Health and Social Care Committee

Yes. I'm Mabon, by the way, Cabinet Minister for health, Mabon ap Gwynfor. We've got Jacqueline Totterdell, who's director general of the NHS, Sioned Rees here, and then Albert Healey. Albert is supporting Delyth, and Sioned is supporting Nerys.

Diolch, Mabon. We have two and a half hours available for questions today, you'll be glad to hear. I do suggest that the committee and yourselves take a short break at a convenient point during the proceedings and I'll give notice of it, so it'll be around the halfway mark.

So, we've got a lot to get through this morning, and a lot of Members are keen to hear from you and ask questions as well, but I'll make a start just by thanking you, first of all, for the paper that we received in advance of today's meeting. Members have all had a chance to see that, and in that you mentioned some of the priorities that you have for health and social care. You've set that out. Perhaps you can expand on those and also tell us which are the most urgent.

Thank you. Can I check that the interpretation equipment is working, that everyone can hear the interpretation? Thank you very much for the invitation to join you this morning. It's a strange feeling to be at this side of the table, discussing and presenting evidence. For those Members who are new amongst you, you're in very good hands. I was a member of this committee before the election and derived a great deal of benefit from the work that the clerks and researchers do. So, we look forward very much to working with you, knowing the excellent work that this team does. So, that's important to note, that this is all about collaboration and we'll be working together over the years of this Senedd term.

I think it's important to put on record, so that everyone understands where we are, that I don't come from a clinical background. None of us as Ministers come from a clinical background. We're not clinicians. We don't come from an operational background, either, in terms of regulation of the health service. We approach this from a policy point of view. Policy is what we do to set the direction for the NHS and the health and care service so that they implement what we introduce as best as we can within legislative, legal and financial limits. I think that's the context for everyone to understand, bearing in mind that so many people are new members of this committee and are new Members of the Senedd.

In terms of our priorities, I've been quite clear. You will have heard the priorities that we set out in the Siambr back in June. The manifesto that we stood on at the election had set out our priorities too, not to mention the 'New Leadership for Wales: The First 100 Days' document, in terms of what we introduced during the first 100 days of this Government. In that, we've mentioned that we want to lay the foundations for developing and strengthening a health service that is fit for the future. That looks specifically at preventing health issues from developing in the first place. It looks at shifting resources from secondary care to those primary care services. It looks at developing new strategies that we will be able to implement to see better outcomes in, for example, cancer care, women's healthcare and in digitalisation. When it comes to the workforce, we've made it clear that there are new strategies that are going to hold the NHS to account so that we see improved outcomes. And we have seen action being taken on those things. If you look at the Active Mile scheme that is being implemented, swimming in schools, those all relate to the preventative agenda. The fact that we have a Minister for prevention is a major step forward, and I'll be inviting my fellow Ministers here to set out their priorities too, if that's okay with you, Chair.

So, that's the kind of vision that we've set out, that's the direction that we want to travel in, and there's a clear reason for that: we have to have a Government that is bold, because it's clear that we can't continue with business as usual. Waiting lists are far too long. Too many people can't see a GP when they need to. The climate change that we see means that there are new challenges ahead of us when it comes to infrastructure and people receiving the services that they need. The fact that we have an ageing population, and that as the population ages the last years of their lives aren't what they should be, makes the situation even more difficult. So, we have to face up to those challenges, we have to be realistic about those challenges and seek solutions that will respond to them. That's why collaborating with you in that regard is so important. But if I may ask Nerys and Delyth to present their priorities now—.

Yes, briefly, because I'm keen to hear what you think is most urgent of your priorities and what you think will be achieved in the first year. So, I'm happy to have the Ministers, but I'm really keen to hear, out of all those priorities, what's the most urgent.

The one that you will have heard me mention several times, and I've made many statements about it, is waiting lists, particularly the two-year waiting lists. It's clear to me that not only has that been an issue for several years now, but there is more evidence emerging as to why we need to tackle those waiting lists, because people's health is declining even more during that waiting period. So, we have set out clear plans for how to tackle those waiting lists. I announced £145 million at the beginning of the summer term, and a fortnight ago you will have heard, hopefully, the plans for how we are going to use those resources to tackle waiting lists. I'm quietly confident that we will be able to hit the targets that we've set out, namely seeing the two-year waiting lists reducing within a matter of months, and that we go back to the position where we were before COVID in terms of those broader waiting lists by the end of this term.

Yes, fine.

Great. Thank you very much, and thank you to the committee for the opportunity to be here today. As Mabon mentioned, clearly, our work has focused in the first 100 days on realising the ambitions we set out. We are now, of course, steering the programme for government, which will be based on the manifesto. But, in terms of that preventative health element that I'm responsible for, you'll be aware that it's the first time we've had that kind of role in Government, so it's incredibly important to set out the foundations in terms of how we're going to take action across this term.

So, we know that, as the Cabinet Minister has mentioned, our healthcare service, we need to put it on a sustainable footing. The fact that we are getting iller as a population and the fact that healthy life expectancy is decreasing will increasingly put pressure on our health service, as we've seen over the last years and decades. So, the status quo is not an option. We need to shift the focus to preventative care measures, and we know that lots of illness and diseases are preventable and predictable. So, the key focus for my work is to get that cross-Government shift. I look forward to working with you as a committee on how we scrutinise that in the areas outside of health and social care.

We know that healthcare only affects 20 per cent of population health; 40 per cent is affected by socioeconomic factors such as education, job status, family or social support, 10 per cent is physical environment, 30 per cent is healthy behaviours—tobacco use, diet and exercise, for example. It's a key challenge for me, and a key priority is how we get that cross-Government working and we get all levers of Government across all policy areas focused on preventing ill health. As I mentioned, it'd be interesting to see how the committee intends to look at that in terms of how other Government policies contribute towards the shared goal of preventing ill health.

What do you expect to see in the first year, in terms of—? You were saying about setting the structure out, really, but what would you expect to see in that first year as delivering?

We're setting out a cross-Government ministerial group, which I'm chairing, in order to get that focus. One of the key things that we need to do is to ensure that there's a well-understood definition of prevention and preventative measures. There are definitions out there. We need to test that those are the right ones, that work well, are well understood across all Government departments. Then it's about following the money in terms of where decisions are made. We don't have a clear understanding of what we spend on preventative health at the moment. So, we're doing a bit of work at the moment, after looking at the definition, looking at what we spend currently, looking at whether there's duplication of projects and initiatives that try and get the same outcome, looking at whether projects and funding are aligned to health outcomes and reducing health inequality and looking at preventative measures. So, getting that definition right, mapping where we spend on preventative health, and then looking cross-Government at how we work as Ministers. I've had bilateral meetings with all Ministers, and am now going into deeper work with a number of Ministers—no surprise that culture and sport is one of those, in addition to rural resilience on food—looking at how we can align. It's fair to say that Government, as many organisations are, as this Senedd is, is quite siloed working. So, it's how do we really meaningfully cut down those silos so we have those early discussions on policies on health prevention and the outcomes, in addition to developing a public health strategy, which will be announced in more detail in the Senedd in the forthcoming weeks.

Diolch. Delyth.

Good morning. It's lovely to be here. I won't repeat what I've already said in the Chamber previously in terms of my priorities. The main thing, the crux of it, is that I want to give more of a voice to people whose voices aren't heard sufficiently at the moment in our health and care systems.

In terms of where—. The danger with this is always that I'm going to leave something out. So, these are some—. I'll give that caveat. These are some—

What's the most urgent?

So, I've got three elements, of course, to my portfolio. In terms of social care, standardising commissioning, giving greater support to unpaid carers, making sure that we are putting the work in place to greater support our workforce. In terms of mental health, I'm hoping to be making the first steps now in a journey towards a truly open-access mental health system, which I think will lead to a transformation in how people can access that—crucially, of course, ensuring that, for people who need that urgent specialist care, that is very much still available. And in terms of women's health, access to abortion, making sure that the pathways for endometriosis are clearer, are more easily understood, and, just as an overarching point for women's health, that women should be listened to and believed about their bodies. I held a summit for women's health in July, looking at strengthening women's voices in their care, but also at how women's pain is just accepted as too normal too often in their care, and how we can work with clinicians, how we can work with primary care, how we can work with women themselves, so that we open up that space, so that we can spot symptoms earlier and improve outcomes.

What do you think patients can expect in that first year in terms of those urgent priorities?

In terms of women's health, we are going to be doing a listening exercise, reaching out—. And I'm really keen to have the committee's support and your suggestions on how we can do this to the best of our ability, too, with this, to make sure that we are truly listening to women's experiences, that they can be part of shaping the changes that we need to see to strengthen the women's health plan.

In terms of abortion services, access to abortion is not where it should be; we need to be looking far more fundamentally at this, and perhaps this is something that you'll want to come back to. In terms of endometriosis, it takes far too long, frankly, for far too many women to be diagnosed. The same is true with many women's health conditions, but endometriosis is almost talismanic in terms of this, that it can take nine years for someone to be diagnosed. I mean, this is just not acceptable. We need to be making sure that this happens partly through training and partly through—. I want to find ways of opening up that space in GP consultations as well so that women feel more comfortable, and men, of course, too. There will be certain symptoms and certain parts of all of our bodies that we don't want to talk about; let's make that more normalised. Again, I'm very aware of time, but I'm really keen to talk, as well, about how we can make sure that people in social care can live independently for longer, that we can realise that this isn't just about changing systems, it's about the reality of people's lives, and that's a fundamental for everything that I want to do with you as a committee too.

Diolch. I'm sure that Members have got lots of questions on all the different topics that you've already raised as well. So, we'll make a start and we'll go to Nigel Williams, who's going to talk about planned care and some waiting times.

Bore da, bawb, and bore da, Minister, as well. I wanted to ask a question—. You've answered some of the questions, actually, in terms of waiting lists, so I appreciate that greatly. You may be aware, as well, that I worked across Wales on performance management, so I looked at waiting lists and I know some of the tricks that go on to reduce waiting lists. One of the things the Minister said a few weeks ago in Plenary was that you weren't willing to accept outside help—outside Wales, I mean. Now, I've spoken to various consultants who tell me that, already, consultants are coming in from places like Birmingham and Manchester to try and reduce waiting lists, and that's great, but one of the things I was told was that, when these people are actually coming in, it's literally trickery. So, actually, what they're doing is they're coming in, they're meeting patients, patients think that they're—. This is anecdotal, by the way, so it's just what I've been told; you may be able to tell me differently, I hope. So, they're seeing patients and then the patients think they've been seen, but, actually, nothing is then going on. Can you elucidate a little bit more on that, perhaps?

First of all, on that point, when you said you raised the question in the Chamber on allowing assistance from outside—I never said that. I know we would allow assistance from outside. What we said was that we wouldn't allow Betsi Cadwaladr University Health Board to be taken over by another health board, which is what the question was.

Fair enough. Okay.

I think it's important to point out that Jacqueline Totterdell has come to the NHS in Wales from—. What was the name of the—?

St George's and Epsom and St Helier.

There we go, St George’s and Epsom and St Helier, which she managed to turn around. So, expertise there coming in. I think you referenced that trust yourself in one of your comments.

Regarding the issue about whether or not some patients were being seen or not, now, that's one of the things I tried to set out at the top. The delivery of health is by health boards, so it's up to health boards to deliver the health services. But how the waiting lists were dealt with in the previous administration is different from what we're doing now. That's why you saw previously spikes in the waiting lists, so sometimes, the waiting lists would go down, great, but then they'd go back up again, because the money that was put was thrown at short-term, temporary measures, which was effectively buying the services from external companies, either outsourcing or, in some cases, insourcing those services, which didn't build that resilience or the sustainability within the Welsh NHS, hence why we saw the spikes. So, you might have, say, a two-year wait of 2,000 people on it, or 4,000 or 6,000, whatever it might be, but beneath that, you've got tens of thousands of people who are waiting who will be reaching that point of a two-year wait unless you put a sustainable system in place to stop those people getting onto the waiting list to begin with or to—[Inaudible.]—them earlier.

I think my concern is that people are feeling like they're going to be treated and they are actually seeing a consultant and perhaps they're not being treated on a timely basis. That's my worry and, of course, during that time, people may have something that turns into cancer and some people unfortunately die before they're treated.

Absolutely. You're quite right, and we accept that and I've said similar things myself. That's why we need to see those waiting lists cut. That's why the project and the funding that we've put in place now, part of the £145 million, is going to look at that validation part, making sure that patients, who are waiting to be treated, are in the right place—that they're not spending time on a list that is unnecessary for them. And that's why we've announced that routine follow-ups will not be happening as a routine now, because we've got 70 per cent of a clinician's time being spent on follow-up appointments, rather than dealing with the treatment that people need. That's the difference in what we are putting in place now. So, much of what you have referenced might have been the case—anecdotal, as you say—in a previous administration. Now we are putting systems in place that will make that different and will improve those outcomes.

And a further question, which I've been asked to ask as well, actually—because I know a lot of people still in health, because I've worked in health—is on incompatible IT systems. And, in fact, I was actually shown two systems within a trust, shall we say, and those systems, I was told, were just not compatible with each other. And they were really, really struggling. And, actually, the person I spoke to waved a piece of paper like this and said, 'It's like working back in the 1980s here.' And he said, 'We can't work like this.' He said, 'That's why waiting lists and people are waiting, even when they're in A&E and places like that, because people—'. He said, 'We are wandering up and down corridors, getting results. It'll take us 20 minutes to walk down a corridor somewhere, 20 minutes back, when I could be treating patients.' Is that a real concern?

It is absolutely a concern. These are things that I and colleagues have raised in this committee in the past. And that's why we are developing now a 10-year digital plan for the NHS in Wales. So, the problem we've got is that we've got systems with health boards, and health boards are independent legal organisations, and they develop their own digital systems that are independent of others, which means that they don't necessarily share that information.

We've got some good best practice out there of a 'one Wales' approach. So, bloods, for instance, that Digital Health and Care Wales, will be looking at, and some other examples of where information is shared—. But by and large, that doesn't happen enough, hence why we need to look at breaking those barriers down, ensuring that systems share information, talk to each other, and that we have that seamless digital system.

And that's part of the problem that we've got in the NHS. The one big frustration that's become apparent is that we are not, as a health system in Wales, as efficient, nor as productive, as we could be or should be. Part of the reason for that is that we don't have the digital systems in place, so we need to improve that. The other part is that we don't have the estates that we need. We've got a massive backlog in the estates, and you might want to come on to that later on, but we need to fix that too.

And the other part is data: so, that data isn't shared equitably across Wales. There's no uniformity of data gathering in some places. There's a lot of data, but it's not uniformly collected. So, we need to improve the way that data is collected and used, and we'll be looking to that.

And I think it's really important, actually, that people in the system, patients, are able to see on a timely basis their own data as well. And I know this from my experience of other countries, where people can actually view their data on a really timely basis—contemporaneous data. If you went here, you just can't see that. Is that something you might look at?

It absolutely is. As we said, we've now commissioned that work into developing the 10-year digital strategy. That may be something the committee might want to look at and feed into, incidentally. I think that would be a valuable piece of work we would certainly welcome. But, yes, if we can make sure that people can access that data—. The waiting lists plan that we've put in place, part of the expectations around that is that health boards will publish their data on their websites so that people can track where they're at on waiting lists—that they know that this health board has a waiting list of this amount and it's going down or up, so that they know the trajectory of each of the health boards, so that we are transparent.

And transparency, for me, would be, actually, that the people on the waiting list know that it's actually a real waiting list and it's not a sham one, shall we say, which I think has operated in the past. I mean, I've seen it myself, so that's a worry. So, how sustainable is this—what you're doing into the future? Is it a sustainable plan?

I would hope so. It's a plan that we're putting in place now. It's a 10-year digital plan, but it would be an iterative plan, because if you consider where we're at digitally now in the world, it's not where we were 10 years ago, and with AI, things are changing and moving rapidly and in 10 years' time, we will be in a different space. So, it has to be an iterative plan, which is what we're putting together. But absolutely, this is one of the things that we've identified very, very early on, that we need to do to improve productivity and efficiencies, and that's what we're doing now.

And we'll come back, sorry, Nigel—

I have one last question.

Yes, that's fine, because we're going to come back to digital a bit later on as well.

Yes, I just wanted one last question, really. What plans do you have to visit best-practice trusts right across the UK, in terms of saying, 'Hey, they do this really well in London. We need to be doing this here in Wales'?

Yes, we're already doing that. One of the things—and some of your colleagues on the committee will remember that I've mentioned several times the OneLondon project in London on digitisation, which I visited. I went up and had a day-long session talking to them about how they implemented it, what steps they had to do, what regulations they had to change to allow that to happen. We are an outward-looking Government. We want to work with others. I have already spoken to, as I said, OneLondon, I've already spoken to, for instance, the Swedish Government on developing digitisation. I'm a member of the European cancer health group. We work with others, we bring that best practice in. We're not afraid of learning from others, because if we're going to improve health outcomes for the people of Wales—if other people are doing it, why not us?

Yes. Thank you. I appreciate that, thank you.

Diolch, Nigel. Gareth, did you want to come in briefly on that?

Yes, I just have a question about waiting lists. So, with regard to waiting lists, it's not just from the outside, it's inside. So, for instance, I know a very well-known consultant who is the head of orthopaedics at University Hospital of Wales and Llandough, and he's pretty fed up that he can't make his own surgeries. So, he's been told by management when he can do surgery, what surgery unit he will use, who his team will be. He basically has no choice or no say over what surgeries he does. He said that, whereas before he could do up to two or three surgeries a day, he's lucky if he does that a week now. So, that was one of the things with the waiting lists.

The other thing that I just wanted to bring up is bedblocking, which I've seen this week. My mother's in hospital with a broken hip and there's a gentleman who has been in there for four months because they've not found him anywhere to go.

Okay. On that first point, I think it's important just to reiterate that, whether we like it or not, and it creates frustrations for many people, it's a health board's role to decide on how they deploy workforce and how they use and utilise their estate and how they manage theatre space. But on that specific point, I think it is worth pointing out, and if I take it a little step further, we have got underutilised theatre spaces in Wales, which means that we're not seeing as many patients as we could or we should, which is part of the waiting list plan that we've put forward, which is to improve the use of theatres in Wales. And it's why we are looking to develop up to 10 surgical hubs in Wales, so that we can have greater access to theatre space, ensuring that people can be seen and treated in a timely manner.

I visited a number of hospitals over the summer period, and I saw for myself where—. I won't name the hospital, but under the constraints that they have, they were using a theatre space as a waiting room, because they didn't have the planned footprint required for their services. Well, that's something simple that should be able to be resolved if we assist them in moving things around and changing the way that they look at how they provide that service in that hospital. So, we can do that and we're helping where we can, but internally it's up to the health boards themselves.

I will ask Jacqueline on the specifics if you want to come in on that, before I get on to the bedblocking, and I know that Delyth will want to get on to what you called bedblocking there.

Just also in terms of best practice, we benchmark ourselves, not just in Wales but across the UK. We have access to the data that can tell us how efficient and effective we are compared to other areas. I'll use orthopaedics as an example. As part of what we're doing to sustain reductions in waiting lists, and the Minister started to touch on that, we're not just giving organisations money and saying, 'Crack on and do as much as you can', we're saying, 'We'll give you money if you become more efficient by doing x number of hips or knees a list'—so, best practice is four hips or knees on an all-day list—'including a range of other specialties, that theatre utilisation is above 85 per cent'—it's quite low in quite a few areas—'so, using your theatres properly.' The Minister has already mentioned out-patients, and we know that we have quite a big backlog around diagnostics. And that's one of the other areas where we've asked both to manage demand there, as well as to make sure that patients who have had a diagnostic test know what the next step is, which is either discharge back to the GP or to have a procedure following that.

So, all the money we are giving is linked to efficiency and effectiveness to make sure that we actually are sustainable with our waiting lists and we're following best practice. We know that, if we treated patients in turn on the waiting list, we could reduce the waiting list now below 104 weeks. At the minute, patients are being picked out of every bit of the waiting list rather than our working from the back in. So, there's quite a bit of work that we're doing, being supported by NHS performance and improvement, to actually be more effective and efficient in order to actually have a sustainable waiting list, and orthopaedics is one of the areas where we know we've got a bit more work to do with the consultants. We also know that having a multiplicity of prostheses, which we have across Wales, is not financially effective either. So, we're working with orthopaedics and orthopaedic surgeons across Wales on how we reduce the amount of access to prosthetics, so that we end up with three. I hope that's helpful.

On what you call 'bed blocking'—personally, I don't like the term 'bed blocking' because it sort of suggests that the patient is at fault, and it's never the case is it, but—on that issue, we have to realise it's the hospital system flow. It's a whole-system issue, where we have to make sure that the front end, prior to the entry to hospital, the primary care sector, functions properly, has the support and the services that they need in order to see people sooner, that, when people come into the hospital, for instance with frailty, they are seen at the front door, that we've got more—and we have got more—same day emergency care centres developing across Wales, so that people are seen quicker, and that, on the back end, when people leave, we've got that support in the community available. So, that's the journey that people will be on during their health journey, and those are the steps that we're looking at. That back-end part, where we provide support in the community, Delyth will want to come in on that, so I'll ask Delyth to come in.

Diolch. I'm really sorry about your mother. And, look, there will be too many patients that this is going to be affecting. Delayed discharges are bad for patients, because it means that there will be too many patients who rapidly decondition when they're in beds for longer than they need to be, and it's also missed opportunities, where we could be making things better, could be freeing up space for other people who need it. We need to be making sure that we are, to more of an extent, standardising how services work together, because, as Mabon said, this is something that we're going to be sharing in terms of seeing where those hinge points are, and we need to be tracking the data to see how we can better standardise those routes.

It needs to be owned, though, in a shared way, by hospitals, by community settings, by local authorities. Everyone needs to be working together. There are pockets of good practice. There have been projects where this has worked really well in different health boards, in different hospitals, but we need to be finding ways of how we can scale up that nationally, because, as you're finding with your mother—as too many people will be finding across Wales—at the moment, it's frustrating. It only takes one thing not to be working in quite a joined-up way and then everything gets held up. And it's not good enough for patients.

Great, thank you. Just finally, how will progress in reducing NHS waits be sustained beyond the funding period?

That's the—[Inaudible.]—question. That's what I've touched on in my previous answer, that we are now building a sustainable system so that we're not dependent on outsourcing, or even insourcing, that we've got sustainability in the system, whereby that validation process is better, we've got improved diagnostics and people are diagnosed earlier, and that, at the back end, after treatment, that people don't necessarily have that follow-up appointment, because they can go back home and, if needed, then they can go and see their GP and are released to their GPs. So that will make a more sustainable, long-term solution for the waiting lists and for the NHS.

Matthew Jones.

Thank you. I just wanted to note, of course, that the health service is full of targets, and the waiting time for treatment is the foremost of them. Of course, in cancer, there's that 62-day threshold before treatment. And I've had quite a few discussions this week about how that target, perhaps, isn't the most effective target in terms of identifying what the situation is for people who are going into treatment. And I wanted to ask: has there been any kind of assessment done about the effectiveness of targets, what targets need to be kept, what ones might need to be changed? Do we need more targets, more information? I know, for example, that there is no measure for diagnostics being done within that cancer pathway. So, I was just wondering whether anything like that was being done at the moment.

I think it's important to note at the outset that these cancer targets and where we are with cancer isn't where we should be. There are too many people presenting at hospital to receive a diagnosis far too late. There are too many people who feel lost in the system and that they don't have clear communications when they are on a cancer journey and that after care. So, we have to see improvement, because, as you know better than I do, one in two of us will be in a situation where we are living with some kind of cancer in future. I think that we will be seeing figures published today that will demonstrate that things have improved somewhat in terms of that target.

But the point—. You asked about targets; we're reviewing the targets system as a whole at the moment. Health boards have several priorities and targets, and there is a view that there are too many of them, and we have to see whether it's possible to decrease the number of targets and to make clear what our expectations are, instead of there being too many targets in the system. So, we are reviewing that at the moment.

We would welcome and appreciate, truth be told, any recommendations that could be made, be they from the cancer community or from you here, on where we should look, because so much work is being done by the Government at the moment. The programme for government is going to be published; the 100 days has passed. A little bit of work like this, which would provide added value, is something that we would very much appreciate, and, I think, something that would be welcomed, because it's not necessarily something that's been factored in, in terms of cancer targets specifically, by us at the moment, because we are going to be developing a cancer strategy in due course and we're going to try to improve quality and outcomes when it comes to cancer care. So, that's something that should be looked at, and we would welcome it.

Jacqueline, do you want to come in just on that specific point?

So, there's been a lot of debate across the UK about whether—. Because we all use, roughly, the same sort of standard, and I know that there are some cancers that, actually, will take longer to diagnose and are longer growing, and there are some cancers you need to see quicker because, actually, they're fast growing and can be more devastating.

I think there are several bits to this, and part of the cancer strategy that the Minister is building is about how do we actually look at the prevention bit first, because, actually, there are quite a lot of preventable cancers, as well as how quickly we can get that diagnosed and the screening programmes that we have that help that, and optimising them more.

We also don't do enough trials in Wales, clinical trials. So, the research bit of that is really important.

Absolutely.

And we also know that we diagnose far too many with end-stage cancer who haven't been diagnosed before in accident and emergency departments. So, how do we actually look at—and I haven't got the answer to this, but I'm with the Minister—what would be the best thing to actually improve outcomes? And you're right, it's very blunt, looking at 62 days, but it's at least one way of making sure that those with cancer do actually get seen as quick as we can. And we've carved out, particularly, in organisations, time to do that.

We know, at the minute, we've got some organisations that are performing better on that and some that actually need to improve. But that's just one blunt bit and I think there are other measures we'd like to look at, which are where cancers are and what the outcomes are from them and how we can change the outcome. If we can get to someone's cancer quicker, then, actually, we know that they get treated better and their outcome's better. Equally, not getting cancer at all and doing behaviours that link in with the prevention agenda actually will help reduce the amount of cancers that we have.

And—

Sorry, we might have to move on. I can see we're getting short on time already. Becca Martin.

Thank you. So, I want to talk about the waits within emergency care and A&E, which, as we all know, are a huge problem, and, obviously, the measures that you're going to be taking in terms of waiting lists and things like that will ease pressure, but we've got an acute need right now. People are waiting for hours—24, 30 hours sometimes—in A&E departments; we've got corridor care. But, aside from that, whilst we know those waiting times are very, very long, that's not the full picture, and we're looking at how people are being treated within emergency departments. And I know that staff are overworked, they're not—. Once you get that care, it's really, really good care and the staff are really, really good, but, when you're waiting, you're waiting on hard chairs, you're waiting without pain medication, you're—. These are people that are ill. They're acutely ill, and that's why they're there. And you might have people that are incontinent, you might have people that have issues with feeding themselves. They're being left without food and water for—. Well, for the whole time at times. It could be 30 hours, like I said. So, how are we going to be looking at making those stays more comfortable for patients?

And then, those that are already on current treatment plans, perhaps those that do have cancer, that are being treated, they're also having to wait in A&E when they have their own consultants. So, how do we sort of move those on to where they need to be, rather than them waiting in A&E for hours?

Yes. This is corridor care, essentially. What you're asking is an ongoing sore and it's something that, again, we shouldn't have to see. It really isn't the position we want to be in. As I mentioned in a response earlier, it's a whole-system approach, isn't it? So, you've got that point of entry and that exit, and what we do in the community to begin with, and then what we do—. Well, in the community post entry, and in the community on exit. So, that's why we've got the project that you might have seen—I would expect that maybe you'll have picked up on it somewhere—called Community by Design. So, Community by Design is what we are really pushing, in as much as shifting resources into the community, making sure that we put focus on the community, so that people are seen sooner and quicker so that they don't have to reach that point and that hospital is the place where only people who need hospital care go to, rather than, currently, where we've got all sorts of people going into hospital for treatment and they don't necessarily need to be in a district, general or acute hospital.

So, that Community by Design will allow us to improve the flow from primary care and increase the capacity, therefore, in hospitals. But, on those specifics, we've looked quite a bit at this because we know that there are calls regarding corridor care, and I have always argued that we have to look at that system. That's why I'll be launching a new emergency and acute framework in November, and that will set out our expectations of the health boards, looking at tackling specific corridor care, improving the flow, delivering better outcomes and experiences. Part of that is identifying and defining what corridor care is, because, at the moment, there's no clear definition of what corridor care is, so we need to define that. And we will be transparent as well in that.

The actions that we're taking now, which you asked, are—again, I touched this on earlier—things like making sure that we've got frailty assessments at the front door in the hospital, something that's absolutely crucial, making sure that we've got a faster falls response in the community, seeing people earlier on, earlier interventions. And I mentioned the SDECs, getting more people seen by the SDECs that we are setting up and that have been set up so that that pressure isn't on that acute service in the hospital. So, a number of actions are being taken, but, absolutely, this is something that we have to look at in the long term to make sure that we're not at this point by the end of the Senedd term.

Brilliant. Can I just add to that as well? I think sometimes there's a lack of communication between staff—and I get that they're very, very pressured, but—a lack of communication between staff and patients, that, 'Actually, you're going to be waiting this long, and—'. Because I think—. My personal experience that I've had in the past was that I'd been waiting and waiting and waiting, and then I was told, 'Oh no, you're waiting for the consultants to come in at 8 o'clock tomorrow morning', and I'd been there from 11 o'clock at night or—. Well, actually, I'd been there all day as well, but I'd been waiting for the consultant from 11 o'clock at night, to then be told they don't actually start work till 8 o'clock in the morning. So, I think that there does need to be some communication there as well within those frameworks.

That's where the same-day emergency care, SDEC, comes in. Because actually, what should happen is, if you're fit to go home, you should go home. It's probably better for you going home than it is sat on a hard chair, and have an appointment with the consultant in the SDEC the next morning. So, you get an emergency appointment where you can be seen, diagnosed, treated, and either admitted, if that's needed, or out-patient treatment. So, that is the point of the SDEC in strengthening those pathways.

We visited a hospital recently, and there was this elderly woman and her daughter, and the elderly woman had broken her arm. They were sat in the chair in the corridor, and they insisted on having a chat with me, and they said, 'I just want to say how fantastic the staff are, how well we've been treated. My broken arm has been looked at.' And we asked the ward manager at the time, 'What is she doing here? Why is she there?' 'Oh, they just want an assessment.' She was sat there for five hours. She shouldn't have been there. She could've gone home five hours earlier. So, it's a matter of culture, making sure that we change that culture and that people understand that there's a new way of doing things now. In order to improve that flow of patients, we have to make sure that people are seen sooner and go out of the door quicker.

Thank you. Just to add on to that, obviously we've got winter around the corner, which is going to add more pressures, as we know, the seasonal pressures. So, I'm just wondering, in terms of the assessments that have been taken, what are the results on that, and how are we going to try and ease those pressures going forward?

You'll have heard my statement in the Chamber—when was it, in June? End of June, possibly, early July—on winter pressures, the earliest time a Government has ever put forward a statement on winter pressures. One of the first things I did when I came into Government was ask what plans were in place for the winter pressures. Because we have to appreciate and realise this is an annual event. It happens every year, so we should really be prepared for it. It shouldn't happen too late in the day. So, we've said that we want to not just start preparing for this winter, back in June, but for the subsequent winters, so that we learn best practice from each one and prepare in advance, and that it's an all-year-round approach. Because we saw, this summer, how the heat waves had compounded pressure on the NHS during the July and August period.

What we've learned from the previous winter is that we had limited bed capacity, that we had high occupancy and inconsistent delivery across Wales. We don't want to be in that position again, learning from those lessons. We've asked the health boards to bring together their plans to tackle the winter pressures coming forward. I'm expecting them to provide me with their papers by the end of this month in order for us to make sure that we are confident that they've got those plans put in place. We'll be looking at improving vaccination, stronger infection prevention and control measures, so that we don't have those hospital-related illnesses spread, and making sure that we've got those earlier discharges and weekend discharges, which is what we haven't seen previously, but we want to build on and make sure that we've got those in place.

Great. Thank you.

Matthew.

Just one brief question from me. I notice that you mentioned the summer there, and there's been huge pressure on the health service during the summer months. Do you believe that there'll be a need in future to have some kind of summer preparedness plan? I know in the hospitals around where I live, over the summer, there was an ask for people to contribute fans to the hospitals because it was so hot in them. Is there a way of ensuring that that is considered as well?

That is a very good point, and yes, that is going to be part of our consideration. That's why I talk about looking at a whole-year programme, rather than just looking at three months out of the year. And to expand on that, I have asked them to consider, for example, El Niño, because we know that the strongest El Niño ever is going to strike us; it's already at work across the world now. But there are potential consequences to El Niño that, of course, will affect our community and the health and care services. So, we need to consider the consequences of that when it comes to, for example, more rain and flooding, damp in people's homes. Are people going to suffer more from respiratory problems because of these things? Are we going to see hospitals suffering because of the fact that there is flooding, or is there anything like that that could affect us? Those new weather patterns do need to be part of our considerations.

Thank you. Just briefly, this is going to be a challenge—it's already a challenge, clearly—in terms of the care service. There are additional challenges in this regard because in the care estate, there are pockets that are independent, there are pockets under the control of local services as well, but there are more complex considerations, perhaps, in that regard in terms of where we locate the rooms of people who live in care homes, because perhaps it won't be safe for them to open windows if they're on higher floors. So, I know that the team has been working on this to see how much data we have, and a great deal of work is going into this. We will have to continue to see changes being made now, because, as Mabon has said, this is going to be an ongoing situation for health and care.

This is of course part of the response to climate change. We all saw that over the summer. Public Health Wales has been doing a rapid review of the impact of the heat over the summer, seeing that there were more deaths happening every day. So, we are learning lessons from that work, and it's going to be part of our long-term planning as well.

Nigel.

I'm going to refer my questions to you, because you were talking about clinical trials. I met with a chap yesterday who had an incurable cancer—like my daughter, actually, strangely enough—and he was telling me that he was really struggling to find trials. My daughter had the same issue. She was researching everywhere for all sorts of things, and couldn't find anything. But the guy had found something in London. They'd asked him to attend four days a week in London, and he just didn't have the resources to do it. Is there any way that we can get these people the resources via health in Wales, to make sure that these people can attend these trials, or bring, as you mentioned, more trials to Wales so people can have the trials here? Because there are no trials in Wales—that's what I was told yesterday.

There might only be trials in London because it's such a specialist type of cancer. I'm really sorry for that gentleman, and for your daughter. I suppose the bigger policy bit for us is that we recognise that we are not a research-heavy country, and we need to do more. Part of that is trials, as well as original research. We have to ensure, going forward, that every cancer patient is offered a trial. That is how it should be. We are a way away from that at the minute, and it will take some time to build that capacity and capability, particularly with pharma and with our researchers, but we need to do that. That said, we have a fabulous genomics service in Cardiff and Vale, and genomics is one of the ways forward about how we can treat cancers going forward. Things like CAR-T, which treat wet cancers, i.e. blood cancers, can be absolutely astonishing in terms of weeks to reach with no cancer in the blood. We have some areas of brilliance, and we have some areas where we need to do better. We're absolutely clear that we have to develop a good, clear cancer strategy, which we are, that includes research and access to trials for patients, because our patients deserve that.

On that, very briefly, if I may—sorry, Chair—I agree with you. We've identified that as a weakness. I've said for a number of years now that one of my ambitions is to make Wales a destination for clinical trials, where we can, to improve research, and making sure that we have those clinical trials. Because it's a matter of health inequity: we've got people here who are not receiving treatment, where they should and they could, and others are receiving that treatment. So, we need to make sure that we bring that quality of research into Wales, that we invest in research, but making sure that we improve the clinical trials space here in Wales.

Thank you.

Perhaps, with the committee's interest in this area, it might be worth writing to us further on this and on your progress, what you intend to do, and perhaps some of the areas of good practice as well, so that we can follow up after.

I would suggest a visit to either Cardiff or Swansea university, or both, because they've got some really good work going on there.

Brilliant, thank you. Any good practice we'd be really keen to see and to follow what the Government's planning to do. I'll just bring in Claire Archibald online.

Good morning, everybody. I'm sorry I can't be there with you today. I do have a question to the Minister about NHS dentists, which is something I'm quite passionate about. Regarding patients in rural communities like Ceredigion Penfro, where I am, what assurances can you provide that the new dental school will improve access in rural areas, rather than simply increasing the workforce capacity in the general populated areas?

Having a dental school established, which is our ambition, in rural Wales will mean that those students learning in the dental school would remain in that rural area. We know that's the pattern we've seen with other health—. Well, when you go to any medical school, the students tend to be retained in those areas. When you've got students coming down from north Wales to train in Cardiff, they tend to stay in Cardiff. There's plenty of evidence showing that people stay in that area—the broader area where the school is based. So, we'll see when we reach the point when we have a new dental school in Wales, and that's not going to happen for a number of years; there's a lot of work to do before that. When that does ultimately happen, then we'll see more dentists stay in west Wales.

Thank you very much. Concerns about NHS dentistry are often linked not only to recruitment but also to retention. What assessment has been made of the reasons dentists leave NHS practice, and why does the Government believe that the new dental school will address those underlying issues?

Dentistry has been a problem in Wales for a number of years. We've seen a number of dentists leave because the previous contract that they had wasn't fit for purpose. Your predecessor committee, going back pre COVID—I think it was in 2018, maybe—held an inquiry into dentistry and found that the contract just wasn't fit for purpose. It has taken a number of years to develop a new contract. There's a new one in place now. What I do really like about the new contract—and we've shown support during the development of the contract—is that the focus is on the prevention, making sure that people are seen early and those that need to be seen are seen on time.

We need to allow the new contract to bed in, first of all, see how it pans out, see how patients are seen, if they are confident that they're being seen and that it's having an impact. We will be reviewing it. We are reviewing it. There's going to be a review in the autumn as well to make sure that the early stages of the contract has been working. But at the same time, we've got the portal that's been set up and put in place so that if patients can't find a dentist, then that dental portal will help and assist them in finding their nearest dentist. So, we're in the foothills at the moment of that new contract. We need to see how it works. I'm willing to give it time, because we can't change things overnight, and see where we can improve on it.

Thank you for your answer. As you know, I used to work in a dental surgery. Dentists repeatedly tell us that bureaucracy and contractual reporting take time away from treating patients, which is obviously the most important thing. Since the new NHS dental contract was introduced in April, what specific pieces of red tape do you think you've removed? Can you tell the committee how much time you expect those changes will give back to dentists treating patients, which frees up the time for them to see more children, who desperately need to be seen right now, especially in rural Wales?

I live in rural Wales myself, so absolutely, I see that. I have to travel myself, 30 plus miles, a 60-mile round trip, just to see the dentist. The point of the new contract is to try and make sure that we take away the bureaucratic side of it so that dentists can see patients earlier. That's why we will be reviewing the contract. It's standard procedure that you review any new contract that's put in place—as I said, we'll do that in the autumn—and learn those lessons.

I'd be more than happy to share information with you as a committee, because I know that there's an interest in the committee in dentistry—it's been ongoing, as I said, for many years—so you can be part of that journey with us, and see where we can improve it, where it might need to be changed. But I'm confident that we have a better contract in place now than what we did have previously. So, let's give it that time it needs to bed in and learn the lessons.

I will certainly give it time, but I have one more question, which is: obviously, it changed in April this year, but can you name one specific admin requirement that NHS dentists had to complete before April and they no longer have to complete today, just to make it easier for them?

No, I'm afraid I can't give you that direct, specific answer, but I can ask officials to bring an answer to you either directly or to the committee.

If you write to us, after today, yes.

Diolch.

Diolch. Thank you. Just around resources as well, and the shift from secondary to primary care, how will that be managed while also the pressures and the crisis in acute services, and how does this approach differ from the previous Welsh Government's 'A Healthier Wales'?

I think one of our main ambitions was to make sure that we shift those resources, and it's an essential part of what we want to achieve if we're going to tackle problems earlier, if we're going to make sure that we intervene at an earlier stage to prevent people from getting ill. So, I think we have to be in a space where we accept that's the right direction. If we do accept that—and, as a Government, that's the direction of travel that we absolutely have put forward that we're going to move in—then how do you achieve that? So, we've asked the health boards to bring together a plan on shifting, as we said in the manifesto, that 0.5 per cent of resources into that primary care space so that we've got more services in that primary care, also in the community.

I convened a summit back in June, bringing those health boards together, and, I'll be honest, it was a really exciting summit. The buy-in from the health boards and the officials and everybody present, saying, 'Yes, this is what we've wanted to do, this is what we need to do', was inspiring, and so they're bringing together their plans and I'm waiting to see and sign off those plans over the next month, so that they've identified the 0.5 per cent that they will be shifting within their resources, and that we are content with that and we are happy to work with them. So, they're working with us, they've bought into the plan and they know that it will improve outcomes on that primary level and it won't impact, therefore, the secondary care either.

Brilliant. I just wonder, because I know there've been lots of summits that have happened, and lots of summits planned, how the committee can keep up to date with who goes, the minutes or the actions of the summit, what's intended. How do we stay in touch as a committee to see all the different summits that are happening?

Okay. I'll give you one idea, maybe, and we'll bounce this around. The primary care summit was so good, in my mind, I thought, 'It's a shame that nobody else is here to witness this and feel it.' So, I've asked for a follow-up primary care summit so that we can track where they're at, so that we keep the momentum. So, I'd like to invite you to attend that primary care summit. I know a previous committee thought about holding a committee session in other places, when events were being held, so if we can accommodate something, it might be an idea that we can work together, you might want to hold your committee on the same day in that same space, or, if that's not possible, then you can attend and see and be a part of it.

We'll look at how to explore that, because I know that there's been a recruitment summit and you've got lots of different summits going on. I'm just keen that, as a committee, we keep up to date with what you're doing and understand who was there, what the outcomes are, so that we can help track progress as well.

Absolutely.

Perhaps we can write to you following this and work out a way that we're able to do that.

Yes, and we want to be transparent, we want to work with you, and if you get that information as well, then that'll improve the work that you do.

Brilliant. Diolch, Mabon. I'll just bring Matthew back in.

Sorry, me again. The Government has committed to employing an additional 100 salaried GPs. In terms of that process, how does that look? Is it employing entirely new salaried GPs, or is it changing the locum contract? What's the process?

That's the piece of work that's happening at the moment, namely identifying exactly how we're going to make sure that we identify those doctors that are needed and where they are needed, and how they are going to be employed and at what level. What we do know—. I'll give you an example. We know that there are problems, for example, in the Glan Clwyd Hospital area. In that area, you have the same number of ambulances going to Glan Clwyd—and how many beds are there, some 400 beds?—you have the same number of ambulances going to that hospital every day as you have going to the University Hospital of Wales in Cardiff, which is a major regional tertiary, teaching hospital. So, there's a problem in that area, and if you start trying to interpret what the problem is, you start to see that there's a weakness that people, possibly, can't access primary care, and they can't see those doctors earlier, so they then have to call an ambulance or go to A&E. So, we have to identify those areas that need that support, that need more GPs in order to be able to draw that pressure off other services. So, there's a major piece of work that we have to do first to see where the need is, to see how that employment is going to look and then to say, 'Right, we're going to employ these GPs'.

Jacqueline, do you want to come in?

Thank you. The bit about the Community by Design is about how we actually have GPs working next door to district nurses, working next door to social care, working next door to mental health practitioners in the community. So, actually, we build a community in the local community of health practitioners—health, social care, mental health practitioners—and particularly that they look after those with long-term conditions, because those of our population with longer term conditions tend to be the ones who end up in hospital because their long-term condition has got out of control and we could have intervened before if we'd actually done things differently. So, for us, it's as much about how we wrap more services as well to support that around GPs, including potentially the '-ologists' from the hospital—the diabetologists, the cardiologists—who can actually give advice, if needed, to try and keep that person at home, in the community. So, that's where we want to get to, so that we are having more people at home, looked after at home by a team of people, rather than in a hospital.

So, that message is that there are considerations that you have to have before you just appoint a GP and say, 'You're going to go and work here'. We want to make sure that it's the right package. And we also have to consider the inverse care law and where community poverty might play a role as well. So, in order to get this right, we have to do quite a deep, intensive piece of work in order to model where would be best for them to go.

Thank you. I think that's a really interesting response and I appreciate it, but, those 100 GPs, where are they now? Are they students? Are they working somewhere else? Are they on different contracts?

Some will be students. We know that a number of GPs are currently underemployed. So, we have GPs across the nations of the UK, truth be told, who don't work in that area although they are qualified GPs and they need those jobs in order to keep their competencies. So, we will invite some in, we will retain some that are trained here, but that's going to happen at the point when we start their employment.

Diolch. We'll move on to questions from Safa.

I want to declare that I am a practising consultant ophthalmologist at a Swansea bay hospital. I just want to start off by asking the Cabinet Minister, who previously described the national care service as painfully slow, what the Government is doing differently and what it will deliver at the end of this year.

Yes, it is one of the major frustrations when you take up post and open up that bonnet and see how awkward some things are, how ineffective the NHS can be.

So, the level of productivity and lack of efficiency that we have can be frightening at times. We're in the twenty-first century, and we've touched on the discussions around digitisation, so why don't we have the systems in place to allow things to be swifter, for information to be shared better? When you look at the backlog that we've got and have inherited in the estates, honestly, I think a news article said it was around £900 million. It's far more than that. It's upward of £1.5 billion. It's a lot of money that needs to be pumped in in order just to maintain things. So, there's a difficult discussion that we all have to have, the public have to have. It's going to have to be a public discussion on: do we just maintain crumbling estates or do we actually say that we can't throw good money after bad on maintaining an estate that was fit for the 1970s but not fit for today, and do we build something new somewhere else? That's a really difficult discussion, but when you look at some of the hospital estates we've got, we've got a hospital in Wales that dates back to the 1960s—corridors aren't wide enough to allow two trolleys to pass by. We can't carry on with that. So, we have to see where we can invest to maintain things and improve things.

Okay. And in terms of publishing this national care service plan, when will you think about publishing that? And what measurable improvement should people see when they're using the social care service? What are they expecting at the end of this Senedd term?

I'll ask Jacqueline to come in in a minute on the plan that we're developing, but I think, specifically on the care itself, Delyth, do you want to come in?

Yes. Thanks for the question.

Mabon was setting this out. When we look at the care system, nobody would design it from scratch as we have it. I think we can all agree on that, but, look, we need to find the best ways—. This is something—. Mabon mentioned that there needs to be a national conversation on this. There's a lot of excellent work that has already been happening in Wales that we are looking to build on. But I think it is incredibly welcome that, from an English perspective, the new Prime Minister has signalled that this is going to be a major focus for him.

It will require cross-party but, potentially, cross-Government working as well here, and I've written to the social care leads of all parties represented in the Senedd to start to see how we can work together. We're not going to agree on everything, but maybe we can have a shared understanding of where everyone thinks we should be getting to. We'll have different ideas about how it is we get there, but things can't stay as they are. The status quo, it's not acceptable for us to state, when you look at an ageing population, a population that has increasing complexity in terms of care needs—. And your question, Safa, in terms of how people can hope to see change on this, this isn't just about looking to see how we can change structures, how we can change how the systems work. It's about the reality of people's lives, and I will be bringing Albert in in a moment here. It's about looking at how we can standardise commissioning and how we can look at how data is being used so that we can see that it's not a postcode lottery. There will be certain elements that are within national oversight. There will be other elements where there will be variation because of different things being done in different local authority areas. And we want to work with local authorities. We want to work with the Association of Directors of Social Services to make sure—. I've had round-tables already over the summer with a number of these key partners to see, 'Right, where is there excellent practice?' What can we do to share that? Because we want to be making sure that people can live independently for longer, as I was saying earlier. We want to make sure that our social care workforce is better valued, and that's true in terms of pay and conditions. Of course, we want to see, at a minimum, that our social care workforce receive the real living wage. I think the latest figures show that it's 84 per cent. Obviously, that needs to be higher. But, as well as that, we're going to be looking through fair pay work agreements to see how we can drive that even further.

But it's not just about pay and conditions, vitally important though they are. It's also about the recognition, the value that is given to social work. And we are going to be establishing a national care academy to be looking at this, so that when children and young people are leaving school, leaving college, leaving university—. When you are very young, being a nurse or being a doctor, they're things that lots of children and young people will think about, and, for many different reasons that we need to get to the bottom of, people are not as aware of the vitally valuable work of being a care worker. And I think it's partly because people are born into the national health service, we interact with it throughout our lives, and it's only when your family or you yourself are in crisis that you usually become aware of the wonderful work of care that's happening. So, I think we need to be shouting about how valuable this work is. We got it during COVID. That's what's so frustrating. We had this moment where we could see how important it was, and it slipped away. So, the national academy is going to be working on that, and I will bring in Albert to talk a little bit about that, but those are some of the areas.

Yes, thank you. Thank you, Minister, and good morning, committee, as well—great to be here in front of you today. On the national care service, the vision, really, is about high quality—high-quality services so that people are supported with joined-up support, helping people to stay independent, to live well at home longer in healthier lives. And we do want to work to reduce some of the inequalities that you've talked about in terms of the outcomes for people as well. The intention is to publish the programme in October—

In October; sorry, I should have said that.

The Minister is planning to publish, so you'll have the opportunity of going through that in detail.

And there will be an oral statement to accompany it as well. Forgive me, Albert, I should have said that bit.

And what's really important, I think, is that the national care service programme will be about high-quality, improving and strengthening social care, and that's about stronger leadership arrangements across Wales. That is about, across local authority areas, greater consistency. We want to see people, wherever they live, being able to access services in a timely, supported manner. There will be areas that you will be really committed to, and I know from your previous report that one is unpaid carers, and that will be a significant strand of our work.

As the Minister mentioned—. Maybe two things, just to add, about improved commissioning—when we talk about improved commissioning, colleagues, we mean across our health and social care system so that partners work together effectively and are in the right place to plan and determine the services and responses of the future. And in the last area, which we're particularly proud of, we've come a long way around data, especially, in social care. We still have a distance to travel, as the committee will be aware, but actually what we want to do—. The data, now, that we've improved—. We publish data on a regular basis, and we're really pleased to see the engagement around that, but what that will lead to is using the opportunity to have better use of social care intelligence and data so that we can actually get underneath the bonnet. It will allow us to be able to then really think creatively.

Just to mention two other things briefly, one is that we do have a good practice forum across local authorities now to share practice. That's relatively new, and we're seeing real benefits from that. One of the benefits was in local authorities where they had developed care academies. The approach of care academies is about how you recruit workforce but also how do you retain workforce—what are the good ways across social care and social work to be able to bring a workforce in and keep that workforce so that they can see careers in social care. And part of that now is the transition into, then, a national care academy approach, and that's something that we'll be able to talk to you about again in the future. Thank you.

Safa.

Yes, I just wanted to follow up very quickly. I know that you mentioned the national social care academy. Of course, you're going to be talking about it or publishing it in this Senedd term. But, right now, one in five social care workers are considering leaving the sector. So, what immediate actions will the Government take in terms of improving recruitment and retention?

That's a really good question, and, as Albert had mentioned there, it's about recruitment and retention. It's about making sure that social care workers continue to feel valued throughout their careers, that they see those opportunities for progression as well. I know that there are different surveys that are conducted into the workforce. And as you said—. What was the figure that you quoted there exactly?

One in five.

One in five. I think that, when we look back at—. When that survey data had been conducted the year previously, it was an even more alarming picture. That didn't end up transpiring in reality, but that is not a reason not to be concerned about this in any way. I think that we need to be making sure, with the academy, that we are learning from what is going well in different local academies. And a number of these academies have seen that, actually, a lot more young men are going into social care, which is a fantastic thing. And we need to be seeing where qualifications are made time for, training. This is something that is going to come partly from the academies, but it's also going to come from the national conversation and work that I'm really keen to work with the committee on, so that we can get that shared appreciation of this phenomenally important work.

I'm just going to go back a bit to that delayed discharge that you were talking about throughout. I wanted to ask: just currently, what percentage in the hospitals is caused by delayed—? How many in-patients are currently in hospital, talking about delayed discharge, due to a shortage in social care provision?

Albert might be able to tell you.

Yes, it's usually around about a third.

A third, okay.

It can vary, and it does vary. But it's approximately in that space. And then there will be a percentage that will be health-related delays, and there'll also be a percentage that will be across the kind of health and social care landscape.

And so what sort of reductions are you looking to achieve in those delayed discharges, as a Government, and how much are you looking to achieve in the next year?

That's something that Mabon and I are going to be working together towards. It's an excellent question. Well, to bring it down as much as possible, in terms of that I don't think that we have a defined metric that we have set on this. Again—. Well, firstly, we'd be keen to hear from your expertise on this, as well as others'. Obviously, bringing down the numbers is important; of course it is. But it's also making sure that—. Sometimes, when you set a target, it doesn't always mean that that is the only way of ensuring that—. There can be perverse consequences that can come from setting the target too arbitrarily. So, we'll need to look into what the best way of setting a metric would be for that.

And just to re-emphasise the point I made earlier that this is a whole-system approach. Sorry, is this on?

Yes.

So, we are putting plans in place now on that Community by Design, making sure that the primary care side of it functions, the community element functions. We are putting plans in place on a new framework in the hospitals, so that we deal with, as I mentioned earlier, the corridor care. And when we have all of those parts of the system in place and we are improving on them, then that will result in us seeing those delayed discharges decrease. But we can't fix one part without fixing the whole.

Okay, brilliant. Diolch for that. I think we'll take a short break now. So, we'll come back promptly at 11 o'clock. Diolch. We'll go into private.

Okay, croeso nôl. We're back in public session, so we will go back to our questioning of the Cabinet Minister and his Deputy Ministers as well. So, first set of questions from Nigel.

Minister, I just want to ask a question about—. Obviously, of interest to me, from north Wales, is the Betsi Cadwaladr University Health Board's position right now. Can you give me a take on what you’ve found in the stages of the examination of what's going on in that trust, please?

Yes. Again, you'll hear me say on a number of issues that it's not acceptable, it's not where we want to be or should be, and I think that's fair to say with Betsi. They've been in escalated measures for far too long. So, you'll have heard the announcement I made before the summer on the steps that we were taking in supporting Betsi Cadwaladr and conducting, more importantly, that well-led review. So, I can't comment on that current review that's ongoing, but that will be fed back by the early winter, and I will be able to brief the Senedd and yourselves on that when the time comes. But I've made it pretty clear that I expect to see improvement in the five places that they said they can improve in. So, that looks at the cancer times, it looks at urgent and emergency care stats, it looks at the financial situation, the ambulance handover delays that they have and the ambulance handover times, and the waiting lists. And I've said quite clearly that I want to see improvements in those specific fields or we will have to see action being taken. And that action will be dependent on that well-led review, what we can do.

We've seen some green shoots in some instances with Ysbyty Maelor. With the ambulance handovers, we've seen some improvement, but it has not been sustained. It has not been sustained in cancer, for instance. So, we've seen some improvements in cancer, only for it to drop back down again. And I haven't been convinced by the financial plans that they've put forward to deal with the end-of-year financial situation for the board. So, it's a mixed review at the moment, but I expect to see delivery soon.

I have a daughter who works in the private sector, in a really big supermarket, actually, and she manages that huge supermarket and, actually, the expectation of leadership in the supermarket is huge. And I've spoken to her about what goes on in trusts, and she finds it incredible that people get away with what they do. They would be fired, essentially, if they worked in the private sector. Are you looking at the private sector to see what they might do and what they do do, if you like, to make sure—? Businesses couldn't run the same way as they operate the NHS, I know that, so it needs a root-and-branch reform, really, of the way things are.

And just while I'm on about that, I spoke to a consultant who said that the boards for NHS trusts were implemented, if you like, when the NHS was implemented in the late 1940s, and they're archaic and anachronistic—so they're out of date. Will you also, perhaps, look at the way boards run NHS trusts in Wales, and are they fit for leadership in Wales?

Okay, so, on the advice from the private sector, we are looking for advice every which way, as we discussed earlier about taking best practice from international examples. We are more than happy to take on board advice provided to us. We've got people who have been working in the private sector working within the NHS, so they are bringing their expertise with them.

On what you call the archaic nature of the boards, the health boards were only set up back in 2009, 2010—

I think I'm on about the general management of the NHS, really. Not a lot has changed over the years. I know that. Dare I say it, I'm speaking from experience of actually working on a board and actually working at management level with the NHS.

So, the health boards were set up back then, and I think my diagnosis, at least, of—. A large part of the problem with Betsi Cadwaladr is that it was baked in from the start. So, you had three health trusts, I think it was then, or local health boards. No, local health trusts—I can't remember the terminology—back—

Well, there were, actually, at one stage, six local health boards covering the area.

Yes, but, when it changed to Betsi, you had those three across north Wales, and they were meant to have merged into one. But what's happened is, essentially, those three have sustained their footprints and, to a large degree, sustained their independence, with a board on top, which is Betsi. And those three don't really share information, share data. They don't, for instance, share waiting lists, which means it's—. And those three don't have independent representation on the board itself—on the health board. So, that is a recipe for a dysfunctional health board. So, we need to see that being resolved and that they work as one health board. But there's a cultural question going on in Betsi Cadwaladr that's been going on for far too long and has been allowed to carry on and we need to improve that culture and that governance level of it so that the culture allows people to take decisions and that decisions aren't just retained by a small group of people, and that we have that improved governance across the board as well of answerability and holding to account. So, those are some fundamentals we need to look at improving, and that's for the independent members to do.

Now, one thing I've been saying over the last couple of months is—. Betsi's budget is two-point-something billion; is it £2.3 billion or thereabouts?

Two-point-three billion pounds, roughly.

So, we've got 2.3 billion carrots that we are providing them, but I only have the one stick, which is to hold the chairman to account. So, they have to hold the executive to account so that they deliver, and that's what I expect them to do. I'll ask Jacqueline to come in on Betsi Cadwaladr with a little bit of information to add value to what I've said.

I mean, I could just add there, actually—I've seen it for myself—it's often death by committee in some of these areas, really, where decisions just do not get made. Is that what you see sometimes?

So, I was part, in England, of when Monitor came in, and it was very much all about governance. Now, I don't think everything's about governance, but it is about, 'How is the board well run?' You know, the chairman runs the board, the chief exec runs the organisation. And what, actually, if you look at the bigger bit—. I've started to do some work with the chairs about, 'What does well led actually look like? What does well governed actually look like?', and working with all of them around setting the standards. Because I don't think we've set the standards to help, actually. So, that is part of it; it's part of the accountability framework.

But I think the bit is—. You know, as an ex-chief exec, my responsibility was to make sure my executives gave the board the right data to enable them to triangulate what actually was happening and be clear what was working and what wasn't. And I think, when you do look at board papers, it's not clear for the IMs. When they get a thousand pages to read for a board, how can you possibly, actually, really understand what's going on there and triangulate at the board, as well as triangulate being out on the shop floor, which we expect our boards to do?

The issue, certainly—. If I look at Wrexham hospital as an example, you know, you don't have the issues that are in front of you because you can't park your car. I mean, people complain about this all the time. The front door was damaged two years ago and wasn't repaired. I mean, fascias like that just show the ineffectiveness, if you like, of management, and that's a real worry to people in the area, you know.

So, I think—. There is work that we're doing across all the health boards around—. And the Government, the Ministers, have been very clear that we want outputs, not inputs. So, what is going to—? How do we know that a change is going to make a difference? How can we actually see that patients are being better cared for? And I'm not just talking about Betsi, but generally. And so we're beginning to do things like—I'm very data driven—actually use something called statistical process control charts, where we can see what's normal variation versus what's improving and what's not. And we've now put that across the whole of all the health boards for performance so that, actually, we have a standard way that enables our independent members and chairs to be able to see where their organisation is going, and it's a lot clearer.

So, there's something about how we make it clearer for IMs and chairs to actually be able to lead their boards and make sure that they are being well governed and that a change makes a difference. And that's the bit, actually—it's about the moving away from rhetoric around a board table to actually evidence that, actually, something has changed.

And adopting best practice.

And adopting best practice. And that's something we're trying to work with all the health boards around, because we're not very good in Wales at—

Well, I was glad to hear the Minister say that you're looking at what's going on between primary care and acute care, actually. And to me, that is really important, because if you can stop people, or make sure that people can access primary care, then they're not going to the acute trusts, and that's so, so important, really. So, in terms of best practice, what are you looking at right now?

So, I can give you an example of best practice, something that's happened in Swansea bay in terms of ward nursing, where, actually, the chief nurse there has actually developed a way of working with the ward staff where they actually have higher graded staff but less money being used, particularly on bank and agency staff, and the ward sisters feel in control of their organisation, in control of their ward. It's benchmarked with other similar wards across the UK. What she's done, actually, has been brilliant, and you're seeing far better care, less money being spent, and, actually, very happy staff. That's one of the best practices that we are rolling out across the whole of Wales, about how do we do that on every ward, in every organisation, so we have really motivated ward managers leading their areas, with the right staff for that sort of ward that are motivated, and patients get a better deal.

And a question for the Minister now: would you actually consider, with your capital budget, actually having walk-in primary care centres? I've seen them in various places around the country, and it does alleviate people going into A&E, because you can be seen. You might wait a little bit longer, but you know you can go straight and see a GP in some areas. We don't have that here.

No, and we are looking at developing a programme of hubs across Wales, not just for GPs, but bringing together other expertise as well, so that people can have that one-stop shop that allows that walk-in ability for patients who want to be seen, not necessarily by a GP. So, I think that would be an improved plan.

Going back to your point, when you asked about learning from best practice, the plan that we've put in place for waiting lists, for instance, isn't a political plan. That was drawn up by clinicians, who drew and learned from best practice across Wales. So, all of that is being done in pockets across Wales, and our intention is to bring those pockets of best practice together, so that everybody benefits. We talk about the frailty assessments at the front door—that's best practice that's been carried out in some places; now we're trying to roll it out across Wales.

And going back to Betsi Cadwaladr, when do you think it might come out of special measures?

That's a very good question. It's been in special measures for too long. We are doing everything that we can to make sure that they are being de-escalated as soon as possible. But in order to achieve that, not only do we need to see them hit their targets, and I touched on the five targets that they've set themselves, but that has to be sustained as well. Sustaining that for a number of months will then allow them to be considered for de-escalation. But until we get that sustained improvement, we won't be able to consider them for de-escalation. So, they have to start immediately, hit those targets. When we look at the targets they've set themselves for cancer, it's a—. Is it a 50 per cent or 55 per cent target?

Fifty-five.

It's a 55 per cent target for cancer for Betsi Cadwaladr. That's not where we should be. We should be seeing far more than hitting 55 per cent; they should be hitting the 70 per cent, 75 per cent. But we're asking them to hit that for a sustained four-month period. Then, to improve on that. So, it is going to take a while, and improvement does take time, but we are doing what we can in order to help them and make sure that they do achieve those.

And in terms of accountability and your department actually chatting, if you like, with all those NHS organisations, how often do you meet with these organisations and senior management right across Wales? I mean face-to-face stuff now.

So, I'll have meetings with chairs and I'll have meetings with others as well, not just at chief executive level, but at director level. But my officials have regular meetings. In some instances, it'll be too often or more often than they want to have those meetings, especially in some health boards' cases, in order to provide that support. So, the Government and the NHS has daily or regular meetings in order to keep on top of what they are doing.

One thing I managed over the years was winter pressures, and I used to hate it being called 'winter pressures', because those pressures are known all year round, really. And there's equipment—. Twenty-four-hour working was talked about when I worked in the NHS a few years ago, and there is still—. I mean, the guy I met the other day, who I mentioned, who had cancer, was saying he had to wait A, B, C and D days, if you like, to actually get a head scan in the hospital, because there's one magnetic resonance imaging scanner, which is in use for so many hours a day, and at weekends, often not. So, what will you do to ensure that equipment—because equipment like that costs millions and millions of pounds—is used effectively and is more in use, shall we say? And I know there are issues surrounding the people who can use that equipment, and there's training, and all sorts of stuff, but, actually, there's equipment often sitting in NHS trusts that is not used for hours and hours and hours every day.

So, you will have seen the plan that we've put in for waiting lists, and in that plan, we talked about spending £45 million of the £145 million on capital costs. Of that, £20 million is allocated to improve situations like ensuring that we've got scanners that work, that we've got theatre equipment that works. In some instances, it's going to be financial bids to improve windows within theatres, to allow that theatre to be utilised, because windows are broken. So, we are putting capital investment into improving those technological pieces of equipment, so that they can be utilised, so that we can see people quicker.

Can I just ask a question? The capital investment, is that the £20 million out of one-point-so-and-so billion pounds, or is it more than that? Is that included in that tranche of money, as it were?

Yes, so there's £45 million—

It doesn't seem a lot of money.

No, it's not—. When you look at the whole estate, the whole estate is £1.5 billion, and it will be going northwards every day going on. But the £45 million we've put in now is going to be spent on those absolute pieces of equipment and pieces of capital spend that is required in order to bring back, for instance, theatre space, in order to take out some scanners to the community so that people are diagnosed quicker. So, it's some of the essential things we know we can do now in order for people to be seen, so that they don't have to go into theatre or that that theatre is used better.

Great. Thank you. [Interruption.] No, sorry, we're going to have to move on, unfortunately, Nigel. Safa.

Moving on to the NHS workforce, when will the new NHS workforce plan be published, and how will it be different to the previous 10-year strategy?

So, again, when I sat in this committee previously, and spoke to health officials and health managers across Wales, it was absolutely apparent that we didn't have a coherent workforce plan. We didn't know where the workforce was, who did what, and information that this committee was requesting wasn't forthcoming because there wasn't that clarity of data around the workforce. So, it became apparent that we had to get a workforce plan in place to know and identify where staff were needed, what they were required to do, and how many we had doing anything at one point in time. So, we commissioned that workforce plan that officials have been working on over the summer. That high-level workforce plan will be with me in, well, the late autumn now, by October, and then we will be going from that, working on that, then, on ensuring that it aligns with other pieces of strategy, that it aligns with what the health boards expect and need, so that we see that as an integral part of our work.

Okay. What actions have you taken in the first 100 days to improve the workforce planning and reduce reliance on agency staff?

So, the workforce plan is now being put in place, so that's part of a 100-day plan, and I'm glad to say that we'll have that high level, as we touched on. On agency, we are putting in place plans now to reduce agency spend even further. I can provide you the data in written form, unless Jacqueline has it to hand, on how much of a decrease we've seen in agency spend, and we will be pushing that even further.

I couldn't tell you off the top of my head, but bank and agency spend in nursing has reduced quite substantially; we've got a way to go still with medical spend.

That would be great. We'd be keen to see that as a committee. So, following today, that would be great if you could write to us. Safa.

And then in terms of—. You've mentioned different summits, including the graduate summits. What sorts of challenges do professionals face, particularly those in midwifery? What challenges do they face in terms of recruitment and retention as well?

So, again, this is a situation we inherited, and it was unfortunate. I see how it happened. So, it dates back four years, to when Health Education and Improvement Wales put their plan together and looked at the retention rate of the NHS and the expected requirement moving forward. You will know that, previously, we've said that retention of nurses, for instance, in the NHS has been poor and that the Government needed to do more to retain nurses. The good news is that more nurses were retained. The bad news from that is that fewer spaces were available for those new graduates coming through to get a job, and, of course, we have a streamlining programme here in Wales that assures a job for those graduates, which isn't available elsewhere.

So, we put that graduate summit together, thinking, 'Right, we need to get the best brains around the table here to identify how we can utilise what we've got in order to find as many jobs as possible for these', because a promise was made to them, not by us, but by the Welsh Government nevertheless, and we had to, to the best of our ability, try and honour that promise. The good news is that in the case of most nurses now, they've found a job, which is really positive. It's not been the case with midwives, which is a concern. So, we are still doing what we can, bringing those people together, trying to identify places for them, so that we utilize the skills that they've developed.

Do we want to be in this position? No. Are we learning from it? Absolutely, yes. But there is a caveat and a warning to that. Because what we found this year is a problem dating back four years; this will be a problem that will have to work its way through the system for a few years yet. That's why we are getting the best practice, the learning, together to try and stop as much as we can earlier on.

Okay. And then, moving on to digital, again, Ireland has introduced legislation to support electronic health records and sharing data with patients across health boards as well, including research and innovation. So, what assessment has the Welsh Government made when looking at a statutory framework to accelerate digital transformation, and really look at unlocking the full potential of health data for research, service improvements and economic growth as well?

Other than Betsi Cadwaladr University Health Board, my biggest frustration is probably around digital, as we touched on earlier. There's so much that digital can offer. There's so much that we can do with it, and there's so much that we're not doing at the moment. And that's why we have started on that 10-year digital plan, bringing that together. We've commissioned a piece of work. In fact, I was providing information and evidence to a piece of work on that only last week, expressing what my wishes were, what my expectations were, what my vision was in that field.

At the moment, we've got an incoherent set-up, where you've got health boards with their own digital plans that are independent of each other, which means that you might have a system in Hywel Dda University Health Board that doesn't necessarily speak to a system in Aneurin Bevan University Health Board. And then, you have Digital Health and Care Wales that provides the all-Wales systems for GPs. Overall, as the evidence this committee had last year shows, GPs are fairly happy with what is being provided to them. So, that's good on a GP level, but it doesn't allow that system to talk with a clinician in a hospital, for instance, or with the care sector. We need to make sure that those systems, not just within health, but between health and care, talk to each other, and that's what we're working on now: how do we break down those legal barriers? How do we design an all-Wales framework?

I am looking currently at legislation and framework around data, which is the first step, because we need to identify what data we can share, who has the right to share that data and who has the right to access that data. That's a key piece of work and a piece of legislation that we will be looking to bring forward during this term, which will then be the foundational building block for improvement on digitisation.

Okay, and I think Nigel touched on it briefly about one patient, one record. What are the biggest barriers preventing this genuine approach to a one patient, one record system? And what actions are you going to take to ensure that patients and clinicians have the right information, at the right time, and at the right setting as well?

Currently, I think the biggest barrier would probably be the legal frameworks in place, because we've got independent bodies who control data, who control systems. So, breaking those down is going to be key to this. It should be possible. As I said in the response to Nigel earlier, when I visited OneLondon, they had 32 health trusts and organisations there coming together, representing the 13 million people living there. And they said, 'Well, this is what the public expect, and this is what we're going to do.' And they did it. So, it's not beyond the wit of a person to do it. But it will be challenging and take time in order to make sure that we break down those legal barriers that are stopping us at the moment.

The final question is in regard to Digital Health and Care Wales. Obviously, they're currently in special measures, level 4. In terms of accountability, particularly to clinicians and also in the care sector, is there a point of accountability to clinicians or carers who are using the services? And how is that accountability shaped or formed? And another thing in terms of artificial intelligence systems as well within digital: is there any sort of incorporation in terms of, again, clinical leads or care leads in this area, such as they have in England, Scotland and Northern Ireland, where they have fellowships within the digital service to help bridge that clinician-carer setting to make the system work for everyone who is using it?

On the specifics, I can't answer the specifics around that, so unless Jacqueline can—and it's fairly detailed information that you're looking for—we can write to you with the specifics around that. But on the broader question of clinical input into designing programmes, absolutely that's a shift that we're putting in place now, and we value clinical input. I don't think there's been enough space for clinicians to have their voices heard through developing policies within Government. We need to allow that. That's why—and I go on and on about it—we developed the waiting list plan that is clinically led. That shows the direction of travel that we want. That same principle applies when it comes to digital plans as well.

Great.

Just to clarify, level 4 is not special measures; level 5 is. But they are in enhanced monitoring and surveillance. At the moment, there is a well-led review of DHCW, which we will receive in the next few months, which will guide us about the next steps in terms of DHCW. So, I suppose that's as much as I can say at the minute.

Brilliant, thank you. Diolch. Becca.

Thank you. It's not so much a question, because I know that you're still developing the frameworks and things like that in terms of the digitisation, but just really an assurance that, when you're developing that, that you're looking at procurement, particularly procurement within Wales, and ultimately ownership of the data. So, yes, just those assurances, really.

Yes, we are. I think it's an important point. When it comes to digitisation, there are two models we could follow. There is the utopian Estonia model, where they built their own system entirely, extremely costly, and we're just not in that space, unfortunately. Or there is the bit by bit, slowly but surely. So, yes, you have to buy off-the-shelf pieces of equipment, ensuring that systems talk to each other. You utilise external expertise. But then within that, you develop your own over a period of time, so that you retain ownership.

Questions around ownership of data: that's why we are now looking at developing legislation on that. It is really important, if not the most important part of this, the foundational part of it: who retains ownership and who has the right to share that data? Ultimately, my principal position is that the patient owns their data, but there are legal questions around that on accessibility to that information, who they allow to access that information, at what level, and do they allow others on their behalf to partially own that data or have access to that data.

Great, thank you. Matthew.

I think that most of my questions are going to be for you, Deputy Minister for Public and Preventative Health. I think that we are all pleased to hear about the preventative agenda. Could I just ask you generally what sort of outcomes you'd like to see coming out of this agenda over the next few years?

Thank you. I think that one of the greatest outcomes is the shift in terms of how we think about preventative health. The First Minister was clear, when he gave me the post, that this is a cross-Government issue and, as I mentioned earlier, making sure that we break down those silos is crucial. Preventative health is not just a health issue. In terms of more specific outcomes, I think that health inequality is what really concerns me when we look at all of the data in terms of preventative health and public health.

And healthy life expectancy—the fact that that's getting worse. The fact that people living in our deprived communities are expected to live more of their years in poorer health, and that's getting worse. And, I guess, linked to that, looking at obesity as a significant public health issue. We know that it's linked to so many conditions of preventable diseases—type 2 diabetes, cardiovascular disease, cancers, for example. That is a prime example why preventative health isn't just a health issue. There are so many interconnecting issues there from housing. I've had some great meetings with Siân Gwenllian on how we can work together on preventative measures in our housing stock, to make sure it's at the standard that it needs to be, with a meeting yesterday on the homelessness duties that are coming in and how we can support people at the verge of being homeless.

Obesity is about food systems. I'm working really closely with Llyr on the new food strategy. There's some brilliant work happening across Wales. Cegin y Bobl in west Wales is one example. I'm delighted that Simon Wright's taken on that role in terms of the food strategy. And it's not about tweaking projects here and there; it's about looking again at the food system, it's looking at what we teach our children and young people. So, obviously, Anna Brychan's part of those discussions. I think that's such a different approach from this Government, where previously it was that food was just a food issue. Well, this is actually a food system issue that affects schools, young people, transport and planning as well.

We can do so much more in terms of changing our planning systems. Wrexham County Borough Council, I think, used health impact assessment legislation that's coming in next year, recently, to stop another McDonald's being built. I think it's the fourth one within a quarter of a mile or something. It just shows the complexities of these issues and how we get the co-ordination of those issues in place.

Also on obesity, it's not just the food strategy—that's the first step. We're looking at healthy food environments. I've already spoken to the retail consortium on what businesses and retail environments need to be doing, what they're doing now and what our powers are so that we can do even more, because all of these things are interlinked, of course.

And then, tobacco and vaping is a key priority of mine as well, looking at the new powers that we have through the Act. There's a consultation live now in terms of trying to make vape products less attractive to young people. I'm really concerned with the rise of young people taking up vaping. They're there as a great tool to stop people smoking, but not as a tool where children are taking it up. So, using our powers and exploring what we can do with that, really.

So, there's lots going on. But the key priority for me is just to break down the silos, make sure that we get that right, and that we catch policies early enough to make sure that we look through the preventative lens at them.

Thank you. You've spoken about a lot of things there, so I won't be able to respond to you on every one. Earlier you mentioned spending money. Is there a specific budget for this, or does this come out of the budgets of all the departments across Government? And is there a way of counting every penny that's spent on this?

This is crucial, isn't it, because we know that budgets change behaviours in terms of the work that's done. As I said, the first job is to get that definition right and then to analyse and disaggregate the current funding in terms of preventative work. We've been clear—the Government has been clear—that we want to see that shift; not just the shift, as the Minister mentioned, in the health service, but the shift to preventative health. So, the first step is to identify what we have, and then we will work strategically in terms of how we define these elements. There are lots of things that are being funded at the moment, for example in terms of sport, and you could argue that those are a part of the preventative agenda. So, the way we collaborate across Government in a very strategic way.

On the question in terms of value for money, there is a lot of excellent work being done in this area already. But to return to that point that we return to often, in terms of what's changed with regard to the objectives and outcomes for the people of Wales, our healthy life expectancy is in decline. Everything's going in the wrong direction, unfortunately, at the moment in terms of these indicators. We are looking anew at where funding is spent, and is it being spent effectively in this area, because, as you all know, there's no more funding coming. There'll be less funding next year. So, we need to ensure that every penny we spend in this area is aligned with our priorities and achieves that shift that we want to see in public health. I don't know if Sioned wants to add something.

It's so important for us to assess what impact we have with the investment that's happening within the healthcare field, but also in other areas across the Government. What we also see is that there are very good projects happening on a local level across Wales, but what we want to see is how we scale those up to a national level, and to go for those that we think will have the greatest impact. So, there's a lot of work to be done in terms of that.

In terms of the definition of 'preventative', that work is being done on a national level. A lot of countries are looking at this, but there are different definitions across the world used for this. So, we do need to look at that and we need to get a definition that works on the cross-Government level that the Ministers want to take on this.

Can I ask, just to clarify, sorry, when do we expect to have the definition, that work, done?

We're looking at that now. That feeds into, as I mentioned earlier, having a ministerial cross-Government group. That is going to be key and one of the first things that we need to look at, so that we are clear, as Sioned mentioned, what is the definition that works across Government. So, that work's imminent.

So, is that likely to come at the end of this year, or—?

It'll be this autumn that we will need to—

This autumn.

Yes.

I've gotten used to 'imminently' and 'autumn' becoming 'spring' suddenly. I'm just trying to pin you down.

We will definitely need to do it this autumn; in order for us to do the work, we need to plan.

This autumn, fine. Yes, that's good for us to know. Diolch. Sorry, Matthew.

That's okay. If I could just move on to public health, then, I know that we've discussed previously that both of us are interested in early diagnosis of cancer. A lot of the screening programmes that are run by Public Health Wales—. Well, they're all run by Public Health Wales, aren't they, but some of them don't reach the goal in terms of the targets. Are there any campaigns or anything that could help to contribute towards getting closer to those targets? I know that there are a lot of charities that run campaigns and have engaged with all of us in terms of identifying signs and symptoms and things like that. But is there more work that Public Health Wales could do to get people in for screening?

Yes, you're right. As you know, 40 per cent of cancers are preventable. So, it's really important that we look at this as part, and we are looking at it as part—. As we develop the cancer strategy, that preventative element will be crucially important. Certainly there is more work to be done, and I think this points to the issue I mentioned earlier about the inequalities that exist with regard to who presents at screening programmes. I'm having discussions on this with PHW to see what more we can do and what the issues are behind the data, and the data are the key, aren't they? We want to ensure that we have the right data at the right time so that we can drive these changes forward. Screening programmes are very good, as you know, but we need to ensure that people know about them and present at them when they should.

And also awareness of symptoms, as you mentioned—I know that you've been very active with regard to cancer, and one of the first conversations we had after being appointed was about the work of Claire's Campaign, which I was involved in in a previous life. I was very proud to work with Claire, after the excellent work done by the committee. I think that was a testament to—. One of the most powerful inquiries of the previous committee was hearing from women who've been let down by the system.

Claire was a dear friend of mine. I was very pleased to be able to persuade her—she didn't need a lot of persuading—to give her name to the campaign and to work on it. Clearly, finding out what the symptoms were—. For those who haven't seen that session, I would encourage you to go back to listen to it. It was so powerful. She'd been let down so much by the system. It was somebody giving her a massage in Turkey who identified that there was a problem and encouraged her to fight for a diagnosis. So, one of the first conversations we had was about how we can continue Claire's work and ensure that we do that in this area.

I think Delyth wants to come in.

Thank you for that. This is an area where Nerys and I will want to work together on with the women's health plan as well.

Like Nerys was saying, it's about empowering women, because the systems need to be there and they need to be working efficiently, but that, in and of itself, won't be enough. Women, firstly, need to have the confidence to go to get symptoms checked, to understand more—and that's why Nerys's work is so important—about their symptoms. But we need to make sure that they will have the confidence that, when they go to report symptoms, they're going to be believed. And so that's going to be a huge cultural change that we're going to have to see in the population but also amongst practitioners. And there are so many knotty reasons—and I really hope that the committee looks at this as well—why, and this is true, of course, in different cases, for men, but, still, we need to make sure that when those spaces exist, they are used efficiently. It's not just about them existing, it's making sure that people can take up the space and can know that they're going to be listened to, that they're going to be believed. And that's something that I feel really passionately about. And I know that Nerys feels, and Mabon—we all feel—really passionately about this.

Diolch. We may come on to more detail on women's health in a minute, but just to focus back on screening—. Sorry, did you want to—?

I just wanted to—. Looking at the latest screening data, I think the two areas and the two screening programmes we're discussing with PHW and we want focus in are breast screening and cervical screening, because they are not meeting the targets and the standards that we would like to see. There are also inequalities with regard to the screening take-up. And I think there are real opportunities on cervical screening. We know that we can eliminate cervical cancer, and all the nations of the UK are looking at this and where we can achieve that. But, to do that, we need to have a higher uptake of cervical screening; we have to have a higher uptake of HPV vaccination. And there's a real opportunity for us there—and this is one I'm very passionate about—in regard to how we can do that for our population. For the HPV vaccine, the inequalities of take-up on HPV vaccine in children up to 15—there's a 20 per cent difference between the least and most deprived areas of Wales. We have to tackle the inequalities within this data as well. But I just wanted to say that we are focusing very much on those two areas that are below the standards that we're expecting in those programmes.

Brilliant. I think we're going to have to move on to Sara now.

Welcome. It's lovely to be here.

I was going to talk about women's health, but I think it's only right that I pause there and rewind a little bit and talk about child health—I know we've mentioned children a little bit—I don't think we've mentioned it enough and it doesn't get mentioned enough in lots of our health discussions. And the reason I bring this up, and I'll declare an interest, is I was previously working for NHS Wales Performance and Improvement as a diabetes transitional care co-ordinator and lots of other conditions looked at what we were doing in this area. I'm also proud to say that I'm the first elected Member to live with type 1 diabetes. I've been diagnosed since the age of three, and my upbringing has had a lot of impact on my politics. So, again, since I've been elected, I've met a young woman with a brain tumour—I know there was a cross-party group yesterday on brain tumours—we discussed her adolescence growing up with a brain tumour. I've met with somebody who's struggling with a diagnosis of endometriosis, and she was diagnosed in her teens and the big impact that's had on her future fertility.

But I am going to talk about diabetes as an example of why I think we need to be looking at transitional care. It falls between people's responsibilities. It falls between people's portfolios. But you mentioned '-ologists' earlier. And so, for example, with type 1 diabetes, if you don't get the right management early enough, you're going to need an ophthalmologist—I'm grateful to have had my sight brought back by one of Safa's friends—you're going to need a nephrologist, which is for your kidneys, you're going to need a cardiologist, which is your heart health. You know, you're also—. One of the things I strongly believe is needed to stop these '-ologists' needing to look at somebody would be psychologists, because how you feel about yourself determines how you will look after yourself. And I think we've seen a big intake of psychologists in paediatric services, but if you're 17 and you haven't seen a psychologist, you won't have one. An example would be in my own health board, Cwm Taf Morgannwg; they haven't got an adult psychologist. We're starting to see some of these across Wales.

So, with that in mind, I just wondered if I could ask whose responsibility does this fall under. I know I wrote to Mabon before, and I asked if we could look for some research into this, and it says that, as discussed, there doesn't appear to be a clear picture of the current landscape in Wales or wider UK in terms of services and support available for your 16 to 25-year-olds. I also think there's a lot we could do in prevention in this area. Again, we've seen the child health report that's come out across the UK; we know child health is worsening. So, I think it is a prevention area, it's certainly a women's health area, and I think it falls under your portfolio, Mabon. So, I'd really like to work with you on this.

If you don't mind, the three of us will respond in part. But you make an important point about how children often get forgotten or fall between a number of gaps in the health system, hence why we are putting together a children's health plan, or children and young people's health plan, so that we do bring together those experiences and identify some of the issues that are impacting children more than others.

We are seeing now obesity rates increase. We're seeing children and young people get cancers that they wouldn't have previously had. We're seeing an increased prevalence of diabetes. These are the issues that we know will be hitting the NHS and our health service in 20 years' time, so we have to prepare for them now. When we look at the cancer plan, a part of the cancer strategy that we'll be looking at will look specifically at children and young people, because we know that the cancers that children and young people have are, by and large, different to what you might have if you're an adult.

So, those things we are working on now, and, again, input would be absolutely valued and appreciated. The other piece of work that we're looking at, and I think is an important point you make, is that cliff edge when someone hits 17 and they transition into adulthood. So, there's a piece of work we're doing now on trying to identify how we can make sure that that transition period is easier, that people don't get lost in the system, that there's a continuity of care for people who go from being children into adulthood. I'll ask Delyth and Nerys to come in as well.

Yes, absolutely, and I think the committee and we would benefit from your expertise in this area as well. The focus has to be on children and young people in terms of prevention. We know that healthy life expectancy is getting worse, so our children will be suffering from that. In terms of the obesity rates, we know that those who are obese, I think it's—. Well, 27 per cent by the age of five are overweight or obese, and only one in 20 who were obese at five returned to a healthy weight by the age of 11. So, we're going to have to focus resources on children and young people when it comes to preventative measures, and that's across all the areas that I mentioned earlier in terms of priority areas. But, yes, I absolutely take the points you mentioned.

I'm aware of time, but I'll just add briefly, because you mentioned endometriosis there and how that links in with general menstrual health and empowering girls and teenagers as well, young women, to be able to spot what is normal, that, again, a big passion of mine—and I know that lots of you will share this passion as well—is about trying to kick start those conversations about how, actually, okay, there are some circumstances in which pain is going to be normal, but too often not, and endometriosis, things like that, about when actually girls—. There'll be elements—. This is a cross-Government thing in terms of education, in terms of, again, how we can make sure that, when something is wrong, we can spot it early and we believe young people when they say that something is wrong and we look into it rather than, too often, them being told, 'Oh, well, this is a normal part of life.' Actually, putting up with pain shouldn't be normal.

Just really briefly, to come back on that as well, you mentioned the child health plan. When we went from a diabetes delivery plan to, then, the next plan that came after that, I argued at the time that transitional care doesn't belong in child health. Transitional care belongs in adult health as much as it does in child health, to have that continuity, because no young child feels lost in paediatric services. That always comes next. So, I would really want you to be mindful about, when you put things in, where it sits, because I think that's really important for the delivery of it.

We're lucky to have Jacqueline, whose expertise is in paediatrics and children's health.

Fantastic. If I could move on, I just have the general—. In terms of the health visitor issue in Cwm Taf, could you explain where we are to the committee and if there's anything we can do with this to move it forward? That would be—.

Yes, I'm extremely frustrated, as I expressed yesterday, by the situation that we are finding in Cwm Taf when it comes to the health visitors. It needs to be resolved; it can't go on. It is an issue of safeguarding for children and young people and their families. We have to make sure that those health visitors are back working. In order to do that, the health board, Cwm Taf, and Unite have to come back around the table. They have to find common ground in order to resolve this so that those people are working again. As I said yesterday, nobody takes the decision to go on strike for fun. It's not fun for them. They don't want to be striking. They are experts in in their field. They are qualified health visitors who want to be out there working, and that's where they should be. But we need to see the health board and Unite discuss to find a resolution. Unfortunately, and I say that advisedly, I can't intervene. It's not in my gift to do so. People who know me know that I wouldn't idly stand by willingly and allow something like this to happen. I'm as frustrated as anybody, but it is in the gift of the health board and Unite to find a solution to this.

Diolch. Becca.

I'm going to be very quick because I can see that the time is running out. I'm concerned that there's a bit of a gap in terms of women's healthcare, in terms of cancers that disproportionately affect women. I see there's no specific mention within the women's health plan, and there's nothing planned specifically for the cancer plan. But there is research that shows that cancer does affect men and women differently and that the side-effects of treatments can be worse in women. And also the outcomes in terms of those long-term side effects—so things like fertility, early menopause, reconstruction surgeries—they are women's issues and they do also appear in the women's health plan.

And then also it's about, as you were saying before, being believed. Because, often, those hormonal imbalances that come with gynaecological cancers are passed off as benign menstrual symptoms and just that normal rise and flow of hormones. So, I'm just wondering if there could be consideration there to having specific reference to women's cancers either within the women's health plan or within the cancer plan.

Certainly in terms of the women's health plan, that feedback is really useful and I don't disagree with you at all. I am looking to strengthen how that plan answers the most urgent concerns of the women of Wales. And so both you as a committee and any women watching this, if when we have that—. It's not going to be a call for evidence, it's going to be just looking to hear from women's experiences. I think that could be incredibly valuable and I am very happy to consider further with the committee how that could be achieved.

With the cancer strategy, very briefly, we will be looking at that cancer journey: from the prevention, through to the diagnosis, through to treatment, through to living well—those four steps of the cancer journey. Women will be part of that, obviously. But we're still in that call for evidence phase, and I would encourage as many people as possible to provide evidence and contribute to that process.

But specifically, something that struck me when I was out in the conference recently is that two thirds of cancers are suffered by men, but two thirds of cancers under 50 occur in women. That's at that productive age—either productive when it comes to work and the economy or with children and caring duties. So, it's a massive hit on us when we see women suffering from cancer in that cohort of people, which is having a massive impact on society, on families, and on the economy as well. So, we realise and we value and appreciate the fact that we have to get this right.

Diolch. I'll bring Claire in now.

I just wanted to pick up on what Sara said as well, and Becca, because obviously women's health is a big part of me. I was looking into policies for a life-course pathway that takes women from adolescence—. Because, in effect, women do suffer from the ages of 10 or 11, right through until they're, sometimes, 70 years old. So, I am very interested in taking it from a youth section, because then people would be listened to a little bit more, if you have—. With the women's hub that you've got right now, I don't want to agitate that at all, I don't want to change that, I just want to add a bit to it. We have so many GPs at the moment who are not really—. Some are coming out and not being employed. What do you think about maybe advancing some of their training to be more independent with women's—? Not a gynaecologist, but trained to be able to listen to children from the age of 11 and up, right up to adulthood. Because I do agree with Sara that there is not enough continuity right the way through for women. And as somebody who has endometriosis, I know what it's like to get a doctor to listen to you. I think that if you attacked it straight on and had a GP who you went to who was trained in listening specifically in relation to women's health, I think that would be a possibility to get into a policy. I'm just asking what you thought about that.

Claire, thank you so much. On the point that you're making, firstly about the life course pathway and looking at those different flash points where we can be looking out for when young women, women throughout their lives are more likely to be experiencing different problems and linking that in with GP training, it's something that I'm really interested in as well and I'm really keen to talk to you more about it, because there are too many opportunities that are missed. I know that, in terms of what's happening at the moment, there's a task and finish group that has been established on endometriosis, looking at a gynaecological clinical implementation network, clinicians coming together to see how we can improve the pathways. But, more generally, on the point that you're making there about how we can maximise the space that's being used already in GP appointments, how women's health hubs can be part of that conversation, too—well, not conversation, part of the solution—there's an evaluation going on at the moment about how effective the hubs have been and are being. I think that there's a lot of variation, it's fair to say, across Wales, so how we can make the best of the spaces that exist physically and otherwise is something that I'm really keen on as well.

Thank you.

Diolch. We'll move on now to Gareth.

I don't know where to start. I declare an interest as a chartered psychologist, and I'm still practising. I have so many questions. I'm interested in the same-day open access mental health support. I wonder if you could explain that and how you're going to measure it.

Thank you, and thank you for your expertise. I think it's really going to enrich what the committee is doing. There are so many of you with expertise in this committee. We want to get to a place where, when someone presents with a mental health problem, they don't have to wait for different referrals and be passed around from pillar to post—that on the same day that they present with a problem, we can minimise the bureaucracy and make sure that they get access to the support that they need that is as close to the community as is appropriate. For the vast majority of people, as you know, having that help in the community, whether that will be in new spaces in the community, will be most beneficial, rather than the culture, which is understandable at the moment, where sometimes we have too many spaces on the estate that are not really suitable to be housing patients who have really acute mental health problems. So, we're looking across the estate as well with this, but the principle here is making sure that people get access as quickly as possible to support, and support that is, where appropriate, in the community rather than taking them away, because too many people get taken away from their community, sometimes outside Wales as well, to get that support. And as you will know, more than I will, that can be incredibly damaging.

It can, but my concern with this is that the waiting lists, as you know, are three to seven years, depending on whether you see a psychologist, psychiatrist, what medication you need. Children who go into child and adolescent mental health services are waiting a lot longer in Wales than they are in England. It's the same with adults. You could get seen in 30 days, up to 60 days, in England and still be waiting a year here. But the reality is it's three to seven years. So, how are those waiting lists going to come down?

This would be part of that, because I agree with you; we are not where we should be in terms of these waiting lists. That can be a particular problem for young people as well. So, it does all link together, and this is something that, again, I hope that the committee will be able to give some focus to, because too many people are being let down at the moment.

They are. The thing is, I'm a private practitioner because of issues with the NHS. I wouldn't work within the NHS, for reasons that my colleague Neil Kitchiner is actually retiring for. But the issues are that people also get labelled really quickly, and there are not enough—I can't say the word; I've got dyslexia—diagnosticians, which I do partly, but equally they put it down to psychiatrists more than they put it down to psychologists. That's wrong. Psychologists probably are more in place to diagnose, rather than psychiatrists, and psychiatrists are more likely to give medication, where psychologists are more likely to give therapy and have the treatments in place. Some of the treatments within the NHS are outdated. Cognitive behavioural therapy, for instance. It's used. I mean, it's one of the oldest. But there's a new therapy called BWRT, which is BrainWorking Recursive Therapy. That won't be used in the NHS because there's not enough evidence behind it. Yet it's used in South Africa; 2,000 psychologists use it in South Africa. It's used all over Europe. What takes CBT 12 sessions can take one session of BWRT. So, that would save the NHS tenfold, and you wouldn't have the waiting lists. It would bring them down. This is something I've been working on for several years. I've worked with charities. I've had my own non-profits, but—. I'm trying to look at my notes. I can't see them without my glasses and I hate wearing glasses.

That's okay. Perhaps you could write on that point, Gareth, to the Deputy Minister.

If you could, that would be really useful, because, again, I know that we're short on time and I don't want to rush this, because it would be really useful for us to learn from this.

I was going to go through all this, but actually, if I could have a meeting and then we could write to—

If you wanted, Gareth, to raise that specific point with Delyth, obviously you're very welcome to, but if you want to move on with some other questions.

Yes, there are others. Again, it's about getting people into the NHS, getting psychologists, getting psychiatrists, and so on. They're leaving the NHS. But equally, there's the Health and Care Professions Council, which is obviously a licence that everybody needs to practise within the NHS. But as psychologists, a lot of us leave as doctors, but we're not allowed to practice within the NHS without HCPC. We get given chartership, but we don't get given that licence, whereas in most other cases, with nurses, medical doctors, they get given the licence straight away as soon as they leave, but we don't. Obviously, that would take a lot of legislation, but I just think that's one of the main reasons you're not getting enough psychologists and psychiatrists within the NHS, and that's bringing your waiting lists up. So, that's something else to look at.

I was at a military—. It was with Neil Kitchiner, but he's retiring now. We had a meeting with them. Their waiting lists are up at eight months for military, which is actually quite quick compared to the rest. There are two different areas that are dealing with just military alone, but I think it could all be put into one. We shouldn't have separate—. That's also drawing the waiting lists up.

From here, what I'd like to know is: do you have baselines? Have you done any baselines on the medical, on health, all the way across the health board? Has there been baselines done? Are there any researchers there looking at the baseline, so that you know whether your trajectory is going up or it's coming down with what you're doing now in Government?

In terms of—. Forgive me; do you mean—

Health in general. Not just mental health, but health in general. You need baselines to know whether you're doing better or you're doing worse. Do you have them? Do you have the data? Because I know that Wales has the worst data in the UK.

Just before Mabon comes in on the more general points, in terms of—. We are doing a lot of work to improve mental health data, certainly. Because I agree with you that it's really important. I know that NHS Performance and Improvement are looking at lots of metrics with this to improve. They're testing different models—again, the open access model we were talking about—improving how we monitor those models.

In terms of the core data set that's being developed, it's going through data standards processes. They're working with health boards to make sure that they are recording and reporting on that data, but that's one—. There are lots of other ways as well, through mental health, certainly, where we have different indicators. I know Public Health Wales use the health needs assessments of the mental health of young people; that was published earlier this year. So, there are lots of individual data sets that are being used, but, Mabon, was there an overview that you wanted to give about the general health data?

I'll try and give a very succinct answer. We've got—

That would be appreciated.

—a ton load of data. We've got a lot of data. We've got data going back many years. Are we making the best use of that data? That's questionable. So, we want to improve the usage of data.

Diolch, Mabon. I'm just going to bring Matthew in and then Sara, and then I'll come back to you, Gareth.

Just a really quick question on mental health waiting lists. I've had a lot of people contact me saying that the waiting times are two years to see someone about mental health issues. Obviously, that's too long when people have a crisis. So, I just wondered how you are looking to incorporate the third sector and community organisations that could provide that. I know there's a lot in my own community—people like Mind who I met with recently. How are you utilising their services to help bring down waiting lists?

And that is again something that is going to be part of the programme that we're going to be setting up later this year as well. Every element of this will have its part to play, and this isn't just something that is specific to mental health, of course; that's going to be true across the board in terms of how we—. Jacqueline, I don't know if there's anything specific you want to say about waiting lists generally and how we're going to be using the third sector.

For mental health.

For mental health. So, coming in—I've been here a year—it hasn't felt, in the health boards, or in mental health, that mental health patients have parity of esteem in terms of the amount of light that gets shone on services. And particularly when we look at in-patient services, we've got 36 small units, and some of them are in really poor condition, and some of them go back a long, long time as well. So, there is a bigger piece—. The piece of work that we want to do, and what we are doing, is not just about how quickly people can have an out-patient appointment; it's actually about where people can be closer to home and get treatment too. We spend £200 million a year on sending patients from Wales into England because we haven't got the right beds, and we have really long lengths of stay. Some of that we need to do because of level 3 forensic psychiatry; we can't do that in Wales. But part of it is looking at how do we actually enable people to be looked after closer to home, back in their communities, in halfway houses, using the third sector to support.

But it's the bones of the plan that we're beginning to try and put together that doesn't just look at the interface on out-patients, but actually looks at those who already have a diagnosed mental health problem, supporting them to stop going into crises, and that when they do go into crises, they get into the right bed and it's near to home, and also that they get out as quickly as possible. And we have halfway houses that are run jointly between social care and the third sector, as well as ourselves.

It's an ambitious plan. It won't be a five-minute job, but I think we recognise the need to do something different for patients who have a mental health issue, regardless of whether it's in child and adolescent mental health services or any other bit of the mental health pathway.

Absolutely. I'll just bring Sara in.

Again, mine goes back to data. So, again, to use diabetes as an example, but I know this would be the same for long-term conditions, there's a link between diabetes management and mental health issues, complications, problems. And, again, I don't know if this is more of a local thing, but it was really interesting that when secondary care, or it could be a GP as well, refer people into primary care mental health, I remember asking the staff there, 'Do you record anywhere whether somebody has diabetes or cancer? Or what's the reason they're asking for mental health support?' And they said, 'Well, we ask, but we only ask to be able to accommodate you in that session if you had any additional needs.' And it really surprised me that, within the health board, we weren't actually collating who's going there, and then that would actually tell you that, actually, if there's a higher percentage of people with diabetes, for example, coming here, we could get a bit more psychology there or anywhere else. I'm just using that one as an example. But there are places where data isn't being collected that I think could really strengthen how we then shape and flow our services. So, I want to just flag that with you.

Could I ask, to Sara and to other members of the committee, when you come across examples like that, if you could write to us with them—where you're seeing examples of how things could be made better? That would be really useful.

Diolch. And we'll just go back to Gareth.

I'll leave it with two more very short ones. One is suicide prevention. What are you doing about that? I can tell you that I have no end of calls at 1.30 in the morning, 2.00 in the morning, because they can't get hold of a Samaritan or anybody like that. So, they call me, and I'm on the phone for an hour trying to bring somebody down off the bridge, as it were. So, have you got something that can be put in place, quickly—phone lines, 24 hours—that come from the NHS themselves?

Thank you for the work that you're doing there to support people in crisis. It's hugely important. So, the NHS '111 press 2' service exists at the moment so that someone with a mental health need can get that triage happening straight away, rather than, again, them having to—. There have already been awareness campaigns about that, but we're going to be redoubling, making sure, because, again, it's not just about whether the service exists, it's whether people know it's there, whether people know that it's going to be used exactly.

In terms of suicide prevention, it's really timely that you're asking this because it was World Suicide Prevention Day, I think—was it last week? And we are working really closely with the National Centre for Suicide Prevention and Self-Harm Research, making sure that, again—. I know this is something that disproportionately affects men, and so we need to be looking at how—. And that is something that we are very much building into the plans about how we can make sure that opportunities are not missed to give that support to people. I know that, again, research tends to show that men will—. It's not that they don't present asking for help, it's that they can, sometimes, present in a more calm way when they're asking for help, and so, unless people have had the training in what to look out for, they won't realise, and there's that opportunity that is lost. So, we're working really closely with them.

We published our first annual report, which was showing progress, on 10 September, to mark that day. And the national centre also published the first of their reports that was looking into how we can look to support people in crisis, how we can ensure that people who are self-harming, who are in need of that urgent care and support, are getting it when they need it, and that we maximise those opportunities. It's huge. I'm really glad that you've raised that.

Last thing—GPs. GPs are quick to diagnose people when they don't have—. It's not for them to do, really. So, psychologists, we write out Likert scales, they go to the GP, the GP is supposed to ask questions, fill out the form. They don't do it now. They just hand out drugs, left, right and centre, without any assessment, without a referral. They're giving drugs: sertraline, citalopram, paroxetine—I could go on. They just hand them out like they're jelly beans. I have no end of patients come to me and then turn around saying, 'Well I'm on this drug, and I'm on this drug.' And I'm like, 'Well who put you on it?' 'Well, the GP.' 'Well, what did they do to diagnose you?' 'Well, nothing.' They didn't even fill out the Likert scale. So, in the old days, the GPs used to pull out a scale, they'd fill it out, they'd score it, because they were taught how to score it, and then they'd know at what level that person had depression. So, the fact is, they're not doing that these days, they're not following the rules, they're just giving the pills out.

I think that that would be something that we'd have to—. With GPs, generally, I'm sure there are ethical means that GPs have to follow. So, if there are individual cases that you've heard of, Gareth—

Yes, there's—

—there are ways to follow that up. But I'm sure that you're aware of what GPs have to abide by and follow through with. I'm sure you're aware of that.

If you're aware of any specific individual instances, then raise them with the GP surgery initially, I would suggest. You can raise it with Llais as well before it then is—

I've actually got a meeting coming up with them.

There we go, that's an opportunity for you. If there is a pattern, then it might be escalated.

Brilliant, diolch. That's good timing now that we've come to exactly the end of this session. Diolch yn fawr to you all for coming in. I'm really grateful to you all for your time, Ministers, and your officials as well, for joining us and answering our questions. You will receive a copy of the transcript to check for factual accuracy as well, and I know that there are number of things throughout the session that you have agreed to follow up on in writing to us and that we've agreed to write to you about. So, there will be that exchange of correspondence. Diolch yn fawr. Thank you for you time.

Diolch. Looking forward to keeping the relationship going.

Absolutely. Diolch.