Health and Social Care Committee

Jeremy Miles, Cabinet Secretary for Health and Social Care.

I'm Sarah Murphy. I'm the Minister for Mental Health and Well-being.

Hello, I'm Jacqueline Totterdell. I'm the director general for health, social care and early years and chief executive of NHS Wales.

Bore da. Isabel Oliver. I'm the Chief Medical Officer for Wales.

Good morning. Nick Wood. I'm the deputy chief executive of NHS Wales.

Minister, online?

Dawn Bowden, Minister for Children and Social Care.

Bore da. Albert Heaney, chief social care officer.

Welcome, all. Thank you very much. We have about a two-hour session today, with the first section looking at more general issues, and the second session more focused on waiting times. We do thank you for making your time available to us today. We have quite a lot to get through, so perhaps, Members and guests, if we can be as succinct as we can, but we'll try and get through it all anyway. Because, Dawn, you have to leave a little bit sooner, I'll probably start with questions to you, if that's okay, and we'll work through those.

We want to look at the social care record and outcomes. I'll kick off. How does the Welsh Government measure success in terms of improving outcomes for people who need care and support, and unpaid carers? What does that evidence show about the progress over the last five years?

Thank you, Chair, for that question. Our measure of success is through the social services national outcomes framework, and we publish that every year. The 2025 report will be published before the end of this Senedd term. That report focuses on what matters to people, so who receives care and support, and unpaid carers as well. It looks at a measure of well-being, quality of care, and involvement in decisions.

I think what the evidence is showing us from that report is that, over the last five years, we have seen improvements. So, I can tell you that people receiving care rating their care as excellent or good rose from 77 per cent to 80 per cent between 2019 and 2023, and unpaid carers rating their support as excellent or good rose from 66 per cent to 78 per cent. They talk about feelings of involvement in decisions and that increased by around 4 per cent. I think what that shows, Chair, is that the outcomes are improving, because we can only test that by asking people what they feel and whether they're getting the service that they expect, and we are seeing more positive results. But that doesn't mean that we've given up or taken our foot off the pedal; I think what that is showing us is it's just the indication that we're moving in the right direction.

As I said when we talked in the session on unpaid carers just a couple of weeks ago, we are enhancing the evidence on unpaid carers with a new national annual collection of data. The purpose of that is trying to achieve a kind of consistency of information from the 22 local authorities. That takes a bit of time, but what I'm trying to explain, I guess, is that this continues to be a work in progress, and we continue to look to improve through our data collection.

Thank you for that update. Obviously, we played this out in the last session we had with you, and there still seems to be a little bit of a mismatch between what you've just shared and, certainly from unpaid carers, how they're seeing things and what we're feeling from what we've had from our inquiry about how they see it. So, this lack of correlation is a little bit concerning, and especially when we look at some of the other information, some of the evidence we received, or rather the Local Government and Housing Committee received regarding the hospital discharge inquiry, and some evidence from the Welsh Local Government Association, which highlighted that waiting lists for carers assessments and services were increasing. I just wonder: can you tell us what the data shows in terms of trends in those waiting times? If unpaid carers are telling you things are getting better, you would think that that would mean that more of them are getting carers assessments, but there's a mismatch here. What's your assessment of it?

We have to accept the evidence that we've got, because this is direct evidence that we've received from people that we have asked. If you look at Carers Wales's 'Track The Act' report, it does show improvements in the satisfaction rates. But what it's also showing us is that we have a huge amount more to do and that there are people that are not getting the support and the assessments that they need. I think I acknowledged that fully in the last session. We spent quite a bit of time going through that. So, I'm not sure that, in the limited time we've got this morning, there's much value in rehearsing what I said just weeks ago. I'm conscious of time.

I appreciate that, Minister. I think those are areas that we're still anxious about, as a—

Absolutely. Can I just say, Chair, one of the things I did talk about last time—? Just to say, I have written to all local authorities about that, and we now have all their responses, which we're pulling together now and we're analysing, and I should be getting a report on that by the end of next week. I'm more than happy to share that information with the committee then about what that tells us about what more we need to be doing with local authorities to ensure that carers are getting those assessments.

Okay, thanks. I'm conscious you wouldn't have had time to digest much of that yet, so we'll wait to receive that, and that would be very welcome.

Just on a reflective note, what have been the key areas in your portfolio where progress has been slower than you hoped or intended, and what are the main factors that constrained any of that delivery? And what lessons should the next Welsh Government take forward from your portfolio area?

Well, the first thing I would say is I'm not sure it's for me to tell the next Welsh Government what they should and shouldn't be doing, but I think that there is significant evidence of what has already been achieved and what needs to be continued, and I think that's really what you're saying. It is important to recognise the significant progress that we've delivered right the way across my portfolio during this Senedd term.

So, we delivered the three pillars of the rebalancing care and support programme. That was the national office, the national commissioning framework, and updating part 9 of the statutory guidance. We've strengthened support for carers. As I say, we had a whole session on that just a couple of weeks ago. We've improved transparency and performance. We've invested in direct provision, and we've made real progress on fair work and pay in social care.

That said, progress has inevitably been at different paces for different developments. So, inevitably, some things we've been able to move more quickly on than others. One of the things I think we've made quite a bit of progress on in this term is the national care and support service, but the main constraint on progress, which I think was the key point of your question, was the scale and the complexity of reform, and the need to maintain stability whilst we're also trying to deliver reform. So, we've got this long-term commitment and a realistic pace that we're trying to move at, and much of that is determined by investment at any given point in time. So, we try to move into reform and we have to continue the day-to-day work, if you like, running side by side. So, lots of things that we have done, lots of things that we still have to do, but I think, generally, we're talking about, you know, looking at getting better social care data. Again, we've talked about that previously.

In terms of moving forward, in terms of advice for the next Government, it is very tempting to say, 'Move quickly on all the things that we have so far made progress on, and perhaps not as quickly as we would have wanted to.' But I would just caution any future Minister against moving too quickly, because what we have to do is build change carefully and sustainably, and that's why if we look at things like the establishment of the national care service, the expert group that advised us on that, and that we worked with Plaid Cymru on to deliver that, made a number of recommendations, 48 recommendations, for us to deliver this. They made it very clear that this would have to be a long-term project, and that this would be a 10-year programme of work to deliver that one commitment of the national care service. So, I think, what you can see is we're trying to reform, we are reforming, we have to do it at a pace that maintains stability, but we also have to do it at a pace that our resources allow.

Yes, thank you, Minister. Mabon, would you like to come in?

Thanks. One brief question. The Chair earlier mentioned the inability to get people out of hospitals discharged into their communities or into care, and then you, Minister, mentioned that there are a number of issues limiting your ability to make progress. In looking at the big picture, one of the main things that I hear, and that we hear on a regular basis in this place, is the failure to get health boards and local government to collaborate. Despite the regional partnership boards that have been established and so on, they still fail to collaborate, and I've heard very recently that there are some local authorities having to allocate tens of thousands of pounds to fight the health boards in the courts, to try to decide who takes responsibility for somebody's care. Do you accept that that still continues to be a failure, and do you think that it's an acceptable situation?

Well, no, it's not acceptable if there are areas that are falling down in the way that you're suggesting. And I certainly know of anecdotal evidence of health boards and local authorities having that sort of tension around what is delivered, particularly around continuing healthcare assessments, decisions, and the delivery. And what I would say is: my officials are working with CHC leads and social care heads of service to try to understand what those concerns are. We're keen to see that broader base of evidence on that issue to get a clearer perspective.

As I'm sure you're aware, in 2023, we established and we host the complex care joint forum. The aim of that is to bring together health boards and local authorities to discuss issues relating to complex care, including the point you were just talking about there, which is continuing healthcare. That particular focus there, really, is on the interface between social care and health care partnership working, between the local authorities and the health boards. And that group discusses and updates and considers potential solutions regarding CHC and other complex care.

So, we're now in the process of revisiting the CHC performance framework and working with health board representatives to ensure the information collected by them is meaningful and it provides a clearer picture of how health boards across Wales are delivering against the CHC framework for implementation moving forward. The aim is that we're going to start collecting that data from April 2026 onwards.

In general terms, Mabon, what I would say is that the health boards and local authorities are working far more collaboratively now as we're working towards building an integrated community care service. If I would say that there is one element of frustration that I still have, it is that, where you see elements of good practice—and we've explored this previously in committee, I know—where we see areas of really good practice in terms of getting people through the system and getting people discharged when they're ready to leave hospital and so on, it is quite difficult to scale up that good practice. That's something that both the Cabinet Secretary and I are very much focused on in our discussions that we have in the leadership groups and in the regional accountability meetings.

Thanks, Mabon. One more question from me, before I hand over to Joyce. How confident are you that our social care workforce is on a sustainable footing for the future? I know in your last programme for government, there were talks of the Government taking further steps to make sure that we had progress to achieve an advance in the service. What's your assessment of that?

I think we've made really positive progress on that. There are very tangible actions that we can point to that we've undertaken in this Senedd term, which has been about improving the sustainability of the social care workforce, and there's clearly still work that's required. But the key step, really, was establishing the social care fair work forum, and that brings together trade unions, employers, local authorities and the Welsh Government to lead social partnership working on pay, terms and conditions.

The forum's initial priority was supporting the delivery of the real living wage, and you'll be aware of that, and we've maintained that since 2022. An independent evaluation has confirmed that that raised pay and improved equity. It been welcomed in the sector and we've continued to deliver that through a really challenging period for the sector.

Where the evaluation identified that some workers are not yet receiving the uplift, we know that 85 per cent now are, so we've got work to do on making sure that the remaining 15 per cent get it. We've committed to stronger monitoring in 2026-27 to ensure that funding is passed on as intended. Importantly, our programme for government commitment goes beyond the real living wage, because that was something that we put in place as a foundation. But there's an awful lot more that we need to do to deliver that greater parity of recognition and reward. The social care forum is now finalising a voluntary pay and progression framework, which is supporting more consistent pay, terms and conditions right across the sector.

All of that taken together, I think, does mean that the workforce is now on a stronger footing as we head into the next Senedd term. But, clearly, a sustained focus and investment will remain essential if we're to build on that success. But I might just ask Albert Heaney to say a little bit more about this, Chair, because Albert has been responsible for leading the work on this and chairing the forum.

Thank you very much, Minister. Good morning, committee. I have chaired personally in my role the social care workforce partnership. We've been really pleased to engage with our trade union partners, our employers, our providers, and, of course, the Welsh Government, bringing to the table the opportunity to work to set the standards for all of Wales as a national approach.

We have produced some exemplar HR policies, which will be really important to the independent sector particularly, to improve working conditions and consistencies. Just to give you a flavour of some of those policies, they include disciplinary, grievance, health and safety, including violence against staff. So, really important areas. Also, we have worked together to produce a recognition agreement, which recognises the union role in the independent and private sector.

Just to mention, Minister, if I may, whilst I've got the floor, in relation to some of the questioning earlier, Chair, around pathways of care and data, certainly data tells us we have increased demand, but the data also tells us, positively, that partners are working together across health and social care to reduce delays in total. And since we started collecting data in April 2023 around the pathways of care delays, we have seen around a 20 per cent reduction in delays by December 2025. Thank you, Chair.

Thank you. Can I bring Joyce in, please?

Good morning, both. Where there has been progress—and that's great—between the integration of care between social services and health, and where people aren't moving, maybe, as quickly as others, or as quickly as they might, is that data that you have disaggregated, so that you can aid those, maybe local authorities, maybe health boards, maybe both in the same area, to move into a space whereby you remove what are perceived as barriers between those two groups working together?

Thank you, Joyce, for that question. Just to reiterate what I said in response to the question from Mabon, we do have these regular discussions. We have regular groups and forums. They're in a very formalised setting. They're very high level. Some are chaired by the Cabinet Secretary for Health and Social Care. Some are chaired by me. So, we're working right the way across health and local authorities in delivering the work towards integration.

There's been significant progress, and I don't want to underestimate how much progress we've made. Albert has just referred to the figures that we've seen around some of the work that we're doing in trying to deliver the improvements in pathways of care. And that's just one element following the rebalancing care and support White Paper. We strengthened both the legislative and the policy framework for integration by updating Part 9 of the Social Services and Well-being (Wales) Act 2014. That changed and clarified the role of regional partnership boards, and strengthened the citizen engagement, and it set clear expectations around joint planning and commissioning.

We also introduced what we call Part 9 responsible officers for co-operation in every local authority and health board, providing clearer accountability for integration. There's been significant investment through the regional integration fund, and the rebalancing care fund, and the housing with care fund. That's supported those integrated models of care much closer to home.

But, of course, you flagged the barriers to making further progress, and they exist, and it would be foolish of us to say that they don't. Those barriers include culture, pay and conditions, fragmented short-term funding, and digital interoperability challenges, which I'm sure you'll be picking up later with the Minister for Mental Health and Well-being.

So, we have all of those barriers, and progress, if you like, but I think it's probably important to set out the examples that we have of integrated models, supporting the kind of work that you've just been talking about, Joyce. We've now got a national network of social prescribers. We've got integrated discharge hubs. We've got single points of contact, integrated community health and care hubs. We've invested in residential and community care for older people, people with learning disabilities, children with complex needs, and multi-agency family support for children at the edge of care.

I think we've got an awful lot of progress that we've seen through this Senedd term—very clear examples of integrated working, and where it is working well and where it's delivering improvements, and accountability mechanisms, with the Cabinet Secretary, myself, and the Minister for Mental Health and Well-being, so that we are keeping on top of the progress that needs to be made.

Thank you. As you say, there are some examples of where it's working really well, and other areas where it could be improved. We know that it's a growing need. The demand is going up, not down. The workforce to provide all of that care is a real challenge. We recognise all of that. But going back to the question I asked at the beginning, for those areas that, perhaps, require further assistance, and that might be the demographic of the area, for example, is there sharing of best practice, where others have already progressed, perhaps quicker—and I recognise there's progress—than others, and that they might be assisted by that knowledge?

Yes, and that's why I was saying, Joyce, we do have these regular meetings, on a regional basis, because the whole regional setup is something that is driving forward the progress. This isn't done in isolation by individual health boards and individual local authorities—this is work that's done on a regional basis. The Cabinet Secretary and I meet our partners on a regional basis, so regional partnership boards, local authorities, the health boards. They meet, and we talk about the plan for the region, they know what has to be achieved, and quite often share the practice that is delivering results.

As you quite rightly point out, what you can't deliver is a one size that fits all, because there are urban areas, there are rural areas, and things work differently in different areas, so you have to find good practice that meets the needs of the particular area. But what we are doing—and my frustration is just the pace of doing this, not the willingness to do it—is that where we do find good practice, and it would work well by upscaling, that is the work that we're focusing on, and trying to get health boards and local authorities to take on board more quickly. But I don't underestimate how difficult it can be to change practice and innovation when you've spent years doing things in a certain way. But, clearly, we have evidence that shows certain things are working well and are working better, and where that is working well and working better, then we want that upscaled and delivered right across the piece.

Thank you.

Thank you, Minister. We're going to move on to some other areas now. Can I ask Lesley to come in, please?

Good morning. I want to look at workforce planning. Obviously, when you've got something as large as NHS Wales, robust workforce planning is vitally important, particularly in areas where there have been issues with recruitment and retainment. I wonder how robust you think the plans are. Obviously, every health board has got a five to 10-year strategy, so I'd be interested to know how you monitor it, how robust you think it is, and whether you think the way the workforce planning is done is good for patient improvement outcomes, and also for the well-being of staff.

Obviously, the health service is its staff, its workforce, isn't it? So, it's a critical question. In terms of the sustainability of the workforce, I think over the course of this Senedd term what we have seen in practice is—. I'm sure we'll talk about vacancies in some areas, obviously, but what we've seen, actually, is huge increases in the level of staffing in the NHS. So, medical and dental staff up by 18 per cent, registered nurses up by 15 per cent, other therapeutic and technical staff up by 16 per cent. The vacancy rate, actually, is now down to about 5.4 per cent, a huge reduction in the agency spend, which we all know is a key indicator of the stability of the workforce. In 2024-25, that came down by 34 per cent, and the following year by a further 28 per cent. So, I think what we are seeing is significant increases in the workforce of the NHS.

I do think, Chair, it is important to say that we can't measure the success of the NHS just by its ability, year on year, to put on double-digit increases in staffing. Clearly, there's a limit to that, and that's, in a sense, asking, in my view, the wrong question. The question is—and nobody's putting that question to me, to be fair—how can we make the best possible use of the staff that we have and support them to do more through technology and other more efficient ways of working. So, there's lots of complexity beneath those headline figures. But you were asking me about sustainability, so I think it is important to have that context.

In terms of what that means from the point of view of patients and staff, I think one of the key elements of progress has been our ability to retain staff. So, I think the planning that we have in place has increased staff retention. I've talked about the reduction in agency spend—that partly comes from that. Obviously, I think, in a sense, you could say the success that we've had in retention creates other challenges, in terms of recruitment levels and predicting future demand based on more people remaining in the health service. So, there are also planning challenges that come from that. But I think, overall, that is a system working pretty well. Clearly, there are things we need to do differently and better. There are gaps in some professional specialties, in some parts of Wales, and we need to do as much as we can to try and address those, obviously.

So, just on your point that you made about technology, for instance, how do you ensure that there is an alignment of workforce planning for staff on future service demands? Technology is changing all the time, so how do you plan for that so far ahead, I suppose?

Well, you have to—. I think artificial intelligence is a challenge in all sectors, particularly, isn't it, so I think that will be—. The pace at which developments are occurring in the context of artificial intelligence is dramatic, obviously. My own view is that it's also a huge opportunity for us, in making sure that everybody going into work in the NHS every day is working hard. How can every minute they spend doing the hard work that they do be most impactful? We're already seeing, in some diagnostics in particular, the use of AI to support clinicians in making the judgments that they're making. We're investing in AI, we're investing in imaging, and the staff, then, to be able to do that work alongside. So, you are right to say aligning those two things is important. That can be challenging in a very rapidly moving environment, obviously.

Where are your major concerns around recruitment at the moment—as in, across Wales—and which specialties?

Okay. So, I think I touched earlier on the point that I think this is a challenge that is quite specific, really, so there are some geographies and some specialties. I would say that perhaps the most challenging areas for us are in mental health, learning disability, some therapy professions, midwifery. So, there are challenges in those areas. Health Education and Improvement Wales is obviously tasked with working proactively to identify where we need to be attracting more staff, where we're able to train more staff. But, clearly, there are recruitment challenges, which aren't specific to Wales—they're certainly not unique—but they do pose barriers, I suppose, in being able to take forward the level of service we want to be able to do in some areas.

So, we did take evidence from HEIW—probably last year—and there were some concerns that there were newly qualified—. I'm going to use doctors as an example, because, certainly, in my own constituency, I've got GPs who can't get any placements having qualified; they're working in accident and emergency or they're doing locum sessions in GP surgeries. So, again, I think that is a real concern—that we're training health professionals and then they can't get jobs. Do you think that's a widespread issue, or do you think that's more localised again?

Well, I do think we shouldn't regard that as a systemic issue; obviously, it does arise. I would say that, in general, the reason for that, when it occurs—the reason for it is often around sequencing, timing questions. So, if we're talking about doctors, for example, there is a potential bottleneck in the transition between foundation and specialty training, which is driven by UK-wide factors. We're trying to solve some of that in the legislation that we're considering next week, in terms of the legislative consent motion. That's intended to bring more order, if I can put it in those terms, to that set of four-nations arrangements. So, there are interventions that we make where—you mentioned HEIW—we have seen pressures recently in terms of nursing, in south Wales in particular. We saw last year challenges in terms of aligning the paramedic workforce to the needs of the ambulance service. I think we've been able to intervene quite quickly to resolve those issues. I would say, generally, that it's about sequencing, timing and local operational factors rather than a system-wide challenge.

My final question—. I'm not sure if Albert is still with us, but I was interested to know how you feel the integration of health and social care staff has gone particularly during your time as Cabinet Secretary. Albert referred to the social care workforce partnership—which I think is what he called it—and I was just wondering if there is an equivalent one that you have for health service staff, and whether that integrates, because I think we need to get that right. How do you feel that's improved?

Yes, we do have an equivalent one. My main observation in this area, I think, and we see it—. One of the areas where it's been at least most visible to me is in the area of allied health professionals, both in the health service and in social care settings, but it's not unique and specific to AHPs. I think we need to get to a more integrated workforce planning that brings both the health service and social care more closely together. It isn't sufficiently uniform across Wales. There's quite a lot of local variability. It works quite well in some areas, and less well in others, so I do think that having a more systematic joined-up way of planning, particularly in some job roles—. It doesn't apply across everything, obviously, but in some job roles I think there is potential to do more in that area, certainly.

Thank you.

Thanks. Can I bring Mabon in on a different subject?

Thank you. Well, on that point, you mentioned—I forget the Welsh translation—the allied health professionals. You mentioned that there are still some vacancies in the health service. Well, on that point, I understand, and I've raised the question with you on occasion, that the chief officer of the allied health professionals is yet to be appointed—a post that has been vacant since before the summer. It's a crucial position. There are gaps in that area in Wales. When will you appoint the chief officer?

Well, just to give you context, you've asked this question to me recently in the Chamber, and I have the same reply for you today as I gave you in the Chamber. It is important that we do fill that role, of course, but in terms of progress in terms of AHP recruitment, that training and recruitment has been significant, so it's important that we acknowledge that. As a result of the growth that's been in general in terms of recruitment, that's also been true amongst AHPs.

But that specific role is important; you have stated that it's important. There has been a vacancy for months now. Is there a commitment to appoint before the election, for example?

Well, I don't appoint, it's something for the civil service. Perhaps I could ask Jacqueline to answer that.

Bore da. So, in regard to—. I'll take those off; I can't hear myself speaking. In regard to that, we have several clear posts that we need to recruit to within the group, and that is one of them; the chief scientist is another. We have tried to recruit to the lead AHP director on several occasions. So, we will be going back out to recruit to that. We just need to give some thought about how we get the right people to apply and are able to appoint, and I think that's pretty critical, but it is a key post. We do need to engage with our AHP professionals as well, and keep looking at different models of working with them in a way that we've talked about. AHPs are the people who work across not just social care, but they're also part of what we're trying to do in mental health and to keep young people out of the justice system. There are quite a lot of areas that they're really important in, and we need to have better visibility and better leadership of them to enable what we need to do in Wales for our citizens.

Thank you. Cabinet Secretary, you referred earlier—I have to translate this on the hop—to the Medical Training (Prioritisation) Bill. I don't know what the translation of that is in English. This appears to be a Bill that is being driven very quickly through Westminster. How is this going to align with policies that this Government has in terms of international training and workforce training?

There has been good collaboration between the four Governments around this Bill, so that's to be welcomed. On one level, I'm not surprised at that, because the co-ordination that's happening currently at administrative level is already going on. So, this is another legislative tier on top of a relationship that's already working well administratively, operationally. It deals with a situation of oversupply, rather than a lack of supply. That's the context for the legislation.

Perhaps we can also say that it also acknowledges that there is a commitment or an expectation that there is a specific requirement on Government to ensure, if you ask people to come to train in medical schools—that there is an expectation that they can continue with that training in the foundation phase and specialty training. That's the context. It does not change our focus on recruitment for the jobs that are needed. So, there's also international recruitment going on. But in terms of prioritising, when you have an oversupply in one area, that's what the purpose of this is.

I'm pleased to hear that there has been good collaboration. That's very important. But in terms of the Senedd and from our point of view, there is an LCM in front of us next week. We've just come across this, to all intents and purposes, today—that it is being introduced. There's been no time to scrutinise. There's been no time in terms of going out to the public to consult, as far as we in the Senedd are concerned, to see if it dovetails with the aspirations of people in Wales and the workforce here. Do you think it's right that so little time has been given to scrutinise this and to consider this, as far as Wales is concerned?

Well, as you know, this is Westminster legislation, so we're responding to a timetable that is going on in Westminster. There is an impact on Wales. Welsh Ministers have powers in the Bill that is going through the Parliament as a result of our requirement as Ministers that that's part of the legislation. That has been agreed upon and provided.

What's going on is a reflection of the work that's already ongoing. HEIW, which has been referred to already, is telling us that we need to ensure that we are not cutting across that collaboration that's already going on. There are more challenges facing us in Wales. If we weren't part of the new arrangement, there would be more problems of the kind that we mentioned with Lesley Griffiths earlier on, in terms of purposeful planning, ensuring that we don't have any shortfalls—there's more of a challenge in not being part of this than there is from being part of this.

It appears that Wales is an afterthought in this, and we haven't had full consideration. It's a Westminster Bill, and we have to adapt to suit it.

It's important that we don't make a political point over something that ensures that the NHS works well. You have a Bill going through Westminster that has an impact on Wales—this happens, of course, on a regular basis. What I can tell the committee—and the committee, of course, will come to a view on the LCM—is that it does match the policy framework that we already have here in Wales, and that there has been good collaboration in planning the Bill in Westminster, and that's not always true.

No. Thank you. The final question I have is in terms of training, in terms of oncologists—forgive me if the figures that I have are incorrect. I hear that, over the next two years, 30 oncologists are going to graduate here in Wales, but only three of them will have placements in Wales, although there's a lack of oncologists in Wales. How can we align better the training places in Wales with posts in Wales, and ensure that the people who train in Wales remain in Wales?

I do think that we are doing that already. I will write specifically to you on oncologists, because it's a question that you've asked for information specifically on. But I would say, in general, what we can do, and we have managed to do, is to ensure, as I mentioned at the start of my answer to you just now, that there is an expectation that people who train here can remain here. And that's the purpose of the LCM. We do that already. The work that we're doing in terms of nursing—the streamlining system makes sure that we can give some kind of priority to those qualifying here in Wales, before going out to the recruiting market. That's another example to you of how we can provide of how we can provide opportunities to people we ask to train here. So, there are challenges, of course, and we've mentioned some of them, but they're not typical of the system in general.

Thank you. Lesley, can I bring you in?

Yes, thank you. If we can look at mental health, please, obviously, this committee did an inquiry earlier in the term around mental health services, and it showed that there were several groups—and it won’t be any surprise to you which groups they are—that were at a higher risk of poor mental health. So, particularly bearing in mind the strategy, how do you think those particular groups are being cared for now, are receiving the services that they require? Do you think there has been an improvement? Do you think progress in some areas has not been as you would want?

Thank you. Well, I'm biased when I say that I thought that was an excellent committee report on mental health inequalities, because I was a member of the health committee when we did it. [Laughter.] I have to say, as well, I'm glad that I did it and I was here to participate in that and hear the evidence and set out the recommendations as well, because it has really informed my role now, in being the Minister for Mental Health and Well-being.

I think what came through really clearly in that report was that there are many pressures on people that were impacting their mental health and well-being. But some of the areas that I think we have been able to try to address in the mental health and well-being strategy that we launched last year are things around access, being trauma informed, 'no wrong door', and then also a lot around cultural competence, because that came through very clearly. What I would say is that what we're trying to do now, through our mental health and well-being strategy, is create a service where, wherever you go in the NHS, wherever you seek help, you receive that equitable offer, which is going to be that same-day access, which is going to be that one-at-a-time session. And I do think that, since we've done that report, we've done an awful lot to raise awareness, to do the training, to improve that offer. But also, just in the last—. I mean, we haven't even had it launched for a year and we've made huge strides in terms of having that open access for people, and that's the main thing. That is what we are trying to do. We don't want people reaching crisis. We want, if you go to your GP or wherever you go, whatever the issue is, that you're able to get that help and support that you need right there, you don't feel—my favourite phrase—fobbed off, and that you're directed towards someone who can help you.

However, what I will say is that, in terms of those specific cohorts, we do not have the robust data collection that we require within mental health, and that is a key part, then, of what we are going to be delivering in the first three years.

So, just going back to what you were saying about that you don't want people reaching crisis, I suppose the new strategy that you launched last year was to try and get that focus, wasn't it, on prevention and early intervention. So, do you think that has been successful just in the last year?

I think that we've seen a huge amount because of two areas: first of all, the sanctuary model, which has been piloted, and that has, obviously, been for 11 to 18-year-olds. We've had some wonderful projects in that area. So, young people now can go in; they set the terms of how those sanctuaries and those spaces are used. They go there after school; it's available after school and it's available on weekends. And it's basically to prevent people needing to go to child and adolescent mental health services. I have an evaluation that is due to be completed and a report coming very shortly, which I look forward to sharing with the committee. But early indications, anecdotal, are showing that, actually, there are fewer referrals going into CAMHS. Because what's happening is that it's a safe space, it's consistent, and young people are getting to have that one-to-one session with somebody to really kind of—. Honestly, a lot of this comes down to just having some focus and attention from adults to listen to them and just be consistently there for them. So, that has already, I think, made a huge difference.

You just mentioned a lack of data, so, you'll know from your time on the committee that there was a core data set promise, which hasn't happened. So, as a Minister, how do you feel that that data set, when it becomes available—? Do you have any idea when it will become available, and how do you think that will help you in planning those services?

It's a huge priority. We don't, in Wales, have the same access to data for adult services now, but it's much better for children and young people. So, this is something that has to be rectified really quickly. So, you'll see that, in the strategy, we do have a list of performance measures, which are already the data sources that we currently have. And that does take into consideration what we gather from the NHS, but also other factors in terms of socioeconomic data. But what we will be doing now—. I and the Cabinet Secretary are working to get the remit for Digital Health and Care Wales signed off, so that we can now have as well—and it is a key action in the mental health and well-being strategy. So, the digital and data group, as part of the strategic programme for the mental health strategy, will provide leadership for the work with DHCW, and that's going to then bring in those data sets that we need.

I'd also say, though, as well, that, through the NHS app now, you're able to see an overview of your—. You know, your 'About Me'. You're able to input data there as well, so people should be able to self-identify as much as they would like to. One of the key areas, for example, is veterans. I talk to a lot of veterans' groups and veterans, and sometimes we don't have a record that they are a veteran, which would make a huge difference on their medical records. So, we've got a couple of really good projects around that and raising awareness. All of that will help us to be able to ensure that, ultimately, we're reaching those groups that we identified in that committee report that we weren't able to access, or, if they were coming forward and asking for help, that they weren't feeling seen and heard and then they were not coming back, essentially.

Thank you.

Thank you. Mabon.

I want to touch on dentistry very briefly, if I may. There is a new contract that will come into force in April, if I understand it correctly. When will we see the regulations for that new contract being laid, and how have dentists responded to date to the new contract?

The regulations are being laid next week. In terms of the reaction from the profession, of course, any change comes with challenges. It's popular with some, less popular with others, but, generally, we see people preparing for that.

There was a discussion in the Chamber yesterday about contracts being sent back and so forth, so we are seeing that happening. It happens regularly for many reasons. Recently, we've seen the value, in terms of the value of the contract—. If you look at that in general, then those values have been coming down, which is perhaps a positive thing. But people are working towards April now, and the changes that will come in then.

There has been long-term discussion on this. A lot of things that are coming in the contracts have been piloted, in a way, through the reforms that have been happening to the old contract over recent years. So, that has been useful. There are some elements that are new, which the British Dental Association had asked for. Those haven't been piloted, but they have been included in the new contract. So, I'm sure that will be successful too.

You mentioned that some will, clearly, have complaints to make, and some are handing back their contracts. What assessment has the Government made of how many dentists are likely to hand back their contracts over the coming months as the new contract comes into force?

Well, as I said, in terms of the values of the contracts, those have been coming down, as it happens. So, that's a good sign, I think. The purpose of the new contract is to ensure that patients can get the service that they need more easily. Specifically, we've mentioned many times how challenging it can be to get equal access to NHS dentists. There are more incentives in the new contract for dentists to undertake NHS work. It's fairer in terms of acknowledging the kind of work that dentists do in the way that they are paid. So, that is going to ensure that it's more attractive, and so I would expect to see that pattern in terms of the values continuing.

And finally, do you expect to see more dentists returning to NHS work because of this contract?

Yes, that's the purpose of this contract. It's not just what you say that's important, that dentists return, but also that those who are already doing NHS work increase that provision. Both things are important.

Diolch.

Thank you. Russ.

Thank you, Chair. Digital Health and Care Wales is currently under level 3 escalation. What impact is that enhanced monitoring having on the Welsh Government's wider digital information work?

Okay, well, I think it's probably—. I'll try and decouple that, in a way. So, the public accountability meeting for Digital Health and Care Wales took place last week—you and colleagues may have seen that—and obviously is happening against the backdrop of the escalation, as you say. The purpose of the escalation is to identify where there are shortcomings in the performance of the organisation, for there to be an agreed plan with us as a Government, for the support from officials and from NHS Wales Performance and Improvement to be made available, and ultimately, of course, for the organisation to come out of escalation.

So, in terms of what impact on the organisation's performance—and, more broadly, the digital landscape, as it were, in the NHS—the escalation itself is having, that's going to be positive, because it's supporting the organisation to improve. The reason I mentioned decoupling is this next point: however, obviously, the reason it's in escalation is because in our judgment, it isn't doing, in a number of key areas, what we expect it to do, and it's clear that that shortcoming clearly will have an effect more broadly in the sector.

So, just to give one example, which was quite extensively discussed at the meeting last week: one of the challenges we have put to the organisation is that, in its programme management capacity, it isn't sufficiently proactive in identifying where there are slippages, where partners may have concerns, how those concerns can be anticipated and addressed when concerns are then flagged that things might be slipping. So, all of those are in quite an important space around managing the programmes effectively, and so we're working specifically with them on particular ways to improve that.

You mentioned officials are supporting—in just a brief outline, just tell us how officials are supporting the organisation.

Well, there's a plethora of engagement around escalation, so there'll be a plan that identifies what needs to happen and what needs the organisation has. There's quite an extensive architecture of meetings around supervision and monitoring and support and additional work that NHS performance and improvement, which is there both to support Ministers to hold the NHS to account, but also to support NHS organisations to improve their performance and improvement—. They'll be agreeing a specific plan of support with the board.

I think my reasonably early reflection is that there's been—how best to put this—there's been a response to the plan and engagement on particular elements of the plan, but that broader behavioural change hasn't materialised yet to the extent that we want it to do.

Sure. And going back to my original question—just because there's so much information, which is a good, comprehensive answer, but—in terms of the Government's digital agenda, because this is so important, is there an impact on that work as a result of this escalation?

Well, I'm trying to distinguish between the escalation and the causes for the escalation. So, the answer to your first question is 'no'. The answer to the second question is, probably, 'yes'.

Yes, thank you, that's good. And the Welsh Government's community care information system was due to be replaced by the Connecting Care programme this month. Can you give us an update on that?

Can I hand over to Sarah for that?

Of course, yes.

Yes, so Connecting Care is a big, very important project, which, when it's completed, will have the 22 local authorities on this system being able to see the data for everybody in the social care sector, and then also the link-up then with the health boards. So, at the moment—. I have to say, the WLGA have been absolutely fantastic, all the health boards are working together, we've had the business case through, that's all been signed off, and it's all going through at the moment, and that's being overseen then by the digital data and technology board, which is chaired by myself and the director general, and we're currently working through the health board business cases, two of which have been signed off. So, yes, this is very time sensitive, and we are managing risk, absolutely, but I'm assured that everything is on track.

Okay, thank you. My last question is: how many fax machines are still operating within the Welsh NHS?

I don't know.

No, that's fine. [Laughter.] It was a half-serious question.

[Inaudible.] 'Too many' perhaps is the obvious answer.

Okay, thank you.

Thank you. Mabon.

I don't usually use these sessions to discuss my personal experiences, but I will give you a story. I mentioned to you previously that my wife had broken her wrist in Cardiff. And in the hospital in Cardiff—the University Hospital of Wales, Cardiff—she had an x-ray scan, and she had to then go, because we live closer to Wrexham, to the hospital in Wrexham a few days later. The doctor said, 'Give me your phone so that I can take a photo of the x-ray', because they didn't have confidence that that information would be transferred from their digital systems to the systems in Wrexham, although it is the same NHS.

Indeed, when we got to Wrexham, the record hadn't arrived, the scans weren't there, and they had to look at the scan, the x-ray, that I had on my phone to see what was wrong with my wife. Now that appears to be silly to me. They're systems that the electorate and the people of Wales expect to speak to each other. Do you accept that that is a failure, and what steps are you taking therefore to ensure that the digital systems do speak to each other?

This comes down to the electronic health record, and I wouldn't say that we're, in Wales, particularly behind. I think that every nation at the moment is trying to get their electronic health record up and running, as they are across Europe as well.

So, at the moment, we do have a plan in place: it is going through the digital, data and technology board. The director general is working very closely with all of the stakeholders on a road map. The electronic health record is a huge part of this and, absolutely, this is the trajectory that we're on, getting all those systems to talk to one another so that you don't have to be doing that.

Okay, thank you. I'd just like to ask a couple of questions on quality, safety and accountability across Wales. We see major service reviews, reports across NHS Wales, including maternity services, vascular surgery, emergency care, and they've repeatedly identified systemic issues relating to quality, safety, leadership and organisational learning, often with similar themes. Indeed, the reviews of maternity services in Wales have highlighted serious recurrent concerns about safety, culture, leadership and such, and we see this repeated in several areas.

In your response to our draft budget, it refers to a forthcoming national patient safety plan. Can you tell us how this plan will ensure that learning from past service failures is embedded consistently across Wales, rather than limited to individual organisations? Could you give us some views on how we're going to address that feedback that we're getting from these various areas that things aren't looking good?

Yes, well, I think there are two things, Chair, that are happening. So, NHS Wales Performance and Improvement are scoping and engaging with the service on how a different framework can be developed—a quality management system. And you mentioned specifically in your question learning from failures, that is important, but it's also important to learn from what has worked well as well. And taking that joint approach is part of that, and there's a national patient safety plan for Wales being developed as well. I might ask the CMO to comment on that, if I may.

Bore da. The national patient safety plan is being developed, on the Cabinet Secretary's behalf, by NHS Wales Performance and Improvement. It is intended to identify a set of actions to help us reduce avoidable harm and to build, as you referred to, a culture where learning and improvement are at the heart of everything we do.

At the heart of this plan is a quality management system. The quality management system defines how we plan for safety, how we improve services for safety, and how we control and assure ourselves of that safety. It helps us advance our work towards the duty of quality, which applies to all NHS organisations and, of course, to Ministers and to ourselves.

It is not the only action that we are undertaking. I, working with the chief nursing officer, have also identified the need for a clinical governance framework, a system that helps us describe the systems and processes that we have in place to ensure that our services are safe, meet the national expectations around quality, and that we have systems for continuous improvement. So, that will define the systems and processes, and then the quality and safety plan is a set of actions to help us to improve the safety of our services. We also, following the ministerial advisory group on productivity and performance, have been doing a lot of work to strengthen clinical leadership and ensure that service improvement in Wales is clinically led.

Okay. We know that the ministerial advisory group's independent review found that operational performance in key NHS services—planned care, diagnostics, cancer and urgent emergency care—requires a lot of attention and we need to see very swift improvement. So, will the safety plan cover some of those key issues? How does that review integrate with the patient safety plan?

If I start and then maybe my colleagues will want to add a bit more about the wider performance arrangements that we're putting in place. Together with the national patient safety plan and our arrangements for quality, we publish quality statements for key areas of work, and those define the national standard for what is a quality service for Wales. So, for example, we were talking about mental health earlier. We will be publishing our quality statement for mental health in March. So, there is a seamless link between these, but there has also been a review, which colleagues may want to describe, of the arrangements that we've put in place for escalation.

Okay. Thank you.

Chair, I might ask—. Nick, do you want to come in on the overall approach to managing the delivery of the MAG report?

Yes. So, obviously, all of the MAG recommendations were accepted. A number of them related to intervention, escalation, performance oversight. As part of the Cabinet Secretary's statement around the MAG, there were two very clear remits for NHS Wales Performance and Improvement, which have now resulted in the appointment of a managing director and a complete reorganisation of how we utilise NHS Wales Performance and Improvement to support organisations. We are now in the process of aligning that to the escalation framework and intervention regime that we have in Wales. So, we've got five levels of intervention from one to five, five being special measures, and aligning that now to how we hold health boards to account for the reasons they are in escalation is much, much clearer than it was. I think the MAG was very clear, and I think we would acknowledge there were far too many overlapping points of contact, if you like, with health boards.

We have seen, this autumn, the introduction of a public accountability meeting that the Cabinet Secretary holds with organisations. This is then aligned to the way the chief executive of NHS Wales and I meet with organisations to pick up particular issues. So, we're trying to integrate all of that into a single framework where we have very clear performance expectations. We have limited the number of performance expectations through the planning guidance. So, you will have seen, last year, the Cabinet Secretary set out clear priorities for organisations. They have been basically followed through this year in the same way. We've set out very clearly productivity and efficiency improvements, and the chief medical officer and chief nursing officer are currently working on what the outcomes framework and patient safety aspects of that look like, so we can bring that all together into a single and clear structure that has less interface, if you like, in terms of meetings, but is much clearer in the way in which we hold people to account.

Thank you. That's reassuring. I'm going to move us on to the last item in this section. Joyce.

Over to me. Looking at system transformation and the Audit Wales report, they made some observations that the current statutory planning and financial framework could be improved and that delivering a financially sustainable NHS would require more fundamental issues to be addressed. So, my question, therefore, to you—and you would have answered these questions to the auditor, I'm sure: are you content that the statutory planning and financial framework does give the NHS bodies the incentive, the flexibility, and the practical levers to drive that transformation at the scale that the auditor said is required?

Well, it's—. The auditor did say it was required, but it's not something that I would argue with. I think we do want to see that transformation at scale, so that's definitely the Government's objective. If the question is, 'What contribution can the planning framework make to delivering that outcome?', I actually think that the approach that we've taken, particularly in the last two, maybe before—I'm less familiar with the ones that we've had in the past for, perhaps, obvious reasons—has been an effective tool for delivering some of that.

So, I think one of the challenges that the NHS is grappling with, really, is, transformation, together with clearing the backlog of activity that needs to be done, and then managing increasing levels of demand. So, the task isn't simply one of transformation; it's all of those things, which is why some of this is, perhaps understandably, quite challenging.

So, the approach that I've taken in the last two planning rounds has been to hear what the organisation has said about being more focused on a smaller number of top priorities. Obviously health boards are multi-billion pound organisations doing lots of complex things every day, so not all of that can be reduced to 10 pages. However, they will want to know what are the top things that I as Minister am going to be challenging them on all the time. So, we heard that message and delivered that.

It, for the first time, has been able to align the planning expectation with the funding allocation, which is challenging everywhere to do, and we've done that now two years in a row, which is good in terms of clarity for the system about where the money is and what's expected of it.

And then crucially, I think, the approach that we've taken to identifying what we call internally 'enabling actions', which probably doesn't mean that much generally, but what they are are a set of non-negotiable, mandatory actions that every health board or health organisation must deliver. They are all in the space of improving performance in general, but they are quite particular about what we expect to be delivered, so, for example, sometimes the number of late starts in a theatre, sometimes the number of operations on a list. So, pretty granular. I don't think any of them are new expectations, but the way they've been delivered has been variable, and we absolutely know that there is a mass of evidence that if those can be delivered consistently everywhere, it will deliver not just a better service for patients, but a better value service for the public as well, which is why they're on the list, basically.

So, I actually think that's been a very useful way of approaching it, and I think it's been welcomed. But, alongside that, is the point that Nick was making about recasting the old NHS executive into something more explicitly focused on performance and improvement, with a more streamlined mission of supporting the NHS to improve, but supporting Ministers and the civil service to hold feet to the fire, if you like, if I can put it crudely.

I think the clarity of that mission is now being understood by the system. What we want is for that organisation to be the first port of call if health organisations feel they're struggling with how they might deliver aspects of the planning framework. The first port of call is, 'How can NHS performance and improvement help us?', and then, obviously, Ministers hold them to account for delivering that. So, I think there's a clarity to that. Can that solve all the challenges? Obviously not. But I think it's a very useful tool in focusing the organisations.

And, of course, ultimately—and you've mentioned it—the transformation is also about the outcomes for the patients—

Yes.

—not just the systemic transformation of an organisation—

Absolutely. Absolutely.

—but what that actually means to people on the ground. And you gave a demonstration there of how that is going to help, and also that there's a road yet to travel. So, you're confident in that.

Yes. I'm confident that we have the plans in place, the funding is following and that that is capable of being delivered. But these are not small challenges, as the committee will obviously appreciate.

One example, which I haven't touched on, and we haven't talked about yet—. This is quite telling, in a way, for all of us; we're more than halfway into the discussion and no-one has talked about primary care yet in the discussion. So, just to say, perhaps the most important system transformation is how we move services at pace, sustainably and safely, out of the least convenient and most expensive part of the system into communities and primary care. That's a challenge we've trying to deliver across the UK for quite some time. The CMO is working to lead, from a clinical perspective, a piece of significant transformation work. There are specific targets in the planning framework that require the health boards to respond, but, alongside that, there is a huge amount of very detailed work, which is in a co-development space, about how we can genuinely motor that process forward quickly. So, not all of that can be in the planning framework, but the expectation is set out there.

And just finally from me, of course it all, as you say, marries together; there's no single unit. The recent announcement of women's health hubs, moving things out to GPs, to the local pharmacies—all of those things come under this umbrella, under that plan, and they fit together. I think that perhaps there is a job of work to be done, somewhere, to explain to people that it is a whole, not a constituent part.

I'm sure that's true. Thank you.

Mabon.

We've heard a few stories in the press very recently that are a cause for concern—I'm sure you'd agree—one in Nation.Cymru about bullying at Velindre, and another in WalesOnline regarding bullying at the hospital in Cardiff. And I've heard also that clinical staff at a health board have had to sign an non-disclosure agreement so they can't share some information. That suggests a cultural problem. Why does that exist and who's fault is that?

I don't think it suggests a cultural problem. All of the challenges that you've set out are important, of course, and you will understand that the situation behind each one of those reports is much more complicated, perhaps, than what is discussed in the press. You would expect that.

As to my role as a Minister, and from our perspective as a Government, the important thing is to ensure, when we see elements of these things going on, that there is a clear expectations for health boards or bodies in the health sector to deal with these things in a way that challenges individuals, perhaps, but it's important that that happens. But more importantly than responding to the situation is that we have assurance that the risk is understood by boards and that there is a culture in place that ensures that that doesn't arise. Of course, it does arise from time to time. I've been challenged in the Chamber by you and others recently in relation to what you referred to just now in Cardiff, for example. I've had several discussions with the new chair over the past few weeks, and she completely agrees with what I've just said. So, I am confident that we have the kind of leadership that ensures change and makes sure that these things don't arise again.

And is this affecting people's clinical outcomes? Do you feel that people's health is impacted or is in the balance because of these behaviours by some health board staff?

Well, you're asking a conceptual question here: is the behaviour of an individual going to have an impact on outcomes? Well, of course that can happen. It's not right to comment on what you're saying today. The details of those things are much more complicated, of course.

Fair enough. Fine.

Thank you, Cabinet Secretary and Minister. That's the end of our first session.

We're, obviously, going to be focusing now on NHS waiting times. Just at this point, though, can I formally give John Griffiths's apologies? He can't make it, for unforeseen circumstances, so we'll cover his areas.

You mentioned we hadn't talked about primary care and things earlier. Of course, we're talking about primary care virtually in every inquiry we're currently undertaking at the moment.

Chair, I was not being critical. I was just drawing attention to the fact that, an hour into a conversation about health, we hadn't yet raised it.

I wouldn't want people looking in thinking we're not focused on primary care. It actually takes so much of our time, and we will be coming back to that another day.

Anyway, in this session, we really do want to focus down—we've got about 45 minutes, if we can, or somewhere near—on NHS waiting times, because it's something that taxes all of us and our citizens so much. So, although we know that activity has increased in various points, the overall waiting lists in Wales remain historically high, albeit we saw the progress that you highlighted in the Chamber last week. So, increasing activity alone hasn't been enough to bring the waiting lists down. So, what does the data tell us about why higher activity has not consistently reduced that total waiting list?

Just to be slightly challenging in response to your question, increasing activity alone is not what we've been doing, of course. I'll just unpack that a little bit if I may. What we've seen over the last seven months, I think, at this point, is, for example, a consistent reduction month on month in the size of the waiting list. There has been a lot more central guidance and expectation in relation to how some of that has been driven—and I think that's partly an answer to your question about different ways of approaching this challenge. So, by driving that additional activity more centrally, that has allowed health boards to focus on some of the points we were talking about earlier—the kind of different ways of working and changing services so that they're more effective. So, there's a balanced approach here.

I think one of the areas where we've seen the most rapid progress—and it's been pretty astonishing progress, I think—is in the changing approach to out-patient activity. So, we had an aim to deliver an extra 200,000 out-patient appointments. We are on track with that. The waiting time for that is now down at 14 weeks as an average, which is quite a significant reduction to the 22 weeks that it was at the start of the year. So, I think we are seeing a huge change there. One of the challenges we're identifying is that up to 50 per cent of the referrals that we're seeing through that could be managed in a different way. So, what that tells us— back to the point we were making earlier—is that there are better and more sustainable ways of delivering that healthcare to people. One of the key ways of delivering that is through making sure that the community health pathways that we have in Wales are more consistently and more quickly adopted by health boards so that people aren't ending up being referred into secondary care because the services and the support they need are being delivered much sooner.

I do think it is important to recognise the scale of the impact that this work is having. The number of people on a waiting list, which is different from the number of pathways—these are the individuals that we're talking about, so moving from the data to the actual lived experience of people—that figure is now down to 591,000. So, that's quite considerably less even than the reduced headline figure for pathways. So, I think that shows a system that is working really well to catch up on a huge challenge. There's obviously a lot further to go, Chair, but I do think it's important to set that context.

So, that 200,000 you talked about, you're pretty confident you're going to—. On that 200,000 patient pathways by the end of this Senedd term, you're almost there, then, are you?

There are two 200,000 figures, unhelpfully. So, the first is the number of extra out-patient appointments that we're making. I can tell you that, as of the end of January, 145,000 of those had been delivered already and an extra 45,000 had been booked for February and March. So, those extra appointments, we'll be there. And I'm confident that we will also be able to get to that overall reduction in the size of the waiting list. We're absolutely on track to deliver that as well, and the information that we see in the system, coupled with the resources that we are putting in, show us on track to deliver that as well.

Okay. Thank you.

Just to be clear, that will have been a 25 per cent increase [Correction: 'decrease'] in the size of the waiting list.

Okay. So, clearly, on capacity, then, you believe the capacity is in place to deliver that and you would assume that capacity would continue that trend on into the next Senedd?

Yes. The question of capacity comes in different ways. So, there's the core capacity of the NHS and there's the additional capacity, both within the NHS and then additional capacity that is being procured from outside the NHS. So, there are different kinds of capacity, Chair. What we've been directing more centrally is that additional capacity. And we've, in doing that, enabled the NHS to get to grips with the backlog and the transformation. So, that's the basic strategy overall. In terms of the capacity and its effect into next year and beyond, what I think we are seeing now is the system coming back into balance, so that, effectively, it's not spending its time catching up; it's spending its time seeing patients more quickly, going forward. That's the picture that we're seeing.

So, you'll be reassuring yourself that health boards are becoming resilient or stable, through that input of capacity you're putting in there now, and you're confident that they are levelling out, that they are creating that secure footing, really, to see prolonged change in the right direction.

I'm confident of that, certainly. So, what we are seeing is the system being able to make faster progress with the backlog, so it's needing to spend less time on the backlog and then it's able to see more patients, in turn. So, that's the general picture. Obviously, beyond the two-year waits, we want to make sure that people are being seen much more quickly than two years. But having a focus both on the size of the list and on the longest waits is fundamental to getting that system back into balance. I think we will see, for the year ahead, based on the question you just put to me, quite a small number of specialties requiring the sort of intervention that we've put in place in recent years, and most specialties not requiring that same level of intervention.

Do you think we've reached a point where that increased activity or bringing in that additional capacity has reached the limits of what it can do to shift the situation we're in? Is there a need for, I don't know, some other focus, or are there bigger constraints sitting in the system that are stopping that progress you're striving to achieve?

Well, I think, it isn't—. I know this isn't the point you're putting, but, just for clarity, it isn't simply a question of more activity; it's about what you're doing, obviously, as well. There are certainly things that—. I'm not a clinician. I'm surrounded by clinicians, but I am not a clinician, but I'll just venture my simplistic understanding of it. There are some things that the NHS is doing today that has not much of a clinical value. Now, we don't particularly want the NHS to do more of that. So, for example, I'm told that tonsillectomies, varicose veins would be in that category. The public would like to have them done. Often, the clinical benefits of it aren't as straightforward. So, it's not about just doing more stuff; it's about focusing on the interventions that make the biggest difference and, bluntly, being better at finding out from the patient what they want from the experience as well. We know that there are quite high levels—and this isn't just a Wales issue; it's general—there are quite high levels of surgery regret, in particularly older cohorts of patients, which could be avoided if different approaches were taken. So, there's a question about how you do things. But it isn't just about activity; it's about being better at identifying best-in-class activity within the health service, and making sure that all providers are delivering best-in-class activity. It's about putting more services into the community. It's about strengthening even further clinical leadership at all levels in the NHS. So, it is not just about activity; it's a different approach, Chair.

So, following on from that, then, where should that next phase of planned care recovery be focused most to achieve more sustainable reductions in waiting times?

My own view is that the approach that I think needs to continue is one where you're looking at both the size of the list and the timeliness of care, recognising the benefits of a central approach to additional capacity coming onstream, a rigorous focus on enabling actions, using external providers to support the NHS where there are still problems about getting the system back into balance—those are temporary challenges where additional capacity can be made available—enhanced performance management of the sort that we have in place now, and linking funding to delivering outcomes. Not all the funding can be done in that way, but, certainly, with the additional funding, we've been, I think, pretty good at linking that to delivering the outcomes that we are expecting for it and funding it after those outcomes have been demonstrated. That has focused the system on delivering the particular things that we're funding.

Thank you for that. Can I bring Joyce in, please?

That leads me nicely on to my question about funding and the investment that has been made by the Welsh Government. More than £1 billion over this Senedd has been invested in NHS recovery and planned care, and there has been further funding added in this year to accelerate reductions in waiting times. So, you started talking about how some of that has been spent—and it has been welcomed, absolutely. But how much of it has been spent so far? You may not be able to do it in the here and now, but it would help us as a committee to have a clear summary showing what was promised, what was allocated each year and what was spent, but, more importantly, the difference that it all made.

Okay. I think I will, if I may, Chair, write to the committee with the detail in response.

Just as a headline point, just to link the two points we've just been discussing, I was reflecting last year, when we were talking about putting an extra £120 million for the additional activity this year and seeing what that has delivered over the course of the last year, out of a £12 billion budget, £120 million is basically 1 per cent. So, I struggle to think, really, in a way, that a 1 per cent budget increase is the only thing that's required to deliver all of that change. I don't think that is the answer. Clearly, the additional funding is welcome and it's important, and it has enabled different approaches, which is good, but, surely, a 1 per cent change in the overall funding envelope isn't the key driver of all of that. It's also about a different approach. I think it's really important that we recognise both those two points—the approach I just laid out in my previous answer. It's having those two things together; you can't have one without the other. You need a bit of extra funding to deliver that approach, but those two things, I think, are the answer.

We're still talking money. We know that some targets—waiting times—are still higher, perhaps, than we would like. So, that being the case, what is your best current estimate of the investment required in the next Senedd to consolidate those gains, which we've clearly made, to avoid a rebound of that growth and that acceleration in Wales?

Okay. I think the answer to that is this, really: as a result of the investment we've made and the changed approach that we brought about, I don't envisage that the totality of that will be required next year in order to continue the level of performance that we have seen and that we are going to see over the next few weeks and months. So, that is a very positive thing for the NHS, and, most importantly, for the public and patients. However, there will be, I think, as I mentioned earlier, a small number of what we call challenged specialties, where some limited, probably, extra funding would be needed in order to continue the progress that we are seeing now. But that's a different kind of challenge, isn't it? That's identifying very specific things that need to be treated, in the same way that we're doing across the piece at the moment. Probably those two areas, I think, where that's most likely to be needed are in some aspects of orthopaedics—so, spinal surgery cases in particular—and then in ophthalmology, some aspects of that as well. But I think they are limited and narrow specialties.

So, you've identified them, and it's much the same as we've identified, to be honest, in this committee. Will the budgets that are needed to improve that be retained so that we can, obviously, see those improvements?

Well, the budgets needed for those types of interventions are significantly lower than the budgets we've had to put in this year and last year. So, I'm confident the budget provides for that, certainly.

Okay.

Okay. Russ, would you like to come in?

Thanks, Chair. None of the original planned recovery targets have been fully achieved within the timetable set. So, do you think that the original ambitions were realistic?

I think it's very important when you're trying to recover from the situation that health services everywhere were facing in 2019, 2020, 2021 around COVID, that you have ambitious targets for recovery because the system responds, I think, to that level of ambition. I think it is important to acknowledge that, through all of those years, there has been progress. You're right to say that some of the time points that we attached to those milestones weren't met. We didn't manage to make that level of progress quickly enough. I'm confident that we're getting there where we are today.

But I think, in a sense, that explains to you why we took a refreshed approach this year and last year. That was, in a sense, the reason for that different approach. And the fundamental things, I think, have been recognising it's about the size of the list as well as the long waits, because unless you're tackling the size of the list, people are still going to be tipping over into the two-year waits at that scale, aren't they, so you're never going to catch up. That was significant.

And I think, as well as health boards increasing their core capacity locally, delivering that additional capacity as a national strategy, which has been good in terms of value for money, actually, also it's been good in terms of overall performance. So, that's really what that's been about.

So, you think that the original ambitions were realistic.

The timescales for some of them—not all of them—obviously weren't met. So, in that sense, that's disappointing. But I guess, from a lessons learned point of view, would you go back and say we'd have much less ambitious targets? I'm not sure what the rationale for that would be. You're not putting it like this to me, but, just to be clear, we aren't commentators on how the NHS is working. What we are looking for is the levers that drive change in the system. And we set targets, some of them are met in terms of time, some of them weren't. So, then you're looking at what other levers you can do to make sure that they are met. That's the process we've been engaged in, and I think we're seeing that bear fruit.

Okay. And would you accept that, when it comes to NHS waiting times, patients deserve honesty and honest data, as opposed to any headline-friendly statistics, if you like?

I'm sure that's a challenge for us all, Chair, but 'yes' is the answer.

Yes. Okay. Thank you. How many people in Powys have been waiting longer than two years for NHS treatment?

I don't want to exhaust the patience of the committee Chair, but I have explained many, many times how the statistics work in this area. So, I'll take this one opportunity, if I may, to put it on the record once again. We will all be aware that waiting times at a health board level are allocated on a provider footprint. So, it looks at what the provider delivers rather than the population receives. In Powys in particular, but it's true in other parts of Wales, there are residents in one health board area who will be treated in another health board area for lots of different reasons. And those individuals are captured in the data for the provider, not for the county footprint. That is a well established and well understood way of describing the data.

So, if I ask you: how many people are waiting in Powys for treatment?

Well, from a provider point of view, there's nobody waiting for more than two years, which is the point I've made, I think, a number of times to you.

So, how many people are waiting? How many patients are waiting in Powys for more than two years for treatment, or don't you know the answer?

They'll be captured in the data for other health board providers and for providers outside Wales.

So, I think you're accepting that there are people who are waiting more than two years for treatment in Powys.

I'll do more than say I've accepted it. I've said in the Chamber specifically that there are patients from Powys, for example, in hospitals in England, who are waiting for more than two years, and I regard that as no less acceptable than if they're waiting for more than two years in Wales.

You've just given some context to the question I put to you. But when you said last Tuesday in the Chamber that no-one in Powys is waiting more than two years for treatment, without giving any context, as you've given now, can you see that that could be seen as misleading by some people? And saying to the average person that no-one in Powys is waiting more than two years for treatment, they would believe that that means no-one in Powys is waiting two years for treatment. Can you see how that could be misleading?

Well, without trying the patience of the Chair, I wasn't saying it to an average person, I was saying it to a former Chair of this committee, and I would expect that Chair to understand how the data is being collated.

So, you think that, when you say that no-one is waiting more than two years for treatment in Powys, I should understand you don't really mean that.

Well, Chair, I think I've made quite clear how the data is captured and the expectation the public would have about who would know that. I'm not sure it's particularly helpful for me to have to make the point again, but I'm content to do that if you think it would be helpful.

Yes, move on.

I'll continue with the line of questioning briefly, Chair. Surely it's important, not just in Powys but in every health board in Wales, for you to know how many people are waiting for treatment in a particular area in order to inform policy. So, it sounds to me, taking Powys for example, that you don't actually know how many people are waiting for treatment for longer than two years in Powys. Is that correct?

I don't have the number in front of me, Chair.

I see—

But I'm I'm happy to provide that, unless—.

I see Nick—

I don't have the exact number, but we will know—. Well, each health board has a detailed patient tracking list, referred to as the PTL, which is used to feed the data that we report on a monthly basis through official stats. There are, I know, clearly patient identifiers within that PTL. So, each health board will know the residency status of everybody that's on their lists. We could access that should we wish to find out the exact numbers. As the Cabinet Secretary has already said, there will be a number of Powys residents within those provider lists, whether that be Aneurin Bevan or Betsi Cadwaladr. So, there will be numbers within there. We could easily write to the committee and set out exactly how many Powys residents, what stage of wait they're at, for what procedure—infinite detail on all of the patients. We have that for every resident of Wales.

And do you know how many people in Powys or, indeed, in any other health board area in Wales are waiting in English providers as well? Do you have that data as well?

Yes, we have that. So, that's reported by, again, the individual health boards, and that will be part of their patient tracking list.

So, you could provide that information if the committee asks for that.

Yes.

Okay. I'm conscious of time and I'm going to move us on, if I may. Can I bring Mabon in, please?

Thank you, Chair. Well, it's World Cancer Day, so it's only fitting that we discuss cancer and, in this instance, waiting lists for cancer treatment. In your written evidence, Cabinet Secretary, you said that diagnostic capacity hasn't caught up with the demand for diagnosis. Why is that? What's holding that diagnostic capacity back? Is it the workforce? We've touched on that. Is it the equipment or the estate, or what else is causing this?

Well, I do think it's true to say that the pressure is on diagnostics, and you are right to say that there’s more than one element to that. I would say that it's a wide term that can cover a lot of things. We do have specific challenges, I would say, in terms of endoscopy, non-obstetric ultrasound, MRI and CT, but you are right to say that it's a combination of factors. We have invested in kit, in equipment. We have recruited more people in endoscopy, for example, and we do have specific plans in terms of non-obstetric ultrasound.

I couldn't say it.

There are plans on the horizon to create more capacity in the system, for example in Llantrisant and other places. But one of the things that we have seen and which is an element of success, you could say, is that because we have tried to increase the number of people who are referred so that we can catch cancer earlier, that has created more pressure, if you would, on the diagnostic system, and there is a question of capacity that arises as a result.

I heard recently that the rapid diagnostic centre in Aneurin Bevan isn't used now because there aren't enough people referred into it. Is that correct? And are you content that the rapid diagnostic centres are being used to their full potential?

That is correct. The point of the rapid diagnostic centres was to ensure that people could get diagnoses sooner. It happens in other health boards, but the performance does vary from place to place, and I think I'm right to say—maybe Jacqueline or Nick could answer this in more detail—that the performance doesn't show that quite in that health board. So, the health board has made a decision specifically in that regard.

But if we have underuse of diagnostics, is there a specific problem in Aneurin Bevan that people aren't being referred, therefore? I'm trying to understand—

It's a pathway rather than capacity. It's a matter of the pathway that the patient follows.

Thank you.

So, in terms of capacity within Aneurin, we've put a lot of extra capacity into Aneurin Bevan and across a whole range of diagnostic tests. My understanding of the reason that they moved away from the rapid diagnostic centre was that they were utilising that additional capacity on a bigger scale, rather than through the rapid diagnostic centre. But I'd have to double-check. At the time, that was my understanding of the reason. They have significantly longer waits for some diagnostic tests in that health board area compared to others, but with the extra capacity that they've put in that we've seen recently, certainly over the last six to eight weeks, the wait times for those diagnostics has come down quite considerably, both from an urgent cancer perspective and from the perspective of core plan diagnostics. So, I think their referral time in cancer overall, from the first point of suspicion to diagnostic, is about 26 days in Aneurin Bevan, which is probably slightly less than the average in Wales.

Thank you. To turn to another health board, in Betsi Cadwaladr in North Wales we've heard recently, with the PET-CT scanner in Wrexham Maelor, that the contract there has come to an end and that patients in north Wales now have to come down to south Wales or have to go to England to receive a scan, and they're waiting longer than they should be for diagnosis because the contract hasn't been signed. How are we in a situation where the health board forgets or doesn't have a procedure in place in order to sign a new contract or agreement on a PET-CT scanner?

As I understand it, it's a challenge around something that arises in the context of procurement in general when a new contract comes in. There's a process around that that can go on longer than anyone or any health board involved in the process expects to happen. But the question that you made in the Chamber was that it is possible to foresee when a contract comes to an end, and, of course, that is possible.

Yes. I'm sure this isn't an acceptable situation, is it?

No.

I'm pleased to hear you say that. One specific question: there was a Rutherford cancer centre meant to be established in Newport with what they call a

'comprehensive range of diagnostic scanners...linear accelerators, 12 bay chemotherapy suites and proton beam therapy'.

An excellent centre that, to my knowledge, has never been used, and the company that was meant to have been commissioned to run it has gone to the wall. Why are we in this situation? What happens to all of that excellent equipment and resource now, and is there a way for us to see that being used?

Could I ask Nick to answer that, if possible?

I'm trying to remember what happened with this. The company that were running it, obviously, either went into liquidation or stopped trading from that particular site. I know a number of health boards did look at the purchase of equipment, but I'd have to check on what happened beyond that from the Rutherford's perspective, and whether or not the local health board in Aneurin Bevan or Cardiff made any further efforts to secure that site and equipment. So, I'd have to come back to you on that.

Okay, thank you. Lesley, if I can invite you in on workforce.

Thanks very much, Chair. Just looking at productivity in this particular area, would you say you've seen the improvement that you would want to see? Do you think there have been any barriers, if it's not the case? And particularly focusing on digital, if you think digital's a barrier, how digitally enabled do you think, in general—this is a very general question—NHS Wales staff are?

Okay. So, on productivity, generally—. Just to say, I was speaking at a staff event the other day with a trade union partner, and I made the point there, which I'll make again—when we talk about productivity, what we are not saying to individual staff members is, 'You have to work harder', what we're saying is, 'The system needs to be configured in a way that delivers more productivity from the system.' It's important, when we're talking about this in this context, for the audience to hear that perspective.

On productivity as a whole, clearly, what we have not seen is an increase in productivity that has matched the increase in investment either through staff or other resources that has gone into the NHS. We would obviously want to see a more productive service overall, clearly. What we have been looking at, in common with other parts of the UK, I guess, is how to recover some of the productivity that was lost in the context of COVID specifically. For obvious reasons, we will understand why that was a significant impact on productivity.

You will recall perhaps that one of the recommendations that the ministerial advisory group made to the Government, which we accepted, was that we should develop what they called, rather technically, a 'total factor productivity' model. So, how do you measure the overall productivity of the health service? This morning—if it hasn't already been issued, it will be issued today—we are announcing that we have launched that this week. What that looks at, both at a health board level and a Wales-wide level, is the productivity of the health service measured as against the baseline of 2019-20, which is the year before COVID, and then it shows how the system has performed in the meantime. There is variability, as you would probably expect there to be.

I think one of the things that we have been able to achieve through the national approach that we've taken and the work of NHS P&I, is improved productivity from the point of view of the planned care programme. That's obviously good, but the whole premise, if you like, the whole purpose of the enabling actions that we've set out for two years in a row now in the planning guidance, is about increasing productivity. Some of that is about—. Well, almost all of it, actually, is about how you deliver the service.

Two very good examples—I think they're good examples, anyway—I was at the Princess of Wales Hospital a few weeks ago, looking at how the health board has reconfigured all of their orthopaedic surgery onto one site at the hospital there. They've been able to do that because we've provided some additional capital, because there are upfront capital costs to enable that to happen. The net effect of it has been that, on the same otherwise running cost and the same staffing complement, they have the capacity now to see twice as many patients as they were previously able to see on three, I think, separate sites. Anecdotally and unsurprisingly, they were saying, 'Patients are prepared to travel a little bit further if they know they're going to get it sooner, and if they know there's less chance of the operation being cancelled because the rota isn't stable.' You're able to reduce that risk if you deliver it differently. A comparable example is the Llandough cataract unit, which has done similar in terms of relocating services onto one site, and has again seen a huge increase in capacity based on the same resources.

Those are two examples. They happen to be both examples that people care a lot about in terms of getting their hips and knees and cataracts done, but there's potential to do more of that, I think, elsewhere. Some of that is driven by technology, obviously, and data capture and digital literacy clearly is a fundamental requirement of having that level of productivity that we want to see.

The current waiting list initiatives, if you like, are consultant-led, aren't they? Whereas previously it was very much outsourcing, bringing in independent sector provision. Are you able to tell us, or perhaps you can provide a note, how much it has cost to have that consultant-led approach, and whether you think that is sustainable going forward?

I can give you an outline sense of that, if that's helpful. What we've been able to do, as I touched on earlier, in taking a more national, centralised approach to some of this capacity procurement, is deliver better value for money as well. So, the per-appointment rates, per-session rates, have tended to be lower than the costs that NHS Wales would otherwise have been providing those for. So, that's been, obviously, beneficial. However, there have been other approaches that we've taken as well that clearly are creating economies of scale. So, for example, part of the transformation work is around how we deliver out-patients differently, and one of the ways in which the system has been doing that is through mega-clinics—that's what we've been calling them. So, you will probably have had many constituents who have been called to clinics in the evening and on the weekends, as out-patients, and that's consultant-led and other staffing as well. And that's been very effective, as you would probably expect. So, the task now is to make that not part of simply a solution to getting the out-patient system back into balance but making that a core part of how we deliver out-patient services into the future. So, that's the opportunity.

That's really good to hear, because, for me, I think the NHS should be 24/7. I'm not saying that there should be out-patient clinics overnight, but you know what I'm trying to say. And certainly constituents I think have been very pleased to attend appointments. If you're working nine to five, then obviously it's much better to be able to attend clinics out of those hours. So, I'm pleased to hear you say that. I just wonder if you could say a bit about consultant contracts, because obviously consultants are allowed to do private work within their contract. What is the ratio now of sessions that they can do, NHS to privately? What impact do you think those consultants undertaking private sessions—what's the impact, do you think, on NHS provision?

Well, I don't have the answer to the ratio question, but I can provide that separately. To the extent we have it, we'd be happy to provide it. In terms of what it means for the NHS core capacity, obviously each health board has very clear rules and procedures, which are managed locally to make sure that private practice does not impact on NHS activity. That's protected, if you like, and that private work is done outside of that capacity. But on the ratio question, I can follow that up, if I may.

Okay. Well, we've come to, basically, the end of the session, but I've got one final, quite important question that I'd like to put, because this will be the last time that we'll have an opportunity to talk to you before the end of the Senedd. So, basically, if the next Welsh Government were to refresh or reset the planned care programme, which elements of the 2022 approach would you carry forward, redesign or discontinue entirely?

Well, that's a big question, Chair. I guess I would say, from a ministerial point of view, that my reflections are twofold, really. So, firstly, much of the discussion that we've had today has been in the context of delivering more effective services so that people can be seen more quickly. What we haven't discussed, really, is how we manage the demand coming into the system, and that is the fundamental question. We can be as efficient and as effective as we like in managing the service, but if we are still facing escalating demand at the rate we are currently—this is not a Welsh challenge, it's a global challenge—that's a system that can never get into sustained balance. So, that challenge of, obviously, more preventative work, but again moving more services out of secondary care—not hospital by default but community by design—all of that is fundamental. Applying those community health pathways quickly, rigorously, universally—that is really at the core of how we do this, making sure that we can develop the primary model so that chronic conditions are managed in a way that delivers continuity of service through particular clinicians. All of that helps us with the demand side of things, but on the planned care programme itself, I think it's about the size of the list as well as the time that people are waiting, it's about a role for national procurement, it's a rigorous approach towards performance management, it's a complete focus on delivering those enabling actions, it's linking additional funding to targets being met, and having that new approach we are seeing is making a really big difference to patients in Wales.

Well, thank you very much for that. On your demand point, absolutely. We've heard that the preventative agenda is absolutely fundamental to the future. Can I thank you all for giving us so much time today? We've covered a lot of areas. There may be some areas we wouldn't mind just following up on. Is it okay if we write to you on those couple of issues? Obviously, there's a transcript available, as always, for you to check over if you want. Thank you very much once again for coming in.

Chair, could I just say, as I reach the end of my tenure, and the committee reaches the end of its life as a committee, thank you from me to the committee for the work that you've done throughout the Senedd term? It's been very valuable. It's helped shape a lot of the thinking that we've had. Sometimes it's been challenging, as you would expect, and some of these discussions are challenging, obviously, as is appropriate. But I just wanted to say 'thank you' for the dedication the committee has shown throughout the Senedd.

Thank you very much, and thank you for your engagement, and, Ministers, for your engagement. We get a lot out of the work we do. Obviously, I'm a newcomer to the committee, but I know past Members have worked extremely hard and continue to do so. Thank you once again.