the team as well, seeing the role that they can have in a GP practice, upskilling them. They can take on some of the monitoring, looking at reviewing medications, but then passing those then onto a pharmacist to deal with the actual clinical bits, the complex bits that a pharmacist needs to be dealing with. So, it's valuing the whole pharmacy team as well.

There's a longer term question as well, isn't there, about how we retain the workforce in Wales. We have a system now where we train pre-registration pharmacists, but places are limited through the Oriel system, and, whilst we attract a lot of good students, how many of them are going to stay in Wales? We talk about wanting to increase Welsh language skills within pharmacies, and if you want to get somebody to work in west Wales, it's much better if you can get a pharmacist who was born and bred in west Wales. So, if he finds it easy, or she finds it easy, to get into university, she'll more likely go back into the community where she grew up, or he grew up, to want to work. So, we do have to take a longer term view as well of who do we want to train as community pharmacists and GPs, where do they come from, what are their long-term ambitions. It's fine training the best students, but if they're going to go back overseas or back into England when they finish their qualification that's not serving the public of Wales very well. It may sound a bit selfish, but, at the end of the day, we have to be able to retain a workforce in our country.

That's a good point. Steve.

Yes. It's a similar point in that we have a pipeline issue in that we've developed a foundation pharmacist, or the old pre-registration programme, which most people will know it as, where, traditionally, somebody would go and work in a community pharmacy for a year and then they became registered as a pharmacist. Now we've developed a process that is a Rolls-Royce training programme. It's an excellent training programme where they spend time in community, time in primary care, time in GP practices, and then they eventually qualify. Yes, as Dai says, that attracts a lot of the premium graduates, applicants, many of whom have got no intention of ever remaining in Wales. So, that's the issue that Dai's already spoken about. But the problem is that to organise that is quite complex, and you are therefore limited to places in each of those areas. Therefore, we're fixed at about 80 to 100 pharmacists that can go through that process. So, our pipeline requirements are maybe 200 or 300, but we've put a bottle stop there that's actually stopping more and more pre-registration pharmacists graduating in Wales. We would hate to get rid of this Rolls-Royce training programme—it's brilliant—but other UK countries train their graduates in the old way, through the old programme. The solution is to allow both to operate together, but we've taken a decision that it's the Rolls-Royce service only, and CPW's fought that for many years, but it just means we're curtailing our own pipeline.

Thanks. Going back to the comments earlier around a pharmacist wanting to be valued and being part of that team and having their skill set recognised, do you think the lack of alignment with 'Agenda for Change' has an impact on the way you can recruit and retain pharmacists in primary care?

I would agree with that, actually, because I'm directly employed by a GP practice but I also have another health board role as well. I see colleagues of mine reluctant sometimes to go into the GP sector because they are worried that they might not have as good terms of employment and so on. So, that is a factor that a lot of people consider. So, 'Agenda for Change' probably does come into it to some degree, just making sure you're protected. I don't know if there's anything you can do with that. I don't think there's anything in your gift to change that, really.

I suppose, actually, going back to Steve's point as well, now that we've got this rotational training programme, if we're getting the grass-roots people coming through, they are more likely to want to stay with us, if you can treat them well. The general practice sector is the sector in most relative infancy. So, there are fewer pharmacy teams working there compared to others. So, I suppose until we can adapt those portfolio-style careers where people can work in different areas—perhaps that's a solution—. But, ultimately, we haven't got the infrastructure to manage all of this training. So, 'Agenda for Change' becomes more attractive then, I suppose, where you're going to go somewhere where you feel safer.

Sorry, if I can just add in another barrier that people may or may not be aware of, that is the pension contribution, the pensions issue, because if there is a role in general practice or in a hospital to work as a pharmacist, say at £50,000, it'll be £50,000 with a 22 per cent pension contribution by NHS Wales. If you go into a community pharmacy, £50,000, but you'll get a 5 per cent or 6 per cent pension contribution. And it is an issue out there that's stopping the flow of pharmacists between sectors that could easily maybe be addressed by allowing community pharmacists, for instance—exploring whether or not they could join the existing NHS pension scheme. But just to let you know that it is a barrier there, which is caused by the difference between pensions.

Yes. Dai.

There's another big issue for me with community pharmacists. I'm very lucky in the fact that I have another pharmacist who works with me and I've got a good network around me. When the urgent care centre was opened in Rhondda, which is based in the hospital, because all the GPs employed a GP to work and to deal with unscheduled care that day for people who couldn't be seen, I could pick up the phone to Aled, the GP there, and we had this great relationship. He would give me some advice or I could refer in. That's now closed. Many of my colleagues in community pharmacy work in a silo. They feel isolated, especially if they're younger and they haven't got any experience. Who do they pick the phone up to to say, 'I need a bit of help or a bit of advice by here'? That to me is a massive issue in personal development, because they become more reticent to get involved with something, they become reluctant to make a decision, and they end up referring somewhere else, when, if they'd had a mentor they could have picked the phone up to, or just somebody they worked with to say, 'What would you do by here?'—. It's a massive bonus, isn't it, when you have somebody you trust that you can talk to.

Yes. Sorry, Liz.

I think the isolation is true in GP practice as well for pharmacists. Because, although you are often integrated into that multidisciplinary team, you are different to the rest of that team as well. So, you do want to have those networks between GP practices of those practice pharmacists so that they can have that peer review, so that they can have conversations regarding expanding their scope of practice.

There is sometimes a reluctance to use your independent prescribing qualification. You've got it in a certain scope of practice, but you feel, I don't know, barriers to actually utilising that, because you’ve got worries. But actually having that network of people who you can turn to and say, 'I’ve seen this', or having those MDT discussions with your colleagues, your trusted colleagues, I think would be really valuable, and mentors for those people later on in their careers as well. So, you’ve got those early years careers, and designated prescribing practitioners and things, but what do we do with our existing workforce as well, and how do we mentor them to expand their scope and keep them supported and not isolated?

Yes. Helen, you wanted to come back.

Only a quick point on that, really, because I know you've addressed a bit of it. So, as we've already said, pharmacists are going to be coming out qualified as independent prescribers. A newly-qualified independent prescriber is not going to be the same as Dai, who's very experienced and could look at a patient and have more clinical judgment skills. I think what Dai touched upon as well, being isolated, that works across the patch, and I feel that we need some infrastructure to make sure that community pharmacists who are prescribing, and newly-qualified pharmacists working in the GP sector, and advanced ones, all have that ability to have someone they can have a discussion with—a case-based discussion—and feedback on their prescribing. It probably needs to be in-built into all of it, because, otherwise, there's a risk that things can go wrong.

Yes. Lesley. 

Thank you. Talking about recruitment and retention, really, what gaps do you think exist in training and professional development, and then, ultimately, career progression for pharmacy staff who are working in general practice?

I think it’s back to that protected learning time. We know they’re overworked, their days are really busy. So, how are you going to fit that in at the end of a long day, that protected learning time? How are you going to find time for that for the whole pharmacy team—so for the technicians, as well as the pharmacists—to make sure that they’re using their core skills and continuing to develop? I think that’s one of the major things, that protected learning time. And funding it as well—so actually funding what that training looks like—and access to those relevant courses as well.

Helen. 

Yes, so protected learning time, definitely, because, obviously, if you’re closing the practice down or—. Something needs to be able to sustain that ongoing service whilst you’re learning. But I think as well it probably just needs to be in-built, in addition to that, regularly. I’ve worked in some practices where I know that, at the end of my week, I can hot-review some of the patients with the GP and get their opinion on some of the things I’ve done. I can go and speak to one of our practice nurses, who’s very familiar with managing these conditions, and we can bounce off each other. So, it is important, in terms of retention, that we feel valued and we feel supported, because, otherwise, you can be quite isolated, I think.

Yes. Anybody else? No. Okay, Lesley. 

Just finally—and, again, you mentioned, Liz, you’re an independent prescriber—if you had more people who could independently prescribe, what impact do you think that would have on a GP’s workload?

I think more—

A bit of an easy question, that, probably. [Laughter.]

I think the more people we have who can do more things, obviously that will help with the GP workload. But I think we just need to be conscious that we need to be supporting those people to use that independent prescribing competently and safely, and expanding on that as well, so that they are feeling supported. Yes, that's—.

Helen. 

I think it comes down to population needs assessment as well, but then sitting down early on and discussing with your whole area and your stakeholders. So, for example, it would be pointless me saying, 'Right, I’ve got three new independent prescribers working in my GP practice with me. They’re going to start doing this', which is duplicating the good work Dai is already doing. We need to have these conversations upfront, and that needs to be part of it, where you plan for your population. There will be always be things that we can take off GPs, but it’s making sure that we’re using our unique selling point, which is medication safety as well. So, for me, it could be—. We do medication safety audits, for example, to make that sure women on hormone replacement therapy are not given the wrong treatment when they’re being treated for menopause. Why can’t we be the prescribers in that, to make sure it’s safe? Things like that.

Yes. 

So, the point about not duplicating, I think, is really important. 

Yes. 

So, who do you think should take the lead there? Should it be the health board? Should it be—? Does Government have a role to play in that?

I think each individual area of Wales will have different issues, and I think you are going to have to look at those issues. We know there are huge pockets of deprivation in certain areas, so you may want a particular focus on that. So, I think, health board-led, but with an all-Wales strategy as well, to identify what those core needs of that particular community are, because there's just such variety, isn't there, across Wales.

Yes. Dai.

That's an interesting question, isn't it, because it depends on the skills of the people involved. I have a pharmacy up in the Rhondda that does 500 consultations a month between IP and CAS, and I've got five other colleagues who prescribe, and, every month, we've got over 1,500 consultations that would have been seen by a GP. But I can't tell you that all those pharmacists have the same skill sets or the same scope of practice. And there's a scope of practice that we aim to achieve, but not everyone is at that stage. And this is a journey. We're nowhere near. This is the start of a journey. It will depend on those relationships and surgeries understanding what can their community pharmacist do, because there's nothing worse than sending somebody to a community pharmacy to find that that prescriber is not there that day. That just creates a barrier for next time. So, it's about communication. It's about IT. It's about systems that can talk to each other, and again, it works on relationships instead of process, doesn't it? That's the problem.

The question was asked whether or not it was health board or was it a role for Government. I think the problem that pharmacy has traditionally faced, and still faces, to some extent, is that it's almost like an ancillary profession that's, like, out there, and I'm not convinced it's part of board conversations at health board level. It always seems to be that the conversation is always on a lower level within a health board, and I think that's always been a barrier for community pharmacy. But like I was trying to say to you, we could see a 30 per cent or 40 per cent increase in prescribing capacity. If health boards aren't having conversations about that, there's something amiss, but I'm not convinced that they know or think or understand, as you're understanding now, what the potential is.

Dai, did you want to come back in?

There's an elephant in the room here, isn't there, because the Government would like to get more people seen, get waiting lists down, get the population needs met, but the health board's got to stay within a budget. As we start to deliver more consultations, our work increases and we get to see more people. Is the health board's target to meet the Welsh Government's target, or is it to stay within budget? Both are not compatible, I'm afraid. That conversation has to happen between Government and health boards of, 'This is what we want, this is your budget, but how do you measure that that budget is being used to achieve your goals?' And that's the elephant in the room. They're different agendas, aren't they?

On that point, you're spot on, because obviously I work in both situations and understand that. I think as well, though, there is a role for the Welsh Government to support us with some of the key patient messaging out there as well, in terms of prevention, taking more ownership on their own health as well, not wasting medication, as well, and things like that. So, if I'm trying to say to people, 'Well, actually, I'm not going to prescribe this to you because it's something you can buy over the counter', we do need to take into account deprivation and so on, but if that message is just coming from us on the ground, it's seen as we're not looking after our patients, so I think we all need to be consistent on that message too.

Maybe just saying that with that money that we are saving in those areas, we can spend that on other services and that you might find more benefits—making people understand that as well.

Yes, that's a key point on messaging. We'll make sure we note that strongly. Lesley, back to you. You're okay, are you, Lesley? All right. Thanks for that. Let's move into something we touched on right at the beginning, and I know Mabon's quite passionate about: digital.

That's a great question. Thanks. I work in a very busy GP practice and I've previously worked in a hospital setting, so I understand the different IT systems. They don't really talk to each other, and that is an issue. We need to progress this work on the single patient care record. But even things just to streamline the work, the volume of workload, the sheer volume in primary care; usually the systems that are done to prioritise appointments, to allow patients to self-book, all of these kind of things, to allow patients to take more responsibility for their own health, they are brilliant systems, and actually they've transformed how we work in my practice. They come at a cost, so that is perhaps instead of, then, another member being added to the team. So, it’s whether or not we can have investment to support with that as well.

Let me give you a great example of an IT system that’s poor. We have a service in community pharmacy called a discharge medication review. So, when somebody is discharged from a hospital, we get an electronic discharge advice letter that comes through Choose Pharmacy, it appears on my screen, my technicians manage it for me. We reconcile the medicines that the hospital has prescribed with what comes down from the GP on the next prescription, and we identify any errors that could have occurred. So, massive safety, big research done on it and it works really well. This electronic discharge advice letter prepopulates Choose Pharmacy, there are no transcription errors, it's a really good system. The health boards have now gone to new transcribing systems within hospitals, and two of the health boards have adopted a system that does not talk to Choose Pharmacy. So 10 years after this system has been developed, two health boards persevered with a system that at this stage does not talk to Choose Pharmacy. So we're back to paper systems. How does that happen in 2025?

I think that we are starting to make progress. It's been slow in Wales. We have the electronic prescription service coming, but it's not fully implemented yet. But that is going to be great for the future of pharmacy and GP services as well. And the app coming will enable patients, hopefully, when it comes and launches properly, to see their one health record and give them ownership of their health and make sure that they can see appointments and take that ownership on for themselves as well, or help them to take that literacy on. So there are issues now and still issues to overcome, but we have made progress. I think we do need to acknowledge that it's taken us a long time to get here. And then we need to look to the future as well. We've got pharmacogenomics on the horizon. How are we going to manage that pharmacogenomics testing into our systems and how are we going to see those results as well? So it's what the future looks like as well. So we need to be preparing for the future, not just what the problems are now as well.

We have been informed that they are working towards it. The spec that the health boards were given included that it could talk to Choose Pharmacy. I'm led to believe that there were other advantages within that system that work better for the health board in terms of transcribing, prescribing in hospitals. So they made a decision based on the overall gain to the system, but it's warts and all, isn't it? That's the problem. And a decision was made by those two health boards that that was a sacrifice worth making in the short term. I don't know where they are with that at the moment in progressing it or how it develops. But it's symptomatic of the piecemeal approach that we get rather than a whole-system approach.

I think that's a decision between the health Minister and the chief execs of the health boards, personally. That's beyond my pay scale, I'm afraid.

That's honest. But just to follow on from that, you're not being communicated with, you're not being asked your views on these things. You said earlier, Steve, that you're second level. You've not got a seat around the table on these big decisions, and that's a clear example of that, is it?

Don't overestimate my importance please. [Laughter.]

Yes, it's an interesting one. I sit here and think to myself, 'How can we have, in a national health service for only about three and a half million people, decisions taken on different IT systems across Wales?' I'm sorry, but to me we should have a national approach, because someone, somewhere didn't consider the linkages with all the existing IT systems, and that has to be done.

I remember, when our Choose Pharmacy system came out, it was all about, 'Let's get an IT system that will plug community pharmacy into NHS Wales.' We started with the common ailments service. And then we added another service on, 'Oh, we're not sure if Choose Pharmacy can handle that. We'll have to make some adaptations to that to be able to do that.' Okay, the same process. A couple of years later, a new service gets on.

We have the crazy system now where we're trying to give flu vaccinations and we have all these firewall issues that are stopping our contractors from getting easily into systems. It's because we're private businesses, the laptops are privately owned, so the firewalls have to be in place, as opposed to in a GP practice, and we're just not thinking about where we're going and why can't we be plugged in properly with a system that's NHS approved that sits there and we can communicate with everybody else within the NHS. But it's like being able to do that part but we're not thinking about another, because that's what we need now.

Is that an issue between you and GP practices? I'm just thinking of our inquiry, looking at improving GP practices. Is that communication, that issue with the firewall and IT—? Is it the same in that—

No. The message will get to the GP practice, it's just sometimes hard for us in community pharmacy to actually do it.

I was actually going to try to bring it to the GP practice thought process, thinking that, actually, there are these frustrations at the moment with the systems not working, but if we had one single patient care record where you could access it when you did that DMR rather than then having to send a note to the GP to say, ‘Well, actually does this need to change?’, you've got systems and pathways set up where you've got access to be able to change things and own it, rather than—. The more steps you put into a process the more likely it is that there's going to be an error. So it just feels like where are we with a single patient care record where things can be adjusted.

Picking up on Helen's point, if I see a patient in my pharmacy and prescribe something, it goes via Choose Pharmacy and that gets e-mailed to a GP as a document on the back screen. It could be two weeks before that's seen. Going back to what I said at the start, if I had read and write access, I would be straight into that patient's record and the GP then couldn't inadvertently miss it. So it is about interoperability, but there's a cost to that as well, isn't there, and I understand that.

Mabon, back to you. 

Many of my colleagues will think any topic with intelligence and me in it don't go together, to be honest. [Laughter.] There's going to be a role for AI isn't there? It's affecting all of our lives, everywhere. There'll be a lot of people, especially the demographics where I live in the Rhondda, who will mistrust it, who won't understand it, won't have access to it. It's going to be a big challenge. It's how we use it. We certainly can't duck from it, can we? If we don't embrace AI, we're going to get left behind, but where it fits into the system and how it's paid for is, again, another big question. 

I think we also need to be wary of the governance behind AI as well, making sure that it is working correctly and just be mindful of how we utilise it. It isn't going to replace our workforce; it needs to be used alongside to support our workforce, but we need to be very, very careful as to how we use it. I think it's an evolving thing. I agree that we can't hide from it because it's coming, but we need to be really mindful that we use it carefully and with due diligence as well.

Liz.

I think, no, our estate is not there. We have got some new modern buildings that are really fit for purpose, but there are lots of antiquated buildings with limited space, not enough patient access, or difficult patient access. So, even with the best will in the world, if you wanted to employ a pharmacist, where are you going to put that pharmacist into that building? You do want them to have the opportunity to be part of that multidisciplinary team, to be able to go and knock on that doctor's door, to have that query about a patient. So, you do need to look at room space across all the estates, really, and have a true evaluation of what we've currently got, what the requirements are, and also possibly how we are going to make it green for the future as well. So, are the estates we've got working in the best way for the environment as well?

Dai.

I put down, 'no', that it's not fit for purpose, so we're on the same page, 100 per cent. It's a difficult question. We've only got to look at Princess of Wales Hospital with the roof and the issues. The whole of the NHS estate is in a poor state.

We have, for the first time now, last year was when we had a grant for premises improvement within pharmacy, up to 45 per cent. I've been lucky enough to get a grant this year to put an extension on the back of my pharmacy to try and increase the number of consulting rooms to a proper standard. I've still got to find £150,000 of my own money to do that. That's a massive investment at my age, where I'm thinking, 'I'm not sure where the future of primary care is.' So, yes, the infrastructure of our estates is poor. It does need investment, but it's not just the investment, it's the confidence of the people working in it to think that the risk is worthwhile of putting that investment in. So, unless you can get the assurance of a plan for primary care and confidence that it's worth investing in, then the key players won't invest in those improvements.

Steve.

Yes, it's that following on from what Dai's saying. I think, particularly from the pharmacy perspective, which I guess was part of the question, we do feel a little bit like a poor relation. We're still seen as private businesses. We're not really embraced as part of primary care, even though now these days, for most independent pharmacies, 95 per cent of their business is NHS business. It's changed dramatically.

So, if we're part of primary care, then we really need access to the estates funding that the rest of primary care has, and to get rid of some of the crazy anomalies there. For instance, a GP practice will pay business rates, a pharmacy practice will pay business rates. The GP practice sends the bill to the NHS, to the health board, to pay it; the pharmacy practice puts its hand in its pocket and writes a cheque. Either we're part of primary care or we're not, and if we are part, then 'Please treat us as equals in primary care' is the plea.

Yes, okay. Thanks for that. Helen.

So, agreeing with everyone in terms of the building infrastructure. Some of the newer buildings absolutely are fit for purpose, but particularly in the Rhondda where we work, some of the practices are old terraced houses, site buildings. There's a lot of damp in there. I remember one practice where we couldn't actually print prescriptions because the printer was becoming damp all the time. So, it's working in these conditions.

If we want to develop the professions and have multidisciplinary teams, we need more space for people to work in. So, it's making sure we are being innovative, we are doing things like hub-and-spoke models, but that's not the answer everywhere. I think we've got to remember why we're doing this: it's for our patient cohorts as well. If care is shifting left, we need to make sure that we've got enough room to sustain that care left, so we are at the doorstep of these patients.

Thinking about some of the simpler things for me is, whilst we may have better rooms, we might not then have parking facilities. Would there be something in making sure there are transport facilities to be able to get patients to and from appointments? Thinking about the greener agenda, that kind of thing, so that not everyone is jumping in the car and so on. Just things like that, really.

Yes. Okay, thanks. Thank you, Mabon. I'll move us on to Altaf and primary, secondary care interface. Altaf.

Thank you very much, Chair. I know we are running out of time, but I will try to keep my questions short, and if I have short answers as well, please. What fundamental system and communication reforms are required between primary and secondary care to establish safe, accountable and clinically joined-up patient pathways?

Sorry, would you mind repeating the question, I couldn't hear it properly? Sorry.

Right, I will. What fundamental systemic and communication reforms are required between primary and secondary care to establish safe, accountable and clinically joined-up patient pathways?

To keep it short, at your request, a single patient care record would be the main answer for that, I feel.

I agree, that's basically what we want, all community will be able to access it, primary care will be able to access it, and at discharge that discharge will just automatically be on that patient's record. There wouldn't be having to be that duplication or transcription where we know the errors occur, so I think, yes, that one health record.

I agree. Is that short enough?

Right, okay. Now coming to the public understanding, my question is: to what extent is your specific role and contribution as a member of the multidisciplinary team understood by general practitioners, GP practice staff, and the wider public?

Okay, that's Steve.

I think it's one of our biggest issues. I'll be honest with you, we have loads of wonderful services in community pharmacies, and people are finding out by word of mouth. That's the way that we're getting there. I do think if we're going to move patients to go to certain places for their care, then we really do need to think about national campaigns to do so, along the lines of, 'Yes, this is where people should go for their common ailments, move to your community pharmacy, not your GP practice', or, 'By the way, do you know they can now treat your sore throat? Do you know they can handle all urinary tract infections? Do you know?' I bet the answer is—. I bet everybody in the committee doesn't know.

I think you're right. [Laughter.] Helen, and then I'll come to Joyce.

Just to reiterate that as well, I think some campaigns are key for patients to be aware. Only recently, I had a conversation with a patient to say I was going to conduct his asthma review, and he said, 'Well, why is that you and not a doctor?' So, these perceptions still exist, and I had to explain why it was within my gift. But I think as well it's managing the message, in terms of that it's not always going to be a prescription or a medication at the end of it, because we know there's overprescribing. So, we've got to check the message we send out, and we don't want patients coming to us thinking that they're going to come out with a bag of something, because that might not be the answer.

Yes. Thanks—

Thank you very much. Chair, I have the last question, really—

Can I bring Joyce in for a minute, Altaf?

We did have a national campaign, because I remember seeing it, and being quite delighted that it was on the tv. So, my question is this: is it the right place to put a national campaign? People are accessing their information in different places now, and I think many surveys have showed that most people aren't even accessing the news on the tv anymore. So, is it the right medium? Because I know there was a campaign, and I know the Welsh Government put a lot of money into it, and I was behind pushing for that to happen and understanding the difference that you make. Maybe it's rethinking those campaigns, and where the message is dropping.

I think we overestimate, people of our generation, how people access information, okay? We had a COVID vaccination clinic in one of our pharmacies five years ago, and we had a message from the health board saying we could do a walk-in clinic on the Sunday. It was appointments the week before, it was a walk-in clinic, we had 200 appointments booked in. So, the pharmacist there put it on Facebook, 'We're having walk-in appointments', we did 500 vaccinations. That Facebook message got around the village within two hours. So, if we want to make a cultural change—that's what we're talking about, aren't we, a cultural change in the way the public access the NHS—we have to look at how the public gain that information and engage with that campaign. Because we think that they will access the information in the way we access it, and they don't—you're right, Joyce, they don't.

So, we agree on that.

We do agree on that, yes, 100 per cent.

That's a good point: go where people go. Yes. Thank you, Joyce. Altaf, you had something final you wanted to ask.

Yes, Chair. I wanted to say what has been already said, but let me repeat it. What targeted strategies are required within both primary care and public health campaigns to enhance this awareness, improve appropriate patient signposting, and ensure the effective and safe utilisation of the MDT while maintaining the ultimate clinical accountability of the general practitioner?

Okay. Does anybody want to—? It's a big question, but how can we improve some of those?

And it tells you about the accountability of the general practitioner.

Yes, yes.

The simplest answer? What I said at the start: get a plan for primary care. Get a plan for primary care, see what you want primary care to actually deliver, and then start looking at who can deliver that within that team. But until you've got an overall plan, how can you start making plans for that?

Using public health data to inform that based on your populations, and then using the education work streams to try to educate patients to take a bit more responsibility as well, whether that's with their appointment follow-ups, or whether that's actually trying to maintain their own health as well.

Yes. Liz.

I think it's the education, as well, of the future generations—how to access medications, what the benefits are of the health service, keeping that younger generation healthy, preventing them getting into ill health as well.

Schools. Again, it's schools.

Schools.

Can I ask a final question?

Yes, please do.

Because you just made me think about something. The younger generation are likely to use the same online advice and buy medication online, which we know—there are cases coming to light—that it's not what they think it is. That's the first thing. And it's costing people their lives or long-term illness. I'm sure you see that, because people will say, 'I had this online, it was cheaper.' So, there's another bit, isn't there, of work that has to be done, and it is that access to information and how we counter that. It's a huge question, and I don't know if you've done any thinking around it.

It's about where that trusted advice comes from. It's about relationships. The number of times I get a phone call from someone, 'Can I ask you something?', 'Yes, of course you can, fire away.' If they've got a face that they know, that they regularly see, and they trust you, they're more likely to listen to the advice you give, aren't they? That's about embedding healthcare professionals in the community where they work. Become part of that community, and you're more likely to effect the change you want.

Yes. Those are wise words there.

A nice way to finish.

For the younger generation, I think we need to be mindful that they may be accessing that education from different sources, so how do we get that—? The face of Dai would have been the trusted individual; how do we get that across to the individual in the future going through the internet? How do we say that, 'This is a trusted website, this is a trusted source of information'? I think that medicines misinformation needs to be key, as well.

Yes. And it goes hand in hand with that thing we talked about: AI. AI's got lots of strengths, but is a massive threat. How do you take confidence that you're not reading something that is totally incorrect? We hear evidence of that all the time.

I'm conscious that we're running out of time. Steve, is there anything you wanted to add to any of the last couple of questions?

No, I'm happy with the responses. I'm not going to add something for the sake of it.

Well, this has been an absolutely fascinating session. We're actually just spot on time. I really do thank you all for your candidness and clarity on what's needed. There will be a transcript available for you to check over. If there's anything you feel is misinterpreted or whatever, please feel free to contact us. But, once again, thank you for giving up your time for such an important discussion. 

Thank you very much indeed.

Thank you for the opportunity.

Thanks for the opportunity.

Thank you. Thank you, colleagues. We're going to move into private now for a session for lunch, okay?

Good afternoon, everybody. Welcome back to the Health and Social Care Committee, where we're in the process of taking evidence sessions for our inquiry into general practice in Wales. This is our third session today and I'm delighted to welcome members of our health boards. Perhaps I could ask you to introduce yourselves for the record; could I ask you first, Paul?

Prynhawn da. Good afternoon. I'm Paul Mears, I'm chief executive of Cwm Taf Morgannwg University Health Board. 

David Andrews, I'm a GP in the Rhondda and I am the medical director for primary care and community services at Cwm Taf Morgannwg University Health Board. 

And Elaine, online. 

Prynhawn da. Good afternoon, everyone. I'm Elaine Lorton, I'm the executive director of primary care, community and mental health for Powys Teaching Health Board.

Thank you, Elaine. Unfortunately, we were going to be having some other representatives, but they couldn't make it toward the last minute. So, thank you so much for making the time. This is a really important inquiry and it's really interesting and so important that we have your perspectives.

We have several questions. We've got about an hour and a quarter, if that's okay, and we'll try and get through as many of them as possible. Perhaps if there are any follow-ups, you won't mind if we write and we can chase those with you. 

Anyway, I'll kick off, if I may. How does health boards' actual spend on general practice compare with the amount allocated by the Welsh Government for the general medical services? It would be really helpful if you could give some information around how that's changed over the last few years, and a broad insight to where we are on that.

Do you want me to start off and then Elaine can come in?

Yes, please do so. Elaine, if you put your hand up—not your electronic hand, just put your ordinary hand up—and I'll bring you in.

Thanks, Chair. As you'll appreciate, the health boards have an allocation of resource given by the Welsh Government for the totality of what we are responsible for, and that includes, obviously, primary care and GMS contracts for GPs. There is other money, obviously, that comes through for various allocations for different specific projects. For example, the work that's been done around cluster development has been funded through different resources that have come into health boards. 

I think it's fair to say that the allocation for primary care, when you compare to what we spend on hospital care, is definitely significantly lower, and has been the case for quite a while. Obviously, with the pressure since COVID to continue to improve waiting times and reduce waiting times in planned care and urgent care in hospitals, that's led to quite a bit of extra resource being put into the secondary care part of what we do.

But I think we've got a collective ambition across Wales now to start to rectify that and start to bring the resources back into primary and community care, because, as we all know, the ambition through 'A Healthier Wales' and through everything we're trying to achieve in the health service in Wales is to try and look after more people in their own communities, provide more support to people in their own homes, and primary care and GPs in particular are critical to that.

If we're serious about that, then clearly the resources need to follow the rhetoric and we need to think about how we, as health boards, improve the way in which we allocate resource towards primary care. But also there's a conversation, I think, about how, within Government, the resources that get allocated to the agenda around primary care, and GPs in particular, can be reflective of the ambition.

Do you think, with hindsight, that perhaps the decision to, not disinvest, but to prioritise resources in other places has become the wrong decision? 

Obviously, as we came out of COVID, there was a large backlog of activity in hospital waiting lists that needed to be addressed, and clearly, understandably, that's been resourced to try and improve that. But, of course, when you've only got a finite pot of resource within the Welsh Government, there then have to be decisions about other things that haven't been given the resource that's gone into other things. So, I think that has been the case, but I think that we are starting to see that change now. Clearly, there is a drive, and we are certainly being asked, as health boards, to look at how we reprioritise and reallocate resource into primary care. We're also being asked to report on now the percentage of resource that we are spending in primary care compared to other services, and being able to articulate how that's going to increase over the next few years.

Thank you. Elaine, would you like to come in? 

Yes, to add to the points Paul has made generally about the allocation that we receive each year, and then in terms of how we spend that within health boards, equally to think about what's happened to that level of funding over the last few years. We know that the total proportion of money that is allocated and spent on GMS is a much smaller proportion now than it was, say, eight or 10 years ago. I think it's gone from about 9 per cent to about 6 per cent. That doesn't mean that general medical services have not seen uplifts. There have been uplifts, and those have been negotiated annually, but the total spend in terms of primary care and general medical services has reduced. 

I think it's very difficult to say whether it's a right or wrong decision. I think the question is what are the outcomes that we are looking for. As Paul mentions, coming out of COVID, there was a significant list of people waiting for planned care procedures, for example. We know that we have rising demand and a rising demographic across Wales, particularly around older people who require unscheduled care treatment; they need to come in and they need to be supported.

My reflections on that are that I believe very strongly that, if we have a really strong whole primary care system, which sits not just within general medical services, but how general medical services, as the medical leads within our community, link in then with wider community service delivery, I genuinely believe that can have a much larger and positive, proactive and preventative space, so that we are earlier in how we're caring for people with chronic conditions, and equally, that our older or more frail population can access more responsive, proactive care, to mitigate and reduce the need or the length of time that they need secondary care treatment. I think that's something that, without thinking about how we're allocating our resources, which we are looking at within health boards, but more broadly across Wales, is always going to be constrained.

Thank you, Elaine. David, did you want to add—? 

I guess I'd like to acknowledge that a well-resourced and well-functioning secondary care service, both in the planned care space and unscheduled care, benefits general practice, but at the same time I echo what Paul and Elaine were saying. If we're serious about resetting the agenda and thinking of the medium to long term future of our services, the status quo is not that way forward. So I would agree that, certainly in Cwm Taf Morgannwg, we're looking considerably at investing left, as we say, to try and work through those challenges. It's an iterative process and a progressive process, it’s not a single IMTP. It's a while.

Thank you for that. It looks like things might be heading in the right direction. Elaine, you already pre-empted, perhaps, a question I wanted to understand a little bit more about: what the levels of investment are, or rather funding as a percentage of the whole going into GP practices, primary care. Do we know how that varies across health boards? Because the reality is, even though there have been additional cash uplifts going forward, we're talking real-terms cuts, really, to primary services, because they're not keeping up with the demographic need, I doubt. And that's why I was pleased to hear, Paul, that that might be a change going forward. But some sort of clarity of understanding where we are on figures at the moment would be useful.

Both the GMS and the supplementary services budget are ring-fenced and come straight through, so we have very little discretion with regard to that. And actually, with contractual barriers, it makes it very difficult to take anything from it or to put anything into it. That's quite tricky.

Okay, that's really interesting, to understand that even if you wanted to add in for some preventative agenda, you might not be able to do that. 

There are things I think we can do through supplementary services, so, if you like, add-ons to the GMS, but the core GMS has a very clear contractual negotiated set of expectations within it. Anything we want to do on top of that is something we would then negotiate at a local level through the local medical committee or other professional bodies. So there are ways you can do this, and I suppose this is where the definition of what is the primary care spend is really important, because as Elaine and David just articulated, there's GMS spend, which is the general medical services money that comes straight from Government, which is ring-fenced, but of course then as health boards we're also spending money on community services sitting around primary care, so things like district nursing services, community therapy services—those are obviously discretionary funds that we as health boards fund, and that's entirely within our gift to look at how we resource that. But in terms of core general practice contracted funds, it's the GMS ring fence.

Just to add to that, I think it's really important to point out that, when we're thinking about the utilisation of those ring-fenced GMS funds, a significant portion of those sit within supplementary services, and the delivery of supplementary services sits at the discretion of the general medical services, not at the discretion of the health board.

There will always be some variation across Wales in terms of how much those supplementary services are delivered between different practices, and the quantity of activity that is then delivered and claimed for, because different practices are all in their own individual position in terms of their workforce, their competencies, and which of those supplementary services they feel able to deliver. What can be quite challenging from a health board perspective is a desire to expand and grow those supplementary services, and yet it is only throughout the year as we see them being claimed that we understand how much resource that requires.

I think most health boards have got to a position where they are in a reasonably balanced state. I can only speak specifically for Powys. I know that I'm spending all of my GMS allocation, all of my supplementary services allocation, on that, but it has taken some considerable time to do that. We've got quite an extensive list of local supplementary services that we've delivered, but every single health board has a set of those.

On the actual GMS funding, that quantum is set, and that would be similar in all authorities. So, that's whatever it is, and what sort of figures did you—? Elaine, you talked about it being somewhere around about 5 per cent of 6 per cent now, as opposed to 9 per cent, perhaps, a few years ago.

Yes. I think we're just over 6 per cent now in terms of total health board allocation that is spent on GMS. That's across Wales. I think, eight, 10 years ago, we were about 9 per cent. So, there has been a reduction in the proportion, but there hasn't been a reduction in the amount.

Thanks for that. Just looking at systems, I just wondered what systems and processes you use as health boards to monitor and report spending on primary care. What are the main challenges in producing a clear and consistent picture of how the funding is changing over times? Do you keep that sort of data? Elaine.

Yes, I'm happy to come in on that. I recognise I'm a little bit quiet, so I'm not quite sure how to change that. So, in terms of the reporting, our shared services partnership provide us with monthly reports, both in terms of the amount of activity claimed through supplementary services and then the amount of spend. So, we can see that on a month-by-month basis within health boards.

Anything else?

No. I absolutely agree with Elaine, and, as I said, we're now being asked by the Welsh Government to actively report to the Welsh Government regularly on the amount of money being spent in primary care, and also community services as well, which I think is an attempt to try and make sure that we're able to encompass the whole spend that we're deploying in that area, because, obviously, GMS is one part of that, but there is also money that we as health boards are spending, then, on community-based care, supporting practices as well.

So, the health boards, whilst collecting that data, are pretty familiar with the challenges, then, that are being presented in primary care. So, the health boards were aware of the pressures there, in primary care.

Absolutely. Obviously, just as people like Elaine and other colleagues in other health boards, we have primary care teams who are very close to the primary care world. They know the practices, they are in regular communication with the practices. We have, certainly in our organisation, good relationships with our local medical committee, which is the formal body that acts as the interface between general practice and the health board. We are very well sighted on the challenges both from a funding perspective and also pressures, demand. If there are particular practices that are in difficulty or are having some challenges, that will be flagged through those routes. So, I think, as health boards, primary care teams are very well used to that relationship with general practice on a day-to-day basis.

Okay. Elaine.