Cynulliad Cenedlaethol Cymru

Diolch, Cadeirydd. Good morning, everyone. Bore da. Can you outline the approach the Welsh Government has taken to developing 'A Healthier Wales: Our plan for health and social care'? 

Yes, happy to do so. Good morning, Chair and committee. We obviously had cross-party agreement on the parliamentary review. Every party in this room agreed on the terms of reference for that and the membership of the panel. We received their report, published in January, and we have developed 'A Healthier Wales' on the back of that. I think the plan that you see before you, in terms of our plan for the future of health and social care, is faithful to the direction and the recommendations in the parliamentary review. We took that forward as we said we would do, by working with our partners in health, in local government, in the third sector and housing as well. So, it really is the first time we've had a joint health and social care plan.

In the past—and you'll remember this, and other people around the table, from previous plans—the Government essentially wrote a plan for the health service and gave it to the health service to deliver, who then told their partners that this is what they had to do. This has been different. We've had partners in the room at the same time, talking about a joint plan across health and social care, and, the response from that, you'll see that we're trying to maintain the way in which the plan has been developed. It has been generally co-produced in a way that other plans haven't. That doesn't mean to say that this plan is perfect in every and any conceivable way, because we'll have to be able to try and deliver it, and there are always events that occur the way. But I'm generally positive about where we've got with that buy-in and the fact that it has been faithful to the parliamentary review process.

Okay. Caroline.

Thank you. What will be the process for developing the new models of seamless locality-based health and social care services at local and regional levels?

Well, obviously, in the plan, the key message is about the fact that our current system of health and social care is not fit for the future—so, a big warning for all of us that change is not just desirable but necessary as well. So, in developing those plans together, we've taken seriously the message from the review in what you see in the plan. We expect those regional partnerships to develop a plan together. So, to make sure that those partnerships are more consistent, we've made it clear that health and housing have to be a partner in every regional partnership board. At present, they are not, so they will be. So, housing will have a voice around each regional partnership table with the third sector health and social care.

It is about those regional partnerships agreeing on what they think are generally transformative models that are scalable as well. Because what we've set out in the plan, but also in the guidance that we've just issued or are about to issue, is that the plans that they develop have to be ones that fit with the 10 design principles. So, we've given them guidance about areas, and in particular the point about them being scalable and generally transformative. The Government won't, though, say: 'Here are the seven areas that we want you to focus on in terms of the service areas.' What we are trying to do is to make sure it has got genuine sign-off, because every regional partnership board has to sign off on what those transformative projects are to bid into the fund.   

What we've also been really clear on though, in going around and talking to partners, is that (a) we're not just wanting for people to bid into a £100 million fund—don't lose sight of the fact that there's a £9 billion joint budget between health and social care and it's about how that, ultimately, is used, with the resources of people, staff and other levers—but also that we expect partnerships to have a focus on things that they would want to both have support from a transformation fund for, but, at the same time, things they can get on and do themselves anyway. And then some of this is about how we promote learning within each region, as well as across the country as well. So, the transformation programme and the fund are designed to accelerate those models, but it is not the only way that we expect that change to happen, and those regional partners have to agree on what to do.

So, as you're talking about the partnerships, do you think that regional partnership boards have sufficient buy-in from all the key areas across Wales to make a success of service transformation? Is there sufficient buy-in?

The straight answer is 'yes', but the honest answer also is that each of the regional partnership boards are at different stages of maturity, and the level of the relationships and how intertwined they are. So, there's a different level of buy-in; we're expecting to see some different pace in what people are able to do. But what's been really positive, actually, is that, in the second round of meetings we're having, we think that those regional partners have moved on and are in a better place than they were before, again. And, not only that, there is—. Whilst we don't want competition between and within public services necessarily—although people in this room may disagree—there's some helpful and constructive competition between regions. No-one wants to get left behind, and people have a level of ambition and don't want to be seen as the part or the only parts of Wales that haven't been able to agree together on how to transform their services. So, that's been really positive for us, and it does give me real cause for optimism. 

So, as there are—. As you've said, they're all at different levels, so how do you anticipate bringing them all to the same level to proceed?

Well, that's the challenge about the projects we have coming in for transformation. And we will have a board that will give advice on which projects to approve or not approve, or to go back and say, 'We need more work done in this particular area', but I am confident that each area of Wales will have an area that it wants to go at itself and have a bid into the transformation fund. But, more than that, they'll have areas they identify for themselves. And, crucially, we're not just thinking about primary adoption for transformative models, but we expect people to adopt models that other people are taking and running forward—if you like, that secondary adoption. So, we don't want anyone to be left behind with no transformative project running across their area.

Okay.

There'll be some more drilling down now in a minute. Jayne.

Thank you, Chair. 'A Healthier Wales' states that:

'The national primary care contracts will be reformed to enable the delivery of seamless local care and support.'

What reforms do you think are likely to be necessary?

Well, we've got eight key areas for negotiation with the contracts. That's improving access, building on multi-agency cluster-led planning and delivery, looking at premises, professional indemnity, enhanced services, quality improvement, recruiting and retaining a diverse workforce, and access to data and improving our evidence base. And so, you'll see a range of areas there that are consistent with what we're trying to do within the plan. There is always what the contract allows you to do, and what the contract, sometimes, prevents you from doing. Actually, we do think there is genuine goodwill about wanting to see the contract fit for purpose for the future. And we haven't had any push-back from people in general practice about the direction of the plan, so we're negotiating with people who want the plan to work as well.

Our challenge is always going to be what we get to practically achieve in having a contract that's pointing in the right direction. That also goes alongside the contract reform in dental services and, indeed, in community pharmacy as well. Because, of course, they have key roles to play in delivering primary care more broadly and our ability to diversify the way in which services are run. So, I'm optimistic about the direction of travel, but it will also, obviously, come down to what do we actually get to agree, and what difference do you and your constituents get to see.

Thank you. Do you think there's sufficient capacity to develop the preventative approaches, in addition to maintaining current service and responding to, obviously, the increase in demands?

Well, there will have to be, because we don't have an option that says that we will just not develop preventative services. Because the very clear message we have is that if we stay as we are then we'll find a system that is over-topped at various points across health and social care. Part of what we're doing with our transformation fund is looking at the largest areas of potential transformation and the ability to double-run some services as well. So, we're looking to help transform the way our services work with the use of money, but actually a lot of this is the way that partners actually get to work with each other. Because in those areas of Wales where we think relationships are more mature, we think things will happen that aren't reliant upon a fund, but are actually reliant upon the nature of the relationships that exist, and that's a much greater area of gain to be made.

But, yes, I think that across the whole health and social care system they understand the message that, as well as running the immediate services in the here and now—which, of course, they and myself and the Minister will be judged on, on a regular basis, in this forum and others—that they also have to have a greater focus on prevention and earlier intervention, and that's key through the planning and the design principles as well.

Okay, thank you. Just moving on to mental health, there are a few references to mental health in 'A Healthier Wales'. How will the artificial barriers between physical and mental health that the parliamentary review noted be addressed?

Well, that does come into our design principles as well. When you look at the key areas that we're interested in, we are interested in projects that address mental health across the country as well, together with children's services and a range of others. So, the focus that the Government has is not going to disappear, and our colleagues and partners in health and social care recognise that, not just because the Government says this is important, but because they recognise it as a key driver for demand for their services as well, and it's part of what they will need to address. I still think there's a wider societal challenge about the way that we talk about mental health, and the stigma that's still attached to it as well. So, we have big barriers that are more than just the way we organise our services, but actually the way that we deal with physical and mental health, the way we talk about it, and then the way we prioritise action for it.

And is it the Welsh Government's priority and your priority to ensure that there could be parity of esteem between mental and physical health?

Yes, that's a long-standing aim of the Government that no-one disagrees with. Our challenge is how much progress we've yet to make to get there, and needing some honesty about the fact that there is still a great deal further to travel. 

Sorry, on this point, Angela, you've got a supplementary.

It is on this point because, actually, reading the vision for health, I don't get the sense that mental health has got the priority it needs to have. In the priority areas for 'Prosperity for All', the five priority areas are early years, housing, social care, mental health and skills and employability, and I would argue with you that early years and mental health are critical, because without that we can't have skills and employability, and without skills and employability we can't make the money to look after housing and social care. So, do you have any concrete plans to try to redress the imbalance between physical and mental health within the health service, in terms of either funding or what are you going to be able to do to actually change that culture? Because, if we're not a well nation, we can't do all the other great things we need to do to make the rest of the stuff work, like how we look after our older people, et cetera. 

When you look at the five areas in 'Prosperity for All'—which, as you know, are outside the plan, 'A Healthier Wales'—you see lots of things that go across more than one of those areas, and that's been recognised in the review that we've had and the work we're doing in Government already about where we are on those five areas, and the progress we still need to make. We've got a mid-point review for 'Together for Mental Health' coming up, so we're looking again at what we've done and what we need to do in the future. As I said, there's no pretence that we are in a place where we can say that everything is fine and you don't need to worry about the future. We recognise that there's more that we need to do, and that is not just from a health point of view as well because, of course, we talk about health in all policies, but it's also about all policies in health as well, and seeing the way in which we all work across the Government.

Obviously, the report that we discussed, 'Mind over matter', last week was about links between health and education in particular, but there's more to it than that as well, because the way people feel about work and the way they're supported makes a big difference to people's mental health and their sense of well-being. So, this is a challenge across the Government, and we know that we  have more to do. You will see more from us not just in the review from 'Together for Mental Health', but in the way in which we respond to what the committee reports, but also, I think, in the way you see transformative projects that really are about mental health, as well as physical health.

It would be really useful for the committee if, at some point, we could have some kind of overview on the kind of transformative projects that you think about when you talk about mental health, because, yes, we're not where we want to be, and no-one's going to beat anyone up about that, because it's just the way society has evolved, but we keep talking about making that step change and we don't see it happening. So, we do want to make a real drive on making sure that that mental health element is brought up, because it affects every single aspect of Welsh society and how we develop.

So, I think, what I don't see, when I look at all of the various integrated plans or plans that are supposed to integrate is that thing underneath it all that says, 'We're going to keep pushing this particular agenda again and again and again and again', and I'd like to get a feel that there's that real resolution within the Government that there are going to be really transformative programmes to get to grips with that whole issue of dealing with people who have a mental injury, rather than a physical injury.

I recognise entirely what you're saying. We expect to see that in transformational bids that come in, but also in the work that each area is doing. As I said, if you go to primary care and you look at big drivers for demand then, actually, mental health challenges are a big driver for demand within primary care. So, it is not something that our health and care system is going to be able to ignore even if it wanted to and, again, we know that the way that we currently deliver services across the country won't work for the future. So, you can expect to see change and an articulation of what that looks like as we have more bids coming in to both the transformation programme and more agreement across regional partners about what they want to do.

Okay. Right, and back to Jayne.

Thank you. And, finally, how do you think the reforms will help address health inequalities?

Well, again, I think health inequalities are central to a range of areas of challenge that we have already. If you look at the focus on local health care and integration with social services, then you're actually looking at lots of the people who have need and who are actually in that space tend to be our less wealthy citizens. If you look at the work that's already been done and has been piloted across Aneurin Bevan and Cwm Taf health boards, we've actually seen a range of work that has actually seen the curve being turned on health inequalities, which is a remarkable achievement, and there'll be a challenge about how we transfer that way of working—because it's a way of working often—into other parts of our system on a more deliberate and systemic basis.

So, again, I think that you will see from not just the projects that we have—I expect to see those addressing health inequalities rather than ignoring them and pretending they don't exist. Because again, if we look at the challenges for contract reform, if we look at the challenges of health and care need that come in, almost all of them are driven by health inequalities with the different levels of need that come into our system. We know that, if you look at economic inequality and health inequality, the maps match each other. So, there are big and significant challenges about the way that we deliver services, as well, of course, as about our activity across the country and across Government.

We were talking earlier about the impact on someone's mental health of work. Well, actually, if areas don't have work or don't have decent work, you shouldn't be surprised to recognise there are both physical and mental health challenges within those communities. So, the health service has a responsibility about the way it behaves with partners in social care, housing and third sector, but there is also that broader challenge of the future of each of those communities that is outside the reach of the health and social care system. But I expect the health and social care system together to design a way of working that does actively address and take account of health inequalities in the way we design services. We could talk all day about the inverse care law, and that might be interesting but may not be fruitful about getting on and delivering the plan.

Okay. Lynne, you've got a supplementary.

Just on Angela's point, I think what Angela and I and some other members of the committee are struggling to understand is how the rhetoric on mental health being a priority in 'Prosperity for All' is actually translated into action for children and adults. You've referred to these transformation bids that are coming in. Can you tell us now what the timescale is, then, for us to be able to look at those and know that this is actually a priority, not just something that's described as a priority?

Well, we don't have a bidding process in the sense of there'll be a six-month time frame to get in and have a timescale, because we're looking for people to have a rolling programme of decision making. So, we expect there to be a meeting cycle every month to look at bids and to approve them and we will, of course, be looking at the end of this year to see where have we got and have we got bids in the areas that we want them to be in. Because we've been clear in the guidance, both informally and that's about to go out formally about areas we want to see addressed in bids as well. So, we will look at what's come in and, if we see areas and gaps, we'll have to talk again with partners across the country about areas that aren't being filled in transformative bids.

There's an obvious tension in saying to regional partners, 'Design a transformative bid that meets the needs of your local population' as opposed to us saying, 'You must develop or have a project in these particular areas'. We've said that every region must agree on two transformative bids in areas where it wants to see projects move forward. Not all of those necessarily get supported by the transformation fund but, of course, we do have a distinct mental health transformation fund as well. So, I think we will be able to describe for you what progress we've made and, crucially, we'll need to be honest about it, so that if we don't see the level of progress that is being made, we reflect that honestly, because I'm certain that committees will do that for us themselves.  

Yes, I was going to just ask about that. Do you recognise that there's a very strong theme now coming forward from committees in the Assembly? There have been two inquiries on mental health in children and young people, and the crucial suicide prevention inquiry here, where when things go wrong they go wrong catastrophically. Do you recognise that there is a real clamour now for there to be action on this? 

Yes, and it's something that we regularly take up with chairs, chief executives and vice-chairs. So, this isn't an area where from, if you like, the performance end we say, 'It doesn't really matter', but it is also then about the services that we have and the service redesign we know is required. Sometimes, that can sound a bit dry, but you're talking about designing services with and for people to make a difference with and for them. So, those statistics aren't just numbers and money, they are people, and I recognise that, and, to be fair, the leaders of our health and social care system recognise that as well. And we need to have an opportunity to have a story to tell, we need to want to actually reflect on the difference we're making as well, because without being able to reflect on the difference, then it will continue to be a difficult and searching inquiry for people like me and others to come in front of this committee and others. So, I'm not pretending that this will suddenly go away if I smile at you and say, 'Trust me, everything's okay.' I think it would just invite further questions. 

Thank you, Chair. Yes, just a couple of questions about the transformation programme. Over various inquiries we've had in this committee, we get evidence of really good practice, really good initiatives, that seem specific to a particular health board or a particular local authority, and the frustration I always find is that why that good practice is never rolled out. I understand about one size doesn't fit all, and all the rest of it, but if we're going to be successful in developing new models of care and practice, how are we going to ensure that that is rolled out across this programme across the country? And what, if you like, are going to be the incentives and the penalties where that doesn't happen, because we can't afford in the transformation programme just to have little pockets of good practice and the rest falling behind? So, how do you feel that's going to be addressed? 

Well, that's partly about projects that get approved for transformation funding. Those design principles have to have meaning, and in particular there's the point about scalability and to be genuinely transformative, because I recognise the picture you're painting: there is lots and lots of good practice in every health board and every area of activity and they'll be able to describe for you areas where they work with housing and with local authorities and say, 'This is really good practice.' What they won't be able to do is to explain to you how that will then scale up across the whole area, and that's what we're looking for. We're looking for projects that have the genuine potential to do so, and there's something about the scale of what comes in but also the buy-in of partners as well. So, the fact that they've got to be signed off at regional partnership board level, with health, social care and housing and third sector partners, I think really does matter. 

We're being really clear that the transformation fund is time limited. So, there's got to be a point at the evaluation at the end of it to be clear about whether it's worked and then a commitment to actually use the main element of funding, rather than additional funding on top, to actually roll that out across an area. Within the incentives we have, there's praise and recognition, and that gets you so far. There's the use of money, and actually the use of money in a transformation fund is I think going to promote and accelerate the way that people look at delivering those transformative projects. Then the point about sanctions and the way that we describe what will happen when people can't adopt good practice will matter as well. I will have more to say in the coming weeks about measures for incentives and sanctions within our system, because I think that matters, because you often hear from people across health and social care that they want to see good behaviour being rewarded and, 'If we're meeting objectives and we're transforming services, what's in it for us?', as opposed to keeping to plug holes that exist where people aren't doing the right thing. 

I'm sure you will have heard the kind of criticisms that we get from local authorities in particular about how they are penalised but health boards tend not to be. Whether that's the difference between reality and perception—there is this perception that health boards get bailed out and local authorities just get hammered, and so that fits in with this whole working together and everybody being subject to the same rules, really. That's where I'm coming from. 

Yes, and that perception is real within local authorities. There's a lot of frustration about the reality of eight years of austerity and seeing their budgets cut, and seeing their budgets cut not just in real terms, but in cash terms as well. That puts lots of pressure on the services of value, and lots of those services are broadly preventative as well.

Having to agree on how to use the transformation moneys with partners in health, local government and others really matters. So, they all have to sign up and say, 'We think this is transformed and we are prepared to support it.' So, it isn't simply about health saying, 'This is how I want to use the money, now come with me.' The cultural change that we're looking for does exist in some parts of Wales at a different pace and I think it will be accelerated in others when they recognise that this is real, and that they can't simply have one partner saying, 'This matters to me, so we're doing it.'

So, how are you going to evaluate the value-for-money element of these programmes, because that's going to be something as well? I mean, there could be very good initiatives out there, but are they actually going to deliver what we're looking for, which will be the value-for-money test, I guess? Because they could deliver good things, but if it's not really what we want them to be delivering, then that's not value for money, given that we've got a time-limited fund on this.

And that's part of the challenge we've had in the past, isn't it? We've had lots of people describe something as, 'This is a really good project', but, actually, does it deliver the right value and is it scalable? That's why we're still stuck with lots of examples that are being described as good practice, but you can't demonstrate how they're working across the whole system. So, within the evaluation, when we have bids come in, we expect them to set out, from their own point of view, what success looks like. There'll be quarterly monitoring of what's happening with each of those projects, and we expect to see an evidence base at the end about whether the project is successful and can demonstrate the value it delivers, because we do want a greater conversation about value across our whole system, rather than saying, 'It's been successful and people liked the service.' There's more to it than that. Otherwise, we're just essentially doing what we've done in the past that hasn't delivered anything like enough change at anything like the pace and scale that we know has to take place now.

And within that timescale, because it is quite a short timescale, are you confident that reforming and streamlining existing initiatives within this transformation programme is going to be doable within that time frame?

Well, I think we have to be demanding and expect to see that happen, because the call that we had in the parliamentary review was really stark: our current systems are not fit for the future. And the idea that you can put all this off—well, we don't have the money to put it off and the demand is rising at such a rate that we will see real harm being caused if we try and put it off. But it's also about the areas of activity that we're able to focus on, because I couldn't honestly tell anyone in this room or outside that we can go at everything, all at the same time and all at the same pace. So, that's why the criteria about what is generally transformative really matters. If you do something at the edges—well, actually, does it transform what exists within the system? And if it isn't transformed, then we shouldn't be supporting it. We've got to be able to say at the end of it, 'Well, has it made that transformation? Is there evidence that it will do, and if there is, what is the timescale for that happening?'

The initial fund is for two years and we'll need to consider, as we're going through, what gain is being made, what value is there and whether we should carry on with that for the future. I expect that some of the bids that get approved won't succeed, and we have got to be able to describe what hasn't succeeded and why, as well as what we are going to carry on supporting, and how partners themselves are going to use their mainstream budgets to carry on that way of working. I think the message about this being a time-limited amount of money and that it's not for recurrent resource use is really, really important.

But where those initiatives have been successful, you'll be looking to roll those out elsewhere in areas where they haven't even been trialled or piloted or whatever.

Yes, and that's the point about secondary adoption. So, other parts of Wales look at what other regional partners have done, and we will need to see that roll out. It may be that we need to be more direct about things that happen, but we want to see genuine local innovation and agreement between partners on what they think will work, and we want to see people lining up to say, 'We're doing the right thing', not, 'We're doing what's local', and to be able to describe how that meets the design principles that everyone has signed up to, and the demands that we know that we all have in different parts of Wales. The context may be different in rural Wales to Valleys Wales and to cities, but, actually, lots of the demands are really common, as well as the drivers that come in. So, telecare will be really important in rural Wales, but it'll be important in every other part of the country as well. So, there's lots that we can see that are going to be common, and models that you could and should be able to see will work in each part of the country. We have to be demanding about, not just the evaluation for those, but the driver to see them rolled out in more than one part of the country. Because I absolutely don't want to see seven different versions of the same challenge and slightly different answers that don't talk with and work with each other.

And simply to add, Chair, and Dawn too: the message the Cabinet Secretary and I have been putting across the piste is, 'Where you see good practice already and that it's working exceptionally well, then can you actually upscale that without using transformation funding so that it would be part of your core business?' So, that £9 billion of combined health and social care spending that sits underneath this—

We know it's already happening. 

Indeed. Do you need the transformation programme to make that happen, or can you do that? So, there is that interesting conversation, in line with our focus on outcomes for the individual, that we often miss within this. If the ultimate object here is improved wraparound, seamless care for the individual, better quality of care, healthcare and social care, then focus on that with all the partners at the table. We often say at every regional partnership board we've been to, 'The solution lies within this room. That's what you focus on. There's your incentive and, by the way, in some of the great initiatives you've done, you're saving money as well.' So, it's what needs to be done with the transformation fund, what can be done within core funding, and normal ways of working. 

Thank you. Thank you, Chair.

We have to evaluate as we're getting towards the end of that two years whether we're making the required progress or not, and whether we want to continue with a transformation programme, and whether that is on a non-recurrent basis. I think the non-recurrent part of it is important, because what we don't want is that, essentially, you just see what is called a transformation fund as a different way to run services, as opposed to making choices about how to run mainstream recurrent services. So, it's deliberately done in that way. We will, of course, want to evaluate the success of the programme and make decisions at that time.  

You say you want to decide at the end of two years whether you want to continue with transformation—presumably you know now that you want to continue with transformation at the end of two years, because you're not going to have transformed the NHS by two years from now. 

Yes, but the point is that the levers and the mechanisms that we use to do that, and how much we'll have learnt within the two-year time period that we have available to us, what our practical financial resources are—. And there's this point about how much thirst there is to transform the system that doesn't rely on the Government saying that there's extra money available to do this, and going to the point that Huw's just made, and we've made before, that, actually, lots of this is available already if partners agree to do it. That's why people can point to examples of good practice, because there are places where partners already do this. The challenge is the scale on which they do it, and the pace of delivering that across the country. Every single partner is frustrated at the pace of change. The challenge is getting every single partner to agree to work at a different pace, and not to be held back to work at the pace of the slowest person in the room. That's part of the reason why this is a frustrating and imperfect process, but we do think that the money will accelerate that.    

In your mind, how does the integrated care fund dovetail with the transformation fund? Certainly, when we proposed the intermediate care fund it was a transformational thing, in a way. How do you see the two working together? 

The ICF, rightly, now—. We can point to so many good examples, in different spheres as well, of integration, of driving out more home-centred support, of driving out digital innovation—all of those things. In fact, in some regions, then, they have decided to upscale them and roll them across, and I can look at my own area at innovations and more freedoms within domiciliary care to empower not only staff, but also to give a better quality outcome for the individuals at the end of it, not far from me down in the Vale of Glamorgan—what they've done there with giving more flexibility and freedom. So, it's not tick-box solutions, 10 minutes here, 10 minutes there—it works and it saves money. So, in some ways, the ICF has already driven innovation and has driven some upscaling and some learning.

But I think where the transformation programme comes in—not just the fund, but the programme around it—is to say, according to the design principles we set around it: two significant points. Can that be upscaled to a regional level, but, secondly, for the first time, can that regional thing actually then learn lessons across Wales? So, where there are common factors and common needs, et cetera, what is good in Gwynedd, can that be transformed down to Gwent? What's good in Cwm Taf and works there in terms of stay at home services, and that close integration around social care and health, is that applicable elsewhere? We sort of know with some of these things, they are, but we've got to that stage now where the transformation programme can help, say, drive this out at a regional, but also at a Welsh level.

So, the transformation fund can drive decisions that are made by the ICF. Do they work that closely?

If the ICF there drives innovation, often in a particular pilot—does this work—but having demonstrated that that works—. A good example is, actually, that some of the stay well at home initiatives were driven initially by ICF funding, but now we're at the stage where, for example, in order to upscale that to a regional level, does it require a transformation programme and transformation funding to make it happen?

Okay. Again, thinking to the end of two years from now, one concern of mine is: you mentioned pilots, you mentioned projects. Projects surely in health and health and care delivery are going to be two years long anyway, aren't they? So, is two years long enough? I see you nodding. 

Minister, I see that we need to be very focused on how we push forward. I think, certainly, we will find programmes in different areas going beyond just a two-year period of time. What we're looking to do at this stage is really to instigate the change happening. So, whether that is in cluster models—we hope that there will be a system that will want to transform all of its clusters at a similar pace, but in some areas, I think that people will inevitably start more with a roll-out. I don't think they'll be piloting a cluster; I think they'll be starting in one area and following through very quickly afterwards. But I think, inevitably, for the next two years, the pump-priming approach is actually just to get in the speed and momentum that was reflected by the parliamentary review. There seems to be a more short-term set of expectations, even if this is about delivering a vision that is going to be there in 10 years' time because that was the original timetable, of course, for the parliamentary review. What will it look like in 10 years?

Yes. And the reason I'm going after this is because I agree with the need for transformation and the need for more permanence than two years, in a way, because whatever we achieve in the next two years, it's just the start of a process that's going to take much longer, obviously. 

I think the sort of transformation that we're looking for is what bolts it in to the core service delivery of health and social care and well-being. So, it isn't simply a two-year project done and dusted. It's whether it makes it a mainstream way of working. Now, already, thanks to previous initiatives around ICF and so on, we know that—in fact, that's what the parliamentary review said—this stuff actually works. So, upscaling it and making it part of the core business of health and social care, with those clusters, with the regional partnerships sitting down and saying, 'The focus is on the outcomes; this is the way we need to go.'

In fairly general terms, how do you expect the projects delivered through the transformation fund to take the pressure off core NHS and care funding, and what are your hopes for the signs we may see in the next two years that that is happening, because we've got to take that pressure off somehow?

Well, that's why we're looking for transformative projects. We're looking for evidence to base the project upon, and then, actually, they'll have to set out what they expect to achieve, and, to be approved, they'll need to be able to set out what they expect to achieve within the bids that they make. They can't just say, 'This is a great idea, but we have no idea really what impacts it will have.' That's not going to be good enough. So, there's got to be grit within that. And I think some of this will be easier once we've actually had projects in that we've approved or not approved, both within the system and more publicly, to be able to describe, 'This is something that we are supporting and here are the reasons for it, and here's the evidence base around which we've approved it, and here's when you'll be able to measure that.' So, I'm fully expecting that, over the next 12 months or so, as we're kindly invited in to come back to this committee, we will have a range of areas where we'll be able to describe, 'These are projects that are going ahead; here's why they've been approved; here's the initial learning on them, and here's what else we expect.' So, you'll get a more real conversation, rather than, if you like, a theoretical one about the parameters we're setting now, but to see them applied in practice, which I think will probably give better answers to the sort of questions you're asking now.

You will now await the good ideas. You'll want to see those good ideas flooding in, as will all of us. What kind of proportion of the £100 million, in your mind, would you expect to go towards digital, for example, as part of changing to a new mid-twenty-first century health system?

I don't have an allocated portion of money for different areas of the fund, either geographically or in terms of service area, because I think that would generate a culture where people bid in for that part of a fund, as opposed to, 'What are you doing that is genuinely transformative?' If you look at our IT infrastructure, for almost everything that you would expect to come in, they'll need to have a sound IT infrastructure around it. So, it's part of what we do. What we've got in the plan, we've got a commitment to look at where we are, and, in the next financial year, to be able to invest in improving the way in which we work, and, in particular, our use of data and our use of digital infrastructure and means. So, you can expect to see that. That isn't necessarily all going to be from the transformation fund, though. We've got to make choices about how we use mainstream budgets, and our expectation of the whole system, that is not just about the £100 million, but is about the £9 billion. So, the Welsh clinical care information system, the roll-out of that, seeing that being done more progressively, because every local authority, as well as every health board, that use that system describe real gains that are made for both partners and, ultimately, for citizens in the way that service is rolled out. So, some of this is actually doing what we think already exists, as well as innovation that will come next.

Okay. I get what you say about IT in some way feeding into all the ideas that come forward, but there's a big difference between using IT to deliver a sort of non-tech integration project—I can think of a few in my constituency, which is just about good ideas being implemented that could have been implemented without any technology. So, there's a big difference between that and actually using technology to deliver a system that couldn't have been done before. Given that you haven't identified a particular proportion that you'd like to go towards digital and data, should there perhaps be a separate digital transformation fund?

From my perspective, I think our opportunity to move forward with digital is more linked to the general allocation than I think it is to the transformation fund. I think one of the dangers for us on the digital agenda has been us perceiving it's about an investment in the boxes and the wiring, rather than actually underpinning changes in clinical practice and change. I think also some of that comes with trying to move the NHS forward about the offer that it makes to citizens in Wales, in terms of how they would use digital in their day-to-day lives, and I do think we need to fast-track that.

I think, Minister, that there would genuinely be some opportunities, as we see the ideas emerging, for us to look to see whether we'll protect some elements of our budget around the digital side of things, as long as it's in that broader service transformation side. I think, certainly, through this year, we're likely to have advice going up to Ministers that will allow us to look to fast-track some of our IT systems, whether that's flexibility within the general main expenditure group at this stage. But I certainly wouldn't want to suppress ideas coming from the service if they could do things quicker, but at the same time wanted to roll out their community-based service models, do more with clusters, and align with social services. So, I think we're going to have to be flexible with that, certainly over the next 12 months, to push forward.

As the parliamentary review highlighted, digital is just one of those significant moments, I think, to demonstrate that this is a service that genuinely can push on at pace. I think they're a very salutary set of reflections that came from the parliamentary review, and I hope that we've captured some of that within the plan, to push ahead quickly with digital.

Okay. I don't know if you've got any comments on that, Cabinet Secretary. I understand why perhaps you want to separate the boxes and wires, but the boxes and wires, and apps, and all these things, are very, very important. How do you, Cabinet Secretary, intend to make sure that, through this whole programme, kicked off by the parliamentary review, we end up driving enough investment into actual digital infrastructure, as well as the ideas and projects and pilots?

Well, as you've heard, that is partly about how you use central funding, mainstream funding, as opposed to having streams that are in a transformation area. It's also about the regular demands for the way in which our digital platforms underpin virtually every part of our service. If you go into general practice, there's a platform; if you go into every and any part of our service, you'll see where we are, and you'll also see some of the inefficiencies that exist. And, you know, we have critical reports that say we haven't invested enough in the past as well, so there's a challenge about how much we invest in our digital infrastructure to be able to take advantage of the opportunities that do exist. But the honest answer is that, in this year, as with every year, we'll have to balance what we do across our whole system. And I can't say that digital will be the priority, when actually we've got lots of other priorities within our system. It's about having something that really does look like a joined-up response to a really significant challenge. The message from the parliamentary review is really clear. This isn't a 'nice to have' or an add-on—this is central to delivering the vision of seamless health and social care.

Yes, and my colleague Angela Burns reminds me that it's recommendation 7 on harnessing innovation and accelerating technology and infrastructure developments. That's boxes and wires, isn't it? We need that.

It is, but it's more than boxes and wires as well. 

Diolch. I wanted to ask you about public engagement in these proposals and plans. How are you going to ensure that the public have their say, particularly in designing the new projects and keeping them? Obviously for prudent healthcare and co-production, we need that active partnership. So, could you tell us—

Yes, and this, again, is one of the key messages from the review: it's centred on prudent healthcare, which has been reinforced by both the parliamentary review and the report that we now have. There is a cultural change required—and it's better in some parts of Wales than others—about how people engage with the public on service redesign, but also in the way that services are generally being run in any event and actually seeing citizens being part of that conversation. So, if you look at substance misuse, for example, we have a strategy that has generally been co-produced with people who use that service, and when we look at what improvement looks like, we will need to talk with and listen to those people. It's the same in every other part of service design as well.

The third sector aren't a direct proxy for the public, but they do bring a different perspective around regional partnership boards. And what we did do in designing the plan was that we had citizen panels to speak with and listen to through April as well—so, having, if you like, a representative group of citizens, as opposed to experts sat around in rooms from health, social care and others, and that's an important part of what we need to do. So, when you see within the plan about the culture of continuous engagement, it really is about trying to have a more regular conversation with the public, to listen to what they have to say. And actually a lot of this is about our staff being enabled and engaged to have that conversation directly, because the public are much more likely to have a conversation of trust with the staff who deliver those services than they are, bluntly, with politicians or people at the top tier of an organisation, as important as it is that the leadership don't just ignore and walk away from that, but actually a genuine and engaged conversation with staff and with the public.

So, do you see a permanent role for citizen panels?

Yes, I think citizen panels are really useful to test and to measure where you're going and to understand the public appetite for change and also public anxiety about change as well. Because we often talk about the three things that hold back real and significant progress and they're politicians, staff and the public. Politicians often get put in a position where, geographically, it's difficult not to say something about service redesign that is sometimes controversial. If staff aren't part of that engagement at the outset, you can understand why staff sometimes say, 'Actually, I don't believe this is going to be the right thing to do', particularly if they're used to working in a service area. And obviously the public as well are not just small 'c' conservative when it comes to change: if you trust what already takes place and you value it, then you'll need some persuading that you need to fix it, if you don't think it's broken. So, yes, there's an important role for citizen juries, I think, as part of this, but I don't think that that in itself should just mean that you don't need to have that broader engagement with the public.

Obviously, difficult issues arise with things like the closure of local hospitals, where there may be medical or professional evidence that this is the best way ahead, but the public naturally want to support their local place. Do you have any proposals about how that could be dealt with?

I think they're good examples of both the challenge we have in talking about health and social care, but also the need to have a much better and broader conversation with the public around change, because the examples that are almost always given about controversial change are hospital based. They are almost always about hospitals, and yet we know, from what the parliamentary review has said and what they say in the plan, that most healthcare takes place locally and we want even more care to take place locally, and yet we default to arguing about hospitals.

But you still have to deal with those issues.

We do, but that's part of our challenge and our conversation with the public about where healthcare takes place and actually, in needing to reform a system to make it fit for the future, it will require change in hospital-based services, because some of those will become more local as well as—. And, again, there's very clear evidence of direction from the review that some of those will be specialist services, but actually there's evidence for better outcomes if they're concentrated in fewer sites. That does require staff engagement as well, because again if you just have the chief executive of a health board with the medical director to go and talk to the public, lots of people won't trust those people—that is the reality. Whereas if you have people working in that service, then that's a very different conversation with them. I'm talking generally rather than getting drawn into specifics that may or may not be taking place around Wales at present.

I think it's also important, as you're going through that engagement with the staff, that you've got to try and engage with the public around that too, and the different bodies that are represented—so, the third sector, the community health councils—and of course being prepared to go out and talk with and listen to the public in a consultation process that is genuine as well, so that when you consult on change, whether it's about changing the way that local general practices work, whether it's about the way that health and social care work, you actually engage and involve people who are taking part in that service. I don't think there is a single answer, but there is an answer about continuous engagement being real and meaningful. 

If you look at Gwent, for example, they've managed to change a range of service areas without a big blow-up of public antipathy to changes. In other parts of the country, it's been more difficult on similar sorts of changes. That does tell you something about the ability of some parts of our health and care system together to have that conversation with staff and with the public, and the fact that there are other parts of our country that need to be better and to develop more trust with our local public to be able to have a meaningful conversation. 

Where do you see the role of community health councils in this? You mentioned community health councils.

At present, they're part of the representative body—

And you see this continuing.

We're talking about reforming the way community health councils work within our system, so they've got a voice across—

That's why I raised it, because you mentioned them.

Yes—so they've got a voice across health and social care in a reformed way. It goes back to an element of trust, doesn't it? Because lots of people didn't trust that what we were saying would be real, about having a genuine voice for the citizen with a representative body that can work across health and social care. There's a challenge there for community health councils as they currently are, or any successor body across health and social care, to be genuinely visible with the public and for the public to know who they are and what their job is. So, there's a challenge for them as well as us in designing the different blocks of our system.

Lynne.

It was just on Gwent, really. I think the difference in Gwent, as Andrew will know very well, is that we got buy-in from clinicians from the very, very early stage. So, what are you doing to ensure that those lessons from Gwent are rolled out to elsewhere in Wales? Because it's quite clear that we're never going to get political consensus on real reform, isn't it? So, the clinicians are absolutely fundamental to this. 

I agree. Our health and care professionals are really important to this. When you see change that's worked successfully, it is because there's been a buy-in from health and care professionals. They've been trusted in a conversation with the public, and with public anxiety and fears that are there, they've been prepared to trust those people. Because it's true that there was cross-party agreement on the review and the membership, but when it comes to it, there's a plan the Government has to come up with, and myself and Huw will have to stand and say, 'These are decisions that we are making', and there will be an entirely legitimate and expected level of scrutiny from people about that, and political parties being political parties, we will disagree. But, the public have to have an element of confidence in their staff, and if they're not part of the conversation, it doesn't exist. We've seen that in the past. Look at the history of change and reform that hasn't taken place; it's largely been because the public haven't trusted the idea, haven't liked it, and they haven't had a consensus from staff that it's the right thing to do. So, that sort of reform will get rolled back down the hill. We don't have the time to not have staff bought in and to try and do things that aren't going to work, because it makes then coming back up the hill at a later point even more difficult to do, and we've seen that. 

Some of the service changes do need to be handled locally, and I think that absolutely does start with clinicians being at the core of supporting the nature of change. I hope that the vision that we've captured about how all of this is translated over the course of the next 10 years really helps. Certainly, the plan appears to have been well received, certainly by professional representatives from royal colleges and bodies at this stage. In fact, their test is less about what the words say within the plan; as always, it's about what does the implementation look like, and the pace around that at this stage.

I'd also hope that approaches that we're taking in here, which are about outlining a commitment to having a national clinical plan, allow us to also not just have individual services being described by local health boards, but we will look to define those at the national level as well. Certainly, the language in here is recognising that we want better outcomes and that we expect changes to happen around our clinical services. It's just to make sure patients are cared for in the right environment.

And finally, really, to ask you about how are you going to promote citizens taking care of themselves more. 

Well, again, that's something that we regularly talk about in this committee and others. So, it's partly about the culture between the health and care professional and the citizen. From the healthcare professional's point of view, it's about the 'making every contact count' approach, but also for the citizen to be able to say and describe 'what matters to me'. And in this, I still think there's something for the health service to take on board about the way that large parts of social services are working now, and putting the voice of the citizen at the centre of it. It's about moving on from the way that healthcare used to be provided, with the healthcare professional telling you what is good for you, as opposed to a more consistent conversation about, 'This is what matters to me. Explain the information and I'll understand the risk, and I'll help to make to make a choice about what matters to me.'

Now, there's a challenge there about the cultural change that we need to see happening. I think that is about empowering and engaging people to make their own choices and having some responsibility for them. It goes back to the things we've said many, many times, including on NHS 70 day, about the big differences that we need to make. Because we can't lecture people and tell them they're bad people for making bad choices, because that sends people off in the wrong direction, and it's about how we get alongside people and help to make healthier choices easier ones. We will still need to be able to do that and describe what that looks like. And often, that is not about medical professionals telling people what they think is a good choice. If you look at the inverse care law work I referred to in Cwm Taf and Aneurin Bevan, that's been led by healthcare support workers in non-medical settings. There's a different conversation and relationship that takes place there.

So, we actually need to think about, when we diversify our workforce—we need to think about who's important. Actually, you've got to place real value on people that aren't there to have a medical conversation, because it will affect the choices that they make. It certainly will affect their health and care outcomes as well. So, there's a real learning for us to take on board across our system about the value of different staff and what they're able to do to help people to make their choices. But there's got to be some consistency from leadership again about the challenges that we face. You'll see that when we're going through the consultation on obesity, and in the other conversations we're going to carry on having, about the fact that we have choices to make as individuals, and this isn't all about the Government making it right for you—it is about how we take more ownership ourselves.

Thank you very much, Chair. I'd like to talk about the health and social care workforce. One of the quadruple aims is to enrich the wellbeing, capability and engagement of the health and social care workforce. Could you explain why so little was said in the vision about how that might be achieved?

Actually, when you think about our vision, it's an essential part of delivering on the vision in the review and the plan that we have, not just about creating a new body, about the way we work with Health Education and Improvement Wales and Social Care Wales, but we're really clear in the plan that the quadruple aim is real. And lots of what we talk about doesn't work without staff engagement. So, there are discrete things that would always take place—whether it's terms and conditions conversations—but it's more than that; it's about the culture and the workplace that people are in. And, actually, diversifying the workforce is an important part of that, because you're delivering on the message of a prudent health and care system where people do what only they can do, and you value the role that different people have to play in that as well. So, I don't think it would be fair to say that it isn't in the vision, but it's about the acceptance that, if you can't deliver on the quadruple aim, if you can't deliver on staff engagement and then making it a good place for them to work, then you won't deliver the sort of outcomes and experiences that you want, because engaged staff tend to do a better job in every walk of life, as you will know from running your own business before you came here.

But it's worth saying that, even before the plan came about, we were already doing a lot of work on integration of the health and social care workforce with early induction training, but also that wider development piece. The plan makes reference to bringing forward a coherent plan by the end of 2019 that is genuinely health and social care workforce. Because if we're going to make this work, it has to feel like those teams on the ground see whichever entry point that they make into the profession as the start of career development and continual improvement and continual upgrading of their qualifications. Now, there's the challenge we have. So, it is there within the plan, but I think it builds on the work, Angela, that is already in train. But there's that commitment to bring it forward by the end of 2019—a coherent plan for the health and social care workforce. That has to be part of it, because, otherwise, this falls to pieces. If we continue to operate in silos—. And, in fact, the good work that we're seeing on the ground in many areas throughout Wales now is ahead of the game with this, so we didn't wait for this plan to come forward with that, but it's in there within the plan that this will come forward as part of it now.

Because, I'll be honest with you, in reading the vision, that was the one thing that I felt it was incredibly light on. I made that comment to you when we did a statement in the Chamber and you said something like, 'Well, you wouldn't expect that level of detail in the vision', but, actually, I do. Because we did the parliamentary review part 1, and that was the overarching strategic direction of travel. In part 2, the parliamentary review team were very much going to tell us how to do some of this stuff. Because we've got bundles of great ideas throughout the whole of the NHS and social care sector, but where we fall down consistently is the doing of it. We talk the talk, but we don't necessarily walk the walk. So, I thought that their final report gave a little bit more about the areas we need to go down. We thought that the Government's vision was actually going to be much more about the nuts and bolts.

For me, the critical nuts and bolts in the NHS and social care sector are the people, and I've been really concerned by how little mention about the people is in there. It's not just the engagement with them and the training—and Huw, I really take on board the points about how important it is for our social care sector to be built up, but to be given a career path and a good sort of professionalisation, if you like, so that there's pride and respect and decent wages and all the rest of it. But, you know, we look across the piece in every health board, in almost every discipline, and staff are melting away, whether it's health, whether it social care, or whether it's the third sector, and we use a lot to underpin it. Earlier, in response to the question that Jayne asked about are we going to have the resources in place to put preventative measures in place—. Looking at the vision, it states:

'Everything should be presented as a single package of support, care or treatment, tailored to the needs and preferences of that person'.

Tick. Absolutely; that is exactly the way that modern medicine and modern healthcare should go. 

'Residential care will flex over time',

enabling people to be there, to come out, to do all the rest of it. Again—but we need the people. And your response, Cabinet Secretary, to Jayne, was, 'Well, there will have to be', but what I don't see in the vision is how we're going to get the, 'There will have to be', because we're short on doctors, we're short on nurses, we're short on carers, we have care homes closing, we don't have the beds to put people in, we don't have the beds to get people out of hospital to where they need to be.

The 40 extra training places—I think it's 40—is incredibly welcome, but given that we know, for example, in one health board, I think it's 30 per cent of the district nurses will have gone in the next five years, retired, and we don't have the people coming in to, sort of, if you like, stem that tide—. So, where's the workforce planning? Where's the—? You know, even if it was a statement saying, 'Whatever happens, we've got to have 500 more nurses' or 'We've got to deploy people in such a different way that we don't need it', there's no real sense of, 'If we haven't got the people, how are we going to get them, if we need the people, how are we going to get them, and if we don't need the people, what are we going to put in place because we don't need it?' Because all of this stuff about how we're going to look after the population of Wales in terms of both healthcare and social care, about bringing it into the community—at the end of the day, it's all about a person talking to another person and providing something to them.

Indeed. I think Ifan will come in on this, but one of the important ways that we need to take this forward is also in terms of the regional partnership boards as well: that data crunching, that analysis of, in their region, in their areas, what are the gaps, what are the deficiencies, what are the training and skills deficiencies, and then how do we meet them within regional workforce planning as well. I think that's key. So, there's elements of national direction and clinical aspects, but there's also the regional planning around this particular plan of the health and social care workforce that needs to be done on that regional basis. But, Ifan, I don't know if you want to add to that.

I just wanted to say something about the process of writing the document. I feel that these documents are quite challenging to write, because there's a considerable expectation, and as you go through the engagement process the volume of contribution that you get from people is quite astounding. There were days when we were receiving 40 pages of contributions, but we were determined to hold on to a document that would have some prospect that people would actually read from cover to cover. It was only at the last minute that we gave in and added an executive summary. What that means is that not everything can be covered in the depth of detail that everybody would be looking for, firstly, and, secondly, that the document itself needs quite a tight conceptual structure in order to manage the contributions that you're receiving.

So, if you look at the vision section, there are no actions at all in the vision section, and the vision section is very much about 'What?' rather than 'How?' It's got some 'Why?' in it as well, but the idea being that—. The brief from the parliamentary review was to set a long-term vision. So, broadly, although we don't put a date on it, it's a 10-year future vision. The actions are over three years. So, the document is very much structured in terms of a vision that hopefully will be lasting and that hopefully is reasonably persistent. So, that's the reason why it doesn't have things in there around specific numbers that relate to today's circumstance, because three years or five years from now, those contextual circumstances will have changed.

The document then runs through to a transformation programme section, which is about this sudden injection of pace, on which the parliamentary review said, 'We have the integrated care fund, we have primary care, we have innovation happening across the system, but it's not scaling at the speed and the pace that we need it to do.' So, that middle section is around how you could bring that pace.

Then the last section, which is called 'Making our health system fit for the future', is around some of those selected key enabling factors. There aren't many of them in there, but workforce is there, engagement is there, digital is there. Stronger national leadership and direction, and I think the balance between local and national is a very important one that we're trying to slightly re-present here. But there are not many in there, so the fact that workforce is in there, that engagement is in there—those are prioritising them in the document as a whole, even though they may not come through in the vision section as strongly as you might be looking for.

I take your point. I do get that, but our job is to scrutinise. The whole point of this vision, which was widely heralded, was that we would have a document that we could scrutinise and have a look at.

Now, I read this document from cover to cover. I quite like reading, so I'm quite good at sort of picking up on all the stuff. I don't see anywhere in here that says, 'Oops, but we know we do not have enough human resource to make our NHS and social care work, so we're going to start looking and we're going to put a lot of emphasis on what we're going to do instead.' I hear lots of stuff—there's a lot of stuff in here about what we need to do to look after our people, and the fact that we need more people around them to deliver that holistic overview, and I completely agree. I do not quarrel with any of it, but when I go through this—and I've highlighted it—always, I've just written, 'Staff?', 'Staff?', 'Staff?', because I just know, from the health boards I've gone around—and I think I've now gone around every single health board, and an awful lot of the hospitals in Wales; less so on the GP practices et cetera: that's all in my area, that I tend to go to—I understand that there's not all the people that we need—the physiotherapists, the radiographers, the mental health professionals—and so I still think that, within this, we need to have some sort of recognition about the workforce planning and what direction that is really going to take, because a map of the gaps is great, but there's no plan to fill those gaps, and that's what really concerns me.

Another reason it concerns me—I'm sorry to bang on about this—is because the people we do have are very tired. They're stressed, they're working at great capacity. We have very high levels of stress in our NHS. We have a lot of people who are on sick, as you know—a substantial amount of the workforce. So, unless we can create that breathing space so that, when people come to work, they feel that they have the opportunity to do a really first-class job, as they've been trained to do, and in a space and an environment that gives them that opportunity to deliver that job, then we're going to keep having them off sick for months on end, and not able to do that, which again then puts more and more pressure on our health service, which means we have to go out and rent locums in, which then gobbles up all the money that we could be using for transformation and all the rest of it.

It's such a vicious cycle, and that's why I would have liked just to have a better understanding of what we're going to do with the workforce. Social care: we just don't have enough beds. We know that. We've done the inquiries. Is 40 extra places or doctor training going to be enough? Do you think it should be something that we're going to have to look at again next year and perhaps increase nurses and physios? It just goes on, and that's the meat I'm trying to get out of this element of whether or not we actually have enough resources to implement what I would broadly say is a good direction of travel, because the ambitions set out here are absolutely right, totally holistic, and are a great way to go. But I just worry that that cornerstone is not in place.

If I can helpfully direct some of those comments. The right comments are being made, by the way, because the resources will always an issue, and the strategic planning, but also drilling down to a local level and to a discipline level as well—vitally important.

Within the document, I refer to the workforce strategy for health and social care that we're bringing forward, and on page 32, it fleshes out some of that thinking that would include the planning for new workforce models, strengthening prevention, well-being—some of the things we've been talking about already, including strategic education and training partnerships, career-long development, and on and on.

Now, within this document, within this vision, it sketches out where we're heading, but it doesn't drill down into the detail that you're asking. But that workforce strategy will drill down into that detail, but it will also be in line with everything that we've said today. Some of this will require direction at that national level, either in health or in social care, or in a combined way, in line with things like what we're doing within the foundation training with health and social care professionals. Others will need to be done very much by the regional partnerships, actually identifying within their area. So, within rural Powys, within Gwynedd et cetera, what are the particular challenges there, and how do they also build it into their workforce planning as well? And not only the workforce planning, I would say as well, the thing that we touched on that we anticipate being part of this is also how you provide that support, not only for the professionals and the statutory bodies, and the people employed within that, and the independent sector as well, but also not just the third sector, but also carers and volunteers, and all of those who provide the well-being. So, that will figure within this as well. 

So, I think that detail that you're looking for is under way, and it will come as part of it, and it is signalled very clearly within this document that that's an integral part of delivering what we want to. But the document doesn't go into all the detail that you want because it is setting out the vision of where we're heading.

But we won't get more of that detail, then, until, basically, 2019? Is that the time frame? Will there be a plan we can look at?

Last week, or the week before, we had a debate at which there was a challenge about the Government amendment that said we'd have a workforce plan for 2019, because that's when we expect it to happen. Health Education and Improvement Wales are in shadow form. It'll be up and running formally from October. I have recently, in the last week, confirmed the public appointment of Chris Jones to be the full-time chair for that with a proper term to run. So, they will be working with Social Care Wales to deliver that plan. Again, that's about looking across our whole system, so the numbers of doctors, nurses, therapists and everyone else, to balance what we think we can do, and that we should do. There's the reality of what we would like and then the reality of the resources we have available to deliver. But there'll be a plan to try and set that out and give the details that I think you're looking for now, which, honestly, you will get when that plan is available, as opposed to me, Huw or anyone else in this room just trying to take a flyer and saying, 'Here's what I think we're going to have.'

Okay. So, just to recap, we need to wait till sometime in 2019 to get the detail that we need on how we're going to be able to manage the health and social care workforce.

You know we've already invested in the future of the health and social care workforce with the amount of money we're putting in and investing, and the way that the training is actually changing to match more closely the jobs that people are doing. So, it's the way people are trained as well as the number of them, and we will still, as will every other part of the health and social care system within the UK, be looking to acquire staff from outside the UK as well. We don't need to rehearse all of the challenges about recruiting from Europe and further afield now, but that will continue to be part of what we will have to do to have the workforce that we know that we will need to provide the sort of care that all of us wish to see.

And simply, to clarify, the workforce strategy—by the end of 2019. But on page 32 of the document, where it highlights some of the timescales—some of the work streams on this are beginning now. So, the recruitment—including, as the Cabinet Secretary said, recruitment externally as well—into the health service, into those gaps, is ongoing now, at this moment. And the idea of NHS Wales being an exemplar employer and driving innovation across the workforce across the regions, that's ongoing now. But the full strategy by the end of 2019—that doesn't mean we're not doing anything now, because we have to do things now.

Can I just ask one last much quicker question, which is about how much—? Do you spend much time, or do you have much influence, rather, I should say, over the training bodies such as the royal colleges, or the Royal College of Nursing, about what they say their specialists need to be like and what they ought to do, and what we think the people of Wales need? Because, of course, a lot of the stuff that we talk about, or you talk about in the vision, relies on a more generalist medical care, and we know that one of the problems we've had in health is that, over the last x number of years, there's been a real specialisation, so you don't just get a guy who does your elbow, but only a particular bit of the elbow. So, do you have much discourse with them to actually say, 'Look, the people of Wales need these kinds of doctors to deal with these kinds of health inequalities, these kinds of issues that we face'. How can that be flexed, or are they pretty, 'No, this is what you've got to do and that's it'?

I recognise the point you make about the balance between specialists and generalists. It's not just saying that we need more general skills or a general practitioner in the room, but we do recognise that there's got to be that proper balance. It's not just within the health service, it is actually about the range of skills we need right across health and social care.

Absolutely.

There's a challenge both in what happens during acquiring a professional qualification and then the way that people need to maintain those skills and what continuous learning and development looks like as well, and about the fact that, whenever someone qualifies and goes into a profession, that job will look different in five and 10 years' time and more as well. So, we should never underestimate not just the initial training qualification, but, actually, the continuous training and development.

I'll just ask Andrew to tell you a bit more about the shape of training that we talk about every now and again, because that is something about that balance between generalist and specialist as well.

I think, irrespective of the pressures within our system and that are visible across the NHS, what we want here is to have people who are attracted by what we're able to offer. Some of that will come with some protection within the system, so, for example, our 'Train. Work. Live.' approach over this last couple of years has been endorsing a Welsh approach about a training contract with our junior doctors who are within our system, to allow them to make sure that they have the right balance of experience. It's a particular offer that we've been able to make in Wales.

I think we've been waiting for the UK to determine what the way forward looks like, with a world that has been dominated by specialist developments over the years, and the need for a centralisation of services that are becoming almost regional and tertiary-based specialties. And actually, the Shape of Training review across the UK has endorsed now the need to rebalance between specialist and generalist care. So, I think the areas that we've highlighted within here about ensuring that we can have a generalist environment, not least to underpin rural healthcare to deliver it in local district general hospitals, has now come through much more strongly at this stage.

Two other functions that I've described that may feature as part of an update on where we will be in the autumn with Health Education and Improvement Wales: firstly, the deanery—it's accommodated within Health Education and Improvement Wales and that moves across from the university sector, and that means that we have a terms of reference for how we're going to be overseeing that particular function in response and flexibly to what we need to have in place for the population of Wales. And, of course, the annual cycle of commissioning remains in place, which, again, is overseen by Health Education and Improvement Wales. So, at the end of this summer, they will be endorsing the next step of changes.

I think that we have seen progress on workforce planning over the last two to three years. As one reminder, because of your concerns on the staffing levels, we have increased nurse places by 67 per cent just over the last two years or so in terms of these places, and no doubt we'll need to continue to increase those. But I would see those as actually within our gift, because they will be contained in our eleventh health organisation in Wales. But it's the Shape of Training review, I think, that's going to give us the authorisation to move into a much more generalist world, as you've described.

Thank you for that. The example I always use, which, sadly, goes back to hospitals, but I think it applies everywhere, is the fact that we have the revolving-door syndrome with elderly people, and therefore if you have somebody who goes in because they've slipped over and broken their hip, they're seen by an orthopaedic surgeon and they don't look at the rest of them, whereas now we've got orthogeriatricians, so they actually don't just look at the hip, but they look at whether they've also picked up some pneumonia because they were immobile, blah blah blah, so at least they're getting out of hospital and staying out of hospital. So, it's that, and we might see it in GPs or nurses—a nurse who is, perhaps, an asthma nurse but now becomes a comorbidities nurse, because somebody who's got asthma might also have deep-vein thrombosis, might also have this, might also have that, as they get older. So, it's that holistic view and whether or not we're actually now driving our workforce towards being those kinds of people, rather than just that single focus.

That also goes back to why we talk about multidisciplinary teams, because you need those teams of people to think about the care for that person. Again, when we launched the plan, we deliberately went to examples of the way that different health and care professionals are working together to deliver better care, and, like I said, the conversation in Aberdare with GPs, one of whom was actually in the service in Llandaff, talked about the fact they would not want to go back to the way they used to work. They were cynical and not supportive, initially, wholeheartedly, of moving to cluster-based working. They now saw the value in it. They actually had their version of a virtual board and it deliberately brought together different health and care professionals. They were describing that they were delivering better care and that meant they were enjoying their job more, as well. So, you see the balance both in the workforce, the way that you organise the service, and, actually, the care that you ended being provided with. So, there is a move that is already taking place, and lots of what we want to achieve is to accelerate that move and to make sure we understand who we need to deliver that, but actually how we then have structures around that for the way that they will deliver their job.

For example, we are going to have to focus on some generalist areas of care, around older people, for example. I think, inevitably—and, hopefully, that's seen within the plan as well—there will be some areas of development that will occur where we will need specialists in different categories—so, just the arena of genetic medicine, for example—and we've outlined some of our approaches in Wales about how we feel that we've got a contribution to make in this agenda. These will be changes that do occur, inevitably, over the next 10 years, but we do need that front-door offer of the alternative services to be in place, whether it's children at early stages of life or whether it's older people, to definitely come through in our more general structures.

Okay. Time is marching on, and I'm very conscious of that, although some full answers have covered quite a few questions. Lynne, are you okay with yours? I think—.

I just wanted to ask one other thing about children and young people. There's been a real shift, with the Social Services and Well-being (Wales) Act 2014, to an all-age model of delivery. How have you ensured that, in bringing together this plan, the needs of children and young people are going to be fully met, rather than just squashing them into an adult model of service delivery?

That's still about what's an appropriate service for the citizen and the context they're in, and, to be fair, the panel recognised that lots of the focus they'd had, a lot of the things that came in, were about older persons' services, where there's big demand coming in. It's often described that—you know, you go into hospital and the average age of a person in a hospital is rising all the time. So, they did recognise that there'd need to be more focus in developing and delivering the plan and making sure that children and young people's services don't get lost in that. So, I think when we come back with those transformative projects—it's not just mental health, but obviously we want to describe that this isn't just a service that is only focused on older adults in the way that that transformation works. So, again, there's a job of work for us to do in what we get to approve and in the recognition of where demand comes into our system at the early age, as well, because the extra pressures on families are delivering extra demand across health and social care services as well for children and young people. So, I wouldn't want you to think that—

So, did you do a child rights impact assessment on it?

Yes.

You did, and so you could make that available, then.

Yes.

Thank you.

It's worth saying, as well, that that's been a common theme of bringing this forward, both through the review and to the plan stage. But it's also been a common theme that's been pushed at us when we've gone round on the second round—the first round and second round—of regional partnership board meetings, where it's been put to us, the importance of making sure, in taking this forward, that children and young people are integral to the way that this plan is taken forward, that they're not an add on or a silo; they're integral to it. That's been quite reassuring—to have that put to us by the people who are going to be delivering this.

That was definitely part of the conversations we had with Gwent and the conversations we had on the same day with both Powys and north Wales. It wasn't that we just had an adult-focused conversation, and it did go in both directions, with questions that we asked as well as what partners were saying that they actually wanted to do, as well.

And how, curiously, the integration, the collaborative model that's described within this plan, going forward, would assist some of those ways of working for young people, as well, so that it was no longer this little section over here, it was much more to do with a wide wraparound of services that could deliver better quality outcomes for children and young people.

Okay. The final section, Julie, on measuring success, if we can get one question out of that. And six minutes to reply only.

How do you plan to monitor this and to measure success?

We've obviously got 40 actions over three years, and so—. We've got time-limited actions in those as well, so for a couple of things we're already doing about taking forward the plan, on the announcement on the transformation board, and on the guidance that's going out as well—so, we're actually making progress on what we said we'd do—things like the creation of a national executive leadership function as well for the national health service. Some of those are about changing parts of our system, but measuring success will come back to both what we said we'd do in terms of those transformative projects and about a measure of success there about where we are and, actually, whether we're able to turn some of the corner on the demands and our ability to meet them within our whole system. 

We also believe and we're expecting that Ruth Hussey will want to come back in at some point and say, 'Here's my take on where you are', so it won't just be about the Government saying, 'We are measuring our own success and you can be reassured that everything is brilliant', but we'll have some external challenge as well. And, again, we should accept at the outset that there will be points where we can say we've made genuine progress, and there will probably be points where we say, 'Actually, we need to think again about what we're doing', because there's no point in pretending that, having delivered and signed off a plan, everything will now be perfect from here on inwards. So, we'll need to be honest again about if there are areas that will either need to refocus, or to think again.   

So, what you would like—if you look ahead three years, what would you like to see happening? How would you see the service in three years' time as it affects the health of people and well-being of people? 

I'd like to think that we would have achieved the actions that we set out in those three years, and we will actually do those. You know, there's always a bit of challenge about the fact that some of those may not be achieved within the timescale but, actually, I'd want to see that we would have made real progress on our priorities to have new models of seamless care, that we haven't just identified, but you can see are properly being rolled out across our system. Because if we reach three years and we can't point to any area where we've made a choice about what better looks like and we can deliver that progressively across the country then that will be a problem for us. So, we will need to see real progress, and not just identifying what a model might be, but being able to say, 'And this is what it looks like in this part of activity'. Also, I think we'll need to be able to describe a move to a more preventative approach, an approach that is more generally about earlier intervention as well. If we can't, and we're just running a system that is still broadly about acute interventions, then we will have built up a greater store of problems for ourselves. 

And what data? How are you planning to produce data to show what's happening? 

We'll have to report against the measures we have in the plan. There'll be the data that the health and social care system regularly provides about where we are going, and how we—. For example, can we describe what we'll be able to do in terms of a shift to a more preventative service? Some of that will be questions about money that we regularly get asked in financial scrutiny, but it will also be on outcomes we're able to describe. So, on patient reported outcome measures and experience measures, that's something that is real. So, citizens themselves are describing what better looks like. 

And then, after three years, what are your plans then? 

Well, if I could tell you what was going to happen in three years' time in the health and social care system, I'd be a very rich man. But we will have to constantly reassess how far we are going with the vision, and with the broad objective and direction of travel where there's broad support for it, about whether we then have another series of actions to help drive us on to the next point. I couldn't tell you now exactly what the next three years after that will be in terms of what we've got now, because that would be proper finger-in-the-wind stuff, but I do expect that there will be a need to revisit where we are and a need to say what are the next series of actions that we expect to have over the next medium period of time to make sure that progress is still being made. That will be challenging for whoever is a Minister at that point in time in this brief, and it will be challenging for our whole health and care system, but the challenge isn't going to go away.   

If you look at who we've got on the transformation board, we've got a range of different people from within Wales, you've got people from different areas of activity—you've got housing, you've got the third sector, you've got the health service, you've also definitely got local government, and you've got regional partnership boards as well. And so we've looked to make sure that there are people who can represent different parts of Wales. The cluster lead that we have is from Ceredigion. The fact that we've got different people who have got national roles, from the WLGA and the NHS Confederation; the fact that we've made sure that we've got—for example, one of regional partnership board chairs we've got is from north Wales as well. So, it isn't all the familiarity of saying, 'I want people that I know personally and people that are in, if you like, my political camp'. There are people who are there to provide real professional leadership and challenge. And I don't know if you'd run through this list of people and say, 'These are all people who will do the Government's bidding'; I think these are people who are serious about making the plan work and about having some real grit in terms of the advice they give on how to transform the future of health and social care. 

One of the issues that we need to address is, of course, rurality and how to deal with that demographic. Apart from one from Ceredigion, there's nobody from west Wales, for example—a couple from the north. I've already had people pointing me to perhaps the lack of geographic diversity there and see that as a problem. 

We did look at making sure that we had people who were from different parts of Wales. The challenge always is about how you make sure that you've got someone who is representative. Otherwise, if we go and add further, then you'll end up having 20 or 30 people in the room, and I think there's a challenge here about accepting you've got some national figures there who are going to have a genuine national overview, as well as making sure that we have made sure that we look at different parts of Wales within that too. And, in the mission, and what comes through, you've got each regional partnership board still needing to say, 'Here is what we want to do from each part of Wales.' And I reiterate what I said in every group of partners that we've seen, which is that I don't want any part of Wales to get left behind, and it's important that those partners have a level of ambition for what they're able to do within their part of Wales and not just wait for someone else to have the idea first, because I think that would be damaging, not just in terms of our sense of a national mission, but, actually, the confidence that people have, in whatever part of Wales that is, that that leadership group are prepared to do something real and serious and meaningful.