Health and Social Care Committee

We'll move to item 3. I propose in accordance with Standing Order 17.42 that as a committee we resolve to exclude the public from items 4 and 7 of today's meeting, and for the meeting on 1 February, when we'll be considering our report on the Welsh Government's draft budget. Members agree. We'll be back in public session at 10:45 and we'll now proceed in private.

We move to item 5. Welcome back to the Health and Social Care Committee. This is the first evidence session to inform our work on the chronic conditions inquiry. We've got colleagues from Public Health Wales here this morning. They're going to provide a briefing to us and then there'll be opportunity for Members to ask some questions. So, I wonder if I could thank you both for being here today and ask you to introduce yourselves for the public record.

Bore da a diolch. Thank you and good morning. I'm Jim McManus, I'm the national director of health and well-being for Public Health Wales.

Good morning. Bore da. My name is Zoe Wallace, I'm the director of primary care in Public Health Wales.

Thank you ever so much, both, for being with us this morning. Over to you.

Thank you. We'll do a bit of a double act, if that's okay, Chair. I guess the key points we want to make are really just to provide a bit of a road map to the landscape of long-term conditions, because it's very complicated, but we're coming from a public health perspective, if you like. The first thing to say, really, is that we have significant and ongoing rising prevalence of long-term conditions, most of which are preventable. In the briefing, we talk about 46 per cent of adults living with them. We also talk about the significant rise in diabetes, so that we may have one in 11 people by 2035. If that continues for all long-term conditions, we won't have a sustainable health and care system and it will impact significantly on the workforce and the economy.

Most of these conditions are preventable. My mother had diabetes, my father had a heart condition and my sister has a long-term condition. In Scotland, we call that winning the Scottish lottery, in a way. [Laughter.] And I've had cancer, so the family hit the jackpot. But actually, that was probably preventable for most of us, and in the mining and farming village I grew up in, that was fairly common. The burden on the NHS is seen significantly there. So, we're heading for a significant burden.

There are a number of key drivers. A lot of them are long term. Most long-term conditions have the same risk factors of diet, activity, prosperity, alcohol, tobacco, but there are also short-term things that we can do, such as early intervention, before things become difficult. The only way we're going to get out of this is by moving to a really prevention-focused system where we look at prevention not just in terms of long-term prevention, because that will take a while to deliver, but also in terms of the shorter term work that we can do, both the optimal living with long-term conditions, but also early intervention at the earliest point possible to enable people not to progress, if that is possible.

We talk, in the briefing, about two policy foci. The first is ensuring people with chronic conditions receive care and support to give them the best possible health outcomes. If you're looking for examples of really good practice, an obvious one is HIV. Another really good one is type 1 diabetes, where there's been a lot of work done. There are other good-practice areas you could pick out as well. Ensuring that we make a really systematic shift towards prevention is the second focus, and that needs to be long term. That's longer than parliamentary spans, for example. But there are shorter term things that we can do, as well.

It does raise, I think, the issue of have we got the right configuration of policies and budgets—making physical activity a default activity for all of us in our daily routine, healthy diet, healthy work, because much of our risk in long-term conditions arises during working age, but have we got the right focus for a really early start. You may have seen the report in the last couple of days that, for people who were vaccinated at the age of 12 and 13 for HPV, there are no cases of cervical cancer diagnosis in that population. What a place to be. That is one way of preventing them. You can't vaccine prevent every long-term condition, but there are things that we can do that we should be looking to do.

Can I ask a question on that? That's good from the patient's point of view, but something in me tells me that might be more complicated to put into practice, because then you've got to make sure different health professionals are all in the same location at the same time. That tells me there's a greater resource, and there could be a difficulty for managing that.

I think it's a real challenge, but where they have managed it, you get a concentration of resources, you change the pathway and you have clinics and do a one-stop shop. We've done that with sexual health in many areas of the country, and the clinicians often find it better, because they get more involved in research and activity, they've got better time, they've got a better relationship with patients. So, there are real benefits in it for the system as well. I'm conscious I'm talking a lot, and Zoe may want to get a word in edgeways.

Thank you, Jim. It is very much about putting the patient at the centre, so it's wrapping our services around the individual to maximise their outcomes and improve their health and well-being. If we can reorientate services in a way that we can deliver one-stop shops or integrated services, community-based services, so we're reducing travel times and making it easier for patients and service users to attend clinics, then we are driving down inequalities as well. So, we recognise that long-term conditions cut across all areas of Government, all of our policies, and we need to move to a position where we have health in all our policies, because it’s addressing the wider determinants, education, employment, housing, which all impact on the health and well-being status and long-term conditions, so that’s something that we do need to continue to systematically address.

Thank you. I suppose, then, perhaps digging into my question a bit more, because from what you’ve outlined, in terms of your mother’s experience, what you’re saying is that this is the position that we should get to: person-centred care. But just give me the definition of 'person-centred care'.

So, I'd probably have a different definition than Zoe might use, but my definition—

That's interesting. That's why I asked the question, because I've got my definition, and I wanted to check.

And I think, to be honest, we've probably all got one. Mine is that it starts with the person and looks at what their needs are, sees all of their conditions, not just a condition in silo, and actually works with them to try and do what they can to take charge of their own health, at the same time as actually wrapping around all the necessary services.

Now, that definition comes from my experience of working in HIV and drugs and alcohol for well over 20 years, where it really worked, and of being a trustee and a volunteer in a hospice for longer than I care to remember, and that really works, so that's where I come from. I look at our current district general hospital configuration across the UK, not just in Wales, and we've got a model that deals with condition by condition by condition separately, rather than taking the person and wrapping the clinical pathway around them.

So, when you talked about your mother's experience, that was a definition of person-centred care, but you go along to say there are wider aspects of that as well. And how would your definition, Zoe, of person-centred care change?

It’s very much ensuring that we’re delivering evidence-based medicine to individuals to suit their health conditions and their lifestyles. So, it’s those 'what matters to you' conversations, so that we’re tailoring interventions to maximise that individual’s outcomes and potential to benefit. So, it could be that somebody with a severe lung condition, chronic obstructive pulmonary disease, what matters to them could be to be able to go out to socialise, to a social network in their community, so it’s maximising their benefits to be able to maintain their mobility, whereas for other individuals, it could be completely different. So, it's very much tailoring our evidence-based interventions to maximise the outcomes for individuals, but also then looking at the individual within our whole population, so ensuring that we’re continuing to deliver population improvements at the same time.

Thank you. So, it's kind of a big question, so perhaps just in bullet form, perhaps, or in short, perhaps answer this question. But in terms of delivering person-centred care, what's the big challenge in being able to do that, and how do you overcome the challenges?

So, my take on this would be freeing up clinical time and having enough clinicians able to do it, and then designing the model. One of the things that Zoe and her team are leading is a programme called 'prevention-based health and care', which I think is designed to do that in health and social care. I think a third issue will be having really good clinical pathways that support it. And then you get into things like IT systems that support it.

I think there is a strong role for positive self-management in people with long-term conditions, because that can help people self-manage, but it can also help people identify if things aren’t going well, and can help people become empowered about, for example, looking after themselves with cancer.

So, those would probably be the first planks, but behind that, I think you need to redesign the budget flows in the budget system, and the access and the appointment systems. So, you add all that up together and it becomes a very complex landscape, but the thing is, if you keep your eye on the prize, you can see the end game in sight.

And could you perhaps expand on what research you've done in terms of person-centred care from Public Health Wales, and is there other work that you think that you could do or you would like to do, perhaps if you had more resource?

There's always more. Do you want to kick off?

I'm not familiar with the breadth of work that we've done, but we can go back and check what we've done specifically in the person-centred policy space. But, obviously, there's a wealth of work happening across health and social care more generally in terms of the enabling legislation that we have, moving to person-centred care through our integrated social services and our community resource teams. So, it is very much the direction of travel across Wales.

I suppose, if you're aware of other work that's been done, give us an example somewhere across Wales or wider where there's an example of best practice.

There's a lot of work happening through the regional partnership boards in terms of integrating health and social care, and the evaluations that have come through investments through the integration fund have demonstrated beneficial outcomes for individuals who have had that person-centred approach versus other healthcare pathways. So, we've got resource teams across the board and I know, in the evidence that the Royal College of Physicians have submitted to you, that they cite a number of examples that would be person-centred care delivery through that integrated lens, with a prevention, long-term condition focus, maximising the outcomes for individuals.

Any good examples internationally—in Europe or wider?

I can think of two really good examples from Wales and a few internationally. So, there is some really good work going on from diabetes clinicians in several health boards—in fact, we were sat with them before Christmas, talking about this—where they're changing patient-structured education when people are newly diagnosed with type 2, to make the education fit around people's lives and lifestyles and cultural choices, and understanding patterns. And I think that's really good because the psychological bedrock of living with a long-term condition is really important for us to get right. And that's one of the things that I pick out from that work that's going on.

Another piece of good work, I think, is Cardiff Metropolitan University in terms of its school of sport and health sciences, where they're actually trying to use physical activity with clinical trainees to build the benefits of physical activity and strength-based exercise for people across the spectrum, but they are looking at long-term conditions. I think their model for training health professionals alongside exercise professionals and activity professionals is really good.

There's a really good hospice model from London on heart failure, where they had a physiotherapy-led service that took people with breathlessness and heart failure and actually reduced hospital admissions and kept them managing themselves, and wrapped care around them in their house rather than have them in hospital.

I think there are some really good promising models of multiple disease management coming out of Germany and bits of Spain, where you've got people who are ageing who have got three or four multiple conditions, and they see one main doctor with the rest acting as a consultant. And, again, I think they've taken that from the world of HIV medicine, because the thing about HIV medicine at the minute is that you have an ageing cohort of people who are now in their 50s, 60s, 70s who didn't think they'd still be alive and, of course, they are now getting diseases of old age.

So, there are models that you could take that address both the pathway, the physical care and the psychological aspects of care, and, I think, the behaviour of the clinician in the system, because how we, as health professionals, behave actually partly determines the outcomes of the people we meet.

You mentioned the examples in Germany and Spain. Is that a whole-country approach or are they specific projects just running in parts of the country, or are they part of their national health service?

I'm not sure anybody's got a whole-country approach to this. So, I've seen good examples from Catalunya of some of the management of long-term conditions. I've seen good examples from the University of Navarra and its medical school and nursing school around what they're calling polychronic conditions. I think one of the things that we haven't yet got to grips with across all of mainland Europe and particularly the US is the challenge of long-term conditions as a significant health economic burden, not to mention just the burden of misery it brings for people living with long-term conditions.

I know I've used personal experience, but my own experience of recovery from cancer was that I took up weightlifting, and found myself part of a research study. The conclusion was that people with my type of cancer did much better and got back to work after doing strength-based exercise than people who—. For about three years, there were still people walking with sticks when I was out doing power lifting. Now, I'm not saying—. You know, there are a lot of others there doing that, but that kind of approach of how you help people to get their lives back after that kind of long-term condition can really, really work well. And some of the work around people with arthritis and strength-based conditioning is looking very promising about stopping deterioration. So, there are lots of things we could do.

Interesting. Thank you. So, Sarah Murphy.

Thank you very much, and thank you both for being here today. I'm just going to follow on, because I'm going to ask some questions now about managing multiple chronic conditions and look a bit more at prevention strategies. I also just want to touch on—. You gave some really good international examples there, but particularly with cardiology and heart failure, in the Princess of Wales Hospital, we have one of the leading projects that there is in Europe. They're considered the rock stars, apparently, of cardiology. I was just wondering if you were aware of their project where they've revolutionised—Dr Wong—this process, where patients can have the B-type natriuretic peptide test and they can have their heart scans, tracing, x-rays, blood tests and clinical consultation all in one single hospital visit. Once the heart failure is confirmed, their treatment is started immediately, and then they follow up with a specialist nurse afterwards. So, I think that this is, like I said, leading the way, and I was just wondering if this is a project that you're aware of and if you think that this is something that could be rolled out across Wales.

Personally, I confess this is my fourth month in Wales, so I wasn't aware of it, but it sounds immensely exciting.

I'm familiar with the excellent service in Swansea, having worked in that part of Wales for a period of time. And what's really great about how the service has evolved is the integration across both primary and secondary care. So, the service based in the Princess of Wales Hospital is supported by a number of GPs with special interests. So, we're training our GP community to have a deeper understanding of cardiac conditions, and supporting patients across the whole of the pathway. The other critical element is obviously supporting patients, then, with their rehabilitation. And they've got excellent, as you say, cardiac nursing services, community-based cardiac rehabilitation services that have won prestigious awards in terms of the service delivery, and it is an excellent model that can be scaled and spread across Wales.

And that's one thing that we're not that good at doing in Wales. We have pockets of excellent service across our NHS community, but we're not that good at scaling and spreading, and that's something that we need to get better at in terms of systematising our health and care pathways. We do need to recognise that what works in one area may not easily be transposable to another because of rurality, geography, et cetera, but the principles of ways of working we can scale and spread and adopt.

That's really helpful, thank you, especially as we're just starting out with this inquiry at the moment. I just wanted to ask, then, whether you've undertaken any research on identifying predictable clusters of any chronic conditions, and how can services and prevention strategies be shaped to respond to these particular clusters?

Is that through the prevalence of disease work we were starting?

Quite possibly, yes.

So, we have a programme that is looking at the prevalence of disease, and we're taking long-term conditions one at a time. So, we started with diabetes because it's 10 per cent of the NHS budget; that's a conservative estimate. The programme that we're building has a number of work streams in it, and one of them is improving the care for people who've already got it. We're focusing on type 2, but also type 1. But there's another programme that is looking at early intervention, where we can get early intervention in. And if we get this right, we hope that we will have some data that enables clinicians to take action early, because, you know, we're predicting that so-and-so is pre-diabetic or is heading for diabetes, and intervene early. I think that will enable us to make some move in terms of identifying people with clusters, but I would probably give two caveats. One is that the social conditions are such that actually we need to start now to be preventing 35-year-olds becoming pre-diabetic in 15, 20 years' time. So, that kind of predictive medicine that we may call population health management will only go so far, so we still need the other aspects of prevention.

And I think there's a third thing, which is that there are some populations for whom the expectation that you'll get a chronic condition by the time you're 40, 50, has been normalised, and we have to change that, you know. So, the idea that you work all your life and then you will spend the last years of your life in preventable disability and pain is something that we have to shift, and that's a cultural norm across many parts of the UK and Europe and wider. And so the early intervention will go some way to that, but, actually, what we have to do is change expectations so that people live as well as possible and age as well as possible, if that makes sense. So, it's one of those things where, if you take a public health view, you're looking at the system and the wider aspects of the system. So, all of these services you're not operating optimally and throwing lots of resource at them won't change the cultural expectations that, 'Well, I'm just going to get ill by the time I'm 40', and—

Don't say that.

—and having, you know—. We all know what the life expectancy in parts of Glasgow was like, and that's as much a cultural thing there, I remember, from working on the ground, as it is in parts of Wales.

Sarah, would you mind if I just bring Jack in and I'll come back to you?

No. Of course. Absolutely.

Jack.

Diolch, Cadeirydd, and thanks, Sarah, too. Really good to hear about the experience of Swansea that Sarah mentioned, and, Zoe, you've referred to, but, in your response, you said Wales needs to get better at sharing best practice. You're not the first person to say that in this committee. I think committee tend to agree; I agree. Do you think, then, that we have the appropriate mechanism to share best practice? And, if not, then, what should that look like? Because lots of people have said it to us, but the question is, 'How do we make that happen?' What are your thoughts there?

It's a continuous practice, really. Where we're moving within the health and care system at the moment in terms of moving towards a national approach to healthcare pathways, which is being systematically rolled out across all our health boards, will very much help to move towards standardised pathways of care, right from prevention through primary care into secondary care and back out again. So, there's a significant programme of work happening now over the next two and half, three years in terms of healthcare pathways that should help to standardise some of that approach. Hypothecated funding often helps in terms of helping to scale and spread, and that could be an opportunity, but long-term investment as well.

Okay. Thank you. That's useful.

Thanks, Jack. Sarah.

Thank you very much, Chair. I just wanted to ask a question—you may or may not be able to answer this, but—it's about newborn screening for rare diseases and chronic conditions, life-changing conditions. I'm actually just—. For clarity, my Chair is actually featured in this report—Russell George—on screening particularly for spinal muscular atrophy in the UK, and I was just wondering if you have anything to do with what we screen for in newborns, because obviously in many cases if you can catch it early then people can go on to live much better lives.

Well, we do run screening services in Public Health Wales. What might be better, rather than me trying to recount from memory the list, is perhaps you might like us to write to you and answer that. But I think there's an important point you make about the best start in life, and I think if you go into that inquiry with this mindset not only will you have the mindset of prevention for people who already are at risk or are getting it, but you'll have the mindset of long-term prevention, which will be a real asset. The more we can do to give our children the best start in life—so, educational outcomes, housing, a decent food environment, all the vaccination and screening that they should take—actually that is a massive public health bedrock. And if I may say, one of the many really attractive things about Wales is the policy framework, because it's like a nation that gets it, from this perspective, and wants to do it, and there's an emotional commitment there. We could make that happen.

I agree. That's incredibly helpful, Professor. Thank you very much and thank you, Chair.

Thank you, Sarah. Jack—Jack Sargeant.

Yes. Diolch, Cadeirydd. From what I've read from the written evidence and other work from Public Health Wales and what we've heard this morning from you both, social prescribing is key to some of the problems that we see here. I want to pick up on the funded scheme, the national exercise referral scheme, which is funded by Public Health Wales. The evaluation of the scheme found it to be a cost-effective intervention for the prevention of chronic conditions that also has positive effects on depression and anxiety, but further research found that only 3.3 per cent of the at-risk population are using that scheme. It's not reaching the most deprived groups, and capacity is severely stretched, leading to long waiting times. So, it's a big concern if you're only reaching a relatively small number but capacity is extremely overstretched. I believe you are undertaking a review of that scheme. Are there any more details you can share with the committee today on what might the outcome be to that, or how some of these schemes could be supported, maybe, in a different way, to reach those most important people in deprived communities, to shorten waiting times and so on?

There's a lot of work going on, and it might be better if we write to you or indeed have a separate conversation. If there's any detail you'd like, we'd happily give it. I think the headlines I would give would be that, as you said, it's effective, we haven't got enough of it, and there are inequalities in take-up and inequalities in access. Some of those are cultural but some of those are—. Some people don't want to. We have, I think, work to do if we really want to move to a strategic shift to prevention to take what is another example of Welsh good practice, because it's doing better than it is in some other countries, let's be honest—I will not be let back into England now, but it really is doing better than other countries—and how we actually really seize that in a genuine prevention-based approach. Sorry, Zoe, I don't know if you want to—.

Yes, so at Public Health Wales we provide the national co-ordination for the service, so it is delivered in all of our 22 local authorities across Wales, but, as Jim says, there is variation in terms of the capacity and the waiting lists, and so that's something that we need to address. Often, it comes down to the conversation that the clinician will have with the individual at the point of referral, in terms of those teachable moments to portray the benefits of the programme. We know it's a very strong evidence base; it does produce the outcomes that we're looking for.

So, there are multiple points that we need to focus on to ensure we maximise the benefits of the exercise referral service. One of the things that we have been doing in Public Health Wales over the last 12 months is changing the referral process to make it a lot more streamlined through an electronic mechanism. The majority of the referrals are generated from general practice, and so we now have an electronic referral system into the nurse database, which also then provides— critically—the feedback loop back into general practice, so the GP, the nurse, knows the outcomes of that individual who has been through that course of treatment. And courses of treatment through the exercise programme are not necessarily just one cycle. It could be that an individual needs multiple cycles as well, so it's a long-term investment programme, like all of our patient education programmes, in terms of how we can empower patients to take more self-control of the management of their conditions.

Thank you. I think the welcome part of that is the move to an electronic referral system, because that's much more beneficial. I think it would be good for the committee to perhaps have some further detail on that.

Sure.

Perhaps a breakdown as well of the differences. Can you do it by local authority? Is that possible?

Yes.

Because it would be interesting to see if it is a north Wales problem, is it a south Wales—. I think it would help our inquiry—

That's helpful, yes.

—work. I want to move on to individuals who experience quite severe mental illness and problems with their mental well-being. I think the studies out there show, in both ways, that, if you suffer severely with mental illness, you may have problems with chronic conditions. Equally, it's the opposite way around—if you suffer physically, you may with mental illness. You touched on the patient at the centre. I understand you won't be able to speak directly to a patient experience, but I just wanted to give some sort of background. I know of a constituent who suffers severely with mental well-being, mental illness—real serious stuff. They also suffer physically. Fibromyalgia is one of the things that they have; there are multiple conditions there. And they tell me quite often that they're told by experts in the field—who do a fantastic job day in, day out—that there simply aren't the facilities or time for staff to provide the care that they need, both physically and mentally.

Is that something—? I'm sure my constituent can't be the only one in Wales. Is that a problem that we need to do a bit more work on? And what does that look like from your view? You're much more of the expert than I am; I'm just trying to share some of the experience, noting that, the individual, you wouldn't be able to respond to that. But I'm pretty sure they're not the only person.

I would probably start by saying that if you're taking this kind of systems view—. And the best thing this committee could do is take a view of the system and look at is the system generating more illness or is the system generating more health, and how do we do that and where are the bits. Because I think you are ideally placed to do that from your position.

I'd say the following things about mental health and long-term conditions. Once you get a long-term condition—a physical long-term condition—there is, for many people, a slide into mental ill health, for a variety of reasons. And some of them are because of pain, depression, coping, inability to move. And we've seen this, I think, with long COVID, where the good long COVID clinics have really done well in helping people cope with the psychological issues from their physical health experience, and the ones that aren't doing so well, actually, are not helping people manage and have the resilience to manage that.

From the other side, conversely, what you get with an awful lot of people who have mental ill health, and sustained and severe mental ill health, is you get physical health problems. Now, some of that is just because mental ill health does take a toll on your cardiovascular health. But it may also be because they can't get services, or physical health services aren't used to coping with them.

So, there are things you can do, and really good physical health checks for people with severe mental ill health, and really good basic physical services—eye health, for example, dental health, smoking, cardiovascular health for every person with severe mental ill health—can really help; and, at the other end, helping people to cope with and live with long-term conditions. So, I'm a psychologist by background and, at the risk of being drummed out of the profession, one of the jokes I tell is: How many health psychologists does it take to change a light bulb? Answer: none, we form a support group called 'coping with darkness'. And then I grab my coat very quickly. [Laughter.]

But, actually, helping people to cope with long-term conditions and having worked in this field, it's the two that need to happen in balance. So, we need many more mental health clinicians really trained up in physical health, and many more physical health physicians trained up in mental health. And I think the place to start is primary care. Not by burdening primary care again, but by actually funding and supporting primary care to do the basics, mental and physical, for everybody. And then wrapping around this infrastructure of community support and self-support groups, the other services, and connection. And I think there's also a lot of—. Isolation takes its toll as well. Sorry, I've talked a lot.

Do you mind if I bring Mabon in? You wanted to come in, then I'll come back.

Dwi'n mynd i siarad yn Gymraeg. Ar y pwynt yna, un o'r cyflyrau cronig mwyaf cyffredin ydy cyflyrau cronig yn ymwneud ag iechyd meddwl. Dŷn ni'n gwybod hynny yn ystadegol. Felly, ar y pwynt rydych chi wedi'i wneud yn fanna, dwi eisiau deall ydy'r cyflwr cronig iechyd meddwl yn dod yn sgil cyflwr cronig corfforol arall. Ai symptom o rywbeth arall ydy o? Neu ydy o’n rhywbeth sydd yn sefyll ar ei ben ei hun fel cyflwr cronig, felly?

My apologies that my Welsh isn't yet good enough to speak in Welsh, but it's all of the above. So, quite often, when you have someone who has severe pain that isn't being managed, that can turn into clinical depression or anxiety. And, conversely, someone who has severe depression, they may not engage with the physical health services if they have a physical condition. So, there can be an almost pathway link between one and the other.

There is also some evidence that people with particular mental health conditions are far more at risk of developing cardiovascular disease, because stress, because of what it does to your biochemistry, can lead directly to cardiovascular disease. And it's different for different people. So, I could point you to somebody I worked with who had both severe depression and a significant heroin addiction, and is now working as a furniture designer. We tackled the depression first, and then tackled the heroin addiction through the multiple services, and he's now a peer supporter. But there are other people who have different pathways, and I think it goes back to the idea of being person centred. It's having enough time to understand what's going on for the person, particularly with mental health.

Most people with a long-term condition will find their resilience is zapped, and the issue is: does that go into diagnosable, treatable, significant mental illness? And, similarly, most people with mental health will find they've got physical health problems as well. There's a concept in public health called 'the syndemic', the idea that you have different waves of illnesses come together and it creates something that's greater than the sum of their parts. Now, we used that during COVID to talk about the impact of COVID. Actually, long-term conditions, we need to analyse through that syndemic lens, that you don't just get a heart condition, you get a whole load of other things alongside it—maybe an inability to work because of mental health. And if you took that lens, I think we'd get a different result. My apologies for being quite so long-winded about that.

Have you finished your line of questioning, Jack?

Just to make one point, Chair. I think this is an important point, really. Jim, you said in response that some professionals, they're not used to coping with certain patients because of the severeness of their mental health problem. That struck me, because that's exactly the conversation I had with the parent of the individual who was suffering with severe mental health. It strikes me that this could be an important line in our inquiry, because they can't be the only ones; there's got to be lots of people out there, where they have severe mental illness but their physical needs aren't being met. And it's not against the professionals who are trying to help; they simply don't have that experience, education, I don't know what that might be. But if you're saying that as well, it seems to be that there's more to this line of questioning that perhaps we can explore further with other witnesses. But I don't want to take too much time, I just wanted to put that on the record.

Thank you, Jack. This is a really helpful session. In terms of time, we've got three subject areas that we want to cover, so that gives us about 10 minutes for each subject area. So, Joyce is doing one and then Mabon and then Gareth, so we've got 10 minutes for each, if the Members can manage that as well. Joyce—Joyce Watson.

I'm going to look at health inequalities and what causes them and how they're dealt with, I suppose. Of course, health inequalities are subject to many things, but the outcome can be multiple chronic conditions. So, poverty, of course, is a big factor, and it's a really big factor at the moment, and you talked about—. Let's just take diabetes at the centre of that: poor diet right at the start and during a lifetime, because the food is cheaper; the inability, perhaps, to be able to even cook your food, so you use a microwave instead of an oven, and pile up salt and sugar. So, what role, in that particular circumstance, would you see yourselves as having?

Well, there's a number of things that we do as an organisation, and if I might preface this by saying that I think the fact you're taking a public health lens to this is really significant, because you're looking at the determinants and the inequalities, and sometimes, with long-term conditions, we go down a route where we only look at one part of it.

So, I think there are several things. I think the first thing is the bedrock, is the policy framework that enables everybody to have good access to healthy food, to understand and be able to prepare that, to be able to put food on the table that is healthy, and not for your food access to be only unhealthy food. I think the second important piece of bedrock is that you need to have good housing, you need to have decent income, because if people's disposable income is being spent on energy inefficient housing, you can't afford decent food—a decent wage. All of these things are the fundamental bedrock conditions for people to thrive and flourish across life, and giving that to everybody should be the first thing.

Then, I think what we have to do is start by making sure that every child gets the best start in life and grows up, so you're taking a long-term approach. We need to do work on our food environment. So, the chief executive of Diabetes UK, who's just stood down, will tell you that, on average, the food choices that we're offered in the high street will encourage us to take in four times the amount of calories that we need. And while physical activity is vital in and of its own right, good diet is almost more important, because you can't out-run, you can't out-weightlift a poor diet. So, the choices of food, the amount of sugar that we're taking in—. And the rise in liver disease in younger people is partly due to alcohol, but is also partly—. So, there's a rise in non-alcoholic fatty liver disease that is being seen more and more in younger people, partly because of the amount of sugar that people are consuming, and that's why we're seeing so many people become pre-diabetic in the formulation.

Now, the most effective things to do there to reduce inequalities are policy and legislation at that level, in terms of the food environment. Then, when you come down the scale to the individual level, enabling people to have the income to buy good food, and then you get to the point where, if you create the environment, it's easier for people to choose healthy eating. If all you can get in a shop is stuff that's packed with sugar, fat and salt, you're not going to have a healthy diet.

I've seen some really good examples of dieticians based in healthcare settings—really inspired people. But then you don't really hear much about them, is the point I'm going to make, in terms of a healthcare pathway. But the importance of good diet, we all understand—we do, in this room; whether we adhere to it is another matter. But there are an awful lot of people who don't understand it, and haven't got time to understand it. So, how are we going to bring that understanding to the people who are in poverty, who are just struggling every single day with paying their bills, to understanding good diet, and making choices that are affordable, if their minds and experience and education allowed them to do that?

So, I would say that there are some really good examples of community projects, and there are one or two in Wales—food collaboratives, food co-operatives, people growing their own. There's a Welsh model that is moving away from foodbanks to food co-operatives and stores. That's really promising. But the fundamental problem is that, as long as our food supply remains less than optimally healthy, and good, healthy food is unaffordable, whatever we do here will be like picking up a bucket to empty a tsunami. That's a rubbish analogy, isn't it? [Laughter.] So, from a public health approach, I'd say you need the balance of the clinical, you also need the balance of legislation and policy, and you need really good education that educates people for life.

And it is taking that life-course approach. So, it's the role of our midwives, our health visitors, right through to our school-based nurses, our healthy school schemes, through to district nursing services. So, it's having that focus on the core fundamentals of good nutrition, good exercise, to build and maintain a healthy lifestyle.

I want to go down another trajectory here. We've had evidence that tells us that black, Asian and minority ethnic backgrounds are sometimes more susceptible to certain health conditions than others. How do we help and support that group?

So, about 96 per cent of schools have signed up for our healthy school programme, I think—I might have got that wrong, I haven't checked it in about a week or two—and we've got all our other programmes in Public Health Wales and the local programmes. So, the first thing you have to do is make those programmes accessible to people from all cultures and make them culturally sensitive, and understand the—. The healthy eating plate, for example, in some of its generations, feels a bit white British. Where is the Asian healthy eating plate? Where is the Polish, where is the Czechoslovakian, the Romanian healthy eating plate? Where is the Nigerian healthy eating plate?

And I think the second thing is about working through community-based groups, and working through people's own communities, and looking at the assets in local communities. During COVID, there was a lot of work that went on with all sorts of community groups in Wales—from faith communities to social communities and sports groups. They can be very powerful assets in supporting and enabling people to act when the food supply system is against them being healthy, and helping people to understand what they can do. And if you can do that at the same time as enabling clinicians to have the right tools to support people from across the breadth of rich diversity we have, you'll get better results. Sometimes we focus on, 'Here's the solution' in health policy, or public health policy, whereas in actual fact you have to do a number of different things to shift the system to create the conditions for better health.

Okay. No easy answers.

But multiple answers that we could use, if we're prepared to take the timescale and maybe create the jigsaw, which I think you're ideally qualified as a committee to do.

Thank you. We'll have to move on to the next section. Thank you, both. Mabon ap Gwynfor.

Diolch, Gadeirydd. Un dyfyniad i ddechrau. Yn ôl yn 2019, ddaru Sophie Howe, Comisiynydd Cenedlaethau'r Dyfodol Cymru bryd hynny, ddweud, ac mae'r dyfyniad yn Saesneg:

'Over 50% of the Welsh Government budget is allocated to health spending'—

rydym ni'n gwybod bod hynna'n gywir—

'with an emphasis on acute services rather than preventative approaches yet we still have some of the worst health and care statistics in Europe'.

Felly, cyhuddiad bryd hynny bod yna ddim digon o adnoddau, cyllideb a fframwaith polisi yn mynd tuag at yr elfen ataliol. Ydych chi'n meddwl bod hynna yn gywir yng Nghymru heddiw?

I would say 'yes'. It's not from lack of intention. This isn't a criticism, but if you really want to move us to primary prevention, there are a number of things we need to do, and the first is we need to have a settled will that this is where we want to be in 20 years' time, and then articulate the route map of where we start today. From that then comes looking at the budgets and the approach of the things that we need to do, and what timescale they will yield benefits in. Our NHS is trying to do its best in very difficult circumstances, but at some point what we have to do is start shifting resource towards primary care to provide good basic primary care that intervenes early and stops people needing hospitals.

That also needs investment in social care. Seeing what local authorities do is vital in terms of primary prevention, in terms of housing quality, physical activity infrastructure, the public realm, clean air, good education outcomes. Those are all vital, and I think the challenge is that you look at it and you think, 'That's enormous', but if you start to lay it out and then think about what you can do in different timescales—. One of the things about Wales is there is the future generations Act, there is this look towards policy, and there are tools that you can use to plan back.

I would say that if any of the nations of the UK could really make primary care happen as a shift, it is us, because of that mindset. What we need to do is work out where the money flows, the policy flows, the systems go and how we deal in the short term with the significant glut of work. And I realise I'm talking very helicopter level on this, but I think that can be done. The issue is then how you turn that into a road map for action, where you can work out are you on track.

In Public Health Wales, we have a long-term strategy to 2036 where we're actually working to say, 'We'll deliver this by 2026, we'll deliver this by 2027', and some of us are starting to use the reverse planning methods to work that out. Finland did it. It took them 20 years, but they went from a nation with some of the highest heart disease in Europe to one of the best. So, I believe it is possible. I think it's a case of how we get there and it's a combination of policy, budgeting that follows that policy, service infrastructure that sees change, and working out what we can do in six months.

So, in six months' time, you could make a significant difference to A&E attendances if we got the right investment in primary care for diabetes, say. You could make a difference. In a year, you'd make more of a difference. In 10 years, you could shift the food environment.

Mi wnaf i glymu dau gwestiwn yn un er mwyn mynd ymlaen efo'r amser. O ran y rhaglenni ataliol sydd gennym ni, ydy'r rhaglenni ataliol yn effeithiol, ydych chi'n meddwl? Ydyn nhw o'r ansawdd digonol ar gyfer anghenion pobl Cymru? A hefyd, ydy'r gweithlu wedi'i hyfforddi yn ddigon da er mwyn darparu rhaglen ataliol gynhwysfawr?

I'd say 'yes'. We've just published an evaluation of the all-Wales diabetes prevention programme, which you know more about, Zoe. That's very effective. The national exercise referral scheme is effective.

On some of our primary prevention policies, for example the tobacco control strategy, we've had a long-term lead-in to try and reduce the levels of smoking in Wales, with the ambition of reaching a smoke-free Wales by 2030. It's 13 per cent now across Wales in terms of adult smokers, but we know that there is significant variation in that figure across Wales, linked to deprivation. But we've had an unwavering tobacco policy that, progressively over time, is moving us towards that target. We have the enabling services, the national Help Me Quit service, which will provide evidence-based support to individuals to help them on their journey to being tobacco free.

Similarly, the recent policy that we have around obesity, the 'Healthy Weight: Healthy Wales' strategy, which came out in 2018, is a 10-year strategy, and again, it's that long lead-in timescale often required to change some of our pathways, to change behaviours to lead to outcomes. And we recognise, as you'll see from the prevalence of disease report, that a number of our indicators are getting worse since COVID. So, it's that recognition that it'll take a long time to turn the curve before we start seeing improvements in some of our prevalence figures across Wales. But it's a concerted effort that we need to join up across the whole of society, because the NHS can't do primary prevention alone. As Jim said, it's the role of local government, the local authority and the critical contribution that third sector partners provide. And we have the enabling frameworks in place in Wales through our public services boards across all of our 22 local authorities to focus on prevention and the well-being of the populations that they serve.

I think the reason that the example Zoe gave about tobacco is so important is because it shows the need for legislation as well as action by services and individuals; you need them both in order to get that. There's a concept in public health that we often talk about—the area under the curve. So, if you look at the decline in smoking-based diseases, we're still not there, we've still got work to do on all of these things. The gains under the curve, year on year, add up massively, but only if you've got the right legislation and the right services that are effective and funded in good enough numbers for people to access them, and they address the inequalities of people accessing them, as well. You get those four things right and you can begin to shift the population.

Diolch.

Thank you. You mentioned work in Finland with regard to the turnaround in heart disease. It'd be interesting to have a bit more information about that, either in written form, or if you've got something; if you've got a short summary that would be useful. Is there anything you can say now, briefly?

It's one of the classic examples. In fact, when I was training many years ago, we were told about how the Finns had gone from having the worst rates of heart disease in Europe, because of the diet, to actually one of the best areas in heart disease in Europe. They did a series—

One of the worst rates because of their diet, or—?

Yes. There were some things in their diet, particularly fish fat, that were particularly unhelpful and unhealthy. They began to shift some of that and it took them about 20 years, if I recall rightly. And it was policy, funding, budgets and a whole range of things. But it was beginning to harm their economy and they were beginning to see it harm the cost of services. There is a lovely little short paper somewhere that I will dig out and send to you, but I think they are a really good example of if a nation sets its mind to achieve something, it can achieve it.

I'd like to see that paper. I think that would be interesting. Thank you very much. Gareth Davies.

Thank you, Chair. Thank you for joining us this morning. I want to touch on secondary and tertiary care. Are there any examples of good practice in secondary and tertiary care and what would they be?

Do you mean care specifically, or prevention specifically?

More generally, I'd say, rather than homing in on one specific area.

There are lots. Where do we start? While Zoe's thinking, I'm going to pick some of the things I've been struck by. I've been struck by some of the diabetes care I've seen in secondary care, where they're really trying to get people onto the right types of monitor, and out from hospital care, back into the community and being managed by community physicians. But all of those are dependent on primary care. There are some really good examples of complex cancer pathways that I've seen, but, again, in all of them, secondary and tertiary services are working hand in glove with primary care and social care, if you like. Perhaps the thing that strikes me most about Wales is where there are these integrated care pathways—I haven't seen the Swansea model, and I'm going to make a beeline to learn about that model—when we're at our best, there is a really good understanding of what secondary care can do and how it can hand over back into the community to stop people coming back in. I've seen some really promising practice there that is helping people not cycle back through hospitals. But I'd have to go and get the details for you.

Some of it's in terms of the clinical risk factors and the systematic focus on regular monitoring of risk factors through primary care—so, blood pressure checks, glucose monitoring, cholesterol monitoring, so that we can identify early any markers of potential disease and then intervene. So, it's good general practice, good primary care, having the time and capacity to undertake that activity. There are some good examples of secondary interventions in the education and rehabilitation space. Swansea Bay has got an excellent pulmonary rehabilitation service that is community based, working hand in glove with the third sector. Our third sector is critical in terms of patient education, patient empowerment. There's a wealth of services across Wales that we could point you in the direction of—British Heart Foundation, the Stroke Association—that are experts in their fields to support patients to manage their long-term condition.

Thanks for that good answer. But in terms of looking after people with chronic conditions to maintain mobility and prevent frailty, there's obviously a reliance on allied health professionals. Do you think that more investment and looking into how we can increase the workforce and provision in allied health professions can meet the demand and keep people well as long as can be achieved, really? Which key areas do you see there as being where patients would benefit the most, whether it's, I don't know, physiotherapy or occupational therapy? Which areas do you think, specifically, would keep people well for longer?

All of them, if we're honest. The contribution the allied health professionals bring to health and well-being is significant, through the individual condition rehabilitation programmes that I've mentioned, or through our community-based services, whether that's supporting hospital discharge or some of our frailty services. It's the collective contribution, so it's no one therapist working in isolation. It's a combination of the physiotherapist for movement, with the dietician to maximise nutrition, to the occupational therapist in terms of those home adaptations, personal adaptations, to really focus on the individual. It comes back to person-centred care and maximising individual outcomes.

We've had an increasing number of allied health professionals that have reorientated their care from hospital provision to primary and community-based services. Through the primary care model for Wales that we've been working to deliver since 2018, it's very much to rebalance the provision of community-based nursing and therapy services closer to home into our communities and working very closely with our general practice, pharmacists, et cetera, through primary care clusters across Wales. So, we’ve got an increasing number of healthcare professionals now being based in general practice, so you may well see a physiotherapist or a pharmacist, or another physician other than a nurse or a GP in terms of your chronic condition management, depending on your presenting needs, et cetera. And so, it is a whole primary care multidisciplinary team approach to manage chronic conditions in the community.

And just finally, how much is COVID-19 proving now to be a barrier to achieving good practice towards people with chronic conditions? Because, obviously, during the pandemic, it was seen as a barrier, and largely in society, we’ve forgotten about it, and moved on, but, obviously, in health settings, it’s still prevalent and statistics show that it’s still prevalent in certain cases. So, how much of a barrier is the COVID-19 pandemic still within those practices, and is it still something that professionals are aware of?

I’d probably start by saying I think it still impacts in a number of ways, firstly because the enduring impact of long COVID is a massive burden that we’re still learning about and that creates more burden on our healthcare system. Secondly, because people are still getting infected, you’ve got quite a number of NHS staff who are still getting infected, particularly people in primary care and allied health professionals as well as nurses in hospitals. I think the third impact is the workforce are tired and exhausted. I’ve done some trauma training with homecare and care home staff after COVID, and we’ve all got a story to tell about the work in COVID and a lot of us, actually, haven’t been able to get fully back or fully out of it, because it’s still around. I think that burden can sometimes sap your energy from finding really creative ways of doing the things you really want to do, and if you want to find joy in your work and you can’t because of the burden that COVID is still having, it becomes, I think, quite difficult for you. So, I think we underestimate the burden that COVID is still creating for our staff and for our patients and for our workforce as a whole.

We’ve been doing work to support people on secondary care waiting lists in terms of how they can optimise their health and well-being whilst they’re on waiting lists, and we’ve recently launched a new website called ‘Add to your Life’, which is being promoted through hospital appointment letters and referral letters, so that individuals can go through a sort of self-directed website process to look at the support in their local community. It could be social prescribing, it could be community-based activities, where they can maximise opportunities around their own health and well-being so their health is optimised before they go into those programmes of treatment. So, that’s something that we will be evaluating. It’s come with a strong evidence base and some previous work as well, but it’s always looking at these opportunities in terms of how you can take those intervention moments to improve health and well-being.

Thank you very much.

Thank you, Gareth. What key recommendations do you think that we as a committee should be making to the Welsh Government in the areas that we’ve spoken about this morning?

Focus on understanding the complexity of the system and the fact you need to do multiple different things, with two main aims: one is preventing—primary, secondary and tertiary prevention of long-term conditions; and secondly, enabling people with long-term conditions to really live as well as possible. I think the third recommendation would be to look at policy, look at system structures, look at budget configurations to align with those policy outcomes, because if we don’t, I think our health and care system will be financially unsustainable by 2040, 2050, because all that's happening is that long-term conditions are going up and up and up, across all developed countries, not just Wales, and certainly not just the UK. But we could be the nation that turns that curve with a systemic approach to prevention.

The three goals, the three areas, that you spoke about there were quite general principles that the Government should follow. Is there anything that you think is more specific that we could recommend?

A few hundred. This might sound general, but there is something about understanding the complex of things you need to do to get the right outcome. So, you need the right policy and the right funding to get a healthy diet—that's one thing.

And how do you do that?

I think that's at least a 10-year shift with a whole load of actions. There's a really good model in public health that we call 'layers of public health', where you might start at the biological, then you end up at the environmental. If you take smoking, you might intervene to give somebody nicotine replacement therapy, and you also do a smoking ban, and you provide a smoking service, and you have 'no smoking' signs in buildings like this—you need all of those in order to shift the population's health. And there is no one solution for a number of these things. So, I would say 'Get people across the system sitting down, working, and really produce the programme plans that will deliver all of these things together, and really make them sit down and think about, you know, "Why does transport policy make it easier or less easy for people to do routine physical activity, for example?"' Now, that's a long-term thing, but if you're looking for short-term things, I would say, 'Invest more in primary care having the capacity to intervene early in the risk factors'. If I had to pick one thing that, actually, is just as complex but is probably more tangible, it's invest more in primary care, to be able to really drill down on the risk factors. If I could have a third: really get to grips with the third sector and what the third sector can deliver, because they are massively important in long-term conditions for us. I'm happy to try and put that in something that sounds more like English or, indeed, Welsh, than me going off on one, perhaps. But what would you—?

As Jim said, there's no magic bullet, and it's that relentless focus on prevention. So, shifting our system from treating disease to preventing disease takes long-term investment, patient education, enabling environmental factors, but it is that shift from the focus of our resource on secondary care into primary and community care, and the scope that primary and community care, wrapping around individuals, can bring.

And just, perhaps, one other question to finish with. We had budget scrutiny with the Minister the other week, and there's an issue of resource in the health service, and resource is going to bring down the waiting lists, and perhaps less focus on prevention. So, if we put aside resource in terms of the financial resource that's needed, what recommendations could we make that don't cost anything?

One thing, as we said, beyond the health service, is health in all policies, so it's all parts of Government doing their most to address ill health in our communities, to address inequalities, address those wider determinants that we've spoken about. The Welsh Government is out to consultation at the moment on the health impact assessment regulations, and, again, it's those enabling factors that we're designing in our built environment, and we're creating the commercial determinants and the food environment, to all maximise the opportunity to make it the easiest pathway possible for an individual to maintain a healthy lifestyle across their life course.

And, Jim, you said you had a few hundred that you could talk about a moment ago in terms of recommendations, but perhaps give us some that don't cost anything.

Well, if I went to the—Zoe gets my vote—other end, look at where you can get more value out of existing spend for interventions. So, there are things like the types of medication that we're using—switch to generics. In diabetes, we've talked a lot with primary care clinicians about medication that is renoprotective and not just controls blood sugar, because, although it might be a wee bit expensive, the pay-off two, three years' down the line when people don't get complications is significant. That wouldn't cost any more, because the budgets are already there, but would save—. It will get swallowed up in the budgets, so nobody's going to cash a cheque, but it would help you get more value from the existing budget. And if I might pick an HIV example, most people with HIV have shifted from very branded drugs—apart from where the patent is still there—to generic drugs, which are about £100 less per month, with good tolerance and good outcomes. So, there's a whole branch of health economics and a whole branch of healthcare, public health that works on this area. And it is possible to do things like medication switches, pathways, medication optimisation, different procedures, and drive that value out. And if you do those both, you'll be working at either end.

That's very good—really helpful. Is there anything else you want to add to this session today at all?

Just thank you very, very much.

Well, thank you very much for being here, and for your advanced paper as well. You've been very helpful in offering some other information as well; we've made a note of that ourselves, so we'll send you that. Particularly on that last question, if you feel that there are other areas that can support prevention that don't have a financial cost, or bring actually a financial saving, I think we as a committee would be interested in hearing about those areas or examples, because that's something that we can dig into further. I think we'll have great interest in that. Diolch yn fawr iawn, thank you very much for being with us. We'll send you a copy of the transcript so you can review that as well. Thank you ever so much—it's been a really helpful session today. Thank you.

Lovely. Thank you for your time.

Diolch yn fawr iawn.

I move to item 6. There are a couple of papers to note in regard to correspondence between the committee here and the Minister for health and both her deputies in response to the general scrutiny session on 8 November last year. So, are we happy to note those two papers? Great. In that case, that brings our public session to an end today. Diolch yn fawr iawn.