Cynulliad Cenedlaethol Cymru

Good morning and welcome to the Health and Social Care Committee today for a very important day for us when we're following up a short inquiry on gynaecological cancer.

I'd like to welcome you all to the meeting, and especially welcome our Cabinet Secretary and Minister. Could I ask you to introduce yourselves for the record?

I'm Jeremy Miles, Cabinet Secretary for Health and Social Care.

And I'm Sarah Murphy. I'm the Minister for Mental Health and Well-being and also women's health.

Good morning and bore da. I'm Sue Tranka. I'm the chief nursing officer and the nurse director for the NHS in Wales.

Good morning. Nick Wood. I'm the deputy chief executive of NHS Wales.

Well, thank you very much for coming in today. It's remiss of me, I've just not gone through and done the apologies. Apologies today from Mabon ap Gwynfor, and we're really pleased that Sioned Williams is substituting. Welcome, Sioned. I know this is an area of great interest to you also. This will be a bilingual meeting with simultaneous translation. Are there any declarations that anybody wants to make, of interest? No. Okay. If one comes up on the way through the meeting, please declare it.

Okay, as we said, we're following up on the gynaecological cancer inquiry we did in 2023. I submitted a letter to Ministers in June, and thank you very much for your prompt response to those, which we circulated out to various organisations. And can I thank you for the submission yesterday of additional information, which was helpful? That was very helpful, so thanks very much for that.

We have quite a lot of questions. We've got about an hour and a half, we may stop for a little break halfway through, but if you're happy to start, I'll kick off with the first set of questions, and that is to look at progress and impact following that significant report, with a lot of recommendations that were agreed, mainly, and so we want to follow up a little bit on that.

So, we know in your original response to my letter you said that there's been some good progress for most of the commitments, but we found that key stakeholders didn't see it quite that same way. For instance, the British Gynaecological Cancer Society says there is still a long way to go. The Royal College of General Practitioners highlight that many changes are still in early stages with little evidence yet of improved outcomes. I just wonder how do you respond—which has led us to today, really—to that initial what seems to be a disconnect between Welsh Government's assessment and the concerns raised by stakeholders.

Well, I think, Chair, that, in a sense, both things can be true, can't they? I've read the response of stakeholders and I think that it’s probably fair to say that there’s a mixed picture in terms of progress. If you look at the waiting times for access to treatment, clearly that is not where it needs to be. There’s been some improvement, but, overall, it’s not where we want to see it, and there’s a long way to go to get it to where it needs to be.

I think, if you look at my letter in the early part of the summer, which you referred to, I went through each of the recommendations, or many of them, where there’d been progress. So, I think, in a sense, you could say, looking at the recommendations, that there has been progress, but the fundamental question of course is: has the overall experience of women with gynaecological cancer improved to where we want it to be? And the answer to that is, 'It clearly has not yet.'

So, I think, in a sense, both things are true. And I would accept that mixed verdict, if you like. I won’t go through what I put in the letter, but the letter sets out where we have, I think, made progress against a number of the recommendations. But, clearly, there are some recommendations where work is still under way.

So, you'd welcome today's opportunity, really, for us to refocus and to give it that additional priority that it needs. 

Well, it's already a Government priority, Chair, and there is work under way in relation to each of the recommendations that we accepted. The point I'm making is: that being the case, I absolutely agree with the thrust of what stakeholders have been saying, which is that there is much further for us to go. 

Okay. Thanks for that. Sarah, is there anything you want to add? I'm not sure how you are planning to manage it. 

Yes, of course. I would echo everything that the Cabinet Secretary has said, and also say that we really do welcome this opportunity. The 'Unheard' report that was published by this committee was seminal, and I think it drew a lot of attention to gynaecological cancer, which was absolutely important, and gave the voice of women, not just through gynaecological cancer and their experience of that, but also just in the wider context of women's health.

Yes. 

So, today, I'm here to talk about the women's health plan, which was delivered last year—that was a key recommendation from the committee report—and also to give some insight into the hubs that will be coming online in the next six months as well. And just to demonstrate, really, that the visibility that's rightly been given to this report, and to the women's health plan, and the hubs, is absolutely, as the Cabinet Secretary said, there for gynaecological cancer as well. It's not one or the other. 

Okay. Thank you for that. A question from me before we move on to colleagues, just for some clarity really. Has the Welsh Government allocated any additional ring-fenced funding specifically to support the implementation of the committee's recommendations, beyond what is already committed in existing budgets?

Well, if we go back to the Government's response to the recommendations in the original report, as usual that refers to where there are financial implications and what the Government will do in response to that. And there were one or two that didn't have financial implications, but there were a range, obviously, that had a financial impact, but in the space of how we deploy the funding already in the budget. So, the committee gave a range of elements of advice about how things could be improved, obviously, but that's in the space of how we deploy the resources that we have more effectively, or differently, to meet some of those needs. That's the generality of it. 

The broad context, Chair, which you and the committee will recognise, is that there is a pressure on resources generally, so it isn't often easy to find additional funding in any event. But I think the thrust of the recommendations were in a space where the Government is taking forward actions in this area, but it needs to be doing it differently, or in different ways. 

However, there were certain elements—the women's health plan, the research budget, some of the digital interventions—where there have been specific budgets allocated to those. Some of that is in the correspondence that we've already provided, so £3 million for the hubs and there's £3.8 million, I think, for research. So, there are elements that certainly have ring-fenced funding, but I think, in general terms, it's about where we allocate the existing budget. 

So, yes, recognising there may not be additional money, but will the money be re-profiled, perhaps, towards some of the recommendations?

That will have been—. It will have varied between different recommendations, and I expect there will be an element of that, naturally, as we look at different ways of doing things. But I was keen not to give the impression that there is a huge pot of money that Governments are able to set aside in anticipation of committee reports. You will understand that that is a challenge. But the task has been for us to look at the committee's recommendations that we've accepted and see what can be delivered within the budgets that we've got. And there have been, as I've just given examples of, particular situations where we have found additional funding.

Okay. Thanks. Sioned.

Joyce.

Good morning, both. I think I'm the only person left from the original inquiry and also I pushed really hard to get women's healthcare in our programme, and I'm glad I did, because listening to women has to be the main priority. When you're talking about women's bodies, you have to listen to the women who know their bodies.

So, we're hearing and have had lots of evidence of lived experience and data that tells us that gynaecological cancer symptoms were often ignored or misdiagnosed, very often, and particularly Target Ovarian Cancer have expressed their disappointment at the lack of progress, and also they feel the lack of priority given to implementing the committee's recommendations. So, what I'm looking for from you today is some reassurance that that is not the case. And there's the question about gynaecological cancers not being included in the women's health plan. So, I'd like to hear your views on their views.

So, in terms of the gynaecological cancers not being in the women's health plan, the reason for this is that the women's health plan was originally, and has been, about addressing the kind of inequality, really, similar to the mental health inequalities report that was done by this committee as well, addressing the fact that, if you remember hearing that original evidence from Judith, from Linda, from Claire, was the phrase 'medical gaslighting', not being believed, not being heard, and knowing that women are being treated unfairly and not believed, and not believed in terms of pain. So, the women's health plan then, obviously, came off the back of a discovery exercise and report that asked 4,000 women across Wales what they wanted to see as priorities within the women's health plan, and then to provide that within the women's health hubs as we go forward. And obviously gynaecological cancer is already part of the cancer recovery programme, the cancer board for improvement, and so that is why they're separate.

Now, we've also published a quality statement that led to the development of the women's health plan and we have been very clear that the NHS services, including all NHS services, must reflect women's needs across a wide range of conditions. But I want to say that I have taken a lot of time to read the evidence that was submitted by Claire's Campaign, by Target Ovarian Cancer, by Fair Treatment for the Women of Wales, and I absolutely accept that we could strengthen what has been in the women's health plan.

Just to say that it is in the women's health plan—gynaecological cancer is there; it's part of the cancer recovery programme page, which is on page 92. We also talk about many other types of cancer that women have as well. But we are absolutely—. I'm very, very minded that I don't want this to become the focus, when the focus has to be on improving services for women across a range of conditions, and also then improving gynaecological cancer outcomes.

So, just to say that we are looking, therefore, at developing a biannual women's health newsletter, and the first will be published in December, to coincide with the anniversary of the publication of the plan. And we will include a section about gynaecological cancer to make clear the links between the women's health plan and the cancer improvement plan and provide updates about ongoing work, so, to really demonstrate that integration.

Can I come in for a second on that? Because I spent some time also going through the women's health plan and I can see why organisations felt as they did. Because it was only until you got to priority 8, and it's about section 8 of priority 8 that mentions gynaecological ones. And it didn't look like it was a priority when you think of your eight priority areas, which started with menstrual health, endometriosis, contraception, and actually the cancers come up in priority 8, in the well-being section. So, if everything is a priority, nothing is a priority, and, once it's not mentioned, I think you can see why that would lead to quite considerable concerns that, actually, our voices are still not being heard, because we haven't managed to get our message over that this is a real priority. So, you can see why they have come from that angle.

Yes, absolutely, but just to be very clear, it is not a priority in the women's health plan in that way. There are eight priorities, as you said, and gynaecological cancer is not one of the priorities in the women's health plan, and the reason for that is that it's in the cancer pathway and in the cancer improvement plan.

Now, having said that and having read through the evidence, and I thought that Target Ovarian Cancer highlighted this really well, what we've had over the last 18 months in particular—although it has been years in the making of an NHS plan designed by the NHS for the NHS; it's not a Welsh Government plan—is we have had a huge amount of visibility on women's health, a lot of it because of the work that was done by this committee. We've had the women's health plan being produced last year. We've had £3 million put towards it; we've had the research as well—so, a huge amount of visibility on the women's health plan. And I think then that what's happened, and I can understand this, is that, when you don't see the gynaecological cancer in there, it feels like maybe then we're not giving the same attention to gynaecological cancer. But, to be clear, I absolutely accept, and will be demonstrating that I have listened to, the evidence that has come from stakeholders and those with lived experience and this committee, but we could not move a cancer pathway and the accountability and deliverability of it solely into the women's health plan and the women's health strategy. That was not the purpose of it, and it's not also the right mechanism.

And to come back to, Sioned, your question about funding, for example, of course allocating funding can be a demonstration of a priority, but also within the NHS—and again I stress that this is being led by Dr Helen Munro and the national clinical strategic network for women's health, and of course then we have Sue Tranka here today, who is our Chief Nursing Officer for Wales, who oversees that deliverability for us, as Welsh Government, and that is the link there—it is also about ensuring that, in those senior rooms, for chief executives, for health boards, for everybody who plays a part in cancer and all health, women's health is a real priority.

So, that's why, for example, £3 million was initially allocated to the women's health plan. That's because—. That now has been distributed through each of the health boards applying, through phase 1 and phase 2, for that pot of money to see what they can do in terms of expanding women's health. So, it is about funding, but also it is about changing, honestly, the systems, the processes, the discussions, the accountability within the NHS as well. So, just to stress that we have taken on board the concerns that have been raised and that we will be doing something now, going forward, that will strengthen it in the newsletter, in the website that is due to come—we're having a women's health plan website that is coming through. And again, I hope, through our committee today now, we will demonstrate as well that, as I said at the beginning, it's not either/or. They are absolutely intertwined in women being heard and believed. But, in terms of diagnostics and the cancer pathway, that is through the gynaecological cancer pathway.

Okay. Lesley wants to come in, just briefly.

Just on that £3 million that you say has been allocated, are you monitoring how that's being spent, what the impact is, and when would we know for sure that that had had a significant impact?

Of course. If it's appropriate now, I'll bring in the chief nursing officer, who oversees all of this.

Thank you. So, yes, in response to your question, it is being overseen, and, of course, at £3 million, it's a significant amount of money being allocated to the NHS; it is necessary to have very strong and robust oversight mechanisms. That happens through the women's health oversight programme board, which I chair. It has been allocated proportionately for all health boards based on their phase 1 plans, exactly what they said they would be able to deliver. They have looked to streamline current services, remembering that the first three areas that they are delivering on and we are supporting them with are menstrual health and, within that, come things like endometriosis, adenomyosis, contraception and menopause. So, all of that—. They have already been delivering services; they have looked to streamline those services and then deliver an interface into the community through a community offer. So, the bids have been, I guess, approved on that basis.

Monitoring happens on a regular basis and we are overseeing their delivery. We intend for all of those—or they intend for all of their hubs, if you like—to be active from around January. So, we've brought the timelines forward because we recognise how important this issue is around women's health, and they've brought the timelines forward, so, from January, all the hubs will come online and they will be phased up until around 1 March.

Okay. Joyce.

That's all good news and I'm really pleased to hear it, and I understand and accept what you're saying, but what our evidence is saying to us here—and we probably were guilty of it in our report—is that we haven't looked at the diversity of the people we're serving, and it's a gaping hole, actually. So, I would like to know how the women's health plan is dealing with that, and also, within that diversity, how individuals access their healthcare, how health boards are sensitive to women's needs within that, and who they see, who treats them. So, that's one part of my question.

The other part, having read through this, is the lack, it seems, in emergency care and other procedures, of recognising women's pain in the same way that men's pain would be recognised, and it's writ large through this report and that really concerns me, and it concerns me when we're talking about invasive procedures, particularly. If women have a bad experience, they don't return, and we know, if they don't return, the cancer—if that is what it is—or any other symptom will progress, because it'll go undiagnosed. So, women's pain and diversity are key questions that I would like to hear your answers to.

I'll answer the first part, and Sue the next. In terms of the diversity, you'll see that, within the plan, we talk a lot about this and also that cultural competency, which is absolutely vital. I also met with the older people's commissioner just this week, and we were talking as well, and there's a section in there as well, of course, of living well and ageing well and this being a life-course approach. Some of these procedures are quite embarrassing, and it's also about encouraging women to come forward and never ever feeling as if they should ever be embarrassed, and always being able to speak openly and know that that's going to be listened to.

I also want to say that the plan makes it very clear that health boards must involve women and those with lived experience and learned experiences locally to implement the actions of the plan to improve women's healthcare. I also wanted to say then that, specifically around your question about pain, and hysteroscopy is the procedure that usually is raised when it comes to this, and I know that this has been raised many times in the Senedd by yourself, Joyce Watson, and Delyth Jewell has also asked me about this, so I went to Hywel Dda recently, and I met with the gynaecological clinical network and this was one of the topics that we discussed. They bring together then, of course, the clinical leads for gynaecological care across Wales, and they were talking about how they're going to, going forward, strengthen the advice around this, strengthen the support and the work that they're doing on that through the clinical leads in each of the health boards, which I think is really important. So, I'll bring in the chief nursing officer now, but it's very, very much at the forefront of our minds with this.

Thank you. So, I'll make three points. I think the first thing I'll say is, from a clinician perspective, the evidence around the lack of belief in women's voices and when women say they are in pain goes and extends far wider than gynaecological cancers or gynae issues. So, I think that's the first thing I want to put on record is that, even as far as it extends to cardiac and presentation for heart attacks, there is disbelief. So, there is widespread work that needs to be done with our population, but, equally, with our clinical cadre in terms of really listening and really spending time understanding what women are saying. So, that's the first point.

The second point I want to make is around diversity and involvement. This has been taken really seriously, hence it's made it very clearly into the women's health plan. We've got a number of areas that have increased women's involvement. So, I've been working with the health boards to look at what they're doing. Betsi, for example, has done a women's voices partnership—you'll see it's in one of your evidence packs as well—and they've brought the voices of women, particularly from our women who are Welsh speaking, who also get a raw deal, quite frankly, and I think that's not acceptable. So, actually they've really engaged our Welsh-speaking population. We've got Let's Talk Women's Health, I think, in Cwm Taf Morgannwg, and they have really sought to bring diverse views into the room. And then, lastly, the funding that the Cabinet Secretary referred to earlier from the women's health research centre—they have brought over 60 charities together, which are called the Women's Health Wales Coalition, and they work under a UK-wide umbrella. They have engaged patient representatives, but also the royal colleges, because bringing both voices and both groups together to really appreciate the views and the perspectives, I think, is where the learning really happens. So, there's quite a lot of work in terms of diversity. There's more to be done, of course, and we've got to do more in-reach and support the health boards to do more in-reach into the communities, I think that's right. But, from the women's health plan, there's been quite a lot of progress in that area.

And then, lastly, you asked how health boards are ensuring that women's voices are heard. Look, I think what needs to happen here is awareness, and Health Education Improvement Wales have already done a first programme on raising awareness, bringing GPs and secondary care doctors together and really helping them to understand what they need to listen for, what behaviours need to change, how to change culture when it comes to listening to women. HEIW and Public Health Wales have, as part of the women's health hub production, got a piece of work that they're doing to continue to bring clinicians, nurse practitioners and the public together to really share some of those stories and engage in awareness and, I suppose, how to really listen. It's a funny thing to say that you should teach clinicians how to really listen, but it does need to be reinforced, I think, periodically through their time in practice.

Thank you. Will that be monitored?

Yes, of course. The women's health plan is being monitored through the women's health network, and they are the ones that are overseeing the entirety of the plan. We are, on behalf of Ministers, overseeing the women's health hub development.

Thank you.

Okay, Joyce? Anything further, Joyce? 

Yes. It's just we're setting up the hubs, and, very often, and we keep hearing it, it's the GPs who are the first point of entry, and if they're not equipped to do their job, then the rest starts to fall apart. So, I'm really pleased to hear that you're engaging with GPs, or more importantly that they're engaging with you. Do we know that they are all engaging? We don't want to end up with a postcode lottery, where some GPs are really switched on and taking it seriously and others haven't engaged but they're still practising.

I think it would be fair to say at this point that we have a large number of GPs who are engaging. Whether they're all engaging will need further time for me to be able to make that assessment. I think the health boards have had some really innovative ways in which they're looking at engagement, one of which is through the cluster model, and that is where you bring all your GPs together. Others have sought to work through a specific clinical lead that they've appointed from primary care and general practice to engage the rest of their GPs.

I think this is a bit of a dosing strategy that we need to be able to support the women's health network and HEIW to undertake, as we start to work with GPs. Often, you will work with those who are interested, in the main, and then we'll bring the rest on board. So, I think this is a matter of time as we continue, for the next six months, to do as much inreach as we can out to the rest of the GPs.

The other thing I would say is that it's not only GPs, there are general practice nurses, as well, and our practice nurses play a very clear and key role within healthcare. We mustn't miss the opportunity to train them to also be able to support. They do a lot of the women's health consultations, but there's quite a niche piece of training and education that needs to go in there.

That's right. And if I could just add, as well, for example, HEIW have produced endometriosis training for primary care, which is making a huge difference and there's a great uptake of that, it's a massive step forward. We know that endometriosis is one of the conditions that women sometimes feel people don't really understand, and that can be extremely painful. Also, it's a lifelong condition and will need to be managed for the rest of their lives, and when they can receive that care in primary care or with a nurse, often, or whether they can go, then, into secondary care and that journey that they're going to be on. We also have some of the health boards that already have menopause champions in every GP, so we're absolutely making progress on this.

And also, just to say that, throughout this journey and being in this role for women's health, there are so many clinicians out there who are incredibly passionate about women's health. I think what we're trying to do and the network is trying to do and the chief nursing officer is trying to do is to really support them and to raise up their voices that they've already been trying to raise and push. Betsi is a good example of this. The service there was already pretty well established and this has now allowed those clinicians there to have even more oomph and that additional funding to boost and spread the good work that they're already doing. So, it's really important to get across that we have a lot of incredibly passionate clinicians out there for women's health.

Thank you.

Thank you. Can I bring Sioned in, please?

I believe this has come through the Target Ovarian Cancer contribution, the written evidence. It does ask here about a diagnostic test for cancer and whether that will be carried out in the women's health hubs. They've asked for clarity on this. Again, I will give absolute clarity today: that is not and never was the purpose of the women's health hubs, to do gynaecological cancer diagnostics. That has never been said, and that is not what the women's health hubs are there for. That is very much for the cancer pathway and diagnostics.

A good example of this is in Cwm Taf Morgannwg health board at the moment. They have a wonderful new gynaecological hub. They have three new additional rooms to do hysteroscopies. It's fantastic. That is not a women's health hub. CTM will also have a women's health hub that will provide these other services that you just mentioned. So, it was never for that. I think, actually, the evidence from Fair Treatment for the Women for Wales highlights this really well, where it says:

'It is our belief that the Women’s Health Plan was conceived to address health issues and clinical areas not being prioritised elsewhere within NHS strategy.'

Again, to reiterate, gynaecological cancers and all women's cancers are already being prioritised in other areas. So, just to be very clear on that. Also just to say, the health board cancer operational managers come together with a focus on gynae cancer pathways. Just next week, the national cancer leadership board is also discussing the next steps. So, again, I hope that today can provide some clarity of what the women's health hubs are for, based on what women asked for, and based on the NHS clinical network and what they are going to provide and lead on in their plan. But also then to highlight and to reinforce what is happening with gynaecological cancers, even though it is not part of the women's health plan.

Of course. But, again, just to reinforce, the women's health plan is based on 4,000 women telling us what they wanted to be their priorities. We have never said that the women's health hubs would take the place of already existing cancer pathway diagnostics. I agree with you, though, it is about access to information. We're going to be having the women's health website, for example. We're going to be doing an awful lot of training. We're going to make sure that there is a better link between primary and secondary care. But, fundamentally, it was about providing services that we didn't have, and ensuring, as time goes on—and this is a 10-year strategy—that we certainly don't have that postcode lottery.

I'll bring in again our chief nursing officer, who should be able to give some more insight into each of the women's health hubs that will be coming online shortly. But again, and I know that I've said this before in the Chamber, some may have them in a physical space, where it'll be everything in one place. But actually, what women are telling us is that they just want to be able to receive the treatment in the best accessible place for them. It might not be everything under one roof, but they will still fundamentally be able to receive those services within the health board, which they might not have been able to receive before.

Thank you. The point I think I will make is that, whilst the hubs have not been set up around the criteria particularly for gynaecological cancers, you can't extricate a woman presenting with symptoms from a gynaecological cancer, because they have to be treated and seen in terms of the presentation. For example, if you come to see somebody for menopause or post-menopausal symptoms and you are experiencing heavy bleeding, that has to be considered in terms of where do the diagnostics occur. My expectation, in the way the hubs are being constructed currently, is there will be access for that. 

There will be a diagnostic made on the day in terms of, ‘This patient requires to be referred to the rapid diagnostic centre’ or, ‘They should be referred back to their GP’ or, ‘Here is some information' that we can provide on the day so they can get timely access to the right level of expertise that is required. So there won't be, ‘Absolutely we will not see gynae cancers.’ They are interlinked in any event, but we won't be delivering the gynae cancers there. What I think we will do is, where CTM is presenting their hub, have ultrasound clinics, for example. If it's available, then a woman will be able to have an ultrasound on that day, and then be referred on to the right place to have the ongoing treatment. I think the hub must be seen as part of the right access to give the right information in order to get the right timely diagnosis. That's the first thing I wanted to just mention.

You ask about communication. Communication will be key for women in our populations for how they access this, because if they don't understand it, they will not use it, and if they don't use it, then you don't want a white elephant standing there. We want to be able to offer something to women that's meaningful for them. So communication will be key. Through the website and the women's health network, we will make this very clear. I'm looking at newsletters, as we talked about, how we send information out to GP practices to then be sent out to women.

I think in the future there is an opportunity for us to work through things like the NHS app, so that you can absolutely receive a notification that tells you where your hub is, and if you link into that, it should be able to link you back to the website so that you know exactly what information is there, what access is there, what support you can have. So I think communication will be key. It's part of the business cases that were presented. Of course, we wouldn't just ask them to develop a hub model without clear communication. Everyone has a comms strategy that will start going into place very shortly.

Do you want to come in on this? 

I'll leave the funding to you and I'll take the second question, if that's okay.

Of course. In terms of the funding, of course we've put in the £3 million initially so that we can do the pathfinder, and the £3 million has been set out to each of them. But yes, going forward, that will then have to be discussed with each of the health boards. But what I would say is that a lot of them, as I mentioned before, are already providing some of these services. A lot of the funding is going into training. If you look at each of the plans from each of the health boards, a lot of it is going into the education and training, so that's really the money to boost education and training that should continue.

I think one of the other points that I would make that is often mentioned to me as well is that these are services that the health boards should already be providing, and that's what really has come through. You know, women's health—the fact that we've had to wait, and we're in 2025 now, and that we're having to give this kind of funding boost, and they're having to give this attention to it, is just shocking in many ways, and it's not just in Wales.

But a lot of it is going into that training and education, and going forward I would expect health boards to want to continue to fund these services as well. But I also think a lot of it is going to be used to bolster what is already there. So, yes, that £3 million is that initial part of that, but as I said, there are other areas we're funding, like the research and what will come of that.

Okay, thanks for that. I'll come back to one quick question—

Sorry, Chair—

Oh, sorry. 

I was going to respond to your question on how will the hubs decrease the rates of cancer. I think initially we can expect just what we've seen in the last few years, the focus on gynaecological cancer made a priority by the Cabinet Secretary has seen an increase in referrals onto gynae cancer lists. And what we have seen—and Nick will give us the numbers because he has them—is that, actually, when referred in, huge numbers of those patients have been tested and luckily diagnosed as non-cancer, and they have a different set of symptoms that need to be managed elsewhere. So, that has been a huge increase.

I think what we will see is an increase in the numbers, hopefully, of non-cancer rates, such that we can then focus and get the diagnostics right from non-cancer, get patients onto the right pathways, so that the cancer pathway can really focus on the single suspected cancer pathway in terms of converting those into the 62-day target. So, I think that's where the focus needs to be, but I think we will see an increase in rates initially, up until the education and awareness are in a better place. 

Okay. We are halfway through our slot and we've got an awful lot to cover yet, so if I can ask if we can all be quite succinct. I want to just pick up one quick point here, just for clarity. We know the cancer improvement plan is due to end in 2026, and the cancer recovery programme is only scheduled to run for two years. So, what plans are in place to ensure there is a long-term strategic focus on gynaecological cancers? 

To make the obvious point, Chair, that will, in a sense, be for a Government formed in the new Senedd to decide on plans beyond that. But, clearly, the focus that we are bringing to gynaecological cancer is one that we would want to see continue, and we've had a discussion today about the women's health plan's contribution to that, which is one part of it, and that is a 10-year plan. Each of those of us competing in the election will be bringing forward plans for the future, but, certainly, the focus we have as a Government is in continuing to drive those plans forward.

Right, that's helpful. Thank you. I'll move on to James.

Thank you. Good morning, Cabinet Secretary and Minister. I want to ask about waiting list times, if that's possible, because as the chief nursing officer said, gynaecological cancers were made a priority by the Government in 2023, and what we're seeing is that the waiting times for gynaecological cancers are the worst of any type of cancer. I think that for the last target in July, the average was 32.4 per cent across all health boards, with Swansea being the worst at 14.3 per cent, and Aneurin Bevan being the best at 47.5 per cent. That's well below the target that is currently set of 70 per cent. The Cabinet Secretary said we'd like to get that up to 80 per cent, the target, in time. I'm just wondering what initiatives you're doing to actually improve those waiting lists across Wales, because they are stubborn at the minute, they're not getting better, and these are people's lives that we're putting at risk here. So, I would like to know what the Government is doing around that.

I'm grateful to you, firstly, for acknowledging that it has been a priority since 2023, which is the case. It is absolutely nowhere near the level of performance that I or any of us want to see. That's the first thing to be absolutely clear about. It isn't, in fact, the worst performing, but that's very little comfort, given the overall picture.

I think when the committee reported, coming up to two years ago, it was at about 27 per cent, which was very, very, very poor. I think if you look at the average—and there is variability month on month, as is the case in a number of areas, but particularly for various reasons in the context of gynaecological cancer—if you look at the last 12 months, I think the broad average is about 40 per cent, but the figures that you've given for July, I think, are the ones—. I accept those figures. What we've seen over that 18-month, two-year period, depending on which time point you take, is, let's say, a 10-point improvement. Just to say that we will all be frustrated by that, but in any organisation as large and complex as the NHS, getting a 10-point improvement in the course of a 12-month period is quite a big undertaking in itself. I want to be clear: it is absolutely not sufficient, but I think it is important to provide some of that context.

What are we doing about it? There's a twin-track approach, I guess. On the one hand, it's about holding health boards to account for the plans that they have agreed and the targets that are set for them as a national target—the one you just mentioned. But there will be specific targets and plans that each health board have, reflecting their particular circumstances and needs, and it's holding them to account for that.

The second aspect is reforming how services are delivered, so, a national change programme. So, some of that is led by the—. Well, all of it, is led by the national cancer leadership board, but there are different elements within that—I won't go back to the conversation we were having some months ago—that have all now been streamlined into one programme of work, and gynaecological cancer sits within that. So, some of the things we've been able to do through that mechanism are around working with health boards on local demand modelling; capacity planning; the digital and data developments, which the committee and others have shown an interest in; changing how clinics are delivered; training programmes, including the HEIW training programme; the rapid diagnostic centre and the national ovarian cancer audit. So, there is a range of things that that mechanism has brought forward.

The fundamental challenge—and the chief nursing officer alluded to it earlier—is that we are seeing an increase in referrals—that is a good thing—and we are seeing more women being told that they don't have cancer—that's also a good thing—but it does mean there's a very significant level of demand on the system, and the system doesn't have the capacity to be able to manage that demand in a way that meets that target. That's, I guess, obvious, but that's what we are doing about it.

Okay. You did mention holding health boards to account, and I'd like to dig into that a bit more, if that's possible. Because they set plans, they get sent to you as the Cabinet Secretary, and NHS Wales, and they all get approved that way. But if health boards—and they're obviously not—aren't delivering on those plans, what mechanism—? I know that the First Minister, when she was health Minister, did an accountability review of how Welsh Government can hold health boards more to account. If these health boards are not improving, and they're not sticking to their plans—and, as Cabinet Secretary, you do have powers in terms of resourcing certain cancer pathways and the programmes—I'm just interested in how you are directly holding them to account and holding their feet to the fire, if they're not improving. Because we can all say that we're not happy with where they are, but if there's actually no accountability for them to do it, then I'm afraid to say that some of these inquiries are worthless, aren't they?

Well, I absolutely would not say they're worthless, Chair. So, what can be done about it? I've just described some of the architecture, if you like, of how we hold health boards to account. On cancer specifically, there is, on top of all of that that I've just described, a separate set of cancer accountability arrangements, effectively, to feed into the work of the national leadership board, and there are other aspects as well. I've mentioned some of the interventions that we have in place. You will know that many health boards are in escalation specifically because of their cancer performance, and that enables that more intensive support and scrutiny to be in place. Ultimately, health boards—and the Government, but health boards—need to manage a set of demands that are, in the context of this inquiry, relevant to gynaecological cancer, but also to other cancers, and also to non-cancers as well. So, there is a level of demand in the system that is very significant.

I don't want to go back to the conversation we were just having, Chair, but that actually is part of the reason why maintaining the focus on gynaecological cancer within the existing work of the leadership board is so important, because it's the same diagnostic resource that's being drawn upon, it's the same out-patient capacity that's being drawn upon. So, seeing that together as part of our improvement programme is absolutely critical. I can go on and talk about what that means in terms of the year ahead, if you like, but that's why it's so important.

I could go on, but in the interests of time, I think I'll let others bring in some of the other issues that they have to bring in. So, thank you very much for that, Cabinet Secretary. That's fine.

Okay. Can I bring in Lesley, please?

Thanks very much. I'll look at prevention and screening. We all accept that it's a very effective form of care, and you said in your letter yesterday how effective you think it is. We're not reaching the target that's been set by the World Health Organization of 90 per cent for human papillomavirus vaccination targets. I think it's currently in the mid-70s now for 15-year-olds, which I don't think is acceptable. Public Health Wales are obviously the main organisation that are responsible for ensuring that people are aware of what is available, et cetera. I think we all actually have a role in that as well. Could you say a bit more about your discussions with Public Health Wales, how you hold them to account, whether you think they are showing effective leadership, whether there are enough awareness campaigns?

Yes. So, the target that you mentioned for 90 per cent is for HPV vaccinations in girls specifically, which is running at about 77 per cent. There isn't actually a target for boys, but the average between boys and girls is 74 per cent, as you say. So, that has shown an improvement, but obviously it needs to go further—I think that would go without saying, in the context of this discussion. Just to say, coverage for the World Health Organization target for cervical screening is 68 per cent, against their target of 70 per cent, so that's almost at the point where we need it to be. So that, I think, is heading more quickly in the right direction.

So, there is a screening engagement team at Public Health Wales. They obviously are focused on working in local communities, and there's an equity lead in those teams—going back to the point that Joyce was making earlier about being cognisant of the range of people that you're trying to reach. So, for HPV specifically, there are some targeted initiatives, working with particular GP practices where we are able to see that the levels of provision aren't where we would want them to be. So, there is specific work in relation to individual GP practices, and also identifying schools serving low-income communities, and particular focus on supporting those schools. So, over the summer, there's been an extra 1,400 vaccinations given to increase the level of coverage. So, there are programmes happening generally, which is about general awareness, general access to screening, and then a specific set of interventions around groups that have historically been less likely to take up the opportunity.

On self-sampling, the plan is to roll it out right across the UK next year, so two specific questions around that. Have you looked at best practice in, I think, the Scandinavian countries, where we can certainly learn a lot from? Have you looked at the uptake there and how successful it is? And also, what work is being done with health boards to make sure they're ready for the roll-out next year, and how are resources being allocated to it from, presumably, the traditional way of undertaking it?

So, there's a piece of work that PHW are leading on, which is to explore the best model for delivering HPV self-sampling. I don't know the answer to your point about having checked what's happening in Scandinavia; maybe Sue could help us with that.

Obviously, what we want to do is drive coverage above the 70 per cent target. So, it is still the plan for that to be rolled out in Wales next year. I think it's also the same time frame in England. We are on track at the moment, but that work about developing the model, and then the resource points that you just made will flow from that, is currently under way, but is on track.

Thank you. In response to your question, 'Have they looked at the best possible evidence?', yes, that is the starting point always when we look to undertake any type of new initiative. So, they have. Whether it's going to be the Scandinavian model, I'm not entirely certain, but it will be the best available practice that will come together to formulate the plan.

The second thing I would say around the cervical self-sampling is that I have asked the women's health research centre—it's a mouthful; apologies—to look at some research with regards to screening and vaccination uptake for women as well, and for girls particularly. So, back to your earlier point on HPV, I think there's so much more that can be done. So, they will be doing and undertaking some research with communities currently, particularly with our underserved communities, to ensure that we can get vaccine uptake up, because this is not just a matter for—. Whilst we're talking about gynaecological cancers today, it's not just a matter for women, but the entirety of our population, particularly underserved populations who have a real disbelief in vaccination efficacy. Some further work needs to be undertaken and I think the findings out of the health research centre can really help to translate across wider populations.

Looking at the recommendations from this committee—recommendation 11 and recommendation 12, which is around prevention and screening—and you mentioned in your correspondence, I think it was in the summer, that there had been no progress made on either of those recommendations. Perhaps you could say a bit more why there hasn't been that progress. And I'm particularly interested, I mentioned that while Public Health Wales take the lead on this, I think we all have a role, but I think there are lots of organisations that could help us reach the target. You only have to look at the flu jab uptake to see that we need to be far more proactive, I think, in making sure people are aware of what's available. So, perhaps you could say why there's been no progress made, what the timeline is and what sort of organisations you think could be brought in to help us with this?

So, on recommendation 11, which is around the provision of information, effectively—since I wrote to you in July, Chair, there has been progress in relation to that recommendation. So, Public Health Wales have issued new literature, which has updated information, and has also updated its website, so there has been some move forward there. 

On recommendation 12, which is around awareness raising for symptoms, we accepted that in part when the report came out, Chair, as you will recall, because, partly, it's about resource implications, and, you know, we still haven't been able to identify the resources to do that. I should say as well, which I think is probably counterintuitive for those of us who aren't clinical experts, that my understand is that the evidence on the efficacy of symptom-led awareness raising is not strong in terms of the correlation with better cancer outcomes. And I think that's probably—. I'm not a clinician, obviously, but I think that's perhaps understandable, given the range of potential symptoms. And the referral guidance—you know, just even a quick glance at that, shows just how complex some of the symptoms can be, obviously. So, there's been less progress on that because we're deploying the resources into the areas that we know, from the evidence, will make the biggest difference, and there isn't, at this point in time, additional resource to make that available.

But, as you say, though, I think it is really important to work with organisations who are trusted, because, at the end of the day, despite the points I've just made, which I believe to be true, the key issue is that if you notice something concerning or worrying, you should go and see your GP. And it's that kind of giving people that reminder that is important and is part of that, isn't it?

If we look at emergency care now, and you'll be aware, particularly from the evidence that we heard from Claire's Campaign, that far too many gynaecological cancers are only diagnosed when people present at the accident and emergency department. I think it was 41 per cent. You've maintained, I think, that you're not going to review individual emergency cases to understand why patients do present in A&E. Could you explain a bit more why you've taken that approach?

Yes. So, people present in emergency departments for a number of reasons. Perhaps they haven't experienced symptoms, perhaps the symptoms were not evident to them until some other concern or condition had become severe. I think there are a sort of range of reasons that I think we understand to be why people may present at emergency departments in some cases of cancer. The fundamental question is: what can we do to make sure that people have access to services at an earlier point so that people don't end up having to come into the emergency department?

So, if one accepts the premise—. And that seems to me to be what we should be doing: improving access, the point we just made about symptoms, but also making it easier to see your GP, for the GP to refer, either onto a pathway or to a rapid diagnostic centre—you know, opening up the range of referral options, providing better learning and skilling GPs better to understand how best to make the referrals they need to make. That I think is where the focus of effort needs to be—access to diagnostics. I have not been able to justify what I would have to be able to do, which is to move focus and effort from that part of the programme into a case note review, which is obviously, understandably, a significant undertaking, unless there was a sense that that would give us a fundamentally different understanding of why people were presenting there. And I think it's because of the reasons I gave earlier. So, that's fundamentally why—it's a choice of where you allocate focus and resource. And I think changing the access that women have to the system is what we need to be doing.

I mentioned that Claire's Campaign told us that 41 per cent of women present. Would you agree with that figure? Do you hold data on that figure?

I don't recognise that myself, but—.

No, I don't recognise that figure either, unless Nick can.

I don't recognise the figure. There's clear evidence that women present at late stage, and that will be through emergency departments, but there's little numerical evidence to support the 41 per cent that we can see from the current data.

So, do you hold any data that could—? You just said you don't recognise that figure.

We hold data of where a patient has first presented, and therefore where they are referred on to the single cancer pathway. I suppose we could, in effect, extract from that whether that was an ED presentation. Unfortunately, I think what the evidence may show is that they will have first been referred for an outpatient appointment and will have been waiting for an outpatient appointment. Symptoms could have got worse. They've then presented at an emergency department, maybe for something different or maybe for the same reason. But the data would then show that their first presentation was at a GP or outpatient stage. So, again, as the Cabinet Secretary has alluded to, you’d have to go through a huge case note review to absolutely access, with accuracy, where their first presentation was.

I think that's quite difficult, then, that we've had that figure of 41 per cent, which you're saying you don't recognise, but you can't give us any further information.

No.

Okay. Just finally, then, from me, you will be aware that Fair Treatment for the Women of Wales thought it would be good to have a dedicated 24/7 emergency gynaecological unit. I guess, both financial resources and human resources—maybe you wouldn't have the staff to do that. But is that something that you have considered?

Well, EDs have access to acute oncology services, as they do to a range of other acute services. That's the model that enables us to make sure that people presenting have the widest range of access to the widest range of acute specialties. And that is currently available to each emergency department—access to that suite of services. And the quality statement that we published in 2021, I think, or 2022—

Twenty-two.

Thank you. That sets out our expectation in terms of what ED departments are able to provide in relation to this.

Okay, thank you.

Could I just ask—?

Joyce, please. We'll come on to you, James.

[Inaudible.]—and Lesley has asked about the HPV vaccination targets, and you've answered those questions, but we don't exist in a vacuum. At the moment, there's an anti-vax movement out there, and I just thought it was right to recognise that while we're talking about vaccines that are actually saving people's lives. We're hoping to eradicate cervical cancer in the same way that smallpox was eradicated, and therefore eradicating what would be a really painful, unnecessary situation, but critically life-threatening, life-shortening. So, having said all of that, how are we going to ensure that people aren't put off vaccination at a time when other people are, in my view, being self-serving and sending out misinformation?

Since I think clinical voices are more authoritative than political voices in this, I will ask Sue to answer that for me.

Thank you, Cabinet Secretary. So, yes, Joyce, it has been recognised that the movement on anti-vax is growing, and it's growing in and around places you wouldn't normally expect, even as far as influencing the clinical voice, you'll be shocked to hear. We have been working with Public Health Wales, and I've asked them to undertake a behavioural-science piece of work around HPV vaccines particularly, but across all other vaccines and utilising behavioural science to work with the population and understand how we can put some messages out. I think there's something about reiterating facts and utilising voices of authority, particularly in the clinical space, not necessarily a Cabinet Secretary—apologies—but I think, in the clinical space, to really help the population understand the trusted voices. And I'll just remind you of the Ipsos MORI survey that says that nurses are some of the most trusted clinicians that come up on top in the survey year after year. So, I think it's using those right voices to share facts, to listen, to understand and to dispel the myths. There is a lot of work that's going on through Public Health Wales, and through myself, and the chief medical officer, who are also both fronting up the flu vaccine campaign this year. So, I think this will have to be a concerted effort on all our parts, and I foresee this being a medium-term piece of work. I don't think this is going away any time soon.

Thank you. 

James. 

Just really quickly on the comment that Nick made about referrals from emergency departments to outpatient appointments—so that should take two weeks; that's what they say it should be. I'm just wondering, does Welsh Government hold data on whether that two-week target is actually being met? It used to be reported on, but then it was taken out. But I just wonder whether Welsh Government hold that centrally, because that would actually tell us a great deal about whether people who are presenting at A&E departments are being seen in a timely manner for that first outpatient appointment.

So, the data that we've got from the front end of the pathway is that 44 per cent of gynaecology referrals, excluding post-menopausal bleeding clinics, are within the two weeks. The range is about two to three weeks on the referrals currently.

So, the figure is 40 per cent—

Forty-four per cent.

That's still very low, isn't it, considering cancer—

Yes. The median number of days is 15, currently. So, it's a 14-day target, as you say. It features as part of the 62-day pathway, the two-week wait, as it's referred to in England. The median is currently 15. We've obviously got some variation, but the average within two weeks is 44 per cent, currently. 

That's still a lot lower than where it should be. But, yes, Chair, that's fine.

Okay. Thanks for that. John.

Diolch, Cadeirydd. Bore da, pawb. Some questions from me on general practice and rapid diagnostic centres. Firstly, on the rapid diagnostic centres, the evaluation shows a cancer conversion rate of 6.9 per cent. Is that considered to be clinically effective and how does it compare with other diagnostic pathways?

I actually don't—

I don't know that. 

I don't know, Chair, I'm afraid. I don't have that information. Do you happen to know?

I don't. I think you might be—. Are you referring to the report that was produced on the rapid diagnostic clinics?

Yes. 

That goes back to the conversation that we had earlier that I was referring to Nick around the numbers that are referred in. So, from the denominator, all the women that are referred in for diagnostics—. I don't know, but Nick will give me the number—it's in the thousands, isn't it, Nick?

Yes.

The conversion to that is—. I think one in 20, I think, convert into a—

Between 5 per cent and 6 per cent.

That's right. 

All right. 

So, what that is essentially telling us is that the diagnostic capacity for managing and giving you a substantive diagnosis is being taken up by—. And that's a good thing, because they are working through a number of women who they're diagnosing and they don't have cancer. That's a positive thing, but it does take up the capacity, because only one in 20 diagnosed is a good thing, but it's a small number.

And that's diagnostics generally, not just the rapid diagnostic centres. 

Yes. 

And just for clarity on the figures, in the last month, there were just shy of 2,000 women who were referred to a cancer diagnostic for gynae cancer, on the gynae cancer pathway, and 1,886 were told they didn't have cancer post diagnostic. So, it was 102 or so that went through for treatment, which is around 5 per cent to 6 per cent of the total referrals. And that's fairly common across the broad range of cancers. So, it's usually in the region of 5 per cent to 6 per cent, I suppose, that you would call a 'negative outcome' from the diagnostic, which is that they've got cancer.

Yes, okay. With those rapid diagnostic centres, what's the strength of the Welsh Government's commitment to them? For example, with funding for them, should that be in health boards' core budgets, if we're going to have sustainability around that particular model and, indeed, possible expansion?

The centres are well liked, they're popular with staff and with patients, and their principal benefit, I think, is in providing faster access to diagnostics for those whose symptoms don't otherwise meet the criteria for referral. So, where a GP has seen a patient and their symptoms don't match up to one of the referral criteria but there is a suspicion that cancer may be the cause, then that's the best use of the capacity in the rapid diagnostic centre. So, it's more to do with that speed of diagnosis than it is about catching cancer sooner, if I can put it like that, which has a range of other factors that go with it. But across the range of things that we ask health boards to do, which is the thrust of your question, there is a huge amount of activity in relation to improving cancer pathways, and obviously we touched on some of things earlier, and what we want to see over time is that becoming, obviously, the core means of delivery on the part of the health board. So, what we're trying to do is move away from a model, bluntly, where there is a pot of money for a new innovation—obviously that is required to establish something—but then over time that needs to become the new operating model for the NHS. So, these centres would be in that mix. 

So, it's up to the health boards, really, to consider whether they think a new initiative is effective and, if so, it gets mainstreamed and sustained?

Yes. It's not entirely a matter for health boards, sometimes we direct action in this space, and we have done that across a number of areas, but it's a mix of the two, really. 

Okay. The community diagnostic hubs—are you content that they work effectively with the rapid diagnostic centres? Is there a danger of duplication? How can you ensure that they work together as best they can, and are there particular issues in rural areas?

Yes, I think that there are a whole range and level of diagnostic tests that can be done. I think it's important that the rapid diagnostic centres, community diagnostic hubs, move into, if you like, free-standing big equipment diagnostic centres as we develop those over time, all interlinked together to provide that range of diagnostic services that we need within the system. The Government has allocated significant capital funding to new equipment, imaging equipment et cetera, to build the capacity that we've got in diagnostics, because it is probably one of the biggest challenges that we've got in delivering both access to cancer services and diagnosis, but more broadly on diagnostics across a huge range of services. So, I think it's imperative that we link them all up and utilise them, as you say, to enable better access in hard-to-reach communities, in communities that are more rural, but recognise that, in some elements, there will be a requirement to travel and there will be a requirement to send people to certain places for more specialist diagnostic testing. But what can be done locally needs to be done locally and done rapidly and quickly, which is the aim, really, of where the diagnostic plan currently is.

Okay. 

James, did you want to come in?

Yes, really quickly. On the RDCs—I'm a big believer in RDCs, I think they're great—how many GPs across the country are actually referring into them as a proper patient pathway, because most GPs could be, perhaps, stuck in the old model and refer on to secondary care in a different way? So, I'm just interested, perhaps on the executive level, how many GPs are actually referring into those RDCs to make sure that we are getting people diagnosed quicker, especially in rural areas? Where I represent, in Powys, we don't have a rapid diagnostic centre, so I can imagine the referrals into them might not be as good as in other areas. So, I'm just interested in what the uptake is of them across the country, really.

I don't have the data at hand, but we're very happy, if we do have it, to send it. I think the RDC report does have some data within it. I think that what we've seen is a huge number of referrals to the RDCs from GPs, remembering that the RDC pathway, to be referred there, is for non-specific symptoms. So, as the Cabinet Secretary said earlier, they're not a really clear set of symptoms that say, 'This is where you need to be, this is what we think, we're highly suspecting cancer, therefore go down the single cancer pathway', and they refer into a different mechanism. But the RDCs have seen quite a lot of referrals to date; I don't have the data, unfortunately.

The last thing I'll say for Powys: you don't have your own, but you do have access up to the north and into the south as well, and that has also seen a fair number. But I suspect—. I'm not sure, has the committee received the RDC report at all? We can send the data, can't we? We can certainly share the data with you.

I think it would be useful, especially the rural areas that other people represent as well, to make sure that they are being used as a patient pathway, because if GPs haven't got one in their own health board area, especially where I represent, they might not be using them as much as they should be.

Of course.

Thank you, James. I'll bring you back, John. We're running out of time. No, you're all right, John.

Okay, Cadeirydd. Sticking with GPs and GP training, on GatewayC, I just wonder if you could clarify, in terms of its implementation review, whether that will assess its impact on how GPs respond to women's health concerns. Is that tool influencing GP decision-making and ensuring that women's concerns are properly addressed?

Just before I respond, Chair, the letter that you had yesterday does include the evaluation of the RDCs. Some colleagues won't have had a chance to read it yet, obviously, but hopefully some of the answers to the specific questions will be in that, which we provided yesterday.

I think the evaluation of GatewayC, which is also included in the letter that came—. I think I'd distinguish, John, between does it change how GPs relate to women's health concerns and women's lived experience as they present on the one hand and clinical decision making on the other. Obviously, there's a connection between the two, but what we do have is evidence that the GatewayC tool is changing the clinical decisions. We don't have evidence—I think it's harder to gauge—that it's changing that broad approach towards ensuring that women's health concerns are appropriately addressed in a general sense. But what we do know is a quarter of the GPs that have been surveyed as part of the evaluation were saying they are referring more people as a result of the tool, which suggests they are better informed about what they ought to be doing.

That is positive. I think we can be confident that what it is doing is increasing knowledge, increasing capability in cancer referral amongst GPs. We've talked a number of times today about the one in 20. What that says is that there is an increase in referral and that people are being referred at the point of suspicion, rather than—. So that, I suppose—. I'm not being very articulate here. We would be concerned if that was a very high number, because that would suggest that the threshold for referral was high, whereas actually, because the number is comparatively low—. Obviously it's awful if you're in that group of people, but because that number is comparatively lower, that suggests a greater readiness, an increasing readiness, to refer, which is obviously positive.

Okay, thanks very much. One final question from me is on the new GP guidance in England, Jess's rule—I am sure you're very familiar with that. Have you given much consideration yet as to whether that could usefully be adopted in Wales in terms of early diagnosis, that concern that so many women have that they're going back and forth to the GP with the same symptoms but they're not being appropriately referred? Is it something you'd like to adopt here in Wales?

We will want to consider what could be learnt from that sort of guidance. Obviously, the referral guidance is already in place and I would expect that to be complied with from the first presentation, let alone the third, and there already arrangements in there around what I think is called safety netting, which is about patients identifying any change in their symptoms and coming back. So, that's already part of the guidance that we have. There isn't a specific equivalent to Jess's law, but we will see if that can be a useful addition to the existing guidance.

Okay, diolch yn fawr.

Thank you, John. Thank you for bearing with us. We've got a couple more questions. We might not get them all in. I'd just like to go back to a couple on waiting times—they're quite key for us at the moment—if you don't mind. You accepted our recommendation to publish regular disaggregated data on gynaecological cancers, yet current reporting only includes general waiting times. Given that those delays vary by cancer type, will you progress that recommendation and commit to publishing waiting time data broken down by gynaecological cancer subtype so that the longest delays can be identified and targeted more effectively?

The answer is 'yes'. This is one of the things that the cancer leadership board has been leading on. The data definitions for the subtypes have been agreed with health boards, and we expect it'll be possible by the end of this financial year to be able to start to report that publicly.

That's helpful. Thank you. Joyce.

And in terms of the disaggregated data, it could—and I hope it won't—show up a hotspot where people are waiting longer, and then that allows you to look behind that, whether you need more training, if there's a particular type of cancer, whatever that might be, that's being missed, and also to help do what we're all trying to do, and that's to make sure that everybody is informed, including the patients.

Yes, exactly.

Another point from me quickly. Recognising all of the data you've had, could you identify what you think the main driver is for the delays in gynaecological cancer care and treatment? What would you think the biggest issue is there?

I think at a macro level, it's the fact that there is an increasing level of referral into the system and there are capacity constraints, because, of course, as I touched on very briefly earlier, Chair, from a diagnostic capacity point of view, from an out-patient capacity point of view, gynaecological cancers, all cancers, are drawing on the same capacity and resource. What I would say is that those on a suspected cancer pathway are given priority, even amongst other urgent and certainly other routine waits for diagnostics in particular. I think there is a particular feature with some gynaecological cancers, as I understand it, of a particular complexity in terms of presentation, and therefore that also means it's a more complex pathway. But that's the basic reason.

Okay. Have you got time for one more question? I'll push my limits a bit. Just for clarity too, in your letter yesterday, you suggested that GatewayC was recognised in it, but the reports that you said were appended didn't come. They weren't with it, just for information on that. That would be useful. 

Just a quick last question on palliative care, if I can. We did have a couple, but if you could bear with me on one. I wonder if you could provide evidence that the Welsh Government's commitments under recommendations 25 and 26 originally are being implemented in practice, specifically whether GPs and acute clinicians are changing their approach to palliative care and whether patients are experiencing earlier access to these services now.

Our commitment remains the same. I'm not sure we have evidence of those things bearing fruit on the ground yet, but this week, Chair, I started the week with the national palliative and end-of-life care team launching the new service specification, which sets out a new standard around access and early access to palliative care, but also out-of-hours provision, specialist provision, so that's now launched and required to be complied with. In addition to that, there's a piece of work that HEIW had been leading on, I think we're calling it a competence framework, which is around how we can skill clinicians to understand where earlier access to palliative services may be appropriate. So, those have launched this week, they're required to be delivered, and so I expect that we'll see that improve. There will be a monitoring arrangement, and I will be publishing data about compliance with it when we have it.

Sarah.

I just wanted to add something before we finish today, if that's okay, but on a separate issue.

I think we've just about finished the questions now and I was going to draw the session to a close. Please, Sarah.

Thank you very much. I just wanted to come back to some of the questions at the beginning about the women's health plan and gynaecological cancer and strengthening the focus within it. This has been something that has come through a lot in the stakeholder questions and from Members here today.

So, just to reiterate that I have absolutely listened and I absolutely accept that we need to strengthen it within the women's health plan. One of the things that we are going to be looking at, as I mentioned, is the biannual women's newsletter, which will mention gynaecological cancer and goes out wide across the NHS. We will also have it on the women's health website, which, again, is about raising awareness for women. Also, there will be an annual report for the women's health plan and that will focus on the progress that's being made to deliver the women's health strategy, but we will also be able to make that reference of how we are integrating the gynaecological cancer work that is happening already.

I just wanted to say, as well, that what this committee highlighted was that we know that there are absolutely inequalities in women's health; they are long-standing, they are historical and they are across society. We are absolutely committed, as a Welsh Government, to addressing those. Wherever a woman presents, wherever they are receiving any kind of care, we want them, as has been said by everybody today, to be heard and to be believed, to be taken seriously and then to be referred as quickly as possible to the right care, the right diagnostics and the right treatment. That is what we are doing with the women's health plan and then that is what we are doing with the focus on gynaecological cancer.

Thank you for that, Minister. That was really reassuring to wind up this session. Can I thank you so much for giving us the time to what I think we all agree was a really important inquiry and follow-up inquiry? So, thank you for your time. There will be a transcript available, as always, for you to go over if you wanted to check the record and make any changes. Can I thank you once again for your time?

Okay, Members, item 3 is a motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting. Is everybody in support of that? Yes, they are. Okay, thank you.