Cynulliad Cenedlaethol Cymru

Thank you, Chair. Morning, both. How are you—all right? Can you both perhaps give us an outline of  how the current configuration of community services in Wales has developed and, in particular, whether there is variation across health boards? So, how's it going, how's it developing and what are the variations, really?

Well, just generally to start, I think that community nursing, historically in the NHS, has played, and continues to play, an incredibly significant part, because it's caring for vulnerable people who are housebound—who are actually at home—so it's care delivered at home. Traditionally, community nursing has been a bit of a linchpin between—. It's been the original type of integration between health and social care, because the role of that district nurse has always been very much to pull those other services in for that vulnerable group. However, in recent years, we've seen a number of quite significant policy shifts: so, the primary care strategy, for example; increased emphasis on integration and increased emphasis on care at home—all of which and the general direction of which travel we support as the Royal College of Nursing, and our feeling, therefore, is that community nursing has almost got a little left behind in terms of the strategic thinking.

So, we do see a number of incredibly important initiatives and pilots and different types of service models across Wales, the most recent of which being the Buurtzorg model. All of those are to be welcomed, but what we feel is that what's lacking is a national strategy, if you like, of how these services should be fitting into that wider picture. So, we would say that there is tremendous variation in the way that services are deployed across Wales and we would prefer to see a more strategic approach to how those services are delivered.

One of the things that I would like to emphasise here this morning is that district nurses exist to help people within their own homes. Lisa's already alluded to that, but the nature of what people require from those district nurses within their own homes is extremely complex. It is becoming more and more complex, and that’s due to a huge variety of factors. It’s due to earlier discharge from hospital; it’s due to keeping people at home to avoid unnecessary hospital admissions; it’s to do with comorbidities, multiple conditions that that person might hold. It’s to do with more than that, though—the effect of the biological, psychological and sociological effects on somebody’s life. To that extent, a person in their own home requires a lot more than is currently, I think, perceived as being needed from a district nursing service. And the district nurses are masters of meeting those needs.

I can give you a case study that helps to illustrate, because I’m not sure how familiar you are with district nursing. I work at the Royal College of Nursing as a primary care adviser, and I’m lucky, occasionally, to go out into the field with district nurses. And, on one occasion—and I don’t ask anybody to do anything special, so this was just a matter of daily work for the person who I was spending the morning with—we arrived at somebody’s home. The referral to that person—and we could come back later on to looking at what outcomes district nurses are hoping to achieve and the way they do receive their referrals—the referral was made to go and visit a lady who had been in hospital and needed her operation wound to be looked at, that sort of thing, to make sure that she was safe at home. And that lady was living in a house that didn’t belong to her; she was living with a member of the family, because her own home was being renovated by the council. She was living in—. It was all very open plan, and she was living in a sort of curtained off area, with a double bed, that you had to pass through to get to the kitchen. It was a very chaotic sort of home circumstance. And, actually, her wound was absolutely fine, but it was very clear that this lady had had surgery that hadn’t been very successful and that, actually, the course of her life might be very changed as a result of it. That wasn’t anything that was previously known about, but she sort of alluded to that.

She also said that she had been spending a lot of time in bed, because, actually, her feet were very swollen. She couldn’t get her slippers on, and so, she was avoiding mobilising for that reason. So, there were clearly some concerns there for her risk of falling, but also the reasons as to why this was happening to her.

She also explained to the district nurse that her mouth was very sore. And, actually, when we looked inside her mouth, it was clear that there were some problems there. She also had been given some information about the sort of food that she should be eating, but she hadn’t quite remembered what that should be. She wasn’t quite sure what it was all about. So, between walking in through that front door and leaving, that district nurse was confronted with things that were to do with that person’s physical, social, but also psychological well-being. Totally unexpected, and, actually, the time allowed for that call was very, very short, as has happened over the years, because district nursing has become very much managed by a task-to-time method.

Those are some of the messages that I would just like to sort of convey, so that we have an understanding of what people in their own homes are being supported to achieve for themselves.

So, service configuration, I think, is something that we could look at from a very strategic point of view, but the bottom of it all is people living within their own homes, supported by their families and their communities. And the broad policy is to help people to regain their independence, and to work to support themselves independently. But, actually, that requires such a set of skills from the person who is working with that person and their family that that needs to be borne into the whole equation.

Yes. And we will probably be exploring a little bit later on the Buurtzorg system that you talked about, the pilot that's going on there, because I think that's starting to address some of those issues, particularly around time spent with the patient at home. So, perhaps we'll come back to that bit later. So, thanks for that.

I just wanted to explore a little bit with you the role of the district nurse and how that is distinctly different from other senior community nursing roles. Because we've heard that the Health Education and Improvement Wales paper is saying that you don't necessarily have to have a district nurse leading the team, that there could be other professionals that do that. What are your thoughts and views on that?

To start with, we have to go back to what the whole purpose of having that qualification and that title is. Really, its essence is about reassuring the public or reassuring an employer about the level of seniority, the level of skills, experience or knowledge that you can expect someone to have. So, I think we would approach that from a very practical perspective of, if there are different routes to that level, one of the things we need is better information from the Welsh Government about who has what, and maybe also we need to ask the question of why we need several, actually. If it's equivalent, it's equivalent. The RCN is working at UK level with the Queen's Nursing Institute to look at the district nursing specialist practicing qualification. We're aware that the Nursing and Midwifery Council apparently is planning to also look at it. So, we hope to arrive at a situation where perhaps there's a clearer standard—'standard' is the wrong word, because there is a clear standard, excuse me—where there is a clearer single qualification, shall we say, for what we would expect someone to be able to do at a senior level.

And that would be distinctly in terms of leading the team, or just in district nursing generally that you're talking about now—the standard.

Yes, both in terms of leading the team—sorry, actually, I think I'll pass on to my colleague as she's the professional expert, because I think there are lots of roles within the team that that level can provide, and one of them is the clinical supervision, the education. It's those leadership roles—I suppose, in a sense, you could probably be in a leadership role but there's also a management role that is important.

I think that, working with district nurses over many years, the leadership role is one that is to do with leading clinical practice, and to lead in clinical practice you need to have clinical confidence and clinical competence yourself. The case study that I described to you just now I think helped illustrate the skills that are needed actually at a very high level. To make those observations, to be able to act on those, to be able to assimilate all that's being observed and that a person is conveying to a nurse is something that is a very discrete set of skills, but actually is quite unique in the world of nursing, especially when it comes to the area of practice. You're talking about people who are working on their own within somebody's home. You would want to assure yourself of the highest level of preparation to work in that role. So, the SPQ is something that has existed as a gold standard, and I think you'd want to have some very good evidence to be convinced that you need to move away from that, to be quite honest. It's an area of practice that is only going to grow, that we are only going to be more dependent on. So, it does seem a bit perverse to consider to downgrade the expectations of skills, competence, and thereby safety, within that sort of conversation.

That's fine, I appreciate that. I just wanted to, around the current workforce, ask you whether you think there's any current data that we're lacking. [Laughter.] Lisa's going, 'Yes, how long have we been talking about this?' But particularly around numbers of staff, the skills that are required, the settings and so on, what is it that we're lacking, Lisa?

Almost everything. [Laughter.] I think one of the things that's important is—let's go back to first principles—why do you need the information? One of the things you need the information for is to assure yourself that public money is being spent wisely, that there are good outcomes. Another reason is to plan the workforce for the future. Both of those areas are lacking. We don't have, at a national level, published data sets that demonstrate outcomes, which is ultimately the important thing. We also don't have activity.

A classic comparison would be waiting times. We can look at waiting times and, yes, we can perhaps have discussions about whether they're the right measures or not, but they certainly give you a picture of what's happening in the acute service. We don't have a similar picture of what's happening, and that concerns us because, first of all, it's a very vulnerable population that's being cared for at home, and, secondly, it concerns us because it's increasingly a large area of public spend. So, the fact that what's going on in there is not available for scrutiny—to Assembly Members, to organisations like ourselves—is very much increasingly a concern.

And then there's the issue about workforce planning. So, what we don't have is, you know, published at a national level—. We have Statistics Wales that publish that number of district nurses and nurses working in the community. What they don't publish is—. We don't have any sense of how many people they're looking after, or the level of acuity of those people, or, as I said before, the outcomes. So, when we—. There is data that exists administratively within the NHS. There's more information that isn't regularly published or available nationally but can be pulled out, and obviously some of that's been supplied to you, for example in the evidence from HEIW. When you look at that, you can see that it bears out some of the concerns that we've had for a while. So, for example, there's one graph in there that demonstrates the skill mix—band 8, 7, 6, 5. So, you can see that although the numbers of registered nurses in the community have indeed increased, the vast majority of that increase is at band 5 level and not at the more senior roles. So, in other words, that leaves those people looking after a bigger team and looking after more people. You can see why our district nurses are feeling under such immense pressure when you look at those statistics, because essentially their role has—. The same number of people are looking after more and more and more staff and people in the community. So, we do have huge concern about the quality of the information and what's missing.

So, what you're saying, though, is that the information's there, the health boards have it, they hold it, they don't publish it, and they don't put it into a form that makes it very useful.

Precisely, yes. So, there's administrative data, but it would need to be collected at a national level and it would need to be, obviously, put into a form that's comparable. And there are issues as well with some of the quality of the data, and we know that, and again, the Welsh Government have alluded to that in their paper—that, for example, we've had coding issues where health boards have coded, 'Well, you're a registered nurse working in the community, so I guess you're a district nurse', or, 'You're a nurse working with children, so I guess you're a children's nurse,' when, actually, those things are specific qualifications and titles, so there are some issues with quality as well. There's certainly a lot to be done on the workforce data. I think it's really important, when we have HEIW working on this workforce strategy, which will be published relatively soon, when you realise that a national agency is working with such a poor picture of what's currently happening out there.

You've got to start from that base, haven't you?

I think I would just add that I don't—. If we go right back to a service being there to meet people's needs, I don't know that we really have the data articulated in those terms: what actually are people's needs? It's easy to count—the number of tasks, the number of patients on a case load, even the time taken—and we tend to default always to those sorts of measures. But I would suggest that to get to more meaningful information about what actually people's needs are, and I believe that that's through the medium of complexity of needs, that we need to learn a little bit more about how to work out how many nurses are needed, and what the workforce deployment should look like.

And it's issues like—. If you start looking at the patient outcomes, you can start seeing what's having the best impact. So, for example, if your goal is to reduce re-admissions and keep people independent, you can then see which model is actually achieving that. That's the kind of policy information and policy evidence, at the moment, that we're lacking because of this. The historical statistics that have grown up have grown up focused on the acute performance in the acute sector.

David, you've got a supplementary.

Yes, just a quick one.

I'll come back to you, then, Dawn.

I agree with Sue Thomas. It's a question of needs, and therefore, to me, when I was looking through some of the papers, I was trying to work out comparisons, if possible, across Wales, but until you know the needs of the patients, the patient population, the impact of deprivation on those communities and those clusters, you really don't have an ability to reflect upon how many staff should be in particular locations, what type of services they will need to provide. That data has not been collected or—

I quite agree. I think there may be opportunities through this sort of inquiry to start to ask the questions about, 'Well, could we move towards understanding more about the population needs?' so that everything else should fall from that information. I would think it would be a very sad thing if we just defaulted to what we've always done.

Okay, thank you.

I can feel a recommendation coming on. Dawn.

Yes, and that kind of leads us on to the next questions on—I know it's one of your favourite subjects, Lisa—workforce capacity, because that lack of data. We can explore the views of front-line staff, and I think it's important to do that, but the lack of data perhaps makes this more difficult. But what's the current view of front-line staff about the ability now to deliver the demands of the service?

Morale is quite low, I think, particularly at the senior levels, in community nursing because of the tremendous pressure they've been under and feel that they've been under for a long time, and also this feeling, as I say, of being invisible to the wider service. In terms of the capacity issue, there are a couple of problems really: the basic capacity to meet the caseload and to deliver the best care; then you have things like the supervision, the education—you know, all those kinds of things that are falling away. There are issues such as, for example, that we know that the most senior nurses spend a great deal of their time, for example, on things like managing the assessment procedure between health and social care, so managing all of the different eligibility criteria for clients' continuing healthcare. So we know from our members that that's taking up a huge chunk of their working lives, and they view that as a bit of a frustration because they actually want to be delivering care as opposed to negotiating that system. And there are other frustrations as well. We've mentioned the lack of technology, which is again adding to the complexities of their working day—literally carrying paper around and filling in computer records later on in the day. That's adding to some of the difficulties. What I would say as well is that I think many of them are frustrated by the current funding system. A very senior nurse described to me, for example, how she was continuously, essentially writing bids for various new funds and having to try and sell her core service as something new and repackage it just to get the funding to continue for another year and that that kind of work was essentially dominating her working life. So, I think all of those issues then are impacting on morale and relating back to capacity.

So, is some of that—sorry, go on, Sue.

I can add to that, just to talk about the staff experience. There is an opportunity, because we do have a workforce here who have traditionally always worked in a very holistic way. That is what they're all about, and yet we've learned that, over time, task time has been the way that the service has been structured. Health policy now will be working towards encouraging that people's needs are met in a different way, much more holistically. So, we have a workforce that can do that, if they're enabled to work in those ways. So, for example, you've probably heard about the expectation that the question, 'What matters to you?' is asked. You've heard about certain ways of working that involve making every contact count. These things are now part of the language of what we do, and that is something that would come very automatically to a district nurse, and the case study would have illustrated how that was the case. And yet a staff nurse said to me the other day that she is so busy, she is so rushed during the working day, so overloaded with the number of people that she's got on her books for that day, that she hardly dares to ask somebody the question, 'How are you?' as they go in through the front door. So, if that's the situation that we are dealing with in reality on a daily basis—and that might not be everywhere; but certainly that was that one person's experience—then we are never going to achieve the policy agenda, but also what district nurses and their teams are capable of delivering. So, we're never going to work towards the change in the culture of care delivery. But it is there; we just need to help that workforce, the district nursing teams, to achieve their potential, because it's there.

I'm just wondering whether some of that capacity could be addressed by different ways of working. As you say, we touched briefly on the Buurtzorg system earlier. I went to have a look at that last week and I met with the teams in Hirwaun, and they were saying that it has transformed the way that they work in the sense that their caseload hasn't reduced, but the time that they've got to be able to do the work has. They get their breaks, they start on time, they finish on time, they get their training days. And that was by, basically, reorganising the service and giving them the IT to be able to do things as they go along rather than—. So, is there something about not just necessarily—there might be some issue about more boots on the ground—but is there an issue about how the work is organised and managed, and the use of technology to assist with that?

Well, IT has clearly helped in the area that you're describing because it has helped them to organise their work in a different way: it organises their work for them just because of the information they put into it. So, the feedback that I've had is similar to what you have heard. You can't get around stretching a service without, in some way, reshaping it. What could possibly fall off? That's what the dilemma is.

Some research that's recently come out of Northern Ireland—it's very small scale, but there is a bit of resonance for us here in Wales—is talking about the element of missed care; those things that get left undone. We know from hospital-based research that it's the elements that a registered nurse brings to that interaction with the patient that keeps them safe; it's the anticipatory care. And what the research from Ireland showed us is that what gets missed are the non-clinical tasks. So, the clinical tasks are still undertaken, but working with somebody to help them with their independence, to help them with health promotion, health education and all of those other aspects of care, which are so crucial to helping somebody to self-manage or to be discharged, they are the things that drop off. So, to what extent we enable district nurses and the teams to do that, I think, is a matter, sometimes, of extra boots, because otherwise we're fooling ourselves into thinking that we can reshuffle what's already in existence.

Is it possibly different types of boots?

Yes, exactly. I was just coming to that. I think skill mix is significant, and I think when you're looking at the numbers and you're looking at the ratios, what you're talking about here is ensuring that, first of all, there's a replacement for the people who are retiring at that more senior level, and there needs to be more of those in terms of actually leading the teams and providing that quality assurance of care. So, it is about the skill mix in the team. Another area—you're absolutely right about the IT—and another area is administrative support. We were pleased to hear that mentioned in the principles—the chief medical officer's recent district nursing principles—and that needs to be met. There are definitely things that can free up clinical capacity in teams.

Sure. Yes, including, I guess—. You're talking about the skills mix. I mean, we've seen some of the development around healthcare support workers and perhaps moving that so that we have band 4 healthcare support workers in some settings, particularly in the community, where they're working on their own. They could do all of those kinds of things: so, the fairly low-level interventions, but the non-medical stuff as well—the kind of stuff that is the proper integrated model, isn't it, of providing whatever medical care is needed, but also just talking to them generally about how things are going and helping them with feeding and all sorts of things like that.

Absolutely. The healthcare support workers are an incredibly valuable part of the community nursing workforce. There are all sorts of issues around making sure that that group of people have access to CPD, that they are valued, that they have reward in the work that they're doing and they're extremely important. But that doesn't negate the need for more of the very highly skilled levels at band 6, 7 and 8, who are the people that provide, then, the education, the supervision and the quality of care.

One of the points that we would emphasise, and I think Sue's touched on this, is: what's important is not to take a purely task-based approach to the care because it's about, actually, the overall knowledge and experience that, for example, a registered nurse can bring to the task. So, the example, as a lay person, that was given to me that made me really understand this was the example of a bath. To a certain extent, yes, of course you can train somebody to give a bath and that person will be clean, so task accomplished, but the nurse will bring to that other issues around, for example, skin assessment, because of their knowledge. And similarly, with any task, whether that's looking in a cupboard and understanding nutrition, or whether that's talking to somebody and seeing the signs of an imminent infection or understanding those wider complexities. It's seeing those issues, so it's the ability to assess, but also, crucially, the ability to act, so that you don't have a system where people are seeing things, reporting back to the centre and then that's put on somebody's agenda to deal with and that person then has to check that that assessment was correct, then they have to decide what to do about it. Whereas if you have somebody actually in that moment, they're doing the assessment.

They can deal with it there and then.

A fantastic example of something that you might think was non-clinical was given to me recently about somebody who'd been to visit a patient and found that this gentleman owned several dogs, which he loved and cared for very much, but of course, he couldn't care for them because he was bedridden. So, the dogs were running wild, and essentially the dogs needed to be cared for before the nurse could care for the patient. And quite rightly so, because the dogs were important to him and the dogs had their own welfare needs, but more importantly, they were really important, critically, to his well-being and health. So, it's a complexity of seeing the person as a whole, rather than just focusing on, 'I'm going to this house for 15 minutes to change this bandage.'

Sure. I understand.

Yes. Lisa's quite right. We're hearing about trying out different administrative roles, for example, at the point of a phone call into the district nursing service, but what needs to be considered is what is being achieved at that point of phone call. The likelihood is that if a phone call comes in, then somebody will take down the request if they have an administrative role, whereas if they are a multiskilled health professional, i.e. the registered team leader, they can sift through the requests that are coming in and reduce the number of actual visits and contacts that end up being the result of an administrative role, because they can triage at the point of contact. So, we need to be really careful about how we do make use of the skill mix within a team and just be careful about what we're aiming to achieve.

Another example of when I was out with one of the district nurses was the simple act of going to somebody's house to assess their need for bed rails. Well, you could argue that that could have been a physio referral, but anyway, we went very, very quickly—I think just allowing two minutes for the visit—but when we arrived in the house, the lady in question, for whom it was thought maybe these would be useful, was a lady with early onset dementia, really very disabled by her condition and unable to care for herself at all. Her husband had given up work to look after her—a very committed, loving husband—and almost immediately—. Well, No.1, the bed rails had been sorted out by somebody else so there was a duplication of effort, but actually this lady was very distressed; the husband was very distressed, because he'd accommodated the whole house to help her to live downstairs and he was sleeping on a sofa to help and look after her, sleeping in the dining room, and he'd been trying to help her to move from a bed to a commode and her toenail had become ripped, so she was in pain as a result of this and he was extremely distressed. So, the district nurse got on with helping to make that good, if you like. There are some other things that also cropped up. The husband was describing how his wife had diabetes and he was really concerned as he was struggling to help her to eat. So, there was a whole host of problems, as well as some appointments that had come through that he needed to manage and couldn't decide how he was possibly going to get her to these appointments. Anyway, it became really clear very quickly that not only was this lady very sick, but she was being totally supported by her husband in the home and he was at risk, very, very soon, of being unable to cope any longer.

Yes, absolutely.

So, when we talk about—. There is PhD research in Wales that talks about the complexity of a situation that is assessed and dealt with by a district nurse. In that case it was a case of making sure that the husband was well enough so that he didn't need, potentially, hospitalisation, and certainly that his wife would not subsequently also need hospitalisation. So, the nurse was working in the home to manage that situation in a way that's so difficult to describe—

The whole situation, yes, not just the—

It's so difficult to describe, and to be able to articulate that and help to recognise what goes on behind that closed door is something I want to just keep conveying to you in the whole consideration of how people are supported through these district nursing services.

And so I guess that we're talking about—we are going to see, aren't we, an increase in the number of people at home, needing care at home. That's the whole direction of travel in terms of everything we're seeing. So, what do you think the impact of that's likely to be in terms of numbers, and, perhaps, the impact on, if we're going to have increased numbers, the capacity of existing qualified staff to assist with training for additional staff? Because you've got to almost take them out of the field to do that, haven't you? So, perhaps just a few words around that.

There are two issues I think that I—. The Royal College thinks that there are two issues specifically in Wales that are very clear right now, which are (1) the need for those higher skilled district nursing roles—those numbers need to be increased, and they need to be increased fairly urgently, partly because of the ageing profile of the people who are currently in them, and partly because we simply need more. The second area is children's nurses in the community. What I would say about anything further than that—. I think those issues are clear now, from the picture we have. But the picture we have now, as we described earlier, is very poor, really, to be quite honest with you. So, I think, if there was a concerted—. There should be a concerted effort by the Welsh Government and HIW and NHS Wales and all of the people responsible over the next sort of five years to build a better profile of the population that is being cared for, and its needs and its outcomes. And then we would be in a position, hopefully, to come back in a few years' time and say, 'Well, now we actually really know what we need for workforce planning'. Because right now we can see the tip of the iceberg, and that's frightening enough, but we don't know what's underneath. So, those are the two areas where I think the situation is clear.

Right, we need to move on, and time is marching on as well, so I'm looking to David for some agility here. Because some issues have already been covered by some very comprehensive answers.

Just a couple of points in that case, since he wants agility. You just mentioned children's nursing, and I know in your paper you talk about the fact that you welcome that Government's increased the student places in children's nursing, but I'm assuming—correct me if I'm wrong—I'm assuming that's a generic children's nursing picture, not necessarily specific to district nursing and children's nursing in the community. So, where are we with getting more children's nurses to come into the community? Will the SPQ, which is obviously district nursing—does that also actually have modules of work on it to actually develop district nurses into working with children's services?

So, children's nursing is one of the four initial fields of practice that registered nurses would qualify in, and what's interesting looking back is the different areas that those children's nurses work in. So, traditionally it was always within the hospital environment, and then we've seen—what we're seeing now is that neonatal care is the big pull on where newly qualified children's nurses are going, is into neonatal care. So, first of all there needs to be an increase at that level in order to simply increase the number of children's nurses, because now we have children with complex needs being supported, living at home, living longer, living more independent lives, so we need children's nurses embedded in the community. What we see is missing is any kind of overall vision or strategy or model for how to embed those in the community nursing teams. So, first of all, we are not clear how many children's nurses are currently working in community teams. So, that's the first problem. The second problem is we're fairly clear there probably aren't enough, so we need more, and we need some kind of vision for the best way for them to work inside community nursing teams, because there would be different ways of integrating that service, and there are probably different types of model currently out there—variation. But, to answer your specific point, traditionally, district nursing and community nursing were focused on the older adult, because that was the population. 

Adult services start at the age of 18 and go through the lifespan, but it is true that district nursing services would tend towards looking after the older person. That's just the demographic that seems to fall into their work, into their caseload. Community children's nurses are a distinct speciality. So, the SPQ that you talked about is a registrable qualification with the Nursing and Midwifery Council, and it is for, actually, several areas of community nursing practice. So, there's an SPQ for district nursing, an SPQ for practice nursing, an SPQ for school nursing and an SPQ for community children's nursing. And that particular group—you could see it as being the generalist, and the Royal College of General Practitioners defines 'generalism' as being about an approach that considers the person in the context of their whole lives. And so a community children's nurse would be the generalist for children within their own homes, in the same way as district nurses are the generalist specialists for adults within their own homes. As I'm aware, there are very small numbers of those individuals. There are courses of educational preparation. I'm not sure what the numbers are that are going through that, but there is certainly potential there to make the most of that resource. 

I understand that because, as you've highlighted, most people associate district nursing with adults and adult needs and therefore there's very little always reflected on the child's needs. We often forget that children in a community have health conditions that need help and support as well. 

It tends to be that each of the health boards organises its areas of practice so that district nurses would probably fall into a community or primary care directorate or division, whereas community children's nurses or children's services would tend to fall into families and therapies. So, they tend not to work in the same team, even though they're working in the same area of practice, and it's just because of some of those difficulties in separating and working out what sits where, if that helps.   

Yes. Okay, thank you. Similarly, we've talked about people in the community—there are also residential care homes, and I know the RCN held a recent event about care home nursing. But you also in your paper highlight that the care settings need to have, effectively, some nursing presence within them, whether that's somebody on site or whether that's somebody accessible. How far are we, perhaps, away from developing an effective service for residential care homes as well, because, if we don't get that right, we end up putting more pressure upon hospitals as a consequence of that, which just works down the line? 

That's a really important point, and it is one of the areas we're concerned about. Just the very language has shifted, in the last couple of years, of policy, so we now talk very often about—. You don't really hear community care being talked about, what you hear is primary care or social care. And perhaps one of the unintended consequences of that is that we've been struggling to make the significant presence of nursing visible, really—visible and valuable. I think that is what's missing. There are some really good initiatives. I know you're familiar with some where health boards have looked to make sure that there is a community nursing presence in care homes as well in terms of a proactive sense—so, not just there in terms of looking after people who are already identified as having nursing needs, but that nursing presence proactively for that population. So, there are initiatives and models out there of that but, again, what seems to be missing is that sense of a national approach to how important this is, and perhaps some recommendations for how that can best be achieved. Sue, I don't know if you want to say anything in terms of your cluster.   

You're aware that care homes—. So, two categories of care homes—residential and nursing—and therein lays a bit of unpicking anyway to order to consider where nursing would be expected to be present, and where not. Of course, in a care home you would expect—in a nursing home, you would expect a nurse to be present, but they are independent sector providers. So, to that extent, their services are commissioned through the health boards; you'll know all of this, anyway.

I can give you an example of—. I also work as a cluster lead at Aneurin Bevan, so I'm familiar with that area, not so much with the rest of Wales. But, certainly within Aneurin Bevan, they've taken a very proactive approach to ensuring that the services that they commission are safe and, in order to help people who live in a care home to stay safely within their care home, they're helping to provide education for nurses working in those care homes. Even though they are the independent sector nurses and are therefore employed by those independent sector employers, the health board are offering education and training so that there can be enhanced skills within those nursing teams to assess, diagnose and treat those people to remain within their own homes rather than be transferred into hospital, maybe unnecessarily and certainly not always appropriately, so—

You just said that you work at Aneurin Bevan and you're not clear about the rest of Wales, so I'm assuming therefore that there is no data on that information across Wales, so we haven't got a clue whether there's consistency across Wales or not.

No, exactly. The types of—. We're aware of individual initiatives or pilot schemes or models, but there's no sense of how community services generally are organised or deployed across Wales. The community nursing strategy, which was last published by the Welsh Government in 2009, was rapidly superseded by developments in terms of the primary care strategy. That's why we're saying there needs to be—. And it doesn't—. It can be within the context of the primary care strategy—that might be the most appropriate way forward—but there needs to be a new national look at these services, because we're seeing variation that is developing for the sake of it rather than because—you know, if something works, then it needs to be replicated.

But I think you're right to ask the question, because, if we're talking here about district nurses because of the fact that they support people in their homes, then you're right to ask the question about people whose own home happens to be a care home. And we also know that there are more beds within that sector than there are within the NHS hospitals within Wales. So, you're talking about a huge population of people and, if we don't have assurance about consistency and standards, then—. We could improve that.

I know that the Chair wants me to move quickly, so just a final question with regard—I'll put two into one. We've talked about the district nurse staffing principles set out by the CNO in 2017. Two questions on that: do you think they are becoming effective and are we spending too much of our time focusing upon those principles and not the general principle of community care?

The publication of the principles we very much welcome; it was a very important step. I think it would be helpful to have some kind of published audit against those standards. However, I think what's missing is the wider strategic picture of community services. So, let's go back to first principles: how are we caring for people in their home, whether their home is their own home or whether they are in a care home? Nevertheless, how do we care for those people at home and what do we need to deploy? And the largest workforce will be the community nursing workforce and then there will be other multidisciplinary aspects—occupational therapists and physiotherapists—that will need to be brought in. But that vision is what's missing. So, yes, the principles are welcome, but they don't replace the need for a wider vision about that service.

I would add that—I know that baseline data was collected at the launch, at the beginning of the principles having been released, and subsequently a year later, and already there are improvements to meeting the expectations set out. So, what I take from that is that it's a very powerful tool to effect changes in some areas that have been covered by the principles. I think there's a message there, which is that, if similar work was to be developed, along similar lines with the same sort of authority, then it just goes to show what could be achieved through being more ambitious. So, I would see that that, as a model, has worked very successfully. I don't know also whether or not you are aware—I'm sure you are—that the Wales Audit Office published, at a similar sort of time to the principles being released, the checklist for board members in respect of district nursing services. We were just revising our knowledge of that this morning as we were preparing to come in, and we could see, actually, that the recommendations that they make, that the framework that they offer for board members, is actually really robust. I don't know, though—you asked about the district nursing principles having been followed up. I'm not sure what's happened to that WAO checklist. I'd be recommending, perhaps, to ask the question as to how the situation looks according to boards using that checklist, and what information is being released through that. For example, they do ask: well, is there a vision for district nursing within the health board? They ask very sensible questions, not actually dissimilar from those that we've recommended in our paper. We do have, actually, a couple of pieces of work in existence that I think could be used, and built upon, because they are there, I think, in quite a facilitative way.

Okay.

Right. Lynne, finally. Some issues have already been covered as well.

Yes, some issues have been covered. Is there anything that you want to add to what you've said already about how the nursing profession is engaging with the new workforce strategy for Wales, particularly in relation to Health Education and Improvement Wales and Social Care Wales?

What I would say is that I think it is—. It would be important for HIEW to be engaging specifically with community nursing. Obviously, I don't know if that's happening; that's a question for them, really. But I think what would be important would be to have those community nursing voices. One of the things that we've mentioned in our paper is the need for that kind of nursing voice when it comes to the design of services and to workforce planning. And, sometimes, that can get lost, because the very nature of the people who are answering those kinds of strategic-level questions are the kinds of people who—you know, the integrated medium-term plan is, essentially, the mechanism at the moment via which the health boards set out their workforce needs.

That process, while it certainly is better and more robust now than it was, say, even a couple of years ago, it's certainly by no means sufficient at the moment, in the sense that the IMTPs that tend to be drawn up to not tend to reflect things like demographics, workforce planning, data; they are not really as robust as they should be. And they do tend to lack that service voice. So, what we would like to see from HEIW is that real engagement with the different levels of the service to make sure that that perspective is feeding in. And what there should be in there, I think, is—very specifically, to return to the first question, I think there needs to be some very clear standards about the kind of information that they're expecting from health boards; the kind of information they need to do their job. Because, you know, just looking at the data that is currently available now, the data that's of a sufficiently high quality to be published nationally, and then the kind of digging down, the kind of administrative data that you can find out if you request through payrolls some further information—to me, it's not sufficient for robust workforce planning in that area. So, that would be what would concern me, and I would suggest that it probably concerns HEIW too.

Okay, thank you. You've highlighted the fact that there are a lot of initiatives, but that Welsh Government tends to, and providers tend to, favour the new over what is actually happening on the ground. That's a very familiar theme, really, to this committee. Have you got anything you'd like to say in addition to what your paper says on that that you want to bring to the attention of the committee?

Just really a plea that, perhaps, when the committee is looking at other areas, like, for example, the transformation fund or the work of regional partnership boards, that these types of questions are asked. Because one of the things that we are concerned about is this kind of: 'We have a fund, go out and fund two projects that are about integration.' Great. So, we have all of these projects now. Well, where is the mainstreaming and the learning from that? So, you know, there is fantastic work going on out there, but we need to make sure that there's a core service across Wales of a consistent quality delivering to people everywhere. So, it's not just that you are lucky enough to be living in an area where the senior community nursing leader has got the time and the energy and the ability to write a fantastic bid—we need that everywhere. One of the things I would say to the committee is we're very grateful for the one-day inquiry—really, really so grateful—and to say that a lot of our members are watching and listening online and commenting on it, and have been very engaged with this evidence—. But one of the things we would hope is we do hope that we've made community nursing visible, so that when you're looking at other areas, when you're looking at care homes, when you're looking at GP practices, when you're looking at different areas of the service or regional partnership boards or whatever, that you bring community nursing in. We would be very grateful if people—that it isn't a forgotten area.

Okay. You've mentioned in your paper that the Welsh Government should invest in supportive technology for community nursing. I know that Dawn is quite interested in this. Are there any examples that you can give the committee of where that's been particularly effective?

We know there are some areas where the hand-held devices have been rolled out and have proven effective. I think we mentioned the one area before. We can certainly go away and look for specific examples if that would be helpful to the committee. What I would say with the technology is, again going back to the more strategic level, one of the things that we've been concerned about is the pace of change and the schedule for change. So, we would like to see a clearer schedule for when developments are going to be introduced at the national level, a clearer time frame, and we would also like to make sure that the community nursing voices are involved in the development of those kinds of software. Because too often what happens is it isn't involved, so by the time the software is rolled out to the community nursing workforce, it may not be fit for purpose. Community nurses are then saying, 'Hold on, actually this is not what we need.' 'Well, it's too late now, because it's been six years in development and six years rolled out.' So, we need to make sure that, at the strategic level, the community nursing voices are involved in the development of the technology, and we would like to see a clearer timetable, and I know there are definitely some areas where those hand-held devices have been rolled out and they have proven very, very useful.

At the end of the day, it's all about pragmatism, isn't it? District nurses are pragmatic health professionals. For them, it'll all be about going to somebody's home, having enough information in front of them that they're able to understand that person's needs, and then to be able to communicate their requirements onwards to either other services or back to their own teams, and that's not always very easy.

We know that the WCCIS—Wales community care information system—is being rolled out. It's slow, and some of the frustrations that Lisa expressed—the time from an idea developing to being delivered is just something that we deal with. The NHS is a big machine. One of the things it doesn't do is it doesn't speak to the GP record. So, although it has achieved a link-up between community services and within health and social care, actually, it is not a whole-system approach. And, of course, time doesn't stand still, and since then, clusters have become much more a part of how primary care and community work is delivered. For example, in my own cluster, they're now developing a virtual ward, which is all about health professionals sitting around a table once a week and discussing those people who within that area might be at risk of deterioration. So, between them, they sort of work up the solutions. It saves onward referrals, the time saved is tremendous, and the heads around the table—it's a really, really good model, but they don't all share the same record. So, time has moved on in the development of what should be a very robust system. We're already changing, so it's about keeping pace with that and enabling practitioners to be really pragmatic on a daily basis. 

David, you had a final question.

Yes, I just want to come back to the workforce. District nursing, as with any aspect of nursing, is 24/7. Very often, we all just talk about the district nurses in the daytime and not the weekend or the night work. Have we got sufficient workforce? I know many district nurses who struggle on the weekends in particular, and actually end up—not just the cluster size, they cover a wider range as a consequence of that. Are we struggling, on those sorts of aspects of district nursing, to actually provide the care that people need over what I would say are not the normal working hours?

'Yes' is the simple answer to that—very much struggling. I think it's a lack of consistency again between different areas. So, there's a bit of a postcode randomness to what you can expect. Also, as well, there's this business about actually—. If you're sending out a skeleton service, what they probably can be doing as well is that referring on. So, they're holding the situation, but someone's picking the actual work up when they're coming in. So, the work is rolled over, if you see what I mean. So, there are all sorts of issues in terms of how that then creates problems.

Of course, the other alternative is that that's when you'll get the peaks in hospital admission and so forth. Again, it comes back to the—. It's not just about the workforce that's available, although that's really important; it's about the nature of the workforce that's available. So, have you got the really good, highly skilled people available at those times, who can actually deal with the situation rather than refer it or move it on. So, absolutely, yes. That's a particular issue.

And are your members seeing a knock-on effect on occasions—not every time, but on occasions—when the GP out-of-hours is not there because they couldn't actually fill GPs in for some services? Clearly, the reliance then comes on the district nurse.

Yes, and I think that sort of co-ordination is an important point. One point I would add into the mix is, of course, independent prescribing, because that is actually an extremely helpful skill set to have within the community nursing team. I think you have to consider about—why are you referring in this case? Is it because we really, really need a GP to assess this situation and deal with this situation? Or are you referring it because, actually, it's a prescription issue? In which case, if you skill up that workforce, then you don't need that. So, there are all sorts of issues around co-ordination with other services. The same could also, equally, be said, of course, when you might need a physiotherapist or you might need an occupational therapist or a social worker. So, the co-ordination between professionals is always a significant issue, but I think what's significant is that we need to really change the mindset of normal working hours and out of hours. At the end of the day, people are people and they will have their needs all the time. So, in terms of that strategic vision that we're looking to be developed, those links between the services need to be robust at all times, really. They can't be, 'Well, this is how it works Monday to Friday, nine to five, and then, out of hours, we have a totally different system.' Ultimately, it's not really a sustainable approach in terms of developing the services.

Could I just add to Lisa's point about prescribing ability? You may be aware that district nurses who go through the specialist practitioner qualification training will come out as prescribers, but just using a restricted formulary, which tends to be only medicines that are available anyway over the counter. There's a difference between that formulary and that training and the independent prescribing that Lisa described, where any prescriber—which would be a nurse, a pharmacist and physio these days; the groups are expanding, but we are talking about nurses—have access, then, to the entire British national formulary. In reality, they work within their area of competence and their area of familiar prescribing. But it just offers so much more flexibility to complete episodes of care—to avoid the necessity to always be referring on to somebody else, and to come in and duplicate effort. So, there's an urge there to consider really making recommendations for a broader set of skills within a group who are spending so much time working with people in their own homes, so that they can complete safe care. I think about the lady with the problems that I mentioned earlier on.

We just had RCN in, as the Chair has said, and one of the questions we highlighted was the data relating to the need of the communities that we are serving, and I just wondered what assessment the health boards have done of identifying that need, because, obviously, different clusters will have different sets of needs. So, have you done any assessments of those needs of the communities so that you can actually be in a place to know what type of community nursing and district nursing is required in those clusters?

Thank you. I think, through the social services and well-being Act and through the future generations Act, the onus on the regional partnership boards and the public services boards to conduct a comprehensive local authority and health board well-being needs population assessment across the health board footprint has been really helpful in terms of identifying local need. So, even in an area like Powys teaching health board, we've got a very comprehensive overview of what the population needs are, but, obviously then, there are local needs depending on the areas. So, we know that the Ystradgynlais area has got high levels of deprivation. That will be slightly different to the position in Brecon. So, there's quite highly detailed information, and that has been useful in terms of determining the needs across the community hospitals, but also community nursing services. And when we say 'community nursing services', I mean the full breadth to include community nurses in mental health, in children's services, learning disabilities and, of course, adults. So, there's been a lot of work and I think it's been really useful.

That's one board.

I would share that view and, additionally, we have done some work locally, through the transformational agenda, looking at segmentation of the population within general practice. So, that will support community nursing as well. So, if I can give you an example of that, within Cwm Taf we have a very high level of chronic obstructive pulmonary disease—so, respiratory issues. We have lots of admissions and repeat admissions around that population. But the segmentation in the practice would actually take it down to another level, So, for example, in one area, it might be that that group of patients requires a certain public health intervention, such as smoking cessation. In another area, it might mean that that population might need more support around nutrition and obesity. So, it's actually targeting that and supporting that element then, and community nurses will be integral to that work.

To an extent, that sounds partly towards some aspect of public health assessments, but also what we're looking at is, perhaps, the nursing needs within the communities. You identified COPD as an example of where that would be needed. So, what I'm trying to work out is what assessment you have looked at for the nursing needs of your communities. That would basically be the basis, I would assume, for your identification of the workforce capacity in those areas—a minimum level in those levels, to ensure that those communities are actually served by those teams. So, as well as the public health agenda, are you also doing the nursing needs agenda as well?

Yes, and I think that the district nursing principles and the work that the chief nursing officer has been leading across Wales, via the directors of nursing and obviously through to the teams, has been quite key, really, in focusing on district nursing particularly, assessing need, and not just the population health assessment, as you've indicated, but how that drills down, particularly in terms of the numbers in an ageing population, which, again, I think, affects all health board footprints, but particularly in Powys. We know we've got a higher number of elderly people than other areas. As a result of that—the evidence base around what more elderly people require in terms of nursing needs—the evidence is there. And I think, through the principles work, I'm sure you will have heard—if not this morning, later—about how the neighbourhood nursing models have been really positive in terms of galvanising teams, district nursing led, understanding local needs and deploying education support and various resources to meet that need locally. So, there's an incredible amount of work in different areas that we're bringing together to ensure that local needs are met, determined, actually, by the district nursing team leader.

I assume Aneurin Bevan will—

Yes, within Aneurin Bevan, we've also done a population needs assessment in line with the transformation and working towards place-based care. It evidenced that Monmouthshire have got an older but healthier population that are more engaged with services, whereas there's more deprivation within areas such as Caerphilly and Blaenau Gwent. And also, in Newport, we've got issues with people who are homeless and how we address those issues, because district nurses get involved with those patients as well. We've also looked at the over-65 population, and on average it's 20 per cent across Gwent. And we've looked at the disease risk registers within the GP practices, and, as you would expect, it's areas such as diabetes, respiratory, but quite surprisingly depression is quite high within Gwent, and then you've got to look at the social isolation and all the issues that come along with that. So, we are basing our skill needs assessments on the disease risk registers for our community nurses.

Okay. That's very interesting to hear, because, clearly, the next question to come is: do we have the capacity to actually deliver to those needs? Do you have the workforce in place to deliver on the needs you've identified? We know that the nurse staffing levels Act does not extend to district nursing, and I know there's a call to move it, but the other tools still need to be used in the assessment. That is still under development, I understand. But, taking the legal requirement out, let's go back to the moral requirement. Do you have sufficient nurses and district nurses to deliver on the needs you've identified? Remember, everyone will ask the question, and if you say 'yes', then they'll want to be able to confirm your 'yes'.

I think there are two aspects to that, and what we also have to look at are the Welsh levels of care and the acuity tool that we require to actually deploy our district nursing service. That is still in development. It's in acute, and we are testing it in community services. So, currently, we don't have a good overview of the acuity of our patient group. So, the data we collect is very much around disease specific and numbers within our own health board, but that does not give you the level of detail you require around, first of all, skill mix, and also around the length of time you need to spend with that patient within their home environment. So, we are challenged around that, if I'm honest. I do think that we do have a robust district nursing service within Cwm Taf, and we do our demand and capacity, and we track that through on a monthly basis. We've seen a huge rise in the number of district nursing interventions over the last two years—quite rightly so, because our aim is to provide care at home, and following the future generations and the 'A Healthier Wales' information. So, I do think we have got a workforce, but are we absolutely clear that that workforce is right for that population? We do need additional support around the acuity levels and more data and IT support to actually really scrutinise that.

I understand that you represent three health boards and I just wonder—. You can't speak for other health boards, and I appreciate that, but, in your discussions with your colleagues, do you get the same view across the whole of Wales? Is there consistency across Wales in this picture?

I think that's pretty much the case.

Yes. I think it's easy to measure the capacity, but, as Lesley said, we need to look at the acuity, intensity and complexity of the calls as well to know how large a workforce should be and how skilled they should be to address that need. And like Lesley said, we're working towards that but we're not quite there yet.

Obviously, one of the questions we had earlier was the fact that we recognise nursing is 24/7, and, therefore, this is an important aspect because I often see challenges when the out-of-hours weekends kick in and I'm assuming you're, sort of, reflecting the demands there because these needs don't change from a Friday to a Saturday. 

No. 

Also, are you looking at the children's—? Obviously, we talked earlier to the RCN about children's conditions and children's nurses. How are you looking at the specific needs of children who require district nursing and community nursing? 

Certainly from my answering you in terms of the needs assessment, we're certainly aware that the needs of children are actually—. We've got a low population base of children in Powys and that is continuing to decrease or is predicted to decrease. We've got a small paediatric community nursing service. It's only just over four whole-time equivalents, actually, for the whole of Powys, but that does meet current needs. We work very closely with the local authority in terms of the integrated disability services, and our community paediatric nurses are aligned to the integrated disability service and we provide care in the community, which is predominantly for children with disabilities but also complex needs and palliative care. The needs are met, but, with more demands and increasing technology advances and disease advances in terms of management, then, obviously, you need to keep an eye on that and that's part of the workforce planning to increase. We have recently enhanced our palliative care services for children in the community, which has been a really positive move forward in recognising that, like a lot of adults, children want to be at home in those situations, with their parents.

Yes. Unless there's anything different, I'm assuming it's the same across both other health boards here.

We do have a children's community nursing service and that service provides care for children following surgery, but it also provides care for children with very complex needs. So, children with a continuing healthcare criteria, they will be in receipt of services from that team. They support parents around hospital at home and respite, and it's very much a partnership with parents around children's services and the wider team—so, the wider health visiting team and the wider community nursing teams. And I think, for us, in diabetes care and also some chronic condition management, having that specialist support for those areas of care for children as well is crucial going forward.

Is it difficult to recruit specialist children nurses into the community services?

That hasn't been our experience.

Not as far as I'm aware. And we have the same within Aneurin Bevan—we've got a community children's service and we're currently working, as Lesley said, with children with complex needs, especially as they come through the transition with learning disabilities, because our district nurses are heavily involved in the case management there. So, I'm working with mental health to ensure that we've got a more seamless process, especially for the parent, because sometimes they can feel a bit lost during that transition.

And if you're talking about not recruiting, are you training more for those specialist services? We've been told that 46 per cent of the district nurses are over the age of 50. That means—. Well, after our debate yesterday, who knows? That means that, clearly, in 15 years' time—I'm going with 15 because that's the current state pension age—you're going to be facing a challenge to replace some of that skilled workforce. And some of those, in that time, will obviously want to reduce hours as well, which means the need is there, but you'll have less staff to deliver. Have you got a programme of training put in place to ensure that you can get people up to the levels required to actually come into district nursing and take on the district nursing roles?

I think it's a really important point. I think, in terms of turnover within district nursing, particularly in Powys, it's been a very low turnover. When we do go out to advert where we have mostly retirements, actually, we don't struggle to recruit. We've probably got an average of about 10 to 12 whole-time equivalent vacancies across Powys at any one time, which feels reasonable in terms of turnover.

I think what's key in terms of education is the workforce planning that takes place and the commissioning numbers, and that's an active process that we're all familiar with. It takes place across all the health boards—I say annually, but it's on an ongoing basis in terms of determining. What's also important is recognising the value of redefining roles and working very closely with health and social care in terms of needs, and recognising that the specialist qualification is really important but, again, we're compliant with the principles set by the chief nursing officer in terms of the district nurse qualification. So, I think our issue is definitely the turnover that we're going to have in the coming years because of the maturity of our district nurses. But we are planning for that and working very closely with Health Education and Improvement Wales.

I think it's a similar picture, as you've described, across Wales. What we actually find is that we've got a workforce who are very expert and we've also got a junior workforce, and that junior workforce—taking them through that pathway to post-reg and the SPQ, we are very keen to develop that. Backfill is something that the Welsh Government is supporting us with. So, once we send our staff off to undertake that qualification, at the moment, there is backfill to support the service in actually delivering that, which is very helpful. I think we can develop further with our HEIW colleagues some particular competencies for our district nursing workforce, and one of those would be independent prescribing as part of the core curriculum going forward. I think that will be very helpful to community nursing in its wider sense but also to other colleagues as well, including general practice. So, we do have that challenge, but a lot of our staff do retire and return, so they still contribute to that workforce, and it's about us being flexible in meeting that need as well.

When you say 'backfill', just out of curiosity, is there specific Welsh Government funding for backfill, or is it part of the health boards' funding?

We've had additional funding for, I think it's two years, for backfill to support getting the health boards up to a level around the SPQ. Fortunately, we meet that principle within our area, but we are still continuing to train staff because we're anticipating that workforce retirement. So, we're taking staff through that, and we have staff at each cohort going through that programme. The other bit, which I think Rhiannon has clearly said, is around that workforce modelling with our colleagues across the health boards. So, from a student perspective, we have to be clear that the pre-reg is meeting the post-reg requirements, and that is really important, because where we actually get our district nursing teams from—some come direct from training and start as a community staff nurse; some actually work for a while within a different speciality or in acute services and then we recruit, which leaves a gap in acute. So, we have to have a whole-system approach, and it starts at pre-reg.

Okay. Obviously, this is an aside because there's a shortage of nurses—we know that. There are vacancies—maybe Powys is better off than others. Are you seeing a challenge in recruiting? How is the percentage of the vacancies in district nursing in comparison with the percentage of vacancies across the health board? In other words, are you recruiting better to district nursing then you are to the health board?

There might be different positions across different health boards, naturally. It's positive in Powys in terms of the numbers for district nursing and community services generally. Our biggest issue is in community hospitals rather than—

Yes, because you haven't got a district general hospital.

And I think it's the same in Aneurin Bevan. We seem to be attracting a lot of newly registered nurses into district nursing, and we've got a very robust programme called the Journey of Excellence within Aneurin Bevan, whereby the students are on that for two years and they've got mentorship, induction; they're released one day a week to work with our educational team. So, they feel very supported on that post-registration journey. Like Rhiannon, I think we struggle more within our community hospitals, and it's how we brand that to make it look more attractive going forward, and we are working on that within the health board.

We looked at some dual roles and rotation between community and hospitals, which, often, the patients are the same people—of course they are. So, that's been quite positive, particularly in Llandrindod Wells, for example, where we have had more difficulty recruiting.

And I think our recruitment is very robust. We actually don't have a vacancy factor in our service. It isn't reflective of across the health board, but we do work with colleagues in acute to manage that risk, and I do think it is about rotation going forwards. But it's also about developing our workforce. So, it's about developing our band 2, 3 and 4 roles, and taking that group of staff through a programme and actually encouraging them to go on and move forward in nursing, and if they want to, take that next step and become a registered nurse. So, our band 4 role, in particular, for district nursing—through the neighbourhood nursing model—has been really positive and has really improved quality for our patients.

You just mentioned there you didn't have a vacancy factor.

No, we don't.

What does that mean?

We have zero vacancies in district nursing currently. Obviously, it changes, but we have just recruited as well, through our transformational funding, an additional 18 posts: eight of those are registered and eight are healthcare support workers, and we've been successful in recruiting those as well.

Can I say you might be one of the unique health boards that actually is good at—? In your view, because we are not—. Again, we talk about—you haven't got a clear picture of the needs. In your view, you've got a full complement of district nursing.

We have at this point, but that does change, and I think it changes with each health board. But we do carry very few vacancies, and we are in a fortunate position around that.

I think Lesley's made a very good point in terms of the more detailed work that we need to do in terms of acuity and needs-based and competency-based care, but if you look at turnover in district nursing, the low sickness rates, high performance appraisal development reviews, high staff satisfaction—that's a mouthful—they're all indicators that will tell you they're satisfied teams. Therefore, they're satisfied because they are delivering and feeling satisfied, with high morale. So, whilst we need further work, the information we've got on our teams would demonstrate that there's good care—and that's through patient satisfaction surveys as well—which would indicate that that's positive in terms of addressing need.

Dawn next.

Yes, it was just on that final point about high morale. I was fortunate enough to come to Hirwaun last week to talk to the staff there, and that clearly is evident in that pilot area. But we've just heard evidence from the RCN, saying that morale within district nursing has never been lower. So, are you talking about specifically in your pilot? Because you're in the pilot areas, where you're running things differently, or do you think that that's not a fair assessment by the RCN?

I wouldn't want to say it's not a fair assessment by the RCN because I'm not sure where they've got the information from, but what I can say, as a result of the national staff survey, is our results in Powys were incredibly positive. And we are able to drill down; we take care on that because there's confidentiality and anonymity, but that does demonstrate positive—. I think you have to take the other indicators: low turnover, low sickness, high compliance to mandatory and statutory training, PADR rates, patient satisfaction. So, I think you just need to look at all factors. As a director of nursing in Powys, it doesn't feel that there's low morale in district nursing for my patch.

I'll just come back on one and then I'll have finished, Chair. I appreciate what you're saying. I've met with district nurses, and a friend of ours is a district nurse who actually packed it in because under so much stress—particularly on weekends, and the workloads were so high—they just couldn't manage any more, to be honest. So, I appreciate some of the assessments you—. Patient satisfaction rates—most patients are hugely satisfied with the work of staff, because the staff are committed and dedicated staff, and you will find that most staff also often don't give you their views because there is still a question of, 'I get on with my job, I do my job, I love my job', but that doesn't mean to say that they're not uncomfortable because they still face the pressures and feel the pressures as a consequence. So, whereas the RCN may be reflecting their members' position, and you may be reflecting surveys, I think there's a balance in the middle somewhere that has to be met; that there are elements of low morale because they're feeling so pressurised at this point in time. Is that a fair point to say?

I think if we go back to workload and acuity, there are undoubtedly times when, in a district nursing case load, because of the casework complexity, there will be additional stress on that team. We recognise that; that's not to not recognise that.

However, I do think there are ways that we can support district nursing teams differently, going forward, and one of those is about using IT systems. And it is about using a scheduling system that we are piloting currently, which is called Malinko. What district nurses are not good at—and I think probably we'd include most of us in this room in that—is taking a break, is making sure that you've had a lunch break; you will always put your patients first. What this system does is it actually schedules the district nursing case load to be equal and fair, and it also schedules it over a seven-day period. So, we have evening rota, and we have staff on duty 24/7. Yes, it's reduced overnight, but the skill mix through the day should be there, and what this tool actually does is it uses the full amount of time to ensure that district nurses then have that time and have that break scheduled in. It hasn't been rolled out to all of our teams yet, but that's been quite transformational. Also, I think around that tool, what it does is it allows our healthcare support worker workforce as well to have that time with patients. So, the benefits that we're already seeing around that support from IT are enormous.

Okay. Dawn.

Thank you, Chair. I'm just going to ask you some questions around your community nursing strategy. Do you all have very clear community nursing strategies that are part of your integrated medium-term plans as well?

We've got a health and care strategy, which is our joint strategy, which is aligned to 'A Healthier Wales', and then there are individual plans against each specialty. So, they've got a plan in terms of how they're going to deliver against the joint strategy. What we have had is a nursing and midwifery strategy, which all teams relate to, so those principles apply across all areas of nursing. So, we haven't got a specific community nursing strategy, but there are community plans in terms of development.

Within the overall nursing strategy. Is that the same for all of you, is it?

It is, and we have a primary care strategy as well and it's very much integral to that.

Okay. And, do you feel that that's supported by clear national guidelines and direction? Do you feel that? Yes. So, you've got that kind of national direction running through everything that you do within your own strategies.

Certainly, from the chief nursing officer's perspective, every year, Professor Jean White indicates what her priorities are in terms of the professional nursing agenda, and we ensure that those priorities are aligned in terms of our own strategic plans, which are usually three years, and we adapt the plans based on those priorities, moving forward. So, there is follow-through, although, of course, we've got our own local needs that we need to address as well. So, it's a combination, but there is, from my perspective, and across all the health boards—you do see that follow-through.

You talked, in answer to David earlier on, about your staffing levels in the community and you're using the acuity tools at the moment, although we don't have legislation in that area. Anything you want to add to that about your staffing levels in the community as far as—? You know, are you meeting—? I know you've said you've got no vacancies; I'm not talking about vacancies, really, I'm talking about—do you have enough on the establishment? And, how have you worked that out?

I think we're doing a lot of work within Aneurin Bevan looking at capacity and demand, because like you said, the demand is very unpredictable. We're also drilling down into case loads to look at exactly what the district nurses are undertaking, and is it all truly district nurse—? Does it need a qualified district nurse, or, like Lesley and Rhiannon said, could that be undertaken by a healthcare support worker? Also, within Aneurin Bevan, I think it's fair to say our community nursing teams are quite fragmented, whereas we've got district nursing, we've got rapid nursing, we've got specialist nursing, but we are, as part of the transformational bid, looking at a whole-systems approach, and bringing it back to place-based care—so, looking at exactly what the population need is within that area, and populating the workforce around that place, which is very much like—. I've been a district nurse for 24 years, so it's very much taking us back to—

How things used to be, yes.

—24 years ago. But district nurses are pivotal in part of that decision making.

Okay. Sorry, go on, Jo. Rhiannon, sorry.

I was just going to add that I think the work that was undertaken by the Wales Audit Office, which I think was probably 2014 now, so it was a while ago, although there was a follow-up as well, was quite instrumental, really, in taking much more of a national approach around district nursing, and really did highlight some of the discrepancies across health board areas. I think they were health boards then, weren’t they? Yes.

They were health boards, yes.

So, that was quite helpful, although of course it was limited in terms of being very much about population numbers versus how many district nurses you should have; community nurses versus healthcare support workers. I think the progression now to the work that's happening, probably stimulated by the Act, and the significant amount of work that's been done in the acute sector, particularly for medical and surgical wards, we're learning a lot of lessons from the way that the Act was implemented. So, we're looking very much at acuity and demand and capacity.

We're doing that work. I think what's important is that that is not rushed, that it's done, it's progressive. We're looking at evidence locally, regionally, nationally and internationally, which is important in terms of getting it right. So, I know there's a lot of focus on the extension of the Act. Certainly from a director of nursing perspective, the peer group are keen on a focus on paediatrics, and paediatric care, whilst we continue to undertake the work on acuity measurement and getting the Welsh levels of care right in order to extend the Act. We're not—

Can I just briefly pick up on the point Jo made about fragmentation of services? We've certainly heard some evidence from ABMU that they were talking about the fragmentation of services there leading to, ironically, the duplication of stuff, so the same stuff being done by more than one team, or one set of professionals, for the same patients. So, is that something that you recognise, or is that something that you have recognised and you're putting right, or—?

Yes, I think we have recognised that, especially when we introduced rapid nursing alongside community nursing, but we are working with the community resource teams to address that, and obviously putting the patient at the centre and looking at specific cases. But I can honestly say that the duplication, there is evidence that that is reducing now, because we are working more closely with the teams.

We don't have lots of different teams within the area that we work in. Our core provision is district nursing services. Our enhanced provision is our joint health and social care workforce, and our core provision is also predicated around the GP practice. We maintain GP attachment, so from a patient perspective, particularly around palliation, there's some benefit to that because you're working with that practice, and we still maintain that. Whilst working in a geographical way, we are able to achieve that because of the way our geography is, as well. It does support that way of working. But that's very important to us.

Okay. And are there clear referral pathways into the district community nursing service? Are other stakeholders clear about the pathway in yet?

It's very simple. It can be a phone call. I think, from a district nursing perspective, district nurses take referrals from families, from patients. It's a very open access service with no major barriers to that, and it's assessed then through a triage system, the response time to that call. People will stay on a district nursing caseload sometimes for a very long time, and it's the value, I think, that that puts into the system for health. So, district nurses will look after patients, sometimes with chronic conditions, for a number of years. If that patient hasn't had a hospital admission during that time, that is additional value that is not currently seen through the health system because of the way that we evaluate and we use our targets. So that is an area to think about.

Okay. That's fine. Thank you, Chair.

Okay. Lynne. 

Thanks, Chair. The RCN has raised concerns with us about the level of involvement nursing directors have in the development of community services. Do you feel that nursing directors have sufficient input into service development and transformation?

As the only director of nursing here, I feel I do have involvement. I think the gap is more in practice nursing than district nursing. But, again, I think that the focus on community nursing, particularly in more recent years, perhaps over the past two years, has enabled that focus. And certainly as a director of nursing peer group we have that attention to it, so I'm not sure I necessarily agree with that view. 

Okay. And I realise that you aren't nurse directors, but what is your sense within your health boards of the situation?

I have one-to-ones with my nurse director, and we certainly discuss the vision for district nursing. It's discussed in the primary care committee, so it has that board-level scrutiny. And, whilst I probably would share Rhiannon's view around some practice nursing elements, I think from a district nursing perspective, we certainly have that engagement and, having been to the nurse directors' peer group, I've witnessed that as well. So there is that—from my experience, there is that engagement. 

Yes, the same with me: I have one-to-ones with the nurse director. I would echo what my colleagues have said in relation to practice nursing, but with Aneurin Bevan, because about 12 months ago we became an integrated community and primary care division, those links are now being established and we are working more with practice nurses to address those issues, because obviously practice nursing and community nursing are very closely aligned. 

Okay. And another thing that the RCN has told us is that they feel that Welsh Government is quite keen on new projects, rather than continuing to fund things that are happening already. What's your experience of that? Is that something that you've seen at health board level? Are you satisfied that the regional partnership boards, through their transformation work, are just as committed to consolidating good things that we know work already?

I definitely think that's the case. I think the regional partnership boards are evolving, to be fair. I know they've been in for a couple of years, but that agenda is much more now focused on exit strategies and how you mainstream initiatives. I think new initiatives are important, but it doesn't feel—certainly from my perspective, it doesn't feel in Powys as if we've got lots of different initiatives. I think Lesley and Jo have articulated that it's quite a non-complex, straightforward approach in terms of community nursing. And probably just following on from your previous question, Lynne, I think in terms of the district nursing voice—and it's probably different because Powys is a community-focused organisation with no district general hospital, so our care is commissioned outside—I know that the voices of district nurses and community nurses, as part of the development of our health and care strategy, was really strong. So I think that that just does demonstrate the voice is heard and it impacts on how we develop services. 

Okay.

I would agree with that. 

Okay.

Yes, the only real new initiatives that we've adopted recently, as Lesley said, is the neighbourhood nursing, and that's extremely positive and all district nurses have bought in to that. 

Okay, because my next question was on the neighbourhood nursing pilots. Are there any particular lessons that you want to draw to the committee's attention?

It's definitely around the IT, and it's definitely around—. If you look at the Buurtzorg model, it's predicated on a very sophisticated IT system that supports clinical practice. And for us, investing in our Malinko software—. We've only actually been utilising this with the team since November, so it's very early days, but the value that that has put into the system for patients, for our staff, if we're thinking about our workforce and supporting that workforce, and for understanding our acuity as well—. So, we have offered to actually work with Welsh levels of care—sorry, it's changed its name, and I always forget it—to actually work with the system so that we can input that in, and it's been clinically led. So, I think one of the criticisms has been that, quite often, IT systems have not been clinically led. It is clinically led by the team and by our senior nurse and that, for me, is one of the benefits that the Welsh community care information system does not provide, because it doesn't provide a scheduling system for your caseload, and it doesn't allocate the calls based on your skill set, which is really important. And if we think about the governance structure required in community services going forward, particularly around integrated teams, enhanced care team working, health and social care, we have to have a system that delivers that governance agenda. So, we need to know where our staff are. We need to know what their caseload workload is. We need to know if we need to change things during the day, and because that's real time, it has been transformational for our teams.  

Okay, and in terms of Powys, are there any issues or lessons from the Welsh community care information system operation in Powys that you want to—a bit of a mouthful, that—bring to our attention, and whether there's anything that we can learn for the roll-out elsewhere? 

Yes, absolutely. I think it is quite challenging and, obviously, Powys is the first health board to actually implement it; it's in local authority areas elsewhere. I think some of the challenge has been around the functionality of WCCIS, and the fact that we've implemented it, particularly in district nursing teams, but we still haven't got the mobile function. So, it can go to the patient's home, we're inputting, but it's back at base, so we haven't got those mobile devices as yet.  

I think the challenge has been that other areas—. We'd want this to be a national system—that's been the focus—but it's not mandatory, and I think Lesley's clearly articulated, particularly through the neighbourhood nursing model, the Malinko system sounds much more aligned to perhaps what we need in district nursing particularly. So, I think there's definitely a challenge to implementation. It is resource intensive, and those resources haven't necessarily been applied to its implementation. But the vision of having an integrated community care information system cannot be faulted; it's just the fact of bugs in the system, testing it, and I think as Lesley indicated, there's been a clinically led model, and that hasn't been the focus with WCCIS so far. It's a challenge.  

Okay, thank you. 

Sorry, I just want to ask a couple of things. Regional partnership boards. You've highlighted that they've started to make an improvement and a difference. What more can we do to push the regional partnership boards to actually improve and support community nurses and district nurses? 

I think it's happening, to be honest. I think the focus on regional partnership boards through 'A Healthier Wales' and the strength that's in the regional partnership boards in terms of the wider areas of responsibility is there. So, through that evolving approach to them, there has been much more of a focus on evaluating impact and ensuring value for money, and closing down. So, where there are initiatives that we don't think are delivering what they were set out to deliver, those projects are being closed down. We're at a stage now where a number of initiatives are being mainstreamed as opposed to them being initiatives, and taking a much more—. I think that the population and well-being needs assessments have been really helpful, because we could have had 300-odd projects funded through the regional partnership board and integrated care fund moneys. We've been able to narrow that down to focus on area of need. There's a very different approach in the north than there is in the mid and the south through district nursing: that's been very much about an integrated approach to care, and following through. We were talking earlier about our virtual wards and how multidisciplinary they are—multi-agency, actually, in terms of the whole process of care closer to home, early intervention and prevention, joined-up care, all the areas that are important in terms of the quadruple aim.

So, I think I've gone off on a tangent a little bit in terms of your specific question, sorry, but I think we are getting there. I'm not sure that Welsh Government need to put any pressure on the regional partnership boards, because I think they are evolving and starting to do what they were intended to do. That's my sense for Powys, anyway. 

I see others nodding, so I'm assuming it's the same view. Lynne talked about the pilots, and as it happens, the three of you are the three boards that are actually in the pilots. Can I ask one simple question? Is it across the whole board or just specific areas?

No, specific areas. So, for us, it's north Cynon, and we chose that area because we already have a virtual ward with primary care, and it actually fitted in with some other work that was happening within that locality. Our local authority partners and third sector partners are included in that pilot, and what we are attempting to do is some of the lessons that we are learning now—rolling out some of those to other teams. So, for example, our IT system; we've used Chromebooks, we've moved to an app-based system. So, we've been able to actually extend that to the whole of Cynon. Picking up your earlier point about weekend working and nights, clearly other members of the team, then, also cover those calls as well, so it's bringing those into that environment. So, it is early days, but, yes, it's two district nursing teams for Cwm Taf. I think we're following quite a similar model. It's just that the environments, being rural and being Valleys and city, are different, but we are approaching it—we work very closely together.

And with your colleagues from other health boards, are you continuing contact with them to discuss the progress of those pilots? Because, to give an example, Cwm Taf, in 10 days' time, will take on part of ABMU. So, it's clearly—

We are.

Yes. It's not something I necessarily agree with, but there we are. I've expressed my views.

I won't comment on that. [Laughter.]

But in the sense that—. Obviously, you'll be taking over the responsibilities for district nursing in those areas of ABMU, so are you having those discussions to ensure consistency across those areas?

That service is transferring to me on the first, and, yes, they work in a very integrated way, but it's not just about the neighbourhood nursing pilot, it's about our district nursing principles and aligning the pilot to the principles as well, and the team leader role. So, clearly, there are different models, and those different models can work. It's getting best value out of those models for that population and the vision for that community, because it is a health and social care model and there will be differences in different areas. But, for the patient, they should receive the same service and the same quality of care and the access—nothing should be different.

Sorry, Chair, I've got another question.

Go on.

Thank you for the papers, as I said, but I read through some of the figures there for all of these. From some of them, looking at them, I don't see a dramatic change in the whole-time equivalent numbers from, perhaps, four or five years ago, and we know the focus is now more in the community. I was surprised not to see some of those changes, to be honest. Is it because—I'm going to give you an out here—is it because, perhaps, work patterns have changed and the models are changing? Or is it because, perhaps, there's no-one driving this at board level?

Not the latter, would be my sense, and I think that it's recognising that teams are multidisciplinary and multi-agency. So, it is about other players within the teams. I think we will start seeing a shift, though, because of the work that we're doing around acuity, Welsh levels of care, so—

So, keep an eye on this over the next few years, then, is it?

Absolutely, yes. But I just wanted to pick up, if I may, on your point around sharing the neighbourhood nursing as well, because whilst we're the three pilots, without a doubt that information is being shared right across Wales with director of nursing colleagues, with reporting on all three pilots going through. It's a really good collaboration between the three pilots—well led, well supported—and that's feeding up through to the national peer group as well. So, we're watching this space, really, and it's come a time with a focus on Welsh levels of care as well; it's really exciting, actually, in terms of district nursing. The one thing in terms of neighbourhood nursing that perhaps I've noticed is it's very locally driven, locally led, and the sisters and the team leaders coming up to the plate, really, in terms of looking at different ways to do things. It's almost permission to act differently. It's been incredible—really, really positive.

Lynne asked about the relationship you have with senior management as well. Is there a non-executive board lead for district nursing and community nursing in your boards? 

There's a lead for primary care services.

Ah, there's a big question. We talk about primary care in this committee.

Yes, and that lead includes ABUHB district nursing, and, actually, our non-exec member was a district nurse by background. So, there is that scrutiny around that, yes.

Right, because I think the RCN were very concerned that the term 'primary care' seemed to cover a wide scope, and district nursing seemed to be getting lost in the ether of that definition of primary care.

Could I answer that? Because, actually, I don’t share that view. I think primary care and community services are integral, and they exist together and, actually, district nurses are part of the primary care workforce. They are part of that core provision. So, whilst they’ve got a health and social care element, they’ve got a public health role around immunisation, they look after younger people, they support general practice around chronic condition management. I don’t share that view. I think there is a voice for district nursing, and district nursing services and wider community nursing, but it doesn’t have to be one or the other.

I share Lesley’s view. I think that, maybe, the RCN are talking about when primary care clusters were coming into being through the strategy and the Welsh Government approach. I think the focus on primary care seemed to be GPs, and when you talk about primary care clusters, people were using the language interchangeably.

Clusters are about multidisciplinary teams, and district nurses are a key part of those clusters, working in partnership with GPs and other bodies. So, I think that that might been the case probably three years ago, two years ago. I don’t see that that’s the position now, and clusters, particularly in Powys—and I’ve heard my colleagues talking about transformation—are about the whole team. And it isn’t just about district nursing; it’s about mental health nursing, learning disability, community children’s nursing, and we're taking a much more all-age, end-to-end approach. I think it's transforming.

Diolch, Gadeirydd. I suppose I'll start off with a nice easy one for you. 'Primary care' is terminology being used an awful lot, and I know we've had discussions with the RCN and officials from the health boards. The RCN believes that the term 'primary care' is actually being used, and as a consequence of that, the concept of district nursing is being lost in the whole picture. Now, the health boards obviously rejected that totally. But what I want to ask is: what's your position on the concept of primary care? How do you see the role of district nursing and community nursing being part of primary care, and is it as important in your mind? It is an important role. It has a distinct position. How are you ensuring that that distinct, important role is maintained in all the strategies you've put into place on primary care? 

Chair, I'll start, but Jean may have a professional perspective on it as well. I think you're right to say that 'primary care' is clearly a term that's been used over many years and decades within the NHS, and it can have certain interpretations at times. Certainly, as we've been trying to use the 'primary care' label ourselves, particularly over recent years, it is a broader label than just about the traditional interpretation of it being about a GP practice. We've certainly extended it out. It's probably important also to recognise that even 'primary care' as a label has always traditionally involved other contractor professions, from dentists to opticians who work in community services as well. I would say that, whilst there may be some dangers about losing some focus within it, I would take the Members to the 'A Healthier Wales' strategy that we launched last year, which very clearly was emphasising a focus on community-based services and on supporting people as close to their home as possible. I think that remains our overall approach on these areas, about how we line up a different approach maybe than traditionally just having individual categories of staff groups turning up in front of patients, whether it's in the home environment or in the community, but a real focus around producing multi-professional teams, often across agencies, ensuring that they are providing proper wraparound care for patients as they move through our care and services.

So, I think that there has been a change in our interpretation. Certainly, if I go back to my health board days, we would have probably used the phrase more about primary and community services, maybe to make the broader distinction, but, certainly from a Welsh Government perspective, and even our strategic plan for primary care, it's very clear that it is an extended definition that extends out to the co-ordination of a range of different community nursing roles, whether they are specialists like learning disability, or whether it's the core district nursing role. But I do think, as we've expanded community services and alternative services to hospital admission over recent years, we've grown more some of the resource around the district nursing service, so we've expanded into other community nurses and other practitioner groups.

It is really important to maintain a focus on the district nursing side, and I'm hoping that, as we deliver a 10-year workforce strategy for Wales, which we are scheduled to do under 'A Healthier Wales' by the end of this year, that will allow us to really give clarity on all of the different professions, but will particularly be clear about what we're doing in the community settings about a workforce for the future. But, Jean, you might have a professional take on this.

Thank you. You asked what our view of district nursing is. In my professional opinion, it is the core physical care service within a community setting. So, in recent years, we've been investing a lot of time and energy in looking at the workforce within that area and looking to help support the ways that district nursing teams are currently working. So, you will have seen in the evidence paper that we gave you that we've issued some guidance about how district nursing teams should be shaped, and quite clearly within that guidance it says the team should be led by a district nurse who's got a specialist practice qualification; their deputy should also have that qualification.

We've increased the number of training places, both flexible and full-time training places, very significantly in recent years. You'll see in the paper I quote 233 per cent. That's quite a lot of extra places in recent years. So, our commitment is to say they are the core service, but we have put money behind that and increased the training to support that going forward.

I think it would be fair to say that some of the challenge we've had with the district nursing teams is they haven't always necessarily had the administrative support. So, some of their difficulties—getting around their patch, being the most prudent and effective in their work—are because they haven't got other things available to them. So, the principles we set out have also insisted that they are given administrative support, and that's what we're driving at the moment, to help them be released to do the things only they can do, rather than some of the other things. 

I'm pleased you've mentioned the 233 per cent, because, clearly, the figures also say that 46 per cent of the district nurses are over 50, therefore, within 10 years, probably will retire. So, it is important that you look very carefully at that sector to ensure that we don't have a gap and a void as those come to retirement, or even take part-time work, because that's still a reduction in numbers available, so—.

Could I, Chair, if you don't mind, just respond to that? One of the things we have been doing is increasing adult nurse training places in pre-registration quite considerably as well, so that there are more nurses that are going to be available to enter the workforce. One of the changes that are being brought in with the new pre-registration nursing standards is to make sure that they're prepared to work straight away in the community rather than having to work in hospital first. So, I absolutely recognise what Mr Rees is saying about the future workforce, but we are trying to put mechanisms in place to make sure that doesn't come to be a reality for us.

Okay. Do we have an accurate—I use the word 'accurate'—picture of our workforce, our capability, and the needs that the workforce will be addressing at this point in time?

I've spoken at committees before about how we're trying to change—and this has been over time—the workforce planning approaches across Wales. I do think that the establishment of HEIW, which occurred last year, helps us to really bring together all of the different strands of our workforce in a different way and to make sure that there is national oversight of better workforce planning across all settings, which will include the community side. There are some limitations in some of the data, as we highlighted in our evidence paper ourselves. We're trying to address that and put some of that right, not least working with our statistics colleagues in Government. What it will mean is that some of the overall numbers for community nursing are accurate, in terms of them reporting the shift that we're seeing and this increase that's happened over the last three or four years in particular. But it does mean that some of the numbers associated with district nurses, particularly those directly with a qualification, is more limited and potentially inaccurate from some organisations' submissions in Wales. I think, if we'd been attending in two weeks' time the committee, we'd probably be able to talk about the latest statistical release, where, hopefully, some of this has been put right. That's actually due out next week, in terms of the official statistics. But I do think that we need to layer some other sources of information.

So, two points I'd make—and, again, Jean might have a professional perspective—we do expect the three-year plans for the health boards to be really clear on their service needs on behalf of their population and how they translate those into plans in all of our settings, whether it's hospital, whether it's in GP practices or actually in the community environment. That is maturing and getting better, but I still think there's some further progress that is required. We are also, however, trying to make sure that we have a better level of detail available through the local organisations, but also through other mechanisms. Clearly, again, as in our evidence paper, using the extension of the Nurse Staffing Levels (Wales) Act 2016 in respect of district nursing, setting out chief nursing officer principles that are being followed, that has allowed us to gather a much more detailed level of information. But, certainly, organisations should have a good handle on the balance of community services that they need to put in place. But I do think Healthcare Inspectorate Wales—on the commissioning numbers—would be in a much better place to direct us for some of the increases that are needed for the future.

Well, I wasn't going to mention the staffing Act, but, since you've mentioned it—. I've read the papers indicating you're developing a tool for that. When do you think you'll have that tool in position, because clearly it's a modernisation, I'm assuming, of the current acuity tool that you're using for acute wards? And when do you think you'll have that in position? Because the needs of the communities, or the needs of these individual patients, are going to be definitely varied and different across Wales in one sense. So, how are you going to make sure it meets everybody's demands—the rural communities, urban communities, deprived communities, all that combination. 

Is it okay if I answer that, Chair? Yes, you're quite right to say that this is very different to saying, 'Let's have a tool for a surgical ward', which is quite a discrete thing. We have taken learning from the acute sector, as we've now got it on medical and surgical wards in our hospitals, and are applying it through vigorous testing with the district nursing teams to see how it applies. So, it's not an issue of geographical things that we need to think about; it's still about the patient's needs. So, somebody who's got a chronic chest or a leg ulcer, it doesn't matter really where they live, that will be a particular amount of nursing time that will need to be spent. So, where they're living isn't really the issue; it is more about how do you work out some of the other things that might be going on, because you're not just treating the person's leg ulcer, you have to think about the whole context in their home, their living arrangements. So, it's some of the wider determinants that have to be taken in as factors.

We are still working rigorously at the moment on testing, and that will take as long as it takes, really, to make sure the tool is right. We are trying to ensure that we go as fast as possible, and the Minister for Health and Social Services has funded additional project support to help speed up some of the testing—and that person will be in post in a week's time—as well as having some additional administrative support to start gathering more of this evidence. So, we're still hoping in the next year or so that we'll have a tool. The Act clearly says that we have to have something that's effective. So, it's not just a commitment to extend; you actually have to have the tool that actually works, because, if you have the wrong tool, you may end up with the wrong outcome. So, we're being very careful about how we do this outside in the service. 

I think the other challenge for us is to make sure that the technology is there to support the district nurses to do it rather than—. A lot of them now work off paper-based things. They need to have more electronic, digital equipment to do this. So, the two pieces of how you do it technologically, as well as what you're actually doing and measuring the workforce—they're going in tandem with each other. 

Technology-wise, we'll come to that at some point later on this afternoon. I just wanted to be confident that the combination of both medical needs and social needs of the community will be included in any acuity tool, because the acuity tool is part of the process of identifying the level of nursing requirement, and social needs will definitely have an impact upon that.  

Yes. Just to say that the methodology set out in the Act describes looking at patient need but also using professional judgment. So, that's a very important point and I absolutely agree with what you're saying—it has to be the context. A person's living arrangements are as important, quite frankly, as, possibly, the condition that you're managing. So, yes, it would be a factor.

And we do need to see the principles linked into impact. So, even in the early days of us just starting the data collection, we already know that we've seen a shift in compliance against the principles—it's up to about 75 per cent in these early stages—but we've also seen an expansion in the reported district nursing numbers that have come through that mechanism as well. Because, by setting them, we are expecting, actually, organisations, obviously, to adapt and change the service. 

Let's go back to the current day, then. Having verified that the needs vary, and that's why the complexity and taking the time over the tool, which I accept, but, today, do you have a figure as to what number of community nurses, how many community nurses, need to be trained in becoming children nurses? How many are, actually, vacant at this point in time—not just district, but community nurses as a whole? Do you have a current picture you can tell us today, 'Yes, I know exactly what's happening today. I can tell you how many vacancies we've got. I can tell you many specialists we have in children's nursing. I can tell you how many district nurses who are qualified that we have'? Do you have that information?

So, we have a lot of information. Whether we have all the information the way you've just described it, I think it would be unfair to say that. So, for district nursing, I can absolutely tell you I know exactly how many we've got, where they're working, because, every six months, we've been gathering data from the service, and they tell us how compliant they are with the Act—sorry, the principles, because this is a precursor to the Act, as you understand—and I know how many vacancies they're carrying. So, I can tell you very accurately what the service has in that.

To do with community children's nursing, that's somewhat different, because we haven't set a particular benchmark for Wales. There is advice that people like the Royal College of Nursing talk about—I think it's 20 community children's nurses for 50,000 patients. That's a kind of a general professional standard. It doesn't have any resonance outside of just being, 'This is what we think, professionally'. So, we know, in Wales, that our community children's nursing services don't match that particular standard. What we expect the health boards to do is to work out how they're going to shape their local services to meet the needs of their population. So, we did a review back in December of 2017 where we were shown how many community children's nurses are actually employed per head of population. And, yes, there are some variances across Wales, but we haven't set a benchmark in the same way that I have done for district nursing. So, the health boards have been shown their data, comparable data, and we said, 'Well, this is what the position across Wales looks like—what are you going to do now about your local services?'

So, there is some variation in my answer to you. Some things I'm very sure about. In others, because we haven't set a benchmark, I'm not quite sure what I would say to you, how many we're short. Well, we haven't actually set a determination about how many they should have, because it's a local determination. Through their IMTP process, they're supposed to work it out.

Okay, I accept that, and therefore you can tell me, basically, on consistency across Wales of district nursing, whether they're meeting their levels. It's a variation on others, but, I suppose, what I'm trying to work out, therefore, is: are you confident there is consistency of service to communities across Wales or does that lack of confidence in then having the detail of knowing those numbers still give you concern that there may not be consistent service across Wales?

I don't think we can say there's consistent service. Some of our national approaches are about setting consistent standards, but there will still be different approaches in the way in which some of community-based services organise themselves. They may give the broader services—and this is beyond just district nursing, for example—different labels, from frailty, for example, to Stay Well at Home in Cwm Taf, which are picking up this kind of client group. So, we're trying to focus, actually, on the standards and then the specification side, in respect of, e.g., the district nursing numbers. We also know that, while we're trying to track it, as I said earlier, some of the occupational codes that are used for some of the subspecialties of community nurses aren't accurate at this stage either, so we are very reliant on the information that comes through from the individual services. 

Let me put it this way, then—. And I understand that. Let me put it this way: are you reasonably confident that a patient in Powys and a patient in Gwynedd and a patient in Morriston would actually have the same care and treatment and services from their community nursing teams irrespective of what title they currently have? 

I think we could be more content with that as a description. We know that some of the district nurses will revert to other overnight community-based services, like an acute response team, perhaps, in Hywel Dda, rather than a district nursing team elsewhere. But yes, our focus is to try and have as consistent a standard as possible. There will be variation, sometimes, on access for some individual areas, because it may well depend on the workload or the individual staffing arrangements, even down at a cluster or a locality level as well, but I think, nationally, our emphasis is on making sure it's as consistent as possible. 

As an aside, as we go through the transformation fund process—and we've been focusing on trying to work our way through individual submissions from regional partnership boards about community-based services—we are, at least on that, having to sit down to make sure that there is a consistent level of evaluation that's happening, again to hopefully answer your question about whether it's a standard approach or whether there are any differences as well. But we have got some innovative approaches that are happening where, inevitably, as soon as somebody's being innovative in one area, it means it will be a slightly different sort of service. But the care standards, we are trying to focus on.

You mentioned the focus on children's nursing in community-based nursing. Irrespective of some problems with the numbers, what we have recognised, however, nationally through the commissioning numbers, is that there was a need to expand those particular areas to make sure that we had a pipeline of individuals that would come through for the posts that we do need in the community service. So, just to say, for children's nursing and also for learning disabilities in the community context, there's also been an over 50 per cent increase in those commissioning places. Again, that will help us over the course of the next five years or so, as those come off the training schemes.

I appreciate that, and I did recognise in the figures that you have increased the placements for those positions. I suppose my concern, and a question I asked the RCN, was: are you confident that the increase in children's nurses will actually go into the community, rather than go into the tertiary sector or the secondary sector? I suppose that's one of the concerns I had.

So, there's going to be quite a significant demand for children's nurses in the community, because it's not just community children's nursing—which is quite a small service, because there is only a small number of children that would need that sort of care—but we do have general services of school nursing, of health visiting, and they're all fed by the child branch of pre-registration. And we do have frameworks for both school nursing and health visiting that do set quite clear instructions to the service about how many staff they should have. So, in the school nursing framework, for example, we have now for the very first time set out requirements for special schools in Wales, because we never had a policy around that before. What they will be doing is actually looking more at a team-around-the-family approach. So, if you've got a child with a learning disability, they will be working with educational psychologists, with speech and language therapists, but with the community team, not just the time the child is in school. So, there's much more about integration across professions and with teams. There's going to be more demand for children's nursing full stop, outside of a hospital setting, and that's right and proper. We don't want our children in hospital, at the end of the day; we want them home with their families.

I'll come back, then, to one final point, and I'll pass on, then, Chair. So, 24/7 services is what we give and that lots of people need, whether it's in hospital or in the community, and I know there are challenges for those services, particularly on weekends and out of hours. What I term as 'out-of-hours' is late evening and overnight. How are you addressing those? Because I'm sure you must be aware of those concerns and you must be aware of those challenges, and particularly when there are going to be some sessions of GP out-of-hours not actually being delivered in a particular location, because of, again, a shortage of GPs coming into those services. How are you going to address the 24/7 agenda to make sure that, no matter what time of day it is, when you need those services they're going to be available to you?

You're right. Whilst the NHS is a 24/7 service, inevitably with access points through the front door of an A&E, or the ambulance service, or indeed in that sort of community setting, there are a number of services that don't, however, run on a 24/7 basis, so we do need to adapt to that. I think that the challenge for us is to ensure that as much as possible is anticipated, so it's not about crisis interventions that occur out of hours, and certainly some of the approaches that we've seen in Powys, about some of their extended community nursing provision, are all focused on trying to accommodate as much ahead of the night period, for example. However, there are always crisis points that need to happen. I think we need to ensure that there is a consistency around out-of-hours provision across the whole of Wales. We're trying to focus on that through our 111 services approach, as we roll that out across Wales. I think that will allow the security of at least a triage mechanism that works consistently, so that people can always access those sorts of mechanisms. And I do think that we can do more to ensure consistency, but at the moment across Wales, in a community context, there will be access to community nursing based on individual patients' needs and, clearly, areas like palliative care provision and supporting those last days of life are going to be really important settings, not just to treat an individual, but actually to care for them in that very difficult set of circumstances as well. But problems of workload, pressures and demand will all add into the mix into that system, and what we need to make sure is that we're always able to provide as individualised care as possible. So, I think, actually, some of the evidence that you've gathered yourself, I think, is useful for us as a committee to inform some of the choices that we need to make in terms of setting some of the standards and specifications for Wales. I accept that there will still be some difficult individual circumstances, but we are trying to build up the jigsaw pieces of a system that can actually provide that holistically and 24/7.

Okay, fine. Just to make a point—I don't want an answer to this one; it's just a point here—the care for the individual 24/7 and the difficulties you have sometimes—. Don't forget the family and the carers, because the stress you place upon them if they don't get the service is huge. 

Indeed.

Okay. Moving on, it's Dawn Bowden. 

Thank you, Chair. I just wanted to ask you a couple of questions around strategy and oversight, and I think, in answering Dai Rees, you covered stuff around staffing principles and additional training places and so on, but given that we don't have a specific national strategy for community nursing, how are we actually monitoring the service? It's going back to your point, Andrew, about consistency, trying to identify how it's—. How are we doing that? And are we confident that the role of community nursing is actually delivering or helping to deliver Welsh Government's vision for transformation in services, particularly integrated health and social care?

So, I'd return a little bit to what I said in my earlier answer, that there is a danger of us wanting to pursue lots of individual visions and strategies for services, and what we tried to do in issuing 'A Healthier Wales' last June was to stand back, to set the vision but also the expectation for the system in much broader terms about settings, and I would openly say that as well as needing to emphasise, for example, the importance of district nurses as a profession—and they are essential, as Jean said, as the core physical caregivers within our system—we are trying to promote the broader concept of the multiprofessional, multi-agency work as well.

Now, we have accommodated a push on the community expectations for the workforce within our strategic primary care approach that was issued last November by the Minister, and we talked earlier about the wider definition that we've looked to apply in that. So, we are trying to make sure that's discharged, but, on the monitoring side and the clear expectations for how the workforce should look, I'm really looking for the workforce plan that will come out by the end of 2019 to just help us to shape that more significantly. I do still think that, although we've made improvements, our traditional approach in Wales was to look at how many people we trained last year and then probably add a little bit to training people next year. I think we've changed that approach over this recent period of time and made a large step up and a large-scale investment in some additional posts on a range of different areas, ranging from nurses to community midwives, but I think we do need the workforce plan to spell out how we would track these expectations and track the development of the workforce in that way. Obviously, we need to be able to track those sorts of areas because, irrespective of the fact that every organisation in Wales is responsible for its own budget and for its own workforce, we know that we will have to make some judgments nationally for the Minister to endorse and accept recommendations on the expansion of development of other staff groups as well, and we do have a role to play around that national commissioning table as well.

On the transformation agenda, fundamentally, if we're saying that one of our tests for the current system is that we will create this shift from an over-reliance on hospital care into a primary and a community setting, we absolutely need the expertise and the experiences of those staff and those nurses who are working in the community sector, and I would hope that, even looking at the nature of the transformation fund proposals that we've had in—some of which are not yet approved—there are distinct and core community nursing aspects to all of those, even if they are across a broader team, and one assumes and hopes that there would have been an expectation that they weren't just, sort of, people sitting in a room being creative. What I've learnt over the years is you listen to your front-line staff. They have the best ideas in terms of the impact it's going to have on patients, and you find a way of facilitating that and brokering it. So, the assumption is that that would have been shaped in those local discussions with that kind of involvement.

Sure. I've seen some good examples of some of the pilot schemes that are running around that. Can I just pick up one point you were making their about district nursing as a career choice, really, and whether we could do a little bit more to promote that specifically, particularly in light of what you've just been saying about that shift of emphasis away from secondary care so that district nursing becomes more of an attractive career option? Because we've actually had quite conflicting evidence this morning. We've had the RCN telling us that their district nursing members, their morale has never been lower and so on. And then we had three health boards that are running the Buurtzorg pilot talking about how the morale of staff is sky-high, it's been great and they've responded well and so on. So, there is a bit about the way you deliver the service, I guess, that makes it attractive. So, really I suppose my question is: how do we steer people who have got a thought about going into nursing to possibly district nursing being the career choice rather than just going straight into acute nursing?

Jean, to start.

I absolutely agree with you that we have to make jobs look attractive to encourage people to go into them. So, it starts in pre-registration and being exposed to it. As you know, we expect nurses to come out at the end of the three-year programme being able to work absolutely everywhere, so it's very important that they have a positive experience of that. But I think more so we need to start thinking about what the career pathways are that keep them in the community, because in the past it used to be you'd be a community staff nurse, then you'd become a district nurse and team leader, and that was kind of it—there was nowhere else to go. So, in recent years, we've been investing in advanced practice, so that's a higher level of skills so the nurses are able to diagnose and prescribe, actually run their own clinics. So, with the workforce plan that Andrew was referring to, we're starting to see what different kinds of roles could be created for nurses in the community that will give them much more of a career. So, in addition to district nursing, there will be advance practice—or nurse practitioners as they're often called, who might work alongside the GPs or almost as an alternative to some delivery of service. You will see chronic conditions management run by nurses, not managed by doctors. In fact, we've had examples of Nurse of the Year winners previously—Louise Walby from two years ago—. She is a community nurse facilitator. She looks after COPD, I think in your constituency area. But we would also like to see at the very top end consultant level nurses who are focused in community. So, this workforce planning in the primary care cluster footprint, looking at the needs of that population, needs to have lots of tiers of opportunities for people so they can see that there is a career outside; they don't have to go into hospital again to get the higher level positions.

And would you see those career opportunities starting really at healthcare support worker level? Again, we saw some great examples in Cwm Taf of band 4 healthcare support workers working in the district with community nurses and so on.

I think we've very well supported healthcare support workers in Wales. I think there's been some real success in expanding and developing that, but we do need to think about these entry points, both for the role itself but as the possible opportunity to progress differently through the structures. I think our approach to community nursing and to nursing more generally would be absolutely wrapping around the healthcare support worker, up to the consultant nurse and finding a mechanism in which we can have lateral opportunities as well as the opportunity to progress upwards. I think that our approach on this has to bring some energy and excitement about the high expectations for community services. I think that's kind of the vision were trying to grab with 'A Healthier Wales'—you know, community services should be seen to be where it's at in some respects beyond the traditional acute experience. I think we can handle the development of roles and offer that. I think a commitment to positive recruitment, including the expansion of training numbers, is important. But we also need to recognise that some of this will be about supporting workload in different ways, because as much as we can be energetic about what the future represents, if you've got a very high workload in a service that's feeling under pressure, ultimately, I think we've got a responsibility to make sure that that individual team feels well supported themselves.

And I hope we've been able to convey some of the opportunities for nursing more broadly in community and nursing in our ‘Train. Work. Live.’ campaign, which we initiated more around GPs and on the medical staffing side but which we've converted to be other professions, but with a real focus on nursing. And it was good to see that, in our publicity and promotion through last year, two of the individuals who stepped forward to talk about their experiences were actually from a community nursing background, hopefully to talk about good things we were up to in Wales as well as having some pragmatism about pressures.

Yes. And two final questions, which are kind of separate but related—and thank you for that, Andrew—. They're separate but related. The very nature of district nursing means that, although they're working in teams, they're very often on their own with the patient in their homes and so on. So, how robust are our governance arrangements around ensuring safety and quality of service when somebody's working on their own in those circumstances? And the linked question to that is: how do we build into the team-working arrangements, I guess, the safety and well-being of the staff who are working in that service? Because it is very much a lone-working environment.

Yes, you're quite right, it's much more difficult, particularly for staff who are on a lower grade, to have the support when they're working in isolation. However, our community services are usually organised within teams, and it is a team approach that goes on. So, the team leader, if it's a district nurse, would make sure that she or he delegates the work appropriately. And there are reporting mechanisms for things like serious incidents. So, things like pressure ulcer damage are quite a good marker. So, say a patient is admitted to hospital with a pressure ulcer that has started in the community, there will be a root-cause analysis that will look into the community to see if there's something going on there. So, it is one of those red flags for us in terms of quality of care.

There are things about supporting within the team; there are things about reporting incidents that will act as a trigger to have investigation. I think it would be fair to say that the teams that are under pressure will feel stress, I think, if there is a high workload and perhaps if they're carrying vacancies. Then, that is exactly, as Andrew's referred to, that is quite challenging for them to manage. And they will have to take a risk-based approach to what work is actually done.

In terms of well-being of the staff, obviously, there is a commitment from the whole of NHS Wales to make sure it looks after its most important resource, which is the staff. In fact, 'A Healthier Wales' has a specific aim that refers directly to staff and making sure we recognise that their well-being is really important. And there is a programme—a health and well-being programme—that is running this year, which is going to look more and more at that. I know Paul's worked in community more recently than I. Perhaps he can give you some real examples of that.

I was just going to say the district nursing staffing principles—at the heart of them is the size of the team so that the team is not too big so that the team leader can't provide supervision, and not too small so that they're not sustainable. Lots of evidence was gathered about the most appropriate size, and that evidence also supports the continuity of care for individuals receiving care from the team. Too big a team, you could have lots of people crossing a threshold, a smaller team, you have—. So, it drives up quality of care. The principles also not only ask for a team leader who has the appropriate qualification, but that 20 per cent of their time—at least 20 per cent of their time—is spent on supervision and that a further 20 per cent of their time is spent on case management. That's actually going out and looking after people. While they're looking after people, they're seeing how others have looked after them, and supervising, they're doing that alongside. So, we are driving up supervision at a very low level but also, the team dynamics are changing because of the principles.

Okay. That's fine. Lovely.

David.

Just on that point, then, is it possible, therefore, to have two teams in one cluster because of the size of the cluster?

Yes. In fact, a cluster will be made up of multiple teams. There's a cluster maybe made up of multiple GP practices.

That's what I was wondering, whether a cluster—. Because we often get distortion from statistics—teams linked with clusters. So, it is possible to have more than one team in a cluster.

Yes. Teams can be gathered around a 5,000 population kind of level. So, yes, some of our clusters—30,000 to 50,000—so, obviously, you can have it—. However, it is important that they find ways of aligning up to the locality models that are in place: aid to access other services such as on the social care side, but, yes, the cluster template is quite important in the way we're overseeing all of our community services.

One of the key principles is that the teams are arranged in a way that they are coterminous with the cluster as well.

I might come back on my 24/7 and the out-of-hours linking in then, because I know, for example, in my area, that the clusters might be there, but overnight, it's centralised somewhere else.

It goes more regional—that's absolutely true, it does stand back. That's why I said earlier some of our opportunities on supporting community services will be, yes, sometimes, you go up a level to access, but that kind of triage mechanism and using the technology—you know, ABMU is an area that has been rolling that out more so than across the whole of Wales, with the 111 changes that they've put in place. But as you assess these services, it will always continue to highlight gaps in service shortfall and I think we've got to keep putting that right, actually.

One of the big gaps is getting people to understand what triage is as well.

Indeed, yes.

Okay. Lynne.

Thanks, Chair. Andrew, you referred to the role that nurses are playing in transformation, but we have had evidence from the RCN who said that there are still problems in this area, and they specifically referred to variation in the level of involvement that nurses have in cluster work. Have you got any comment on that?

I think, again, if I stand back and think about our 64 clusters in Wales, on the one hand, while we allowed them to grow from local arrangements and oversaw it, we've been much clearer over the last couple of years about our expectations for the clusters. So, we've been even using negotiations on, for example, the GP contracts, which have had a cluster focus over the course of the last two or three years or so. But it's definitely true that clusters are still progressing at different stages across Wales. I think some are performing really well in a multidisciplinary setting and a multi-agency setting, with a very wide representation around the table. One of the tests for that is how many of the clusters, have, for example, housing representation there. There are others that are probably at an earlier stage, almost consolidating some of those locality-based relationships, probably between the GP practice team and the health board teams at the same time.

I'd be disappointed if the general message was that there is no involvement of any community experience, because, again, I go back to my health board days, the trick was how you had to make a strategic decision on behalf of the health board, but you absolutely would run it by reaching into the organisation to get that expertise. So, I would've thought that, unfortunately, there probably is variation within organisations on that approach, irrespective of the fact that we see some variation across Wales. But we are trying to grab the expertise of individuals. So, just to refer to one item that you might have an interest in anyway, but on the development of our community systems in Wales, we have linked into district nursing expertise, community nursing expertise on the records, on the nursing documentation, on the specification for the way in which their part of the system would work. And we have ensured that we've drawn them into that, because that is a transformation agenda. So, if there is evidence on specific areas that we're getting it wrong, then, obviously, I can pick that up more through a conversation with the chief executive for them to be aware of it, but I personally have always tried to make sure that we listen and draw in the front-line staff.

Okay, thank you. Can you tell us, then, what community nursing projects are being supported through the transformation fund?

Actually, all of the transformation fund proposals that have been approved but also those received that are pending approval are all in line with the community specification. They all are intended, however, to not necessarily only say, 'This is about having more district nurses' or 'more children's community nurses', they are holistic multi-agency proposals about gathering the right range of individuals. For example, in Cardiff, there's £2 million that went to them as one of the individual parts of their proposal that was about supporting quicker and earlier discharge home. And obviously, as you would expect, the community district nursing element was a part of that, but it was also alongside others.

If I move from the transformation fund and I think about other areas that are being invested in and have an impact, the Stay well@home scheme in Cwm Taf, which won the NHS Wales award last year, I think has been a really excellent example of community-based working across different professions. There, again, is a nursing aspect to that as well. So, there's a material amount of funding that's gone in. Today, I haven't really got—well, what would be the extra contribution, which is the specific community nurse. If it would help to get some summary of those to you, perhaps through the lens of the community nursing perspective, I'd be happy to provide that afterwards. But I can assure you that all of them are community focused, and therefore, there is an alignment with the community nursing profession and an alignment with district nursing, as well.

Okay, thank you. Are you able to provide any further update on the neighbourhood district nursing pilots, in particular, the timescales for evaluation and roll-out?

We can. It's been a very specific commitment to go in. I suggest that Jean is best to give just a brief overview, but actually, we've got our resident expert with us, Paul, who is overseeing the Buurtzorg implementation and uniquely, has, therefore, been there and seen it in terms of the original model as well. So, I don't know if you had any introductory comment, Jean, but I'd suggest we use Paul's experience to comment.

Yes. I mean, we've been focusing a lot on numbers of staff. Actually, what they're doing is really important. So, the Buurtzorg pilots are really allowing us to test out different ways of working, and we're trying to learn from examples outside the country. So, part of Buurtzorg, for those of you who are not familiar with the term, this is a Dutch model that is very much a social enterprise background. We're looking to see how they shape their services and apply it in particular areas.

Before I go on to the three pilots, just to say we took the learning from that and applied it to the principles, so the whole thing about 15 staff to 5,000 patients, that's all come from Buurtzorg. It's all about small teams with expertise looking after small populations, having continuity of care, and so on. So, we've already taken some of the learning and applied it everywhere. So, the three pilots are not the only thing we've done with Buurtzorg, but Paul is in a better position because he is much closer to this than I have been.

So, the pilots have been prototyping different ways of working. The three health boards are Cwm Taf, Aneurin Bevan and Powys, representing the Valleys, urban and rural areas of Wales. It's two-year funding. We're just coming to the end of year one, and if this committee had been in a couple of weeks, I would have had the end of year one reports from them.

I have been and visited all the sites. There is some really good early learning, so, we know from Cwm Taf they've got some specific scheduling software. The scheduling software enables better use of nurses' time during the day, it helps route them. On average, it's saving them something like 14 miles a day, which has given them the time not only to have breaks, but to have a meeting during the middle of the day—they call it the huddle. It is something to behold, because you actually see them using technology when they do it, and I'm used to seeing district nurses carrying diaries, so it has been a cultural change for them, and it means they're getting home on time, so their well-being has improved.

In Cwm Taf, they also didn't have any administrative support within their district nursing service, and they put in the minimum 15 hours for the two teams that they're piloting. They feel that that has released enough nursing time across the whole team that's equivalent to having an extra registrant. So, they're actually getting another visit in—everybody—which is the same as having another member of staff. So, it really shows that it's not just the number of district nurses you need, it's the way we support them to be able to deliver their care. Technology can help, skill mix will help, and I'm sure they gave examples of how they're trying to improve skill mix within healthcare support workers.

Powys had already done virtual wards right across their system. They had really good ways of working. They had really low admission rates, so they're going to find it difficult to demonstrate the impact, and that's part of their challenge for prototyping: how are they going to demonstrate impact? They were already very neighbourhood focused because of the rural nature.

In Aneurin Bevan, a very urban area, it's: how does the district nursing team reflect the community that they're serving with all the challenges? And they've had significant challenges in their areas through staffing and skill mix and getting people, getting the team settled. So, they've made a start, but I've yet to see it and I'm waiting for their mid-term report.

Towards the end of the second year, I'm hoping to get end-of-term reports, but I want to see how they have taken learning that has worked, and then rolled it out across their health boards, so we understand how we can scale it up so that, at the end of the reporting period, at the end of next year, we will be able to say, 'Well, this worked, and this is how we scaled it up to the rest of Wales'. These pilots are not in isolation. They are part of transforming primary and community care. They're part of the strategic planning for primary care across the whole multidisciplinary team, but it's not just an isolated nursing pilot, this. So, all the reporting mechanisms are through the directors of primary care, as well as to us.

Okay, thank you. In terms of the Welsh community care information system, why is that not being mandated across Wales, given the commitment in 'A Healthier Wales'?

It's a mandated system for the NHS, in terms of the community care information system. It's not mandated for local government, because, ultimately, local government has a different reporting arrangement through its local democratic arrangements, and can determine the systems that it wishes to do. But the principle of it is for this to be available to all local authorities to use, to have access to that social care data and information. In fact, 12 of the initial organisations who were using the system actually are local authorities themselves. So, I think if I was qualifying the label of the mandate, I think it's just respectful of the fact that we oversee—Welsh Government—the NHS, and there's a different relationship in there, but there's been good progress on the local government side.

On the NHS side it's also important that, rather than just respond to Welsh Government requiring the system to be in place, it has to be owned by the organisation. They have to have worked through their business case. There's a danger of people seeing it as about just plugging in a couple of wires and, there you go, there's an information system to be used, and actually this is about change and supporting staff in their clinical practice in communities, and we often don't recognise the change aspect of it. So, we've got Powys local health board already using it. I think that represents their particular environment in Powys and they were always keen to be there at the outset. We've got deployment orders that have been put in place by two others of our organisations at this stage, and others will come down that aspect. But a lot of that is just because they have to manoeuvre their business case for the investment that will be needed, both for the staffing and for the IT, through their board mechanisms at this stage. 

I'd like to see this rolling out more quickly. At the moment, for those organisations already signed up, including the additional local authorities, we would be seeing all of those have got to their end point of implementation by probably around April 2021, although that could go into 2022. But we need to persuade the other organisations to move forward on this, so one approach that we're taking on this will be to look at our use of digital funding that's been announced alongside 'A Healthier Wales'. And I think our intentions are to allow ourselves to mobilise this, because this was one of the explicit commitments that was given in 'A Healthier Wales': we would be using this information system. And I'm still mindful that, whilst Cardiff, for example, does have a community information system, a number of the health boards still have their staff very reliant on just using paper spreadsheets and records in that way, and that is not conducive to good support or care. So, technology would make a difference. 

Okay.

Dawn's got a supplementary.

Yes. It may be an unfair question to you, Andrew, but just in terms of considerations, on technology, with the transformation fund bids, for instance, we've seen a number of pilots, and I'll just give you an example: in my patch, we've got the introduction of general practice support officers in the GP surgeries. But because it was a joint bid between the local authority and the NHS, they're sat in GP surgeries but they're employed by the local authority. And the two IT systems can't speak to each other. So, they sit there with two computers on their desk, an NHS computer and a local authority computer, so that they can do the work. Now, I don't expect you to have the answer to that, but is that something that is—? As we're moving towards greater and greater integration, we surely have to have IT systems that can speak to each other across these services.

That's the whole point of the Welsh community information system: it is to create the standardisation and the consistency. It's why we've had the sign-up, which, uniquely, was across the sectors in this way. And it's why, in Cwm Taf, for example, we are expecting that they will be looking at their own deployment order to do that, because the danger otherwise is staff find their own ways of working through the system on behalf of good care for patients, and that is the whole purpose. 

There is a bit of an outstanding issue for us as we deploy the system. Local authorities are, in effect, replacing systems that they already had with an improved system. We are putting in the community information system, in many respects, for the first time in some of our areas. So, certainly, getting the specification right for this system is quite important. So, whilst Powys got over the line and we're learning a lot from them, a larger health board implementing it for their own patch is quite important to learn from at this stage. We are up to 11,000 users, but, in Cwm Taf, it will be the Welsh community information system that will actually stop that need for staff to have that access to separate systems. It's not conducive to good care or staff workload, I'd suggest.

No, absolutely not. Frustrating for the staff, as much as anything. Yes, thank you. Okay.

Okay. Lynne, are we done?

That was my last question, on the interface.

Lovely. Okay. David, did you have any further issues?

I suppose one, yes. I applaud your vision. Everything we've heard this afternoon, linked with what the health boards were telling us this morning, gives us the impression that everything is going well and smoothly, but if I go and talk to some of my district nurses, I can tell you I won't get that same message. So, I suppose what I want to ask is: how do you hold the health boards to account to ensure that this is actually improving? You said earlier this afternoon you rely on their three-year plans and assessing their needs, but one of the big questions I have from various people in my constituency is: who holds the health boards to account? So, how do you hold them to account to make sure they are actually delivering what they should be delivering? Do you insist upon a member of the non-executive board to be actually a representative, or have responsibility for community care, community nursing, not primary care in this case—I'm specifically using the words 'community care and nursing'? So, an important question to ask is: how do you know and how do you hold them to account, not listen to what they tell you, but how do you check what they are telling you, and how do you hold them to account? 

I think there are a number of different approaches. We have just received in January this year three-year plans from organisations in Wales. For a couple, there were annual plans there as we look to make progress, but our guidance was actually updated last autumn with the expectations of 'A Healthier Wales', because it was such a significant plan to take us through the next 10 years in terms of aspirations. We have used the three-year planning mechanism beforehand also, I should say, to put a particular focus on individual areas. In fact, I think back in the previous financial year, we did put a particular focus around some of the community nursing areas to work through. We've just been assessing those to see how different they feel on the back of 'A Healthier Wales' and for a justification.

We are trying to track different ways of understanding the choices that are being made by health boards and trusts in Wales. So, for example, as we went through budget scrutiny, there's always this discussion about how we ensure that allocations are being made more towards prevention and community settings, rather than the traditional hospital services, if that's the strategic direction of approach. So, I'm sure that there'll be some financial opportunities for us to track how the budgets have changed. Some decisions are actually for us centrally to discharge, so if I look at the transformation fund areas, rather than just pass the money over and then wait a couple of years to see what happened, what we have are clear evaluation criteria that we've put in place to track those things through, and there are contact points with the organisations about the progress they're making and the shifts that are happening. But we have lots of performance management mechanisms to try and track these things through—monthly meetings, mid-year and end-of-year-reviews that happen, and, certainly, the framing of this year's reviews will be the progress that is on 'A Healthier Wales', whilst recognising that there are general measures that we still need go at.

I think on the professional side, Jean, you always have that opportunity to ask particular questions about the nursing aspect. I know last year you were very focused on the broader Nurse Staffing Levels (Wales) Act 2016. I know this year you'll be really focusing on the district nursing principles, for example, as one of your questions in that setting. We have to have a degree of trust, however, with the organisations, so those organisations that are more in escalation probably have a bit more contact and focus with us than those that are not, but, again, if there's any evidence or concerns that are happening that some organisations don't seem to be making the progress that we do, I hope you would pick up on it. But sometimes we have to use the intelligence round us as well, whether that's AM concerns, committee concerns or, indeed, sometimes the levels of complaints that we receive centrally as well.   

The other thing we were told about was the Wales Audit Office checklists. Are they being effectively used? I worry about checklists, because it's easy to tick a box. It's actually assessing that that box that's been ticked has actually correctly been ticked. Are you using the checklists and are you ensuring that they are being applied correctly?  

So, the Wales Audit Office put it out for the health boards to use. I understand that the Wales Audit Office has not gone back to do to a follow-up, because it's their tool, so it wasn't really for us to performance-manage them. I think it's a fair question to ask and, certainly, one we could ask about how they're being used, but we haven't been reviewing that compliance with the use of it. But it was more of a 'Here's something helpful for you to follow' rather than 'You must do this' kind of a measure. So, we haven't been using it in that hard performance way, if you like. 

I appreciate that it's helpful, but I just wondered—it would be helpful for you to look at it, because if it's a helpful tool and they're not using it, I'd want to know why they're not using it, for example. 

We're just about to go into the round of the performance areas. We'll throw that in as one of our questions, irrespective of whether we try to get that back to you or not. We'll just ask that as one of our general questions.

I omitted to answer your question about lead individuals. There's a danger on the one hand to almost place the whole focus of community services on the shoulders of one individual independent member, because I think the shift that we're expecting is for everybody to own it for the whole organisation. But, typically, whilst they have a technical responsibility for primary care, it's been the vice-chairs of the health boards who have used the broader definition of primary care for that to cover community services. So, again, from my past in Aneurin Bevan, I can tell you the vice-chair absolutely was looking at the community service provision that we were taking forward, and, of course, there are individuals who sit around that table who also have the direct service responsibility as well, whether that is a nominated director of primary care or whether it's accommodated within the chief operating officer roles. In my time in Aneurin Bevan, genuinely, there was a real balance in our agenda between the focus on the hospital services and actually on the community services, including mental health, and we did feel that the agenda was able to reflect that. But I did have a number of individuals who were previous LHB chief executives and probably had more insight and experience, maybe, into some of the environment around community services. So, that was helpful for me in my patch—but that was a decade ago now, I've just realised.