Health and Social Care Committee

I move to item 3, and I propose in accordance with Standing Order 17.42 that the committee resolves to exclude the public for items 4, 7, 8 and 9. Are Members content? Thank you. We'll go into private session and be back in public session at 11.30 a.m.

Croeso, pawb—welcome back to the Health and Social Care Committee. I move to item 5, and this session is in regard to that, earlier in the year, the committee agreed to hold a scene-setting session with relevant experts to gain a clearer understanding of health systems across Europe and how we in Wales might learn from other areas. So, this morning, I would very much like to welcome Mark Dayan and Professor Scott Greer. So, thank you ever so much, both, for being with us this morning. Just to say that it's a hybrid meeting, so one of our Members is on the screen, Mabon ap Gwynfor, and the other Members are in the committee room here in the Senedd in Wales.

It might be helpful to start with if you just give us a little bit of background about yourselves, a bio, that would be helpful, and your background, and tell us where you're beaming in from as well. That might be helpful as well. So, shall I come to Mark Dayan first? Mark.

Yes, thank you. So, I'm Mark Dayan. I am head of public affairs and lead our Brexit programme at Nuffield Trust, and I've done responsive and comparative policy work for us for a few years as well. We've worked on programmes on integrated care in the different UK countries, and on a number of reviews at the request of different parts of the Welsh health system, or the Government. So, I have worked through our comparative within the UK programme's work, which hopefully should be relevant. I'm also our correspondent for the European observatory's health systems policy monitor, so I feed in items of reform from across the UK, including Wales, and discuss those in a wider context, which I hope should be helpful in his session. I'm beaming in from London.

And Professor Greer.

Thank you for having me, above all. So, I'm Professor Scott Greer. I teach health management and policy, global public health and political science at the University of Michigan. I'm beaming in from Brussels, because I'm also senior expert adviser on health governance to the European Observatory on Health Systems and Policies, and I've spent a lot of time in my past working on Wales, but haven't done any original research in Wales now, so I wouldn't consider myself an expert in Welsh health policy but I’ve done a lot of work on comparative European health systems and ways that they choose to allocate their resources over the last few years.

Thank you, both, and I suppose, in one sense, we as committee members won't expect you to be that familiar with the Welsh health system, because we want to pick your brains on health systems elsewhere across Europe, but, of course, it's helpful that you know some context of the Welsh health system because we want to look for comparable nations.

So, as a health committee, our job is to scrutinise the Government, make recommendations to Government. So, perhaps just give us a starting point, for us, in terms of, as a health committee, what might be your suggestions of places that we could look or areas that we could look to, and, I suppose, in the context of perhaps looking at systems across Europe that might be similar to us geographically and population wise and have some of the same character—that might be helpful in that context as well. Give us some pointers where we should be looking to additionally. And perhaps also, if I can add as well, how our health outcomes compare as well. Ultimately, we want to look to countries where there are good health outcomes and that we can learn from, I suppose, as well, in that context. Who wants to go first on that? Go on, Mark.

I'll go first, that's fine. Then I'm sure that Scott can give a much better informed take in terms of European health models.

I think the first thing to say is that there is potentially some really interesting work for this committee to do at perhaps a more fundamental level, which is just in terms of how difficult it really is to compare Wales to other countries’ health systems and to understand some of the differences and similarities. You’ll be familiar with the difficulty of comparing Wales to other parts of the UK—data tends not to align. And unfortunately, that is magnified when you take that through the fairly limited number of types of data that are collected in an internationally comparable way, mostly by the Organisation for Economic Co-operation and Development, and then you try to look at other countries.

So, much of the data that we have treats the UK as one unit. Somewhere out there will be more or less comparable Welsh data because the Welsh Government is submitting it through to form a full UK figure for a lot of these indicators. And so that does offer a potential resource to improve understanding. But, beyond that, I think there’s also a lot of detailed work that largely has never been done, as far as I know, in terms of whether you compare Wales to comparably sized autonomous nations, regions, elsewhere in the UK or comparably sized countries at a much finer level of detail than we’ve ever really got through the OECD and prefabricated international data—so, lining up basic things about how the workforce works, how admission and discharge work. There’s certainly scope for studies into that, which would have to go much deeper into those countries’ data, but it’s not something that’s been very extensively done so far.

And then the second thing just to reflect is that the overall context is increasingly one that’s defined by financial strain, and that’s true everywhere—financial strain and the drive to maintain capacity and activity. We’re seeing bigger overspends within Wales at the moment than I think has historically been the case. Wales is within the UK, which is a strained spender in terms of having a relatively small state for a country with universal healthcare and that has been passed on in a Welsh context. And so I’m sure that this is something that’s very much on your horizon, but looking at ways that that context of strain on resources and strain on finance and in particular long-term investment, which has been a longstanding UK, I’m afraid, I think generally, including Wales, weak point—. And what other countries can teach about that is important. But, at the same time, there is always a risk, frankly, of finding a much better funded country and seeing the interesting things it does, but discovering that, actually, that would be really challenging to transpose into a country where funding is considerably lower.

Sure. Before I bring in Professor Scott as well, I think, from my perspective, we're used to, in this committee, comparing Wales to England. It's quite common. But I suppose, in this session this morning, in a wider context, Wales is relatively the same as England in terms of how our systems operate. So, I suppose when we're asking questions about Wales, it's Wales/UK on that basis, compared to some other countries as well across Europe. Yes, Professor Scott.

I'm really glad that Mark went first, because I want to underline that, in a comparative context, frequently the most important thing about all the UK health systems is how hot they traditionally run, no matter how you count it: fewer beds, fewer nurses, fewer doctors per capita, less percentage of GDP. That's not quite as true for Wales as it is for England, but it's still striking compared to countries like Belgium and Germany. They just have more resources. And what that means is that, in many ways, a tradition of austerity shapes the NHS systems and gives them really, really—. They deliver a lot of healthcare for the amount of money put into them, but we don't know much about what their culture and performance would look like if they had higher expenditure, because we had, essentially, one short period under the Blair and Brown Governments where they had a level of funding that you would expect from western European peer countries.

That also matters because, when you're picking comparator countries or regions, one of the important things is all the other social determinants of health that come in ahead of time. So, one of the things I like to point out is that the United Kingdom Government and the Swedish Government do about as much to equalise income, Gini coefficient, as each other. So, the United Kingdom Government, through taxes and transfers—so these are UK powers, overwhelmingly—they redistribute about as much as the Swedish Government. The difference is actually in the pre-existing level of equality, which is down to things like the structure of the Swedish economy. So, when you compare to Sweden, you're starting with a very different population before taxes and transfers and also before they have or need any social services.

What that means is that I would echo Mark's point that it's tricky to identify regions, but it's really useful that you identified areas that you might want to think about, because there are a couple of ways that you can think about Welsh problems that are very comparable to the problems of other parts of Europe, and I would just highlight two of them. One of them is workforce. There are a lot of health systems right now that are undergoing a great resignation, that are having trouble attracting and motivating and retaining workforces and adapting them to the needs of a changing skill mix and changing technologies. And the other would be the extent to which, outside taxes and transfers, outside remodelling the entire economy, there's a lot of local-level activity that's very effective in terms of prevention and promoting healthy lifestyles, where a lot of Governments in Europe are comparable in that they control local government, they control a lot of infrastructure, they control the design of a lot of public services and they can do a lot. So, I'd look at those two policy areas for really interesting precise comparators on where you could solve problems.

Thank you, Professor Scott. This is a free-flowing discussion as well, if Members want to indicate to come in. I know, Joyce, Professor Scott just mentioned workforce issues and I know you had some questions around that. Do you want to come in on those now?

Yes. Good morning, both. One of the things about workforce is, of course, combining health and care workforces, because one is mutually dependent on the other, and if you can you give any examples of other European countries, and maybe a reference to pay, terms and conditions and staff retention, that might be useful to us.

I'll take that in two parts. One is that I would say there is a consensus, and there has been a lot of research and research synthesis because a lot of European countries are facing serious workforce problems. And broadly, the three-step plan for working on your workforce is to make sure that you adapt training to skill mix changes, so, if you're investing in primary care and you have a lot of surgeons, you're going to end up with demand created by surgeons that will reduce the effectiveness of your shift. One is better working conditions to reduce attrition and retain staff. Notice I said 'better working conditions'. Pay matters, but so does the nature and organisation of the work. And the third one is ongoing retraining and professional development for all professions. It's very easy to focus on especially nurses when you're talking about retraining and forget all of the other occupations in the health system. And I think that's pretty close to the consensus of what works from research and policy experience.

Integration is tricky, and we have, including within the UK and Northern Ireland, for example, a lot of cases where literally integrating health and social care was no panacea. It didn't solve the problems because, essentially, the hospitals ate much of the social care budget, as you would predict from the way the politics of medicine tend to work. What does seem to work—and you can do this in any organisational format—is thinking about how to have a better resourced, better working conditions, better trained care workforce, because right now, in most countries, if you don't spend enough on it you default to all the problems we know about: privatisation, meaning people finding somebody from another country to look after grandma; you get a lot of low-quality operators; you get a lot of turnover; you get a lot of demotivated staff; and problems like that. So, thinking hard about the care workforce as the object of policy is a necessary complement to reorganising the nature of the workforce itself, I would say.

Mabon wanted to come in as well. Joyce, did you want to—? I'll come back to Mabon and Sarah. Do you want to jump in as well afterwards? Shall I come to Mabon first?

Do Mabon first.

Yes. Mabon.

Yes, thanks, and thank you both for coming into this committee and giving your expert evidence. I suppose, if we go back one step, albeit that we have different legislative frameworks in the various regions and countries, one comparison that's used every time is how much money per head is put into the health service, and we see that in the UK. In Wales, we have this amount spent per head, in England it's this amount, in Scotland yada yada yada. So, can you, just on that basic level, give us an idea, if you have that information, on the various spends per head that we have on health, and who spends more, who spends less, and which countries are more effective in their spends?

I was going to add to that, as well, to Mabon's question, in terms of: does it also follow through that the more you spend on health follows through to outcomes as well? Is the chart the same for outcomes and spend?

Yes, that's a great question. Unfortunately, in terms of the year we're asking it, it's an unusually difficult time to give a really robust answer, because we have had the issue that additional spending during COVID-19, particularly in the UK—or a lot of it—got counted as health spend. It's caused these quite sharp fluctuations that we've seen in the last few years' worth of internationally comparative data, and to some extent it's done that in the UK as well, boosting apparent spending in England that is arguably more categorisable as COVID-19 spending related to the pandemic across the UK as a whole.

With that said, I think, if you go back over a slightly longer time period, there are two basic points that I think should underpin understandings and hopefully will answer your question a bit. One is that Wales does have a reasonably consistent position in terms of its spending per head on health, and that's basically somewhat higher than England, but certainly lower than Scotland and Northern Ireland. So, if we look at the pre-pandemic years, Wales is usually spending 3 per cent to 10 per cent more than England, which is a significant additional sum. I think, insofar as this work's been done, it's potentially a bit less than the additional need that Wales might be expected to have, and it's slightly less than a proportionate translation of the Welsh total public spend compared to that of England, which has prioritised the NHS more within a public sector generally subjected to quite sharp austerity in the last 13 to 15 years. And then you can take the UK, bearing in mind that Wales is spending slightly more than that, and compare it to other countries.

A complicating factor here as well is: what are these other countries you're comparing it to? For a northern European country, the UK is usually spending a good 1, 2, 3 percentage points less of GDP on health than most of its neighbours, countries like France, the Netherlands, the Nordic countries. It spends a much more similar amount to southern European countries like Spain or Italy, sometimes more, and, of course, a far lower proportion than the USA, which has very high health spending. So, generally, Wales is a slightly above average spending nation within a slightly more below where you'd expect spending overall state.

And I think one last point to pick out there, just to bring back something I said earlier, but I think it does bear repeating: historically, although this has slightly changed in recent years, another notable thing about the UK has been its low level of fixed capital investment in health—so, less spending on buildings, IT purchases and initiations, equipment, than comparable countries. At times, that's been really strikingly low. And while there's a lot of ups and downs in that in Wales, because, as a relatively smaller country, individual projects can mean quite a big increase in capital spend in-year, the draft budget for this year, which I was looking at recently, would include still a relatively low level of capital spend as a proportion of overall health spend compared to what you'd see in many other countries.

Mabon, do you want to come back at all, or carry on with the discussion? No. That's fine. I suppose, from my—. I'm coming to Sarah next now, but, from my perspective, what I would hope to get out of this session today is to see if there are countries' or aspects of countries' health systems that we can look at that you think would be worthwhile us exploring as a committee to improve outcomes in Wales. I suppose that's where I would want to try and head in some of our discussion today. Sarah.

Thank you. So, we've had a discussion—. Sorry, first of all, thank you, both, for being here today; it's wonderful to be able to pick your brains about this. So, we've talked about how much funding there is, but I'd like to look a little bit more at how that money is being spent and where it's being spent, specifically in relation to the research that you've done around building up community health and care services. So, I'll be honest with you, I have some people who have described some of our hospitals now as actually just being care homes. I have a hospital in my constituency where we maybe have about 300 beds, and, at any given time, maybe about 80 to 100 of those patients are probably ready to go home, but there's not that link-up at the moment—although we're getting there—with the social care service for them to be able to leave. And I noticed in your research that you've said that most countries with similarly low numbers of acute beds to the UK but with shorter lengths of hospital stay tend to direct more of their healthcare spend towards non-patient, in-patient services. So, you've said Netherlands, Sweden, Denmark, Norway. And it seems to be that that degree of—. By long-term reallocation, you've said, of resources—. It needs that long term. And I think the problem that we've had is we've been going through so much crisis that the long term is difficult to plan, right, but this has been happening everywhere, to be fair.

So, it would just be really helpful, I suppose, if you could expand a little more on this and what's the progress with those countries, I guess. Are they seeing that it's making a difference, having more services in the community? A little bit more on the benefits would be very helpful. But, mostly, coming back to what the Chair just asked there, Wales does have an ageing population. We are older and sicker in comparison to other parts of the UK. So, it's all well and good, I suppose, looking to the Netherlands, Sweden, Denmark and Norway, but it would be particularly helpful, right, looking at countries that are similar in demographics to us as well, so we can learn from them is this working, do we need to really make a conscious shift to that long-term funding.

Right. Well, I'll respond to that, because I think that's our report that you're talking about.

Yes.

I'm glad that you've seen that. Yes, I think, to answer the first part of your question there, this is, potentially, an area that's very relevant to Wales, because this report, in which—. For those of you who haven't seen it, we sort of looked at the UK as a whole, and then further drilled down to England, as this country that, just as Scott said earlier, runs very, very hot, and we looked at other countries that have comparably few hospital beds per person, and several of them are managing a shorter length of stay in hospital, which, generally, is indicating that you may be able to cope better with that lower bed base, because you're, essentially, fitting more patients through each bed each year. So, that's relevant to some of the sorts of access and waiting times problems that we discuss so much.

And for Wales, this is maybe an even more pressing issue, I think, because Wales doesn't have that many more hospital beds than England, but it does have a considerably longer length of stay. And there's a lot of uncertainty about—and you've probably been through this as a committee—the comparability of the data. So, I don't think anybody would dispute that patients in Wales tend to spend much longer in hospital, which potentially suggests there's more to be gained from finding ways to move them through faster.

So, those countries that we looked at, they are the star pupils in terms of having the shortest length of stay in Europe in the OECD, and there are so many interesting points to learn from them. I think the point about demographic differences between Wales and them is one of two caveats to really bear in mind. And certainly, I think that's not just a question of the ageing population, because all of these countries will have population ageing. They, I think in all cases, will have a higher life expectancy than Wales, and so they certainly have large and growing populations of older people. But there are other really important demographic differences as well, and those will include, for example, where the population is in Wales, the levels of deprivation and some of the public health problems being inherited. So, that's one thing to really think about when making the comparison, and then, of course, the other is the level of resourcing. These are all relatively high-spending countries, which may make it somewhat easier for them to trade off that idea of shifting some of the capacity out of in-patient care and into other things. But, with that said, as you will have seen, some of the themes that we pick up for further investigation about how these countries may be achieving that are that some of them have had a really conscious long-term process of change to streamline their hospital sectors. Several of them are actually spending a lot more on out-patient care, not just on community and primary care, although they are doing that as well. And mostly all the Scandinavian ones, at least—

Sorry. Where are these countries, Mark? Sorry.

Sorry. These are—. So, the four that we really focused on are Denmark, Norway, Sweden and the Netherlands. In the case of the first three there, so the Scandinavian countries, what they also have is a model where responsibility for health and social care is much more blended. So, their municipalities, which are local government areas on a really quite small level, share responsibility for both non-hospital healthcare and social care. So, they have a wider remit across that. In some senses, that's a degree of general decentralisation as well that goes beyond what you see in any of the UK countries.

I was going to say I'm trying to make this a free-flowing discussion, so if anybody wants to come in with a quick question, to clarify, then just indicate; I'll bring you in straight away. Jack, do you want to come in now?

I think Professor Greer might want to add to those points, and then perhaps I'll come in after that.

Oh, yes. Thank you. Great. Thank you.

Thank you. I just wanted to say there are also countries where part of this intentional process has been to create a happy and professional and fairly stable care workforce, so it's a job that you could legitimately have for life, and view as skilled and as having professional prospects. And you see the benefits, that a happy and professionalised workforce gives you better quality, and it also gives you better quantity. And there are a lot of sad experiences around Europe of something much more comparable to the UK systems, where there's not enough of the publicly funded care and just a lot of not-very-good quality private operators working for all sorts of different sources of income.

Just in terms of comparison, the other thing is these are very equal and basically healthy countries, so that's a good starting place. I was trying to take up your challenge to think of comparable parts of Europe. Northern Spain runs NHS-model systems, and they have a lot of the problems of—. Essentially, they have a lot of mountains, they have a wide variety of different kinds of economies in a place like Asturias, which runs from former coal-mining towns all the way to very beautiful green mountains. They also have a relatively ageing population, a fairly high level of income inequality as part of Spain as a whole.

It sounds just like Wales except for the weather. [Laughter.]

They get most of the—. Spain gets as much rain, overall, as the United Kingdom. It's just that all of that is in the north, so don't leave your anorak behind, if you go.

Ah. Okay.

The other place, though, I think, if you're looking at what can you do with social determinants of health problems, is northern Germany, northern France, large parts of Belgium. They're totally different health systems. You're not going to learn a lot of directly applicable lessons from getting into the weeds of Belgian social insurance, but you can learn a lot about broader determinants of health—things like the built environment, things like dealing with pollution, things like the nexus between social care and recapacitation and care in the community. The things that influence health—you'll often find they're dealing with many of the same problems and many of the same constraints in the formerly industrial northern half of Germany, the northern parts of France and Belgium.

Do you want to jump in, Jack?

Yes. Thanks, Russ. And thanks, both, for being here, as others have said. We've talked about a few policy areas. I wonder if there is perhaps another policy area that is looking at the efficiency of current systems and infrastructure, and rather than buildings and hospitals et cetera, more IT systems and the infrastructure around the digitalisation of our healthcare and social care—the integration of those. Because we've had numerous examples where information can't be shared from GP to GP, or NHS service to NHS service, or social care service—we speak a lot about electronic prescribing, which will hopefully be sorted. But there's a case, perhaps, to focus on the efficiency of our system and how we can increase that. Is there any particular region or area where the efficiency of their system is pretty good, pretty sharp, that we can perhaps take a quick look at from a policy level?

And just to jump in on an earlier question, you've mentioned northern Spain and a part of Germany, just to understand, is there a degree of devolution in European countries? Perhaps talk to that point as well as addressing Jack's wider point.

Yes. I'll answer the country point before I go to Jack's subsequent question. Spain would look very familiar to you. The regional governments run their health systems, they were basically all set up, quite literally, on the NHS model—they hired consultants in from the United Kingdom. And they therefore have a lot of the same policy mix. There is a social security administration run from Madrid, but there is a health system and local governments that are quite clearly under the control of the regional governments. So, if you look at the data on the population, they're fairly comparable and they get some pretty good outcomes, and they are grappling with some of the same problems, such as their care workforce is not the professionalised, happy, Dutch care workforce, it's much more kind of what countries in the world default to, which is small, private homes of varying quality. So, I would think seriously about them.

The Germans and the French, they're devolved, in a meaningful way, in things that aren't directly healthcare. So, social services, the built environment and local government—basically, things and not health people stuff you'll find are under their power. So, if you're looking at, for example, encouraging people to walk to work, that's a thing on which a French, German or Belgian regional government is quite able to talk.

On efficiency and technology, technology generally gets you better quality, it doesn't necessarily save you money. Over and over again, we find that if, for example, you introduce really good health IT, you frequently end up getting more tests, because one of the reasons you introduce health IT is so that a dialogue box pops up and says, 'Have you checked this patient for sepsis?', to pick a currently very salient topic. Well, then you get more looking for sepsis. If you throw in, 'Has this patient had a screening for a particular cancer?', you get more cancer screening and you're likely to get more cancer treatment. And it doesn't necessarily reduce the duplication. It can reduce miscommunication, but you'll often find that you have a patient who arrives for an orthopaedic consult with an x-ray, and your average orthopaedic surgeon has no respect for any x-ray not taken by a specialist orthopaedic x-ray facility. So, you end up with two x-rays, both of them effectively saved in the system.

I spend a lot of time arguing with people who see health IT as a panacea, and I would say that you'd want to control it very, very tightly, because you can improve quality, you can spend a lot of money—the efficiency gains are often really not that impressive and it can really distort the practice of healthcare if you don't manage the introduction of the system well. There's a standard of care for many countries of, 'You should, if attending a birth in a hospital, have two nurses', and most nurses will tell you that one of the nurses is there to nurse everybody in the room and the other nurse is there to nurse the electronic health record.

I've got some questions on technology myself. Did you have anything else, Jack?

No.

I suppose I was a bit surprised to hear what you said, because we have lots of evidence about—. We just did a piece of work on dentistry, and dentists telling us there's a lot of bureaucracy and duplication of systems, there are two or three systems operating, or dentists have to duplicate data rather than it being populated. So, there's a lot of improvement in IT that could be done to make things more efficient. I had a constituent last week who contacted me saying, 'Look, my GP can't e-mail the x-rays to the hospital because they operate on different systems.' So, to me, it seems like it's an obvious thing that IT can help save and make efficiencies.

Yes, but what we're talking about often is precisely the legacy of previous IT systems that were introduced to create efficiencies. And it's very, very easy to find that you're stacking new systems on top of the others. So, you can simultaneously get better quality, because now a dialogue box pops up to say, 'This patient needs a cervical cancer screening', but at the same time, somehow, if you were to have two non-interoperable electronic health records, you're not getting the efficiency—you're getting twice as much bureaucracy. So, rationalising existing health IT and often replacing it with better integrated systems that do the same thing will probably get you an efficiency gain. But, in many ways, it's solving a problem created by the previous legacy in health IT.

Okay. I can see Mark wants to come in. All the time in my mind as well, I've got—. We want good examples of elsewhere in Europe where something might be done better that we can learn from. So, Mark.

Just to come in on both halves of that, we've done some work looking at comparable digital initiatives in different countries. And what Scott said generally about the impact of technology absolutely is—. What we see with almost all types of technology in healthcare—they are not going to deliver efficiency. And I think there has been a definite tendency across the UK to greatly overestimate the ability to twist some policy lever and suddenly you'll be delivering productivity gains of 10 per cent or 20 per cent. It's never happened, and it would take something pretty extraordinary. But with that said, are there countries that do better in a couple of key dimensions? From our research—and this is a report I'll certainly share with the committee—yes; there are certainly countries that are better at interoperability. So, that's the sharing of data between different services that he describes. You won't be surprised to learn again that Denmark is probably a reasonably good example of that, and Finland too, I believe. That was done in both those countries with quite a concerted national programme.

Another really important dimension to think about—. Because we've very much been talking about digital technology as something within the NHS, beyond its front door, but the role of patients in some of these countries is quite a lot bigger. So, they have greater control over their health records. And there's a higher level of trust in many of these countries, which facilitates removing some of the political difficulties that are often associated with why permissions for interoperability and the legislative framework that enables that aren't always easy and non-controversial to get off the ground. So, a lot of these countries, over some time, and across sectors, have built trust in using digital tools to manage your interactions with the state, which, in both those countries, like Wales, includes most of the health service. And so there are certainly areas of digital technology where there are good examples in other countries, although there are deep reasons why that may be.

On efficiency, I hate to sound a note of pessimism—I would love to give you a brilliant comparison point that you could go and learn a lot from—but, on across-the-board efficiency, that is really incredibly difficult to map out. And that's for the very simple reason that, to really learn about efficiency, you need to fully understand both the outputs and the inputs. And on an international level, we're a long way off doing that for the UK or Wales versus other countries, really. There are interesting studies looking at proxy measures, like administrative spend and just the number of discharges that you do relative to your amount of funding, your amount of resources, but we're a long way off having that level of understanding. So, I think, in a sense, you'd need to pick a country first, maybe based on more specific areas like length of stay or interoperability, and then try and go in there and build that kind of comparative data, to really understand that.

Great. I've just got Sarah, then Mabon waiting. So, Sarah first, and then Joyce.

Thank you. So, this is coming back to a few of the points that we've covered. I'm looking at the report and its talk of alignment of incentives and joined-up delivery to enable integration. So, one of the things that you've picked up on—and, obviously, I know this is England but it's the same for Wales; it's the same structure—is that accountability tends to be split between local councils and the NHS. We have the same issue here. And you've used the example of Denmark where what they've done is that the municipality—so, their local government—has full responsibility for determining the appropriate level of health and social support needed following discharge from the hospital. So, you've said GPs will do follow-ups, nurses, different community-based staff, and then it's all under one umbrella. And I suppose the themes that seem to be coming out here, then—you've mentioned a couple of times the decentralisation of power. So, would you suggest, then, that—? You said about being blended. Do you think it's better if it's all under one umbrella? Does that seem to have better outcomes?

And the other thing that this highlights again, which you mentioned previously—we are very big in England and in Wales, really, on the preventative and getting out to see people in the community. But another theme that seems to be coming through is that we need more focus on the aftercare, on the out-patient on the other side of it, because I do think that that's something that's showing in our data, that people are going back home and then coming back in again very quickly, right?

Those are both very good points, I think, that very accurately reflect our report's findings. I think on the prevention versus post-discharge elements of out-of-hospital health capability, I certainly wouldn't suggest that, on some fundamental level, prevention isn't much more important in a wider sense that includes all the determinants of health through society, in that that's determining the total disease burden, essentially, that your health service is facing. Where I think that a lot of countries in the UK have run foul of this—a slightly characteristic UK tendency is to try and use everything as a way to save some money next year, in assuming that you can do a little bit of that with GPs going out and helping people to take their asthma medication better or whatever, and you'll immediately see some sort of drop-off in people coming to hospital. There have been plenty of attempts to do things like that.

In England there was an aspiration that the better care fund that they had there was a local government/NHS joint initiative that would save 10 or 15 per cent of emergency admissions in its first year. Obviously, it had essentially no effect at all, just because the drivers of disease are very, very deeply rooted; there are all kinds of complex interplays with what services are available. So, if you're trying to solve health system problems, then the thing that's near in focus, yes, is your ability to discharge people, to have them looked after safely somewhere that's less resource intensive than a hospital and closer to where they live. And, as I say, there are very good grounds for thinking that should be a big priority for Wales, because it does have longer lengths of stay in hospital, or beyond what you would obviously expect compared to England and Scotland.

On the other part of your question about pooling responsibility in these countries, you're absolutely right to pick up the axis of decentralisation and not just combining responsibility, because in a country like Wales or England it's not just that there are two sides, but that one of them really answers nationally and the other one answers locally. So, there is quite a deeply rooted de-alignment that can't really be overcome just by improving joint working locally. These are definitely interesting models for Wales to look at, but I think you've also got to be really aware of the costs of structural change like that and the risk that a structural change doesn't translate through to a cultural, practical change.

Looking much closer to home, there's obviously the—. One part of the UK has fully integrated responsibility for social care and health for decades, which is Northern Ireland, where social care has essentially moved over to the NHS, because there were concerns about the way that councils were using the services for different community groups. And it's not an exemplar of perfect joint working and I think you'd find very few people there who'd say it was, because although the structures are aligned, it doesn't mean the incentives and the culture are. And that may be what works quite well in some of these examples in those countries.

Thank you.

That's fine. Mabon, do you want to come in?

Yes, thanks. I guess there are two parts to this, which are interlinked. First of all, just to give a picture, of which you're probably aware, Wales is a very rural, sparsely populated country, or at least parts of it are sparsely populated, and the distances that people have to travel, even though we're a relatively small geographical country—. The mountains, the valleys and the rivers mean that people have to travel a long way. I'm thinking of a Beveridge-type health system; are there any comparable countries out there with that type of healthcare where they've transcended those distances and meant that people can travel from a rural area to a centralised hospital system that we can look at? And also, because of the devolution that we have in Wales, health is largely devolved, but a lot of our health services are provided by English hospitals, and I'm thinking, are there other comparable countries where a lot of the health service is provided in other jurisdictions?

I'll jump for the rurality. Everybody is dealing with this in one way or another, and there's no top-line place where they have solved the problem. What we do often find is that there are real limits to your ability to centralise services. I was just looking at the data from the US, which I think we'll all agree is a much more car-centric, driving culture, and for a normal medical care appointment Americans drive 14 minutes, and they drive 27 minutes for a hospital appointment. And that's in the United States, which has far, far, far greater tolerance for living behind the wheel. It tends to be the case that you end up trying to figure out how to provide as many services—in particular primary care, preventative and after-the-fact, after hospitalisation, chronic care and so forth—in the community, because otherwise adherence just drops off by a lot.

Obviously, you also want to work on the actual quality of the transportation, which is a really, really easy thing to make false economies in, if you end up with a patient sitting in a dialysis clinic for four hours waiting after they've had their procedure. So, fixing healthcare transport is important, but there's no easy answer to how do you centralise services. A lot of the time the answer is think hard about how to maintain a strong level of local services through things like changing the skills mix and models of provision. For example, doctors really like to live in cities. This is definitely a problem that affects large parts of Wales. Basically, they want to live in Cardiff, and that's not unique to doctors in Wales. Nurses and other health professionals are far more likely to be scattered across the entire country and like where they're living. It's a different career trajectory. So, there's a lot of work on nurse-led models essentially everywhere, because to the extent that you can have the nurses as the face of the healthcare system, you're much more likely to be able to staff it in every town.

I've got Joyce waiting to ask a question, but there's an overarching question I just wanted to raise as we have this discussion. Is there any European country that has significantly changed their model—their funding model or their model generally—and what has the impact of that been? Because we may as well stop having a discussion if it's going to be—. If we're going to look for a significant change to how we operate in Wales, you might tell us, 'Don't bother changing what you've got. Just tinker round the edges'.

The Dutch made their system much more expensive.

What was the impact and the outcomes?

It was more expensive, but otherwise it was about the same. It was essentially the same people delivering the same services but with a very complicated new insurance model sitting on top.

So you're telling us, 'Don't make significant changes to a model, but perhaps adapt the model you've got'.

Change is hugely costly. You're usually doing some form of double running, no matter what it is, while you're trying to do the change. It creates a lot of incentives you don't understand. The Dutch had their ways of preventing bad behaviour, but they had to invent new ways of preventing bad behaviour when they introduced a whole new insurance scheme. And also, if you're thinking about things like integration of care, continuity of care, prevention, most of the other health system models have less incentive to invest in that. So, if you move towards, say, a social insurance model, you might get higher patient satisfaction, but you're much less likely to get preventative care, for example.

Okay, I understand. Mark, you wanted to come in, sorry.

I think this comes down to what you mean by significant changes to the model, because as Scott said, there are very few examples recently, apart from some of the former Soviet-aligned countries, of countries really massively shifting their model from NHS-style in terms of being tax funded, to being funded from social insurance, from payroll level for ease, or private. Once something is set up on that level and it's consuming a tenth of GDP or something, that is just an absolutely massive shift that it's very difficult to think of that many examples of. That's absolutely not to say that there aren't fairly significant shifts short of that, which other European countries do, like shifting responsibilities between a regional authority and the centre, changing the role of GPs and whether they're gate keeping like they do in the UK, whether they have lists of patients, changing how professionalised social care is and, in some cases, reforming social care quite extensively—you know, that sort of level of change, which is a significant change, but whether it's a change to the model depends on what you define that as. That absolutely does happen.

I think you've answered my question—there aren't many examples of significant change in models or systems.

Joyce is next, but I just want to perhaps focus discussion, in particular for us as a committee, to have examples from across Europe that we can learn from, I suppose, and very specific examples of countries and systems that we can learn from, in this next half an hour or so. Joyce.

And that's where my question leads exactly, because everything has to be paid for; whichever system you adopt, everything has to be paid for, whether it's—whatever. So, my question is in terms of any models that may or may not, if there are any, be advantageous in terms of collecting the money that we need. We have a system at the moment where it's collected through national insurance, and we have fewer people paying it because of the age demographic, obviously. So, have you any examples where people are willing to contribute, financially, more money and accept, then, that they've had a better outcome as a consequence of that? And, of course, the other side of it is the expectation that we have here in the UK, the right to inheritance and the unwillingness to pay for care later in life. I think those are key questions, going forward. So, if you have any examples of those things, they might be useful.

On paying for long-term care, which is where we're having these—. A lot of countries are having the conversation very directly. Some of the UK ideas attracted a great deal of interest around the world. There are basically two models that are being taken up. One is to make it essentially an individual, insure-yourself scheme. So, leaving it completely to families to organise turns out to be a really non-viable idea. How do you get a stable funding base that will allow you to have adequate quality and adequate quantity is the problem. In Germany, for example, they set it up as a long-term insurance scheme, and it just doesn't look like the finances on that are going to work; it looks like the contributions that people are willing to accept for their old-age security are just not in line with what it's actually going to cost to deliver a reasonable quality and reasonable quantity—[Interruption.] Sorry?

Sorry. I said that's almost what I expected. So, what's the answer?

So, the alternative? When you individualise it, you don't raise enough money for a specific long-term care tax or insurance policy, and also, there is intergenerational redistribution, people are paying into something in their twenties that they don't expect they're going to see until their eighties, and possibly they just think that their Government will take the money and run. The other way to do it is to frame it internally to the system—that you pay for it out of general taxation or the general social insurance contribution and you kind of reform it and make it better, but you attach it to the same funding systems as the health system broadly. And that seems to work better, because, otherwise, people below age 50 really are sceptical of the idea that they should be paying into something that they're not going to get benefit from. People don't mind paying for their parents, but they don't necessarily believe that an insurance policy does that.

Can I just underline something Mark said as well, that there's this UK tendency to improve asthma care and expect fewer hospital admissions next year? Getting better quality is good, right? So, with better managed asthma you might not see the hospital budget reflect it, but you see somebody with better quality of life, you see somebody who can engage in paid work more productively and pay taxes. You also see somebody who can do more unpaid work, which is the absolute beast of what actually provides care. So, enabling unpaid care is a policy goal in itself, even if it doesn't show up in fewer hospital admissions for something.

I'm looking around for anyone who's got questions. I wanted to ask a question around prevention. The significant part, obviously, of a health system is preventing people from going into the health system in the first place. Are there any examples across Europe you can point to where we can learn lessons in that regard from? You're both looking like you can't think of anything.

It's such a broad question in some senses, I think, because—

Yes, I understand.

—as you'll know, there are so many drivers of ill health, most of them well beyond the health system. Lots of countries have, frankly, considerably better public health than the UK generally on almost any metric. How do they achieve that? It goes all the way down to the structure of their economy, it's the regional distribution of opportunities, it's factors like pollution and diet. All of these are incredibly important, but the reason I was staring into space a bit is: is there a country that had some sort of special targeted initiatives specifically to stop people going to healthcare and it's had a massive overnight effect? Well, I'm not sure, because, in a sense, much of what's been done in these countries in these areas will have had improving the health of the population as their primary aim, just like Scott was saying, and benefits to healthcare are almost secondary.

I am a bit cautious about over-relying on this, partly because there isn't much evidence for it in the short term. There is always a phenomenon that drives healthcare spending and demand at quite a fundamental level where new things can always be discovered, right? So, particularly in a country like Wales or England, where there is a literal queue in accident and emergency and a metaphorical queue for elective care, it's not totally obvious that fewer people coming forward with certain conditions will mean fewer people coming to the health system. It might mean you can let other people in who can also benefit from healthcare and currently are deterred because access is difficult. So, in terms of are there policies that Wales could learn from that would improve population health—and some of those people needing healthcare now don't need it—yes, absolutely. Are they in a neat initiative targeted to reducing healthcare need, and if they were, would that necessarily work the best? I'm less sure. Scott, who knows more about this, may know of something.

I'll bring you in now, Scott. I'm just looking at Mabon and Jack. Do any of you want to ask a question on this point?

I'll come back in.

It's a new point. Yes, okay.

A new point from me.

A new point from you. Okay. I'll bring you in, Scott, then, on this point. Thank you.

I just think an example would be cancer. If you want to reduce cancer, reduce tobacco until you get down to the last smoker stubbing out the last cigarette. That's probably the best buy you can get. So, for example, making it difficult or impossible for under-21s to access tobacco is a really good policy, because, under 21, your brain is much more likely to become physiologically addicted. So, if you start smoking after 21, it's far easier to quit again. Tobacco is just an unbelievable driver of health problems, far beyond cancer.

When you talk in terms of preventative healthcare, though, suddenly it flips that not smoking means you're less likely to have a series of health problems. Screening people for cancer produces cancer care. You end up with more cancers identified, more cancers being treated. So, a lot of the obvious preventative healthcare that you can do out of an NHS system does have this way of improving health and improving quality of healthcare and not improving the budgetary situation. So, for prevention, I'd look very much at things like targeting tobacco, targeting alcohol, enabling walking communities, things like that.

Mabon.

I've got a million questions I could ask, but I'll try this one now. Leading on from what you said there, Chair, about preventative care: ploughing resources into sections of health, we know here in Wales and the UK, 80 per cent of the work is done in primary care, yet they only receive something like 5 per cent, 10 per cent of the funding. Now, is that comparable with other countries, or do we see other countries ploughing more into primary care and less into secondary care, funding-wise, resources, and does that have better outcomes?

I don't think there's a happy primary care sector in the world that feels adequately funded, but there's a lot of them that have more resources than any of the NHS systems in the UK. And a lot of the time, again, it comes down to the extent to which they're encouraged and able to hire and offer good careers to people who aren't doctors.

Scott, could you just elaborate on that a little bit?

You can tell this is a bit of a hobby-horse for me. There's so much of a focus on doctors, and to a lesser extent, nurses, and a lot of the time, where you can get really good value for money in primary care by putting any additional resources, and you see a lot of this in the UK—. There's a lot of good practice around Wales and the whole UK toward people who are various forms of physician assistant, nurse, counsellor, home visitor, that kind of job, and it's easy to forget, it's easy to leave those positions unfilled, and it's very easy to make sure that they're not good, desirable careers, and that's leaving a lot of potential health value on the table.

And Jack.

Thanks, Chair. Just trying to draw back to where we started, really, and the question around comparable nations and similar populations, similar Governments, jurisdictions and so on. We've talked a lot about the Scandinavian countries; we've talked a lot about the Dutch and so on, and their models are slightly different. But northern Spain really interests me, in how (1) it's quite similar in terms of economy, it's quite similar in population, and it's also quite similar in the rurality of the country itself, or the region itself. So, that, it seems to me, is the most direct comparison that we can perhaps come up with. Going back to your point, Professor Greer, to start with, we need to do some work as a committee of looking at particular policy areas in which we might be a able to make a difference, rather than the whole model itself. In the north of Spain, are there any particular policy areas where we perhaps could learn from, and look at, to help in our thinking going forward?

The Basques do a lot of innovative things, but they do it with quite a lot of money, because of some quirks in the Spanish overall financial system. Asturias and Cantabria, they're not the most innovative Governments in Spain, but they have put a lot of effort into running services well, so I think you find, at a minimum, a very good confessional of shared problems and sort of ways to address them on the very practical management service and design, that sort of level. So, the Basques would have a lot of good ideas and be willing to share them, but some of them might not fit within your budget envelope. One other one, if you're looking at health IT, is Estonia: a million people, and, basically, the whole country's a website.

That's very interesting. We have lots of discussion about IT here, and I take your point about efficiency, both points about efficiency earlier, but it does seem to me that we need to be at a level where IT infrastructure is sound, if that's the right word for it.

Running IT well: fantastic idea. It's just that, in health, so often that turns out to be hard.

I think there are two policy areas that we need to do some work on, Chair, I think—on what exactly we might be able to do.

Sure. I suppose, as we've only got 10 minutes left of this session, it's about drawing some key things that Wales can learn from our delivery of healthcare and other European countries—that's the general question, I suppose. It's about pointing us to examples, as we conclude, which you think that we can learn from in particular—any particular examples of where we can look to. And I suppose, also, we've spoken to both of you today, but is there anybody else you think that we should be speaking to?

So, on areas to look at, I think—. Scott and I haven't always been immensely helpful at coming up with really unique case studies. We tend to emphasise that it's incredibly complicated and you need to be careful with whatever you do. But on the previous question, I don't think—. I personally wouldn't put a total counsel of despair around the idea of learning from other countries just because they have a subtly different funding model or the political accountability is at a bit of a different level, depending on what the thing you're choosing is. Because the reality of care being actually provided might not fall neatly into matching those neat buckets and there may be some similarities.

So, two of the things that we've touched on as we've gone around—obviously, we've done a report on this—we're very interested in the ways in which countries are able to discharge patients faster in some of these countries. And partly, those will be things that are very difficult to transfer in terms of the level of resourcing or maybe of the ways that systems are set up. But there's almost certainly still interesting learning on the actual details of how that is done: what is considered a safe setting to discharge to? How the assessments work? What proportion of patients are in particular categories in hospitals and how is that different, and what proportion of patients are assigned to different community services? I still think that that could be an interesting thing to explore.

And then, as we've touched on various points—

Which areas, though—which countries are you suggesting that we look at in that regard?

So, the ones we identified were, again, the Scandinavian ones and the Netherlands. The Netherlands has a more different system. The reality is that Wales, compared to England, because it has longer lengths of stay in the first place—. Other countries would also start looking quite a bit quicker at passing patients through, including Ireland, actually, which has a health system in some question in some ways, but does have shorter lengths of stay.

The other theme that I think is worth maybe coming back to is social care professionalisation and workforce, which, as Scott noted earlier, is something that a lot of countries have really been grappling with. There are lots of examples of different ways they've tried to create a career structure and a more appealing work space—some of them have gone well, some of them maybe not so well—and that includes countries like Germany and New Zealand, where they've tried to improve conditions, in New Zealand in particular, by introducing a greater level of professionalisation. So, there's certainly plenty there as well.

Any other questions at all?

I think in terms of public health pay-off, you might look at Finland for a lot of things, because Finland doesn't have the wonderfully healthy, egalitarian population that you see in the Scandinavian countries. And, it's not in Europe, although sometimes it claims to be, Canada.

Did you say Finland? Isn't Finland a Scandinavian—?

Yes, Finland, but also Canada—

Okay, yes.

—which is an honorary European country. They deal with a lot of the problems and you see a lot of innovative, practical efforts to deal with things like a rural workforce, telehealth, managing decline in some areas and centralising policies in others. So, there are a lot of lessons from different Canadian provinces.

And the Scandinavian countries you've pointed to a number of times. Are they all similar in their structures, in terms of the Scandinavian countries? We're talking about Scandinavian countries. We're talking about are Sweden, Norway, Finland—

So, with Sweden, Norway, Denmark, you have these really healthy populations and that makes a lot of things easier. For example, the finances work out better because you don't have really rich areas and really poor areas, in the same way that you don't have really rich people and really poor people. Finland is different. The Finnish economy doesn't produce quite such a healthy population going in, which means that a lot more of the impact seems to be from actual public health policies.

Jack.

We're talking about different countries—Canada, Finland, everywhere. As I said earlier, I think we're going to have to go away and think about the particular area that, perhaps, we want to focus on rather than the whole-system approach to the policy area. I'm just wondering, away from this meeting, whether you'd be able to maybe draw down—you've said Denmark, you've said a range of countries in Europe and elsewhere—where there might be one or two particular policy areas in these countries that we could really go and have a look at, have a significant way of going—. If we decide it might be social care and parity of esteem for social care, which is crucially important, there may be a country that has got that particularly well developed there, and there may be another country that might be good at IT infrastructure. And when we have a discussion later on about what we want to do as a committee, we may be able to make these comparable choices, well, informed choices, of where to look. I think that might be useful, if that's something that you can provide.

And any contacts that you can provide in these areas that we can perhaps ask for a further discussion on. Yes, Scott.

We both work with and mentioned the European Observatory on Health Systems and Policies. I think they would love to help, and they do spend a lot of their time doing things like organising policy dialogues on specific problems with Governments.

Lovely.

Good. That would be useful.

I suppose, just to end, is there a summary of any main points or areas or elements of health and care delivery that we should be considering?

Something that we haven't really discussed but it is something that stands out about the UK and international comparison is actual clinical outcomes from health treatment, which are incredibly difficult to compare, again, and they're at a UK level not Wales, but in general the picture is not great. Mortality that should be preventable by healthcare is quite high. If you look in years of delay after cancer diagnosis or days after heart attack or stroke admission, survival is not great. That probably takes you down potentially a more clinical path than much of what we've discussed, and it's fairly inseparable from the kinds of health of the population issues for which Scott was maybe suggesting that Finland, which also doesn't have great outcomes, is a good comparator, but that might be another dimension to consider. I often feel like it gets slightly oddly overlooked in UK discourse, given that when you look at what international data is available, if anything, that is the problematic thing that tends to stand out about the UK.

Okay. Thank you. Any other final questions from Members at all? Was that a good summary to end on?

That was very good, really interesting.

Yes. I suppose I'll ask is there anything that you—the last question kind of asked this, I suppose, but is there anything that we've not asked that you think we should ask you? It's good if there's nothing, it means we've asked everything correctly. [Laughter.]

There are a lot of potentially bad questions I prepared for, but I didn't need my responses. [Laughter.]

No.

While I'm talking, I would just say that so many of these problems, more and more, turn into workforce problems, so I would be fully prepared to discover that whatever you try to do an inquiry into you end up with the workforce.

Okay. Thank you. I appreciate that. Thank you ever so much, both, for your time. We really appreciate it. It was a really useful and fascinating discussion, so you've given us plenty of food for thought in our private meeting now to discuss. So, thank you both for your time this morning, it's very much appreciated. Diolch yn fawr iawn.

Thank you.

We move to item 6, and I've never seen so many papers to note, so I'm not even going to attempt to summarise them. I'm just going to say there are a large number of papers to note that are all available in the public pack. None of them needs a response, they're for noting generally, so are Members happy to confirm the papers are noted? Thank you. In that case, that draws our public meeting to an end this morning. Thank you.