Cynulliad Cenedlaethol Cymru

Diolch, Cadeirydd. You did indicate earlier on whether there were any declarations, but I'll just mention that my wife's an employee of Abertawe Bro Morgannwg University Local Health Board. So, I'll just make that clear.

To HEIW in particular, in this instance, in your paper that you provided, you identified two functions as workforce intelligence and workforce planning, and one of your strategic objectives is building a sustainable and flexible health and care workforce—excellent. What I want to know is: where is the intelligence? What data have you collected? What picture do you have at this moment in time for us to see where our shortfalls are and will be, because we have to project into the longer term to make sure that we've got enough staff for three, four or five years' time? 

Yes, thanks, David. Nice to see you today. Obviously, as a new organisation, we've been very keen to make sure that we know what the baseline is around the workforce issues that we've got in NHS Wales, and there is, I suppose, a variable picture. In some areas, we've got some good intelligence, particularly around the traditional secondary care sector. And in other areas, as you know, in primary care, we don't have such good workforce intelligence. So, that's something that we're working on at the moment closely with primary care colleagues.

I think the key issue for us when we look at the workforce strategy and we look to the future, as you've described, is that we need to be really clear about what that service model looks like in the future in order to understand what workforce information we need, and that's a critical link, really, for us, now, in workforce planning terms, which is not to plan our workforce and our individual professions in isolation, but to make sure that we take an integrated approach to that, going forward, to make sure that we're meeting the needs of patients in the future, not just rolling forward a programme of workforce planning based on the information that we've already got. But Julie might be able to expand a little bit more on the workforce intelligence part of your question.

Yes, thank you. It's lovely to be here today. As Alex was saying, we've got some robust information in some places and, in other places, we have less information available. We have the electronic staff record, data warehouse, which now is accessed through our new function in Health Education and Improvement Wales, and we have a number of tools that we've got available. So, we know a lot of management information about our workforce—we know where they are, who employs them, we know the occupational grades and types, and we have information around sickness absence, well-being and those sorts of things, including things like statutory and mandatory training. But a lot of that information is not in the public domain. So, in contrast, Social Care Wales, perhaps, has less information, but, actually, that is published annually. So, one of the things that we have put as a priority in our annual report for next year is actually looking at how we map the data sets that are available to make sure that we've got an holistic picture.

We're also working in partnership with the Welsh Government around some funding that they've released to support a new primary care workforce tool that will help us get a better handle on the workforce within the primary care setting, because we know quite a bit about GPs but we don't know much about those other staff working. So, it is a mixed picture, as Alex has said. We do have some information. Part of the workforce strategy work is to actually, at the outset, look at collating the data that is available, and one of the things that will be in the workforce strategy later this year is a statement about the shape of the workforce and the size.

I'm assuming that that information will include a description of the skills of the workforce and the skills that are lacking in the workplace. So, we have to ensure we deliver those skills, because you mentioned everything else but you didn't mention skills.

Yes. Sorry, yes. It will include skills gaps as well. That's one of the important things that we're looking at as part of the workforce strategy—what skills we need for the future. And I think if we go back to the prudent healthcare principles, it's less about the type of person and more about the skills that are needed in the future. I think the focus has traditionally been on, if we have one of these professionals, that's what they do, whereas, actually, we're trying to move the emphasis into what it is that we need them to do as opposed to what their label is.

I'm assuming, therefore, you are working also with Social Care Wales because, as you said, there's a set of skills required there.

Yes.

Would you like me to respond?

Yes, please.

One of the things that we do at Social Care Wales is an annual survey. So, any organisation that employs social care workers—who is a regulated worker—we have lots of detail on that, and those figures are presented and published every year. So, we'll have things like the qualification requirements or recommended qualification levels. And just something I looked at this morning: over 70 per cent of social care workers who are employed by local authorities have the required or recommended qualifications. The area where we have a large gap in knowledge is those services that are commissioned by local authorities—so, over 1,000 social care providers in Wales, not directly employed but commissioned by local authorities, not yet registered. When we get them on our register—and that's in the process now—by 2020, we will have all domiciliary care workers on our register and we will have really detailed information then about that much larger workforce, including their qualifications and their skills.

You may be aware that we've been in the process this last year, working with Qualifications Wales, to completely unpick 240 different health and care qualifications to streamline those into 40 core qualifications that will come into play, starting from September 2019. That will give us a much more comprehensive and consistent quality approach to the standard of training that domiciliary care workers will be having across Wales. So, I think the future is looking very good in terms of getting better information, supporting that workforce to upskill, and dealing with some of the complex health issues that people are living with in their own homes.

Do you find that you have good relationships with the third sectors and other organisations that, actually, are being commissioned for those services?

We've got excellent relationships. There's a national provider forum. We have a care and support at home steering group, where representatives attend. We're in regular dialogue. Some of you may be aware, on the registration process for domiciliary care workers, that there are now three routes to register, and that was based on close dialogue with those providers, and the workforce, trying to understand the challenges they may have in helping their workforce get the required qualifications. So, we're really working in partnership to make sure that quality is improved, the status of social care workers is raised and that we have a much stronger intelligence base going forward.

And to you both, are there any obvious data gaps you've identified yet?

Well, the one I just mentioned there.

Other than the one you just mentioned. Yes, I appreciate that.

I think it's the primary care one for us. We know that that's a critical part of our future service model and a critical part of our future workforce strategy. So, that's the one that, clearly, we do need to understand in a lot more detail in order to plan properly for the future.

Okay. Helen Mary.

Bearing in mind what you've said about the gaps—and bearing in mind that your answer to this question, we'll accept, won't be a complete picture because you've told us what the gaps are—with the knowledge that you've got at the moment, where are the most significant workforce pressures in both workforces, in what settings, what professions and what specialisms? We've heard concerns recently about lack of capacity in the diagnostic workforce, mental health services and obviously some areas of domiciliary care. So, what do we know about the gaps already, bearing in mind that you're going to be filling in more of that information?

Yes, and I think, even though we haven't got a lot of data, we do know where the gaps are, because they manifest themselves, don't they, in some critical service delivery challenges that we see in our services every day? So, absolutely, the diagnostic workforce is definitely a key gap for us, and in particular when we're looking at improving cancer pathways, and also with the introduction of the single cancer pathway now over the next 12 months. And so, we have been working, for example, with the cancer network to think about how we can add value in terms of endoscopists, in terms of the radiography elements of that, and histopathology, which are some of the key bottlenecks at the moment that prevent us from improving on that pathway. So, that's definitely a gap that we know about.

If we look at something more strategic, like our intention to develop more primary care, again, we know that that's going to be based on much more of a multiprofessional model, but we also know that there aren't enough GPs as well. So, again, it's about looking at plans to increase the number of GP trainees and it's about looking at how we can make better use of people like pharmacists. But if we're using pharmacists in primary care, then, actually, we need to increase the number of pharmacists, because we can't use them in hospitals and in community settings at the same time. So, there are a number of key groups, if we look at primary care, that we need to develop and build on.

If we look at unscheduled care, again, which is very topical this time of year, when we have such pressures on the system, have we got the right number of people in our emergency departments in terms of senior decision makers—whether that be doctors or whether that be advanced practitioners—and also whether we've got the right number of people working in our ambulance services in terms of paramedics and advanced paramedics as well?

So, I think we could go on for a long time, identifying where we think we've got some of those gaps, and what we're trying to do is not necessarily wait for the workforce strategy to start to address some of those. We've got some of those key areas in our annual plan for next year, which we think we could start to help shift by targeting some education, training and development at some of those key professional groups to see how we can attract more people in, or develop the capacity of our workforce even further.

Shall I add to that? Domiciliary care, obviously, we've mentioned. When you look at some of the figures on things like turnover, there's about a 30 per cent turnover in domiciliary care. When you look at that, it looks very stark, but, underneath that figure, about 50 per cent of those people move to another social care provider. So, although it's turnover within that organisation, they're staying in the care sector, which I think is good news.

The other areas where we have gaps are nurses working in residential care settings, if it's a nursing facility—there are big issues there. Registered managers—that's another issue. But the whole fragility of the care market you'll have seen in the press regularly. It is a very fragile market, and one that we need to nurture and develop stronger relationships with.

The other areas are rurality and providing services in the Welsh language. We're doing all we can to try and increase the numbers of practitioners at the front line, particularly who are able to offer services in the Welsh language and to try and stimulate local jobs in local areas right across Wales, whether it's the Valleys, urban or rural. We're hoping that, by registering the domiciliary care workforce and raising the status and the profile, we'll start to attract more people in.

Thank you, that's helpful. I think when it comes to the domiciliary care workforce, what we pay them is a fairly crucial question, isn't it? I'm pleased to hear you highlight cancer services and cancer diagnostics as one of the areas that you are going to be working on, and I'll certainly be interested to see what's in the annual plan around that. If I can specifically look at bowel cancer screening, we know that the FIT programme will begin to roll out, but as a committee we've had some concerns raised with us about some fairly unambitious targets, really, compared to the age thresholds particularly, which are going to be higher here. Will you be specifically looking at ensuring—. We've been told that that's basically what the system can cope with: if we do that number of tests, throw up that number of possible positives, we've got to be able then to do the next stage of screening, haven't we? Will you be specifically addressing that and in such a way as we can look, in future years, to reducing the age and be testing in the same sort of way as they are in Scotland?

I suppose it comes back to how we're developing the capacity of the workforce generally around cancer services. I think, to start with, we're a very new organisation, obviously, at just four months old, and one of the things that I'm really working hard on for our annual plan for next year is to make sure we connect up all of the things that we've got in our organisation on education, training and workforce planning with those service issues. We won't be able to achieve it all necessarily in the next 12 months, but we want to make a key start. So, the diagnostic part of the single cancer pathway is one of the things we think we can do something on. 

However, if we are looking at, for example, increasing endoscopy training—and I think you've probably had a session from colleagues on that—as part of the nationally directed endoscopy programme, we are going to be working on looking at the first all-Wales programme for endoscopy training for non-medical staff, which will help us grow the capacity of that workforce to do that diagnostic test. That will have a knock-on effect in terms of other aspects of cancer services, or even planned care, by actually making available a workforce that has got more of that skill to help with that workload.

So, I think there will be knock-on effects in that sense, anyway, but there are so many issues that we would like to get into, and so many opportunities for us to provide assistance, from a workforce point of view. One of the things we've got to do at the moment is to balance which ones we can do first, and which ones, actually, we need to do in years 2 and 3. It is going to be, I think, affected by that improvement in endoscopy.  

In terms of that balance, and where you start, with any new organisation—of course, you're new, but not entirely new, as in there were people doing that work before—how are you making those decisions about prioritising where you should be making the first impact, then?  

So, there are quite a few sources of information that we're using to do that. One is, obviously, the Welsh Government has given us a remit letter for 2018-19, which set us some clear objectives, and we've inherited, as you say, work programmes. We've been doing a lot of work with NHS organisations to understand, from their perspective, what their priorities are, and where the added value of an all-Wales approach to some of those workforce issues can come. Obviously, my background is in the NHS as well, so I'm trying to make sure that we've got a good bridge in that sense of understanding those day-to-day pressures that we need to support on, and then, obviously, looking at 'A Healthier Wales' and thinking about the information that gives us about what we need to be doing going forward as well.   

We're getting connected into a lot of the national programmes of work—so, the national unscheduled care board, the cancer implementation group, as I've mentioned, the national planned care programme, and the national endoscopy programme—to make sure that, as an all-Wales organisation, we're doing the right things for all of those stakeholders and that, actually, we're not coming up with an idea where they're saying that that's not top of their list of priorities and that they would prefer us to focus on something else. When we develop our annual plan that goes into Welsh Government at the end of the month, there will clearly be a negotiation with Welsh Government at that point around, actually, whether those are the right priorities. Would they prefer us to focus slightly differently? And we'll agree that then by the end of March.  

So, we've tried to bring in as much intelligence as we can over the last four months, and I think the issue for us will be that there is a very long list of priorities, and probably only a certain set that we can get going on in the next 12 months. But the opportunities are huge for us to really make an impact and add value. 

Thank you. 

Good. David. 

On that point—I know you used to be with ABMU—are you having those discussions with the health boards, and are you comfortable, with the various health boards coming together, that their priorities are clearly set out and, in a sense, compatible with one another, or are they in conflict with one another? 

I think, clearly, priorities vary across Wales. So, some of the service themes are similar but, as we've already touched on the rural issue, in our discussions with Hywel Dda and Betsi and the mid Wales stakeholders, clearly, there are different issues that affect their workforce that perhaps Cardiff and Vale and Aneurin Bevan don't experience. So, we do need to have a flexible approach, even though we're an all-Wales organisation, and we are very keen to make sure that local access to education in particular, which is a priority in those areas, is something that we focus on.

I think the service themes are, however, similar. I think what we haven't been very good at in the NHS is articulating what the specific root causes are. So, as we know, the operational parts of the NHS are very much pressured by day-to-day pressures—making sure that we can actually cope with the pressures tomorrow, the next day, next week. What we probably needed to do was to look at the workforce issues that are underpinning that and come up with more strategic and coherent solutions that are sustainable, and that's exactly what we've been set up to do. 

So, one of the things we're trying to do at the moment is to say, 'Well, what do you mean by a workforce problem? Do you mean a skills gap? Do you mean not enough people, or do you mean the workforce model is wrong? What is the specific intervention that we can make?' And that's the bit that we can help with because we've got the expertise in our organisation to understand those things, probably in more detail and with more specialist expertise than perhaps colleagues who are working in an operational setting all of the time. So, I think—you know, we've had good engagement from NHS organisations. As I said, we only had four months run at it; hopefully, next year, we'll have even more time to properly engage with them as part of their planning process and have more of an interface. I don't know whether you wanted to—

So, how confident are you now that either you currently have sufficient information—or, if you don't currently have sufficient information, when will you have sufficient information to actually start looking at the workforce strategy, because your job is to lead on that? So, when do you think you're going to be in a position to actually start taking that sort of lead?

Okay. So, Sue, do you mind updating on the workforce strategy?

I think the workforce strategy, as you know, we're doing that jointly, which I think is very helpful. So, we've commissioned an organisation to help us with some of that data gathering. And we're going through that very process at the moment. So, there is active engagement happening with a whole range of professional groups, health bodies, local authorities, social care providers, to try and gather that intelligence—you know, what are the issues—so we get some early indications of what is data they have that we don't yet have, can we start collecting that. And, next week, we'll have one of our steering group meetings where we're going to look at some very early, rough and dirty indications of figures, and we'll have a better picture of what are the real gaps in our information. We'll also have those very early indications of what are the pressures coming from both health and social care, which will give us a very strong starting point.

Our aim is to try and develop that, a first draft strategy, by about May, based on engagement with key stakeholders. Once we've got that draft strategy, we will start having a formal consultation process where the public can potentially get involved, making sure we've got documents available, and we'll probably use the citizen panels that are established by the regional partnership boards to really get out and engage with people, because it will be about talking to the public about maybe different new roles that are not very familiar, so things like social prescribers, community connectors, trying to help the public understand that you don't always need a doctor, you don't always need a nurse or a social worker; there are other professionals and practitioners that we can upskill and really put that front line, strengthen that front line, so we really preserve our most expensive and most qualified resource for when you actually need them at critical times.

So, our whole strategy is based on the 'A Healthier Wales' document. And, as you know, that was all based on extensive public engagement through the parliamentary review. So, there's a lot of consensus in terms of what the future should look like. You'll be aware that there are now transformation proposals coming in from each of the regions. Alex and I sit on the advisory board, so we are seeing all of those transformation proposals, and we're almost scrutinising them to look at what are the workforce issues arising there, to try and capture a real cohesive picture across Wales to see where are the gaps in learning.

One of the areas we think it's probably worth us investing some time in is a joint leadership development programme. Again, we'll use the intelligence that is happening across the UK. We were in Dublin together a couple of weeks ago, really trying to understand what are the other parts of the UK doing, really learning from best practice, using our partner that we've invested in to help us do some of that evidence gathering, literature search, to help us identify where are the likely gaps. And even things like artificial intelligence, digital, new technologies—our organisations are probably going to be in a bit of a better place to do a bit of horizon scanning.

But I think these very early days are about gathering the intelligence that we have now, which may be in lots of different places, gathering those real pressures from each of the health boards, each of the local authorities and the social care providers, trying to bring that into a cohesive picture, and then, during the consultation period in the summer, we'll have to start making some of those difficult decisions about what are the priorities, because we won't be able to do everything. And we're imagining that, by the end of the year, we'll have a strategy that, hopefully, everyone will sign up to, but below that will be implementation plans for those employing organisations—health boards, local authorities, or care providers—to start implementing, using their own budgets to prioritise what they do and when.

And I think the transformation fund, for me, gives us that two-year window of opportunity to really test out different service models, different roles, different upskilling and training requirements. And it's, I think, an excellent opportunity to try and see where we can start to use that intelligence at the end of that two years to think about, 'Okay, so what is the new model of care, what is likely to be more sustainable, is there more training we can offer to our health and social care professionals that increases that generic capacity and upskills more people?' So, we're ambitious, we're hoping it will be a good piece of work that will use a lot of intelligence and knowledge and to come out to the public and stakeholders to consult with during the summer months and then start to prioritise, ready for implementation towards the end of the year.

Okay. Well, we'll be drilling down into some of that detail later on. David—oh, you're done. Jayne.

Thank you, Chair. Good morning. You've touched on some of these issues, but what formal processes and arrangements are in place for joint working for the development strategy?

Okay. We've established a steering group. Alex and I both co-chair it, and, again, I think some of this is a deliberate attempt to demonstrate, from the top of the shop, that we're in this together. And we've made a commitment—we've got a whole programme of engagement, workshops, activities, and at every event we're going to try and ensure there is a member of staff from Social Care Wales there and a member of staff from HEIW there. It won't always be Alex and me—we won't be able to be everywhere. But we have a comprehensive schedule of things happening over the next couple of months. And I think it's that kind of leadership that will demonstrate that we're serious about doing this.

So, we have a steering group, we've got a wide engagement programme in place, we'll have a joint senior management team event next month, and then we'll have joint board meetings established for April. And what we're going to try and do at those two events is not just look at the workforce strategy, but also share with each other what are our priorities for the next year and the coming years, and are there pieces of work that it would make sense us doing some joining up on. And, if it isn't a joint piece of work, making sure that we synergise, so, if HEIW are doing something, we make sure we don't do the opposite, which scuppers their plans, and vice versa—so, keep each other very well engaged and informed, and that's our intention.

We're meeting very regularly, e-mailing almost daily, it feels like. So, I think we're—. I think the good thing is that I previously worked in the NHS, worked with Alex years ago, and I think that helps. A lot of this is—I understand the NHS language, it's not new to me, so I think that helps. And we've got people in both organisations who have various experience across different sectors, which I think helps. So, we're trying to be outward-looking and focus on what do our citizens need, rather than what does this professional need, or what does that professional need. But it is a change of approach—it is a different mindset.

But you're confident that you'll work together in practice as well as in theory—that that's okay.

Yes.

Can you demonstrate how you're engaging with the public? Again, you've touched on some of the things that you're doing, but perhaps you can say how that activity is going to go forward and how you'll measure it.

I guess, for me, there's something about being realistic about how far we can actually reach the public. So, we'll certainly use the regional partnership board citizen panels, or any of the existing patient groups or client groups that organisations like the Older People's Commissioner for Wales, or the Children's Commissioner for Wales—or some of them are third sector colleagues—already have in place. But for particular pieces of work, and one piece of work I'll mention, which is aligned to our workforce strategy: our attraction and recruitment campaign that we're focusing on, which will be launched in March, we see that as a real targeted piece of activity that we really want to get out to the public, to those influencers—parents, teachers, careers workers—who influence future adults' career of choice.

And we've been quite concerned about some of the messages and the anecdotes that we've been hearing about what influential people may be saying to their youngsters. And even a few months ago, at a skills event in Wales, fed back to us was a careers adviser openly acknowledging that she'd heard teachers in schools saying, particularly to women—and I think it is a concern for us—'Oh, why not choose hair and care?', as if it was the last-chance saloon—you know, 'You're not going to go to university'. So, I think, for me, there's something about, as a society, how are we valuing the social care workforce. In some ways, the NHS—. We all love the NHS—it's fantastic—and we celebrated its seventieth birthday last year, but nobody mentions the 1948 National Assistance Act, where social care and local government were established. So, the well-being of individuals—just as important that social care plays its part there. 

So, we have a lack of parity, I think, in terms of the NHS. Because everybody is registered with a doctor, everybody knows what doctors do, we've got shiny big buildings. Social care is very often in the local community, in people's homes, a lot of people don't wear uniforms, so it's—. We are trying to share with the public the value of social care and the variety of roles that are there in social care. It's very much a misunderstood sector, I think, and, before we started our attraction campaign, we invested in some research with the public—with focus groups right across Wales—to try and understand what do they know about social care, do they know about certain roles and types of jobs, and it was amazing, the lack of knowledge. Whereas if you ask somebody, 'What does a doctor do? Or a nurse?', people are more able to articulate it. So, I think we do have a way to go to try and make sure that we do raise the status, raise the profile, of the social care workforce.

Alex.

Yes, just on that particular point about public engagement, I think that's a really important point in terms of our workforce strategy, because, if that's going to be ambitious and future-thinking, linked with the service models that we want, we have to engage with the public because, actually, we want people who we currently employ to be doing different things. And we know that, if we do that without explaining to people why that is, people sometimes think they're getting a sub-standard service.

So, one example would be how we've tried to use the multiprofessional team already in primary care, use GPs in a different way, use triage techniques or phone-first techniques, et cetera, and looking at referring people to physiotherapists first or mental health counsellors first, et cetera. So, I think that's already an important point that we need to pick up once we're a bit further down the line in the workforce strategy, when we've got some of these key messages.

And also I think it's not just about how people are working in their own right—it's how they're working with digital technology as well. And, again, I think that most people—members of the public—are quite used to working with apps and phones and computers and things like that in terms of most elements of their everyday life, but, with healthcare, there's a little bit of a way to go in terms of that aspect. So, prevention as well, people taking responsibility for their own health being at the centre of actually how we're delivering care, all of those things—. I think it's really important that we get those messages across, because they will be fundamental to the workforce strategy.

Thank you. Is there buy-in from health and care staff to the strategy as well, including professional bodies?

I suppose, from our point of view at the moment, we are at the very early stages of this, and that would clearly be a key part of the engagement that we're going to do. We have been trailing this for a number of months really. So, all of the introductory meetings that we've had as an organisation with professional bodies, education providers and other all-Wales and even UK bodies, we've been trailing this to say, 'You need to get involved now, during the spring', so that we do get that wide-ranging input—and also through the partnership forum as well. 

Yes. So, we have, as colleagues will know, a national partnership forum, where we work with trade unions and the employers and Welsh Government together in the same room to look at strategic national issues, and this is something—the workforce strategy—that we've been discussing in that group for quite a while, so partners are very supportive. We've also had direct conversations with the royal colleges and others. Obviously, at the stage we're at at the moment, the consultants are working with us very much on the desktop basis, just talking to key professional groups, but, next month, they'll start broadening that out into a wider group of people, so there'll be more engagement. And I think that'll help, then, because people will start to see some of the messages coming through. But there has been significant engagement.

Thank you. How are you striking the balance between filling the gaps of the current workforce and the current workforce challenges and the existing staffing models under the development of new, enhanced ways of working? Do you think you're going to strike that balance? How are you going to do that?

It is a difficult challenge, because there are, as you say, significant gaps that are affecting services right now. So, us developing a workforce strategy is a positive thing, because that will give us a sense of direction and give us a sustainable way forward, but it doesn't affect the issues that we've got now. So, we do need to make sure that we're not spending all of our time on the long term, and helping address issues in the short term. So, that's exactly where, with things like I've already mentioned, in relation to, for example, how we can provide endoscopy training to non-consultants, because we can't necessarily grow lots of consultant gastroenterologists overnight, but, perhaps, on a shorter time frame, we can give other people the necessary skills and training to do that.

We've had a really good example of developing, for example, emergency nurse practitioners by having much more of a targeted, modular-based approach in the workplace to help them develop skills, which makes up for some of the gaps that we've got in terms of our doctors' rotas.

So, there are things that we've got within our organisation that we can bring to bear, to help identify and accelerate some of those shorter term issues that we've got. I don't think it's going to be enough to satisfy the gaps that we've got at the moment.

Obviously, we've got two issues. One, have we got enough people coming in? So, as you know, the education commissioning budget has grown quite significantly over recent years. There are more people coming through the pipeline. They're not quite with this yet. So, the other alternative to that is to make sure that we're focusing on our existing workforce and providing them with all of the opportunities that we can. And this is where, I think, the prudent healthcare principles really come in, because, actually, if we can give them additional support to work at the top of their licence and to really do the things that only they can do, and support, perhaps, other groups of staff, like healthcare support workers, to come in and to take on some of the workload that they don't need to do, then actually that does increase capacity. That still requires training and development and support, but it's probably more feasible to achieve in the shorter term.

And I think there are still examples where we haven't fully deployed the prudent healthcare principles in workforce models that we've got at the moment. And, again, that's something that goes right through all of our work, really—that multiprofessional team, and how we maximise the capacity of that and not just think about the fact that we haven't got enough doctors and nurses available.

So, you know, with a lot of the service examples we see, whether you take cancer, unscheduled care, eye care, whatever it may be, there is definitely a role for developing other people's skills to compensate for those capacity gaps. So, that's a real theme for us.

Do you think there's a good understanding about the cost implications for developing the workforce needed to deliver the vision set out in 'A Healthier Wales'?

It depends how ambitious you want to be. You know, it's almost like a piece of string, isn't it? That's why we'll have to prioritise, because everybody will want something. So, I think, having a strategic way forward means that there is a collective agreement, hopefully, on what are the must-dos now, as well as investing for the future. And the whole reasoning behind investing and upskilling domiciliary care workers is exactly the same prudent principle. So, you get your very front line as highly skilled as they can be while we're trying to redesign those qualifications, because those are the very care workers who are helping to keep people out of hospital for longer, who are helping to get them back home after a hospital episode. So, if we don't have that foundation in place, strategic social care and NHS services could be in real danger. So, I think that very front line, the very early intervention and support, is vital—that we keep that capacity there.

And I suppose, one of the things that we do know—. So, we don't know the cost of the workforce strategy at the moment, obviously, because we haven't done the work, but we know that there is a commitment to invest in the workforce, and we also know at the moment that we're spending a lot of money perhaps that we don't need to be spending. And, obviously, the Wales Audit Office report came out yesterday about the cost of agency, and at least one of the reasons in there was clearly that we haven't got enough staff in the right places at the moment, and a lot of that is going on vacant positions. So, that's a premium cost that perhaps we should be redirecting into more sustainable workforce models that actually—. So, it's not all about new money necessary; it's using what we've already got as well

Turning specifically to recruitment, retention and training issues—David.

Before I go on to other points, you mentioned in-service training, because upskilling people is an important, critical element, and I fully agree with that. But have you had discussions, or perhaps taken the lead, on telling health boards that, if we're doing this, staff must be given time to be able to do it? Because, very often, we are finding—. We all know the pressures on staff in the health service and the care service, but they sometimes are being asked to do this on top of that and not being given opportunities to actually take some time to be able to be upskilled. At the end of the day, the upskilled individual will provide a far better and more effective performance than someone who's stressed and struggling to balance everything. So, have you had these discussions with health boards?

Not directly, currently, David. But you're right—there's an absolute pressure in the system, and obviously I know that from wearing my previous hat. You want to do the sustainable thing, which is give staff the new skills, but sometimes you can't take them off the ward or off the service in order to do that. So, that is an area that we do need to explore, because I think there is a middle ground, isn't there? We don't want to take people necessarily away from the workforce to train them; we want to train them in the workforce, but that still requires them to have the time to do that. It links very much with the well-being agenda, doesn't it, really? Because, actually, what we don't want is already under-pressure staff feeling that training and education is yet another pressure. We want them to see that as investing in them, valuing them and helping them to do their jobs more effectively going forward. So, that is a tension, and we don't have a magic solution to that at the moment, I'm afraid. 

I appreciate there's no magic solution, but I think it's an area you need to have discussions on, because what we don't want to see is more staff going off with stress as a consequence of all this, which adds pressure to other stuff.

Yes, and I think well-being is a key issue that we feel that we can provide some support on. I don't know, Julie, if you—

Yes, absolutely. We are supporting the national work around the health and well-being agenda for the NHS workforce. We've inherited some staff who were in one of the former organisations who were leading quite actively in this space. We've recognised that as a key priority for us going into the new year, into 2019-20—things like rapid access to the 'once for Wales' occupational health service, how we actually support people to have attendance at work as opposed to sickness. Those sorts of things are things that we're clearly strongly plugged into.

So, in the sense of social care, are you seeing specific areas where there are questions as to being able to provide opportunities for upskilling?

I mean, it's a real pressure, isn't it—the demands on the workforce? If I use domiciliary care, because I think it's a hot topic at the minute, we've had things like the Social Services and Well-being (Wales) Act 2014, so having to operate under new legislation, new regulations in terms of registering with us, and new qualification requirements, and there are the demands anyway in terms of demographic pressures, more people surviving longer with long-term conditions, more children surviving with disabilities. So, the pressure in terms of volume is still there.

What we're trying to do to support those employers, whether they're in the independent sector or in local government, is to develop a whole range of resources that they can access online so that they can still learn in the workplace rather than having to come out. We've also developed a code of practice for employers on what we would expect from those employers, and that would include protected time for individuals to learn. Then, the very act of registering means we set out our expectations in terms of qualification, skill and knowledge required. So, we're quite clear in what the expectations are. We give the employers that code of practice to help them prioritise. Even things like effective supervision makes a massive difference to people's well-being. So, we provide lots of support and resources to help employers.

But, as I mentioned earlier, there are over 1,000 employers, small and medium enterprises, many of them doing excellent work with limited resources and very stretched budgets, but we're working through the national provider forum to really cascade our expectations. We work jointly with Care Inspectorate Wales, so, when they go in to regulate the service, one of the things they do is look at how the staff are being trained, supported and developed, and they will feed back any of their concerns to us and we can take action where necessary.

Because of course, obviously, upskilling is not just to provide a better service, but it's also providing career paths for individuals as well, so it's critically important. Sue, you mentioned earlier the challenges you've had in promoting healthcare as a career path, basically. In that sense, you talked about your campaign coming up very shortly. I'm assuming that campaign was done in collaboration with the sector.

Yes.

Have you had discussions also with the further education sector in the sense of how we can help people into the pathways, to ensure that there are programmes there to encourage people to move on to it—even those without formal qualifications who may be wishing to return to a profession and a career, but they want to see a career path and not just, as you say, what they were told when they were in school?

Yes. We're working with anybody who we think may be influential—even the Department for Work and Pensions, careers advisers, schools, skills bodies and FE—and we have a wide engagement strategy with all those key stakeholders there. We'll only be able to design the marketing materials, if you like, and have a website where people can come. We will rely on schools, others, and we've got what we call 'care ambassadors', who are full-time employees that we don't employ but, through the goodness of their campaign, they are willing to work with us. They will go out into schools to encourage children to start thinking about careers and to explain what sorts of opportunities there are in the social care sector. So, this campaign isn't just a marketing campaign. That's the sort of badge, if you like, but we're going to have activities happening over the next three or four years.

A good example: we recently went to some retail areas where we knew there were going to be redundancies. So, we're trying to target parts of Wales where people are seeing their job opportunities going. Are there some individuals there who may have skills that would be suitable? I think the key thing for me is, when you're providing social care to very vulnerable people, you do want the right sorts of workers. So, their compassion and their care and their ability to understand people in times of vulnerability is absolutely critical.

So, we have things like an app, 'A question of care', where youngsters, or anybody of any age, can go in and almost self-assess whether care is a potential career for them. So, it's a good example of using the latest technology, using digital, but getting people to think a bit differently. If they've never thought about care previously, maybe it's something that they could think about in the future. I think you're right—that whole idea of a career pathway—. Something that Alex and I are keen to do is to see if we can encourage more of that cross-fertilisation, or secondment from health into social care, or from social care into health, and break down some of those professional and organisational barriers. Some of the new models of care and multidisciplinary working are going to need some of those professional boundaries to be broken down, if they are getting in the way.

You've triggered a question from Helen Mary Jones.

Yes. I was going to ask this in a different place, but actually, this is best, probably. You are talking about cross-fertilisation between healthcare sectors. In my immediate previous role in the university, we were doing some work around this area. One of the things that was suggested to us is that there are very often situations where the health service may be putting on certain training in a community that would be relevant to, particularly, smaller providers, and that, as part of a key role in improving the skills of people in the care sector, they could get access to NHS training—some of which would have no extra cost to the NHS at all, to have a couple of extra people from the care sector in there. Is that an idea that's appealing, and are there things that you can do jointly as organisations to encourage that?

I have to say, I was quite surprised that that wasn't happening. When we're training people to do exactly the same thing, or to comply with exactly the same bit of law, it's completely daft that the public sector is paying a huge amount of money to private sector consultants to come in and provide the training for them, which may actually not be of the same quality, or it may—. There was some evidence that we were given that you have got people coming in from England to provide that private sector training and so, actually, they weren't training the Welsh care workforce necessarily in things that were compatible with our legislation. So, is there more that you could do to help promote that?  

It would be worth bringing Sarah in. We are doing a pilot down in the Hywel Dda area that would be worth exploring. 

Yes. So, I suppose we are already working jointly on a number of areas, and I think that that is worth emphasising. Operationally, we are not waiting for the strategy; we are already jointly working together. One of those areas is an induction in relation to health and social care that support workers and social care workers will undertake. As much as we've got the framework in place, we are piloting, through Hywel Dda and some social care employers, whether there could be a shared training approach that could be taken, which should provide opportunities and efficiencies for both sectors—but also that cross-fertilisation of learning between those working in healthcare settings and social care settings, and enable that transfer as we move across and forward.

We've already got joint health and social care qualifications. Some of that is already in place, and that does provide pathways for individuals at level two, three, four and five as we progress on the vocational training platform, and apprenticeships are also health and social care. So, there are a number of areas where we already have that work. We also, for a number of years, have had a Social Care Wales workforce development programme fund, which came across to us from Welsh Government a couple of years ago, and through those mechanisms local authorities have partnership approaches, where, yes, there is some funding there, but they provide training and opportunities, not just to local authority employers, but across then to all social care employers and providers in the sector. So, there are some models that have been used that perhaps we could also learn from about thinking across then health and social care as we move forward. What other opportunities are there? And, certainly, we're linked in with all of the regional partnership board workforce boards. So, there are some direct links where we can be thinking through operationally what are those opportunities for us to work more efficiently.

Safeguarding is one area we've been looking at with the safeguarding boards. Obviously, across all of our sectors and much wider, we will undertake safeguarding training. So, what opportunities are there for us to have shared approaches in relation to safeguarding training, moving forward? So, I think this is an area we really do need to be looking at as we move forward, and building upon some of the positive examples we've already got.  

That's really encouraging, but somebody said to me the other day something about Wales suffering from 'pilotitis'—that we pilot an awful lot of stuff but we're not always very good then at spreading that out. Can you say a little bit—and if it's too early days to say, then just say, 'It's too early days,' and we'll come back to it—. If those pilots that you're talking about in Hywel Dda do work well and if they're successful, what plans have you got then to roll that kind of approach out nationally? 

It's just starting, so it's too early for me to give you any confidence on that model in itself. But what we do have is the shared framework that's already in place. So, the structure is there, it's really about are there opportunities for us to support the sector in how we operationalise that. So, there'd be individuals in both sectors working through that induction approach. Is there a way they can undertake the shared training? Undertaking that is the bit we're really testing and what's the best mechanism to do that. 

Okay, back to David. 

Thank you, Chair. Just based upon that then, are you therefore talking with providers to ensure that some of that training is actually in community settings, because you've both highlighted very much this morning the possibility to change to more community-centred care and provision? So, are you ensuring that the providers are going to be delivering some of that training in more community settings so that they understand what the future model might be?  

It's early days for us yet, but already we know that, actually, a lot of the health boards have worked very closely with their local education providers to develop their own education much more locally, and we're very keen to support that.

The other aspect of our workforce strategy will need to be actually taking much more training and education in general out of hospital settings into more community-based settings. So, in a different sense to perhaps the point you're making, but very much about—people don't need to learn everything in hospitals any more. There's lots they can learn in primary and community settings, but what we need to make sure is that the education and training infrastructure is there. So, again, one of our priorities for the next 12 months is to understand that better, because we want to be training not just GPs in primary care settings, but more pharmacists, more therapists, more paramedics and more nurses, to make sure that, actually, people experience primary care and know that it's a great a place to work, but also that we develop people who can actually have the skills to work in that setting as well.

So, I think that we will see that more locally based education and training taking place in a lot of different ways with a lot of different providers over the next couple of years. In particular, where you've got rural communities, that is absolutely essential, because people don't want to have to trek off to university centres in order to get their education. So, that's going to be part of the strategy, for sure. 

Thank you, and just two final points. On the workforce strategy, which you've talked about, and we've talked about it with yourselves this morning, it will include a requirement to ensure the well-being of the staff doing their training, because one thing we must ensure is that, as we go forward, we protect the staff who are currently in place. Eighty per cent, we anticipate, will still be there. 

Absolutely. I think that's a really important point, David, because we do talk an awful lot about the new people that we need to come in, but, as you say, we've got an awful lot of staff in the system now, and they're still going to be here in the next 10 years. There's a real strong theme, obviously, in 'A Healthier Wales' about staff engagement and well-being and developing the capability of those staff, and a lot of what we need to focus on has got to be about reskilling and helping people develop new skills. So, we have had quite a rigid system up until this point. We need to be more flexible, we need to take on board prior experience and prior learning and help people develop career pathways that actually are interesting, stimulating, motivating and make the best of their skills, because even people such as—I know we've got a GP in the room, so I'm hesitant to say—GPs are saying to us, actually, after a certain point in their career, they would like to diversify and do different things, and we need to support people to do that, because we want to keep them within the NHS. I think there are lots of things like that that we need to build into the strategy. 

And, perhaps the final point from me is we talked earlier about intelligence. It's only just crossed my mind we're talking about—. With the workforce and pressures upon the workforce—. As part of that intelligence gathering, have you assessed why people are leaving? Is it the models of provision? Is it—surely, because they want career development, they don't see in their career pathway where they are. Have you gone into that information? Are you going to collect that information so that you can have a look at, actually, what is it that is driving the workforce at the moment in the health service and the care services?

If I just respond on the comment I made earlier about domiciliary care. We're really concerned about the fragility there, and that 30 per cent turnover in general. But then, when you go underneath, and really unpick that data, 50 per cent of those are staying in the care sector, but moving to another employer. And I think it does relate to terms and conditions. We know it's very difficult out there, very challenging for providers to offer not much more than the minimum wage. So, I think that's certainly an area that we need to have a look at. And I think it's too soon, at this stage. We're only gathering that data, gathering that intelligence but, I think, by the time we get to April, we'll have done a lot of our engagement with the front line, with health boards, with local government, with providers. We'll have much more intelligence about what are the biggies. So, I think more information will be coming forward.

Okay, you've inspired Dawn.

I was going to pick this up when I came on to my section of questions, but I think, as you've raised it, Sue, the issue around terms and conditions, because it was something that has bothered the committee—. It's something I know from a previous life that I was involved in, that this was an issue—the disparity between social care workers and healthcare support workers doing very similar work across health and social care, and how much of an impediment that is to the development of the integration agenda. Because, when we've got people working side by side, doing pretty much the same job, holding them in the social care sector is quite difficult. And you've already talked about the joint qualifications that people are undertaking, so they're undertaking qualifications in health and social care. But there isn't really much of an incentive to stay in social care when you can work in the health service on much better pay, much better conditions, and really, I suppose, what my question around all of that is is: what are you doing in both sectors to try and address that? Because unless we can address that, it seems to me the point you were making earlier on about parity of esteem just isn't going to happen, because there won't be parity of esteem without parity of recognition in terms of terms and conditions.

I think it's a really strong point, and the Government's attempts to look at how well are we spending our health and social care resource—so, already, we're using, between us, 50 per cent of the Government's budget. So, there's something about: are we using it in the best way possible? So, being more efficient—Alex mentioned things like employing agency staff—if we could be more efficient, that would help. The social care levy. So, is there something about—? Can we do something about terms and conditions if we can attract more funding in for the Government to utilise? It's obviously a major issue,

Added to the difference, we've estimated that, depending on the roles within that sector, there could be between £3,000 and £5,000 per annum difference in pay, like you say, doing similar sorts of roles. There are more pressures on care workers now to take what I would describe as 'health-related tasks'. We're expecting them to do more, so we're equipping them to do more, we're upskilling them, which is great, but the relative difference in protection of budgets for the NHS compared to local government, I think, over these years of austerity, is now coming into sharp focus.

The national health service is brilliant, isn't it? A decision is made, 'We'll increase the pay by 6 per cent'—I think that was the latest overall for last year for the NHS. You don't have the same in local government, because it's not a national care service, so there are different rates of pay across Wales. But they are much lower when you compare with those very similar roles. And the fact that 'Prosperity for All' names social care as one of the priorities for Government, the fact that Government are thinking about a levy, so increasing the funding, I'm optimistic that we will see a bit of a difference, going forward, but it's very challenging, isn't it, at the moment, with austerity, for the Government to find the money to make that happen.

Sorry, Chair—. I guess, really, what I'm saying is that unless we can start that process—. I think you were touching on that earlier on—starting that process. You've already identified that social care in particular—. I know, from some work I've done in my own constituency, talking to health and social care providers and talking to constituents about it, that people always talk about the value of the NHS. You very rarely hear anybody talk about the value of social care. So, there's a huge piece of work that we need to do to raise that parity of esteem, so that people see social care in the same way as they see and value the NHS. I was at a care home in my constituency recently. We were talking about the 'mum test': 'Is this the kind of place you'd like to see your mum?' And actually, we're putting our loved ones, our nearest and dearest, into the hands of people who are paid the lowest rates of pay in any of the sectors. But if we were able, in some way, to have some kind of campaign around the esteem in which we ought to hold our social care workers—. Because, again, anecdotally, you hear that people don't like to say they work in social care, whereas people are always very proud to say they work in the NHS.

Well, I'm proud to say I work in social care.

I know, but we do hear that.

Our attraction campaign is that very—

It's just that thing, yes.

Yes. It's looking at both, not just recruiting—it's looking at raising the profile, and that's why we use the word 'attraction'. So, it's not just a recruitment campaign, it is about getting the public, the wider public, not just people who may be thinking about a career or their next job—the general raising of the profile of social care. Because it's not understood well, and we know that through our evidence gathering, I think the attraction campaign is absolutely vital.

Good. You need to join my policy campaign about creating a national care service, Dawn.

Indeed. I've advocated it for a long time, Dai.

Yes, I'll reach out. Before we forget about retention, can I just ask from the medical point of view, because, obviously, I have some medical connections in my family—? One of the issues I used to have with the old Wales Deanery—. Now, obviously, that's in the past, and we're all very happy now to have HEIW instead, but one of the issues was our junior doctors. Because we haven't got enough medical school places in Wales, lots of our bright Welsh schoolchildren train as doctors outside of Wales, and there's always been an issue, then, about how to get back into Wales once you've qualified in England or Scotland, or indeed elsewhere. It used to be very clunky. Of course, everything is done online now, and at different points and stuff, and it's all computerised—the UK jobs market. But it was a particular difficulty for those new medical graduates, junior doctors—and junior doctors are, obviously, our future consultants and future GPs. It was an issue getting back into the Welsh system, because, obviously, they graduated outside of Wales.

And the other point that was always an issue with the Wales Deanery was our junior doctors, as they are now, were feeling overworked, rota gaps, a terrific amount of responsibility at a very young age—you know, power of life and death and all that sort of stuff. They're feeling a bit unloved and stuff by admin in general. It's an issue that's been going on for years, really. That wasn't my experience when I was a junior doctor, back in the day, only about five years ago, but it is an issue now. So, I was just putting that out there as something to look at. Alex.

Yes, I absolutely agree. I think you're right. The recruitment processes are clunky at best, and a lot of them are run nationally across the UK, which doesn't always make it completely transparent about how we make sure that people do get back to where they want to get to. So, that's certainly something we've got to understand in more detail in HEIW, and also look at what are the softer things we can do around that, to reach out to those people that we know have gone to medical schools elsewhere but actually do want to come back to the Welsh postgraduate training programmes. So, that's certainly something that is on the medical director's list of things to look at, because, clearly, we know that where people train, then, will often determine where they will end up, so that will help medical recruitment overall.

I think some of the problems that you've mentioned in relation to working experience for trainees at the moment—this certainly is something that is high on our agenda. I've had a number of conversations with the British Medical Association junior doctors committee about these issues and, as you know, they've developed the fatigue and facilities charter—partly, that's for health boards to help with as well, because there are a lot of issues around rota management et cetera. But some of the things that we can help with are, for example, exploring what a single-employer model would give them, so that they weren't going through a lot of that administrative burden every time they changed their place; making sure that they're supported through the education process properly; that they can access the right services within what was the deanery, and now HEIW, appropriately; that we review—for example, we do exit interviews, trying to understand why people might be falling off the training programme. So, there are a number of things that we're working through as a result of those conversations, to try and improve the working experience of our trainee doctors, because, as you say, that's quite critical, really, to keeping them in the programme and making sure that they stay with us as consultants in the future.

Great, thank you. Dawn, do you want to finish your bit on social care?

Yes, because I think you've covered the stuff around domiciliary care, so I'm quite happy with where you're going on that. But it was about unpaid carers, really—I just wanted to pick that up. I think, in both your evidence, you mention the role of unpaid carers, so I just wanted some kind of assurance, really, that the workforce strategy is giving sufficient importance to that role, and working alongside paid and professional carers. So, it was just if you've got some information around that, really—some thoughts on that.

Yes, we've certainly built that into our steering group, and our fact finding. And we know—370,000 unpaid carers are the ones we know about. So, we're already doing what we can to support them anyway. So, any of our e-learning resources are available to unpaid carers. We've added unpaid carers into our priorities for the social care workforce development programme grant—that's the annual grant we give to local government to work with providers, and to upskill the workforce. We've included unpaid carers in there; we want to see more pressure and more reaching out to unpaid carers with that resource. We also did a literature review with an organisation called SCIE—the Social Care Institute for Excellence—to understand what works best for carers. They looked at international evidence—it wasn't just what's happening in Wales. So, we're working now with representative bodies like Carers Wales, Carers Trust, to see what else we could do to help. We've recently developed and launched an e-learning resource with the NHS, because, obviously, carers—sometimes the first place they're identified is at the GP practice. So, we're working very closely with health colleagues to try and understand who the carers are and what more support could we offer. We have what's called a LIN—a learning and improvement network. So, any officers working within local government who have responsibilities for supporting unpaid carers, they come together regularly to share best practice, to try and understand what the challenges are, and we facilitate that learning network, because we think it's critical. As I said earlier, if we don't support carers well, both the health and social care system will collapse.

And I guess one of the—a good example of where some of our online resources have been useful: last year, we developed what was called the dementia good work framework. So, the health Minister launched it—I think two years ago now; it was in the pilot stage then—but certainly the anecdotal information we've had from some front-line practitioners, professionals and unpaid carers is they're seeing that as a very useful resource. I think it's good—the more that we can develop common language, common learning approaches. Helen Mary Jones mentioned earlier about sharing some of our training resources. I think that's a good example of where we're trying to make sure that we're writing those resources, making sure that anybody can understand them, whether you've got a care background or whether you're an unpaid carer.

So, are you offering training to unpaid carers, or just offering them guidance and support?

Guidance and support, but they can use all our resources. A lot of our training are online resources.

They're online resources, yes.

Yes. And obviously, in local government land, we use our SCDWP grant—a significant amount of money going back into local government. We set out every year there the priorities that we want them to use that budget for. And we've included unpaid carers in there as a priority.

Okay, thank you very much.

Okay. Turning to rural—[Interruption.] Oh, Jayne—you're too shy and withdrawn; be more assertive.

It's just a quick point because, obviously, there are many people in the NHS who might later go on to become unpaid carers and might leave the NHS workforce quickly because they don't feel perhaps supported to look after their loved ones. But are we doing enough to identify those people, perhaps who are coming, not necessarily to the end of their career, but those people who have been very experienced in the NHS, and, obviously, it's about how we pass their skills and learning further down the chain, but also supporting them to stay in work while also becoming an unpaid carer?

Yes, and obviously, from our point of view, we're not the employer of a lot of those staff and that's something that the health boards would be looking at. However, we do know, and this links back to David's question about retention, doesn't it, that, actually, a lot of the time, the reason why people are leaving the NHS is because of the lack of flexibility around the working patterns that they can have? So, that is definitely something we need to build into our thinking, going forward, because that would clearly be a key issue for people with caring responsibilities.

It also works the other way around, I think, and one of the things we're keen to do is—. People who have been carers actually have got a lot to offer the NHS, so how do we make it easier for them to actually get proper paid roles as part of the NHS—

Because some people have given up their job, or they've been looking after somebody for a long period of time, and when their loved one passes away, they don't really feel like they've got the skills, but they do, because they've been caring for somebody.

They do, and so this goes back to, actually, how do we demystify some of the roles that we've got in healthcare, and make that a lot easier and more accessible to people to bring those skills into the system?

Okay. As heavily trailed, Helen Mary Jones on rural areas.

Yes, so you both mentioned in responses to other questions some of the specific issues and challenges and opportunities relating to the delivery of health and care services in rural areas. So, can you tell us a bit more about what specific focus the workforce strategy will give to those challenges and opportunities in terms of providing services for people in rural communities?

Yes, I think, certainly, it goes back to the point that I made earlier I think, that, although we're doing an all-Wales workforce strategy, we have to make sure that that doesn't assume a one-size-fits-all right across Wales, and the rural challenges do need a specific focus. But probably the principles of that are actually an extension of what we're trying to do anyway in terms of primary and community services, because clearly the strategic direction is to take care closer to home and closer to where people are, whether you live in the middle of Cardiff or whether you live in Aberystwyth. So, the principles are the same and the workforce that we're trying to develop—that very, sort of, more mobile, closer-to-home workforce—will apply.

Some of the specific issues that I would think the workforce strategy—. We're predicting what the workforce strategy's going to come up with and it's very much about how we enable local communities to do their learning and education closer to where they live, and also how we enable people to not necessarily have to just devote their whole lives to education and training, but to work more on a part-time basis. All of those flexible routes into education and training are really important, but also, then, are clear pathways that clearly take them on from that. Flexibility I think is key there, because, actually, what we're going to be relying on in those communities is definitely that multiprofessional team and maximising the skills of that multiprofessional team and making it easier for people to diversify, really, in terms of those career pathways, so that, again, they don't think they have to go off to the big shiny hospital in order to develop those skills, but that, actually, those opportunities can be built into local programmes. So, that's probably the main thing that's emerged to date from the conversations that we've had with the more rural health boards and partners, but there may well be more themes and issues that come through from the workforce strategy as we get into that discussion.

The only thing I would add is that, in terms of our attraction campaign, what we're already recognising is that we may have to target particular areas or think differently about how we get that message across, and rurality would be one of those factors.

Yes. At the risk of being slightly mischievous, Chair, I'd say that the people I'm worried about are the people who don't live in Aberystwyth or Cardiff, but who live in those very scattered rural communities across the whole of the region that I represent. But I'm reassured by that approach—that is helpful.

One of the things that we—. We took a piece of evidence not very long ago about specifically GPs in rural areas and the level of skill that they may need to have if they're serving deep rural communities that you wouldn't necessarily need to have if you're a GP in a big town or a city, because you'd get that person straight into hospital. I'd be interested perhaps just to feed that into your thoughts as you're working on workforce development plans, because it could also, of course, be a way of retaining GPs in those communities. Because if you are able to be trained to do more interesting and more technically challenging work, that may be a reason to continue to serve that community rather than feel you've got to go, as you said, Miss Howells, to a big town to get those opportunities.

The committee's medical recruitment report recommended that Welsh Government should work with Welsh medical schools, health boards and the then Welsh deanery to develop a joint action plan for rural medical education and training, and I wonder if you—. You'll be conscious of that from deanery days. Will that work be built into the workforce strategy, or can you provide an update of any action that has been taken so far specifically on that recommendation?

So, obviously, we don't commission directly the medical schools. That still goes via a different route. But, obviously, we're working closely with both of our medical schools to develop better links in terms of that pipeline, and, as you'll be aware, they've increased the number of students this year by 20 each. Certainly, I think they're looking at really innovative ways of addressing some of those challenges, particularly in north Wales and in west Wales in terms of some of the types of programmes that they're putting on. And also, I think, building in that sort of more practical experience, more primary care-based experience, and making sure that people have a taste of what it's like to work in more rural settings and to certainly support north Wales more effectively. So, that'll have to be evaluated to see what that means for us going forward, but I think they've done a pretty good job, really, in terms of setting some of the foundations that we can really build on then through the postgraduate programme.

One of the things that we're looking at at the moment, for example, is increasing the number of GP trainees. We know that there are some underserviced areas, particularly in north Wales, so how can we not just grow the number of GP trainees in north Wales, but how can we grow the education and training infrastructure that those GPs are going to need as part of their training going through? So, that's certainly a priority for us at the moment that we're working with Welsh Government on.

Thank you, that's helpful. If I can move on, then, to a separate but to a certain extent related issue, and, Ms Evans, as you mentioned earlier, services through the medium of Welsh, and we know how important those are. It's not just a question of preference; there is a strong research base that shows that receiving those services through the medium of Welsh affects not only your immediate well-being, but, in terms of the health service, the speed of recovery, especially for older people and for children. Obviously, in rural communities, we will have higher percentages of Welsh speakers in some cases. So, can you say a bit about how the workforce strategy will take into account the need for improved access to Welsh language services, both in health and care and in a range of settings?

Again, we've put that in as a very strong feature of one of our gaps in terms of the intelligence. I mentioned previously our SCWDP and our annual survey. So, we've got quite good intelligence where social workers and social care workers, if they're employed by local government, but because of the dispersed nature of other employers providing social care, it's very difficult to gather that intelligence. Once we start registering domiciliary care workers, there may be an opportunity to collect some of that wider intelligence.

But we're working very closely with Work Welsh to—. We've had a grant of £250,000 this year to really get out to the front line, to do a baseline assessment of who has Welsh in certain parts of Wales, offer them training, support, mentoring, some dedicated resources. We've been helping the Work Welsh part of Welsh Government design specific social care-related language and training and case studies to make that learning relevant to providing care in the medium of Welsh. So, by the middle of the summer, we'll hope to have a real good analysis of: has that worked? Is that a good way? So, we're actually getting out there and having bespoke training for social care workers. If it's worked, can we do more of it? Can we roll it out to other parts of Wales? And, obviously, we're actively promoting everything we can through the medium of Welsh. All our resources are available bilingually. We make sure that all our training and learning is offered in both languages. So, we're pushing as hard as we can, but we're really trying to use this Work Welsh period and investment to really get underneath how better—you know, what more can we do. Is this bespoke training module—is that the way to go, and can we get more resources to roll that out? Sarah.

I think it's probably worth building on that in terms of the work we've done on 'Mwy na geiriau' and working with the health and social care national partnership board to really try and understand how we can move forward. I think, for me, it's on two fronts. It's the awareness of the whole of the workforce, in recognising the importance of language and supporting individuals' language choice and need in a number of areas. And also, then, how do we increase the Welsh language skills?

So, as well as trying to work with the existing workforce, we've also done quite a lot of work going out into FE and into schools and those sorts of settings to really talk to younger people about the importance of keeping their Welsh language skills and how that's a real employment asset to keep their skills and those language skills alive so we can be drawing them into the sector and not losing that language between leaving school and then coming into employment. I think we spoke to about 1,500 children last year.

So, it's trying to take that continual journey, not just trying to get people onto the Welsh language training courses, because there are a number of challenges with that, and also opportunities that we hope to build upon, but also looking at the whole approach that 'Mwy na geiriau' really tries to—for us to embody as we move forward.

That's really helpful. Do you want to add anything from the health perspective?

Yes, of course. Very similar to Social Care Wales colleagues, actually, we've also sat on that national group, we've got representatives there, and in my former role within Welsh Government that was something that I was connected with, so we're very supportive of that activity. It is very early days for us, however. In terms of our own organisation, we're not named in the legislation as being required to comply with the standards, but the board has taken a decision that we will try to adopt those standards. So, we're starting to try and get ahead of the game.

We've got about 10 per cent of our workforce—our new workforce—signed up to undertake Welsh language training, and all of our board members have actually agreed to learn. So, that's very positive. We had Meri Huws, in her role as commissioner, attend the board some months ago to actually talk to us about her expectations, and there were some positive commitments given by us as an organisation. And we're reaching out to the sorts of organisations that you would expect us to. Alex and I recently met with Coleg Cymraeg Cenedlaethol and spoke to them about our continuing partnership with them. One of the organisations we've inherited sat on their previous stakeholder board, so we're going to look to replicate that in the future and just see where we can join up around things like the widening access agenda that Sarah mentioned. I think there's been less done in our sector, so we've got some opportunities to learn from colleagues, but also to seize these. 

In relation to Welsh language data, we know that that has been a recurrent theme—that actually a lot of the staff in the NHS don't fill out that box on their electronic staff record. So, each organisation, in line with the new requirements, is actually having a push on people recording their language abilities and preferences. And this is something, obviously—as the holders of the intelligence on a national basis, this is something we can look at as well. So, I think we've got lots of opportunities—bit behind Social Care Wales colleagues, but right noises and right direction, I think.

That's all really encouraging. Picking up on your point about people, particularly in the health service, who may be able to speak Welsh but don't tick the box that say that they do, I certainly know that, in some communities in the west, that will be because somebody—particularly the slightly older workforce—may be perfectly happy to converse socially through the medium of Welsh but may not be confident, let's say, to undertake the nursing profession because they don't have the technical language. Will the workforce strategy be able to look at—? I know there has been some good work done in spots in working with those, if you like, social Welsh speakers, to enable them to work professionally through Welsh. Will the strategy be able to look at how we can build on the good practice in that area? Because I know individuals who will say, 'Oh, I'm not going to tick that box, because they're going to be asking me to work through Welsh, and I don't think I can do that.' No sense, of course, about how widespread that is for the reason why people don't tick the box, but, if we could actually use the skills and build the skills that are in the workforce already, I think that might help fill some gaps.

Yes, I absolutely agree. Like you, I'm aware from my previous role of a number of great initiatives across individual health organisations where they are actually encouraging people to have the confidence to use social Welsh as opposed to business Welsh, so I think that's really important to build on. But, as Sue and Sarah have said, actually, the Welsh language will be a fundamental part of this strategy, going forward. It's something that we know needs to be addressed. So, that will be a main plank in there.

And a last question, then, in a very detailed field: can you provide an update on where we are with nursing numbers? Do we have enough nurses to meet the requirement of the Nurse Staffing Levels (Wales) Act 2016, and particularly the anticipated extension of that Act into other settings: paediatric wards, mental health wards? I guess this will have to be something that the strategy will need to look at. 

Yes. I think we're just getting involved now in the nurse staffing Act work. Because previously— obviously, it has been going on for a while, and there's a team at Public Health Wales that has been supporting that. We're getting involved now as they are looking at the paediatric element of that. When you asked me earlier on about shortage areas, I don't know why I didn't mention nursing, because, clearly, there is a shortage at the moment of qualified nurses in the system across a range of specialties, and it's one of the things that's driving the agency costs that we talked about earlier on, so I don't know why I missed the most obvious one there. So—

You've put that right now.

So, clearly, I think, the nurse staffing levels Act is setting a clear standard, and that will put pressure on the vacancies that we already have. However, in parallel with that, we do know that there is a lot of service redesign needed in terms of how we're using our in-patient capacity to do the right thing at the right time. So, there's a balance to be struck there in terms of—. Again, it's this thing about the service model, what's the service model we need to staff for the future, then we can decide whether we have got enough coming through the system, based on current gaps and current education numbers. So, I think—you know, clearly, at the moment, I'm sure that is causing some kinds of pressures for health boards to manage. I'm not sighted on the detail of that at the moment. But what we need to do is to then work with them to look at where are those gaps, how can we help fill those gaps, or how can we help them develop different staffing models that take the pressure off those very acute wards—the medical and surgical wards that we are currently talking about—to enable them to do the very acute care, but actually perhaps to provide the other care that is currently provided in hospital settings in other ways and places. Obviously, that's something that we need to work very closely with social care colleagues on, because that's where we see the interface between hospital and community. So, that's something that—. Again, in our plan for next year, we will be getting much more involved in that work to try and help our colleagues with doing the right thing in terms of quality and safety.

I'm conscious that we have got the chair of the cross-party group on nursing here. So, David. 

Thank you, Chair. I was also chair at the time that the Bill went through. What I'm asking is—. The Bill went through in the last Assembly. You say that you are getting to grips with it now. This is something that the health board should already be getting to grips with, because they knew of the possible unintended consequences because they were highlighted clearly. The demand on nursing and nurse training was highlighted clearly. Why aren't the health boards up to scratch and actually identifying, at this point in time, what their needs are now, so that you know what those needs are and how you can address those needs? Also, she should be looking at—everyone should be looking at the future because we always talked about future additions of areas in that Bill. I'm just trying to understand why we are in a sort of catch-up position when we should be in a 'we know where we are' position. 

I think that, to be fair, the education and commissioning numbers for nurses have been going up over the last couple of years. One of the key drivers for that would have been the need to prepare for the nurse staffing levels Act. So, I'm not saying at all that the health boards haven't been focusing on this issue. I think that, as we all know, the pipeline takes a number of years to produce staff at the other end. So, we might decide in one year that we need more, but, actually, it's going to take probably three to four years to actually enable those people to come out into the system. So, we are now starting to see—. In the next couple of years, we will start to see the increase in nurses going up.

What we don't know, of course, is which specialties they will choose, where they will want to go to work, and whether that's going to be enough for all of the other demands on the system at the same time. So, for example, I know that Welsh Government has got a critical care programme at the moment, where we need to expand critical care facilities, so that will be a drain on nursing staff as well.

So, one of the reasons why we've been put together as an organisation is because nobody was really coherently looking at what all of these workforce plans need, what all of the different professional groups need, and what the service needs for the future are, to actually make some kind of logical assumptions about that. So, everybody's been doing it to the best of their intentions locally, or in a professional way, but nobody's been looking at the overall, and that's what we've been set up to do. We're four months in. We're getting on top of that issue, and, during the next year, I think we will be able to start to integrate that much more effectively and be much clearer about how we're going to meet some of those demands on the system. 

You've just said that the Welsh Government has a critical care plan that puts pressure and additional needs on this. Are you in discussions—or does the Welsh Government have discussions with you on those ideas? Because, clearly, that puts an additional burden upon the service, and it's an additional demand upon the need and recruitment, so are they having discussions with you when they bring these ideas forward? 

Yes, we're fully involved in the critical care network groups that are looking at this. One of our members of staff is fully involved in the workforce group. So, there are lots of national programmes of work, as I said earlier on, that we are either involved in or getting involved in. We are still new. Obviously, four months in, not everybody in the whole of the health and care system knows yet what we're doing, so we are still working on that and making sure that we raise awareness of what we can add and why we need to be involved in these processes. But, yes, as far as possible, we are having the right conversations with the right people. 

Helen Mary. 

I'm not sure if the point I'm going to raise is a matter for yourself, so, if it isn't, I shall raise it somewhere else. But, again, going back to the academic work that I was involved with in my previous life, we did some work with stakeholders around the very practical front-line stuff, and one of the issues that was raised with us is the way in which—. Obviously, we want to grow our own nursing workforce, we don't want to carry on using agencies, but, as you identified, Ms Howells, there's then that gap between—you've got a four-year gap. One of the ways, of course, in which health boards do address that is overseas recruitment, and obviously that needs to be done with care and you don't want to be taking people out of developing countries, but we do do it. And it was put to us, in the course of this research, that there needs to be more join-up between health and care, because you have nursing needs in the care workforce. People at a local level were saying to us, 'Well, we don't ask, and the NHS don't ask, our private sector counterparts 'Do you need three or four additional nurses in this community to work on that? Can we build that into our recruitment?' And also they were describing to us a health board going out to the Philippines and then a different health board going out almost the next week. Is there an argument—? While we want to get to the point in the end, I'm sure, Chair, where we don't need to do that international recruitment, but we do at the moment, is there an argument for trying to have a more joined-up approach both between the sectors at a local level, but also is there an argument for a national approach to that, because what they were describing seemed to be pretty wasteful? And expensive, of course, because you've got to fly people out there and—. 

I think there's definitely value in looking at a national approach to how we use some of these things. The priority we've picked off for next year is to look at the medical recruitment side of things and to set up a small team to try and co-ordinate that better and make sure that we're targeting the needs of all the different organisations in Wales to make the links with all the different countries that we need to and to see how that works. We would very much like to talk to colleagues in the NHS about how we can we build on that then going forward to take some of the burden off them in doing those, because they are big programmes of work, and there's reliance on lots of external parties in order to support that. So, that's certainly an area where we think we could add value, where we would like to work with the NHS. I think, as you say, definitely opportunities then not just to go out for individual professional groups, but to actually look at it on a much broader spectrum of resources and people and skills that may be available in different countries—so, I think you're absolutely right that's definitely an area for development. 

Thank you. 

Okay. That's it. 

Yes.