Cynulliad Cenedlaethol Cymru

Yn ôl i Chwilio

Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

20/02/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Dai Lloyd AC Cadeirydd y Pwyllgor
Committee Chair
Darren Millar AC Yn dirprwyo ar ran Angela Burns
Substitute for Angela Burns
David Rees AC
Helen Mary Jones AC
Jayne Bryant AC
Lynne Neagle AC
Neil Hamilton AC

Y rhai eraill a oedd yn bresennol

Others in Attendance

Simon Dean Dirprwy Brif Weithredwr GIG Cymru, Llywodraeth Cymru
Deputy Chief Executive NHS Wales, Welsh Government
Vaughan Gething AC Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol
Minister for Health and Social Services

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Bethan Kelham Dirprwy Glerc
Deputy Clerk
Claire Morris Clerc
Clerk
Philippa Watkins Ymchwilydd
Researcher

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:32.

The meeting began at 09:32.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Croeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd. O dan eitem 1 mae cyflwyniadau, ymddiheuriadau, dirprwyon a datgan buddiannau. A allaf i estyn croeso i'm cyd-aelodau o'r pwyllgor a hefyd datgan ein bod wedi derbyn yr ymddiheuriadau arferol gan Angela Burns? Mae Darren Millar yma yn dirprwyo ar ei rhan. Hefyd, dŷn ni wedi derbyn ymddiheuriadau'r bore yma oddi wrth Dawn Bowden. Gallaf i bellach egluro bod y cyfarfod yma yn naturiol yn ddwyieithog. Gellid defnyddio'r clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. Os bydd y larwm tân yn canu, mae hynny'n golygu bod yna dân, felly dylid dilyn cyfarwyddiadau'r tywyswyr. 

Welcome, everyone, to the latest meeting of the Health, Social Care and Sport Committee here in the Senedd. Item 1 is the introductions, apologies, substitutions and declarations of interest. Can I welcome my fellow members of the committee and also state that we have received apologies from Angela Burns? Darren Millar is here on her behalf. We've also received apologies this morning from Dawn Bowden. Can I further explain that this meeting is bilingual? You can use the headphones to hear the interpretation from Welsh to English on channel 1 or to hear contributions in the original language amplified on channel 2. If a fire alarm sounds, that means that there is a fire, so please follow the directions of the ushers. 

2. Gofal Iechyd Gwledig: Sesiwn dystiolaeth gyda'r Gweinidog Iechyd a Gwasanaethau Cymdeithasol
2. Rural Healthcare: Evidence session with the Minister for Health and Social Services

Felly, gyda chymaint â hynny o ragymadrodd, fe wnawn ni symud ymlaen i eitem 2 ar yr agenda ac ein hymchwiliad ni i mewn i ofal iechyd gwledig. Dyma, wrth gwrs, gyfle i holi'r Gweinidog am rai materion a godwyd yn ystod y sesiwn dystiolaeth fendigedig yna a gawsom ni cyn y Nadolig gyda Dr John Wynn Jones, arbenigwr yn y maes—meddyg teulu sydd hefyd wedi bod yn feddyg teulu yn ei amser yn Nhrefaldwyn ac yn gwybod cryn dipyn am faes gofal iechyd gwledig. Felly, dŷn ni wedi derbyn pob math o dystiolaeth ymlaen llaw, ac, fel sy'n arferol, awn ni'n syth i mewn i gwestiynau. Mae'r cwestiynau cyntaf o dan ofal Neil Hamilton.

So, we will move on to item 2 on the agenda, which is our inquiry into rural healthcare. This, of course, is an opportunity to ask the Minister about some issues that were raised during that wonderful evidence session we held before Christmas with Dr John Wynn Jones, a professional in the field and who has also been a GP, in his time, in Montgomery and who therefore knows quite a lot about the area of rural healthcare. So, we have received all kinds of evidence beforehand, and, as usual, we'll go straight into questions. The first questions are from Neil Hamilton.

Diolch yn fawr, Cadeirydd. The background to this inquiry is that it's 10 years now since the rural health plan was published, a rural health implementation group was established, and, in January 2012, Lesley Griffiths, the then Minister for health, said good progress had been made. Your own evidence to this committee states that, in 2013, an implementation group recommended a centre of excellence be set up. The mid Wales healthcare study supported this and called for a mid Wales healthcare collaborative to develop a service model for the region. We'd really like to know what has happened since. But, in the first instance, could you, Minister, please briefly outline what you think are the key current concerns about rural healthcare services, and in particular what areas of practice or parts of the workforce are considered most fragile?

Well, there's a fair amount of similarity in the challenges about rural and urban Wales in the sense that there are challenges about access to care—access in the sense of whether people can make appointments with a healthcare professional when it's convenient for them as well as the healthcare professional. There are challenges about physical access. If you live in an urban centre, even if you're closer to a point of care, there are still challenges about getting across the city, for example, so the time may not be dissimilar to some rural communities, but there is a much greater distance, of course, in some parts of rural Wales to centres for care as well, so that is a particular challenge that exists.

On our broader challenges, again on workforce, every part of the country is seeing challenges on workforce training and recruitment. You'll find general practice in Cardiff and Newport facing some challenges about consolidation, just as you will in some parts of rural Wales. Broadly, though, the further west we go in the country, our recruitment challenges tend to be—not in every instance, but tend to be—more challenging. So, we recognise that there are particular challenges about the model for rural healthcare that we're working through and that are being worked through. And, actually, the work that was done with the rural health plan, the work that then became the mid Wales study, is generally being taken forward by both Betsi Cadwaladr, Powys and Hywel Dda. So, there are challenges that are particular to rural Wales, challenges that are common across Wales, and the whole point of having a national plan in 'A Healthier Wales' for health and social care is to make sure that we're able to address those and able to think about how we transform the way in which we deliver health and care.

What I regularly say, actually, on general practice is that I think that the rest of the country on general practice needs to look a bit more like Powys, because the level of ambition that exists amongst general practice in Powys and the way in which they've constructed their local relationships has gone from a period where, actually, there was real despondency not that long ago, historically, to a vision now where—. For example, in southern Powys, the Brecon, Hay and Talgarth practices did not have a positive relationship, and they themselves acknowledged in a meeting with me a couple of years ago that they would refer people to different centres for treatment based on where they thought the other centre was referring people to, and, actually, since they've come together in a cluster, they've managed to get over some of those challenges in their working relationship and they now provide a much better service. It's why, when we talk about the virtual ward, we are actually talking about a model that was developed in southern Powys that we are now trying to roll out progressively across the rest of the country. They've got relationships with the third sector, with other health and care professionals, and I think there's a real model there that is being taken on as the new model for primary care. So, as well as the challenges of being rural, there are many things that I think the rest of the country could do with learning from the way that rural practice is moving ahead. 

09:35

Of course, 'rural healthcare' is a broad, generic title, and even within rural areas, and in the region that Helen Mary and I represent, there are significant variations in provision, and problems exist in some areas that don't exist in others. To what extent can you say currently that residents in rural areas in Wales have equity of access to quality healthcare compared with their urban counterparts? There are special difficulties in our region that don't exist in, say, Cardiff.

Yes, and, look, this is a real challenge in delivering health and care in any part of the UK, and we're certainly not immune to it here in Wales. So, if you think, as a practical example, about stroke care, we have had really robust and clear advice from the Royal College of Physicians, supported wholeheartedly by the Stroke Association, that we need to have fewer centres admitting for strokes, and there's evidence in other parts of the UK—urban and rural parts of the UK—that outcomes have been improved. So, the challenge for us has been, 'You need to make progress with this', because in every part of Wales, we're going to expect there to be an improvement in outcomes, so reducing avoidable disability and actually reducing mortality.

Now, that's a challenge because the evidence the health service is working with suggests that, rather than approximately 13—I think it's gone down to 11—centres admitting strokes, we should have around about half that number, and actually the clinical lead for stroke care is based in Bronglais, and his view is that we have too many centres. He says what you'd have to do is agree where you'd have what they call hyper-acute stroke units, a lesser number of those, and you then have to have a practical view on what you do in particular for west Wales—so, in north-west Wales and in mid and west Wales—and about what you do and the choices you make about whether you have people travelling further for treatment where they have a form of treatment that exists there that in isn't a hyper-acute stroke unit. Now, that's a practical challenge to work through. There is a point about equity of access there, because what I wouldn't want to say is, 'If you live in a rural part of the country, you just need to accept that you are never going to get access to high-quality care, and that's just how it is.' That is not the vision we have for the health service, but you have to recognise that there are practical challenges in getting to—. For example, we're talking about stroke care—there'd be a practical challenge if your nearest hyper-acute unit, for example, is Swansea, how do you then deliver something where you're not reducing access to high-quality care? Because the last thing that I would want to do is to say, 'As long as it's local, then that's okay for rural Wales', because that isn't okay. So, you have to make sure that the quality is what drives what we do, and we have to think about how we practically make sure people can access that care. We have regular conversations about ambulance responsiveness, about the role of the emergency medical retrieval and transport service in trying to level up equity of access for different parts of the country to appropriate care. So, in unscheduled as well as scheduled care, we have real challenges.

09:40

Obviously, nobody's going to expect every single person in the country to have exactly the same access wherever they live. Clearly, no amount of money would satisfy that aspiration, but we're talking in terms of generalities to an extent, but not at a macro level—we're trying to bring this down to sensible areas in which you might expect, broadly speaking, there's a rough equity of treatment.

I think a good example is midwifery care. There are people who have children in every part of the country: rural wales, urban Wales, semi-rural or semi-urban—that will depend on your point of view. We've invested in midwifery care in both mid and west Wales, in north Wales and indeed in Powys as well, and so actually we find a group of staff who are enthusiastic about the vision we have for midwifery services, who are providing that access to care. So you may have to travel further if you really do need consultant-led care, but actually we've managed to move to a position where there is greater confidence amongst the profession or professions, and indeed amongst the whole community, that they have high-quality care that's delivered by a midwife, and you don't have to be within 20 minutes of a consultant. If that was the case, then we'd say to people who were having children, 'There are large parts of Wales you're not allowed to live in.' We don't say that, and if you talk to midwives delivering healthcare, in Hywel Dda and in Powys in particular, they're really proud of the investment we're making in those midwifery-led services. So, it does show that deliberate investment—and because, actually, we have people acting at the top of their professional competence, where now, for example, there are people in Powys who are not being sent to Shrewsbury for consultant-led care during their pregnancy because of the capability of our midwifery workforce across Powys, and that's a good thing.

Good. My final question, then, to wrap up this section from me is: you referred earlier on to the fact that we've been looking at this area roughly for 10 years now. To what extent can we say that we're much further on than we were when the rural health plan was introduced back in 2009, and to what extent, therefore, does 'A Healthier Wales' offer the same sort of integrated models of care and workforce roles as were posited under the original plan?

We've been really clear that a more integrated approach to healthcare is exactly what we need to see right across the whole country, so, as I said earlier, there are models of more integrated care that exist in rural Wales that we want to see more of, not just in rural, but in urban Wales, too. If you were to ask people who are campaigning and had real concerns about the future for healthcare, and in particular about the mission of Bronglais, but the broader way in which healthcare was delivered across that part of Wales, there has been real and genuine progress.

When I was a student in Aberystwyth, I regularly used the health service because I had been diagnosed with nephrotic syndrome in the year before going to university. I had to restart university because of my health, and so I regularly saw my general practitioner in a way that other students did not. I regularly spent time waiting for many hours in the out-patients department in Bronglais hospital. So I got to see a fair amount, and I was an in-patient in Bronglais hospital during my time as a student as well. I had problems with my eyesight that were related to my condition and the treatment. So, since then, when I go back, I can recognise change that has taken place.

And more than that, my GP at the time is now retired, and he was one of the leading campaigners who were not at all persuaded that there was a real commitment to the future of healthcare delivery in that part of the country. He is now much more positive, and that's because the health board—health boards plural, have recognised they needed to invest time in regaining the trust of people who live in that part of Wales. And if you look at Jack Evershed and Ruth Hall, our former chief medical officer, they are now the co-chairs of Rural Health and Care Wales, the centre for excellence. The Mid Wales Healthcare Collaborative has sign-up from health boards, with a chair of a health board and a chief executive of a health board being the leads attached to it, and it's an area that we look on as planning the delivery of healthcare in a way that didn't take place in the past.

So, actually, from the rural health plan to where we are now, there has been real change, not just in the structures of how we're trying to do things but, actually, in the level of confidence and ambition there is for the ability to deliver health and care. And, actually—this is absolutely genuine—some of the changes that have taken place there are part of what I think we need to see more of across our health and care system across the whole country. 

09:45

Your paper describes the mid Wales joint committee as having 

'a strengthened role in the joint planning and implementation of health and care services across Mid Wales, with ambitions to further develop this approach into an All Wales Rural Health and Care Alliance in the coming years.'

Can you provide some further information about the role of both the committee and the proposed alliance?  

The proposal for the alliance comes from Rural Health and Care Wales, and they think that there is an opportunity to generate more research about rural excellence in healthcare, and what that looks like, how that might affect the training of medical professionals in the future and, frankly, to draw together those people that want to see high-quality care delivered across Wales. The joint collaborative committee, that has a planning role.

So, we've drawn together, during this term of the Assembly, health boards into groups to plan services together. So, in south-east Wales, Cwm Taf work with Cardiff and Vale and Aneurin Bevan and, obviously, they have a conversation with Powys who commission services from those health boards. Currently, ABMU, soon to be Swansea bay university health board, and Hywel Dda health board work together to plan and deliver services. The mid Wales collaborative, or the joint committee—they have a role in helping to plan healthcare around that sort of nexus between Powys, the northern end of Hywel Dda and, indeed, the southern western part of Betsi Cadwaladr. So, they have a role in helping to plan the future of the health service.

Of course, we continue to make investments into healthcare in that part of the world. it wasn't that long ago that I opened Tywyn hospital, the repurposed Blaenau Ffestiniog and, indeed, you can see additional developments taking place around there. And, actually, when we look at our primary care clusters, one of the first federations is in the northern part of Ceredigion. So, we're seeing real progress there. And I think that the joint committee has a role in drawing some of that together to make sure that the three health boards, who have to work together to deliver provision, don't get tied up in the boundaries on the map, but actually recognise the communities they all have an interest in and a responsibility to serve.     

The 2009 rural health plan was widely welcomed by many as a means to ensure the future healthcare needs of rural communities would be met. 'A Healthier Wales' makes no specific reference to rural issues. Do you think there's a risk that, in the absence of a rural health plan today, the challenges of rural communities won't be met? 

No. We spent a long time getting to have 'A Healthier Wales'. We had a parliamentary review at the start of this term of the Assembly, agreement on the terms of that review, agreement on the people to undertake that review. There was a year of the review taking place. We responded. We now have a coherent health and social care plan for the country, and that is not just a plan for urban Wales or a plan for rural Wales; it is a plan for Wales. And we recognise the context in which we deliver health and social care. The part of the country you're in affects some of what you are able to do and the specific local models of care.

But we also know that the central message has been that you've got to transform the way we deliver health and care, and the statement yesterday was talking about the progress that we've made since the announcement that there would be a transformation fund just over a year ago, and what we've actually managed to do since then. When you think about what we've actually had come forward since then, there's a significant chunk that is about delivering health and care in rural Wales. And it's worth reminding ourselves that every health board—every health board—has a chunk of what we would understand and describe as 'rural Wales'. The rural Vale in the Vale of Glamorgan. I see an Aneurin Bevan constituency Member here, and part of every Valleys constituency has a significant chunk of rural Wales within it as well. So, we're not just talking about Powys and Hywel Dda and parts of north Wales when we talk about rural Wales. As I say, every health board has a responsibility to deliver health and care with and for that population, and not just a chunk of it. 

For me, the big challenges are our ability to deliver the vision set out in 'A Healthier Wales' and the transformation that is required, and the challenges of confronting Brexit. And they're the two big challenges that we face in the here and now, and I really don't want to get diverted from delivering the vision in 'A Healthier Wales', because then the coherence we have could easily disappear if I set off and try and have specific plans on geographic locations about addressing the need and the expectation I have that, in a planned healthcare system, we'll be able to plan and deliver healthcare for all parts of the country, in a way that delivers equity of access and, indeed, the excellence that all of us should expect. 

09:50

You mentioned the parliamentary review, and in that they called for Welsh Government to enhance access to good-quality care for rural communities. How is that recommendation being taken forward?

Well, if you look at what we've done, and I've just mentioned the transformation fund—a large part of that actually is about recognising what we need to do in delivering health and care in rural Wales. If you look at the west Wales projects that we've approved, that is about delivering healthcare in rural Wales. If you look at the NHS Wales Awards, there are awards that recognise the steps that health boards have taken on delivering better access for health and care in rural Wales—in particular the Pembrokeshire project that was recognised in the NHS Wales Awards finals and, indeed, the multi-award winning virtual ward that I referred to earlier. So, there is real ambition to change and transform the way we deliver health and care in rural Wales, and that is absolutely part of the vision to take forward in 'A Healthier Wales'. And with the bids that I have, that I'll be reading through the rest of the week, and indeed the bids that I know are imminent, you will see, as I said yesterday, that every single health board has put in a bid with its regional partners, so every area of the country has a stake in the transformation, and that, unambiguously, includes rural Wales. So, I just think the facts don't support an argument that rural healthcare is being forgotten or left behind. It isn't forgotten or left behind by the Government, or indeed the health service and partners in local government, the third sector and housing as well.

And do you think there's a sufficiently robust, consistent approach across all Government departments to rural healthcare impact assessments?

The rural-proofing approach that we have is one that is embedded within our approach in Government. There was a review in 2014, I think, that recommended some changes that have been taken on board. So, it's a regular part of policy formulation in every part of the Government. And I think the challenge is, not whether we look again at processed measures, but actually looking at whether we are delivering something that is better. Are we delivering against the vision we have, the quality of services that we want to deliver? And, equally, our challenge is on regenerating the rural economy, with all of the shocks that we expect to see happen out of the system, regardless of what happens by the end of March. So, you do see an ambition, you do see real policy drives going in across Government, as well as in my particular specific area of responsibility across health and social care. 

Hapus? Troi nawr i faterion yn ymwneud â datblygu'r gweithlu gwledig, ac mae'r cwestiynau yma o dan ofal Helen Mary Jones. 

Happy? Turning now to issues regarding developing the rural workforce, and these questions are from Helen Mary Jones. 

Yes. So, if we can drill down into a bit more detail around some of the workforce issues—can you tell us about how successful the 'Train. Work. Live.' campaign has been in terms of attracting GPs to serve in rural areas?

Anecdotally, I've met people who have chosen to come to Wales or to come back to Wales. When we look at the figures, though, the average fill rates—I've got some figures here, before and after the launch of 'Train. Work. Live.'. For Aberystwyth, the five-year fill rates were 27 per cent for GP training schemes, 58 per cent after the launch of 'Train. Work. Live.', and we have ambition to do more. In Bangor, 73 per cent before 'Train. Work. Live.'; 131 per cent afterwards. Carmarthen: 82 per cent up to 90 per cent. Dyffryn Clwyd: 60 per cent to 69. Pembrokeshire: 50 per cent to 108 per cent. So, in each of those areas, there is a material increase. And the message that I have given and have been consistent about is that where we have the ability to overfill, and there is the capacity to overfill, I'm interested in stretching it as far as possible. So, the limiting steps are often about the number of training practices we have, as well as that we don't just have expressions of interest but actually they go through and want to come up with an application. And so, last year, we underfilled one part of north Wales, but overfilled another. Because if we'd insisted that people went to the part of north Wales that had some gaps, we may well have lost them to Wales full stop. And so we have to take a pragmatic approach to doing that.

I'm also clear that—and in answers to business questions yesterday, we heard the commitment given by the Trefnydd that we would have a statement from me in April, when we get the round 1 figures for GP fill rates. But as well as 'Train. Work. Live.', the incentives that we've introduced within that—so, the additional moneys for people to apply to particular areas appear to have worked in helping us. They appear to have—I'm interested in a proper study, a proper evaluation, to understand how much of a difference that has made, as well as the fact that we're trying to make a career in general practice in rural healthcare more attractive anyway, as well as the Wales-wide incentive of paying for exam fees. And that's made a difference. And what I'm really positive about, though, is that if you talk to young GPs—the stand that we had at the BMJ careers fair was staffed by young doctors who were really positive and enthusiastic about a career in medicine in Wales. And you can't create or manufacture that enthusiasm. So, they're prepared to talk to their near peers and colleagues about the opportunities to work in Wales, and the sort of commitment that they believe exists across the whole system. Now, that doesn't mean to say they're all waving around pictures of me, saying, 'This guy is great'; it is actually about their ability to work with peers and colleagues in a system that is serious about transforming and working in a new way that is much more attractive than any individual politician, sadly.

09:55

So, if 'Train. Work. Live.' is working well for GPs, and that does sound really positive—. So, it currently covers medicine and nursing doesn't it? Do you have any plans to extend that to other health and care staff?

Yes, we're rolling out, from this April, to pharmacy, and we're working with colleagues in therapy, and others, to think about an effective roll-out for areas where we need to recruit as well. But we are definitely rolling out in pharmacy from April onwards. And it does show that we're learning from what's happened in the initial phase of 'Train. Work. Live.' with doctors and nurses. In some of our initial imagery for 'Train. Work. Live.',  we had actors, essentially, posing—actually, it was much more effective when we rapidly moved to having people who are actually doing the job. So, in the first phase of the nursing campaign, and in all subsequent phases of every single 'Train. Work. Live.' campaign, there are real people, working in the health service, who feature in the boards. So, their story is a real one. It isn't just, 'Here's an example of what you could do', but 'Here is an example of what a real person within the health service has done', and the split between their working life and their social life. Because it is about all those things—the quality of training—. We do well on the quality of training in all the comparator surveys; that's a real feather in our cap. And, again, that isn't because of decisions that I make, sat at my desk; it is about the commitment and the strive for excellence that exists within our service. The working part—the job still needs to be a good job to keep people—and, of course, living in communities as well, and highlighting the different opportunities that exist. So, we've learnt from each of the previous phases, and you'll see that in the pharmacy phase.

I just want to probe this issue of training places and attracting people into Wales. Why is it that, last year, there were 7,192 applications for nurse training, and only 1,771 people were actually offered a nurse training place, when we've got a critical shortage of nurses across the Welsh NHS? Why aren't you creating more places in order to meet the demand, instead of paying through the nose for agency staff in our health boards?

We've expanded nurse training places about 68 per cent over the last four or five years.

Well, it's clearly not enough, is it, because you've got a greater interest in people wanting to come and train here, and yet we're turning them away? It's barmy.

That is a real-world view—these are actual figures, as reported in a written answer that you gave to a question.

If you take a real-world view, then not only have we made a significant—

I'm just asking—you're saying I'm not taking a real-world view; you're suggesting I'm not taking a real-world view. These are your figures, in response to a written question. Do you accept these facts?

Well, I would rather you didn't suggest that I wasn't taking a real-world view, when clearly I am simply quoting figures that you have provided through written answers. Do you accept the facts?

You might want to listen to the answer, Darren. If you take a real-world view—

And I suggest you don't try and shout and argue over—it might be great for headlines, not great for scrutiny and understanding what we're doing, Darren.

Why are you trying to patronise my suggestion that—I'm quoting—I'm not taking a real-world view?

10:00

I think we're asking the question and now we're answering it, okay? Thank you.

If you take a real-world view on what we've done, we really have significantly increased nurse training here in Wales—deliberate choices we've made. There are always constraints on our ability to do that, and that's part of the real-world view. There are the points about money and the money that we choose to invest on both supporting nurses—. We chose to maintain a bursary, not just for nurses, but across a wide range of NHS staff. That is part of the reason why we've been successful at expanding our numbers and keeping people here in Wales. Part of the real-world view is our ability to have a significant expansion in the numbers of training places. We don't have the capacity to train 7,000 nurses each and every year across the national health service. There isn't the room for a 7,000 cohort. That's what I say: that isn't a real-world view, because our service doesn't have the capacity to do that. Actually, you need a much bigger service to have those places. 

So, there is an honest conversation about the training capacity that we have. If you ask the Royal College of Nursing and other trade unions, like Unison and the GMB, which represent nurses in the workplace, they would of course want us to expand the numbers of training places, but they also recognise that we made choices, with a reducing budget, to significantly expand the places that we have. They would also recognise that there was a limitation within the service about the numbers that we can train in every year. We're also having conversations about the parts of the service where the opportunity for nurse training may exist outside of the commissioned places for the NHS. A cross-party group have come to see me about the potential opportunities around Glyndŵr, and that's a conversation we're engaging in. And the limiting step in all of that is the capacity of the health service to have enough training places to expand to the level that any of us would want to. And, of course, we do need to think about how we fund this as well. So, that's an honest answer to the question you asked.

Let's take a real-world view: there are clearly more training places that can be created at universities like Glyndŵr, which are currently having people apply for courses and pay for them themselves, without access to a bursary for training, because they know that there's a shortage of nursing staff, not just in Wales, but in other parts of the UK too. So, why aren't you allowing that investment, which is currently going to agency staff, as I mentioned earlier—£135 million was spent on agency staff last year in the Welsh NHS? That significant cash loss, effectively, could be invested, could it not, into training the number of nurses that we actually need in Wales, rather than turning away thousands of individuals who could make perfectly decent nurses and be recruited into our national health service? It's not just nurses, is it? You mentioned doctor training places. As you know, I referred to this yesterday during the business statement—50 per cent of individuals who had applied and were eligible for doctor training places in north Wales were turned away last year, in places like Wrexham and in places like Bangor. Rural places are seeing surgeries close.

Now, I appreciate what you said earlier about the fact that we need more GPs to become training centres, if you like. I understand that that is a challenge, but why don't we accelerate what we're doing in order to fill this gap, because, as I say, we're currently paying extortionate rates on locums? There's a false economy in the system at the moment. You say you haven't got enough money to be able to invest in these things and yet we're spending shed loads of money on filling gaps in rotas in systems unnecessarily, simply because you're not training enough. And you were warned 10 years ago as a Government. Previous Governments have been warned over 10 years ago that we needed to increase the training places, and didn't do it. So, why don't you act now to significantly increase those training places that are available, so that we're not turning people away who want to come and train and work and live in north Wales as GPs?

I've already referred to the fact that we've made a significant increase in the number of nurse training places here in Wales. That's been recognised by every objective group with an interest in the health service, and, of course, we make choices about our ability to do more. This year I announced another record sum to invest in the training of non-medical health professionals, including, of course, nurses, midwives and others. So, we are putting our money where our mouth is, but you can't avoid the reality that the resources that govern are significantly constrained and there is not an unlimited sum of money for the Government to spend on the future training and education of health and care professionals. Every choice we make is a difficult one, and I won’t get into a rather formulaic sort of argument around austerity, but it affects every choice you make within the Government, including—

10:05

Do you accept it’s costing you more because you haven’t trained people in the past?

Well, do you want me to answer the series of questions you put to me or do you just want to have a row, Darren? Because it’s not very helpful or illuminating.

And on the broader point about Wrexham and Glyndŵr, well, there is a conversation that is ongoing. So, the national health service—

Well, with respect, Darren, I'm answering the question. It might help if you—

It might help if you listened rather than—[Interruption.] Well, this is ridiculous, Chair.

It's answering session now; you've had the question. Minister.

So, Wrexham. I met with the vice-chancellor of Glyndŵr University. I met with a group of people across party about the opportunity that might exist there, and that’s work that the university needs to work through with the health service about what they think their offer is, about how much they think they can do, and on also the capacity to have those nurses trained within our system. And the one thing I have said is that what I do not want is that an additional group of nurse training comes in from outside the commissioned places that potentially threatens either the number of nurse training places that we commission within north Wales or indeed the quality of that training as well. But I don’t have a hard and fast view that says that, no, that can’t happen. It’s a practical point for the potential provider to work through with the health service. And that’s an honest way to approach the matter. And, actually, that’s the approach that the university said they were happy with as well.

And on the point about doctor training, of course, I’ve recently announced additional numbers of doctor training through our two medical schools and the partnerships they have with both Bangor and Aberystwyth universities, together with Cardiff and Swansea. And if you recall the significant campaign for a training centre in north Wales, and in my responses, I tried to make it consistently clear that I was just as interested in training in mid and west Wales as well. And we’ve actually been able to deliver that. So, we have got an extra number of places, and as I was saying earlier to Neil Hamilton, there will be more doctors training, and training with a significant chunk of their study—and we are aiming to have the whole of their study, as far as possible—delivered within north Wales, certainly. So, we are genuinely looking to do that.

And the money on agency—we recognise that it would always be preferable to have permanent staff instead of agency and locum. Well, we’ve taken action on reducing those costs. We’ve saved £30 million over the last year because of the choices that we’ve made. But I don’t think you can say that money is lost cash, because, actually, we need those people to be able to maintain and sustain the services that we have. So, I think describing it as lost cash isn’t—[Interruption.]—isn't a necessarily helpful way to describe it. It is a necessary part of delivering our health and care system. I want to get to the point where we have more permanent staff to deliver on a basis where we all recognise and it will be a more efficient use of money. But there are practical, real-world challenges to be able to do that.

You mentioned there, Minister, the Cardiff-Bangor collaboration, which is something that you know my party has particularly warmly welcomed. Are you confident that this will be opened as planned for students in the 2019-20 academic year? And if so, how many places are you expecting to be made available in—it’s this autumn, actually, isn’t it?

I can’t remember the number of—. I was trying to think of how many there for this autumn, but I am expecting that, yes, we will have people on schedule, but I can’t remember the number, of the additional 40 between Cardiff and Swansea, that will start to have their year of study in the first instance in north Wales this year. I’m sure I’ve mentioned it in the statement, which I don’t have to hand. I’ll happily come back to the committee.

Yes, perhaps if you can—. That’s good to hear, that you’re confident that will happen.

If we look at the rural and remote health and medical education programme that was introduced in Swansea in 2011, the point of that of course was—one of the points of it was—to increase the number of students and doctors practising in rural Wales. Do we have evidence as to how effective that’s been, given the programme's been there for quite a long time? And if we do have that evidence, how transferable is that model to other medical and healthcare training programmes?

Sorry, are you talking about the pilots that the medical schools—?

Yes, the messages we have on that are that the model should be transferable to other medical health and care programmes, and we do think that it’s had a positive impact. I can write to you with more detail about the impact of that, and I’m happy to do that to set out how that’s being taken forward.

10:10

That would be helpful, because if it has worked as well as we hoped it would, then that, obviously, as you say, is a model that could be used elsewhere. Thinking again about models that could be used elsewhere, the north of Scotland's rural-track programme for GPs, which was introduced in 2012, aims to equip GPs with some of the advanced life support and other skills that can be used to manage patients in really deep remote rural areas. Are there things that we can learn in Wales from that particular pathway?

Yes. Despite the differing perspectives of the two Governments in Wales and Scotland, actually there's a practical relationship between officials and the two parts of the national health service. Our officials get on well, they exchange ideas. For example, what Scotland did on its ambulance model was largely lifted from Wales. They weren't quite as reticent as England were about recognising that they looked to Wales to try and understand what we were doing. Equally, in this area, Health Education Improvement Wales are in contact and they're looking at the programme with interest. Chris Jones, the chair of HEIW, was involved in helping Cardiff University to shift its approach to a C21 approach to training. Chris is really interested in innovation and improvements and wherever good ideas come from. That is part of the culture that we're creating within the organisation. So, yes, we're definitely interested in what they're doing, and if there are good ideas that we can make work here in Wales then I'm happy to take them.

Thank you. The 2009 rural health plan identified a key role for specialist generalist healthcare workers within rural communities—rural GPs, nurses, allied health professionals. Do we need to develop that generalist role more and to attach greater value to generalism in services, particularly in the rural context?

In every part of Wales, frankly, and every part of the service. We have this challenge of having gone from an approach that looked like it was about super-specialisms to recognising we'd undervalued the value of generalists, and I see a generalist in the room nodding his head. The shape of training took a long time to reach an end point, but it is about having effective training for doctors in particular and how we make sure the value of generalists is recognised. If you look at fractured neck of femur for older people, then actually it isn't just that you need someone to fix their hip, you need a generalist to look at their broader care and to understand how you're going to help them to recover and return. So, actually, those people recognise the need for specialist generalists as well. A GP is a specialist generalist. And actually, more than that, within healthcare overall, the way we see paramedics, both those moving on to the new band 6 arrangements but also the advanced paramedics—we recognise that as generalists there's real skill that they have that can be used both in emergency medicine but also in primary care as well. Part of our challenge is how we effectively deploy the skills that they have. When I was in Tenby recently, part of the model around that facility for the future links with the health centre next door, it links with pharmacists within the community, both the local independent and the large multiple, who I won't name, but it's also about the link with paramedics, and in particular about those advanced paramedics who are part of the healthcare team and their rotation between working within what is essentially advanced primary care and working within the emergency service as well. So, actually, the way in which we rota our workforce will be important, because for many people that will make their job more interesting and more sustainable. Some people can feel burned out working in the emergency service, and this gives the ability to work between that and primary care to maintain their skills and keep them within the service. So, yes, there is definitely a bigger role for generalists in the future. That's part of our multidisciplinary team approach as well, to value what each member of that team can do.

Diolch, Cadeirydd. On that particular point, several years ago the Royal College of Physicians actually published a paper on the future of hospitals and they focused on that they wanted more generalists because of exactly what you pointed out, Minister, in the sense that they need to be able to look at individuals. Have you had discussions with the Royal College of Physicians, and perhaps with what's now HEIW but was the deanery, to look at whether they are moving in the direction of training more generalists, not just for GP purposes but also hospital purposes, so that we can actually look at a wider picture? ENT—when I was young, ENT was one consultant. Now, you have three. One for E, one for N and one for T. For those not quite sure, that's ear, nose and throat. You can see they're specialising, but the generalist would be able to actually have a holistic picture of individuals. Are you in discussion to actually get that training programme in place so that incoming doctors are encouraged to be generalists?

10:15

Yes, there's a part about the change to the core medical training programme, but I think the point that you raise is about the time for people to have in a generalist role before going in to more specialist training. This is the balance that is always a difficult one—which areas do you really need a specialist who needs to do a particular part of a service on a regular basis, and then how often do they need to go to maintain their skills, and where do we need more generalist skills? And that is a balance that is not always straightforward. We're making changes to the curriculum for training to try and actually try and address that balance—to give people more general training during their medical education and training. But it's not a simple one where we can just say, 'Forget specialist training—we'll just have generalist training.' You've got to have the balance between the two and what they mean. And, actually, the way in which we're looking to make sure that more people are exposed to general practice—that's maybe an unfortunate phrase—more people to have the opportunity to undertake general practice as part of their training, because for some people, they don't think about it, because so much of the early training is hospital-based. And to actually see the opportunities to work in a different way and a different part of medicine—well, actually, of course, the great majority of our healthcare interactions are in primary care, but so much of our time and attention is focused on the hospital end of the service. So, yes, it is absolutely part of what we are already doing, it's what you can expect to see more of in the future, and not just within medicine, but within other roles within health and care as well. 

Okay, thank you for that answer. From that answer, I assume that you are having those discussions to move that forward. 

Okay. In your paper, you highlighted some points on the transformation fund, which came following the 'A Healthier Wales' publication, which was in 2018. I know you've talked about the virtual ward being an example of how projects are being moved forward, but I remember the Member for Brecon and Radnor very often talking about the virtual ward before the publication of the 'A Healthier Wales' document. You've reflected upon 65 per cent of the £100 million being already allocated to projects in all but one regional partnership board, and in your paper, you've got a footnote that says you will give us an update on that one in this evidence session. So, perhaps there's an opportunity for you to give us that update on that one.

The figures, you'll understand from the statement yesterday, we've actually allocated—I've decided on £41.2 million. The larger figure you have is for the bids that have come in. I haven't agreed to all of those bids, because, as I said earlier, I'm reading through bids with advice that I've had, but I want to understand what I'm being asked to approve, and if I have questions, I'll be asking questions before I agree for another significant chunk of money to go out.

We have now had more details of the bid from Powys, as I mentioned yesterday, and that was the last regional partnership board where we're looking for a bid to be provided to have more detailed discussions with officials. So, as I said yesterday, and I think I said in earlier questions, I am confident that every regional partnership board will have submitted a bid, and I'm also confident that every part of Wales will have a transformation project to take forward. And that does show that there is a genuinely national programme and, equally, that each regional partnership board is taking seriously the opportunity that exists as well as the need to transform and improve. But in many ways, Powys is getting a lot of things right now, and that other people could look at and think about how they wish to adopt. And the virtual ward is a good example of that. You now see things called virtual ward projects in Valleys communities where, in a conversations I had with a particular group of GPs around Aberdare in the Cynon Valley, they recognise that their job had changed, and since they'd taken on that virtual board approach, they thought it was a better job for them to do as professionals, but more importantly, they we're delivering better care as well. 

I apologise for not being there yesterday to listen. I was actually away with another committee on business, so I missed your statement yesterday.

David, I'm hurt. I'd have thought you'd have watched it on playback. [Laughter.]

I could have, but, unfortunately, my iPad was, actually, battery-flat, so I couldn't see it. [Laughter.]

Well, trust me, what I say is true. I did confirm there's £41.2 million in the projects already announced, but the other figure is what I've got coming for me to consider.

Right, so, it's actually not £65 million allocated—there's £65 million in projects that have come forward to you.

Yes, £41.2 million has been specifically allocated and approved by me.

Okay. So, that's clarification from the paper that we've received. That's okay. Thanks for that clarification, because it is important. By the way, are there any examples other than the virtual ward?

10:20

Yes. In the NHS Wales awards, we recognised a range of areas in rural healthcare practice that have been finalists or have won awards. When you think about the transformation fund bids—I've mentioned the west Wales approach. And the really positive thing about west Wales is, not that long ago, if you'd had a conversation in mid and west Wales and you'd asked the three counties in Hywel Dda what they thought of each other, it wouldn't have been necessarily a very positive or constructive conversation. We're now in a position, though, where those bids were signed up to by the leadership of the three counties on a unanimous basis, together with the health board. Now, that's real progress, and that is progress in one of our more rural parts of the country as well. So, there is an approach—. For example, the approach on proactive technology-enabled care is really important for health and social care, and, actually, I think there's an opportunity for them to take a lead in that. I've been really interested in some of the work that I've seen in Llanelli on having technology-enabled social care as well as healthcare.

That's interesting, and I'm sure that somebody will come back to the questions on the technology agenda, because it is critical, especially in the rural areas, because we use technology to help people.

'A Healthier Wales' is ambitious. It's very important that we ensure that we're able to deliver for, as you say, all parts of Wales. You've already mentioned this morning, very much so, your ambition to ensure that everybody in Wales is able to access similar healthcare. Is it being done fast enough? Are we at the right pace to ensure that people get it as quick as possible, safely?

I'd always want to move quicker, and I know that Members always urge me to move quicker on things that they support, and Members urge me to pause when there are things that they don't support, and that's part of the deal of being a Minister. You still have to make choices. I would much rather that we were making even faster progress.

'A Healthier Wales'—. The thing that is different about 'A Healthier Wales' is that we have a better chance of delivering it. We have sign-up across health and social care and the third sector. Our previous plans, people didn't broadly disagree with in terms of the health service, but actually our ability to deliver them is not what we would have wanted. The Chair, and others in this room, will recall we've had conversations that are not too dissimilar from some of the drivers we talk about in 'A Healthier Wales'. If you go back to Wanless, there are similar messages about the demand and capacity of our health and care system. So, the most radical thing about 'A Healthier Wales' would be to actually deliver it, and that's why it is my top priority, together with Brexit, because we could deliver a real transformation, and, as I said, not just £1 million in the transformation fund, but the ambition and the ability of health and social care to be genuine partners with each other and with the citizen to fundamentally transform the way we deliver health and care.

I can't leave this session go without asking about ambulances. As you know, I've also asked about ambulances in my constituency. We have a semi-rural area, with the upper Valleys, as well, so there are concerns about that. The 2009 plan actually highlighted ambulances as something that needs to be looked at, because we were operating the traditional model at that stage. I appreciate we're 10 years since, and I know that there have been changes in the ambulance agenda and the response times. Are there any other models that you've been looking at in that period of time to see how those ambulances in rural areas can be most effective, and to ensure that we can deliver A&E, and emergency treatment, most effectively in those communities?

Well, I guess there are a couple of different things. The first is the acknowledgement that you've given that we do now have a different model, and we've had a review of that model overall. We've also then had the amber review recently. So, we're looking at areas where we do recognise there are still long waits within the system. So, rather than saying, 'Just look at the headline red figures and everything is fine,' because Powys and Hywel Dda, for example, have very good response figures for both red and amber overall, we do have to look, if you like, at the tail of waits, where there are far too many people waiting far too long for a response. And that is the challenge that part of the amber review was there to address, to check that we've got the right categorisation when calls come in, and then the right response, and our capacity to deliver that response. Your point about delivering the right form of care, well, some of that is access to where people need to go. That's about the ambulance service being properly plugged into the rest of the health services to understand where there are pressures and if people need to be diverted to get somewhere more rapidly. That's part of it.

It's the investment that I talked about earlier in EMRTS, the system to deliver greater equity, to where the most serious and critical care is needed to make sure that people can quickly be taken to the right centre. But it's also about what we need to do within our whole system so that people have alternatives to pitching up in hospital. And it's part of the reason why we're thinking about our investment in pharmacy and in general practice as well, and actually in what we can do in minor injuries units, because where people can be safely and effectively seen there, we need to be able to get them there rather than get them to an emergency department, where they could wait longer for their treatment than they would otherwise do if they had an alternative. So, it's partly about how we help the public to make choices if they're going somewhere themselves, but it's also about helping the public to make choices when they call the health service and ask for help and support. I recognise that we've still got further to go on that, so I'm certainly not pretending that all is perfect, as things stand now.

10:25

Okay. I appreciate all that and I accept your points about educating the public; I do believe that society needs to understand what is an emergency and what is not, and having other services and features. That, I think, is a crucial point, because the question here is about the emergency services, and not necessarily someone who can't get an out-of-hours and turning up to A&E as a consequence of that. The model I want to focus on is the emergency service model so that someone is able to be treated as quickly in a rural area as possible, as they would be in an urban area. Are you confident that the current model that's in place is delivering that equality of experience across Wales?

Yes, I'm confident that it's the right model. Our challenge is what we need to do to understand where it isn't working as well as we think it should do. And that's partly in urban as well as in rural Wales as well. So, I wouldn't want to try to tell you that the need for improvement only exists in one part of the country and not in others. That was the point of the amber review—to understand if this is the right model and the right approach. Do we need to make any changes? And then, what do we do about the parts we recognise and don't think are getting the right response in the right time frame to people who have a real need for emergency-level care?

Thanks, Chair. Social accountability and citizen engagement in the planning and delivery of health services is widely recognised and is particularly important. What assurances can you give that the voice of Welsh citizens will be at the heart of service transformation in rural Wales?

Well, in rural Wales as in urban Wales, we want citizens to be genuinely engaged in the future of health and care services. Part of our challenge is how we engage people effectively in doing that through the period of change rather than at a point where people are being encouraged to join demonstrations and petitions against it. It's part of our challenge. If you look at mid and west Wales and the difficult conversation they've been having with the local population about a new plan for delivering health and care, they've had people who are determined to say, 'This is wrong', and, as we live in a democracy, they're perfectly entitled to say that. But how do you engage with people who may want to say, 'I want to listen and understand where you are and why you're suggesting changing the way we deliver health and care'?  Some people did engage in that process and the challenge is how that isn't just a one-off but is a regular point of engagement. It's part of what our community health councils are there for, but, actually, every health board needs to have a mission to regularly engage.

Now, we talked earlier about the mid Wales joint committee, and they've got a patient engagement involvement forum, and we talked about the two joint chairs for that. It's also part of what we're aiming to do in 'A Healthier Wales', and it's one of the areas that I want to see improve and make further progress on, because I wanted us to be in a different position now. I don't think that I should try to start a wider national programme of engagement and a conversation about the health service whilst the only issue that people talk about in public is Brexit because I think it will get drowned out. If I try to do this in the next four or five weeks, I don't think it'll get noticed. So, there's a practical choice: if we want to start that conversation, I think it will actually need to be after the massive uncertainty that crowds everything out has actually got some shape to it.

But it is about the approach to take, and we're looking to reform CHCs to have a citizen voice that goes across health and social care, too. That's one part of it, but not all of it; it is the regular mission of the health service. And you'll know that the experience you have in Aneurin Bevan is not perfect, but there is an attempt to have a conversation—they do have citizen panels that exist and talk. If you're not on the citizen panel, you may think, 'No-one has asked me', but if you go into different health boards, there's a slight variance in approach. It's about drawing together what people do and recognising where you think there's a better approach to that engagement, and how regular that is as well. because that's the aim—not to, every now and again when there's a crisis point, ask the public or tell them why you need to something difficult, but, actually, to have a regular conversation about what their healthcare looks like.  

10:30

Can I ask a supplementary on that? I think you're right—there's no point in trying to have a national conversation about anything just at the moment other than Brexit—but longer term, your answer to Lynne Neagle suggests to me that you're acknowledging that there is better practice and worse practice across health boards in Wales. I don't think anybody thinks anything is perfect, but there's better practice and worse practice in terms of how the health boards engage with their local communities. One of the real problems with delivering service transformation in west Wales, for example, is that the public simply don't trust what they're being told. Now, whether that's fair or not is another question, and it does go back to a historical tendency to put things out for consultation when people don't really feel consulted.

Longer term, Minister, what plans do you have to help health boards learn from each other about what does work in terms of long-term engagement, and in terms of building that trust so that when the health community has to go to the community and ask them to accept difficult decisions, they actually believe what they're being told and that they don't just see any kind of reconfiguration as an excuse for cuts, because that is certainly—you know as well as I do—the reality of the way that some communities in the west react, whereas difficult decisions are being able to be made in other parts of Wales and the communities come out with a better healthcare pattern afterwards? So, what can you do nationally to get those health boards to learn from each other? 

There were a couple of points. The first is that some people won't believe what they're told, no matter what it is and no matter who says it. And some people, after being told, just think, 'Well, I don't believe you'. And the history of wherever you are will affect how some people think and feel about that. It is never uniform, but it is part of the picture. When you think about how that conversation is about meaning and trust, the role of our staff is really important, because if I sit here and I say, 'Trust me, I've read all the papers, this is really difficult but it has to happen', there'll be a whole bunch of people saying, 'Well, why on earth would I believe him? I might like his suit and his tie, but I don't believe a word coming out of his mouth, because he's a politician, or she's a politician'. And actually, it is about the conversation that takes place with people who live and work in an area that people are used to seeing, used to dealing with. That is much more important and of much greater value.   

And actually, our staff also need to be persuaded and believe that there is a real need to have that conversation. It isn't just about, 'We need to do something difficult', but it is about, 'Well, let's have the conversation', before you hit the point of saying, 'We need to do something difficult'. Let's understand where we are so we feel we're part of a conversation, where we're inputting into a conversation before you get to say, 'Here are the choices'.    

And Hywel Dda have done now that hasn't happened in the past, to be honest, is they have had that engagement with their staff in a way that didn't exist in the past. That came over a period of time that was—. To be fair, the medical director invested a significant period of time in talking with and listening to staff in the health board. Not everyone agreed with the answers that came up, but the fact that you had staff presenting to the board about, 'Here's our view', and the fact that you had the lead emergency department consultant in Glangwili saying, 'I think we need to change the mission of my hospital, including my department, to deliver better care', I think is quite powerful. It's even more powerful, because it isn't a politician, and it isn't the chair and the chief executive of the health board making that case. 

Now, not everyone will believe him. That's, again, going back to that first point, but, actually, without that engagement with staff, I think there's precious little prospect that they'd be able to get to have a plan where they've got broad agreement around it. That is part of what you need to look at in other parts of the country, because, in other parts of the country, they have fewer problems. They've had that engagement with staff and they've had an engagement with the public, and they're engaged with their CHC who believe they're doing the right thing, broadly.

And we are looking to do some of that nationally. It's one of the actions in 'A Healthier Wales'—it's one of our 40 actions. It's about that national conversation, and sharing national learning about the quality of conversation and the regular nature of that conversation, if we are to carry on transforming and changing healthcare, as objectively all of us in this room accept we need to do.  

So, what about community hospitals? Do you see a role for community hospitals in keeping people closer to home and out of district general hospitals, maybe with the added use of technology to help, et cetera? 

Yes. There's always a challenge about what people describe as a 'community hospital'. Some people would hear 'community hospital' and would say that if it hasn't got beds, it's not a hospital. And if you change it into an integrated health centre, people are immediately suspicious that they're losing something of value. And it's also the reality, again, that there are difficult conversations about what you have in different parts of Wales. So, we've invested a significant sum of money—several million pounds—in Blaenau Ffestiniog, in the health centre there. But there was a challenge about there not being beds within that centre anymore. And some people are resolute in saying that it's reduced the quality of care because there aren't beds, rather than, actually, those beds are better provided somewhere else, and keeping them there would actually have provided local healthcare that wasn't high-quality healthcare.

It's the same with the investments we've made, for example, in Towyn, in Flint and in Alltwen, which I've seen as well. Over the last 10 years, we've invested quite a lot in different centres around the country and, earlier, I was talking about the investments we've made in midwifery-led units in Hywel Dda and in Powys. If you talk to midwives in Powys, they are genuinely enthusiastic about being able to care for women more locally. 

So, we are definitely investing in having those services in different centres to give people options that don't necessarily mean that they've got to go to DGHs. And some of that is quite specialist now actually, and it wasn't that long ago, you would have seen that within a DGH. The regular example we give about the shift in treatment is wet macular degeneration. Initially, injections were given, so, that was a step forward, because, otherwise, people would have said, 'I'm really sorry', and 'I can't do anything for you.' Then there were injections that were given in theatre conditions within a hospital, and now you have nurse injectors able to deliver that treatment in different settings—not all in community hospitals, but in different settings in the assets we have, whether that's your local optometrist or your pharmacist or otherwise. We're definitely trying to spread out care to make it generally closer to home.

10:35

Okay. You referred in your answer to David Rees to the national technology-enabled care programme. Can you just tell us a little bit more about that in terms of what the priority areas of work are and what the timescales are for taking that forward?

We set up Health Technology Wales to assess the evidence base for new technologies and recommend where they're adopted. We're looking to, frankly, have a more 'adopt-or-justify' approach to the use of new technology. Going back to the point about pace, I would always rather see things adopted more quickly, and I think it's important that I do take that approach; otherwise, I just end up explaining away why things haven't happened as quickly as citizens want them to and I actually want them to as well. 

So, they'll be producing an annual report so that we'll be able to see what they've recommended and the progress that has been been made against that. And we're also looking—. And I think it's really exciting that we've got technology-enables social care as well. I think that is something where there'll be real value, not just in delivering care within people's homes, but also something about loneliness and isolation as well. Because, for some people, the regular call from someone to check what's happening and seeing, through to non-enabled care, what they're actually doing in their home, is that person's connection to the world. It's also why lots of people place value on the community pharmacy as well—the home delivery service for some people is their human engagement within that week. Now, there's a broader challenge about loneliness and isolation, but to recognise the role in the way we deliver health and care can have a real impact, as well as wanting those people to engage more broadly within their communities—.

Okay. And is there anything else you'd like to bring to the committee's attention in terms of the steps you're taking to maximise the use of new and emerging technology in rural healthcare?

I actually think that, when you look at what we're doing, we really are looking to make better use of all the assets we have. I've mentioned pharmacy and optometry, but we've had to invest in IT to make that work. The investment we've made in making the patient record more widely available— that's of real benefit the more remote people are from accessing a big centre within a hospital, but actually, it's just more appropriate, even if you live close to one of those, to go and get some of that care within a more local facility as well. So, I think there's real gain to be made from the investments we're making across the whole system—so, whether you're in a Valleys community, whether you're in a city centre, or whether you're at the far end of west Wales, I think that there are real gains to be made in that investment programme that we have and in making much better use of technology.

Ocê? Troi nawr at y mater o gostau gofal iechyd gwledig. Helen.

Okay? Turning now to the costs of rural healthcare. Helen.

Your paper refers to an ongoing review of NHS resource allocation. What evidence are you considering to ensure that the funding allocated to health boards accurately reflects the level of need and the additional cost of delivering health and care services, because we really shouldn't be talking about them separately, across rural areas? You'll be aware of the Nuffield report that came out in January this year that highlights, again, the additional costs of making provision in rural areas. So, what evidence base are you going to use for this review of the geographical allocation of resources?

10:40

Well, we're interested in the relative need that exists and having a funding formula that properly reflects that. And again, there was this conversation in the run-up to the Townsend work and the change that was delivered there, and we'll have similar considerations in the sense that we won't just have evidence about the geographic distance from communities to healthcare; we'll have evidence about relative need and about different levels of deprivation, and about equity in access in its broadest sense. So, it isn't just one factor, but the rural nature is part of what we will consider, and so we're looking at—. A technical advisory group is looking at comparative analysis across seven high-income and mainly publicly financed healthcare systems. Those include New Zealand, England, Scotland, the Netherlands, New South Wales—the other south Wales—Ontario, and Stockholm in Sweden. So, we're looking at a range of systems to understand what the evidence is, and then we'll need to apply that to a range of factors.

Now, I've said in the paper that that should be available to take effect for the NHS part of the funding formula from the 2020-21 year. So, we'd realistically need something by the end of this calendar year, to have an impact on the way in which we allocate future funding. Now, as with Townsend, rather than saying you want to apply something to the whole budget, it's likely—and I haven't made a choice, but it's likely—that will affect growth. Because, otherwise, if you affect central, core resource that is already there, you will understand that moving money around in that way could potentially undermine the delivery of healthcare in different parts of the country. You can't predict what that would look like. And so, there's a fair amount of pragmatism that you'll need to engage with to change the way you move money around in the system. Now, I'm fully expecting that when that work is complete and we're ready to do something, that the committee will want to ask me and officials about how we've got to that point and what we're considering in more detail. That is the health part of funding.

On the social care side of it, you'll know we have an inter-ministerial group. You know that I will be looking to meet with spokespeople across parties, and indeed members of this committee, to have a conversation about the work we're doing on social care—so, the future funding for social care, how we may be able to make use of the relatively new powers the Assembly has, and what that might look like. Now, that work is more medium term than short term, because, actually, if we're talking about making use of the powers that we have, we're going to have to have agreement on what they might look like, what sums of money we think they might potentially raise, and then what that would actually deliver. So, we need to marry up the vision for what the future of social care might look like together with resources. We're having to do some work that we are commissioning and taking forward on a better understanding of those future demands. We've had some useful work done by the association of directors of social care in Wales, and that helps to inform the conversation. So, it's work that the inter-ministerial group is doing, it's work that we're doing together with the local government family, and to be fair, that is genuinely cross-party. Every local authority recognises that social care and education are two big budget areas, and they want to understand how those will be affected in the future, and equally, I want to make sure that it's a conversation we can have as grown-ups here in the Assembly as well.  

I'm very encouraged by what you say about the approach to social care funding, Minister, but if I can take you back to looking again at the health formula, if you don't—. People providing healthcare in rural areas would say that the current formula doesn't help them, and we can argue about whether they're right or not, but they would say that. If you don't look at the core—. I can see why, pragmatically, it's much easier to look at how you reallocate any growth in funding, but if the work that you do throws up a position where the core allocations are inequitable—. And I'm very pleased to hear you describe the international models you're going to look at—it seems to me entirely appropriate—and some of those also include post-industrial communities, which are important as well. But if that work throws up a real inequity around distribution and around the core, are you really telling us you won't look at that? I mean, I suppose this is speculative, because you haven't done the research yet. I'm all in favour of pragmatism, Minister, but if pragmatism perpetuates injustice, I think we have to challenge it, don't we?

10:45

In reviewing the formula, we have to look at a range of factors, not just one of them, and if we just say that people in rural Wales say that they don't think the formula helps them, what you'll then have is people in post-industrial communities saying, 'Actually, we don't think the formula works for us.' 

The two best funded per head health boards in Wales on a relative-need basis are Powys and Betsi Cadwaladr. Now, that's the way our current formula works and is provided when you look at the overall figures that go into them. Actually, when you think about it, there's a phrase from Powys's integrated medium-term plan where they say people in Powys live longer and spend more years in good health, including eating more healthily and being more physically active. That's the overall picture for people in Powys, and if you then say, 'Actually, what we need to do is to put more money in a funding formula to guarantee that's what will happen', well, you know there'll be an entirely predictable and understandable reaction from other parts of Wales to say, 'Well, hang on a minute, if, actually, health inequalities—if your prospects of a long and healthy life are better in some parts of Wales, why do we need to invest even more money in that part of Wales rather than areas we recognise, when you map multiple deprivation and health inequalities, the maps neatly fit each other?'

So, actually, we have got to think pragmatically and practically about what we do, and that's what I'm trying to flag up, because I don't want to have a dishonest conversation here and then come and say something entirely different in the autumn. We all need to look at all of the factors, and we need to take account of relative need in different parts of the country, what that means for our funding formula, and then how we apply it. That was the choice that was made about implementing Townsend. It was about growth in budgets, for exactly the reason that if you try to address that into core budgets—. If, for example, the formula says that, for the sake of argument, Powys and Betsi Cadwaladr have more money than they should do on relative need, so you want to address their core budgets, actually, you will understand why that could potentially destabilise where the healthcare is delivered. So, one person would think that is an injustice, that they have too much money in one person's terms, but it could actually mean that you could undermine the way that healthcare is delivered. That would create a different injustice in the quality of care that is delivered.

But, actually, the way that we have grown the formula has been on Townsend shares since we've introduced the formula. So, I'm flagging up that it's entirely possible that's the approach that we could take, but it does depend on what the review says about the formula, and we'll be open about that. So, when I am about to make a decision, when I'm considering making a decision, I'll be open about what we've had come in, on the technical advice, about the choices that are in front of us, and I will then have to make a choice about it. But I'm absolutely clear: it will not just be about one element of that. It will be about all of the elements, about the way in which we need to address funding and addressing health inequalities. 

Some of us still bear the scars of the Townsend debate from about 19 years ago, including Lynne, who I think was still in school at the time. But anyway.

I certainly do, and of course, had we implemented Townsend fully back in 1999, Gwent and Cwm Taf, who serve some of the poorest communities in Wales—in fact, probably the poorest communities in Wales—would have had considerably more money than they get now, and they are still consistently the health boards that generally live within their means. So, I welcome what you've said about the evidence, and I would just like you to reiterate, really, that you will look back across the whole history of this long-running debate as well, and to re-emphasise the importance of deprivation, health inequalities and the inverse care law in how you take forward any work on this area. 

Well, it's essential, because otherwise you're not looking at relative need, and it would not be conscionable to say, 'We'll ignore relative health need and inequalities in any new funding formula.' So, that is not the approach that we're going to take. We're not going to throw that aside and say that there is only one element that will trump all others. We have to think about all of those factors, and you're right—there are Valleys communities with concentrated deprivation. I represent a constituency that is a mix. It has a middle class chunk and then it has, largely, the poorer southern arc of the city of Cardiff, and here, within a stone's throw of the Assembly, we're next to one of the poorest communities in Wales, near the middle of Cardiff.

So, you have to understand where that disadvantage exists and how you then can have a formula that takes account of all the relative need within each health board, and between health boards as well. So, I'll be absolutely up front about the evidence we've had and about the decisions that we'll make and about how we'll actually be looking to address inequalities in healthcare in any formula that we take forward. 

Good. We're coming towards the end now—a couple of issues that Darren is going to tackle succinctly. 

I just wanted to ask you about workforce planning in relation to the Welsh language. Obviously, in terms of the general population, there's often a grater proportion of people speaking Welsh as their first language in rural parts of Wales, and, obviously, it's important, because of the Welsh language duties on public services, that we try to make sure that people can liaise with the health service in the language of their choice. So, what specific actions is the Welsh Government taking to make sure that we've got sufficient people in the workforce with the right Welsh language skills to be able to communicate with their patients?

10:50

Well, I guess there are two things. There's the approach of 'More than just words', the general approach, about making sure that language isn't a barrier, and what that means for how we help staff within the service today. Lots of staff recognise that language is part of a care need; it's not an optional extra. And so it's about how we encourage and enable our staff to maintain Welsh language skills or to learn and acquire them. I've met lots of people who have come in with English being their second language and have gone on to learn Welsh, because they recognise that it's part of delivering good, high-quality patient care. 

There's also a point about newer staff, and so we've had a pilot project with the Coleg Cymraeg Cenedlaethol and universities to identify and improve the prospects of people from Welsh-speaking communities to actually look at careers in medicine or the wider health service. There was a pilot that I agreed to fund in 2018. I've agreed now to extend that into 2019, because we've been successful in encouraging, in old money, sixth-form students, to actually think about those additional careers. And we've looked at Welsh-speaking areas of the country, and, indeed, we've made sure that we've thought about Welsh speakers in areas of the country that are less likely to go to medical school. So, part of it, for example, has been about Welsh speakers in Blaenau Gwent. I spoke at an event in the summer, and it was really interesting talking to students at that point in time, and, actually, some of them would not have thought about a career in medicine were it not for the proactive offer that we've made in encouraging people to want to come into the service and to see their language as an additional skill that will be of value of them and the service.

And it's also been helped by the steps that Cardiff and Swansea medical schools have made in having more Welsh domiciled students for interview and actually being accepted in places in their medical school. They understand that they do need to respond to the nation that they are in and the healthcare needs of our health service, and not simply be medical schools that are interested in training doctors for the world. I'm actually interested in having a decent supply of doctors who want to come to Wales and stay in Wales, or want to remain in Wales. And there is our alternative challenge of how to encourage staff who have gone to pursue medical education and training in the rest of the UK to come home. 

Can I just explore this issue of the training in the Welsh language? Obviously, this is why location is often very important in terms of training places, because, very often, the training is only delivered through the medium of English in many of our different settings, and that can sometimes be detrimental to attracting people who are passionate perhaps about the Welsh language and want to make sure that they can use it in the workplace. What is the Welsh Government doing to work with universities like Bangor and Aberystwyth to make sure that there's a much higher content of their training and course materials, if you like, delivered through the medium of Welsh?

To be fair, that is part of the deal between Cardiff and Bangor with the expansion of places. So, you can expect to see there being greater opportunities to undertake their medical education training through the medium of Welsh, in addition to the measures that I've outlined about making sure that people have the opportunity to acquire Welsh language skills if they don't have them first hand. I've launched a range of different tools, online training and learning, within social care and healthcare to do that part of it, but the new additional places that we've created—Welsh language skills are absolutely a part of that. 

And just one final question on this from me: obviously, being able to communicate in Welsh for patients where it is their first language is very important, particularly if they've got a mental health need and might need to access to talking therapies, or they may be in a situation with dementia, where their speech and language skills have diminished in some way and their English-speaking skills may have disappeared. What specific action are you taking in terms of the mental health care and dementia care workforce to make sure that they are appropriately targeted within the work that you're doing?

10:55

Yes, that's a specific part of our approach. And I know that the cross-party group on dementia have taken an interest in this. I've had a letter from the chair—who may be amongst us—specifically on this, and that's part of what our approach needs to take account of. Because we do recognise that people are more likely to want to use their first language in a range of settings, including, at times, where their condition means that they will revert to, in all circumstances, their first language—the language that you think in. So, that is absolutely part of our approach, and certainly not something that we're ignoring. And that means, again, that we need to look at the language skills of our staff to make sure that, where there is—because that is a care need, not a care preference.

So, what proportion of the workforce working in mental health, and dementia services in particular, have Welsh language skills at the moment?

Oh, I couldn't tell you—I don't have figures of that detail to hand, or in my head.

Okay. Are you going to measure those things in the future or—? Do we measure those things at all within the workforce?

I'm most interested in whether people have the opportunity to be able to use their language when accessing health and care. I'll happily come back to the committee about our assessment of current Welsh language skills within the workforce—

Just briefly, the points you've made in response to Darren Millar about initial training through the medium of Welsh are really important. But we also have, particularly in nursing and in care professions, potentially a bank of people who can use Welsh socially, who've perhaps been in the profession for 10 years, who've never been trained and who are not confident to use the language in a professional context. I have myself taken a child who didn't really speak any English at the point into a hospital, where I could see two nurses who spoke Welsh socially, but neither of whom were confident to do that—. There has been some interesting work done—I think in Hywel Dda—to upskill and enable existing members of the workforce to develop their confidence to use their Welsh language skills professionally. Is that part of the work that you've been talking about, in terms of making sure that we've got those skills?

Yes. That's why we've launched those measures, to make them more confident about using their own language skills. And some of it is about the confidence of the staff member, and to understand the level of reassurance that provides for people as well. So, there is some of this that is soft messaging, about, 'Actually, think what you can already do', as well as, 'If you're not confident, then actually there are training and support packages available for you to become more confident', as well as people who would not say that they have Welsh language skills, apart from the typical being able to recognise signs on a toilet door and being able to order a drink, but actually there's more that they can do as well, and even very basic Welsh language skills can still make a difference with patients and people entering social care, when—people are often frightened and feel vulnerable when they come into a health or care setting, and so that even the small use of Welsh can make a difference as well. So, it's about encouraging staff to think in all those terms as well, and how we need to be able to support them to be confident to do so.

Yes, Brexit—if we can just touch on Brexit just for a few moments. Obviously, Brexit is a backdrop to everything that's going on in Wales and the wider UK and Europe at present. And you've made statements in the Chamber about the potential impact that it might have on the health service. Can I just ask you: do you think that there are any specific differences, other than the general comments that you've made about the potential risks that there might be, or changes in the health service? Are there any specific issues that you think would be more exaggerated, or there'd be a greater impact for rural health services?

No. The uncertainty pervades everything. My frustrations about what it is doing within the health service, about our ability to focus on an improvement, are real. We had the health and social care stakeholder forum yesterday. It was not an enjoyable meeting to run through all of the risks that exist. And the challenge is that lots of our focus is on 'no deal'; we also need to be preparing, of course, for a deal that may look like the Prime Minister's deal—that's still possible. It's also possible that we still won't know by the time of our next meeting in the middle of March whether there is going to be a deal or not, or what that might look like. Now, that uncertainty is really corrosive. It affects us within Government—so, I have officials who are being drawn further and further and deeper and deeper into Brexit preparations and into trying to scenario-plan for all of those different ranges of uncertainties, and that means they are not driving forward work to improve health and care in the here and now. In a conversation on the way up I was talking to a chief executive of a health board and she said that one of her staff involved in planning health services in that part of Wales was now spending 40 to 50 per cent of their time on Brexit preparation. Well, that is an appalling use of resources, but it is entirely necessary, because we can't not prepare for an event that is on the horizon, just days away.

So, I am incredibly frustrated and, whatever happens, we will find that we have spent time preparing for scenarios that are not going to happen. We will have spent money for scenarios that are not going to happen. And, if you talk to anybody about the loss on agency staff—well, there'll be a real loss on Brexit prep for all that work that we could have spent on genuinely improving the quality of health and care, but we are not able to do so, and I find that incredibly frustrating. Bluntly, the more time we spend doing it, I go from being frustrated to being generally angry about the position that we are in. I really am angry about the damage we are doing to the prospects for the future of our health and care services and beyond, and the lack of certainty is just appalling.

But I won't get too far drawn into that, in case I start saying things that are not entirely—

11:00

Yes. I was just going to say, obviously, it's not in our gift as to which deal is secured, but I agree with you: I want to put an end to the uncertainty too. I just wanted to make sure that there is no factor that might be different for rural areas versus urban areas in terms of the potential impacts for the health service. But you've made it clear that you feel that it's the same impact across the board. 

Yes. Look, if there are small—. There are probably more likely to be small care homes in rural Wales than in urban Wales, but there are small care homes in urban Wales. Small care homes may be more vulnerable to challenges around the deal. Larger care homes, if they're part of stable groups, probably have supply routes that are more likely to be robust. There is a potential area of differential risk, but I wouldn't say it was just a risk for rural Wales—that is a risk across our health and care system, and I'm not particularly sanguine or happy about it, but we are doing all that we could and should, given the enormous uncertainty that we are facing. 

Yes. I think one of my concerns is that everybody's mental health is going to be adversely affected, but I wonder if you would comment on the fact that there may be particular concerns about the farming community. We're going to be discussing suicide prevention this afternoon, and the farming community is a high-risk group for suicide because of their ready access to means. Have things like that been factored into your planning? 

That's part of the work that we're doing, actually, and they're a particular risk group that we're looking at—so, not just in the general work that we're doing on mental health and thinking about messages for men in, bluntly, middle and slightly older age—

But in terms of Brexit, obviously, when things get really tough. 

In terms of Brexit and specifically rural communities, yes, we are looking in particular at farmers and messaging and support, because I recognise exactly what you say about risks. So, that is a specific area of work that you could see as directly targeted at rural Wales. And that work is ongoing. 

Diolch yn fawr. Mae'r amser ar ben, felly fe wnawn ni dynnu'r sesiwn i'r diwedd. Diolch yn fawr iawn i'r Gweinidog, Vaughan Gething, am ei bresenoldeb a'r dystiolaeth hefyd. Diolch i Simon Dean, dirprwy brif weithredwr gwasanaeth iechyd Cymru, am ei bresenoldeb hefyd, ac am y ddarpariaeth o'r papur ymlaen llaw. Diolch yn fawr iawn i chi'ch dau. Mi fyddwch chi yn derbyn trawsgrifiad o'r trafodaethau er mwyn i chi allu gwirio eu bod nhw'n ffeithiol gywir. Diolch yn fawr iawn. 

Thank you very much. Time has come to an end, so I will bring this session to a close. Thank you very much to the Minister, Vaughan Gething, for his evidence, and thank you to Simon Dean, who is the deputy chief executive for NHS Wales, and for your paper beforehand. Thank you very much to both of you. You will receive a transcript of the discussions in order for you to check they are factually accurate. Thank you very much. 

3. Cynnig o dan Reol Sefydlog 17.42 (vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn a'r cyfarfod ar 7 Mawrth 2019
3. Motion under Standing Order 17.42 (vi) to resolve to exclude the public from the remainder of this meeting and for the meeting on 7 March 2019

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod, a'r cyfarfod ar 7 Mawrth, yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting, and the meeting on 7 March, in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Fe wnawn ni symud ymlaen nawr, a chynnig o dan Rheol Sefydlog 17.42 (vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn. Ydy Aelodau'n gytûn? Diolch yn fawr, felly fe wnawn ni symud i mewn i—. O ie, mae hyn hefyd gogyfer y cyfarfod wythnos nasaf hefyd, pan fyddwn ni yn trafod pethau, so byddwn ni yn breifat yr amser hwnnw. Diolch yn fawr. 

We will move on now to the motion under Standing Order 17.42 (vi) to resolve to exclude the public from the remainder of this meeting. Are Members content? Thank you very much, so we will—. Yes, this is also for the meeting next week when we will be discussing things in private at that point. Thank you very much. 

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 11:04.

Motion agreed.

The public part of the meeting ended at 11:04.

Archwilio Cynulliad Cenedlaethol Cymru