Health and Social Care Committee

I think it's probably worth just reminding people that over 50 per cent of the Welsh budget is spent on health and social services, and most of that goes directly to the health boards and to the health trusts. Some of it obviously is kept centrally, some of the money goes on children's services, some of it goes on care. Obviously within that, there's the mental health part within the health boards. And of course, that is used to fund all the thousands of activities that take place treating patients every day. Just to remind you quite how much is done, in an average month, we're talking about 370,000 people being treated within secondary care. In December [Correction: 'In one week in December'], we treated about 400,000 people in primary care. We had contact with about 400,000 people, which is a huge amount; we've never seen anything like that.

I've already confirmed that about £8 billion of the NHS funding will go to the front-line NHS services, and that includes an additional £115 million to meet the core costs and demand pressures. You'll be aware of the considerable pressures at the moment on the NHS. I've again made £117 million available to tackle waiting times, and that is consistent with our pledge at the beginning of this Senedd term to spend £1 billion on addressing the backlog. We've continued to support mental health services; we've invested a further £25 million in addition to the £50 million that was provided in 2022-23, so that's a total of about £75 million new investment in mental health services. And then, we've invested a further £10 million in social care reform, increasing that to £55 million.

I think, at the beginning of this process, I made very, very clear that our No. 1 priority was to make sure that actually, from a Government perspective—because it actually only partly impacts on this direct budget line—the priority was to increase the real living wage for care workers. We wanted to make sure that that happened not just in our budget; obviously, that had an impact in terms of what was happening in local government. Obviously, it's been a really tough budget round, given the kind of inflationary pressures that we've seen within the health services, so I've tried to limit my priorities and the instructions that I've given to health boards in terms of what they should focus on next year. I think we've got to be realistic about what that means and there will be an impact in terms of deprioritisation as a result of that.

You listed the increase in the living wage is one priority. You said, Minister, that you've deliberately limited priorities due to the reasons you've set out. Are there any other particular priorities that you would like to highlight as well that you're focusing on this year that might be an alteration to this year's budget?

In terms of the budget, obviously, most of it is going directly to the health boards. So, what we've got to do is to try and give them an indication of where we'd like them to focus their spend. In the guidelines in preparation for their IMTPs, I've just made it absolutely clear that I want them to focus on six areas, and I can go into a bit more detail about those, if you'd like.

No, that's fine. We'll pick those up later on. You've mentioned the need to deprioritise some areas; can you perhaps give us some examples of those areas?

The reality is that when we pass on this funding to health boards, we've got to understand the kind of budgetary pressures that they're under. You've all heard me talk several times about the £207 million bill that we had this year for energy that we weren't expecting. That money has got to come from somewhere. We did get a certain amount from the UK Government. We haven't got a commitment for what will happen next year in relation to that. So, they're going to have to find that money from within their budget, which means, effectively, cuts to NHS budgets, which means that there will have to be a deprioritisation. Unfortunately, there will be areas where I think they'll probably just have to draw back a little bit, maybe on prevention, which is the last thing we want to see, but I'm afraid that's probably the reality of what's likely to happen, and maybe some of the decarbonisation agenda, as well.

Is it fair to say that the deprioritisation of some areas is—? What you're saying to committee is that these are areas for the health boards to consider rather than yourself. Is that a true reflection?

What we're doing at the moment is we've said, 'These are the areas we want you to focus on.' We'll obviously, once they present their IMTPs, need to look at what are the implications of those and to work out if we are genuinely convinced that the other areas that we will obviously see them drawing back from as a result of that prioritisation are areas that are going to be politically acceptable for us.

Sure. I suppose, from our perspective, in scrutinising the budget and scrutinising the health budget overall as we go out into next year as well, as a health committee, it does make it more difficult for us if so much emphasis is on the health boards, understandably, to decide their priorities. So, will health boards be publishing their priorities and how are we going to be able to scrutinise health boards on your advice in terms of some of the areas that they might have to deprioritise? Is this information going to be published?

Well, obviously, it will be published within their IMTPs, so you'll have the same opportunity. I'll obviously go through and agree the IMTPs before, so there will be a political blessing to the IMTPs, and then, obviously, you'll have an opportunity to scrutinise those.

Thank you. Members will have different questions. I suppose they can direct them to you, Minister, and you can allocate them as you feel, unless they're obviously questions to other Ministers. If it's okay, because we've got a two-hour session but there are a lot of questions to get through, are you happy if Members politely interrupt you if we're not quite getting to the point?

Sure.

Thank you. Rhun ap Iorwerth.

Sorry, Gareth, did you want to come in?

Just to expand, I know what it is, but the public might not know what an IMTP is, just for the public record.

These are the plans that are a statutory duty now—so, they're in law—that we expect the health boards to present to us, setting out the plan that they have in terms of what they propose to do within their health board—

But what does it stand for, though?

Intermediary medium-term plan. Is that right? Integrated.

Well done. We'll give you eight out of 10 for that, Minister. Rhun ap Iorwerth.

Good morning, and welcome to all the Ministers and officials here today. I'd like to focus on what's being called a national crisis by the Welsh NHS Confederation, which is the delayed discharges from hospital and the relationship between that and social care when it comes to responding to this. Could you give us an overview, first of all, of how this budget is giving consideration to this crisis and how it proposes a way forward in terms of expenditure in order to try and loosen things in the system?

Are you okay for me to start, and then I'll bring Julie in? First of all, we have an allocation, £144 million, within the regional integration fund. So, we have an allocation there, where there is a responsibility on health boards and local government to work together with the third sector to do that bridging work. That's not an insignificant amount of money. On top of that—

Just to interrupt, can you confirm if that's—because I wasn't sure from yesterday and your statement—£145 million over five years or—

No, per year.

Per year, for five years.

Per year, yes, over five years. This is a replacement of the transformation fund and the integrated care fund. What we've done is to take the best of the transformation fund and the ICF and look at what worked. We've had a lot of analysis, we've prioritised, we've only put six priorities on the RIF, and I think about three of those are relevant to the delayed transfer of care and trying to stop people from going into hospitals. So, that's a not insignificant amount of money.

Also, as I say, the No. 1 priority I've set in terms of guidelines for health boards is that they need to address the delayed transfer of care issue and to work with local government on this issue. So, that's the No.1 priority. There's an expectation there that they need to shift resources. We've been having very good conversations with them about the need to actually follow the 'A Healthier Wales' plan, which is very, very clear: you need to move care out from hospitals into the community. It's really trying to make sure we supercharge that work, which has always been in our strategy. It's getting an understanding that, with an ageing population, we've got to move things back into the community.

I think most people would agree with that. You say that what needs to be done is ensuring that local authorities can carry their burden. I will come to that and the pressure on social care in a minute. But I've come to the conclusion personally that social services are being asked to do the impossible, that the burden that the Government is asking them to carry is excessive, and that we are paying the price for losing so many community beds, the step-down care within the NHS, rather than the step-down having to all fall on the shoulders of local authorities. You have revealed plans to create 508 community beds. You're talking about creating more. First, do you agree with me that there is a problem here and that the loss of thousands of beds is creating a problem? Secondly, how is this budget allowing you to go further than those 508 beds in order to get rid of this blockage and take the pressure off local government?

I think it's important that we understand, in terms of these community beds, that this is a temporary thing. What we've done is we've bought packages. We've bought beds from care homes. I think what's needed is more of a structural change. We need to move—. Because, in truth, what we really want is to care for people in their own homes—

As a principle, that's great. The problem we have is that there are too many people who aren't quite ready to go home, and that's where the community hospitals have been useful. Where does the budget allow that to happen within the health service when people are not ready to go home?

I do think that there are different ways of doing things that perhaps didn't exist in the past. Hospital at home is an example where you can monitor, you can see. But, what's needed is to move people who are currently working in our hospitals out to the community, people like occupational therapists et cetera, so that they can move out and do their work in our communities. That's what we're trying to do. That's the discussion we're having.

So we're not likely to see this budget, or future budgets, taking a different approach in terms of trying to increase that capacity in terms of community beds, cottage hospitals and so forth, as we saw in the past.

What we have in mind is more care in people's homes rather than opening new hospitals. Obviously, we have very little capital to do that.

We'll come back to you on that point, I'm sure. Moving on now to the emergency within social services, Care Inspectorate Wales mentions a gridlock within the system, saying that a shortage of staff is the major problem. Again, how does this budget try to respond to that crisis?

I'll ask Julie to come in on this.

Diolch, Rhun. Well, obviously, we recognise the huge pressures there are on the local authorities, and you referred to the pressures on social services, and we're very aware of that. As a result of that, we have actually increased the support that we're giving to local authorities by 7.9 per cent [Correction: 'by an average of 7.9 per cent'], and that is in recognition of the really tough job that they've got to do. Eluned has already mentioned the fact that we've seen the real living wage as a very important step in recognising the importance of the care workers, and, of course, you referred to the shortage of care workers. So, we have put in £70 million of funding in order to pay the addition to the real living wage, which will make the payment £10.90 per hour, which is not what we want it to be, because we accept that it isn't necessarily solving the problem, but we do think it's very important to recognise the care workers, and that is one of the ways that we are addressing this issue and the shortage of care workers.

The main area where we are short of social care workers is in providing the care at home, it is in the domiciliary care workers, and we're doing all we possibly can to attract people to that job. It's such an important job, so we're trying to build up the profession by registration, by our WeCare.Wales campaign. And, as I say, our additional money that we put into local authorities, and the money we put in for the real living wage, we see those as the key areas where we are supporting the staff.

With the £70 million, it's easier to identify what that one can achieve, because it's meant for something very specific: a wage uplift. What are you hoping—or what are you expecting, I should ask—local government to deliver additionally, given the 7.9 per cent increase and the fact that inflation is running way above that?

Well, obviously, inflation is causing a major problem for local government, because it wasn't anticipated and they've landed up in a position where there's huge inflation and huge costs that they weren't anticipating. So, despite the fact that we've given this 7.9 per cent increase, we know that they have to make very difficult decisions. Obviously, it's up to each local government in each area to decide how it moves forward, and the money that we give, as you know, is not hypothecated, so it's up to them to work out the best way that they can use that money. Social care is a priority for local government, they've told us endlessly how important it is for them, so I think it is recognised in local government.

Tell me what kind of improvement, increase in capacity or improved performance you're expecting in return for that 7.9 per cent.

Well, it's going to be very difficult, as we've already said, because of the competing difficulties that are being faced, for example—

But it's an emergency, you must have—

—the energy bills. All the things that local government has got to cope with means it is going to be very difficult for them to improve things. One of our priorities is to try to build up the social care workforce. We know that local government acts as the conduit for the additional money, the £70 million, which, as you say, is easy to identify, or easier to identify, so we expect to see that passed on, because, as you know, 80 per cent of the provision is in the private sector, so we need to trace that that money goes there. We certainly expect to see that. And our example so far is that the first amount of money that we gave to putting the real living wage has gone to the people who are doing—the social care staff. So, we certainly expect to see that happen. But what we've got to do is to try—[Interruption.]

Rhun, I think Mr Heaney wanted to come in as well.

Of course, yes.

Diolch yn fawr. Albert Heaney, chief social care officer with the Welsh Government. Thanks very much for the question. Just supporting what the Deputy Minister was saying, I think one of the issues where we have a challenge is around assessment. One of the key activities that we've taken forward is working with Social Care Wales to look at the modelling for the number of social workers coming through, working with local authorities about growing their own social workers as well, so we can begin to tackle the real challenge we have around assessments. And as part of the financial package going forward, there's now a £10 million package per year [Correction: 'over three years'], which is an additional package of just over £4 million in terms of bursaries for student social workers coming through. So, we've been able to model and begin to work through, so we can begin to build that workforce. Alongside that, Ministers have continued to allocate a £45 million workforce grant as well to local authorities. Diolch.

That's about improving the interaction between—. The first point you made, about the assessments, it's about improving the interaction between social care and health, not necessarily increasing capacity within social care itself.

What I would say with the responsibilities of statutory director is that assessment is a core statutory function, so I would say that by improving the capacity around social workers going forward, that allows then local authorities to be able to discharge their statutory core duties.

In terms of steps that you can take as a Government to try to ensure that local government is delivering what you want, a couple of examples. Newport City Council, I think, are looking at making £3.75 million-worth of cuts to social services, including cuts to day-care services and staffing changes. Is that something that worries you, given the need to invest in social care? And what steps can you take in response to that as a Government? And on the other side of the coin, Denbighshire in particular is having trouble with the increase in safeguarding referrals, so that's taking money away from possible action to address delayed discharges.

No, absolutely. We are very concerned about any action that has to be taken that will diminish the service that is being given, and there is an interaction between Welsh Government and local authorities. But in terms of the actual details of those two local authorities, I know that in the month November to December, overall, there was an increase in adult safeguarding referrals over Wales, and a decrease in children's safeguarding referrals, but increasing numbers of children on the child protection register, which obviously is a matter of great concern, and obviously we're very concerned if the actions the local authorities take, if the result would be to work against our overall aims about what we want to achieve in Wales. So, obviously we have a great deal of concern about that, and obviously we will interact with the different local authorities to see how any harm can be minimised.

The point I make, of course, is that because of pressures right across the social care spectrum, it's very difficult to see how local authorities can take on this huge burden of trying to address delayed discharges. I've made my argument that I think there's a problem with the lack of community hospitals, but they're being asked to do the impossible, aren't they?

I'm not saying it's impossible, no. I think that we have got things in place, and that if the things that we do by working together, with health and social services working together—. I mean, obviously that is the absolute key issue, that they work together. We have been able to get the capacity for 508 additional equivalent beds in the community, and we plan to do a lot more of that, to try and build up the provision in the community. So, that is one way that we have worked together, Welsh Government, health and social services, to try to identify the need that is there. So, we have been able to do that, and I anticipate that we'll be able to do quite a bit more of that.

Rhun, do you have any final question on this section?

Two very short ones that I just need on the record. One of them relates to the decision to discharge patients without a care package. I think you're very clearly on the record in the Senedd yesterday explaining why you think medically that's the right thing to do, but what are the budgetary implications of that? Does that, in your planning, release money that can be spent?

Is that your second question as well? Do you want to ask both questions now?

And the second one is: what are the implications of that on unpaid carers and the fear that they will be asked to take on more caring responsibilities?

I think there's a section on that later on that we might come on to, if that's all right, Rhun.

Yes, that's fine. That's fine. It was in this section as well.

Just for time as well. Gareth—. I know there are three supplementaries. Gareth, do you want to come in with your question?

Yes, thank you, Chair, it's only a quick one. It's just about the real living wage. How many local authorities or social care providers are real living wage accredited, to your knowledge? I noted that, UK-wide, there are 11,986 employers who are real living wage accredited, and they include Aviva, Burberry, Everton Football Club, Ikea—the list goes on. But, to your knowledge, how many social care providers or local authorities have that real living wage accreditation, so that when they say—? You know, if they come out tomorrow and say, 'We need to pay our staff £14, £15 an hour', because of their accreditation, they would have to duly oblige to the Living Wage Foundation's recommendations.

Okay. Just a brief answer on that if you can, Minister.

I haven't got the exact numbers; I know there are several local authorities. What I can tell you is that in the space of social services and our expectation—and we've given them the money—we would expect people to be paying the real living wage for care workers. So, we can talk about that. What the councils are doing beyond that is obviously a matter for them. Cardiff, for example, I know is a real living wage employer. There are others around Wales; I don't know—

I think it's important to distinguish the two, though, isn't it? Because you say 'real living wage' but it's actually a foundation, isn't it, that recommends that wage and that salary, rather than the Government coming out and saying, 'Oh well, we're paying the real living wage', when it's actually the Living Wage Foundation who recommend to yourselves that you should pay that fee. And I think it's quite clear—. You know, it's important to be clear, to distinguish those two, so the public know that when you say 'real living wage', it's actually a result of the Living Wage Foundation saying, 'You should be paying this.'

That's right, and it's a big commitment. It's gone up about 10 per cent for the next financial year. That's a significant increase, and we have prioritised that above a lot of other things because we are committed—and we were committed in our manifesto—to paying the real living wage to care workers. This is not easy. There are a lot of care workers.

Jenny.

That's the strength of it.

I wanted to just pick up on what the Deputy Minister was saying about the biggest difficulties being in getting domiciliary care workers. Is that down to wages or is it down to capability and capacity, in the sense that if you're asking people to work in isolation, it's very different to working in a care home under supervision? So, at what point are you rolling out the integrated care that you talk about through the regional integration fund, whereby ancillary workers are working as part of a multidisciplinary team with trained nurses and other people?

I think the wages are a real issue, because £10.90, it's gone up £1, but it's still not enough to really compete. So, I think the wages are an issue, and terms and conditions are an issue because social care workers fare so badly next to the NHS workers, for example. And what we want to do is to get integration between the two types of jobs, which are the same jobs but paid very, very differently. So, as I said, I think it's wages and terms and conditions that we need to improve, and that's what we've been working at doing. For example, there's been an issue about travel, and we have given £10.1 million to the local authorities to use for domicilary care workers, in terms of getting a stack of electric cars, for example. But because of the pressures that there are now, that money, some of it is being used to increase the travel rates for domicilary care workers. So, that is a big issue, the travel rates that are given. So, I think it's getting those conditions, and that is part of our longer term planning for social care, and we really want to see much better integration between the two.

Okay, but you have no plans at the moment to integrate relatively unskilled—in the official sense—domiciliary care workers into teams of people, some of whom are much better qualified.

Yes, we do have plans to create—

But that has not at the moment led to an increase in uptake of—

No, that is something we are working on at the moment to produce multidisciplinary teams who can work together in a way that can tackle all the issues that there are in the community. The work we want to develop is in the community to prevent hospital admission, and to get people where they want to be, which is at home.

So, what's the financial—? What finances are you using to make that happen? Obviously, we need that to happen yesterday, so, what is in the budget to accelerate this process?

We will be using the existing budget to set up these—. Well, I mean it's at a very early stage really, so we can't talk about them in too great a detail. We are meeting and discussing it now, but we intend to use some of the existing budget to create ways of working in the community, which we hope will tackle all these issues.

Okay. Joyce Watson.

Just talking about budgets, and we can't escape the knock-on effect of poverty that's been created by the cost-of-living crisis, which we all know was created by a disastrous budget earlier last year, so, what I'm interested in knowing here is the impact of that that you're seeing in social services, particularly around the safeguarding issues. There are clear links between poverty and safeguarding and vulnerability, particularly domestic abuse, for example. So, it's putting pressure—undoubted pressure—on social services in many different ways. So, are you looking at that additionality in terms of the pressure on social services, whilst at the same time, trying to deal with the pressures of hospital discharge and all of those factors as well—

Just briefly.

—as a direct consequence of the cost-of-living crisis?

Yes. I think I responded to an earlier question about safeguarding, and children safeguarding referrals, actually, in the month from November to December, did decrease; but adult safeguarding referrals increased and children under child protection have increased. At the start of 2022, there were 2,788 children on the child protection register, but by December, there were 3,095. And I think that we all know that the cost-of-living issues put additional pressure on families and it's very tough to cope. So, absolutely, I think there is a great deal of concern about the cost-of-living pressures that are there. But we do work very closely with and fund the National Independent Safeguarding Board, which looks at issues of safeguarding on a Wales-wide basis. We give £200,000 per year in order for them to develop their work and also, we do look at the local regional safeguarding boards and we fund them as well—

Minister, Mr Heaney wanted to come in as well. Shall I bring him in?

—to help train social workers in child protection and of course in adult abuse, because another area that is a matter of great concern is adult abuse. We are preparing an action plan to try to prevent adult abuse.

No, I was supporting the Minister, Chair, in terms of the fact that the Minister was going through some of the funding, the substantial approach—for committee members to be assured—around safeguarding, both for adults and children. We work with regional safeguarding boards and fund them, for example, to assist them in training the workforce. That, again, is on a multidisciplinary basis, as you would appreciate, because safeguarding is an absolute priority and the protection of adults and children is a priority. We are, as the Minister said, developing the action plan. You will have seen, back in the middle of last year, the consultation that took place in relation to the draft action plan to prevent the abuse of older people. And, again, funding is going into that, to reassure Members today, to assist in terms of the progression. Thank you.

Rhun, I mistakenly thought you were going into an area that others were asking about later, but that wasn't the case. So, do you want to ask your questions again?

Yes. Briefly, it was in relation to the decision to discharge patients without having a care package in place before they leave the hospital. The first part was: what are the budgetary implications of doing that in terms of releasing money that can be used elsewhere in tackling the backlog; and secondly, what are the implications for unpaid carers who will rightfully think that they're being asked to take on more responsibilities and will need more support to deal with that?

I hope that Steve will be able to come in after this, but just to—. My understanding is that, actually, it doesn't release any money, because obviously, those beds would just be filled by someone else who needs them, so my understanding is that there isn't a release of money as a result of that. But what we do have is people who need the kind of support where, actually, an intervention is required, will get that intervention quicker and obviously, that will help the flow. So, it's not about a money-saving exercise, it's more about actually improving performance. Steve, I hope I've got that right.

Yes. Steve Elliot, finance director in health and social services here. Exactly right. I mean, you'll be aware of the pressures on finances of the health boards. So, this isn't about releasing any money, it's about just creating better flow through the hospitals.

And on the unpaid carers?

Our expert.

Yes, I'll answer that. [Laughter.] Obviously, we have put in money, recognising the huge job that unpaid carers do, and I think during the pandemic, everybody recognised, finally, what unpaid carers do. So, I do think that they are recognised for the contribution that they do make now in a way that they weren't before. We do put specific money in to focus on unpaid carers, and the interface when the people they care for are admitted or are discharged from hospital. So, in 2023-24, we've allocated £1 million to focus on unpaid carers and on that particular interface, with them moving into the community.

You don't get much for a million nowadays.

No. That is one thing that we're doing—yes. But I mean, it is recognising how important it is that they interface. But actually, since January 2022, overall, £42 million has been announced to support unpaid carers over the next three years, and I think we have recognised the importance of what unpaid carers do by the carers support fund, and you'll be aware that we paid £500 to all carers who receive the carer's allowance earlier in this year in recognition of the additional work, the burden they've had to take on. Obviously, they love the people they look after, so they certainly don't see it as a burden, but we recognise the huge pressures that there are on unpaid carers.

And that this decision around discharging patients earlier could increase that burden.

Well, what I think we have found is that unpaid carers are very keen to get their loved ones home, but they're also very keen that it's done in a way that supports the person they're looking after, and supports them in looking after that person. And a lot of the concerns that we've had—nothing to do with the present situation—have been the communication element between hospital and unpaid carers and unpaid carers and hospital, and that's something we're very keen to improve.

But in terms of supporting the role that unpaid carers are actually carrying out, we have given a lot of financial recognition to that. I accept that the £500 was a one off, but that was very important. But, we do have a £4.5 million carers fund, which is not restricted to carers who receive carer's allowance, and that has been widely used by carers to help them with their daily living. It's a relatively small grant, say about £400, but it's had a huge impact. And we've also created the short breaks fund, which is £9 million that we put into that in order to ensure that carers do get a break. That is something that is being run by the third sector, so the money is going to Carers Trust Wales, and they're going to come up with innovative ways of giving the carer what they want and need in order to manage to keep on caring. So, it's in that sort of context, obviously, that we are working with unpaid carers.

I'm conscious of time now, so for each section, we've probably got no more than seven or eight minutes, so, if I could ask each Member to be sharp on their questions and Ministers to be specific in their answers so that we can get through everything.

Joyce, I'm just wondering, I might come to you first, because it follows on from questions that have just been asked, and I'll come to you next, Sarah, if that's all right. So, Joyce Watson.

That's very good of you. Thank you. I would like to ask about respite for carers, because one of the key things that keeps carers going is knowing that, at some stage, they're going to have a break. That's how they manage; it's the only way they can manage, and their mental health and physical health demand that. So, have we got any funding allocated that ensures that respite is available? I bring you back to the day-care centres that are under pressure with local authorities' budgets, that was one form of allowing some respite, and knowing when that respite would be is equally important.

As I said in response to Rhun, we have got this £9 million specifically set aside to develop respite, and that's done via the Carers Trust. I think it's important to say that the local authorities have a duty to assess the needs of carers and that this £9 million is additional to what the local authorities would be doing as part of their responsibilities. So, this respite scheme is going to concentrate on what the carer would want. I think when we traditionally think of respite, we might think of the person they're caring for going away for a while to give them a bit of free time, but it's very varied what people want. People want, for example, to be able to go to an art class once a week, something like that, to be able to have a weekend to go away with a child. So, we wanted to be focused on what the individual wants, and this also will cover young carers. That work is ongoing, and so I think that we will come up with a good scheme.

I went up to look to see what they were doing in Scotland, they do a similar sort of short respite focused on the needs of the carers and not looking at traditional things, basically, and it was very impressive, what they were doing. I think we've learnt a bit from that, so we'll see how this goes now.

And then, on the day-care centres, yes, I think there is a concern. We are aware that some day-care centres have not reopened, and I have had people come to me about the pressure on them, really, particularly looking after people with learning disabilities. I think Jenny Rathbone has raised some issues with me last year about that, about the pressure that is on when the day-care centres haven't reopened. So, we're meeting with the ADSS, the Association of Directors of Social Services, to try to get a clear picture of where day centres haven't reopened after the pandemic and what the plans are with the local authorities. Now, I know that Albert is working with that group, so he may be able to say a bit more about that.

I think there are a number of authorities, for Members today to be aware, that are looking at how they modernise their services and support. I think all authorities recognise the need to prioritise unpaid carers. They see that as an absolutely critical feature of supporting people in their communities. We're currently working through a number of new initiatives that will assist and help, and I think that the blended approach here of both funding directly the provision for respite, funding as well the organisations around—. Carers Trust Wales has been greatly appreciated, and I meet regularly with those organisations, as well, to talk through the critical issues. So, even this week, we've been in conversations around the cost of living and the impact and what we can do to try to do to mitigate that, and, of course, some of the actions that Ministers have taken forward. For example, the £500 fund to support carers was directly to try and alleviate some of the real critical features.

Going forward, we're also linking to research, and I think it's really important to recognise that we need to understand this area better, so we've commissioned some work that we believe will help us and inform us in making better choices as we go forward. But I would stress, in terms of the budget, going forward, from a social care perspective, the funding that we're putting in is in a great effort to really look at how we support unpaid carers in the roles that they do.

I know that time is precious today, Chair, but I just wanted to come back in, if I may. On the hospital discharge pressures, the decisions and the advice that's been offered out has not been offered out with a view of trying to pressure one group above an other, not at all, but to genuinely look at how we balance risks. It's that dilemma sometimes of the pressure on the system that has meant that, joint working together, we've really tried to do the right thing at the right time to support people in their communities.

Joyce, do you have any further questions?

No.

Thank you. Sarah Murphy.

Thank you, Chair. Thank you, all, for being here today. We've touched on some of these areas already, but I'm just going to ask some specific questions, if that's okay. In terms of social care, an idea of the timeline would be great of when we can expect action to improve social care workers' terms and conditions. In last year's draft budget scrutiny, the Deputy Minister stated we must give urgent attention to terms and conditions. So, can you tell us what tangible progress has been made since then, please?

Thank you very much, Sarah. As you know, we've got the social care fair work forum that is working on these ideas, which is independent, made up of employers, unions and other relevant bodies, and they've been addressing all these issues. They advised us on how to bring in the real living wage, and did actually significantly change the way that we had thought to do it. This group is working on going beyond now the real living wage, because, as I said in response to an earlier question, it's terms and conditions that are really important for social care workers. They are working towards producing a statement early this year about their work, updating everybody. We anticipate that they will try to set up a system for voluntary collective bargaining by the beginning of the next financial year, by April. So, that again would be a step forward. All this is linked to our commitment, long term, to develop a national care system. I think it's very important that we see all these national initiatives in that context, as moves towards a national care system.

Thank you very much. Also, can I ask what is the Welsh Government doing to improve sickness pay specifically for social care workers? Do you accept that the removal of the Welsh Government's COVID sick pay enhancement scheme means that many social care workers are currently working in a worse position in terms of sick pay?

This is something we agonised over, the Minister and I, when it was stopped—in August that ended. We certainly didn't want to stop it, but we didn't have the financial means to keep it going because it was actually paid from a grant that had been given from Westminster—a COVID grant. So, social care workers are no worse off now than they were before we actually had the COVID period, when we put in this additional help. But, of course, they need statutory sick pay, and this is something again that the social care fair work forum has been looking at and is coming up with recommendations for. But, in terms of what we can afford, that is a big issue, but we absolutely recognise that this is the way I think that we will reach a satisfactory system, when we've got all the staff in social care having a good, reasonable wage, good terms and conditions, sick pay and all the other things that most of us benefit from in work. Most of them don't get any of that. So, I think the work done by the social care fair work forum is very valuable. They are coming up with recommendations on that, but, as I say, I don't know where we can go with those at the moment.

Okay, thank you. Just one final question. I actually met with the Royal College of Occupational Therapists yesterday, and it was really wonderful to hear from them so much praise, honestly, for the Social Services and Well-being (Wales) Act 2014 and how transformational that has been. But, as they said, what was core to that is having that 'what matters' conversation with patients. They very much told many stories, as I'm sure you've heard, that you can have somebody who has been waiting for their care package to go home for maybe five days in hospital, and if an occupational therapist or a physio specialist can come along and have a chat with them and be like, 'What does matter?', and have that time to do that assessment with them, you can get them home so much quicker once you realise what really is important to them. But they did tell me that, at the moment, things are just so rushed—and we know the pressures—they're not always getting to have that 'what matters' conversation, which is so vital.

And also, as we've touched on as well today, there is the discrepancy with occupational therapists in particular that, if you're working in social care, or in a hospital, there is £6,000 difference there in salary as well. So, it's an example, I guess, really, of what's good and what maybe needs to come back now as well, and I was just wondering, if you've heard any of this feedback, what can be done to make sure that we do now shift, I suppose, back to that crucial 'what matters' conversation. And I assume as well, as you've been talking about integrating the delivery of joint healthcare and social care workers, that occupational therapy and the discrepancy in the pay would also come under that, then.

Well, I think, longer term, obviously, that discrepancy in the pay is very damaging, really, that there is that gap, and, yes, I've had people come to me about that. So, in the longer term, when we have a system that is probably integrated, yes, we will, obviously—that is something that I'm sure we will be able to address.

I think it's great that you brought up this 'what matters', because it so key, isn't it? Because 'what matters' is something that you can only get by the individual attention that you give to the individual who's looking for help and support. I think the legislation that we've got in Wales is first class, and in all the discussions we've had about the reform of social care, never once has there been a query, I don't think, about whether we've got the right legislation, because I think all the legislation that's been brought in is absolutely right. It's the implementation that is, obviously, where we have to strive to ensure that that does happen. I think that's always the most difficult thing, isn't it—to actually make sure that things are implemented. So, I absolutely agree that 'what matters' is crucial.

Okay, thank you. Thank you, Chair.

Thank you, Sarah. Jenny Rathbone.

Thank you. Minister, you made it really clear in your opening remarks that there is no more money; we've got the budget we've got. What I'd like to explore is how you plan to ensure that this budget of nearly £10 billion is used to meet your priorities. You've already indicated that you think prevention's going to suffer, because we can't do everything. So, what are your priorities, and what are the outcomes that you hope to see in the next financial year?

So, I've issued guidelines for people to prepare their integrated medium-term plans. There are six priorities. Top of that list is to address the issue of delayed transfers of care and to make that shift into more support within the community. It's to really drive that progress in terms of 'A Healthier Wales'. The second one is to make sure that we address issues relating to primary and community care, and that, of course, means improving access, making sure that we have better access to general practice, to dentistry, optometry, pharmacy, and also, of course, that wide range of community allied healthcare professionals. Rehabilitation, mental health—all of those things are part of that second priority.

Then, obviously, there's urgent and emergency care. We've got very clear plans around this and they're actually working, believe it or not. The demand means that we're struggling at the moment, but, in terms of having a very clear strategy, we've got six goals for urgent and emergency care. And then we've got, obviously, planned care and recovery. That's got to be a priority. We are making progress in that space. Obviously, for the first time before Christmas, we saw the data coming out to suggest that we are actually falling for the first time since the beginning of the pandemic. We've got a long way to go—I'm very clear about that—but at least we're heading in the right direction. On cancer, I'm very keen to make sure that we follow through with the quality statement and make sure that we're giving people the support they need, and then mental health and child and adolescent mental health services. So, those are the six priorities. Now, you know, people will start screaming straight away and saying, 'What about my priority?' Making political decisions, determining priorities, is part of what you have to do as a politician, and that's a tough choice, but if we don't fix those, I think it will be difficult for us to address all of those other issues that people want us to support them with.

Thank you for your clarity on what your priorities are. How are you going to make that into a more efficient and effective use of the money in the sense that, often, early intervention is much cheaper than later? So, mental health is an obvious one, and better access to primary care, et cetera. How are you going to do that in the sense of getting people working collaboratively to jump on problems before they become major crises?

So, obviously, in that preventative space, I think there's a lot of work we're already doing with the primary care sector in that prevention space. I don't know if Alex might want to come in on a little bit of that in terms of what we're expecting from primary care, and then maybe I can ask Nick to follow up on some of those.

Thank you, Minister, and, just in terms of introductions, I'm Alex Slade, director of primary care and mental health. As the Minister described, this is around understanding the access and demand on individual services, because it does vary across Wales, and therefore orientating those local services to meet that local demand. As was provided in the evidence, there's been investment so that those local services can be orientated, whether that's direct access to physiotherapy, to support rehab needs, or whether that's expansion of pharmacy services. We see expansion in the common ailments service, so we see people going to pharmacies for low or minor conditions and having that direct access. So, it's really making sure that the services on the ground, on cluster footprints, are orientated around those population groups rather than a blanket approach to meet those needs.

Okay. And in the paper, you talk about integrated health and care hubs—I think that's what they're called. How much of that are you able to do, given the restraints financially?

Partly that's a capital question, but the programme around integrated hubs and well-being facilities is developing in earnest at the moment. So, in the first year of that, the first scheme was approved by the Minister last year, which was the Newport east scheme, which brought together a range of services—general medical services, dentistry and wider multidisciplinary teams. So, that's a platform, in terms of the infrastructure, on which we can develop those joined-up and integrated services. But, equally, we can do that virtually as well. Some of the questions around community beds, some of that can be done through virtual wards and how we look at the technology and digital aspects with which to enable that—so, a multifaceted way of looking at how we bring services together such that the patients see the right professional at the right time in the right setting.

And it doesn't even have to be a professional, does it? It can be voluntary services. And the shiny new building won't necessarily change the culture.

No.

So, how much are you able to pursue this virtual integration?

There are two facets of work. One I understand is a sort of good practice around virtual wards—Swansea bay have got really good examples, where they've rolled that out across all of their cluster footprint, and we're having a look at how that is improving flow, what that means for hospital admissions. Of course, that's around delivery of 'A Healthier Wales', keeping people at home but providing those services and that support to them in those settings, and of course they're then in the community with those wider opportunities, and as you describe, some of that is third sector and voluntary support to them, and mental health is a good example of that in terms of the pathways available to people around third sector capacity. So, it needs to be done not just through the infrastructure, which is why I think the virtual wards example is really good, and the digital aspects of that are really important. So, Technology Enabled Care Cymru are currently scoping out what the digital provision of services to people virtually, remotely, would look like to enable expansion of the virtual wards work.

And how are you going to measure the progress you hope to make when we come to have this conversation again in 12 months' time? How are you going to be able to demonstrate that, in what you set out to do, you've been able to make the relevant amount of progress?

We accept it's challenging, with the moving picture in demand, but it's actually looking at what it involves for hospital flow, given the virtual wards are around keeping people in the community or moving people back into the community, as we've been discussing around the flow question, providing the right support to them in primary and community care settings. So, a lot of it is that flow question about where we've got people, but, as the Minister touched on earlier, there are more people flowing through the system. So, the performance of health boards and the volume and demand and usage of virtual wards will demonstrate to us the effectiveness of that, which is what we're looking at with Swansea bay's roll-out of their virtual wards across all of their cluster footprints.

Thank you.

Can I just add, in relation to prevention? One of the things I'm keen to see, because I am really concerned that we'll see a stepping away from prevention, and I just think it's so important—. I'm very aware that we've got a lot of people waiting, on waiting lists, and I think that there are lots of conditions where prehabilitation significantly helps clinical outcomes. And so I've asked the team to explore what more we can do within that space of prehabilitation, where we've got access to a lot of people, and then, of course, they'll go home and talk to their families about it. And I just think—. So, I've asked them to explore—. We've got a ready-made audience there, that is actually—. Because a lot of this prevention stuff is quite difficult: how do you get to people? And I think there's an opportunity there for us to explore what more we can do in terms of prehabilitation, where we can give advice on eating healthily and mental health support and all of those other things. So, that's something that we're exploring, and I've asked to ring fence a certain amount of money to explore that particular issue, because I am so concerned about stepping away from prevention. So, we'll do it in the context of the waiting lists.

Thank you.

Lynne. Lynne Neagle.

Yes, I just wanted to add to what Eluned said about prevention, really, and recognising the challenges that we face with the budget, but there is a very strong focus on prevention in things like the work that we're doing around 'Healthy Weight: Healthy Wales', the work that we're doing on the tobacco control plan, and that has dedicated funding to underpin that. So, hopefully, that will make sure that that work will continue, notwithstanding the pressures.

And you also mentioned prevention in mental health. Obviously, the Welsh Government has made a commitment to prioritise funding in mental health, and that commitment has been honoured. It was £50 million extra last year, £75 million extra this year, and it will rise to £90 million next year, a not inconsiderable achievement, really, given the financial pressures that we're facing. But lots of the mental health money could be considered prevention, I think, if you're looking at the work that we're doing around tier 0, open access without referral, the work that we're doing with children and young people to prevent problems escalating. So, prevention is very much written through the work that we're doing with the extra money on mental health.

So, one of the greatest preventative strategies is breastfeeding, because of the impact on the child, as well as on the mother, in preventing them getting gynae cancers. So, no mention of breastfeeding in the paper that you've submitted—how much is that going to be a driver to ensure that it supports the 'Healthy Weight: Healthy Wales' strategy, and also the attachment between mother and baby and all the other physical benefits?

Well, Jenny, as you know, the health budget is £10 billion. The committee put questions in and we try to answer those questions in evidence, and we weren't asked about breastfeeding. But just to assure you that breastfeeding is a priority within the work that we're doing on 'Healthy Weight: Healthy Wales'. We have a breastfeeding action plan. We've got new staff coming on stream, somebody to work with the chief nursing officer and also a dedicated member of staff within Public Health Wales to drive our breastfeeding action plan forward. And part of that plan will also include every health board having a designated member of staff to drive that work on a local level, because you know as well as anyone that implementation is where the challenges are. But I absolutely agree with you—that's absolutely vital.

Rhun, you wanted to come in quickly.

Yes, if I could on the preventative agenda. I still feel that it's a side issue when it should be front and centre. I was very pleased to hear you talking yesterday about the need for people to stop smoking and to exercise more, and it's sort of 'Hallelujah'. Hopefully, that's the sign of a Minister who wants to really get to grips with the preventative, but I think where you've got it wrong is that it's not just a matter of asking people or telling people what they should do. It has to be at the heart of Government budgets across the board, because so many of the decisions around living unhealthily are due to poverty, and it's bad housing. Point to me in this budget where there are serious amounts of money going into the preventative. You have an eye on the budgets of other Ministers too. Where's the preventative being dealt with, and where's the work being done now to prepare for a massive investment—when financial situations are slightly better than they are now—a massive investment, not the tens of millions, but hundreds of millions, in the preventative across the board in Welsh Government?

I think prevention is very much at the core of what we're doing, Rhun. Most of the money that we're talking about today goes out to health boards, and they have got a legal duty to consider prevention in the way that they spend their resources, just as we have. They also have a duty to consider the Well-being of Future Generations (Wales) Act 2015. So just because you can't point to a pot of money that is entitled 'prevention' doesn't mean that prevention isn't happening, and I think I've illustrated that with our commitment to mental health. So, absolutely, prevention is a core part of what we're doing, and we can demonstrate that both with targeted resources, but as well with the directions that we're giving to the NHS in how they spend the money.

But it doesn't come through in an attempt to change the culture of Wales. We have a fire storm currently with the NHS, and rightly that's your focus. But we're always going to have a fire storm unless there's a real gear change in saying that, 'No, our mission is to make us a healthier nation', and that has to be reflected in budgets, and I'm not getting a feeling that it's there.

So, one of the things that I think is really important is to recognise that it's not just in the health budget that health is addressed. And later on this year, we'll be introducing, obviously, the legal requirement for a health impact assessment across the whole of Government—so, every policy will have to be measured against its health requirement and the impact. So, that is a significant change in what we'll expect every aspect of Government to consider, so I think that is going to be completely in the prevention space.

Julie Morgan.

I think one of the areas that is not health in the traditional way is the huge investment that we're putting into childcare and Flying Start, the development of Flying Start, which is absolutely crucial in terms of developing a healthy lifestyle right from the very beginning and having additional help from health visitors and parenting skills. All those things are, in the wider sense, you know—

Free school meals.

Yes.

Well, maybe it's time to be more explicit in branding them as health, part of a whole-Wales health preventative strategy. But that's—we could spend a lot of time on that.

We will see if we can make you an extremely long list, because it will be a very, very long list—everything we're doing on child poverty, for example. It's a very, very long list, so you'll need to give us a bit of time to pull that together.

Mr Rees, do you want to introduce yourself and come in on that?

Bore da. Irfon Rees, director of health and well-being, Welsh Government. Just to support what Ministers have said, I think that narrative, that actually the future generations landscape is absolutely Government articulating that as being core, and prevention being one of the key elements of that, and the drive to reduce inequalities being core to policy, when we look—. And the list goes—. On the budgetary interventions that have a knock-on effect on the health and well-being of the nation, absolutely those that are addressed on inequalities, active travel, lots of legislative frameworks around smoking and other things that are absolutely in the prevention space. When we look specifically then into the NHS, we want to make prevention core, and so whilst there are targeted investments to pump-prime approaches on obesity, as the Minister referred to, and we can put budget lines there, what we want in our narrative with health boards and trusts is that prevention is part of everything they do. So, prehabilitation, as the Minister said—we want making every contact count to be part of all aspects of services. Primary care plays a huge part in secondary prevention. And so, as we look at the IMTPs, which were referred to earlier, as we engage with the executive teams of health boards, we challenge them to think about what opportunities are they taking within their gift to drive the prevention agenda. That is quite hard to demonstrate, because of that core block allocation, as Ministers referred to.

Thank you, Mr Rees. Is that okay, Rhun?

Yes. Diolch.

Just a quick question, Minister, on the guidance that you've issued to health boards letting them know your priorities and, if I have understood it right, how they should reflect your priorities in their IMTPs: is that something that's been published or can you publish that guidance?

That's something that I've written to health boards with. I don't think there's a problem with sending you just the guidelines. But one of the other things—. Just so we're clear, they had a few other bits in there that—. Obviously, we're setting out some clear guidelines. But one of the key issues that I've also pointed out is that, in everything we do now, we need to think digital in terms of how we are delivering our services as well. So, in all of those priorities, we need to think digital.

Okay. Thank you. I'm looking at Ministers. We're due to finish at 11:30. I'm relaxed. If you want a five-minute—

What time do we finish?

Half past eleven we're due to finish. I'm relaxed. Do you want us to carry on or would you like a five-minute break?

I'm happy to carry on. It's poor old Julie who's done all the hard work so far.

No, I'm happy to carry on.

Are you sure? [Interruption.] We need a break. Okay.

You need a break, okay.

Others want a break. We'll take a five-minute break. Thank you.

Welcome back to the Health and Social Care Committee, and the next set of questions is from Gareth Davies.

Thank you very much, Chair, and good morning, Ministers and officials. For the 2021-22 financial year, six of the seven health boards projected an end-of-year overspend—an estimated figure—of nearly £160 million. What's the Welsh Government's approach to this, and can you tell the committee a bit more about what's going on—that £160 million—across the Welsh NHS?

Yes, well, obviously, we did give a significant additional injection of funding to health boards this year, with £900 million to organisations to cover those costs of demand growth and pay increases, those exceptional energy costs, and, obviously, the ongoing response to COVID. But, as you say, despite that, we are in a situation where we are expecting to see significant deficits. And, of course, part of that is a result of the massive demand that we've never seen the like of before. We've got massive inflationary pressures that you'll be aware of. Just to give you an example, the drugs bill this year is 5 per cent more than it was in previous years. So, all of these things are huge, significant costs, and, obviously, the other thing that has gone up is the continuing healthcare packages of support. We've seen a significant increase in that. So, despite the fact that they were expecting and we were trying to push them to make savings of about £140 million, which is not an insignificant amount at a time when there's a lot of pressure on them, it does look like we're going to see a shortfall of about £30 million there.

There are things like staffing. So, in lots of circumstances, in order to deal with the pressures, what we have seen is an increase in bed capacity in some health boards. But you can't do that—. There's no point in putting beds in unless you put the staffing in. And, because it's not ongoing, you can't employ staff, so you're paying agency staff and, obviously that then increases the agency bill.

So, is that a contributory factor to the overspend?

Definitely, definitely. And, then, of course, there are things like sickness rates. If you think about it, 7 per cent sickness rates across the NHS at the moment. That means you've got to backfill with agency staff, which, obviously, is much more expensive. And we have to do that, otherwise we'd have to close wards, or we would have to not comply with our legal obligations on staffing levels. So, all of those things are extremely difficult, and, of course, what we're doing is keeping a very close eye, on a monthly basis, that that's exactly how that works, just to make sure that we are keeping on top of them. I don't know, Steve, if you'd like to add to that.

Can I just clarify the numbers on savings, because they are going to be delivering about £140 million-worth of savings this year? They will deliver that, and that's an increase from last year, which was about £115 million. So, they are improving their savings delivery this year compared to last year, but it's about £30 million short of what they said they needed to do. So, that's a contributory factor.

As the Minister said, we've put quite significant amounts of funding into the service this year to support, in terms of core uplifts, obviously, pay increases. We've supported the exceptional costs of energy, as well as, obviously, the ongoing response to COVID. So, the ask of the service was then to balance their core financial positions, and, for the reasons the Minister just outlined, to a degree, it's not surprising that health boards are in this position. We're not unique in Wales. I think, in England, the integrated care boards are forecasting something like £800 million, £900 million overspend in England as well. So, it's a reflection, I think, of the fact that over the last two years we've been able to support the significant costs in terms of responding to COVID, but this is very much a transitional year of coming away from that non-recurrent funding and trying to embed back the core financial management approach that we need to get back on top of.

I suppose what I'm asking, really, is what the role and the duty of the Government is in this situation, rather than just providing an ongoing commentary to the situation, because you note in your evidence that the Welsh Government isn't prepared to support or underwrite some of these overspends and issues. So, what is the role of the Government in this situation, and what is the plan, going forward? Do you give the health boards that autonomy that they need and potentially let them spend themselves into oblivion, or where do you step in, and where do you go, 'Okay, this isn't the right situation and we need to do something about it?'

So, there's a really structured approach, in particular with those health boards that we think are not on course to meet the financial targets. What we do then is we have a very structured process of intervention, and they have to then confirm the reasons for their financial deterioration. They have to show us what they're going to do in terms of efficiencies. They need to show how those are going to be translated into deliverable saving schemes. So, we've got Cardiff and Vale at the moment at an increased level of escalation, and Cwm Taf Morgannwg and Hywel Dda all under increased scrutiny when it comes to financial pressures. Is there anything else I should add there, Steve?

Just to make the point that when we say we're not supporting or underwriting it, we're not going to bail out organisations that are not managing their core financial position. What we have done, just to be clear, is we have provided them the cash that they need this year to make sure they meet their financial obligations, so they will be able to pay suppliers et cetera. But I think we do need a focus with organisations on getting back into that financial discipline, so that's why we're not effectively writing off or just giving them money to cover those deficits.

It would be remiss of me as a north Wales Member not to mention, obviously, the £122 million that's been unaccounted for in Betsi Cadwaladr University Health Board, which came to surface over Christmas and the new year. A lot of people locally will be saying, 'We're missing out on treatments, we've got high waiting costs, and the health board can't account for such a significant amount of money.' So, in this situation that Betsi's currently in in that regard, along with obviously the myriad other things, what's your position on that and what are you going to be doing to hold the health board to account over that significant amount? Let's remember it's taxpayers' money as well. It's public money that should be invested into the right areas so we can tackle some of these problems, rather than seeing headlines that health boards are not accounting for a significant amount of money that could be spent on the health board's priorities.

Obviously, there's an investigation ongoing, so I can't go into too much detail on this. There is an interim finance director in place that I understand is making a big difference already. Steve, is there anything you can go further on?

I think, just to clarify, the £122 million that's referred to was the level of expenditure in the accounts for last year that the auditor general wasn't able to complete his audit and testing on, and that's why the auditor general qualified the accounts. It's not missing expenditure; it was a decision by the auditor general to qualify the accounts because he couldn't verify that full amount of expenditure.

Yes. I don't think there's any suggestion here that people have pocketed money or moneys. This is about poor accounting—

No, I'm not suggesting that in any sense of the imagination, because, obviously, it's subject to an investigation. Like I say, it's unaccounted for. I'm not trying to say it's gone in the back pockets of people. That would be a scandalous allegation to make—just to make it clear that's not what I'm suggesting. But what further interventions would the Welsh Government be prepared to implement in health boards who are not meeting their financial obligations? What do we do in the future? What specific things can the Welsh Government do to put that pressure on health boards to be more efficient with their spending?

Well, what we do is we escalate and we put them into part of the escalation system where we monitor them more directly and more visibly and keep a much closer eye on things. So, that has already happened in those cases where we have concerns that they look like they're going off-track. And I know that a lot of the health boards are now taking initiatives to correct the situation very seriously.

If I can just add to that, I meet regularly, monthly, with the finance directors of the health boards and with my colleagues in the finance delivery unit. So, as well as the specific interventions with individual organisations, we're working more collectively with finance directors, and they themselves have recognised the need for a programme of work to respond to the financial challenges that they're experiencing. So, there's a collective, supportive approach as well as the specific interventions that we need to undertake as well.

And just finally, do you agree with the Welsh NHS Confederation's call for a clear strategy and a rethink on how health and social care are delivered, because they've said that it's vital that the Government and all politicians are open with the public regarding the pressures facing the NHS and social care and what they can expect in the future? Do you support that view of the confed?

I do, which is why—it's not why; we were planning to do this anyway—we'll focus far more clearly on a smaller number of priorities. That's what we've given now as a framework for the NHS to work on. So, I hope that the confederation will agree that streamlining, that being much more focused in terms of priorities, is the right direction to go in. Certainly, we've had a very good response from health boards to that.

Thank you very much.

Thank you. Jenny Rathbone.

Just looking at efficiency savings, in the last Senedd there was quite a focus on the need to reduce the budget for prescriptions because it had risen substantially in the last term. I just wondered, as it was then over 10 per cent of the Welsh budget, what it is now in relation to the rest of the budget, and is it an ongoing strategy to reduce the dispensing of prescriptions.

So, I'm really clear that, particularly at a time when budgets are going to be squeezed, we need to make sure that the money that we do use is spent as efficiently as possible. And I think there is a bit of space for us to go further, and that's why I'm really pleased that Judith Paget, the director general of the NHS in Wales, has now set up and is chairing a utilisation of resources group. And that's going to be looking at things in that space to see what we can do better in this space, and I'm sure that prescriptions will be one of those areas that she'll be looking at, because 10 per cent of the budget is not insignificant, so there have got to be some savings that we can make there. I don't know, Nick, if you'd like to add to that.

Yes, thanks, Minister. I think, on medicines and establishing a very clear medicines management programme, there are many, many drugs that come off patent over a period of time and you get a generic supply, and therefore making provision to switch patients onto those can save considerable amounts of money over a period of time. I think that, perhaps, over the last couple of years, because of dealing with all of the pandemic issues, some of the focus on some of those very clear efficiencies that don't affect patient care but just basically save us money or expenditure need to be refocused on.

I recall in my time in Aneurin Bevan the focus that we had on inhalers and the switch on inhalers, which can save hundreds of thousands of pounds without impacting on the volume of drugs that you are prescribing over a period of time. And there are many opportunities that come up each year with drugs that come off patent, go onto generics, and there are no safety issues particularly in switching patients to those. So, I think what we talked about at the last utilisation group was setting out a programme where we ensured that all health boards followed similar guidance and we got consistency of delivery right across the piece. I think there's a lot of that that we can do in terms of the use of resources, in getting that consistency right across the seven health boards and the trusts in Wales so that everybody benefits from the same approach and the same utilisation of the resources that we've got.

Okay. Switching to generics is one way of reducing the budget; another is preventing overprescribing—

Absolutely.

—which often leads to people going into hospital with polypharmacy.

And regular reviews of people's prescribed medicine. There are many stories of going to visit some people in their own homes and opening the cupboard and they're like a pharmacist in their own home, because their prescriptions haven't been reviewed for such a long time. And what Alex was talking about earlier in terms of the pharmacy within the primary care remit and doing regular medicine reviews for patients is a really effective way of keeping people safe and well at home, but also a better use of the volume of drugs that we prescribe in Wales.

And lastly on this issue, what's your strategy for preventing prescription drugs from being used by criminals for sale as highs and lows?

I think there's been much work done, hasn't there, on the use of prescription medicines that are addictive or long-term prescribed. I think what I've seen in work that I've done previously is an assessment of GP prescribing across that range of drugs to look at where we've got outliers, where there are particular practices, potentially in particular areas, that prescribe high volumes. They can then be picked up by the local primary care or pharmacy teams to assess whether or not that level of prescribing is appropriate and what could be done with those drugs elsewhere, obviously.

In monetary terms, what are the efficiency savings you hope to achieve on the prescription budget?

At present, within the utilisation of resources group, we haven't set out a specific amount of savings nationally around that. I think what we said, Steve, when we met last time was that we would bring prescriptions to the next group, which I think meets either at the end of this month or early next month. What we've seen in previous years is that anywhere between 4 and 10 per cent can be saved on medicines, but I think we need to establish a national figure for that as we move forward, based upon the opportunities.

Does bringing back financial balance need tough decisions on services?

The Minister laid out earlier the six priorities. I don't think the priorities were a surprise to the health boards. I think it's how we use the resources within those priories that is important, and a shift in focus away from the more expensive or high-cost elements of service is a main feature, if you like, of the six goals programme.

That programme is an integrated approach to urgent and emergency care. It starts in primary care and follows all the way through to a patient being discharged back home and potentially then being prevented from being admitted. Delivering all parts of the pathway ultimately delivers an efficiency in the system. So, if more people go to an urgent primary care centre than go to an ED or a minor injuries unit, the cost per episode is much smaller. We've got 7,500 people from a standing start of zero over the last 18 months monthly going to an urgent primary care centre. What we've set out within the priorities is better utilisation of those sorts of services.

The Minister last month launched the optimum hospital pathway work that we're doing at the other end of the six goals programme, which looks at how we can reduce people's length of stay. A single night in hospital is extremely expensive. Reducing length of stay by a day or a day and a half can save huge amounts of money in secondary care. Over the last three months, we've seen the number of patients who are over a 21-day length of stay—which is a measure of too long a length—reduce substantially because of the work we're doing with delayed transfers of care or with that optimum hospital pathway. The more we can focus on that within those six priorities, then the more effective the use of resources that we've got is, and then the more investment can go into the recovery of the waiting list, the mental health service et cetera. So, I think, what we've got to get the health boards to look at is how best to deliver each of the different pathways so that we're putting the most effective and the most efficient part of that pathway to the most effective use.

Thank you, Nick.

Can I just come back on Jenny's point on the medicines, if you don't mind? One of the key things that I'm really focused on, as you know, is digital transformation in the NHS. We've got a specific programme on digital medicines transformation. That's true for primary care. We're going to see a roll-out of that in the summer in primary care, in secondary care also, and then we'll have the central repository for all prescriptions. All of that will mean that we've got a view on what's going on in relation to medicines, which will make it much, much easier for us to monitor. So, all of that is coming very, very soon. It's taken a long time, but we're almost there.

Nick Wood, you make a really clear case for what we should be doing, but health boards don't appear to have been doing it in this financial year, because so many of them are recording that they're going to run a deficit at the end of this year.

I think as Steve has alluded to, it's almost been a bit of a transition year this year from dealing with the pandemic and the challenge that that's had both financially and operationally. I think Steve referred to getting health boards to focus back on that discipline of financial and operational delivery, which they need to do. I think by laying out very clearly the six priorities, as the Minister's done, through the planning guidance, we are refocusing them on those sorts of things. I think in certain areas, we've seen the efficiency, or the effectiveness, start to come through this year. It's been slower than we would have liked, but certainly, in things such as the primary care programme and the six goals programme, we've made progress as the year has gone on, and I think we've got to roll that into the next financial year so that that becomes a way of working that they deliver on a daily basis regularly.

Thank you.

We'll have to move on. I've got Joyce, Gareth and Sarah next. If they can just be quick-fire questions with succinct answers, if that's all right. Joyce Watson.

Mine is quick. You've got £170 million of revenue funding recurrently to tackle the waiting times backlog. What are the outcomes that you're hoping to achieve with that finance?

We've set out our planned care strategy. It has very clear targets. I think some of them were a little ambitious, in particular the out-patient one, which wasn't something that they've had in England as a target, but that was trying to really galvanise the system to get them to understand what's out there. But I think we're making significant progress in relation to our two-year waits, and of course, you've seen for the first time that overall, our waiting lists are coming down, which is not insignificant. I think what you should take from that is the fact that actually, we have been doing a lot of urgent cases, so they've been leapfrogging when there's an urgent case, which means that actually, that's why the lists are coming down, because we are getting through them; we're just not getting through them in terms of the cohorts necessarily that we have asked people to prioritise. So, we keep on trying to refocus them, just to say, 'Come on, go back to the longest waiters. You need to see these people.' And we keep on pushing them to try and focus on those cohorts. So, there's still work to do on that, but we're heading in the right direction. There are challenges, obviously. When you've got the kind of situation, the pressures we're under now, very often, planned care just gets knocked out for a few days. So, we are doing all we can in that space. I don't know, Nick, if you want to say anything else.

Can I just ask about orthopaedics? You could be waiting on a waiting list for orthopaedics, but if it's impacting your life and the life of those around you, if you're working age, for example, then you need to get back into the workplace, so you can become productive again, and ease the pressure right across the place. Are you reprioritising in terms of not just the amount of time that people are waiting—which, of course, concerns those who are—but the people who are actually waiting and their ability to remain in, say, a two-year space?

That would be a really difficult call, because where are you going to start with that? Are you going to say, 'Senedd Members, jump the queue'? Are you going to say, 'Police, jump the queue'? Are you going to say, 'Teachers, jump the queue'? Are you going to say, 'NHS workers, jump the queue'? Once you start down that path, you're getting into quite difficult and sensitive territory. If there's an urgent case, of course, they go to the front of the queue, but I think you'd have to be very brave to start making a call on who gets to jump the queue.

Gareth Davies.

Thank you, Chair. I'll be as quick as I can. When will the workforce strategy be published?

Thanks. Well, I've been—

Just a short answer, just give us the date.

I can tell you the short answer is before the end of this month. It's gone back and forth a lot. We've been waiting—so, today, I've been waiting for responses. It's gone out to the system, people, stakeholders, just to make sure that it lands in the right kind of ballpark. Not everyone's going to agree on it, but quite a lot of work has gone into it just to get it into the right place. It's not going to make everybody happy, but it will move things along. Obviously, you've got to look at that in conjunction with the report that will be coming out very shortly on HEIW's action plan for the next year, where, of course, we've put £262 million into training the next generation of health workers.

And what are we doing to reduce agency staff in the NHS?

Some of that will be part of the discussions that we are having with trade unions tomorrow, but also we're hoping that that will be reflected in the workforce action plan that we're talking about. Quite a lot of work has been done around it. It's not simple, and I think it's really important that people understand that, actually, in terms of quantities, it may not be as big as people think. If you think about the budget, about 65 per cent of the NHS budget goes on staffing, and from that, 6 per cent is spent on agency. Obviously, we can make some savings, and, of course, if we weren't to spend them on agencies, we'd be spending on staff, so you take that money out as well. So, it's the profit bit that you need to look at.

Does that stretch into locum work, as well?

Local—?

Locum. Like locum GPs, locum physio—

Yes, we'll be looking at every aspect of that. I'm not sure—. Here we go, we've got a breakdown: nursing and midwifery, £152 million; medical and dental, £84 million; additional clinical services, £28 million. So, there is scope to go further. Just keep on remembering, 7 per cent of the workforce are sick at the moment, so you do have to fill up those places. And there are areas where I think we can go further faster. There are some areas of agency that are significantly higher than, for example, if you give extra hours to people who are already in the workforce. So, we're just working with trade unions to see how do we make this easy, how do we make this work for the people who, perhaps, would like to do the additional hours, but we need to help them to set out earlier when the opportunities are for them to take up those additional hours.

Rhun.

Very briefly. You're quite right, of course, there will always be a need to bring in additional staff in some places. Isn't one answer to outlaw private profiteering from agency working and have a fully public staffing agency for Wales, so at least you're tying the money in within the NHS?

There are aspects of things that we're working on already where we're trying to—. We've done this in the past, where we've got the spend down considerably. Pre COVID, we managed to do that. We did have a national action across the whole of Wales. Because, of course, the difficulty is that if one health board does it and then the other doesn't, then, obviously, people are going to be crossing borders. I think this is an area where we do need to act nationally, and that's precisely the area that we're trying to explore.

Should there be, and what are the consequences of putting, a cap on health boards in terms of the spend on agency staff?

I think you've got to be really careful with this stuff, because if you get to a position where it's really difficult to recruit anybody—. I don't want to see A&E shut down because we can't get the staff in. So, we just have to be practical, I think, but I think we can go a lot further than we've done so far.

Okay. Sarah Murphy.

Thank you, Chair. A question to you, Deputy Minister: could you clarify the details of the Welsh Government's budget allocation for mental health services and what outcomes you're seeking to see from the investment?

Also, if I could just add on as well, obviously we've had—. Eating disorders have been much more on the agenda this year—my own contribution, and we also heard from young people through the Mind Cymru work that they're doing as well, who were very brave and very candid with us, and also, in anticipation, the eating disorder cross-party group will be starting up again this year. So, if I can just ask as well if there's any money here that's been allocated for scoping or putting in place the residential unit that has been called for now for over 20 years.

Thank you, Sarah. You'll be aware that the mental health money that goes to the NHS to health boards is ring fenced, and that is continuing. So, there's an allocation of £773.639 million gone out to health boards for mental health services as part of the mental health ring fence. That's the biggest allocation for any subject area in the NHS. But, on top of that, you heard me say earlier that the Welsh Government has honoured the commitment to prioritise investment in mental health, so there's an additional £75 million been put into the budget for mental health this year, and that is protected spend for mental health.

In terms of priorities for spending that money, a key priority for me is the HEIW and Social Care Wales mental health workforce plan, which you heard me talk about in this committee before that was published in November. I think it's an excellent and very thorough piece of work and I'm really keen to do what I can to make sure that we fund that. Because you can keep pouring money into the NHS, but unless you've got the workforce to actually deliver then it's not going to deliver what you want it to. So, the workforce plan is an absolutely key priority for me. There are long-term measures in the workforce plan, but also some short-term things that we're looking to do as well. So, we're looking to implement our clinical associate in psychology programme, we're looking to increase training numbers, implement the specialist allied mental health pathfinder scheme, multi-disciplinary teams and peer support, and also to increase capacity in primary and community mental health teams. So, there's a lot of work there, and we're in the final stages now of agreeing the costings around the workforce plan. But I strongly believe that to make services sustainable we've got to make sure that we can deliver that plan.

In terms of other mental health priorities, we will also be targeting funding at the areas that have been prioritised to the NHS, so recovering waiting times, recovering CAMHS waiting times; we've also got the delivery unit review of CAMHS that we're looking to fund. We're rolling out 111 press 2 for mental health, which will be a 24-hour commitment for people to ring for urgent mental health support across Wales. So, that will be a priority for funding. I'm also very keen that we continue to prioritise areas like eating disorder services. As you know, we've done that over the last few years. We're starting to make progress at a community level in terms of making sure that we can meet those waiting times, and, as I think you're also aware, the Welsh Health Specialised Services Committee are currently scoping for us the possibility of an in-patient unit for eating disorders in Wales, so I'm waiting for further advice on that.

If I can just say, on transitions as well, I had the session with the Children, Young People and Education Committee, and we also commissioned our own work with young people on transitions. So, I am in no doubt at all that transitions and ensuring that those happen in an appropriate way for young people has to be a priority, and I'm making that clear, and we'll also look at any funding that we need to attach to that.

Thank you very much.

Thank you. Rhun ap Iorwerth.

Could I ask how budgets are supporting primary care to deal with the pressure on them, and also to transform services?

Well, like you say, there's been a lot of pressure, on primary care particularly, currently. If you see the number of people—. And you've heard that there are 400,000 people a month [Correction: 'a week'] being seen; that's an incredible figure, I think. What we're trying to do is to ensure that we have this transformation programme in place, and it's something that we've been focused on in all four areas that we're focused on—GMS, dentistry, community pharmacy and optometry. And what we're trying to do with those contracts is ensure that we get value from them, not just new value, but value from what we already have in place. If I could ask Alex Slade perhaps to give a little more detail about what's happening in those different areas.

Of course. Thank you, Minister. We've been working with stakeholders and patient groups around what that reform of those areas looks like, around ensuring that professionals are used to the highest end of their abilities, such that we build the teams around them so that there's a wider mix of individuals. All of the different contractual areas have different aspects and challenges that we've been broaching. So, through GMS, it's around the capacity, meeting the demand, working out where the other options are for self care, bringing in things like social prescribing. The Minister touched on earlier that, in December, in one week, there was 400,000 contacts in GMS—that's in a single week. About 20 per cent of that is mental health demand. So, where's that going? We talked about third sector pathways. So, really working through what the opportunities are to deal with that demand, which is why the demand and capacity conversation is really important, looking at the needs of the population so that services are orientated for those, expanding clinical services through pharmacy so that people have walk-in opportunities to pharmacy to have direct, free access to advice and support.

Obviously, the committee has undertaken its inquiry around dentistry, so I probably don't need to go into the detail around dentistry, but, as you know, there's a prevention and need focus through the dentistry reform agenda. And on optometry, over the next two years, there'll be a significant expansion of what primary care optometry provides, which reduces secondary care activity or pressures in terms of referrals—so, expanding services around glaucoma, medical retina services—and that's supported with new investment. So, there'll be additional funding for 2023-24, and then rising to £30 million in 2024-25.

The other aspect more in the community space is the allied health professionals—clearly, that's not a contracted group, but—expanding the allied health professional capacity, looking at frailty teams, community resource teams, how that supports the six goals work, how that supports dealing with that capacity that we're talking about and provides that direct access so that it's not all through a GMS gateway.

One of the dangers of transformation funding is that it doesn't always lead to transformation. We could find lots of evidence of that over recent years, I'm sure. How do you make sure that the money allocated in this budget now isn't just used to maintain and keep under-pressure services going?

So, as part of the planning process and the IMTPs, clusters across Wales also produce cluster plans, which then feed into those health board plans, and that's the opportunity to really look at what the local needs are and where there's cluster funding that can be allocated to address those needs. Some of those are communication, so patients understand what the options are available to them, some of them are around looking at—. In Hywel Dda, there's expansion of frailty teams around those high-risk individuals. Lots of individuals who fall over at high risk of frailty end up in hospital—that's a pathway we've obviously discussed, and, if that can be prevented, that has lots of benefits. And, of course, expanding the capacity; I've touched on direct access physio. So, using those plans for the health boards to scrutinise, assess where that money is going and what that's achieving, and then looking at how that's then mainstreamed going forward. So, the cluster funding, the Minister's predecessor doubled that funding to £20 million a year in 2018, and we've seen an expansion of all of those activities as a result of that doubling of the funding. That £20 million is an annual investment into local activities as a result of those plans.

And finally, the NHS Confederation said that it's capital funding that you need more than anything to transform, perhaps, and the lack of capital funding available does hold back elements of what you might want to do in terms of transformation. We've touched on capital spending limits already, but if you could just sum up the extent to which the limited scope for capital spending is holding back what you would like to be doing in terms of transformation.

So, I think we'd probably like to do more in the space of regional working, just trying to get health boards to work together, particularly, perhaps, in some of the planned care space. I'd like to do a lot more in relation to digital. I think that's going to be a never-ending pot where we could pool some money, so I'd be more than happy. And obviously there's the kind of major transformational changes that we need in terms of have we got the right infrastructure across Wales in terms of our hospitals, in terms of everything else. So, there are some very big issues around that, where we wouldn't even scratch the surface with the kind of money that we have available.

And you'd certainly agree with the NHS Confed that lack of capital is perhaps the biggest barrier to transformation.

Absolutely, and this is something that—. I think there's an understanding that that is something that is definitely holding us back.

Okay, diolch. Thanks, Chair.

Any other questions on this section, or any other final pressing questions from anyone?

On capital, I just would like to know the implications of the reduced budget that you clearly received from the UK Government, and the real implications of the lack of that capital investment. Because you talked about innovation going forward, which is clearly going to need some capital investment, there's no question—you can't modernise and innovate unless you've got some money behind you to do that, and that's just one area alone. So, what impact is it likely to have on the aspirations that you have and the people who want to deliver it in terms of the timescale now because the UK Government has failed to give you adequate funding?

Well, clearly, we could absorb a lot more capital, and, at the moment, what we're managing to do is to try and keep the lights on. That's the important thing—we have to make sure that we comply with fire regulations. So, that's got to be our first priority. And then one of the other things I've asked them to do now within health boards is to come up with their 10-year proposals in terms of what their longer term plans are, just so that we don't have a system where whoever comes in first gets the money. So, we've changed the way we are allocating. But I certainly think digital transformation is somewhere I'd like to go a lot further a lot faster on. There are some limitations around that, because actually it's revenue and it's people that are the restricting factors on that—everybody's trying to get hold of these technicians. So, in the digital space we could probably switch some into revenue, but it's the longer term, big picture: what does the health service in west Wales look like in future? What does tertiary care in Wales look like in future? It's those kinds of big, long-term plans that you can't switch on overnight. You saw how long it took to build the Grange, for example. That was a very, very long process. So, you think about the next generation, what's coming next—we need to start preparing for that now, and you've seen some of our hospitals are already creaking.

Okay. A quickfire question from Gareth.

Thanks, Chair. Very quickly, could I just have a quick response on the ambulance staff strikes in Wales today? It would be remiss not to put something topical in. Just because this is the second walkout we've had in a month, I'm just wondering what discussions you've had with the GMB and what your response to today's actions is.

So, we obviously support the right to strike. We understand the frustrations of members of the ambulance service. I think some of this is not just about money—it's also about frustration in terms of them not being able to get on with their job, and that's part of what we need to do as a Government, is to make sure that we improve that flow through the system, much of which we've touched on today. But I must say that, in the last ambulance strike, what we saw was committed workers who did go out on strike but, when there were real emergency cases, they left the picket lines and they went and did their job. These are not people who are taking industrial action lightly. We obviously have a conversation with them tomorrow, where we've tried to see what we can do in terms of being able to negotiate a way out of this situation, and we'll be discussing that with them in the meeting tomorrow.

So, you're meeting the GMB tomorrow.

We'll be meeting all of the health trade unions tomorrow.

Okay. Thanks.

And a final question from me, Minister. The 108 beds that you've confirmed—is that enough? Is that sufficient?

Sorry, the 508—.

Five hundred and eight beds. Sorry, yes; quite right. Five hundred and eight beds.

No, I mean, obviously we've got ambitions to go further with that, and we meet fortnightly, don't we, Julie, and it's been, oh, it's been really, really hard work to get to 508, which is why it's quite interesting to see that they're only just starting on this process in England, because it's been hard work to get to 508.

So, just talk me through the budget consequences of that. If that's not sufficient, is there flexibility in your draft budget to increase the 508 beds that you've worked to—

So, we've got money in this year's budget, so we're using some of the regional integration fund money, local authorities are putting some of their money in, health boards are putting some of their money in. This is very much a co-ordinated effort, where everybody is pitching in and making a contribution. So, the money is available for this year.

And then in terms of the draft budget, which is the subject of today's discussion, what are the consequences of that in terms of the flexibility that you have for a further increase in bed capacity, if needed?

So, I think the important thing is for us to try and fix the flow issue, because that's what we want. We've said time and again that what we want to do is to get people into their homes, and we look after them in their homes, but there will be some capacity and some money within the RIF programme that we can use to expand, if we need to, next year.

In next year's budget. Yes, okay. Thank you. Thank you, Minister, I really appreciate your time and the time of other Ministers and officials this morning. Diolch yn fawr iawn. Thank you also for your advanced paper ahead of today's session as well. So, thank you very much.

Thank you.