Health and Social Care Committee

I'm Rowena Christmas. I'm a GP in a small practice in Monmouthshire, and I'm chair of the Royal College of General Practitioners Cymru Wales.

Lisa Turnbull, and I'm from the Royal College of Nursing in Wales, the head of policy.

Lovely, thank you. And Dr Williams.

I'm Dr Hilary Williams. I'm the lead for the Royal College of Physicians in Wales and an oncologist practising at Velindre. Unfortunately, we've got a clinic crisis this morning with staff off, so I'm going to be here for half an hour or so, if that's okay.

Well, no, we understand if there are pressures, so thank you for being with us. Can I just check, Dr Hilary, that the Welsh translation is okay for you? If I could ask the translators to say something.

[TRANSLATION: 'Testing interpretation. Testing. One, two. If you can hear that, can you give us a thumbs up?']

Could you hear that?

No.

No, okay. We'll probably just need to—. Is there a breakout room of some sort we can take Dr Hilary to? We'll try and help with this. We did a test earlier on, unfortunately, but I'm just conscious that you won't hear any questions in Wales, Dr Hilary. Okay, right. So, if I can perhaps ask the witnesses to start with: can you define what 'person-centred care' means, or how do you define that? Dr Christmas.

Yes. I guess 'person-centred care' is what we try very much to achieve in primary care, in general practice. So, the doctor has got their expertise as from their medical degree and their further training, but you see the patient as the expert in their own condition. So, you're two experts trying to meet common ground. And that enables us to have a sort of more holistic approach; we can see the patient as a person within their environment, looking at their social factors and their environmental factors. And we know that if we can get this right, involve family and friends and carers, get the whole picture, that's going to decrease costs for the NHS, which is important, but equally, it's going to significantly increase patient satisfaction, and we're going to get a better outcome in the long run, so it's a good thing.

Okay, thank you. Any other definitions from Dr Hilary or Lisa Turnbull?

Just to add: I think it's useful to say from the perspective of nursing as a profession, that kind of holistic approach to examining the person and the environment, and caring for the person, I think is quite central to the nursing tradition, because nursing is about caring for a person, as opposed to specific interventions. So, it does fit quite naturally, that approach, I think, with the clinical approach of nursing as a profession. I think that's worth mentioning, and I think possibly also the fact that if you then take those principles from the individual clinician-patient relationship, it's also about designing the services to make sure that they obviously facilitate that approach.

So, for you, what are the key challenges in terms of delivering patient-centred care, and how do you overcome some of those challenges?

I think that what I would say initially—and I think it's very relevant to this inquiry—is that the national health service, historically, I would say, and still to a certain extent, is set up to treat specific conditions, often specific conditions maybe that are regarded as or expected to be temporary, that can be cured in an intervention—so, I mean like a 'let's fix a broken leg' type thing. Whereas, the whole nature of what we're discussing here, people with chronic conditions, it's effectively life. Very few people are not going to fall within this category, actually, during the course of their lifespan, so this is about caring for people. So, I suppose what I would say the barriers to that are are probably the barriers that we will explore in further questions, which are about caring for people holistically over a span of their life, rather than intervening, doing something, prescribing something, getting out.

Sure, thank you.

Could I add something there?

Yes. I'll come to you next, Dr Williams, yes. Dr Christmas.

One of the things that makes person-centred care much easier is if you've got some continuity of care, if you've built up a relationship with patients. So, if I've got somebody and I'm trying to manage their heart failure, but I've seen them six months earlier and we've discussed their diabetes in detail, you keep that knowledge in your head, and also you know that their granny is not very well and they're having to look after them and travel to Cardiff three times a week—all of that information becomes incredibly important in how you manage the patient, and it develops a trust. Patients with longer term relationships with their doctors are more likely to follow advice. They're more likely to challenge their doctor if they disagree. They're more likely to take their medication. That overarching leads to much less likely to need emergency services, much less likely to be referred to hospital or be admitted. So, again, it decreases costs, keeps care closer to home, gives the patient the outcome that works for them and their family. So, relationship-based care is absolutely key to managing chronic conditions well.

I'll come back to you in a second. I'll bring in Dr Williams as well, but I just wanted to add to that question, Dr Williams, as well, in terms of what I've already asked. Of course, in 2015, the Welsh Government brought in the individual care plans—. I'll come back to you as well on this, Dr Christmas, but if I could perhaps ask you to perhaps comment on that as well, Dr Williams, in terms of whether those individual care plans have actually seen an improvement in terms of the relationship and communication between healthcare professionals and the patient.

I think it's a very real issue, isn't it, and absolutely supporting what Dr Christmas—Rowena—said, I think there is a problem in that we are too distant between primary and secondary care, and, actually, if you think of the patient at the heart of that, they are going often between different systems, particularly with cancer or a complication that does require hospital care. I think there was a good point made in the HIW report this year, that people are sort of falling between the gaps, and something so basic as a discharge summary, or what I'd call a discharge summary, which is a letter written by, often, the doctors when someone leaves hospital, it bears no relation to what a clinician in the community might need. So, I think our digital services are letting us down there, but we are probably far too distant in terms of our acute and community care. I think we do work in different places, and I do think it does mean patients are falling between the gaps. I'm not aware of the treatment plan. It may be something that perhaps is a little bit more nursing led. But there is a bit of a tendency, I think—. For something like cancer, we almost take over their care, which is probably not ideal, because then they miss out on the strength of having a good GP relationship, and I would say, if GPs can provide continuity of care, I absolutely agree with Rowena; they absolutely hold the reins and support that patient to make some much wiser decisions. Once people are in secondary care, they often get pushed down quite a rapid journey of lots and lots of tests, lots of complicated things, and that may not always be looking at the whole person when that happens, I'd say.

Okay, that's helpful. Dr Christmas, do you want to come in on that last point about the individual care plans?

Yes, I mean, just talking about what Hilary said, it's amazing how often you see a patient and you talk about a condition and talk about what might happen in hospital and then ask, 'What do you want?', and frequently they don't want the very expensive investigations or the tests. People who are more frail and towards the end, they will tell you, 'Actually, what I want is—' and it's much less. So, if you can take the time to find out what people want for themselves, and some people do want a lot more, and that's fine—we can arrange that as well—but, without that continuity, you never really find out what matters to the patient. Now, the tricky thing in primary care, unfortunately, is that relationship-based care is becoming less; it's almost becoming a privilege, when you're lucky enough to be in a practice that has it. The shortage of GPs, which has been getting progressively worse, and is really acute now, means that access—. And of course, you can only provide a quality service if patients can see a doctor or a healthcare professional. Access is very important, but the drive for access over and above everything else is just knocking continuity out, and I so often say to my patients, 'There are five doctors in my practice now; we used to be just two. Yes, if you have to see a doctor the same day, of course, see whoever is available, but, actually, you're so much better if you can just hold on and see me or see one of my colleagues, because we've had this conversation now; we don't have to have that conversation again. We'll deepen our understanding of what's going on.' So, we've got to push away from access being the absolute holy grail; it isn't. Continuity and understanding the patient in their lives, in their conditions, that's the holy grail, but access is important too.

No, understood. I'm going to bring Gareth Davies in, if that's all right, because I'm just conscious of time as well. Gareth.

Thank you very much, Chair, and good morning everybody. I want to cover managing multiple chronic conditions, if I may, and healthcare, as we've heard many times over the years, operates in silos, traditionally. How can we improve communication and collaboration, to be improved between the different parts of the healthcare system to manage the care of those with multiple chronic conditions? That's a question to Dr Williams.

It's such an important question, Gareth, and I've sort of been pondering this, actually. The most obvious thing is to empower the patient, isn't it? And if they knew absolutely everything that's going on—. And, actually, my sister's got chronic conditions, and she's very well informed, but I think we're still not very good at that. And there is a downside, I think, if—. You know, there's talk about everyone in England having some sort of app with all their information on; a lot of our patients in Wales don't have that sort of digital capacity, so it does worry me, if we go down a very digital route for that, that we actually won't support the people with the most need. But I do think that it is actually giving the patient the information they need, and I was thinking more about—. Because we know, with lung cancer, 50 per cent of the patients that die in hospital, they're spending 25 per cent of their life in the last three months of life in hospital, and that's probably not their choice, and they've probably got multiple conditions. But we've really got to up the capacity to give them an ability to make decisions, so I think it is switching away from quite a medicalised approach to empowering our patients. It's not an easy thing to do, but—

Yes. That's good to hear from a patient perspective, about empowering patients, and I fully agree with that. But, in terms of specialities and different healthcare professions, how can that be done within the workforce? You mentioned digital as well. Is there a silver bullet to solving that within the workforce? Is it digital, or is it just better relationships?

I think better digital would really help. I think the renal teams have a good summary. So, I was looking after a patient that had renal failure and cancer, and, within 24 hours, we were able to make a joint decision; he was a very straightforward chap, and actually had very good support. And their records were good; I think ours were perhaps less clear to them. But I think we do have to be really clear that the information, that it's there, so that I can access and understand what's going on. And how to contact that health professional is incredibly important, I think. But it has to be in an understandable way, and there has to be an across-Wales way. It is a bit of a holy grail at the moment, but I'm sure there are better ways of doing it. I think being able to access the GP systems I find very helpful, to be able to look at what medications and things they are on, but, the more we can do that, the more we are going to be able to work across specialities.

But also we recognise that we need to develop clinicians that have that skill set and retain them in Wales, and something I'm very interested is what the skill set of a generalist in a rural hospital is, and I think there are people that definitely want to train in that, but we will need to support them for that training and empower them to say stay in Wales doing what they enjoy doing, because I think some of the doctors in Hywel Dda, for example, are really excellent at that, but they are quite small numbers of people to deliver that care.

And we hear as a committee—most recently from Public Health Wales and others across the period of this Senedd—of pockets of excellent service in different minutiae of Wales, possibly. How can we best learn from good practice and spread that good practice around further, so that we are learning positive lessons, and we can learn off each other, so that we can create that all-Wales system that you speak about?

We've probably been relatively successful in what I call acute oncology, which I'm involved in, and that's been very much bringing solutions from the shop floor rather than imposing them from above. But also I think we have to be realistic that, in Wales, we are a smaller country and we are trying to do an awful lot, and I think we have to perhaps be a bit bolder and say, 'These are the things that are really going to make a difference in the next three years. Let's really empower our staff and deliver on those', rather than doing too many things, because I think we're trying to do an awful lot. And I think it is focusing on those things that really deliver on the ground. What I see a lot of is very good policy that doesn't get delivered, and too much policy that doesn't get delivered, and I think we have to stop writing documents and actually deliver what we know are some of the solutions, and really—. And there's a bit of devil in the detail there around the delivery as well. I think you have to work quite hard on the delivery, not just on writing the plan.

Thanks. Just finally to Dr Williams, could you expand a little bit more on the patient booklet, or the red book, found in paediatrics, as you referred to in the paper, just to give us some more information on the details of that?

Yes. Sorry, I'm not a paediatrician. I think it happens in maternity health, and I think there is very much an aim that people have their own information with them, and we're probably a little bit slower in parts of Wales than we should be. I'm sorry; I don't actually know about the red book per se, but I think the principle is, and it's done in lots of different things now, that the patient holds the information about their own health decisions. I think one of the problems is getting that information in a way that it makes sense to people but also acts as a medical note, and there's a bit of a conflict there, I think.

Gareth, the other witnesses wanted to come in as well. Do you want me to bring them in now? Or do you want to pose any other questions you've got and then I'll come to Lisa and Dr Christmas?

No, feel free to introduce the other witnesses—yes.

Did you have any other questions, Gareth, on your side?

I've got one to Dr Christmas, if that's okay.

Well, ask that now, then, and then I'll ask them to expand on other points as well.

Okay. Thank you, Chair. Your written paper says that the standard 10-minute GP appointment is insufficient to build meaningful relationships, particularly with patients with the multiple chronic conditions we've spoken about. What changes do we need, as the number of people with chronic conditions rises, and how healthcare services can rise to the challenge of growing complexity and their patients' needs?

I think we need to give ourselves more time with patients. We've gone up to 15 minutes in my practice with each patient, and even that's quite tight. So, with endless amounts of money and endless amounts of doctors it would be easy; we would have half an hour with each patient. But that's not realistic. So, I think what we need to do is have the GPs with more time with the highly complex patients, and then develop our primary care multidisciplinary teams, with our excellent nurse practitioners, paramedics and practice-based pharmacists seeing other patients. Everybody needs to be working at the top of their ability, but with enough time to do that work and enough time to supervise the multidisciplinary team as well. But we will definitely provide a more quality service if we've got the time to do it.

Can I just ask, Gareth, if you don't mind—Joyce wants to just come in?

Just on that point, we're seeing more and more a hub, a medical hub, where different disciplines exist within that. First of all, do they ease the situation you describe and allow a GP to have more time, and, if they do, or if they don't, how could they?

I think, overall, they do. When I became a GP 20 plus years ago, I did all the smears, I did lots of minor illness. I haven't done a smear for years, because our nurses are brilliant at that—highly capable. So, you definitely can delegate work and train appropriately. Where it becomes difficult is when there's a lot of supervision to be done and there's not really enough time for that supervision. Then it becomes very stressful and, potentially, becomes less safe for patients. So, you absolutely have to recognise that, when, for example, a physician associate is working in a practice, they need to be seeing a specific scope of practice patient and they need to be supervised by a GP. Every patient needs to have a discussion and a hot review afterwards. I know, for me, I can see four patients, and that's one level of stress or anxiety. If I'm supervising someone else to see four patients, that's actually a bit harder, so you need to have that protected time to do a good-quality service there.

Lisa, did you want to come in at all?

Yes, please. If I can just refer to the point about people working in silos, people with multiple conditions, bringing that together—if we can just go back to that point. I would like to go back to the point that Dr Christmas made earlier about that relationship of care. I think what's central there is somebody is leading the person's care and has responsibility for doing that co-ordination and bringing that together. That has, traditionally in the past, been the GP role. It has also been a community nursing role, it has been the role of the district nurse. It can also be a specialist nurse, because if we're talking about chronic conditions, we're also talking, in nursing, about consultant nurses and nurse specialists who may be providing that continuity of care and, crucially, have the responsibility to co-ordinate that and outreach to others.

If you don't have that individual, that clinician doing that role, you're either putting the burden on the patient and saying, 'You co-ordinate', which, quite frankly, is an enormous burden to put on somebody who is clearly already—otherwise they wouldn't be there—having a chronic condition, or you're just relying on happenstance. And, yes, things can assist in that. Good digital systems can assist, because clinicians can see what's going on. But once it's everybody's business, it's nobody’s business, in a way. So, there is something there about the patient having a relationship with somebody who is overseeing that care for them. So, I think bringing and emphasising that role back—and, as I said before, that could be a plethora of appropriate people, depending on the situation—is important.

The second thing I'd really like to emphasise, and I think it's the answer to some of the questions that have been raised so far, is once you're already in the system, making that system work is an important question for the committee to answer. What I'm concerned about is people who are not, if you like, in the system, and this comes back to this whole access to primary care. I do think that access to primary care is in a bit of a crisis point, actually, in Wales, and I do think it's something that the committee might want to focus specifically on. Because it is extremely difficult, if not impossible, to get, in some places, an appointment with not even just a GP, but perhaps someone else in the surgery, such as paramedic or nurse, et cetera. It can be very difficult to get in. And then, of course, there's the pressure on time, the person's skill set that you're seeing—all of those things might impact on the ability to actually determine the actual future, the care plan, the holistic approach that we've talked about. So, there is something about access to primary care and that access point.

The third point—sorry, I will be quiet then; I appreciate the pressure of time—I just wanted to make is the very important point about discharge being an issue and the lack of communication between primary and secondary care. That's very important, that almost breakdown in communication between primary care that's led by the GP and the hospital. But there's also an equally significant breakdown of communication with the community nursing team, who are often, post operation, post hospital, providing that care. That lack of information on patients discharged into the responsibility of that team, and people in that team scrambling then to try and put stuff together, is extremely important. So, I just emphasise that triangle, actually, of care in the home, primary care, and perhaps the consultant in the acute hospital.

Thank you, Lisa. I think some Members might want to pick up on some of those points in their questions later on as well, actually. Can I just check with Dr Williams—? Can translation just say something, please, to make sure Dr Williams can hear?

[TRANSLATION: 'Testing interpretation. If you can hear that, can you give me a thumbs up? Thank you.']

Can you hear that? There we are. Thank you, Dr Williams. Mabon ap Gwynfor.

Thank you very much, Chair. I wanted to ask a few questions on mental health in relation to chronic conditions. We've heard evidence that not enough mental health support is available for people living with chronic conditions, so what action do you think could be taken to improve mental health support for this group of people?

Is there anybody who would like to take that question? Lisa Turnbull.

I'll start by saying that I think this goes back to my point about what services are available in primary care. Because I think—again, going back to my point—almost the category of people living with chronic conditions is the population. Again, if you're wanting to access that for the first time, that does depend on what services the GP—and I say 'the GP', but the GP surgery, as such—has access to, can refer you to, like counselling and so forth, what might be appropriate. So, if we're talking particularly around low-level, medium to minor conditions like moderate depression, anxiety, that kind of thing, resilience, all of those kinds of areas, there's a lot that can be done in that primary care service portion. If we're talking about specialist mental health services that are specific, we have, jointly with other royal colleges, raised attention of the fact to the health committee previously that there needs to be an investment in the workforce, because we don't have enough of the workforce in there with those high-level skills, I think, to really appropriately support the population that need it. The consequence of that is very long waiting times, not being able to access that type of service. So, I'm highlighting workforce issues, but they're almost two types of workforce issues that I think are relevant in this scenario. So, that would be my starting point.

I think many, many people with chronic illnesses have, as you say, low-grade mental health problems, and perhaps they're not even mental health problems; perhaps it's loneliness or difficulty accessing services, difficulty with transport. Often, chronic illnesses will reduce your financial ability. So, something called social prescribing, which is where you improve the infrastructure in communities to create a healthy environment, will make a huge difference. I read last night that 30 per cent of patients who visit their GP are coming with a social reason. So, that's using our skill set in a way that—. You know, somebody else could probably do that better. But the RCGP tracker survey last year showed that only 26 per cent of GPs have access to a social prescribing link worker. These people know where to signpost people to. Often there are a huge number of brilliant things going on in communities.

What is a social prescribing networker?

A social prescribing link worker. They have different names, but that's what we tend to call them. You'd refer a patient to them, and they would then have a host—. And it doesn't matter whether they've got loneliness, anxiety, or they're struggling to pay their gas bill. The social prescribing link worker will have a resource to direct them to. It's absolutely brilliant, really.

Thank you. Mabon.

Thank you. That's very interesting. I'm thinking there about someone who has a chronic condition and how they can fall into mental health difficulties due to the waiting lists and not being able to access treatment et cetera, and at the same time we have people who have long-term mental health issues that, due to that long-term mental health issue, can fall into suffering from a physical, chronic condition. So, in terms of that second cohort, is there enough being done for that cohort of people?

No. I think people with significant mental health problems will develop chronic illnesses perhaps 20 or even 30 years earlier than the population who don't have serious mental health problems, and that's partly because of the medication they're prescribed—that often increases their cardiovascular risk, it makes them more likely to be overweight or obese. They often really struggle with motivation, so they're not getting out of the house and going for a walk, they're not meeting with people, they're lonely, they're isolated. Often, they don't come to the doctor to present with symptoms; they're more likely to live on their own, so they haven't got a wife or a husband or a son saying, 'Get to the doctor, Dad'. We know that people in that situation—. We bring them into the surgery once a year, if we possibly can, so that we can do all of those checks. But sometimes, we send letter after letter after letter and they ignore them, because that's part of their illness, rather than who they are. So, this is a huge problem and, yes, something that we could do with doing better at, I think.

I'd like to specifically mention here, actually—I think it's appropriate—learning disability. Again, we've referred a specific paper that we've produced on this to the committee. There is a shortage of learning disability nurses in Wales. The learning disability nurse is classically the empowerer and the co-ordinator of person-centred care for the person with learning disabilities. It's the person who will take on that role that you've described, of ensuring that the individual has access to the kind of support services that might prevent a physical condition, or prevent it from worsening. Because people with learning disabilities—and the statistics show this—are very vulnerable, as you've described, to developing physical chronic conditions. So, I think that's a very pertinent group to mention at this point.

Dr Williams, did you want to come in as well?

I think there are a few things to consider here. I actually think that we're getting better at treating people with cancer—we're getting much better at treating people with mental health issues. I think the medical profession and the nursing profession are writing people off a lot less. I think some people with mental ill health and anxiety, et cetera, are absolutely brilliant at looking after their own conditions. I've been really impressed. When people have that ability to say, 'Well, I'm on these drugs, I know what to do with them, I know who to reach out to if I'm unstable', it's so reassuring when I'm giving them cancer treatment. Not everyone can be like that, but when they can be empowered and supported and know they've got their community psychiatric nurse if things go wrong, it's so much easier.

I think the other thing that really strikes me—I cover south Newport—is that we have a lot of patients, sadly, who fall into that category, but there are probably bits of Wales that don't, and I do think we've got to consider the deprivation in the areas. I know quite a lot of Wales does have more issues around this. Actually, staff need a bit more time. But if we get it right, it can be successfully negotiated. But it is about having that right support and right expertise, and it definitely takes a little bit longer, but I would say I think we're improving.

To me, it's also just not taking away the control from the patient ever. I think the more we take over everything, the more dependent we make people—. That might be very simplistic, but I do think it's really important that we empower. And I think the social prescribing and knowing how to look after yourself can be a real game changer there. There's lots of evidence that, if we support people in the right way and with the right people, with things like social prescribing and looking after themselves, it can be very powerful. It doesn't work for everyone, but even if you get a number or a percentage of people looking after their own health, the long-term impact of that can be brilliant.

Thank you. Do you have any other questions, Mabon?

I have one final question, if that's okay, Chair. We've received evidence about the effectiveness of both social prescribing and the national exercise referral scheme in promoting mental health and well-being for people living with chronic conditions. Do these schemes have enough capacity, do you think, to meet demand? Are they doing what's required of them, or should they do more?

I think the broad point I would make about social prescribing—and that specific scheme, as you say, is very well regarded—and the link system that you described is it relies on those community activities being present. So, if you don't have the community choirs or art classes or exercise schemes or any of this activity going on in the community, then obviously it continuously reduces the options to be able to offer the individual. So, therefore, I think this ties into the broader issue of public funding and being able to see benefits holistically, so that, while some might say, 'Well, that's an arts and culture issue', 'That's about public transport', well, actually, they all have a fairly significant impact on health. Because if you cannot get to the leisure centre—or if there isn't a leisure centre, for that matter—if you can't get somewhere via transport, or because the pavement hasn't been gritted, or there are no dropped kerbs, or there are no public toilets available, then you can't do the exercise in the park, or whatever it is that's helping your mental health, or your physical activity, or whatever it is. So, I think there is a broader point here about how we assess and understand the impact on health, on the NHS, of some of these broader community activities.

Thank you. Right, before I move on, I know, Dr Williams, if you do disappear—you mentioned you had to go early—we'll understand. So, no problem at all. Joyce Watson.

I'm just going to bring one other thing into the whole question, and it's a sudden change in a person's well-being, through maybe a stroke, a severe heart attack, or the onset of Parkinson's and being diagnosed with what, effectively, is a long-term, life-changing event, and the advice then, holistic advice, that they would need going forward, particularly in the area of mental health and well-being. How well served are those people—you will know many more than I will know—that suffer a sudden change from the person they were the day before?

For instance, on the people having a sudden heart attack, we've got a cardiac rehabilitation service, and the evidence for the people who attend and go to every session, for how well they do afterwards, is really strong. So, we're quite well supported in that. That's an area of improvement, really, along with the fact that far fewer people are having heart attacks at all now, because we are managing chronic illness better. There are some good news stories here.

Parkinson's disease: we've got long waits for neurology, that's really tricky. We're advised to refer to a neurologist before initiating treatment, but, frankly, that very rarely happens because people are really suffering, so that's tricky. But we do have really excellent Parkinson's specialist nurses who will visit people at home. They're that point of contact that Lisa was talking about before, so the patients feel very safe with their Parkinson's specialist nurse that they can phone up and talk to. So, we have got good things in place for that, but there's always room for more.

I'd like to come in here specifically on the point about the specialist nurse. Because as probably Members of the Senedd in this room will know, if you ask the question, 'How many specialist nurses are there in Wales?', you will receive the answer, 'That information is not held centrally.' And this, I think, illustrates profoundly the problem that we have with specialist nurses. Because, where they exist, they are excellent. Now, if that nurse gets another job, or retires, who replaces that person? And then the entire service actually can collapse, and this is even more the truth when we're talking about the very rare nurse consultant posts. We've never had—. Before the Assembly was established, there was a survey done to see how many consultant nurses were needed in Wales, and the answer at that time came back as 52. To my knowledge, we've never reached that point, even now.

What we have been calling for is a national postgraduate, post-registration commissioning strategy for nursing. Because in order to become a specialist nurse, in order to become a nurse consultant, obviously, you need to undertake more education, more training, more experience, and so forth—these are very specialist posts, obviously. So, that is paid for and commissioned by the Welsh Government, by public money. But at the moment, there's quite a random approach to this. Whereas what we are saying is, what we need to do is we actually need to look at the population and say, 'This is how many we need, let's do some succession planning for providing the education, so that, in five years' time, we will have those people and we can provide those excellent services to the people who need them.' That's opposed to the situation we have now, which is, 'We happen to have an excellent nurse here, so we can have an excellent service', or, 'Oh, sorry, we don't happen to have anyone here, so we can't provide that excellent service.' So, I think there's a critical point here about planning the number of specialist nurses, who've often provided exactly what you describe—the advice on management, practical, emotional advice on how to change one's life, adapt one's life, and flourish in one's life while having this chronic condition in the situation you describe.

Could you send us something on that?

We most certainly can.

Please. So, I'm going to move on to inequalities. We know, and you've already mentioned it, that certain areas are more likely to experience multiple chronic conditions, particularly in their good health, because of where they live or who they are. So, what role can, and do healthcare services play in helping to address some of those inequalities?

Well, the problem we've got—

Oh sorry, I'll just bring in Dr Williams.

I'm probably going to need to leave in a second. It's just—[Inaudible]—and I think in answer to this as well, I think what we really need to do—. I do worry that the education of Health Education and Improvement Wales, which is our education body, is falling a little behind Health Education England here, in that what HEE are doing is projecting what the healthcare needs of their population are going to be in the future, based on Office for National Statistics data. And I think we're all beginning to understand that the rural communities, which are a big issue for Wales, and the older population is growing and growing. I think, exactly as the previous speaker said, we need to start planning our workforce based on that future need, not on this ad hoc basis. I think we need to be much braver about that, and probably not overcomplicate it, but we need the staff working in rural communities to do exactly all the things that we're talking about.

That would be a huge recommendation from me: plan much more ahead, so that we don't—. We have got some great pockets of care and there's probably more in Cardiff than elsewhere, just because that's where your population is, not because of the quality of the staff, and that's what I think we need to do for the future is to start predicting and understanding. And the older co-morbid population is absolutely what we need to plan for. So, a really useful session. I'm really sorry, I'm going to have to leave now, but thanks for your time.

I understand your pressures. Thank you, Dr Williams. All the best. Thank you. Dr Christmas.

Yes. Unfortunately, the inverse care law that Julian Tudor Hart talked about is alive and well in Wales. We know that people in deprived areas will develop more chronic conditions, they will develop them earlier, they'll tend to be more severe, and that's partly because, in deprived areas, people are more likely to be overweight, they're more likely to smoke or drink or have mental health problems. And just those places where you need the really excellent staff, you're less likely to have a specialist nurse.

I was in surgery yesterday. A specialist nursing in chronic obstructive pulmonary disease phoned me up and said, 'I'm really worried about such and such patient. Her oxygen saturations are dropping a bit, she's going to end up in hospital, I'm worried about it, so shall we do x, y and z?' I said, 'Absolutely brilliant.' She's now on x, y and z and she's much less likely to end up acutely unwell and in hospital. If that person was living in the Valleys, she's less likely to have a specialist nurse who would go and see her at home. And so, the pressure on those areas increases and she's more likely to end up in hospital.

So, if we can invest in the community, more specialist nurses in the communities where people are less well, we are much more likely to empower them to stay well and stay at home. And health literacy is really, really important. I read a statistic that 43 per cent of adults, if you give them written information about their health, won't understand it, and that number goes up to 64 per cent if that information includes numbers as well as words. So, we can do that better. We can provide them with information that's more understandable, or we can prescribe them with—. We can give them people who will help to explain it to them, and that doesn't need to be a trained medic, that can be a lower paid person who has the time to sit and explain information to them.

So, there's a lot we can do to try and help people to help themselves to stay at home and stay in the communities, because nobody really wants to be in hospital, apart from the people who've got a planned operation, and we want to be able to get them in for their operations.

Yes, I would definitely, absolutely echo all of that. I think it is about planning. We know where certain geographical areas or certain vulnerable populations are in Wales, so we should be planning services around the population as opposed to the ad hoc way we've done this in the past.

I think in terms of the public health thing as well, it's also about investment in other areas. Take, for example, the role of the school nurse—potentially hugely valuable in that kind of health literacy at an early age. So, there are certain public health nursing roles that are not about treating individuals, but are about assisting in the situation that prevents illness and prevents these conditions from worsening, and helps manage those conditions.

So, there is something there about that approach, but absolutely critical is the investment in primary care and the investment in community care in that neighbourhood. That is community nursing, pharmacy, mental health, GPs, all of that.

And talking about children, I appreciate this is chronic illnesses, but gracious me, the number of children who are overweight and obese and are developing diabetes and other problems associated with that is just shocking. And yet, if I've got an adult who's overweight, I've got services to refer them to: they can go to the exercise referral scheme, they've got weight management services. Kids, there's a real lack of anywhere to—. The poor parents will come in, anxious, and beyond telling them to go to the swimming pool, which is often closed, or to go and join a junior parkrun, which is brilliant, but—. There are things we can do, but, again, they need to have Sunday morning off to go, they need the transport to be able to take them. It's very tricky, and we need to be looking at children to optimise their health to prevent this problem. These poor kids who are unwell now, they're going to be very unwell and unhealthy middle-aged people.

But there's also another specific group, and that's the black, Asian and minority ethnic group, with known factors of health issues that they will perhaps present with. How do we help and support those not to fall into being chronically ill? How well are they supported, and how should we support them, beyond anything else that you've said?

I think we learnt a lot during COVID, when that group of people were less likely to come forward for vaccination. We had people going into their mosques, or the places where they go, and increasing their health literacy there, so trying to capture them because they were less likely to present. So, it's building on that, building on that knowledge that we learnt during the pandemic to improve things now. Because you're right: they're a vulnerable group, and they're perhaps less likely to present at the doctor's surgery or come for annual checks than other people.

I would completely support that, absolutely. I think I would add as well there's something—again, going back to my point—about community infrastructure that benefits the community. And that community geographically could happen to be predominantly Asian or black, but would benefit that community. So, I suppose it's a question of—. It's difficult because if you overgeneralise, you can actually miss the point. It may be, with certain communities, that they are more inclined to have that disadvantage, because of factors like, for example, lack of investment in transport, lack of health facilities or lack of access to primary care. So, it may be an intervention like that that can actually prevent these kinds of disadvantages from emerging. So, I think, looking at transport and looking at the actual location of health and leisure facilities is really important.

Going back to the point about encouraging physical activity in children, for example, if you don't have access to a playing field or recreational area that is safe for the child to go to, particularly if it's by themselves, so it's about crossing roads, then where are they getting that physical activity? If the curriculum is so squished that there is no room for physical activity and that kind of thing, then all of those things are reducing the opportunities available for people to access. So, I think that thinking about it in that way can also be extremely helpful.

Thank you.

Thank you. Sarah Murphy.

Thank you. I'm going to ask a question now about primary prevention. Many of you have actually touched on this morning about empowering and educating patients, social prescribing in relation to health literacy, and the Royal College of General Practitioners, in written evidence, have said that you need the time and resources to promote well-being, rather than treating sick people. So, last year our committee commissioned a report on health literacy, which was written by Dr Emily Marchant and Professor Tom Crick. And it does show that evidence states that patients who have greater levels of health literacy are less likely to rely on health services. Therefore, the more knowledge a population has, the more time is freed up for GPs. You've touched on a number of ways this morning of how that can help, and I also just wanted to know your views, really, on the peer-support groups that are out there, which are often run at the moment by third sector groups. It seems to be that funding is being sucked away from those. And you also mentioned the social prescribing links—we call them community navigators, in my community. They're called the best kept secret, because if you can find one, brilliant, but most people can't. So, I was just wondering what your thoughts are, really, on those peer-support groups that are out there, if there's enough of a link to them, and if you see the benefits of them.

I think they are, when available, absolutely hugely valuable, but they're not routinely available. If any of us are going through a difficult experience and you meet someone else who has gone through the same thing, or is going through it, just sharing those vulnerabilities, sharing tips and ideas is incredibly important, incredibly useful. It does feel like we're missing an enormous trick here. The idea of having group consultations for people with high blood pressure, where you can talk about a low-salt diet, more exercise, cutting down on smoking—. I've been in a room where people will—you step back and they start talking to each other, moaning about how hard it is to give up smoking, 'But I tried this', or, 'That Champix is really good.' You know, allow people to be experts in their lives and share that. People come away—there's a hubbub of enthusiasm and positivity. Of course, you're also then addressing loneliness and isolation. There are wins throughout doing this.

I often think that we should be getting our patient representative group on to this, but, of course—. I get into surgery—and I'm sure you're the same—I'm in surgery at 7.30 a.m.; I get home about 20:30 at night, rung out and exhausted, and there just isn't the time in the day for these quite time-consuming quality improvement things to be set up. It was good in COVID, we had all these volunteers just doing amazing things. I can remember thinking that we've got to harness this, and then, of course, life got back to normal and busyness happened. There are opportunities in communities to set up expert groups of patients who will gain themselves from sharing their knowledge and their expertise. There's nothing more empowering or that makes you feel good about life than helping other people.

I couldn't agree more. I think peer groups are absolutely incredible—the work that they do. What I would say is that there is, as identified, a cost there, but there is an administration issue of who is setting these up—

I agree, yes.

Technology's fantastic in this regard, because, actually, this can address issues of isolation and loneliness, because it means that people don't necessarily have to travel physically to have the support of that peer group; they can just log on and have that discussion. It's also an opportunity—. And often as well, this could be the specialist nurse, or nurse, or therapist leading this type of group—perhaps 'leading' is the wrong word, but potentially contributing when the group wants to. But it can be very helpful in terms of addressing misinformation.

One of the other areas, of course, that's important to flag when we're discussing health literacy is the fact that we have a situation now where long-standing approaches to understanding what science is, and understanding the authority of science and the spread of misinformation is very difficult. So, having a support group where people can collectively say, 'This is the latest suggestion online, what do you think?'—having someone there who's able to say, 'Well, actually, this is the evidence one way or the other', can be an incredibly timely intervention into that community.

I agree. Thank you very much. As we're short on time, I'm going to skip over now to secondary and tertiary prevention, specifically looking at older people. So, as we know, older people are more at risk of chronic conditions and experiencing frailty. Some of the written evidence highlights the role of frailty nurses. So, would you be able to give us some evidence on what impact frailty nurses are having in supporting older people with chronic conditions, and whether they're accessible to older people throughout Wales right now?

Well, I think that they're doing an absolutely fantastic and amazing job, and incredibly important. However, I suppose what I would say is that this is a new name, it's not a new specialism. Looking after and empowering people who are frail, older people who are frail, is a key component of nursing.

One of the things we've identified in our community nursing paper is that part of this comes back to what we would call a bit of a neglect of that community nursing important strand of the NHS. A lot of the funding is being funnelled now through these regional partnership boards and involves bids for new things. So, very often, the core community nursing service is engaged in rebadging itself, or rejigging itself in order to access these new pools of funding, whereas, actually, what could be more useful in some respects would be increasing the core funding of the community nursing team and the amount of people and the level of skills that they have access to, and that would include frailty nursing, exactly as you describe, which is really important and has a huge impact.

I think it's also worth saying that, if you're talking about frail older people with chronic conditions, if they're in their own home, they will be receiving packages, potentially, of support. What we're seeing is, as pressure comes on funding, a difficulty to access that support, but also a stripping of the skill base from that support. So, what you end up with is a task-based situation. It's like, 'Right, this person is going into this person's house to do this task, and then they're going out again.' Whereas, actually, if you have the system of the community nurse, a senior level district nurse, or a senior community nurse, they're going in and assessing the need and thinking, 'I need to refer them to here', or, 'This has happened', or, 'What's the situation with the heating in this room', or, 'Actually, we need an occupational therapist in here and some aids.' Where is that holistic assessment of what's going on and the co-ordination of care, as opposed to, 'Right, we've found out this person needs a task done', so somebody will go in for 15 minutes every Wednesday and do the task? So, what happens then is, when there's a crisis, it's GP, out of hours. What are we going are we going to do? We're going to get into the hospital and blah blah blah, and the system, basically, is not helpful for that individual, and it's certainly not helpful for the system as a whole.

The other point is, in residential care, which is the other potential place where you might find that population, again, there's a stripping out of the nursing expertise, because, 'Do you need actual specialist nursing care?' 'No, you don't.' So, if you don't need specialist nursing care, how are you seeing a nurse? Whereas, if there was nurse present, they'd be doing that assessment, that holistic care. So, one of the things we've often said is that there needs to be, in commissioning services, residential services, not this sharp distinction between, 'Do you need some kind of medical care? In which case we'll get it for you', and, 'What is your health need?', for the population as a whole. Those are the answers to that question. The first question: absolutely, yes, frailty nurses are marvellous and it would be great to have them, but I think there's a wider point about how that service is provided, planned for and delivered to that community.

Yes, I agree. Thank you.

I think that's key. We have got an ageing population, and because we're doing very well, our ageing population are living with chronic illnesses because they're not dying from them. What I see is just how guilty our ageing population often feel. Instead of celebrating the fact that they're elderly and they're doing well with their conditions, they just feel so guilty that they're such a burden on their family, or society or their GP. That's just dreadful, dreadful that they're in that situation. So, we really do need to do better. And I think that you're right: good-quality holistic nursing and care makes all the difference. Rush in, 10 minutes to heat up your meal in the microwave, dump it on your lap and rush out again—and it's not the carer's fault. They've got unbelievable pressures on them, and they're not terribly well paid. But it does add to that, 'I feel guilty. I'm just a terrible burden to society' feeling that older, more frail people have.

Thank you for sharing that. You're right. Thank you, and thank you, Chair.

We are over time, but are there any key recommendations you can bullet point to us, in terms of our discussion this morning in supporting people with chronic conditions, that you think that we should be considering to make to the Welsh Government?

For me, the way to look after people with chronic conditions best is at home, so invest in the community. And I can't emphasise that enough. And the whole of community service—so, district nurses, primary care, GPs, and our whole teams. We want to keep people with chronic conditions out of hospital. They are far better for that. And if you ask them, that's what they want as well. But for us to do that well and effectively, so that people don't just survive at home, they flourish at home, we need more time and resources to do that.

And is there—and I understand that point completely—anything Government can do that doesn't cost anything—

Get a plan.

—financially?

Get a plan in for how you're commissioning. Because you're commissioning postgraduate, post-registration nursing—the Welsh Government is doing that anyway. There is a budget that exists for it, it's happening—the only thing that we are calling for is for that to be planned better. That would be my point on that. The other thing I would add to that—I couldn't agree more with absolutely everything the speaker's just said. I think access to primary care is an issue here.

And continuity—try and find a way to incentivise continuity of care. Put it into nursing and medical student curriculums, so that we're teaching it from the get-go. Make it as important as access, and you will see demand on secondary care fall.

Okay. Thank you, both, for your time. I know you've provided some papers previously as well, which has helped our discussion this morning as well. So, thank you, both, for being with us this morning. Diolch yn fawr iawn.

Thank you.

Thank you.

We'll take a 10-minute break.