Health and Social Care Committee

Bore da, Chair. Hywel Jones, director of finance for the health and social services group.

Bore da; good morning. Albert Heaney, Chief Social Care Officer for Wales.

Good morning. Nick Wood, deputy chief executive of NHS Wales.

Good morning. Matt Downton, deputy director for mental health and substance misuse.

Bore da. Irfon Rees, director of health and well-being.

Thank you very much for being with us this morning. I should have said that if there are any declarations of interest as well, then please do say. No, there are not.

Great, thank you. Thank you, Ministers, for being with us this morning and for your paper in advance of the session today. Can I ask, Minister, in terms of—? You can make some opening comments in response to this first question as well, but can I ask, in terms of activities and objectives that are being prioritised, what are your priorities and what is being de-prioritised in your budget this year within the main group for health and social services?

Thanks very much and thanks to the committee for inviting us here this morning. I think, before getting into the detail, it's probably worth just setting out the big picture in terms of what's happened across Government, which is—and you'll all be aware of this—that, in this financial year, we've had to go around the entire Cabinet table, who have made significant contributions to try and keep the wheels on the bus in relation to health. That's happened, again, effectively. That's been baselined into the next financial year.

So, in all, there has been a significant increase going to health and social services. Obviously, it has been painful. It has been painful for everybody around the Cabinet table, but also I think it's important to make clear that, because of the inflationary pressures, because of the massive increase in demand that we're seeing, for all kinds of reasons, that actually there will still be a need for health boards in particular to make real efforts to try and balance their budgets, not just this financial year, but next financial year as well.

So, what we've had to do is to make sure, for example, that the savings in the budget this year are carried through into next year. So, in particular in relation to the central money that we hold back from the NHS. You'll be aware that the vast, vast majority of money goes directly to the health boards, but we do hold back some to try and drive efficiencies, to try and drive change in the system, and we've had to cut back on that this financial year. And, again, we've had to baseline those into next year. So, some real frustrations and it has been really painful, because we've had to give up some things that were very important to us, but we have focused on front-line services. So, I think that's the fundamental piece of what we've been trying to do in relation to health: to make sure we retain that focus on front-line services.

We have issued the NHS Wales planning framework ready for next year. That was issued to the health boards on 18 December. And what will happen next is that they will go off now to draw up their IMTPs, their intermediate—integrated medium-term plans. I always get that wrong. And they will then come forward with their priorities based on an assessment of what their populations need. But we have given them a very clear steer within that framework in terms of where we'd like them to focus.

Can I just ask a question on that, Minister? Sorry to interrupt. The framework that was issued on 18 December to health boards, has that been published at all?

I don't think it has, but I'm happy to give the committee a copy of the letter that we've sent out, if that would be—

Okay. That would be helpful, because that presumably sets out your priorities in terms of what your expectations are.

Yes, but I think it's probably worth just setting out some of the things that are in that paper. So, first of all, they need to stabilise their financial position, and we've been really strict with them. We cannot continue with them overspending in the way that they do. And to do that, they need to increase efficiency, they need to reduce waste and harm and variation. So, it's really interesting to note how some people perform much better in some areas than others. So, why are we having such variation? We have national programmes that they should be following, but also there's a board that's been set up with officials, but driven by the NHS chief executive officer, where all of the chief executives come around the table to drive value and sustainability. So, it's a value and sustainability board, and there's a whole list of things that are being driven within that board.

I'll just bring Sarah in in a moment, but it probably would be helpful for future years if the framework that was published in December could be attached to your paper for our budget scrutiny in January, if that's the timetable next year, because that would help us in terms of preparing for this session. Sarah, did you want to come in?

Yes, thank you very much, Chair, and thank you all for being here today. Straight off the bat, I just wanted to highlight, of course, that we do have the junior doctors' strike at the moment. Today is the last day of this particular strike action, but potentially, then, there will be more. There have been people saying, Minister, that you have not met with the British Medical Association, that you have refused to come to the table with them. So, it would be great to have clarification there around your conversations with the BMA.

Also, it is my understanding that, at the moment, without knowing from the UK Government whether or not that is new money that they're proposing to pay for the junior doctors' uplift in England, it is very difficult for the Welsh Government to plan what they are able to offer Welsh junior doctors. So, again, it would be very helpful to understand any conversations that you have had with the UK Government and the Treasury around this. Thank you.

Thanks very much. Well, first of all, I can assure you that my officials meet very, very regularly with the British Medical Association, but I did meet myself with some representatives from junior doctors before Christmas, and I met with the BMA again last week. So, you know, those communication systems are very much alive and we're always ready to discuss with them.

Just in terms of the uplift from England, it is really frustrating, the lack of transparency, in terms of where they are securing the funding from to offer what they are offering in England. So, we don't know if that's coming from a central budget or if it's coming from the health budget in England. Obviously, if it's coming from the central budget, that would be additional funding, which would mean that we would be eligible for consequentials, but we don't know. There's no transparency, not just around next year, but even this year; even what they've done this year, we don't know where they stand. So, you can imagine how difficult it is for us to plan from a budgetary perspective without having that kind of transparency.

Can I—?

I don't know if Hywel would like to come in.

Let me just add to that as well: add some detail onto that because I find it—. It's unbelievable. You've got to be able to plan and you've got to know if this money is coming to you or not, and as you said, if it's money within the existing NHS England budget, then you wouldn't have any additional funding, but if it's come centrally, then you would, and I would have thought that would be straightforward. So, explain why it's not so straightforward, if possible.

Yes, of course. So, the 5 per cent, you would recognise, was part of our existing planning assumptions this year. From an 'Agenda for Change' perspective, we have had clarity on the consequential position from UK Government in terms of the autumn statement and supporting evidence around that. As the Minister's described, from a medical perspective, junior doctors, consultants, there is no clarity in terms of consequentials at this stage. They are questions that officials are constantly asking their counterparts, myself directly with mine, Treasury colleagues and so on, but at this stage there is no clarity.

And what is their answer? Official to official: 'Is there going to be an allocation consequential for Wales, please, UK Government official, yes or no?' What—? How is there—? Explain why there's this issue in the first place. It just seems bizarre why there's not a straightforward response.

Certainly. So, the response to me is that it's part of a number of assumptions that England are working through in terms of the NHS position this year, and clarity will follow in terms of second supplementary budgets and other processes, but at this stage, we're not clear on that position.

Yes. And then, when they say that, you would say, 'Well, can you tell us when that's going to be?' And then, what do they say back?

There's a clear process and timescale around that in terms of second supplementary budgets, but the content of that, it's not being shared with us at this stage.

Okay. And in terms of Minister to Minister, do you ask, Minister, or is that done through official channels?

It's mostly done through official channels. We haven't met with the new Minister for health yet—I think there was something in the diary, but that was postponed—so, we haven't met with the new health Minister; and prior to that, Steve Barclay, I think I met once, maybe twice.

But you could presumably write and ask.

Oh, yes. I mean, we're constantly asking these questions.

Okay. It—

We're just not getting answers.

It does seem bizarre. Sorry, I know a number of Members want to come in. Jenny, and then Mabon. Jenny.

I mean, there's a UK Parliament that's supposed to be scrutinising the UK Government's budget, so what role is there for any of our Welsh MPs? The shadow Secretary of State for health, Wes Streeting, why isn't he asking these questions? And, indeed, the shadow Chancellor, Rachel Reeves. I mean, we need to put pressure on these people to get on and do their job, so that we are able to make informed decisions.

And the Welsh Affairs Committee and the Health and Social Care Committee.

The Welsh Affairs Committee. Because there seem to me to be a load of different people who are not stepping up to the plate on clarifying what devolved Governments have in their budgets.

I can't answer for those people.

No.

Fair enough.

But no action has been taken to try and get them to do what is their job to do.

Mabon, did you want to come in?

Yes. Following that question about the money that comes from England, when it comes to the offer from the Welsh Government of 5 per cent to the junior doctors, is that your final offer, absolutely?

We don't have any more money. Presumably, you've looked at the budget and you have seen that not only do we not have any more money but we've had to go around the entire policy area of the Welsh Government to find cuts to keep the wheels on the bus. It's not about increasing; it's about keeping the wheels on the bus. So, any thought about going further than that would obviously mean even deeper cuts than what we've had to go into so far, and the alternative, of course, would be to cut within the Welsh health service, and I don't think anybody would thank us for that, with the pressures on the services at the moment.

Okay, right. That's your final offer. There will be no change on the 5 per cent. You say that the budget—. I've read the budget documents. You're not opening up the books fully for us. You say that there's no more available. You haven't given us all the details. Could you please tell us what is the value of that 5 per cent, and, for each 1 per cent above that, what would the financial value be? We know that there are 4,000 junior doctors in Wales. That's one figure that we do have. We know that 5 per cent is your offer, but, apart from that, we don't have any further details. So, what's the financial value if you were to offer 6 per cent? What's the value of that 1 per cent extra?

Well, I don't think it is about just saying, 'Right, let's just offer them 6 per cent then and it will all work out'—

No, but what is the value? What is it?

It's 1 per cent—. I've got an expert finance person here. So, the amount that we spend on junior doctors is about £28,000. That's their annual salary. So, 1 per cent of that for 4,000 people. So, it's a fairly easy calculation to make. But there is no point in putting 6 per cent on the table, (1) because we haven't got it, but (2), they haven't settled in England. For 6 per cent, they haven't settled. And can I just make it clear as well that, actually, that 5 per cent is what has been offered to everybody across the NHS in Wales, in terms of 'Agenda for Change', and that has been accepted? So, once you start saying, 'No, we're going to offer 6 per cent for this,' you can be damn sure that other parts of the Welsh NHS will say, 'Well, what about us?'

Two things arise from that, because, for one thing, you promised pay restoration back to the 2008 level. Why did you promise that if you weren't going to deliver it?

When we've got the money—. Last year—. If you look at how much we were able to put on the table and to offer last year, we gave 6 per cent plus 1.5 per cent in terms of just a one-off payment. That's not an insignificant increase when they only gave 2 per cent in England. So, when we're able to, we work towards pay restoration. This year, we are not able to.

If I may, Chair, just to be clear, when the Government promises something, it's not a promise but it's an ambition.

Well, hang on a minute. Let's be clear, we have said that we're going to work towards pay restoration. We have said that very, very clearly, and we stand by that, but we can't magic up the money. When it's available, as we've proved in the past, we go over and above what they've offered elsewhere.

Finally on this, you've given us a few indicative figures. The financial officer is here. Could you give us those figures on paper so that we can clearly see the financial value? What exactly are the figures we're talking about? Is that something you could do, please?

We can send you what we think the approximate amount would be, but it's not an offer we're making.

Thank you, Chair.

Thank you, Mabon. This is the final year, isn't it, of the three-year spending period outlined in the 2022-23 budget. So, considering the issues around inflation and other financial constraints as well, are you on track to fund and deliver everything anticipated over that period, and, if not, what won't be delivered?

Well, it's no secret that we're a bit frustrated in terms of waiting lists—that we haven't managed to meet our waiting lists targets. But those were set out just after Brexit, and with COVID—we're just coming out of COVID; we've had inflation since then—obviously, there's a huge backlog that's built up. And what's incredible is the numbers of people who keep on coming onto our waiting lists.

So, waiting lists is an area of frustration, obviously. I wouldn't mind Nick giving you a little bit more detail, just to give you a sense of how much we've done but how much is coming on in addition, just to explain why we've been unable to meet some of those ambitions. Nick.

Yes, thanks, Minister. We launched the recovery plan in April 2022. In the period between now and then, we've seen 2.3 million referrals onto waiting lists. So, that's for treatment or out-patient, and the rate of referral continues to increase. Our overall waiting list in that period of time has remained fairy stable; I think it's a sort of 1 per cent increase in total terms. So, we've been able to, I suppose, manage what's come onto the list over that period of time, but unable to reduce the total size of the waiting list. We're seeing, on average, an increase of about 20,000 patients per month compared to pre-pandemic levels, in terms of referrals, when you compare to 2019-20. So, that's a very challenging position.

Within the recovery plan itself, we set out in 2022 that we would seek to increase activity to levels of 110 per cent of pre-pandemic, so a 10 per cent increase on 2019-20 activity levels, which would have then allowed us, based upon plans, to bring down the waiting list in total and deliver the two-year and 52-week waiting time targets. In that period, we've seen out-patient activity increase by around 12 per cent. So, we've managed the out-patient backlog to a large extent, but, in terms of the activity going through theatre—so, procedure activity—that is still 6 per cent below the 2019-20 numbers. So, in essence, that's where the issue is.

There are many reasons why we've not been able to get back to that 100 per cent and then 110 per cent level. Some of it is a productivity issue. Some of it's around availability of staff to staff the theatre sessions that we've got, and we've not seen the increase in theatre sessions that we planned to increase. Others are then patient related, where we've got quite significant numbers of patients who are deemed urgent or acute coming into the system. Many of those will require in-patient episodes rather than day-case episodes, which, obviously, reduces the number on the theatre list, et cetera. So, there are a myriad of, I suppose, pandemic issues that are playing out now in terms of the waiting list.

We have seen a reduction in wait times. So, the number of patients waiting over two years is down by around 60 per cent over the period. It's not where we wanted to be. I think I've been in a couple of these committees where we've talked about the waiting list reductions not getting to where we wanted to get to. In essence now, only 3 per cent of pathways are over two years, so 97 per cent of patients are being seen, treated and discharged from the pathway within the sort of two-year period. And the average wait in Wales is now down to around 20 weeks. At peak, that was 29 and, when we launched the plan, that was 24.

So, there's been progress—not where we would expect it to be—and the challenge now with the budget position is how we utilise the budget that we've got to really drive productivity. And as the Minister alluded to previously, the value and sustainability board is very much focused on the opportunities for productivity, and that will be within theatres and other areas.

In terms of driving down the challenge in waiting lists, to what extent is that about budget, and to what extent is it not about budget?

We've invested £170 million per annum into waiting list recovery. Without really driving green elective sites, more capacity, that's going to be really difficult. When we've got inflation running as it currently is—and that's for prosthetics, the cost of running a theatre list et cetera—then we are, in effect, getting less value for our pound in terms of the number of procedures that we can do. So, a big increase in the budget would, obviously, allow us to buy more capacity elsewhere, or more theatre sessions. So, it will restrict our ability to really buy more. What we need to do is make what we've got more productive.

Sure. I'd better just ask the Minister, but I think the question is more about if you were in a position where you had the budget you would like, to what extent would there still be difficulties in driving down that waiting list. If you've got a budget but you can't get the staff, you've still got an issue, haven't you? I'm trying to get some balance on that.

So, certainly, staffing is challenging. So, we need to make sure that we keep on investing, which is what we're suggesting in terms of training the next generation. So, that budget hasn't been cut. But the other thing, I think, is about, as Nick says, what more can we do to increase productivity. And one of the things is to establish more of these elective hubs. So, you've seen that we've already done that in Swansea. We've got an elective day hub in Hywel Dda. We're building a new one now in Llandudno, and, obviously, there's a new diagnostic centre that we're planning to build in the Royal Glamorgan. Potentially, we could have an orthopaedic site there as well. So, I think that kind of regional approach would help productivity, but you need money for that, because then you can get those that you do have, in terms of the experts, you can put them all on one site and you can get a much faster and more efficient service.

Sure. I'm just conscious we're 25 per cent through our time allocated and we haven't moved off section 1, and we've got nine sections. So, keep that in mind in terms of questions being asked and responses. Questions in section 2, Joyce Watson.

Good morning, everybody. Health board funding, that's where I'm going to ask my questions, and the budget narrative clearly highlights that they're going to have huge challenges. So, what specific strategies, Minister, do you believe that health boards should employ to manage their individual budgets?

Thanks very much. Well, first of all, they need to stabilise their finances, and that's the key requirement of them this year, and that's quite difficult in the face of the kind of massive demand that we're seeing, the fact that they still need to vaccinate people in relation to COVID, and we've seen inflation. All of those things are quite difficult. So, what we have asked them in that letter is, 'You've got to protect your core budgets.' They are going to have to make quite tough choices.

One of the things we've done is we baselined the money for things like COVID, which we used to keep separate, and we've put that into the NHS budget. So, there will be an expectation now that they put that into their core budgets, and the same thing with energy. So, we're doing the same thing with energy. Where, in the past, we had to—. I kept on quoting, if you remember—I think it was the year before last—that it was £220 million extra that we were charged for energy, which we weren't expecting, and that was an in-year cost. So, there were lots of challenges. The value and efficiency agenda is absolutely key, and that sustainability board is key. But one of the things that we're really keeping on top of is their need to get those target controls—they have to meet those. And I know Hywel is breathing down their necks to really make them come in on budget. But they are going to have to make those tough decisions. Those tough decisions they will work through now within their IMTPs, which will be presented to me, and then I will have to approve those or not.

Obviously, it's going to be quite difficult, because they should be balancing the budget over the three-year process. I'm not sure to what extent we can expect them to come up with a solution for that this financial year, but we will be challenging them. There's an iterative process now where they work through, 'Right, this is what our population needs look like, this is where we want to put our priorities', and then we will have a dialogue and a conversation with them about whether those actually meet what we've set out in the framework document that we've sent them.

How would that look on paper? How will people be able to see the transparency of what those health boards are doing and, therefore, the accountability? What's the mechanism in place for that?

Well, there are numbers of different mechanisms of accountability, and you'll be aware that I've set up a governance and accountability review, because I think that we need a little bit more clarity in terms of that. I think there's clarity for politicians, I think there's clarity for the public. So, first of all, obviously boards—that's the key area for accountability. They are responsible; I delegate responsibility for service delivery to the health boards. The non-executives, they have papers coming—those are public papers, so the public can see what's going on in those boards. Just internally, in terms of management, I have my officials poring over the detail. Also, the NHS executive now has an important role in that. If there are any material changes during the year, then they have to come back to us and tell us, so there's transparency in that sense.

There are a few things where we have said, 'Look, we want you to really drive down change', so, for example, in relation to agency spend, and we are seeing some very positive progress on that. But in terms of local services, they will have to make some really tough choices in the light of the financial situation that they're facing, including, perhaps, reconfiguration of services. But if they do need to reconfigure services, then they will have to go out to public consultation, so that's where the public will have a view. And also, of course, Llais is the independent patient's voice, and they have a role, also, in making sure that the patient's voice is heard.

We hear a lot about agency working, but what we don't hear a lot about is, if we don't use agencies in some places, there won't be any service at all. And I live in Pembrokeshire, and I've seen what happens if you can't get staff: staff equals services, quite frankly. That's pretty obvious to me. So, in terms of reducing the agency—. And you've talked about increasing and keeping the money there for training—those two will take time to meet: the reduction in agency spend and the increase in people ready to take their place. I don't expect an answer right now, but it might be useful to have a paper, to see where we really are in terms of what we've got, the training that you're keeping pace with in terms of the finance, and the reality check about services that are being provided.

I think in terms of the challenges, workforce is the challenge. It's not a Welsh challenge, it is a global challenge. And the World Health Organization have calculated that there's going to be a 10 million shortage of health workers by 2030. So, we are in a very competitive world here, which is why I have a huge amount of sympathy for this requirement, this insistence, that they should be paid more money. We understand their frustrations and that that they have other options. I mean, I was really heartened, actually, over Christmas, when I did some unannounced visits to lots of hospitals, to hear that, actually, there has been a shift, in particular in emergency departments, from the use of agency workers to getting substantive people in post. So, there has been a shift. Now, we need to continue with that shift. You'll be aware, Joyce, in Withybush hospital—and I spent the night in Withybush hospital pretending to be a nurse—50 per cent of the nurses there were agency. So, you can't switch this stuff off or the hospital would close, so you have got to do it gradually. But the fact that we've trained significant numbers of nurses—. This is not something we're starting now, it's something we've been onto for a long period of time. The other challenge, of course, is it's not just about recruitment, it's about keeping them, it's about retention. And we've got a whole programme going on that we've worked through and developed with the Royal College of Nursing in relation to retention. So, we've got to just make sure we deliver on that and make the conditions as good as they can be in order to retain people in our NHS. And, obviously, there's international recruitment as well.

Coming back to the budget, the here and now, you said quite clearly earlier on that, if you had the money, you would increase the offer for pay. If you had more money, would you use some of that to provide additional in-year funding to health boards, if they were struggling?

Well, there are always circumstances where we have to give more in-year funding, and, in terms of pay rewards and uplifts, then we generally do that in year. So, we do hold some back so that we can honour that from the centre. I don't know if you've got anything to add to that, Hywel.

Is this in the context of next year's budget or this financial year? Just to be clear on the question. Is it about 2023-24, or the budgetary terms for next year?

I can't hear you, actually. I can't hear you.

Hywel was asking whether you're referring to the budget for the next financial year or this financial year—I think that's what Hywel was asking.

I'm just talking generally. If there was additional in-year funding available, would it go to health boards? If you move your mic, we might be able to hear you.

Thanks, Hywel.

Thank you. As the Minister's described, I think there are always circumstances where funding streams are provided on an in-year basis. If you look at this year, for example, when we were in committee in November, I think it was, we'd just done the written statement and announced a number of allocations in year. Equally, our traditional approach on things like pay awards would be to give notification to organisations that Welsh Government will hold the assumption on pay and then allocate that funding on an in-year basis once those awards are made. I think, in broad terms, for the next financial year, as a principle, we recognise that what we've allocated to health boards is the best funding that we can provide at this point, and we're looking for them to plan on that basis. We've issued a very clear allocation letter, we've issued very clear detailed planning assumptions. The Minister referenced earlier around the planning framework and our expectation in terms of priorities. So, we're really looking for health boards to develop the plans that meet the needs of their population within those resources that we've made available.

And how do you see those plans aligning with the priorities of Government—the health boards' plans?

I suppose that's set out in your framework, in your letter to them.

So, some of the things we've set out, for example, in the planning framework—. You know, we reference things like reducing inequalities and improved outcomes; delivering improvements against 'A Healthier Wales', which, obviously, we're going to do a refresh of; looking at transformation and innovation in the design and delivery of pathways; strengthening primary and community care; looking further at accelerated cluster developments and enhanced community care, which is more hospital at home and those kinds of things; making sure that there's real focus on quality and safety; and a real focus on women and children, and, as I say, reducing health inequalities. And there are a few national programmes where we're expecting change as well—so, urgent emergency care, planned care, cancer, and, obviously, mental health, including child and adolescent mental health services.

Thank you. Thank you, Chair.

Thank you. Sarah Murphy.

Thank you very much, Chair. I'm going to ask questions now about funding for local authority social services and unpaid carers. So, the Welsh Local Government Association and the Association of Directors of Social Services have said that councils are facing record levels of demand for social care services, which has led to a £108 million overspend this year. They calculated that there will be £261 million social care financial pressures in 2024-25. So, how does this draft budget account for the record levels of demand for social care, and what are the anticipated impacts of this identified funding gap on services?

Thank you very much, Sarah, for that question, and bore da. Well, in 2024-25, local authorities will receive £5.7 billion from the Welsh Government in core revenue funding, and that will be an increase of 3.1 per cent—and that's about £170 million—because we know that local authorities are right at the coalface, so to speak, and we as a Government are very committed to ensuring that we do get that money to the front line. So, despite the very challenging circumstances that we're in, we have done this 3 per cent increase. And even though with this increased settlement, I do absolutely recognise that, with the demand for services and the increased pressures, there will be difficult decisions that local authorities will have to make about how they provide the services.

But, obviously, as you know, local authorities are accountable and responsible to their electorate, and they will have to take account of the full range of pressures that they have within each local authority. So, obviously, what they do is a decision, then, for them. But we do feel very strongly that we wanted to make sure they got that 3 per cent increase, although we do recognise that it will be difficult. And we know that social services are a priority and continue to be a priority for local government, and I think we know that it's a big amount of the total funding that local government has got has to go on social services.

And we have put a lot more money into social care, and our agenda to eliminate profit has meant that we've put £68 million between 2022-25, and £20 million of that will be delivered in 2024-25. This is part of our whole transformation programme that we want to get to make sure that we can reach children at an earlier stage, help families earlier, and if children have to be placed, that they are placed nearer home, and all that will ultimately result in less money having to be spent by local authorities, because one of the big elements that is in the local authorities' budget is paying for very expensive care for children, who sometimes have to be placed outside their own local authority and outside Wales sometimes. Those are huge sums of money, and we do want to—. We're putting that extra money in in order to tackle that—well, it's one of the reasons we're tackling it.

Thank you. That's excellent. How does the Welsh Government respond to the Welsh NHS Confederation's call for a renewed collaboration between Welsh Government and local government to address this variation in social care investment? I have to say—because I'll get told off otherwise, which is fair enough—from my discussions with my own local authority, there is a sense that they're in an impossible situation at the moment, because they must provide the statutory services but they also want to maintain the community services relied on by disabled people, older people and carers. But what they always say to me is, unlike the health boards, the Welsh Government does not have to cover their deficit. So, can you just let me know your thoughts on that, Deputy Minister?

Yes. Well, I think I would repeat what I said in the previous answer that, in fact, the local authorities are accountable politically to their own public in their areas. So, there is a different set-up than the health boards. But what we want as a Government is to move towards considering health and social care together as one system, and that's why we've invested heavily in developing regional partnership boards. We intend to further strengthen regional partnership boards. And those boards are there and the projects that they fund are based on prevention, looking at what's available in the community and trying to offer people the support they need without having to intervene in a way where people have to be admitted to hospital, for example. So, it is trying to give that community support.

We've got excellent examples of very close working together between health and social care, and we want to build on those partnerships that are already there. That's definitely the way we want to go. But we have been working very closely, the Minister for health and myself, on new pathways of care delay to try and improve the situation where people have to stay in hospital when they need to be in the community, and when they don't need any more medical help. And so there's been really intensive collaborative work there between health and social care, and we are now seeing a reduction in the number of people who are in hospital who don't need to be there. Because obviously it's very damaging, isn't it, that people stay in a hospital when they need to be in the community, and we want people in the community. I have got some figures for that. In April last year, there were 1,750 people who did not medically need to be in hospital, and then that had gone down by nearly 200 by December. We're expecting some more figures tomorrow, and the trend, we know and hope, is continuing. So this working closely together is happening, and is successful.

Albert Heaney, did you want to come in?

Yes, thank you very much. Thank you, Minister. It was just to add that the Minister referenced, earlier on in her replies to the questions, the children's services transformation. She referenced the £29 million going in to eliminate. But I think on this part it's really important the Minister referenced the importance of regional partnership boards, and the collaboration and working in partnership agenda. Just to say, Chair, the regional integration fund is a five-year fund. That's very much in the space about community services, prevention and earlier intervention. For the next financial year, that money has been protected, so it will be £146 million across the regional partnerships, which is a significant funding stream. Thank you.

Thank you very much. I'm just going to come to my question, then, about unpaid carers. While the focus is understandably on protecting statutory services, Carers Wales have been in touch and highlighted that when unpaid carers can manage and provide effective care to their loved one who relies on them, this eases pressure on formal care services and the NHS. But unfortunately, when carers struggle without that support they need, this places further strain on the budgets of health and care services—as I know we're all aware. Obviously, earlier this year, Deputy Minister, in March 2023, we had the evaluation of the Social Services and Well-being (Wales) Act 2014 that came out, so it would be great to have an idea of how and when the Welsh Government will respond to the findings and recommendations in the evaluation. Also, any information that you can give us about how this budget—. You know, one of the main things we hear from unpaid carers is about that need for respite care. So, anything that you can cover from this budget in terms of respite care would be very appreciated. Thank you.

Thanks very much for that question. Certainly, in terms of the evaluation of the legislation, I think there's universal agreement that we've got the right legislation—person focused, looking at individual needs. But in terms of implementation, that's where I think some of the evaluation has indicated there are areas that we've got to do more work on. And then you referred to unpaid carers, and of course unpaid carers are absolutely vital. We know the whole system is held together by unpaid carers, and we absolutely recognise that and want to do all we can to help unpaid carers.

We do have the national short breaks scheme, because you mentioned respite, and there is no intention to reduce that. That's £9 million over three years of the programme, 2022-25. It provides additional funding through regional partnership boards, which we've mentioned before as being the key areas of delivery, to provide opportunities for unpaid carers to have respite. This is intended to be very flexible, and this scheme is intended to ensure that an additional 30,000 carers take a break from caring by 2025. As I say, we have maintained that funding.

Then, in terms of people who are older and disabled, we are trying to create an age-friendly Wales, and this is not statutory stuff, but it's stuff that is so important because it's trying to ensure that there are opportunities for older people to be involved in the community, to fulfil their lives, and for a relatively small amount of money we've been able to do quite a lot of that. We are maintaining that money.

If I could just end on one other area that I think is so important, it's young carers. I've met many young carers. I've met lots of groups of young carers, and this summer I was able to attend the young carers festival. We started the young carers festival because they asked us could we have a festival for them. They had three days in Builth Wells where they were able to speak to each other, support each other and take part in some absolutely great activities, and that's something we were able to fund. It's the second year we funded it and I'm very determined that we find the relatively small amount of money to continue that next year, because of the huge uplift it gives. If you can give young carers that uplift, they can go back and do all they do with a renewed vigour.

So, I would say on carers as a whole we're maintaining what we're doing. But, obviously, we recognise how much they do contribute.

Thank you very much. Thank you, Chair.

Thank you Sarah. Gareth Davies, do you want to come in?

In the first set of answers you gave, you mentioned the Welsh Government's and the co-operation agreement's programme to eliminate profit-making childcare services. Given that it makes up 80 per cent of the sector currently, and given the budgetary pressures that we are currently facing, do you think that's a prudent spend of public money to take such vast amounts of resources out of the private sector and put them into the public sector, given the budgetary pressures that we're currently facing in Wales in 2024?

We want to give the young people and the children who have to be looked after by local authorities, by the Welsh Government, the best chance in life. We think that this is the best way of giving the best chance in life. This is what young people have told us and this is what the evidence shows. We are committing money in order to build up the resources that are there for the local authorities—

But did they ever say to you that services run by the state are going to improve their prospects of receiving better care and closer to home? How can you be assured that that being run by the state is going to be more effective than businesses that have been in operation for a number of decades and invested huge amounts of personal sacrifice and personal money into those services? How can you be assured that the state can do a better job of doing that than what businesses are currently doing now?

Young people have told us that they don't want to be placed in services where people profit, and in many cases the profits that are made are very high from the position that they're in. It's not only because we think it's right to do this; it's also prudent, because I'm sure you're aware of the thousands of pounds per week that is spent on young people who are being placed in private sector placements, some of which may be very good, but it is a huge drain on the resources. And when we go round local authorities, they say that children's social services are one of the biggest drains on what they have to pay out. So it is a prudent policy, as well as one that we think will result in better outcomes for children.

But can you be assured of the quality of service at a sustained level given the current budget pressures? That's essentially the nub of what I'm trying to get to. Because if you bring it under the state and if you bring it under the current budget pressures that we're facing, it's going to be subject to future Government decisions, future budgets, future times that we might not necessarily have a crystal ball to look into now. But what the private sector will give you is that autonomy to overcome those governmental changes, different economic times. Essentially, can you be assured that that service is going to be enhanced and be better, given the current state of play that we're in?

I think what local authorities would tell you is that children's services are not in a good state now and we want to move to a much better situation. That's why we want to transform children's services. We're not satisfied with the way that they are being delivered at the moment. Absolutely, I know there are private independent services—. I'm not denying that some of them may be doing a good job, but overall children's services are in a state that I don't think the local authorities are happy with and we're not happy with. But, of course, we also want to develop the voluntary sector, because there's been a lot of very good work done by the voluntary sector in terms of providing children's residential accommodation and children's fostering and adoption services. We do want to encourage the voluntary sector as well.

The logic of your argument also doesn't hold water; it suggests that all private sector is good, and it's not—sometimes they go bust and sometimes they don't follow regulations. So, actually, if you're looking for stability and solidity, you can just look at the broader care sector to see that shift, for example, in places like Carmarthenshire. They're deliberately saying, 'Actually, that private system is too fragile; we need something that's a bit more stable, because they're closing down.' So, I just think this suggestion of 'private: good, public: bad' is not something that we politically would sign up to.

That's not what I'm suggesting at all. Essentially, what I'm trying to get to the bottom of is how can we be assured that the public sector can do a better job, given the current budgetary pressures that we're facing. Because whether it's a good or bad service currently, essentially, they're autonomous, they don't rely on public money. On a budgetary level, which we're discussing here in committee today—

They do; they totally depend on public money.

—how can you be assured that the quality of service can remain and improve, given the budgetary pressures that we're facing? If you can't assure that today or whenever, how can a private business owner be assured that the Welsh Government or decision makers are on their side and have the best interests of children at heart, truly?

This has all been done in the interests of children. The system as it is is not sustainable.

This may be a discussion that we can have outside the committee. It could be a long discussion otherwise. Thank you, Gareth. Jenny Rathbone.

Thank you very much. I just wanted to follow up on the earlier conversation about the strikes and our inability to pay any additional money to junior doctors at the moment. I spoke this morning to the chair of Cardiff and Vale health board about what it's going to cost the health board to manage the three days that they've had to plan for this week, and he's assured me that it is a top priority for them to understand that and we'll get that information as soon as it's available. I just wondered if the Government has made a calculation of the cost, because it's clearly huge to bring in consultants to cover for junior doctors, for the management time and just re-establishing services, for all the figures you've given us about the numbers of cancelled procedures and all that sort of thing. I just think it's relevant to our budget discussions.

I just think we've got to be clear that any additional funding, if we were to find that in order to avoid the strikes, wouldn't be a one-off payment; we'd have to baseline that into future years. So, it's not a one-off payment; this would go on forever, and quite rightly so. But we couldn't make that calculation until we were clear how many people had actually engaged with the strike. We know that the figure is that around 76 per cent of those 4,000 actually participated. It's a huge amount of preparation to get consultants to cover. Obviously, part of what we had to do was to pay consultants who wouldn't otherwise have been in on that day to come in. That's where the main cost is. But we'll be getting those calculations, and I guess, by the end of this week, we should get a better sense—

By the end of this week, you say?

I should think we'll get a better sense by then.

I beg your pardon?

I think—. Will we? By the end of this week? Sorry.

What the Minister has described is that we haven't got an assessment at this point. As the Minister has described, there will be an additional cost for that additional cover that's been provided, offset by the reduced cost of those junior doctors who've taken part in industrial action, and also the reduced cost of activity that may not have taken place in terms of cancelled appointments, and so on. That assessment is being undertaken by each local organisation and then we'll be consolidating that. That is something we're looking to get an assessment of as soon as possible.

So, you might be able to give the committee a figure by the end of the month.

We're looking for organisations to do that assessment by the end of this week, so then it's our ability to consolidate that and share that view.

So, we might be able to get that by the end of the month. Thank you. My only other question, having talked to all these people who work in junior doctor positions, is: how well does the health service look after its staff to avoid burn-out? Some of these people are working very long hours, they sometimes get to eat a proper meal during a shift, and sometimes it's frowned on by colleagues, who say, 'You've left the ward. Why?' These are important issues for ensuring that people keep well and are able to continue doing a good job, as opposed to absolutely having to take sick days, because they just can't continue. I just wondered what conversation you have with health boards to ensure that people really are acting in line with the Social Partnership and Public Procurement (Wales) Act 2023.

Sure. Thank you. As I said earlier, retention is one of the key issues that we're really focused on. What we've got is the workforce implementation plan, which has been a plan that has been built with the unions, who have helped us to figure out what is important to them, and we've got a whole programme now to put in place to make sure we deliver on what their priorities were in order to try and do something to address that retention issue.

We have more people working in the NHS than ever before, so it's not that we're not investing, we are. It's about the demand, the demand, the demand. It just keeps on coming. Part of our issue now is, look, if we do have a ceiling in terms of how much we can spend, where would we go for this additional money? There's one obvious place to go, and that is you could cut staffing. That's the last thing we want to do now, and it's not something, I'm sure, that the junior doctors would welcome either, because it would put even more pressure on the people who are there now. So, that's part of our real struggle here. We would like to honour them by giving them a decent pay award that is beyond what we've been able to offer, but that's really difficult, because where do we get it from? You're aware that 65 per cent of what we spend in health goes directly on staffing.

Yes, and my question is, really: how well do health boards nurture their staff, because, otherwise, they will go elsewhere or they will burn out?

They have to comply with that workforce implementation plan, and we've made that very clear. Despite all of this pressure we're putting on them to come in on budget, actually, they do need to acknowledge and to respect what has been agreed within that workforce implementation plan. Anything to add, Nick?

There are also a number of mechanisms, I think, within health boards that encourage both an open culture of listening and talking about some of the issues that you've referenced, whether they be long shifts, unsocial hours, et cetera, and the staff survey was moved to an annual basis. There's a requirement for health boards to produce a response plan for every staff survey, and it's really important that we encourage staff within the organisation to participate in that, and then, also, for the organisation to listen and act on that. I think the issues that you reference are really important in terms of that motivation and the morale of existing staff. Health boards have a real duty to respond to some of those issues. We constantly monitor how they're responding to things like the people surveys to make sure that there is that response, alongside what's already been agreed from a social partnership perspective.

Thank you.

I think it's probably also worth mentioning the compassionate culture and leadership that is fundamental. I know, for example, that Betsi Cadwaladr is planning to bring the guru of compassionate leadership in to do a session with their leadership team in the next few weeks.

Just to add, as well, that we've continued to fund Canopi, which used to be Health for Health Professionals, but now provides support to anyone working in the health and social care workforce. That's a significant investment that we've continued to make to make sure that there is well-being support available for health and social care staff.

Does that include ensuring that people on the night shift are still able to get hot meals?

Sorry?

That people on the night shift in a hospital are able to get hot meals, because that's their day job.

I think that would be more under the other measures that Eluned has described, really. This is about well-being support, mental health support.

Okay, more mental health.

Yes.

Thank you.

Thank you, Jenny. Mabon ap Gwynfor.

Thank you, Chair. Just one point on what you said earlier about the strikes and the BMA's argument. You've promised to restore pay back to 2008, but then you've offered a below inflation pay rise. It's impossible, therefore, to restore back to 2008 wages if you regularly offer an increase that is below inflation, so I don't see how you're going to achieve that ambition, because clearly, it is an ambition.

There are a few promises that have been made by you over the past few months regarding pay awards to the workforce. Are you going to be able to keep to those pay awards and those promises that you have made to the different workforces within health? And can you give us assurances that that will be kept to?

Yes. Whatever we’ve promised, we obviously will honour, yes.

The Deputy Minister earlier on, in response to a question from Gareth Davies, gave an answer that I think I fully agree with politically, in terms of the profit that's made in the childcare sector, with the reasoning being that it's prudent, a strain on resources, a drain on resources, et cetera. The same is true when it comes to the agency workforce within the health sector. So, can you give us an assurance now that you are going to reduce that spending on agency staff, and what can we expect to see in terms of spending on agency nurses, for example, at the end of this financial year?

I can give you an assurance that this is a priority for us, and certainly, in terms of the work that is being done by the group that the NHS chief executive has convened and is working on, agency workers is something that that has been focused on. We want to see a major difference in that area, and I expect—. I don't know, Hywel, if you have figures that you can share, but they are significant figures in terms of how much we think we can save this year, and we'll have to look forward to the future to see if we can continue with those savings.

Yes, diolch, Gweinidog. So, we’ve seen a reduction in our agency spend from what was £325 million in 2023-24. That’s currently forecast to be £266 million in this financial year, which is a reduction of £59 million. From an agencies perspective, going forward, we’ve got a range of workforce measures, as the Minister's outlined, through the value and sustainability board on a national basis to support what health boards are doing locally. We are intending to take very specific sort of targeted recruitment in terms of where there are areas of sustainability challenges within health board plans, with a view to strengthening some of those services and also reducing cost.

And from that £325 million previously and £266 million this year, how much of that is profit for these private companies?

I don't have those figures at the moment. I'm happy to follow up with an assessment of that.

If you could, that would be great. The same principle, therefore, relates to locum doctors—that same general principle. I know that there are merits to having locum doctors, but we are too reliant on them at the moment, so will we see the same emphasis being put on locum doctors, and the expenditure on locum doctors therefore reducing?

Of course, we're very eager to see a decrease in that expenditure. What we want to see are people who are entirely committed to the health board, where you see sustainability, that they see people, that they're embedded in the organisation, so I'd expect that to happen in terms of that board.

Yes, we would, and the only thing that I would balance in response is clearly there are instances where having a flexible workforce is really positive, so there will always be a requirement for a locum medical workforce. Being clear on why we have that, is it sustainable, for what purpose, what outcomes, what outputs we’re delivering for that, is again the focus of that group.

Thank you for that. In terms of expenditure on the workforce, we know that there are 43,000 or so nurses. We've talked about 4,000 junior doctors. They are big numbers in terms of that workforce, but at the same time, I've challenged you previously about nursing associates; we have seen an increase in physician associates too. Is it your intention to roll back a little bit on the specialist role of a nurse or doctor by bringing in more general roles and less specialists roles through positions like nursing associates or physician associates? Is it your intention to reduce spending on workforce and bring in this workforce?

I don't think that what is driving us is to reduce expenditure. What we're trying to do is maximise the benefits for the patient and I think it makes sense to ensure that we're using nurses at the top of their licence and that we deploy them where it's appropriate, but if we can use other staff members to help out, why wouldn't we do that? And I do think that that is something that it's important that we consider. We already have some physician associates in place. There are new ways of entering the NHS to help out. I think that you have spoken in the past about the importance of apprenticeships and so on, that there are new routes into the NHS, and these are some of the step-ups that people can take during their careers, and I don't think that that should be a problem really. I think seeking new ways for people to enter the workforce that doesn't necessarily mean attending university is a good thing.

Thank you. And also one of your ambitions—. You've talked previously about, and Nick mentioned earlier, waiting lists, and one of your ambitions is to reduce waiting lists here in Wales. We know that there's been a great deal of coverage, politically and in the media, about that. How do you intend to do that with the current financial settlement? Is it realistic to see those waiting lists reducing?

Well, I think it's going to be a challenge, and the greatest challenge is the fact that the demand just increases, increases, increases. And just to give you an example: in 2019, around a million people were referred into the system; today there are 1.2 million being referred into the system. So, that is a huge leap where there is a real challenge in terms of funding.

So, what we hope to do is to focus on the kinds of steps that Nick mentioned earlier: efficiency and ensuring that we do more work, perhaps regional working, and I think that there is a great deal of emphasis that we can put on those things.

Nick, would you like to expand on that a bit?

Yes, I think, as the Minister has alluded to, the regional opportunities are quite significant and we ran what was called a 'perfect week' in north Wales, following a number of issues that we'd picked up around productivity. We considerably increased the number of orthopaedic procedures going through there and, as a result of that, are now making an investment into the Llandudno site for a specific orthopaedic unit there. So, I think there are number of steps like that that we can take.

The other key issues, I think, are around the utilisation of our resource, whether that be physical or people, as we move forward, and making sure that, when we run theatre lists, the process to get patients in is effective, but also that we get as many patients as possible on each list and that we utilise all of the times available within core budgets and core staffing to drive productivity. We know that we've got a huge opportunity in that area, particularly with day-case and day procedures' start and finish times. There's a whole myriad of things that we are bringing through the value and sustainability board that will be driven through the planned care programme and the NHS executive over the next 12 months or so. So, that should, as I alluded to earlier, increase the activity towards that pre-pandemic period and the increase that we expected to see, which will then result in the reduction in the waiting times that we want to see across Wales.

That's very interesting to hear and I'm looking forward to seeing that. Interestingly, the only two candidates for Labour Party leader and First Minister have promised to reduce waiting lists, so I wonder if that is what they have in mind—if that is their plan. Do they know something that you don't, maybe, about waiting lists?

In terms of the social care workforce and the care sector, the current budget can't promise to pay the real living wage to the care workforce. So, what impact will that have on the current workforce? Will we see the same number of people staying, or will we see people leaving the sector?

Well, the Minister for Finance and Local Government, under whose budget the real living wage comes, she has confirmed that there's funding within the revenue settlement to support payment of the real living wage for social care workers. And that was in her letter to council leaders on 20 December. So, we do anticipate that local authorities will be paying the real living wage, and we think it is very important that the social care workers get the real living wage, because there are difficulties in retention and recruitment, and I think keeping the real living wage is absolutely crucial.

It is good to hear that. Lastly, Chair, if I may, just thinking about training, there will be a flat settlement in terms of the social care reform fund; in terms of training for the health workforce, we see that there will be no increase. How is that going to impact the number of people coming in to train to be a part of the health workforce, and will we see fewer people being trained? And if so, which departments will see the biggest impact? What do you expect to see in that regard?

So, we haven't cut it; it's flat. So, we were hoping to be able to increase it, but it's flat, so—

And because it will be flat, there will be fewer places.

Well, first of all, we have to consider that there are more people than ever before working in the NHS, that we're spending £281 million per annum on Health Education and Improvement Wales. What will be happening now is that every health board will say what they need in terms of training. That goes into HEIW, and they then consider, 'Right, how many dentists do we need, how many orthopaedic surgeons do we need?', and so on. So, the decisions on who will be trained and how many will be trained are something that emanates from the health board and then HEIW makes a decision on the basis of the entire picture. So, we don't have those details yet, but of course we will hope to see those details soon.

So, do you think that it will be impacted and we'll see fewer people being trained?

Well, I don't think there'll be a short-term impact, because it takes a while to train people. Hywel, do you want to come in there?

Yes, thanks, Minister. So, I think it goes back to the Chair's point on prioritisation at the start. I think, strategically, what we're doing from a workforce perspective here is that we're having to temper some of our longer term investment just because of the short-term challenges that we have. So, whilst we are holding the budget flat, we are working with HEIW to finalise how those training places are distributed, and working with them to look to increase the number of commissioned places even within holding that budget flat. So, even within that environment, we have some confidence that we may be able to increase the training places that we're commissioning above 2023-24 levels. And then, complementing that through our planning process, looking at what are the very wicked short-term challenges that we have and more targeted recruitment solutions in those areas, referencing some of our previous discussion on workforce.

Diolch.

Thank you. We've got 40 minutes left and there are four sections. I've got Jenny leading one, then Sarah, then Gareth, then Joyce. So, it's about 10 minutes for each section, so if you can bear that in mind and if Ministers are happy to be politely interrupted if Members feel they're not quite getting to the point. Thank you for that. So, Jenny Rathbone.

Thank you. First, congratulations on the success in making primary care much easier for people to get to see their doctor or their nurse. Certainly, in my inbox, I am not getting complaints about that any longer. So, I want to focus my 10 minutes on prevention. You will recall that yesterday I raised with you the issue of malnutrition and admissions to hospital, done by The Guardian. In hospital data for England and Wales, 800,000 people were admitted to hospital with malnutrition, which would translate roughly to 40,000 for Wales. I appreciate that there's a niche problem around elderly people with dementia not feeding themselves properly, but this is much wider than that; this is to do with observation from schools about people having bow legs, as a—. You know, this is a major issue. So, looking at the regional integration fund, £147 million, the Public Health Wales fund, £150 million and the initiative of social prescribing, how well are we enabling people to know what healthy balanced diets look like, rather than the very inadequate diet that many people, including pupils I speak to regularly, are actually eating?

Minister, shall I start on that, then?

Please.

I mean, obviously, you've highlighted a really important issue and it's linked to the awful cost-of-living crisis that we are all living through, and Welsh Government is doing everything that we can to mitigate the impact of that, whether that's in direct investment in supporting people who are experiencing food poverty—. So, this year, we've allocated an additional £2 million to tackle food poverty through the winter period; that funding has supported community food projects. We've also got the Big Bocs Bwyd, which you are aware of, I'm sure, which has now been rolled out to 65 schools in total, with a further 38 on the waiting list. We've got support for FareShare Cymru as well, and also things like the local food partnerships. But what we're also doing as well, through the work that we're doing with 'Healthy Weight: Healthy Wales', is a range of measures. As you know, that's a multicomponent plan to tackle some of the challenges we're facing around obesity and healthy eating. And we're working at—you know, whether it's early years, through things like breastfeeding, free school meals, which we've invested in as a Government in partnership with Plaid Cymru—. You referred to the investment in Public Health Wales; obviously, they've got a really strong focus on prevention. They've got a new website now that they've implemented for us around 'Healthy Weight: Healthy Wales'. But there is a whole range of other measures as well. As you know, we're committed to making the food environment more healthy in Wales. We recognise it's not just about individual choices. We are all living in an obesogenic society and we're committed to introducing secondary legislation this year to tackle the healthy food environment, to try and make the healthy choice the easy choice, to try and incentivise supermarkets to make healthy food cheaper. But it is a really complex issue, and that's why our 'Healthy Weight: Healthy Wales' is a 10-year multifaceted, multicomponent strategy.

So, I just want to pick up on something that Sarah Murphy mentioned the other day in relation to the child poverty debate we had in the Chamber, which is that there were cookery classes funded by the European money that we used to get, and that is—. According to one of the people that were spoken to in Swansea, that was transformational for that family because they suddenly knew how to make a nutritious hot meal, and cheaply. And I'm afraid the message from a lot of the foodbanks is that people are handing back stuff because they just don't know what to do with it. So, it's a really complex issue and I just want to know how much attention is being paid to just having basic cookery classes. I know both in schools, which is not your responsibility, but also in the community, through social prescribing, through Public Health Wales, ensuring that everybody can be referred to get tips on how to buy things that are good value for money as opposed to what is being promoted on the television—.

Well, I mean, you raise a really important point, don't you, about people being able to cook with healthy items. One of the things that we've continued to invest in, and I'll bring Irfon in here, is Nutrition Skills for Life, isn't it, which is also about ensuring that people do know how to make healthy meals. We've continued as well to invest in our Healthy Start vouchers, which are for the poorest families to have help with the costs of buying things for little children, and we've got an ongoing programme of work around that. We've spent a lot of time raising awareness of Healthy Start vouchers, and our take-up now is the best in the UK. We're also—

Oh, really—what is it now, then?

It's over 70 per cent.

Over 70 per cent.

Oh, well that's—. Congratulations. That's amazing, because originally I was being told by health visitors, 'We haven't got time to help people fill this in, and it's a complicated process.'

We have done a lot of work, and we've brought health visitors together, and we've also developed bite-sized training for health visitors and midwives, so that they are much more familiar with the scheme now, and we're starting to see the benefits of that in the uptake of that. We are also looking at whether we can get the scheme devolved to Wales, but we do need to do some more further work and evaluation on the scheme so that we are in a position to make a decision on that, and, if we move forward with that, to make sure that it is the right approach for Wales, really, because at the moment we are pretty hamstrung by the UK Government, who operate the finances through NHS business services. I don't know, Irfon, if you wanted to add anything on that.

Well, quickly, on the Healthy Start, the training the Minister referred to we've actually made mandatory within the health sector for those working with pregnant women and young children, so that we can do what is within our gift to increase that uptake. The Minister has a number of other efforts. We're obviously working closely with our education colleagues on the curriculum and the area of learning around health and well-being, so some of the issues you raise can feature there. And also, under the auspices of the healthy weight strategy, you're probably aware we've maintained funding for some of the children and family pilots—three pilot areas—and, within those, where there is demand from those or particular issues locally, nutrition skills can feature in those as well.

Okay. Could you write to us with some detail on this, because it really is about how you're using the resources, i.e. the money, to drive that? I congratulate you on the work you've done on Healthy Start, but, clearly, there's a great deal more of work to do, not just in schools, which is for a separate committee, but also in the community itself and with families who need to feed their kids at home.

Yes. As Irfon said, public health officials are working closely with education officials around free school meals, and we've been very clear that, if we're going to make this big investment in free school meals, then we have to make sure they're as healthy as they possibly can be for children and young people. Irfon also mentioned the children and families pilots, which we've got in Anglesey, Cardiff and Merthyr Tydfil, and we're working with Public Health Wales at the moment to evaluate those pilots. We're continuing the funding in the draft budget for that work, but what we want to do is take the learning from those pilots and extend that then to the rest of Wales. They are taking a nested approach, doing very intensive work with families, and that would include things like how to cook on a budget and how to have healthy meals et cetera, but I'm very happy to provide some more information to the committee on that.

Okay. So, a decent proportion of the resources that you've outlined in the prevention section of your paper is going into this, and obviously other important things like smoking in pregnancy.

Yes, absolutely. We've protected resources for prevention, whether that's 'Healthy Weight: Healthy Wales', our work to reduce smoking, our work around vaping. The budget for Public Health Wales—and all their work is really focused on prevention—is £150 million next year. So, there is still a really strong focus in the work that we're doing on prevention, and indeed the planning framework that the Minister has issued makes it clear that we're expecting health boards to continue to prioritise prevention. As Julie said, it's not just about health boards; it's about the regional partnership boards, and they've got their £146 million through the regional integration fund, and prevention is a really key theme in the work that they're doing as well.

Okay.

Thank you, Deputy Minister. I'll bring Sarah in.

Thank you very much. I have a question specifically about the NHS Wales chronic obstructive pulmonary disorder, asthma and COVID recovery apps. It's been raised with me that, at NHS executive level, they may all be closing down at the end of this financial year, which is obviously only in a couple of months. So, about 15,000 people, I understand, are still on the COVID recovery app; about 25,000 patients use the asthma and COPD apps. So, I understand that it has been offered to the individual health boards, if they want to pay for that themselves, going forward, but none of them have taken it up yet. So, there's obviously now a growing concern with campaigners, Asthma + Lung UK, for example, about what happens in a couple of months, when they drop off. What happens to those potentially thousands of patients who are really using them, and using them well, and it's truly working?

Thanks. And I remember having a presentation on this, and I must say, I quite liked what they'd been doing. So, the COPD apps were developed as part of the respiratory health delivery plan, by the respiratory health implementation group, so that funding came to an end after eight years, as has the procurement arrangements for that respiratory toolkit, and that includes the COPD apps. At the moment, the health boards' executives are arranging for an evaluation of that toolkit, to determine whether that should be reprocured, and I don't think I can comment further whilst that process and that exercise is going on.

Thank you very much. Okay.

Can I just add as well, in terms of Jenny's question—and I know that diabetes is an area that you're very concerned about—just to let the committee know that we've continued funding for the all-Wales diabetes prevention programme? We're seeing really good results through that. As you know, we're incredibly worried about the costs of the explosion in the number of people who are getting type 2 diabetes, so we're continuing our prioritisation of that work.

Thank you, Sarah. Gareth Davies.

Thank you, Chair. The finance Minister said that the Welsh Government is carefully examining whether charges for some services, such as NHS dental care and domiciliary care, need to be raised to help extra funding for public services. What impact would increasing dental charges have on patients' ability to access services, given the pressures within the dentistry system?

Well, thanks very much. Well, you'll be aware that there is a system in place for charging people at the moment, which is means tested, effectively. So, those who don't have the ability to pay don't pay for that dental work. But we have an ability—and I think it's probably worth looking at the difference between what we charge in Wales compared to what was charged in England, in relation to dental care. Look, we don't want to do any of this—and I think we've got to make it absolutely clear—but we are in a position where we do have to look at every possible avenue, to see how we can increase revenue. So, I don't know if you've got any of the details on that, Hywel, in terms of how much we charge in Wales compared to England.

I think only to add, Minister, as we are looking at that, given the budget pressures that we have, we can no longer hold off looking at increasing those charges, but it's with a view to increasing charging in order to improve access. And we're also looking at the evidence on public perceptions as part of our wider considerations, including what the charging mechanisms are in England.

So, just to give you an idea, the band 1 charges are currently 75 per cent higher in England, and the band 2 and 3 are around 50 per cent higher. So, there is a massive difference between what people are charged in Wales compared to England. Those who haven't got the means won't pay, but we are considering what might be done in this space.

And how much autonomy do you have in terms of setting those prices and adapting them according to, obviously, what you deem to be affordable, essentially, but in a way that can increase NHS provision within the current difficulties? Obviously, you mentioned, recently, looking at the NHS contract, but in terms of charging, would that be something that, if you were to have a lower price system than what it would be in England—does that necessarily mean a higher governmental spend because you're making up the difference, essentially? So, what are the reasons why Wales can charge less than England, then, for dentistry treatment?

So, that's the point—we're making up the difference at the moment. And what we have to consider is whether we can afford to make up the difference in future. So, that is something we're exploring at the moment. We have the regulatory ability to raise charges, so we don't have to go out to public consultation, so we have that ability. So, obviously, we're putting some thought into that. We've got to balance it against whether people will be put off going to dentists, and so we've got to get that balance right. But I think, if you look at the differential between us and England, you'll find that that is a significant difference in terms of what people are charged in Wales.

Thanks. And the news that the higher domiciliary care charges may be on the horizon—a great deal of concern for people dealing with increased living costs currently. What more can the Deputy Minister tell us about what is being considered, including how much the cap may rise and the likely funds that this would generate, and an indicative timescale for any proposals?

Well, this is something that we are considering, as I think I told you in the Chamber last week. Officials are in the process of looking at how this is going to progress at the moment. And obviously we absolutely understand that this will be of concern to the public. I think it's important to note that the maximum charge, notwithstanding inflation and other factors, hasn't increased from a £100 per person as a cap per week since 2020. And in contrast, local authorities have seen very big increases in terms of care levels, of demands for service, and all the additional costs, with energy and the cost-of-living issues. And this is something that the local authorities have asked for us to do, to raise the cap. We as a Government have got to work out how we can ensure that care can be sustained in the communities, and this is one of the areas that we're reluctantly having to look at. And we broadly estimate that a £10 increase would have the potential to raise up to £4.8 million in revenue. We hope that we'll be able to announce what we are planning to do, but, of course, this will be dependent on consultation. There will be a proper consultation period and people will be able to say what they feel about this and how it would affect them.

Thank you.

Can I just add to that?

Yes, sure.

No decision has been made on this yet, obviously. So, it's just something that we just have to explore in the current situation. But I think it's probably worth just emphasising that there is no cap in England—that people can be charged literally thousands of pounds a week for domiciliary care—and that this is means tested. So, if you don't have the money, you don't pay. So, there is protection for the least well-off.

My concern, principally, isn't England, specifically; I'm concerned about this aspect in Wales—

No, absolutely.

—with all respect. But if this is the situation, how can we ensure best access to care and support, if that was the case? Because this is an issue that has been highlighted by Disability Wales, who have expressed concerns about this. So, how can we ensure the best access to care, given that situation, if we do indeed face it in the future?

Well, as the Minister has already referred to, I think it's roughly a third of people who don't pay anything, any charges at all, and a third pay the top amount—the £100 cap—and there's a third in the middle. And obviously, the points you make, we absolutely understand them. As I say, this is something that we are having to do reluctantly, to try to ensure that the local authorities get the money in, so that they can actually manage to run the services. But this is dependent on consultation and on looking at the impact assessments, and there will be every opportunity for the organisations who speak up for disabled people, in particular, to have their say. And my officials are active members of the disability rights taskforce, where Disability Wales and other organisations are able to make their case. All this will be done in a proper way to ensure that everybody has a chance to have their say, and any changes will be informed by public consultation. But as the Minister said, this isn't set in stone at the moment. At the moment, we are considering it and officials are looking at it, and we regret it very much.

Thank you. Disability Wales also highlights the financial hardship disabled people face with the cost-of-living pressures. Is this something that the Welsh Government recognises, the specific financial struggles that people with disabilities face, obviously, in the current situation, and also their families and support network? And how do you intend to help them as best as you can?

Yes, we're aware, in this cost-of-living crisis, that disabled people is one group that's usually disproportionately affected by such a crisis, and we want to do all we can to help. We are involved in all the different forums with Disability Wales and the disability rights taskforce, so all our officials are part of that. So, we are very well aware of the issues that they are raising, and I believe that recommendations are going to be made soon from one of these groups about what things can be done to help.

But there are some things we're doing. We're addressing direct payments for continuing healthcare, for example, particularly for individuals who are transitioning from social care to a healthcare-funded package to be able to access direct payments. That is a big issue for disabled people and that is one of the things that we're in the process of looking at now, and we hope to bring in legislation about that. So, that will be a great help, I think, to disabled people in a social care Bill. And then, we've—. I know you're well aware of the single advice fund, and more than half of the people who have accessed the funds—I think 54 per cent—have reported that they or a family member are a disabled person, or have a long-term health condition. So, since that single advice fund was introduced, services have helped more than 250,000 people deal with over 1 million social welfare problems, and those helped were supported to claim additional income of £132.9 million and had debts totalling £36.1 million written off. So, that has been very effective, the single advice fund, and that's something the Welsh Government has done and is a huge help for disabled people. And it has got this very innovative way of being delivered, using partners to actually deliver the money.

Another thing we do, we fund the Family Fund project Take a Break Wales, and the aim of this project is to provide grants for short breaks and enable breaks from caring within the home to families with disabled and seriously ill members. That's linked to our earlier discussion, that we are determined that carers, wherever possible—we want to give them all an opportunity to have a break. And grant funding for that project was from April 2022 to March 2025, and the total awarded was £1.8 million.

So, those are just some examples of the way that we are trying to reach and help disabled people, because we absolutely accept that it's a very difficult time for everybody, and particularly for disabled people.

Thank you very much.

Thanks, Gareth. Sarah Murphy.

Thank you. I've got some questions now about mental health services. We could probably do two hours just on mental health services, let's be honest—

And we've got five minutes.

—but we don't have it, so I'm going to keep it very specific to the budget. So, in the Welsh Government's evidence paper, it says that mental health funding for the NHS will continue to be ring-fenced, and that £800 million is included in the draft budget for this. But then it also says that it cannot increase additional funding by £15 million as originally planned, and that it has also reduced the existing mental health central budget by a further £6 million. So, Deputy Minister, could you just clarify: have there been cuts made to the mental health budget? And if so, can you just give us some idea of what the priorities are at the moment?

Okay, thank you, Sarah. Well, what we've chosen to do is prioritise front-line services, and as you've highlighted, the mental health ring fence in the draft budget is increasing by £25 million to £800 million. What we have had to do to balance that is, you'll recall that we had made a commitment to—. We increased funding in 2022-23 by £50 million for mental health, in 2023-24 to £75 million, and we had originally hoped to go up to £90 million in the forthcoming year, and we haven't been able to take that final step of the additional £15 million, because we've prioritised the delivery of front-line services. Obviously, we've been having some really difficult discussions with health boards, both about this year's money and next year's money, and one of the things that was becoming apparent is that some health boards were talking about flexibility around the ring fence, and I was personally really worried about that, because I think the ring fence is incredibly important. We know we've got more work to do in terms of delivering parity between mental and physical health, so it's been a really big priority for me throughout these discussions to make sure that that ring fence is protected, and we have achieved that.

In terms of the reduction of £6 million in the central mental health MEG, just to assure the committee, we've been able to make that reduction through underspends. So, as you know, we've invested so much additional money in mental health that health boards haven't been able to fill all the vacancies with the service improvement money that we've made available. So, we have been able to do that through underspends. And also just to emphasise to the committee that we're still fully committed to the mental health workforce plan. There's £6 million allocated this year for that. We're currently working on the figures for next year because some of the money will come from central workforce budgets, but we are committed to doing that. That's very important, that we do have that sustainable investment in our workforce. And also to add that we have invested £2.2 million in the strategic programme for mental health in the NHS executive, and I can't tell you what a difference I think that will make, having that dedicated NHS executive resource with a mental health programme to drive improvements across the NHS in Wales.

Thank you. And that does bring me on to my next question, then, about how does the ring-fence allocation compare to health boards' actual spend? I actually visited Mental Health Matters yesterday, which provides the peer support and outreach for the community of people with eating disorders, but also the tier 2 service that's been set up for eating disorders in Cwm Taf Morgannwg, which is absolutely tremendous, and makes a huge, huge difference. But what I do hear is that unless Welsh Government, unless you, say that it's mandatory for that to be used for eating disorders, for example, even within the mental health budget it won't necessarily go towards that. So, it's also about drilling down, isn't it, to those questions? And that also, I think, goes for substance misuse services too. So, your thoughts on that would be appreciated.

Okay, thank you. Well, I think it's important, with the ring fence, to recognise that it's a floor, it's not a maximum we want health boards to spend. So, if I give you the example of 2021-22, the ring fence that year was £726 million, but health boards actually spent £961 million on mental health services—so, considerably more than the ring fence. We will be monitoring the ring fence very rigorously. I had a meeting with vice-chairs last week where I emphasised to them the importance of them monitoring the ring fence within their own health boards, and we've got very developed processes to drive performance in mental health—obviously, through the integrated medium-term plans, but also through the work that the NHS executive are doing in our regular meetings with health boards to monitor performance. Clearly, the ring fence will be important to that. But also to add that we've also got the service improvement funding that we've maintained a central allocation for. This year, that's £26.5 million that we've made available for health boards for things that are priority areas, like eating disorders, like child and adolescent mental health services, like perinatal mental health, and we're currently working on what the allocations will be for the forthcoming year. We've also, of course, got our new strategy for mental health that we'll be publishing, and our new suicide prevention strategies. They will be published as well, with delivery plans, which will be costed.

But you're absolutely right that it's vital that we monitor that funding, and we are very rigorous in doing that with the service improvement money. So, the health boards don't just get the money at the start of the year; they have to continually report to us on what they're doing with that money to show that they're using it as we anticipated.

Excellent, thank you. And if I could just ask, because I know we don't have time to get into it—

Really quickly.

But with substance misuse as well—

Oh, substance misuse—

No, it's just that I can see you've said the £10 million funding will continue to deliver the out-of-work peer mentoring. I met with Stori Cymru recently; I could see the difference that makes. But if we could have, maybe in writing, a follow-up, and a little bit more about services like the Brynawel rehab centre, for example, and how much money is going into that, when people do need to go into a centre and have that detox.

We do not have too much time, but if it's a quick answer—

Just very quickly to say that we've largely protected substance misuse services. So, the substance misuse action fund, which goes out to the area planning boards to commission things like the services you've described at Brynawel—we've got a £2 million increase for them in the draft budget. There's also an £812,000 increase in the health board allocations, and we've also protected the funding for children and young people as well that goes out through the APBs for the children and young people's work.

And just to be clear with the committee as well, though, that we have had to take the decision to withdraw funding from the Wales schools police programme. That was £1.98 million, and we've been discussing that with the police. But, generally speaking, we have protected substance misuse services. I'm very happy to provide more detail to the committee on that.

Thank you, Minister. And, just quickly, you mentioned local authorities that have spent above their increased allocation for ring-fenced mental health services—I think you said £691 million against the £726 million, so that's about £140 million. So, does that—? What are the consequences of local authorities spending more on mental health services and impacting other children and adult services if they've taken that money from elsewhere?

Well, it was health boards rather than—

Health boards, sorry.

—local authorities, and, obviously, they'll have taken that money from their discretionary NHS allocations, and they'll have done that on the basis of prioritising mental health. We know that mental health demand is rising and that there are significant pressures in the system, and also increased acuity of people that are being referred into that system. And they will have made that decision on the basis of prioritising mental health, which is what they're meant to do as health boards, on the basis of the needs of their population.

And I suppose it also points to the fact that their ring-fenced allocation isn't sufficient, because they're spending above the allocation that's been ring-fenced.

Well, I think it's about prioritising mental health. The ring fence isn't the only money that we provide for mental health. The ring fence is taking account of things like inflation et cetera as well. I'll bring Hywel in.

So, we test it on an annual basis. The £961 million described is the fully absorbed cost of providing those services—direct, indirect costs, overheads and so on. So, we test that on an annual basis, and our focus is on managing the ring fence and increases on an annual basis.

Sure. I appreciate that.

And we do lots of work around measuring likely increases in demand, but we're also equally focused on prevention and trying to make sure that we get upstream of that level of demand, because that's clearly where we need to be as a Government.

I appreciate that. Can I just check with Ministers and officials: are you okay to stay on for an extra five minutes to 12.05 p.m.? Does that cause any problem at all, just so I can give Joyce Watson the full 10-minute allocation to her set of questions? Lovely. Joyce Watson. Thank you.

Okay. I'm going to talk about, in five minutes—

Ten minutes.

—capital infrastructure and the national office for care and support. It's a key area. If you're going to invest to save, very often that means some capital expenditure. Also, what's defined as 'capital expenditure' and what people understand might be capital expenditure is also up there. So, in light of what I've just said, how great is the barrier of a reduced capital expenditure to improving services in the now, as according to the Welsh NHS Confederation, and also in the future?

So, I have lots of frustrations in my job, not having enough money for capital is right up there at the top. Because if you do want to transform things, you do need some capital.

Absolutely.

So, what we've got to do is to get the balance right between, 'How do we keep the wheels on the bus today and how do we transform services for tomorrow?' And, Joyce, you'll be aware that things happen. So, in Withybush, we had reinforced autoclaved aerated concrete. In the middle of the year, we had RAAC. We had to go in there and shore that up immediately, and it cost us about £12 million, I think it was, that we weren't expecting. So, there's the kind of day-to-day, 'How do you keep the show on the road?'—. And some of our infrastructure is ageing. The other part of that, of course, is that, actually, you know, ideally, we'd like to do some new build—although we're not bad if you compare to what they're doing in England; if you compare those 40 new hospitals that Boris said he was going to deliver, he's nowhere near delivering that number of hospitals. In Wales, if you look at the same definition, I think we're six times ahead of what they're delivering in England, so we are delivering some significant new investments in Wales. But what we do have to do, in the light of the fact that we only have £380 million, is to prioritise, and it is difficult to prioritise when you've got all of those additional things going on. And if you look at next year's budget, the fact is that about 80 per cent of the capital budget is already committed—because capital doesn't stop from one year to another; you can't build a hospital in a year or a health centre in a year—so, a lot of that money is already committed. So, it is quite challenging for us, especially when we are keen to do more transformation, we are keen to decarbonise. But having said that, the other part of this is that, actually, there is a ring-fenced allocation for the integration and rebalancing capital fund projects—so, these are the projects where we're trying to work with local government and with other agencies to bring together all of these services in specific hubs—and 17 projects have already been agreed in relation to that IRCF capital funding.

Of course, you've rightly mentioned infrastructure, as in the physical infrastructure, but we've also been told that the digital infrastructure that's needed to drive the same change, to make all those things that we all want to see, including you, Minister, happen, is also affected. So, moving forward, and also taking account that in the digital sphere, it can deliver equalities—equality of opportunities—to access care and information, how are we going to move forward in that space with the limited budget that we have?

So, we do have a specific budget allocation for digital and we've tried to protect that as much as we can because that is about transformation. We know that the money you invest in that, that the outcomes—you really get a good return. It's not easy to do digital transformation in the NHS; history is littered with people who've tried to transform digital in the NHS and have failed, so we're trying to do that very carefully. Of course, we have Digital Health and Care Wales, who have made real progress, but obviously we'd like to go further and we'd like to go faster in this space. We've got things like the Welsh NHS app now. So, there is lots of activity going on, but we would like to go further, ideally. Of course, there are opportunities for health boards themselves to use the allocation that they're given to actually put some money into that as well. We're encouraging them to do that, and obviously, within the framework letter that I've sent to the health boards, I've been clear that digital transformation has got to be something that they focus on.

There's also the social care capital fund. Do you want to expand on that?

Are you talking about the IRCF projects or are you talking about digital specifically?

Well, I think I'm talking about anything that—. Because there is a fund that is the social care capital fund, if you can't expand now, we would like to know exactly what does that mean and what it's going to deliver.

There are things that we're very keen to do in the social care space, and I don't know if Julie might want to come in on this as well. We are trying to do a lot more remote monitoring of people in their homes. This is going to be a step change in the way we do things: more hospital from home, more community-enhanced programmes. Telehealth is, I think, where it's going to be at in future, but again we have to be very careful in the way we do that. There is a potential of up to £5 million additional funding from outside the digital priorities investment fund, to incentivise the pace in particular on telehealth and virtual ward, which is an area that Julie and I have been looking at specifically.

Okay. And finally from me, you've got a new national office for care and support, and obviously it comes with costs and resources. The question that has been raised is whether it's the right time to set that up, with a limited budget and therefore resource. Could that money be better spent elsewhere?

Thanks very much, Joyce, for that question. I can assure you that we've looked intently at all areas of our work to see if any reductions can be made, and so we did certainly look at the spending on the national office, which is a relatively small amount, because it's staff salaries based here in the Government. In terms of developing our social care, in terms of our transformation agenda, in terms of trying to turn things around, we need that national office to take it forward, and I think it would ultimately be counterproductive not to recognise the benefits that this national office would bring. So, yes, we did look at it, but we decided it was too important in terms of our longer term plans.

Thank you.

Thank you, Ministers. Is there anything else—? Mabon, you didn't have a question on the back of this—? No. Thank you.

Chair, could I just say—? I think I gave the wrong figure in the last question that I answered from Gareth Davies, about the money from the Family Fund. I don't know if we can correct that.

Have you got the correct figure? What's the correct figure?

It's £1.08 million. I think I said £1.8 million, so my apologies.

Thank you for that clarification. Thank you, Ministers and officials, for being with us today. There were a couple of areas where you agreed to supply some additional information, so we're grateful for that. If it's going to be in time, though, for our report, which needs to be laid quite quickly, then having that information delivered to us as quickly as possible would be appreciated, in order for it to impact our work. So, thank you for that. Thank you, of course, for your advance paper as well. Thank you very much, Ministers and officials.