Cynulliad Cenedlaethol Cymru

Diolch, Cadeirydd, a bore da, good morning. We've heard that the National Institute for Health and Care Excellence on antipsychotic medicine are being breached. The drugs are not being used or monitored correctly in care homes across Wales. Do you accept that this is the case and to quote the Older People's Commissioner for Wales: when will we be compliant with the NICE guidelines in Wales? 

Thank you for the first question. I think it's fair to say that we recognise that there may be challenges in some parts of the care home sector. I wouldn't want to give the impression that we think that every single care home is not compliant with NICE guidance, but there needs to be a recognition of the problem to be able to deal with it. And in our evidence paper, you'll note that we think that there probably is something for us to go out on with the care home sector and with prescribers who work in the care home sector. And I guess our challenge is about how we get to the point where NICE guidance is implemented rather more consistently, and that's a challenge that I would certainly accept. 

We have a range of work ongoing that you've seen in our evidence paper, trying to have a firmer base on which to understand where we are, because understanding the data is itself difficult. So, we've set out in our evidence paper some work that should start from this April. Some of it has already started—the national prescribing indicators have launched, which should give us a better base to understand what's being prescribed. And it's then about the appropriateness of that prescription as well. So, those are the areas that we are looking to concentrate our work on, and, of course, the training and support that we're looking to give for staff as well.

So, that's the broad approach that we're taking. I don't want to set artificial deadlines for improvement, but it's about how we understand improvement and I think there's also a question there about commissioning as well. So, it's a conversation that I think commissioners will be interested in and should be interested in about health and local government spending significant public resources in the care home sector, about what we're actually getting from it on a quality basis, and not just a price basis as well.       

Okay, thank you. In your evidence paper, you note that there is evidence and concern about the use of antipsychotics, but you don't go into any significant detail about the action that you intend to undertake to address the issue. So, the case of greater leadership from the Welsh Government was a theme in evidence we received. So, are you willing to prioritise this issue and take a more directive approach? 

I'll ask Andrew Evans to come in and maybe to give some more detail on the work that we are already doing. I've talked about how we get to the point where appropriate prescribing and management, then, of someone's condition and their prescription takes place, because there's something about the initial prescription decision. There's also how that person is then managed afterwards, and you'd want to make sure that, at each of those points, we are doing what we can. That's why the data point that I made is important, but, Andrew, do you want to come in and explain that in some more detail?

Thank you, Minister. To come back to the point around NICE guidance, just to set the context for it, I think that whilst NICE set out the broad principle that we would prescribe fewer antipsychotics and that non-pharmacological interventions would be used in preference, the guidance is more subtle than that. There are nuances in it. There are times when it is appropriate to prescribe antipsychotics, and that gives us a challenge in trying to determine, at a population level, what is appropriate use and what isn't. What we are able to do, and the plan we've been putting in place, which we hope will be ready for April 2018, around understanding how antipsychotics are being used in the care home sector, is to look at the data we can collect nationally that will allow us to identify clinical variation, particularly in those areas where it would appear that antipsychotic prescribing in older people is particularly high, and then allow the health service to implement interventions that would reduce the rate of antipsychotic prescribing in those areas.

So, things we're putting in place or have put in place already include guidance from the All Wales Medicines Strategy Group on the appropriate prescribing and de-prescribing of antipsychotic drugs in patients with dementia. The Minister's made a brief reference to, and our evidence paper talked about, the indicator we're hoping to put in place from April 2018 that will measure the rate of antipsychotic prescribing in older people using linked data from general practice systems. There's also work the All Wales Medicines Strategy Group are undertaking to define a national audit, based on one that Aneurin Bevan health board, I think, presented in their evidence to the committee, which can be taken by individual GP practices or other prescribers of antipsychotics to determine not simply the rate of antipsychotic prescribing in their practice, but how appropriate it is in the context of the NICE guidance. So, are patients being reviewed? Are non-pharmacological interventions being offered?

Thank you. Diolch, Cadeirydd.

I'd like to turn to the role of the Care and Social Services Inspectorate Wales. We have heard some pretty damning evidence from the Royal Pharmaceutical Society among others. They said,

'Nobody is inspecting what's going on with medicines'

in care homes. The RPS said medicines haven't been mentioned in CSSIW inspection reports since 2007-08. Others called on CSSIW to require documented evidence of medicines monitoring during inspections.

Now, suggesting that there is basis for that really serious criticism, CSSIW have responded to what they have heard in this committee by saying that they have now set out improvements to the way it works in this area. Why hasn't medicines monitoring been a sufficient part of inspections until this committee raises the issue?

I'd politely say that I don't think that that's an accurate portrayal of the situation—

Which part?

Let me respond. The point about whether nobody is inspecting what is going on, or that this wasn't a priority until the committee started looking at it—. I think committees looking at things is really helpful, actually, because it does cause people to think again about what they're already doing. I understand that Care Inspectorate Wales indicated that they are looking to do a review in 2019-20 and that antipsychotic prescribing will be part of that. But, the idea that no-one is inspecting what is going on and no-one looks at prescribing and medicines use, I just don't think is borne out by the evidence. And to give an example of what's supposed to happen in practice: an inspector is supposed to compare a medication chart with the care plan and look at the medication alongside the indication to see if they're being used. But, also, Care Inspectorate Wales have actually, in the last 12 months, issued 54 notices of non-compliance in relation to medication practice in older persons care homes, and they couldn't do that without looking at medication use.

So, I'm a little confused about where this comes from. I think there's a difference between saying that you want to call for greater priority on something and asking whether we're doing all that we could and should do, and making the rather bald assertion that nothing is happening. So, I wouldn't accept that nothing is happening, but I am open to looking at what we currently do across our health and care system, and looking at where we can see improvement. I think, in that, a committee inquiry is very helpful.

Just to clarify, when the Royal Pharmaceutical Society said that medicines have not been mentioned in CSSIW inspection reports since 2007-08, you would say that that's not true.

Are you talking about their annual report on the overall picture or individual care homes, because, actually, they couldn't issue 54 notices for non-compliance without looking at medication use—the two just don't make sense, do they?

Why would they not mention them in the reports?

Sorry?

Why would they not mention them in their reports then for 10 years?

In the national reports, they talk about a whole range of things across the sector. If they talked about every single issue, you'd have the room full of paper.

These are inspection reports they're talking about; not annual reports. These are inspection reports.

In issuing a notice for non-compliance, they have to have picked up an issue by an inspector. It isn't simply done on the basis of, 'We feel like slapping this on a care home', without having had any evidence.

I'm not sure I'm talking about notices of non-compliance; I'm talking about inspection reports, and they're saying that medicines have not been mentioned in CSSIW inspection reports since 2007-08.

Well, I'll confess that I haven't looked at every single care home inspection report—

I wouldn't expect you to.

But my point is that, if the impression is given that nobody is inspecting what is going on in medicines, well, that can't be right because otherwise you wouldn't have non-compliance notices. Having 54 of them does suggest that, actually, there is real evidence that inspectors are looking at medicines usage.

Will you acknowledge this or say it's not true, or can you acknowledge that the RPS is saying that medicines have not been mentioned in CSSIW inspection reports since 2007-08?

Andrew.

This is a matter that I discussed with the Royal Pharmaceutical Society. My understanding of the point that the Royal Pharmaceutical Society made relates to annual reports by Care Inspectorate Wales. I, myself, yesterday took a random inspection report from 2015 for a care home and found a medicines issue reported in it. So, I think perhaps the evidence from the Royal Pharmaceutical Society is intended to relate to the annual reports by CIW, rather than individual inspection reports, about which, as the Minister says, the indications would be that they do include information about medicines-related issues.

And I'm sure the RPS can confirm that when we contact them.

What do you make of the fact that CSSIW have responded so quickly, which is a good thing, to what they have heard and clearly have been troubled by in this committee as part of the inquiry?

I think that's looking to get behind the reason for a response rather than taking the response for what it is. I think it's a good thing that Care Inspectorate Wales respond to the committee and respond promptly during an inquiry. I think to try and read into that that they recognise that they haven't done anything properly is perhaps going two steps ahead, and actually we should look at the recognition of an issue, which has had its profile raised by this inquiry, and that they wanted to reassure the committee and the public that this is something that they are addressing. As I say, the evidence of the notices issued is evidence that they do look at this. But, again, you should always be prepared to take a step back and look at what you're doing to see if you can improve it.

Do you think that perhaps a lack of priority in this area, as reflected by a lack of reference to medicines in reports—? Do you think a lack of priority in this area of scrutiny of the way care homes work has contributed to the problem of overuse of antipsychotics?

I think it's really difficult to make the leap between the two, because, firstly, we'd have to say that there's a lack of priority, and we've just talked about the fact that they've issued 54 non-compliance notices in 12 months. It is difficult to then say that there's a lack of priority.

But if you accept in any event, you could always look at what's happening and there's a general impression, and some evidence, about inappropriate prescribing and the continuity of prescribing, and that's an issue that we'd want to have a look at, but it isn't just Care Inspectorate Wales because, of course, every prescription decision is made by an individual registered health and care professional. They've got their own duties at the point of prescribing and also at the point of managing that person and their prescription. So, it's actually a broader point that we need to look at, and not just say that this is Care Inspectorate Wales's unique responsibility. But, they have a role in that system, of course, and I welcome the fact that they've responded promptly to the committee and are looking to further improve on what they do.

Your evidence paper notes that the new care homes directed enhanced service requires at least one medication review per resident. We've heard evidence that this isn't sufficient for antipsychotics use, which should be regularly reviewed and time-limited. How do you intend to address that and ensure that regular reviews do take place, along the lines of evidence that we've heard?

The new directed enhanced service is about improving the quality of care that people receive in care homes, and I'm pleased that we were able to conclude that agreement with the BMA to ensure that that service is more consistently available for care home residents. And I think it would be really useful to understand the quality of care that we receive as that service beds in.

The requirement for at least one medication review is exactly that: at least. So, we are setting a baseline for every resident, and not every resident in a care home, of course, will be on antipsychotic medication.

This comes back to the point that this is about prescribers taking seriously their responsibility to not just prescribe medication at a point in time, but also to ensure that regular reviews take place as is appropriate. And the 'appropriate' point is, I think, the thing that matters. For some people with a physical health condition, you'd expect them to be reviewed more regularly than once a year. For other people with mental health challenges, you'd expect them to be reviewed more than once a year. It's about what is appropriate, and, again, that comes back to that healthcare professional, having made that decision, being clear about when they need to appropriately manage that person's condition and the medication or other interventions they've prescribed. So, I would not expect someone on antipsychotic medication to simply have an annual review; I'd expect that to be an appropriate decision and for it to be appropriately reviewed by that healthcare professional.

The problem is, of course, they haven't even been getting an annual review, lots of them. That's the evidence that we've heard. Some of them have been on antipsychotics for years.

Well, that shouldn't happen.

I agree.

And there's a point here about saying that that shouldn't happen; there is a recognition, and no-one will dispute that. The new directed enhanced service is about setting a bare minimum for what should happen for every care home resident, a number of whom may not be on medication, but, as I say, age doesn't come alone, and those of us in middle age, even, are starting to feel that.

But, you know, the reality is that you expect appropriate prescribing decisions to take place and appropriate management of that person's health and care. So, I'm not going to try and say that it's fine if people are on antipsychotic medication long term without appropriate reviews. I actually think that the new directed enhanced service and the new data that Andrew Evans referred to will give us a better understanding of what is actually taking place. So, I think we'll be in a better position as a result of that.

How wide, do you think, is the understanding of the alternatives that can be used to the prescribing of antipsychotics?

I think most health and care professionals recognise—in fact, I would expect all health and care professionals who are prescribers to recognise—that prescription is not the only option available. It comes back to the appropriate choice being made with and for that person: so, to look at their circumstances, to look at the condition in which they present, but also to take account of all the information that is available.

And there's something about some of the concerns that people raise that if people are anxious and are worried in a new situation, is that seen as, 'Someone's difficult, you need to do something about it and reach for medication'? Actually, both in the training on 'Good Work' more generally for the whole health and care workforce, but, actually, as I say, on that individual professional responsibility for prescribers, I would not only expect there to be greater awareness, but the proper use of that. Because that's part of where we want to go to understand those choices. So, the data on prescribing will help us with the number of prescribing decisions that are being made, but, as you know, we are looking to invest in our allied healthcare professional workforce and others to try and look at a range of areas, so that prescription is not the first and only response to someone who presents with any form of anxiety or difficult or challenging behaviour, as perceived by the person there, as opposed to understanding that if someone is put in a new and different situation, you can understand why there is a response.

Yes, I think we all understand that professionals can be under pressure to prescribe, but do you have any sort of knowledge of what is the existing position? Obviously, we're going to invest in more training, and we did have the impression that many people did not know about how to go through the checklist of things that could be done instead of immediately prescribing. I wondered what your plans were to ensure that that did happen.

Actually, we have a range of activities on looking at alternatives. I'm looking at checklists to try and make sure that people can go through and understand the range of different alternatives available. There's the first point, going back to my point about commissioning. So, understanding what we are commissioning with the public purse. So, in health and local government, we are looking at the range of activities that are offered in a home in the first place, and then, when you come to the point of issue, you have a health or care professional dealing with an individual, that they understand the range of activities and alternatives that are there. I don't know if Jean or Andrew would want to go through some of the stuff about the range of different things that we are looking to do to get to a point where we can actually provide, if you like, greater guidance and help for people to understand that.

I'll start, if that's okay. We have got a wide range of examples across Wales about the types of interventions that care homes are doing, but more importantly about what health boards are supporting the care homes in their area to do. A lot of the areas now have inreach teams that are working with the care homes to show them the variety of alternative types of approaches, but a lot of what care homes are doing already don't require a great deal of equipment or anything like that. The types of interventions that we need to do is to assess people's pain appropriately, to do things like music and drama and some life-course-type conversations to help people to keep in touch with themselves as a person. We have a wide range of examples across Wales.

I think the challenge we have is that it's not consistent everywhere. With a lot of these things, not everybody's doing everything consistently. So, the 'Good Work' education training programme that's being rolled out, which was actually designed with social care and the third sector's involvement, will give people much more of a structure to understand the types of things they should do. The education programme emphasises the importance of looking at medication and medication reviews and emphasises the other types of things to do.

NICE guidance sets out quite clearly the types of things that people can do, and then there are various supports that the care home can pull in from the health board to help them take this forward. I think, with the greater emphasis later in the year when the dementia action plan becomes available, that will also re-emphasise and reinforce that it's not just about giving a drug, it is about making sure that you assess a person's anxiety, have they got depression, are they in pain—because pain is often a trigger for behaviour. A lot of the care homes are now using positive behavioural support mechanisms, and one of the checklists that you're probably referring to is around making a determination about what's triggering the individual's distress.

They use ABC: they look to see the trigger—so, the antecedent—they look at the behaviour, then they look at the consequence. The care home can then create a care plan designed to meet that individual's needs that will understand what's affecting them as a person. We can't treat everybody the same here. It is very individualised care that has to be organised. Andrew may wish to add something. 

I don't think there's a great deal I can add, other than the importance of—as you mentioned, Jean—particularly identifying patients who may be perceived as having psychological behavioural symptoms when actually it's a manifestation of pain or the end of treatment for depression. So, checklists that support identifying the root cause of people's behaviours are a really key part, and that's very much part of those checklists. As Jean said, the dementia action plan provides a basis for re-energising those.

So, these sorts of things would be a key part of the dementia plan, when it comes out. Right. Thank you very much.

Thank you, Chair. Jean, I think you just mentioned the issue of lack of consistency across alternative therapies. I think one thing that came across clearly in our evidence that we heard was lack of consistency around training—that was variable across Wales and it needs improvement, particularly around dementia awareness, understanding performing intimate tasks in a sensitive manner, and specific skills such as de-escalation and safe restraint. The older people's commissioner told us that she's not found any want of good intent, but what she found was a lack of knowledge, resources and support. Care Forum Wales stated that training and awareness of the possible causes of agitation that may lead to aggressive and destructive behaviour are absolutely imperative. Also, quite worryingly, CSSIW stated that, with the EMI beds, many of these homes—they found that there were a number of instances where neither the staff nor the manager had any specific training in dementia. Obviously, this is worrying for us as a committee. Can you say a little bit about what you're going to do to improve staff training or get that consistency across Wales?

As I said, you have to accept there's a problem to be able to address it, and some of this is not really about prescribing, but it's about the quality of care that we're commissioning, and if people say that they can care for people with dementia, that they are actually able to do so, as opposed to advertising themselves as being able to care for people with dementia and then not having appropriately trained staff. I went to the launch of 'Good Work' in a hospital setting, when it's actually put together to cover health and social care and, as Jean said, designed with people in health, social care and the third sector. And actually, Social Care Wales's forerunner body were part of helping to design it. Part of our challenge is how we roll that out and make that more consistent—but that actually, then, providers are then held to what they say they're going to provide and they're commissioned to provide. Otherwise, we'll end up continuing to accept a poor standard of care. This isn't about warehousing people. It's actually about providing them with a certain quality of care, when they need to have care provided in a different setting, and with dignity as well. Those broad things come into every part of that, including the point about staff training—so, not just on antipsychotics. We're actually talking about how staff go about their day-to-day activities, and they're not just medical professionals—they're not even all going to be members of the nursing profession—but there's a whole range of staff who need to be aware of this, and that's part of the challenge that we accept. We'll have more to say on the issues of dementia more broadly when we publish the plan, but it isn't just an issue for people who have dementia. 

Okay. Thank you, Cabinet Secretary. You mentioned the 'Good Work' framework. CSSIW noted that awareness for this is low and hasn't been adopted in many care homes. That was what they suggested. What more work should be done, and how can we go about improving that communication?

Well, it's disappointing that there isn't not just a greater awareness, but a greater take-up of 'Good Work'. It's been designed with the health and care sectors, the third sector and Social Care Wales. So, we want to see greater take-up of that, and the dementia plan will be an opportunity to reset some of this. I'm not going to prioritise every single part of the plan, but there will be an expectation that, actually, there's not just greater awareness but a greater take-up of that training, which, as I said, is for everyone within the health and care sector, because we think that will improve the quality of care that people will receive. And actually, it will help staff to do a better job, and that's likely to make staff feel better about the job that they do as well. So, it's a recognition that there is more to do, and you'll hear from us in the near future, as we publish the plan, and more broadly, how we're going to go about doing that.

Okay, thank you. Finally, the RCN suggested that, given the complex needs of care home residents, we need a formula to calculate the skills mix required for the staff. What work is planned or under way to ensure safe staff and appropriate staffing levels in care homes?

The RCN are very consistent on this issue. They would like there to be a skill mix and staff planning and workforce tools available in pretty much every part of the workforce, and you understand why they're doing that. Care homes is one of the areas, which Jean can now fill you in on, that is being led from the chief nurse's office.

We have the nurse staffing levels legislation, which has two duties in it, and the first duty, which came into force last April, talks about having sufficient nurses to care for patients sensitively. So, that means, when the health boards commission placements in care homes, there is a duty on them to ensure that the commissioned place actually has enough nurses to look after the patients. We are starting to look forward to the integrated medium-term plans that will come out shortly, which is the planning process for the health boards, and they will need to demonstrate to us, sensitively, how they have taken this first duty on board, and how they're going to use it in their commissioning arrangements.

We've had work on nurse staffing levels in Wales since 2012, and there are work streams, now, that cover not just hospital settings but district nursing, health visiting, mental health and, most recently, care homes. So, the work to date: we undertook a commissioned review of all of the types of tools and different types of approaches used in care homes, and that report is being used now to set a particular work programme to test out the appropriateness of developing tools or guidance specifically to help commissioners when placing patients who need NHS-funded nursing care or continuing health care.

We've also run a number of delegation workshops, because what we need to make sure of is that the registered nurses working in care homes feel confident that they can delegate certain duties to the support staff available to them. So, that means they've got to look to see the training of the care home support staff working with them. Otherwise, they can't be confident they're giving it to people who are competent to do that. We've run workshops throughout Wales that we've funded and supported, essentially, from Welsh Government. So, we've got attention in this area. The challenge we have, should we, at some point in the future, wish to, say, extend the nurse staffing levels law to the care home sector is that the evidence base for workforce tools just doesn't exist, and the law requires us to have an evidence-based workforce tool ready and available before you can extend the law to an area. So, part of what we're doing at the moment is trying to work out what is the evidence that tells you what is the right number to care for patients—clients living in a home, with particular types of needs.

So, the work we're doing this year is working out how you determine the level of acuity, dependency and need of individual patients in a home, but then for you to make a professional decision about how many registered nurses and how many support staff you need, and what's the skill set those workers need. And it's very different from a 600-bed—almost like a community hospital, these very large homes are—to something that's got 12 beds, which is more like a residential home. So coming up with a tool that covers both of those situations is really quite tricky, but there is a lot of attention we're paying to this because there are more beds in the care home sector than there are in our hospitals. So, it's in our interest to get this right, otherwise patients will be moved on from a care home setting into a hospital when they should be actually managed and looked after in a care home. So, this is really important to us but it's not an easy, 'Yes, let's come up with a tool that will fix this'; it's a more complicated process we have to go through. 

Thank you. 

Angela, you had a supplementary on this. 

Can I just flip it on its head and ask you whether you're aware of a great number of incidents that have occurred that wouldn't have occurred if a nurse had been present? Because, of course, we talk about the fragility of the care home sector, we talk about the lack of nurses, we have a shortage of nurses, we talk about the affordability, and particularly in high-need, complex patients to find a good care home that can take them, it's becoming extremely difficult, because there are lots who can manage up to a certain level, but then the needs get so complex they simply can't, so these people often end up back in a hospital because there is nowhere else for them to go. Because I'm interested in this. The RCN, obviously, have talked to all of us about it, and I'd just like to try and understand where you think the tipping point might be, because it's an evaluation of risk, isn't it, all the time? And I'm interested to just try to work out whether, if we were to go down that route, we would actually be closing the care home sector off more from the EMIs and the high-dependency needs. So, I just wondered if you have any evidence base of how often it's gone wrong because a nurse—. And also, have you looked at other things like nurses, perhaps, working for the health board but going out and covering the care homes and covering a number of care homes, and doing rotas and things? Because, of course, if it's a small care home and you've got one nurse and then she goes on holiday or sick, you're back to square one, aren't you?

Obviously, we have some instances where the care home has turned to the health board to seek support because they may have staffing issues, and there are very good examples of collaborative working between the health board and local care homes to make sure that patients don't come to harm. CIW has worked—. Part of their inspection when they have escalated concerns about care in a care home, where they've then engaged with the health board to look to see what arrangements—. So, I can't give you a figure to say, 'This amount of harm has come to this'. What I do know is that there are processes in place so that problems are identified if there is chronic difficulty of staffing where the inspectorate has raised concern or put requirements on the home and then they've worked with the health board to try to make sure that patients, or the individuals, don't come to harm. It might mean that they have to be placed somewhere else if the home can't be sustained, if care is dipped so that patients are coming to harm, or it might be that they need just some support to bring them back up, because the consequence, you're quite rightly saying, is we could end up with homes closing, and that's in nobody's interest if there could be some support. So, I would say there is probably evidence out there. Could I put a number on it? No, that would be quite difficult.

It might also be useful to say that, following the Flynn report that looked as a consequence of Operation Jasmine, which is around failures in caring in care homes, we have now a whole series of recommendations that the Government has accepted. This is a report given to the First Minister, as you may recall. One of those areas is around harm to do with deep pressure ulcers. So, we are testing a system about reporting and recording those identifiers. Pressure ulcers are related to staffing, and not just levels of staffing, but understanding. I'm afraid we're a little bit away from the antipsychotic medicines agenda, but this also relates to the issue of staffing.

My question was just similar, really. Do you actually monitor, then, cases of people who are stuck in elderly mentally ill wards because they can't get an appropriate care home placement? I also know of people who had been placed in care homes but then had to get sent back to the EMI ward. Some of those patients are there—and from personal experience—for two years or more in a district general hospital. Do those figures get monitored anywhere?

Yes.

'Yes' is the simple answer. We look at what are called delayed transfers of care and what is part of our monitoring, particularly through the winter pressures period, which we find ourselves in now, because what we don't want is the patient flow through the system being affected. Because if you have beds filled with people who really should be cared for in a different environment, whether that's back at home with a package of care or in a care home, it means that the availability of beds is then not there for those people who want to be acutely admitted with flu or bronchitis, or whatever it happens to be. So, yes, it is one of the things that we're looking at. Obviously, patients may have to be re-admitted to hospital because their condition may have deteriorated. So, it's quite a complex thing just to sort of say it's because of some failing in the care home. It might be that the person's needs just will have changed, and they will have to go back in because they've had a fall or if they've got an infection or something. So, it's quite difficult to give you a kind of blank answer on that.

So, you don't monitor the number of people who either have been re-admitted to an EMI ward because of challenging behaviour that can't be managed in a home or weren't ever able to be put in a home because of challenging behaviour. It does link to the antipsychotics because, obviously, that's why, in a lot of these instances, people are given antipsychotics to deal with what's perceived as challenging behaviour.

I think there are a couple of different things, if I can separate different things out. There's the point about people who are longer term delayed transfers of care, whether that's about capacity within a local area, or whether that's actually about the appropriateness of care and people who have very specialist need. We have seen instances of that where someone is effectively in a hospital because there isn't provision available for them within anything like a reasonable distance. There is then the point about the appropriateness of managing their condition and whether they're being appropriately prescribed and managed, and that comes back to, I guess, the general point of this inquiry, which is how we assure ourselves about those prescribing choices and the continuance of them, and how that affects where people are cared for. As we've indicated, we are looking at ways to try and understand more of that, and so we'll have a better basis to understand what we have within our system. But this goes back into, again, the points about the staff, staff training and equipping people to make the right choice.

It is your questions now anyway, Lynne.

Okay, thank you. One of the things that the committee's heard is that there are barriers to accessing allied health professionals in care homes, despite the fact that we know that having that access can bring very real benefits for residents. How does the Welsh Government intend to ensure that there is appropriate access to allied health professionals for people in care homes?

There are just two things, and then I'll ask Liz to come in to talk a bit more about the directed enhanced service and about what we expect people to do within that. The first broad point, though, is that we continue to invest in the future of the workforce, not just training the workforce we currently have, but, actually, in the choice that I announced not that long ago, we have invested even more than last year. So, last year, I announced a £95 million investment in the future of the workforce—so, nurse training, midwife training and allied healthcare professionals. This year, again, I've announced £107 million, which is a real increase, and that's not an easy choice because you're taking money from somewhere else. But that's for the future of the workforce because we really do recognise that allied health professionals, whether they're in the care home sector, whether they can get people into their own home—you generally recognise their value to the service. We recognise they're a partner and not just an enabler of the future as well, and it's a greater recognition of the role that they can bring as part of that wider team. That has to be the case in the care home sector as well. I know Liz might want to talk about, like I said, what we expect in that directed enhanced service. It isn't just about GPs, but it is about broader provision as well.

In the DES, the expectation of the GP is that they should make a visit to the patient in the first four weeks of their stay, and then act in a sort of co-ordinating role, drawing together the skills that are needed to support that patient. I think critical to all of this is the individual. It's the individual, their needs, their preferences, their foibles that inform the care plans. The care plans are the things that help us to anticipate challenging behaviour and maybe learn how best to deal with that sort of reaction to stress for that particular person.

So, that first visit by the GP in the care home is very important, identifying perhaps—it may be as simple as the patient needs a chiropodist, because there's pain in their feet; the responsibility to draw that in when it's needed. This all contributes, then, back to the issue that we're here to discuss, the prescribing of the antipsychotics. Because if we knew every patient to the degree that we should know them, and do that by means of the care plan that tells you about that person—who is important to that person, what that person's personality was and is—we'll get a far better service. We know; we've seen the interventions. We've seen interventions when secondary care meant older persons mental health teams coming into the care homes and setting up this team around the individual. We see the prescribing of the antipsychotics not just drop, but plummet; much happier patients, and a much nicer place to work, as well.

Could I just ask specifically then about speech and language? We know that they can have a very particular value in working with people with dementia, and particularly managing challenging behaviour, which arises from communication difficulties. But we also know that we've got real shortages with speech and language therapists. Are there any particular plans to address that in relation to care home residents?

Well, as I say, I've invested more in, obviously, general training, and we continue to invest in training speech and language therapists. So, that's 44 training places within this year's package. So we do continue to want to replenish that workforce, and there's a recognition of their value in a wide range of parts of providing health and care, not just the care home sector, but for children, in recovery from stroke. In lots of different areas, speech and language therapists are part of that team, and the challenge always is: where do you need a speech and language therapist, their specialist skills? How do we then provide other people within the care team with skills to help people to do that? So, some of this is about how they pass on some of their skills to people at an appropriate level, and that again is part of our broader point about workforce training.

Okay, thank you. You'll have seen, I'm sure, that the Royal College of Speech and Language Therapists and the Royal College of Occupational Therapists are calling on Welsh Government to look to the Scottish model and pilot a request for assistance scheme and a funded allied health professional dementia consultant post to look at these issues and to improve access across Wales. What is your response to that call?

That's quite specific around dementia, and that's something that we will be covering in our plan. I don't want to pre-announce every single choice we made in the plan, but that will be covered when we publish the final plan.

Thank you.

Okay.

In the near future.

Thank you, Chair. I just wanted to ask a couple of questions on data collection, if I may. I think Andrew Evans talked earlier on about using linked data from GPs, but generally the lack of data was something that was highlighted as a problem by a number of witnesses. Many were calling for audits to establish the scale of the problem and to measure the baseline. When will we be in a position, do you think, to meaningfully assess the baseline and to collect and monitor data on the use of antipsychotics?

I think it's fair to recognise that we share the concern of individuals who responded to the call for evidence and the inquiry relating to the challenges of data in this area. In Wales, we have an approach around national prescribing indicators that's very well established. It has led to significant improvements in the quality and value of prescribing in areas like reducing antimicrobial use, or reducing use of anxiolytic and hypnotic drugs, but there are constraints on that data as it stands at the moment. It's data derived from prescriptions that are dispensed and payment for those prescriptions, so it's linked—. It's restricted largely to information about cost and volume.

In the last year, we've been working very hard with the NHS Wales Informatics Service and the NHS Wales shared services partnership to understand what alternative systems there are in place to collect data and link data, as many of the respondents identified as being a priority. We've been trialling that for the last year, and we're pretty confident now that we will be able to collect data looking at certain demographic characteristics of patients in general practice with prescriptions for antipsychotics. So, we are proposing, from April 2018, to collect data for every general practice in Wales, looking at the rate of antipsychotic prescribing amongst patients who are aged 65 years or over. We haven't, at this point, gone to look at any data beneath that, because the problem you have with linking data is that it relies on high-quality coding in the systems that you're trying to link. So, we're very confident we can identify antipsychotic prescriptions and the age and certain demographics of the people to whom they're prescribed, but, at this point, until we try that, we don't want to go further. But it does mean that, from April 2018, so in the year 2018-19, we will start to understand in very great detail the rates of antipsychotic prescribing in people who are most at risk of dementia from those medicines.   

Is that your aim—to establish a baseline? 

Yes. 

And you're talking about April next year. 

April of this year. And we've got that agreement. We've built and tested the software that's going to run those tests and, as I say, the intention is to start collecting in April, which will mean, around three months after that—we tend to report data quarterly on prescribing—we should start to see the first set of data in June or July of this year. 

Okay, that's fine. Thank you. Just one other question, if I may. This is just about targets to drive change. In England, there's been a target set to reduce the use of antipsychotics by about two thirds, I understand. Are you willing to set targets in the final dementia strategy? 

No. I think we need to see a shift, with evidence about what's happening, so the data matters about where we are. We want to have appropriate prescribing decisions. If I set the targets, then people will work to that target as opposed to looking at the person in front of them and understanding what is right for that person. Antipsychotic medication could be appropriate for that person, but it may not be. If I set the target, I think I'm trying to intrude into an area where we actually want appropriate decision making, and the data will help us to understand what is then happening within that sector. And also, the directed enhanced service will again help us to understand more clearly what is taking place, and I think that's important. And, within England, despite having set the target, it hasn't changed prescribing practice.  

But you would still see it as a success of the strategy, presumably, and the kinds of things that Liz was talking about, as a reduction in the use of antipsychotics would mean that the strategy was working more effectively. 

We'd expect that appropriate prescribing choices would mean that we would see a reduction in the current prescribing volume—percentage, rather. But to them, to say that we should set a target for that, we don't have enough evidence to set a meaningful target. Part of the challenge about targets is you often target time or volume because it's easier to measure, but that doesn't always tell you about the quality of the care that's being provided or the outcomes for the individual. I would want to be assured that we know enough to set a meaningful target that would make a real difference to someone's quality of life, and I just don't think we're in that position. So, I wouldn't be prepared to set a target. That might be great for responding to the inquiry or getting a headline, but I don't think that would ultimately lead to better choices being made with and for those individuals.  

Thank you. Thank you, Chair. 

The final round of questions, from Angela, then. 

I was just listening to your answers to Dawn there over the data collection that you intend to put into place. I assume that you won't just be using the metric of those with dementia, and that you'll be looking at other metrics as well in the prescribing of antipsychotic drugs. Do you have any feel at all, given your answers to Rhun right at the very beginning, for how much or how severe the problem is currently, in Wales, of the overprescribing of antipsychotic drugs, especially in care homes?

If I gave you an indication then I think I would simply be looking to give you an answer to get through the next five minutes, and I think the honest answer is going back to what's appropriate. If we think there's evidence, and we accept there's some evidence, that we think that different choices could be made, that's enough for us to look at it. The measures that Andrew's set out in answer to a couple of different questions that were taken on data will help us to better understand where we are, and then to understand the different choices we expect will be made. And within all of this, of course, we're expecting to expand. Because of population change, we think there will be more people in the care home sector. We think—we certainly hope—there'll be more people that are diagnosed with dementia, because I think we underdiagnose dementia at present. So, we should have a better basis to understand what's happening and to interrogate ourselves but also for health and care professionals to understand the choices that they are making. I don't want to try and set out, 'The scale of the problem is X or Y', because I think that is finger in the wind stuff from me, and I don't think I should do that. 

So, you've got no data, though, that might underpin any of this. Because, obviously, we feel that there might be a problem, hence our decision to have an inquiry. The people who've come to see us have indicated that they have concerns and, of course, we've changed, haven't we? We have a much more holistic attitude towards people. We don't lock people up any more and throw away the key if they're mentally unwell, as we used to do 50, 60, 100 years ago. So, you know, it's great that we're moving on and we're becoming much more holistic in the way that we look at people, but I think that all of this can only work if there is a real belief—and I don't quite feel it yet, from Welsh Government—that there might be a significant problem in this area, and that's what I was really just trying to touch on. 

In our evidence paper that I set out, we did actually recognise that we think there's a problem, and we set out, in that paper, some of the extra detail we haven't been able to give today about wanting to have a proper data baseline to understand what is currently happening, and then to try and look at how that is, or isn't, meeting people's needs. In almost every field of health and care, you could interrogate it and understand a need for or an area for improvement. We think this is an area for improvement. We think our current data collection isn't where it should be. That's why, from April, we'll have a firmer base on which to do that, and after the first quarter we'll have figures, and we'll learn more as we go through, and it's then about how we use that data intelligently to improve the quality of care and the outcomes from care. 

Okay, thanks.