Health and Social Care Committee

We move to item 3, and under Standing Order 17.42 I propose that we go into private session for items 4, 7, 8, 9 and 10, if Members are content. Thank you very much. In that case, we'll go into private session and we'll be back in public session at 10:30.

Welcome back to the Health and Social Care Committee. We move to item 5, and we have a COVID-19 evidence session with Welsh Government officials this morning. I'd just be grateful if you could introduce yourselves for the public record. Who will go first? Sir Frank Atherton, if you want to go first.

Dr—or Sir—Frank Atherton, Chief Medical Officer for Wales.

Next on my screen—. I can't see, sorry. Go ahead, somebody else. I can't quite see you. Yes, go ahead, Rob.

Hi. I'm Dr Rob Orford, I'm the chief scientific adviser for health in the Welsh Government.

Brendan.

I'm Dr Brendan Collins. I'm head of health economics in the Welsh Government.

And Chris.

I'm Dr Chris Roberts. I've been supporting and leading on behavioural science for the technical advisory cell during the pandemic.

Thank you all for being with us this morning and for your time. We appreciate it. Perhaps you could just start by giving the committee a general overview of the current picture for COVID-19. I don't know whether somebody would like to lead on that or whether you've discussed who might want to take the lead on that first question.

I can give a quick update on where we are, I think, Chair, if that's okay—

Thank you.

—and then others can come in behind. Over the last few weeks, we've seen a continued reduction in community transmission here in Wales. There's been quite a rapid decline, actually. We're still in the grip of the omicron BA.5 wave. That's the predominant strain at the moment. But the rates really have come crashing down. It was only a few weeks ago we had the ONS figure of one in 15 people in Wales being infected. The latest figure, which obviously has a bit of a time lag, is one in 110. So, it's come down very quickly and that's mirrored certainly across the UK nations, and indeed across many comparative countries in Europe. So, that's all really quite positive.

I would say we're not out of the woods. We are seeing across the rest of the UK—. I meet with the other UK CMOs on a weekly basis to look at the data, and we are seeing a bit of an increase possibly in Scotland. Of course, their schools go back earlier than schools in Wales. And we have seen, of course, in previous waves that when things have been coming down and going in the right direction, schools going back into session does sometimes lead to a bit of an uptick. Possibly, there is some signal in parts of England that a similar pattern may be being followed. So, I suspect—and it's only a suspicion—that, having gone down very steeply in terms of community transmission, we're probably bottoming out, plateauing out.

As ever, the hospital activity figures have really followed shortly behind the reduction in community transmission. So, the rates have been going down quite well in hospitals. We still have patients in hospitals. I wouldn't like to mislead the committee—we still have significant harm coming from COVID. We still unfortunately have a small number of people dying each week, but the numbers of people requiring hospitalisation have come down, and that really reflects both the reduced community transmission and the success of our vaccination programme. And of course, we have recently just started the autumn booster programme to boost immunity in the population, getting ready for what may be to come.

So, I think that's the broad brush, Chair. Hopefully that gives a feel as to where we might be.

Thank you, Dr Atherton. That's appreciated. I suppose an obvious question is, given the fact that the testing regime and the reporting regime are very different now to how they were back during the main course of the pandemic and the fact that many people may not report a positive test, if you like, how accurately therefore can we look at these figures that you've just spoken to?

It's a very good point, because we don't have the visual acuity that we used to have when we had mass testing. When anybody who had symptoms went forward for a test we got very good data on what was happening in Wales. Having said that, we still have extremely good data on the prevalence, because the Office for National Statistics survey is well designed and that gives us, on a weekly basis, a random sample. They take a random sample of the population and survey those, do swabs, and give us a very accurate figure. The problem is, of course, it's not in real time—it usually refers to two weeks before the publication of statistics, so it's a little bit historical. But we do have other sources. What we're forced to do in the absence of mass testing is to look at a basket of indicators, if you like. So, certainly the ONS is one of the most important sources of information, but we still look at wastewater. The wastewater signal—you're welcome to talk about that—is pretty encouraging still at the moment. We do have lateral flow tests that are available to people, certainly in health and social care, who are symptomatic, and we do get some signals from that. And we are boosting our surveillance capacity. So, Public Health Wales are leading work to make sure that we have adequate surveillance as we move into the winter months. We can talk more about that, if you like, at some point. But Rob may want to come in on the other indicators.

Yes. Thanks, Frank. I think that was fairly comprehensive. We are still monitoring the wastewater—it covers about 85 per cent of the population and it's fairly flat in most places at the moment. We also look at the types of variants that might circulate in the wastewater, which is consistent with best practice in other European and international countries. It's important to also note that we do compare notes with the other UK nations on what's happening, and we also look overseas. There are very good updates from the European Centre for Disease Prevention and Control and the World Health Organization on what's happening right now and what might be happening in the future. It's not a new practice—sentinel surveillance is something that Public Health Wales have done for a very long time and they're strengthening that with the Public Health Wales respiratory surveillance plan for the winter. So, whilst we don't have the same numbers coming through—it makes it slightly more difficult to look at things like vaccine effectiveness if you have a new variant, because obviously you need the numbers of patients coming through that are confirmed—we do have systems in place to help indicate what the future might look like in the days, weeks and months ahead.

Okay. Thank you, Dr Rob. Joyce Watson.

Good morning. You did briefly mention that there have been deaths from COVID with people and the mortality rate in July shows that that was 4 per cent. So, in terms of taking this forward and asking people to protect themselves but not frightening them at the same time, what do you suggest is the right way forward?

Well, my main point, I suppose, is that we're not out of the pandemic. We're in a good position at the moment. Vaccines have really provided us with a great deal of protection in terms of breaking—not breaking, but certainly reducing—that link between high levels of community infection and serious harm in terms of people going into hospital. So, the deaths, you're right, continue, as I said, but they are at a much smaller rate than previously. I think that that 4 per cent figure's been superseded in the latest month, shall we say; in September, it's about 2.5 per cent. So, again, things are moving in the right direction, but there is still harm accruing.

So, what is the way forward? Well, it is first of all to continue our stage in the vaccination programme, which has been an absolute game changer. That's why I've embarked on following the JCVI guidance on a booster programme for eligible people here in Wales. That started on 1 September; early days, but going quite well so far.

And also, we do need to synch and work with our public, and we can talk perhaps about the public communication messaging, but we do need to work with the public so that they understand that, as we move into the winter months, respiratory viruses generally tend to circulate. COVID is one of them. Flu—we're quite worried about the resurgence of flu potentially this year. There are other, though, respiratory viruses that can affect people and they always tend to come in the winter months. I would say COVID has not yet settled into a fully seasonal pattern, but we do expect a resurgence as people gather more closely together.

So, there are things that we've learned through the pandemic that we can do as individuals and as communities to protect ourselves, and that involves issues like social distancing as well, not going out and about if we have symptoms, and about using face coverings in health and social care settings when required.

In terms of that we know omicron is the dominant strain now, and vaccine immunity wanes, and we know that—because you've mentioned it—we've got a vaccine programme under way, are you content that that vaccine programme as it exists is the right programme to avert the crises that we've seen in the last two winters, in terms of the spread of COVID-19?

You're right to stress, to point out, that vaccine effectiveness does wane over time, but the good news is that the reduction in harm, in serious harm, seems to be maintained, and that's really why we've followed the JCVI guidance to move to re-vaccinate, to boost the immunity of our population between September and Christmas. So, that is the right thing to do. It is our best protection still, and I think that's the right process to follow. If we look back at just the most recent wave, really, the people who ended up in hospital were by and large people who had not been properly protected or fully protected with either a primary dose of vaccination or the spring booster. So, there's really clear evidence that vaccines are the best protection. So, that's the right thing to do.

Dr Orford, I think, wanted to come in on an earlier point.

Thank you, yes. Just to go back to the, really, having your vaccine, if it's offered, is the best available defence—you're far less likely to end up in hospital than if you don't get your booster jab—I think it's important to stress that that takes pressure off the NHS if you have your vaccine and then you're less likely to go to hospital and require care of the NHS. I think that's really important. I think it's really important to say that the original vaccines work; they give a boost to that immune system. In the same way as you eat an apple a day to keep the doctor away, then having your vaccine helps top up your immune system and you're less likely to have a serious or moderate illness than if you hadn't had it. So, I think we really have to stress that point that vaccines are very effective. There is a new range of vaccines, of bivalent vaccines, coming out, but the single vaccine is also very good. So, that's a really important point.

Just to go back to the earlier comment around deaths, people are still dying from COVID. There are still excess deaths that are non-COVID, and it's really important that we understand why that's occurring and the impact of COVID on the population, whether that's through acute illness in people who haven't had a vaccine and have died, people that have underlying co-morbidities and fragilities that we need to look after. Understanding the impact of COVID longer term on the population is going to be really important for us.

Thank you. My final question is: the ONS data shows that there are around 90,000 people in Wales experiencing long COVID—that's a significant rise on earlier estimates, so how accurate are these numbers in representing the extent of long COVID in Wales?

I can go first, if you like, on that as well. The accuracy of the figures is not something that I would particularly question; ONS has robust methodologies. I think this is an evolving field. The one thing I would say about long COVID is that there is still an awful lot we don't know.

The definition of what we mean by long COVID is really important. That is starting to settle. It's still a little bit disputed sometimes, but both the National Institute for Health and Care Excellence and the WHO have come to an agreement, I think, that the persistence of symptoms beyond about 12 weeks is important. Some people look at four weeks, but 12 weeks is pretty much an important cut-off. Certainly, those people who have persistent symptoms beyond four weeks, many of them improve by 12 weeks, and some of the people who have symptoms by 12 weeks will continue to improve, but the improvement drops off. So, whatever the accuracy of the number, and that will become more precise with time, there is a large number of people who are suffering from persistent symptoms as a consequence of COVID, so we call that long COVID, post-COVID syndrome, or what you will.

Where does that take us? It takes us to the lack of knowledge and lack of understanding, first of all, about what is causing it, and there's a huge amount of work going on into the pathophysiology, the etiology, why people are getting this. There are all sorts of theories about disordered clotting mechanisms, about disordered immune systems, about persistence of virus. So, there are many, many theories, so that needs to be properly unpicked, and the diagnostic pathways are not yet clear.

We have set up, of course, a recovery programme here in Wales, we've invested £10 million in recovery systems through the NHS, through the local health boards, and that's a start. But firming up the pathways, knowing what treatments can be provided and what actually works—we're still a long way from that. That's really why the National Institute for Health and Care Research, the NIHR, at the UK level has invested, I think, about £50 million in a large number of studies, of which Wales is playing in. So, there's a huge amount that's unknown, there's a huge research agenda around this and the need to continue services, but certainly the figures are high. There are a large number of people who are requiring help.

Rhun, you wanted to come in.

I've a couple of areas that I want to respond to, and you tell me, Chair, when is best to bring them in. If I could come straight in there on long COVID, in response to some of the comments that we heard just there, there's a big discrepancy between some of the statistics we're hearing about self-reporting of long COVID symptoms, maybe 90,000 people in Wales, and I think the latest or fairly recent Welsh Government figures, saying there have been maybe 2,500 or 2,400 diagnoses of long COVID in Wales. It's a massive discrepancy, of course. What's your assessment of the work that's been done to actually try to give a diagnosis, a formal diagnosis, to the people who are clearly living with symptoms, some of them, no doubt, serious?

Yes, well I think that—. As I say, self-reported symptoms, of course, are important, because that's how people feel, that's how people respond, how they're reacting to recovery from the virus. A significant number of those people who have self-reported symptoms will improve over time, irrespective of what you do. Time is a healer in that regard.

I think the figure of 2,500 relates—. I think it probably relates to the number of people who've been through the referral pathway and have received services through the Recovery programme, which all of the local health boards have been funded to provide. That provides community-based rehabilitation, multi-disciplinary, and that's based on NICE guidance as to what is the best—what do we know currently is the best—treatment. So, that's probably the best that we have available.

There are other ways that people are accessing support and help. There is an app, of course, which Welsh Government has invested in, which promotes ways that people can use for self-directed recovery. And, of course, we've invested in producing guidelines for GPs, for health professionals more generally, as to how people can be supported.

Now, the caveat on all of that is that, as I say, there's a lot we just don't know, and these guidelines, these apps, these systems of support, will change over time. But I think the discrepancy is about the number of people who have symptoms and the number of people who have come forward and been passported into the system and have had formal support through the NHS.

Dr Orfod has indicated he'd like to come in, but before I come to you, Dr Orford, you just said there that there's a lot more that needs to be learnt. Is enough being done to learn? Yes, we do have the Adferiad, the Recovery, programme, but is enough resource going in to try to understand and map the best way forward in relation to long COVID?

Well, I think globally it is, and certainly I think at UK level there's huge investment through NIHR—£50 million is the figure currently. That's the last figure I've seen. I can't remember whether it's 17 or 19—there's either 17 or 19 very large-scale studies in which Wales plays a part. There's the LOCOMOTION—. Just two that come to mind are the LOCOMOTION study, which is looking at new treatments and what treatments, in terms of medicines, might be appropriate, and there's also another programme that is looking at how people can support themselves to become healthy. So, there are a number of those, and Wales is playing into those, but that's really being co-ordinated at a UK level.

I think Rob wants to come in.

Dr Orford.

Yes, thank you. There is a heck of a lot of work going on out there. There are at least four in Wales. Health and Care Research Wales are always looking for studies that residents, people in Wales, can access and, of course, we've funded the Wales COVID-19 Evidence Centre, which has published a number of papers on long COVID. There's much to do and there's work that we're doing that looks at the current snapshot in Wales of what we know about COVID [Correction: 'long COVID'] and the work that's going on, and, importantly, what could be done to support people that do have COVID [Correction: 'long COVID'], as well as the referral pathway, the programme that Frank mentioned, that's being evaluated on its effectiveness as it goes along.

I think it's also important to say that it's kind of disproportionate [Correction: 'disproportionate, who is impacted by long COVID']. It affects different age groups differently. A higher percentage of adults, working-age adults, slightly older adults, seem to get features of COVID [Correction: 'long COVID'], and about 20 per cent of those people reporting features of long COVID say it has a significant impact on them and 70 per cent or so either a minor or no impact on their life. And then, of that cohort of people, probably 30 per cent of them or so don't resolve after 12 weeks. So, we need to keep looking at these figures and trying to tease them apart, but it's very complex. The common ailments, the common symptoms, are fatigue, fogginess, and it doesn't really matter whether you have a significant COVID illness or not. So, it's really complex, and I think it'll take us a long time to understand what's happening here, and, importantly, what we need to do as a system to support people who are suffering from long COVID. And I think what we've also seen, in the delta wave and the alpha wave, and the omicron waves now, is a similar proportion of people who are reporting long COVID. Some of that might be awareness, but also it might be to do with the underlying behaviours of the virus itself. It's not a particularly nice infection, is it?

Brendan may want to comment on the social costs of long COVID as well, which are significant, given that I think around about 8 per cent of people in Wales who have reported to have had COVID then go on to develop long COVID. There are different figures out there. Given that we've had so many cases in Wales, it has a significant impact, and the number that you've quoted of, I think, 99,000 people is significant because of the significant number of people that have had COVID. But Brendan may want to comment on the health inequalities and the social cost of long COVID, and COVID.

Yes, by all means come in, Brendan.

There is evidence of the effect of health inequalities around long COVID. It affects people from more deprived communities more, partly because they were more at risk of COVID earlier in the pandemic, but it does seem to affect people from socially deprived backgrounds more. As we move through the pandemic, the social cost of long COVID cases has evolved over time. So, initially, the majority of the QALYs, the quality-adjusted life years, that were lost through COVID were from people sadly dying from it, whereas now there are a lot more QALYs that are lost from getting long COVID as a result. So, there's been a shift from mortality to morbidity being the majority of the cost through the time.

We've published papers on this, which have been quite influential, I think, with people in other countries as well. And with the modelling that we've done around COVID, we've always tried to include long COVID, even from quite early in the pandemic, even though there was quite a lot of uncertainty around what the costs are of long COVID and what the health losses are due to long COVID, but we've always tried to include it.

I think it's important to try to understand the economic impacts of long COVID over time, because we've seen a lot of people leave the workforce since the pandemic, and we don't know how much of this is due to what they call 'the great retirement' of people just leaving work and not coming back, and how much of it might be due to other illnesses that were associated with COVID infection—there's evidence that cardiovascular disease may be more prominent in people who've had COVID—and then how much of it might be related to long COVID as well. So, there are some estimates that in maybe around 2 per cent of people in the workforce, it is due to long COVID, but I think we'll know more about those as time goes on.

And I think we need to understand how many people are likely to have long COVID, and what the long COVID costs are. Also, spending money on long COVID services now may save money in the longer term, if it helps people get back on their feet. But I think understanding all those health and economic impacts is really important and all of the research that's under way at the moment, which the chief medical officer mentioned, I think will help us to understand those impacts.

Thank you, Brendan.

I'm really grateful to you for that. We very much appreciate, as a committee, I'm sure, any updates on the work that is done on that, and I speak as a co-chair of the long COVID cross-party group here in the Senedd as well. We've gone off on a bit of a tangent there, but I think an important one.

It's not why I put my hand up actually initially—that was to ask a question to Dr Orford. You mentioned a significant number of excess deaths that we're still seeing. Could you comment, I wonder—or Frank Atherton—on research that's been published in the New Scientist this month, looking at a significant jump in excess deaths between April and August of this year across the UK—some 22,500 more deaths than we would expect, looking at the five-year average? Maybe half of those related directly to COVID—people who have suffered from COVID—and the rest potentially resulting from the impact of longer waiting times, delays in treatment and so on. What's being done in Wales to understand that excess death picture? Perhaps you could bring us up to speed on our understanding.

It's a great question. I'll start off, and I'm sure Rob will come in as well. So, it is a worrying feature, the excess mortality for that period that you mentioned. There is an excess mortality across the four UK nations that is not seen in some of the other countries that have been through similar COVID waves. So, there’s a lot of thinking about what is the cause of that. I spoke just a week and a half ago with all the other chief medical officers and with UK Health Security Agency staff about this, and there is work going on at UKHSA level to try to unpick it.

So, if you were to ask me, ‘Well, what is the cause of the excess mortality?’, there are a number of hypotheses, and they are hypotheses at the moment, I would say. The first one is that, as we got less precise because of the changes in testing regime, some of the deaths that are not labelled as COVID may actually be COVID related, or may be related to COVID infections some time previous to death. So, there may be a misclassification.

You’re right, there is a hypothesis that some of the care that would have been provided were it not for COVID, in terms of people seeking care and care in the NHS, has not been provided. And there are two elements to that: one is that the NHS is currently under severe pressure, and that may be contributing to this, but also we believe—and UKHSA is looking at the data on this—that some of the secondary prevention that we previously provided through the NHS, largely through primary care, has fallen away over time with COVID. So, things like statin uptake, things like treatments for stroke, for high blood pressure, for high cholesterol are not being provided to the extent that they were in the past, and that could lead to an increase in cardiovascular mortality, and some of the increase in excess deaths is currently labelled as cardiovascular mortality.

So, there are a number of hypotheses and we’re trying to unpick those at a UK level to really understand those, and I think what you will see is certainly a big push on secondary prevention. I know that’s something that CMOs have been looking at promoting, as part of our recovery, to get back to that. But Rob will have some more details.

Do you want to come in, Rob?

Thank you, Frank. Yes, there was a study published on the weekend that looked at excess deaths in Singapore, from the Singapore health ministry, which I thought was very good. They looked at cases of deaths where COVID had been occurring at least 90 days before, and when they adjusted for that, they found there weren’t excess deaths [Correction: 'non-COVID deaths']. So, possibly this goes back to the conversations around the longer term impacts of COVID, with people that are older, that are frailer, that have underlying comorbidities, that do less well when you have a COVID infection on top of that than the line.

And I think yesterday there was a publication by the Office for National Statistics looking at excess mortality, and it talks about months where we’ve seen actually lower than the five-year average mortality, and that’s by something called mortality displacement, where people who are older, frailer and have contracted SARS-CoV-2 have unfortunately died before they would have died if they hadn’t contracted it. So, you see those troughs, but now we’re seeing this period of higher excess mortality, which possibly goes back to that combination of factors, as Frank was alluding to, but possibly COVID infections that occurred some while ago that have exacerbated those underlying conditions.

Yesterday, I think, or the day before, there was a really big study published—SAIL colleagues in Wales were involved in that—looking at a 48 million patient cohort and showing that if they had had COVID, there was a higher association of vascular problems. So, I think we’re still trying to unpick this, and of course mortality is the tip of that iceberg, really, of the impact it’s having on the health of people in Wales. In March we published a technical advisory paper on excess mortalities, something that we’ll keep revisiting as time goes on.

Thanks, Dr Rob. Sarah Murphy.

Thank you very much, and good morning, everyone. I just wanted to follow up with a question on what you said, Rhun. I’m also a member of the cross-party group on long COVID. So, you mentioned there about how many people are leaving the NHS workforce, and we know that there are a lot of people who have told us that they believe that they caught COVID whilst they were at work. So, we have the figures, roughly, of how many patients caught COVID whilst in hospital. Do you have the return-to-work records of how many staff likely caught COVID whilst at work?

Is that something you would hold, Dr Atherton?

I would have to go to workforce colleagues just to ask if they hold any data on that. I don't have any figures at my fingertips.

No. Perhaps we can ask the Minister that question when she comes in next week as well.

Okay. And just in addition then, just to ask: in your opinion, though, do you think it should be recorded as a workplace injury?

Well, I suppose it's really fascinating to know how many staff have got COVID or had COVID at any particular time in the pandemic, but, of course, members of staff are members of the community, and saying that somebody has caught COVID because of their occupational exposure is extremely difficult, because they could equally have caught it because of their exposure within the community. And what we've seen with each of the waves of the pandemic is that when waves are high, staff absences have been high as well. So, I think we need to be careful about saying it's an occupational cause when we can't really prove that, but that's just off the top of my head, really.

Okay. I guess that will be why it's useful if we can have any data on that because, like I said, if we're able to say that we think thousands of people caught COVID in hospital, it is probably likely that some of those staff as well, who have now got long COVID and possibly can't return to work because they've caught long COVID, may have caught that at work as well.

Well, I think you can't rule out saying where people—. You couldn't get it really precisely defined where people have caught COVID. What you can say is that the protections that were put in place around staff over the course of the pandemic were very carefully thought through and were designed and were successful in reducing the transmission from patients to staff, from staff to patients, and, indeed, from patients to patients as well. There was a whole journey that was embarked on there, of course, around the evolving nature of infection prevention and control. But, it has been successful and we know how to protect staff now, and, by and large, those measures have been deployed and have been deployed successfully, I would say.

Okay. Thank you very much. I'll move on now then to ask some questions about the impact on health and social care services. I recently had a meeting with my health board, Cwm Taf Morgannwg University Health Board, and we were told that our hospitals are now effectively care homes, and this is not just in Cwm Taf Morgannwg, this is across the board. Bed occupancy in general, acute and medical beds, is currently at over 90 per cent. And we also heard yesterday in Plenary from the Minister for Health and Social Services that there are 1,200 patients in hospital beds awaiting discharge across Wales. Obviously, the problems that this creates, it's many problems, but the two main ones are that it is impacting waiting lists, and also it does mean that those people who are in beds are very vulnerable if there is a COVID outbreak.

Now, my local authority, Bridgend County Borough Council, has suggested that this would be massively helped if there were more step-down beds. So, for example in Cwm Taf Morgannwg, Prince Charles Hospital has access to 100 step-down beds. The Royal Glamorgan Hospital has access to 100 step-down beds. The Princess of Wales Hospital has access to six step-down beds. So, do you think that the solution to how many people are currently in hospital who need to be discharged is more step-down beds, and if not, what do you think is? And what is being done for those potentially, at the moment, 1,200 people who are in beds who are very vulnerable to catching COVID if there is another outbreak?

That's a complex question. Just to start with your opening, which is around the pressures on the NHS—well, let's say the health and social care system—I absolutely recognise that they are much more extreme than we've seen at this time of the year in any previous years. So, the NHS, the health and care system, is under pressure. Every morning, I see a list of the hospitals in Wales and the level of escalation. It's a rare day at the moment when fewer than 50 per cent of our hospitals are below level 4, which is our highest level of escalation. So, you're right that the system is under pressure.

Why that is is a complex reason. First of all, more people are, of course, coming forward for the catch-up. The health system is trying to catch up with planned care services that were not provided through the pandemic. And there is a problem in social care in terms of getting people out of hospital. And let's be clear, the worst thing for frail, elderly people is to be stuck in a hospital bed, because they rapidly decondition and the longer they stay in a hospital bed, the harder it is for them to get back to the place they really want to be, which is back in their own homes. So, that has to be the ambition of the system.

On the question of step-down beds, I would say that they are part of the solution but not the whole solution. In fact, there is an ambition across the NHS to create—. Well, originally we were saying 1,000, but between 900 and 1,000 additional step-down beds. Some of those will be physical beds in community hospitals and some of those will be the equivalent of beds by providing better services around people at home. So, we do need to address those 1,200 people who are medically fit, fit for discharge, but are not able to be discharged because there isn't sufficient social care support at home. There are huge efforts to do that. And that involves both the NHS in terms of the creation of these beds, if you like, but also working very closely with local authorities and social services to boost the capacity of social services. Because sometimes, it's just quite simple care needs that people need at home; sometimes it's very simple personal support, personal care needs that people need in order to get home. But there isn't enough capacity in social care at the moment. So, there's a lot of work going on to try to address that.

And then, of course, the whole system is problematic. I talked about the catch-up in planned care, and there is a risk, of course, that the catch-up in planned care will be delayed if we don't address the current pressures within the system, because we need capacity, we need beds for people to come into if they're having planned care. But there's also something about stopping people from getting ill in the first place, stopping people from needing to come into hospital in the first place. And there's a huge effort around six goals for emergency care, which are all aimed at trying to prevent people coming into hospital, to improve the flow through the hospitals and to get people out of hospitals as quickly as possible.

Thank you. Is more funding going to be given to the health boards to create more of these step-down beds, and when do you expect them to become available? Because, again, when I asked my health board what would be happening for the winter pressures that we're basically in now, I was told that they may be able to get another six step-down beds for the winter, which would take us to a total of 12. So, can you just give us an idea if there is more funding and if that's going to be put in place for this winter? I do understand that there are longer-term and bigger-picture issues here, but what's being done right now for where we are right now?

Dr Atherton, if you think that's a question for us to raise with the Minister next week, then by all means point us to that.

I think, Chair, you are seeing the health service planners anyway, but what I can say is that there is a significant resource going into the system this year, to try to resolve the urgent pressure that we have. I haven't got the figures in my head, but there has been investment through the six goals programme. So, health boards have received additional resources. The Minister will have all that information at her fingertips and her colleagues in health service planning and management will be able to answer those more fully, I think, next week.

Okay. Great. My final question is around modelling. What modelling has been done on the potential demand over the winter period? What is it showing? What are the trigger levels in terms of hospital admissions? When do we know when it's overwhelmed, if it does get overwhelmed, and what happens?

That's a good question. It's perhaps to colleagues as well, Dr Atherton, but I suppose knowing what the trigger points are for potential further restrictions as well is perhaps an add-on to Sarah's question.

Just on that, there is no trigger point as such. There's no point at which you say the NHS is overwhelmed; what it's really about is the trajectory. I know Rob and Brendan are perhaps masters of modelling, so I'm sure they'd be happy to talk about the modelling and how we look at what might be coming our way in future.

Thank you. We are doing quite a bit of work thinking about what winter might look like and the challenges that it might bring to us. We've done that in a number of ways. We've looked elsewhere. We've looked at countries that have already had their winter in the southern hemisphere and looked at their experiences. Australia, for example, had an earlier flu season. We were all going through a similar position with omicron. We've looked at our lived experience and the past waves that we've seen in alpha and delta, and now three, possibly four waves of omicron, and looked at those impacts and said, 'Okay, what happens if these happen again?' Sorry, I've lost my screen, can you still hear me?

We can hear you fine, yes; no problem at all.

Good. So, our relationship with the virus has changed. The very successful vaccination programme and successive booster campaigns have changed that infection to fatality ratio and it's changed the infection to hospitalisation ratio. But what we saw last year, when we came to speak to you around about the same time, is that we were met with successive waves of these omicron variants with growth advantage. Whilst we didn't see the same proportion of deaths that we saw in previous waves, it did have a significant impact. So, we've looked at last year and said, 'Okay, what happens if that happens this year, what happens if flu comes at the same time, and what happens if RSV occurs at the same time?' So, we've come up with different scenarios.

I must say it's very difficult to do at the moment given the high level of vaccination and the hybrid immunity of people who have been exposed to the virus. It's quite difficult to do the crystal ball gazing of what the future might be. So, what we've done is made some propositions of, 'This is what a reasonable worst case is, this is what the most likely case might look like'. Brendan may want to come in. It is quite confusing; I've lost all visuals. Brendan may want to come in on some of the work of looking forward.

Thanks, Rob. If I may come in, Chair. For this winter we've produced scenarios of what we think might happen if we see similar pressures to previous seasons around COVID, influenza and pneumonia and bronchiolitis, which is usually caused by the RSV virus—respiratory syncytial virus. And scenarios are based on historical hospital activity data. So, we've looked at data for previous winters. We included pneumonia because it's often caused by flu or other winter viruses that might then lead to bacterial infections, and it's not always recorded as flu in the data even when that was the initial pathogen that caused people to be admitted to hospital.

What those scenarios suggest is that we could be up to between around 14 per cent and 18 per cent of NHS beds occupied by people with these conditions. But it's very uncertain and it's really sensitive to whether we see a resurgence of flu this winter, and whether we see new variants of COVID that might be more transmissible or lead to more severe disease. So, there's huge uncertainty, and I think there's uncertainty around the timing as well, so if we see a COVID and flu peak at the same time, or whether they were to happen in sequence where they would almost compete with each other and you would have maybe a peak of the one virus and then a peak of the other virus.

I think there's also a risk if we have a lot of people co-infected with both viruses, because we do have some data from early in the pandemic that there are worse outcomes if they're infected with flu and COVID at the same time. And, as Rob said, we've been looking at data from places like Australia and Hong Kong, which might give an indication as to what kind of flu season we might see. So, in Australia, they have had a flu season. They've had quite a few cases of flu, but the pressure on hospitals hasn't been as bad as it has been in previous seasons. In terms of Hong Kong, there's not evidence of any hospital admissions at all from flu so far, so Hong Kong looks quite optimistic so far. I think it's still possible that we could see a quieter winter in terms of pressure from these winter viruses. Things like vaccination rates are really important in preventing severe disease, so if we get high COVID and flu vaccine uptake, then this would reduce the risk of a really high-pressure winter for the NHS.

In terms of RSV, RSV seems to have already possibly peaked and gone down again, but there's still a possibility that we might see another peak at some point in the winter. Last season, we saw an early peak in the summer, which stopped, and this year it's even earlier still, so it seems to have gone very much out of sync from where it used to be. It used to be that with RSV you could almost set your watch with when the peak would happen, towards November or December time. RSV doesn't cause a huge amount of pressure across the whole system, but it's particularly in young children that it can cause problems, so potentially causing paediatric ICU admissions. But there is palivizumab, which is an antibody treatment for children who are at high risk of being admitted to hospital with RSV, and I think that's been quite effective as well, so that's helped in terms of reducing the pressure from that.

Thank you, Brendan. We've got some other subject areas to cover. Gareth Davies.

Thank you, Chair, and good morning, everyone. I want to focus on the COVID-19 vaccination programme, if I may, and the evidence that there may be inequalities in the take-up of the COVID-19 vaccinations. What is being done to maximise the uptake of the vaccine so everybody has the best opportunity possible to receive the vaccine? An example of that may be setting up clinics or points as close to people's homes as possible, or encouraging people in socially deprived areas, or people of an ethnic minority. So, what's the plan in terms of trying to maximise that uptake so we're giving the best chance to everyone to receive the vaccine?

I will start, Chair, if that's okay. I think it's a really important question for us at the moment, because given everything else we've just said to the committee today, we are very, very keen that we get high levels of uptake of the booster and that they are equitably provided across society. When I think about equity, I think about all those protected characteristics—ethnicity, gender, age and socioeconomic status. So, it is a really important issue for us. And of course in the previous rounds of vaccination, we've seen extremely high levels of uptake by the Welsh population—very, very high. There's a risk, of course—and Chris Roberts might want to talk about it—that people get tired of this and that the uptake of boosters may not be as high. So, we're doing everything we can to work with communities to provide information, to provide communication, to encourage people to come forwards.

But your question is also right, because it's important that health boards, who are charged with the delivery of the vaccine, getting vaccines into arms, really think carefully about how they provide that service, so that it's as easy as possible for people to get their boosters. We learnt a lot through the previous rounds of vaccination. Of course, we had a vaccine equity group working at a pan-Wales level, and that worked with communities, it worked with faith leaders with regard to a number of models to get to those harder-to-reach communities, I would say. That involved setting up clinics in mosques, setting up pop-up clinics where people could go close to work. So, there are a range of things that have been done through the NHS, and they will continue to be done. I would expect them to be deployed equally for the booster campaign as they were for the previous rounds. I could go into more detail about what the different health boards do, but it really is their responsibility to make the vaccine as easily accessible as possible. And there is something both for the health boards and nationally that we need to do about encouraging people and reassuring people that they should come forward and that it is the best way to protect themselves from serious harm in the winter to come.

Did you want to come in, Chris Roberts? Yes.

Yes, thanks, Chair. Just to pick up on Frank's point there, I think it's important to note from a communications perspective that there's a lot of work that goes on, and I think co-production is really key to that—so, working with those community groups to maximise uptake as far as possible. So, for example, we have a community engagement group that we see, we translate materials into multiple languages, we have online panels with trusted voices, and working with community leaders has been really, really important. And it's also important to add that Public Health Wales will be running their campaign over the autumn, which will focus on both COVID and flu, which will specifically target minority ethnic groups and those from lower socioeconomic groups as well. Also, some social media posts focused on particular risk groups, such as the over-50s and front-line medical staff, for example. So, there has been a lot of activity that has happened, but also a lot of activity is currently planned for the coming months.

I appreciate the responses there. I'll focus on the winter strategy, if I may. Recently, the Welsh NHS Confederation has expressed concerns about the capacity needed to deliver the vaccinations over the winter. So, is there the capacity there to achieve this, and what challenges present themselves in that process?

Well, as I say, the health boards are all working to get that scene into arms. It's early days. We only launched the programme at the beginning of this month. We're aiming to get through everybody who is eligible by Christmas. That is going reasonably well at the moment. As we get into next month, we'll start to see precise statistics about who has been vaccinated and whether we're on track or not.

The issue of capacity, of course, is about people. It's about people to put injections and jabs into arms. There is a problem, of course, a difficulty for health boards—there's no doubt about that—given the pressures that we were just talking about. The system is under a lot of pressure. But, everything I've seen so far suggests that vaccinations are being provided by the health boards, that they are running clinics and running them effectively, and that people are coming forward and getting their boosters. So, it seems to be working at the moment. Obviously, it's something that we keep under constant review. If we do have a resurgence of COVID, then it becomes an increased risk because more health staff, as we talked about earlier, potentially become affected because they're members of the community and so we lose staff in that regard. But, at the moment, there are sufficient staff through health boards. I talk with directors of public health, who often lead the vaccine programmes at local health board level. I was talking with them just last week about their plans, the plans of the different health boards. Everywhere tailors it a little bit differently. There is not one—. Health boards have a responsibility to know their population, to understand their population, to provide the information for their population and to provide the services in the best way. So, you do get slightly different patterns of provision in different places, but by and large—. I believe they're on track, but we'll get more statistics, more precise data on that into next month and then into November.

Thanks for that. It's reassuring to know that things are on track currently. Just finally I want to just take an education tack, if I may. It's just to ask about children and young people. Are they going to see, possibly, another year of disruption in schools and their education if teachers and children have to isolate if they do test positive? Is there any evidence that that may be the case, if the worst comes to the worst?

Maybe Rob might want to just start off on that one.

It's a really important question. COVID has wrought significant harm on the education of children in Wales and other countries, and it's something that we'll need to monitor very carefully, I think. It's a disease that disproportionately impacts older people, but of course younger people have been impacted as well, as well as long COVID, albeit at a slightly lower level than older adults. And, as I said, the cumulative impact on education in Wales has been significant, even during the omicron period.

There is guidance available to schools of what to do for respiratory illnesses. As we said, we don't have a crystal ball—we don't know whether there'll be a flu season, we don't know what will happen with respiratory syncytial virus. We assume we'll have another wave of COVID—we've seen three in eight months, so it's likely that we'll see another one, and, if so, it'll be important that we characterise it to see that it's not having deleterious impacts, or more deleterious impacts, on children's health or their education. Earlier in the pandemic, carbon dioxide monitors were given to schools and there's guidance out there on what good air quality looks like. That's going to be made more difficult this year because of the cost of living—the ability to heat schools and keep adequate ventilation—but there is good guidance out there about what 'good' looks like in terms of rebreathing others' air and how to reduce risks associated with the classroom environment.

Thank you.

Thanks, Gareth. Can I just ask a question on the omicron variant? We know that's more transmissible, but we've seen some evidence of waning vaccine protection. I just wonder, Frank, if you can just talk to us a little bit about any concerns you have about any further variants of potential concern.

Yes, of course. So, the virus evolves. It continues to evolve—that's what viruses do. So, it's trying to find a way around our defences, and it's a global pandemic, so viruses can evolve anywhere in the world. And because of our inter-connectedness, then, as we've seen with previous waves, they will eventually land on our shores. And there are a couple of variants around the world at the moment, which we're watching with considerable interest. There's nothing at the moment that gives me cause for undue alarm, I would say. But there are variants arising all the time that have higher transmissibility. If we look at what's happened in the past, omicron was more transmissible than alpha or delta, and that's why it's gained ascendancy. We were also very lucky, let me say, with omicron, because we had the vaccines, but also it was less pathogenic—it was less dangerous in as much as it tended to affect upper airways rather than the deep lung tissue, where alpha and delta waves have predominantly led to so many problems in the NHS, et cetera.

Now, 'lucky' is good, we were fortunate, but we can't guarantee that a future variant may not be—. My worst scenario, worst fear, would be that a new variant could arise somewhere in the world that is more transmissible, more resistant or can bypass the vaccine and more pathogenic like some of the delta or the alpha variants were. If we were back in that position, then we would really be in a difficult position once again. And in our planning, of course, we've framed that in terms of COVID stable, which is where we are now, and potentially COVID urgent. So, we need to be ready to step up to COVID urgent if something like that was to happen. I really hope it won't, but hope is not a strategy—we have to be ready if that does happen.

If I'm right to say that if there is a new variant, then often, you as health professionals don't know exactly how that particular variant is going to pan out, so it's very difficult then to make judgments. How do you balance that judgment, if you like, in terms of a new variant you know nothing about versus the possibility of restrictions and the removal of people's ability to mix again? How do you balance those two?

Well, this again is about our horizon scanning. The lab scientists are a lot better—they've developed huge skills in identifying in the laboratory whether something is likely to be more transmissible and likely to be more harmful and whether it's likely to evade the vaccines. So, that gives us a little bit of an early indication. But the best canary really is what's happening in other countries. So, in all the waves that we've had so far, we've seen waves growing in other countries and they've come and washed up on our shores. And that's something we really need to maintain as well—that international surveillance so that we can see what's coming and what's likely to be affecting us. We do get a bit of a heads-up from that.

And then, at the UK level, of course, we've seen that things tend to start off in the centre, in England, sometimes in Scotland, and then tend to radiate out. So, watching the pattern of disease across the world and across the rest of the UK is really important to us, but Rob may well want to come in on that because he's been looking at variants for a considerable amount of time.

Yes, since I was in shorts. [Laughter.] There is room for evolution, and there are a handful of variants—second-order omicrons out there that continue to evolve, and there's a global community that's pretty well-connected looking to see whether they'll become dominant. I think it goes back to the point that BA.5 is the dominant one at the moment, and there may be others that have growth advantage over BA.5 in that they manage to get round the immune response that we've collectively gathered. I think there is a positive in that the first vaccine was derived pretty much against the mother strain, and that will continue to be effective. So, I do believe our relationship has changed, but, as Frank said, I think it's pot luck as to whether we'll see more deleterious characteristics of a variant alongside that growth advantage where it's able to infect more people because it can get round the current immune response.

But we need to stress that we know what works, we know the vaccines work, and it's important that you take up the opportunity to have one if you're offered them. They're safe and they're effective. If you're symptomatic—'I've got a head cold today, so I'm at home, rather than give it to you'—there's guidance on that, of what we should do and how we should behave if we have upper respiratory tract infections, and if COVID comes back, we know much more about transmissibility in the environment and we know that good ventilation is really important. And there are things that we can all individually do, like stay at home if you're unwell or wear a well-fitting mask as well if you're in a busy, crowded place, and they're all choices and decisions that we can make as a population that will ultimately impact the way that we experience it as a population. So, we're all still in it together, unfortunately. There is this pandemic; it hasn't gone away, and I suspect until there's the next generation of vaccine that will hopefully impact on COVID once and for all, that we're still with it. We don't know what the future will hold but hopefully the vaccines have made a significant difference in our experience.

Thank you. Rhun ap Iorwerth.

Picking up on your comment there, saying wearing masks is still the sensible thing to do, we have lived for two and a half years with really strong public health messaging, and those public health messages—the frameworks—have been dismantled in a way, gradually, over time. There are some concerns about that, and the WHO suggesting that we should be making sure that strong messages persist on things like mask wearing. Are there plans to try to reintroduce those kinds of public health messages on mask wearing or anything else, or has that boat sailed?

I wonder, Chair, if Chris might want to come in on this, because this is a really important question about communication and how we work. Clearly, we've moved away from legislation on all of this, and I think that's the right thing to do, but how you persuade people to do things that will protect them is really Chris's domain.

Thanks, Frank. It's a good question and, to some extent, people are still following some protective behaviours. So, ONS do produce data fortnightly still that suggest that there are relatively large numbers still, for example, washing their hands, which is really important and shouldn't be forgotten. But you're right—the others have gone down, in terms of things like wearing face masks, for example, and social distancing, and they've come down specifically since the spring, I think, when the regulations changed to guidance in most cases.

The risk communication and behavioural insights sub-group of the technical advisory group that has been supporting Welsh Government did suggest quite recently that the collective response in Wales has been really important, and that should underpin future messaging, and it's also consistent with previous evidence around the role of emergencies. And, I think, building on the successful Keep Wales Safe brand, I think, has also been quite important. The group also looked specifically at the uncertainties that Frank and Rob have both previously mentioned in terms of unpredictability, and that needs to be recognised, I think, in messaging as well, and that will, I think, come out in the autumn and beyond. And things like Rob mentioned, things like isolating the symptomatic actually are really important still, as well as things like ventilation and hand hygiene, and, most importantly, probably, still getting the vaccine.

But the Keep Wales Safe campaign, I think, has continued to share messages throughout the period since the regulations were dropped in the springtime, which is consistent with the COVID stable situation that we've been in since then. But, clearly, if there was a move to COVID urgent required at some point in time, that work could be stepped up, and I think resources are available to do so.

We've always, I guess, applied a two-tier approach as well, which has been one that is at a mass population level and one that is targeted particularly at those who are more vulnerable, so, perhaps immunosuppressed people, or people working in front-line services as well. But planning has gone on over the summer, based on evidence that has been collected, to inform the campaign and work will be rolled out now. I think the next Keep Wales Safe launch will be around mid October and will also follow up the work that Public Health Wales are doing to reinforce the importance of vaccination boosters as well.

Okay. Thanks for that. Just one last question from me, and I think it's to Frank Atherton again. We have a new public health emergency, I guess, in Wales, which would be the cost-of-living crisis and how that is affecting everybody. Has that, in reality, overtaken COVID now, or is it the case that there is potentially a dangerous interplay between the two in that the cost-of-living crisis will hit the most vulnerable hardest and make them more susceptible to harm from COVID and its impacts?

You're absolutely right. It hasn't replaced it, so these are issues that are running in parallel, and one of the difficulties, and it's one that Chris and I sometimes talk about, is the fact that the public bandwidth to manage the complexity of both the COVID emergency and a cost-of-living emergency is quite a difficult thing for the public to deal with. So, I absolutely recognise that.

But there are some tensions between managing COVID and managing the cost-of-living crisis, into which, of course, there's a huge amount of cross-Government effort to think about how we address that. But there are obvious examples. So, Rob was talking about ventilation; we want schools to be well ventilated. Well, how can you ventilate a school well when the energy costs are going through the roof, and the same in people's houses, really? I'm really worried about the risk of older people, and particularly frailer people, turning the notch down on the thermostat because they can't afford to pay fuel bills in the winter. We know that warm houses save lives, they have reduced excess winter mortality over recent years, and we could go into reverse on all of that. The difficulty of choosing healthy foods at a time when food costs are escalating are absolutely there. So, these are public health issues that compound each other, and which are—. Absolutely, we need to find ways to try to manage those across those.

But we shouldn't just assume that COVID is finished, it's gone, it's over and done with. There is a temptation in all of us, because we're sick of the thing, to think that way, but we just need to be a little bit careful about any future resurgences we've talked about. But we absolutely need to start to address those problems, Rhun, that you're mentioning around the cost of living. That's a huge, huge problem for us.

Thank you. Thank you, Chair.

Thank you. I suppose, just to follow up on some questions from Sarah Murphy, just so I'm clear: what further actions can be taken to ensure that hospital-acquired infections are kept to the bare minimum?

It's really important that we do that, and so continuing to make sure that we work and that health boards work to the four-nations IPC guidelines is really important. The deputy CMO Chris Jones with the chief nursing officer recently have written out to the system to remind them of those guidelines. We continue to run training sessions so that people can access training sessions and really understand how the guidelines work. Making absolutely sure that personal protective equipment is accessible—. If you remember back to the early days of the pandemic when it looked like we were very close to running out of PPE—we never actually ran out of PPE, but we came very close. So, making sure that our stocks are adequate is really important.

Are they adequate, the stocks?

I'm assured that they are. There are no particular items that we're in danger of running out of in the near future. So, I think the pipeline is good on that. So, those are the things that we've learnt through the pandemic that reduce hospital transmission and transmission in care homes.

Testing—of course, we have moved away from asymptomatic testing, because the prevalence is so low in the community. But testing symptomatic people still remains important, whether they're patients in hospital or staff in hospital—they still have access to testing if they are symptomatic. And, of course, we are continuing to provide testing for people who are being discharged into care homes as actually we talked about, about people needing to move from hospital back into care homes and making sure that they get tested before they move back out into the care home. So, there is a huge amount of work continuing around that, but it's really drawing on everything that we've learnt throughout the pandemic. Thank you, Chair.

Thank you, Dr Atherton and colleagues; it's been a really helpful session, I think, to us as Members. We really appreciate your time this morning. If I could just ask you to stay with us for a moment while I just deal with the next item of business, if that's okay.

I do move to item 6. We've got a large number of papers to note: correspondence between ourselves and Government Ministers, correspondence with other committees and other stakeholders as well. They're all available there in the public meeting pack as well. So, are Members content to note these papers? Yes. Thank you very much.

In that case, that brings our public meeting to an end, and we'll now go back into private session. Diolch yn fawr.