Cynulliad Cenedlaethol Cymru The National Assembly for Wales Y Pwyllgor Plant a Phobl Ifanc The Children and Young People Committee
Dydd Iau, 8 Tachwedd 2012 Thursday, 8 November 2012
Cynnwys Contents Cyflwyniad, Ymddiheuriadau a Dirprwyon Introduction, Apologies and Substitutions Graddau TGAU Saesneg Iaith Haf 2012 GCSE English Language Grades Summer 2012 Materion Iechyd Plant Child Health Issues
Cofnodir y trafodion hyn yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. These proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included.
Aelodau’r pwyllgor yn bresennol Committee members in attendance
Angela Burns	Ceidwadwyr Cymreig Welsh Conservatives
Christine Chapman	Llafur (Cadeirydd y Pwyllgor) Labour (Committee Chair)
Jocelyn Davies	Plaid Cymru The Party of Wales
Suzy Davies	Ceidwadwyr Cymreig Welsh Conservatives
Rebecca Evans	Llafur Labour
Julie Morgan	Llafur Labour
Lynne Neagle	Llafur Labour
Jenny Rathbone	Llafur Labour
Aled Roberts	Democratiaid Rhyddfrydol Cymru Welsh Liberal Democrats
Simon Thomas	Plaid Cymru The Party of Wales
Eraill yn bresennol Others in attendance
Leighton Andrews	Aelod Cynulliad, Llafur (Y Gweinidog Addysg a Sgiliau) Assembly Member, Labour (The Minister for Education and Skills)
Chris Tweedale	Cyfarwyddwr, Grŵp Ysgolion a Phobl Ifanc, Llywodraeth Cymru Director, Schools and Young People Group, Welsh Government
Cassy Taylor	Pennaeth Rheoleiddio Cymwysterau Cyffredinol, Llywodraeth Cymru Head of General Qualifications Regulation, Welsh Government
Dr Ruth Hussey	Prif Swyddog Meddygol Cymru Chief Medical Officer for Wales
Dr Heather Payne	Uwch-Swyddog Meddygol, Iechyd Mam a Phlentyn, Llywodraeth Cymru Senior Medical Officer, Maternal and Child Health, Welsh Government
Swyddogion Cynulliad Cenedlaethol Cymru yn bresennol National Assembly for Wales officials in attendance
Claire Morris	Clerc Clerk
Kayleigh Driscoll	Dirprwy Glerc Deputy Clerk
Anne Thomas	Y Gwasanaeth Ymchwil Research Service
Victoria Paris	Y Gwasanaeth Ymchwil Research Service
Dechreuodd y cyfarfod am 9.32 a.m. The meeting began at 9.32 a.m.
Cyflwyniad, Ymddiheuriadau a Dirprwyon Introduction, Apologies and Substitutions
[1] Christine Chapman: Good morning, everyone, and welcome to the Assembly’s Children and Young People Committee. I remind Members to switch off any mobile phones or BlackBerrys, because they affect the sound. We have had no apologies this morning.
9.33 a.m.
Graddau TGAU Saesneg Iaith Haf 2012 GCSE English Language Grades Summer 2012
[2] Christine Chapman: I welcome Leighton Andrews, the Minister for Education and Skills; Cassy Taylor, head of general qualifications regulation; and Chris Tweedale, director of schools and young people group. I know that you have sent a paper, Minister, but I also know that you would like to make a few opening remarks.
[3] The Minister for Education and Skills (Leighton Andrews): Thank you, Chair. The decision to regrade the English language GCSE was not taken lightly, and it is a very rare instance of a Minister becoming involved directly in regulatory issues as distinct to policy issues on examination and qualifications. The only other occasion I can recall that happening during my time in this role was last year, when The Daily Telegraph ran a series of articles concerning examination seminars. As a result of that, I intervened with WJEC over a rescheduling of GCSE ICT examinations due to a breach of security, and established a task and finish group to look at the structure of the examinations market in Wales. That group reported to me before the summer recess, and I published a statement on its report in July for Members to consider.
[4] My officials have diligently sought to continue to operate on the basis of a three-country regulatory system. It is the case that, since June 2010 and particularly in the last year, this has become more difficult because of policy divergence between Wales and Northern Ireland on the one hand, and England on the other. Indeed, earlier this year the Northern Ireland examining body, the Council for the Curriculum, Examinations and Assessment withdrew its qualifications from offer in England because of the increasing policy divergence with England.
[5] I have, of course, read the evidence from the WJEC and Ofqual. I was surprised when the chief executive of Ofqual told the committee that her organisation had only been in existence for a couple of years. I have minutes of maintaining standards meetings held in October 2008 with Ofqual, when issues relevant to today’s discussion were discussed, which were flagged up in the report of my regulatory officials in September. Of course, the current chief executive of Ofqual was not in post at the time, and nor were a number of her senior officials. The purpose of these maintaining standards meetings was to ensure that, where new qualifications change specification, outcomes year on year should be comparable when cohorts were similar.
[6] It is only recently that Ofqual has published its maintaining standards work and couched it in terms of fighting grade inflation. The phrase ‘grade inflation’ was not used in the first three Ofqual chief regulator’s reports. Instead, there was repeated reference to ensuring that awards are consistent and fair and that standards are maintained year on year. Even as late as 25 July this year, a standards and research report issued to Ofqual’s board stated that its approach was intended to ensure comparable outcomes, meaning that if the 2012 cohort entering for a subject is of similar ability to the 2011 cohort, the proportions of candidates achieving particular grades should be similar. However, in a letter to the Secretary of State in England on 22 August, the chief executive of Ofqual made it clear that Ofqual regards comparable outcomes as an approach to containing grade inflation rather than ensuring fairness to candidates, saying:
[7] ‘One consequence of this approach is that it can make it harder for any genuine increases in the performance of students to be fully reflected in the results.’
[8] Members will be aware that the September report by my regulatory officials analysed the information available on the 2011 and 2012 cohorts, and concluded that there was no reason why performance should have been significantly worse in 2012. On that basis, we concluded that the results were unfair to candidates. Members may not be aware that informed commentators, such as the Financial Times education correspondent, Chris Cook, have suggested that Ofqual’s own most recent report on English Language GCSEs does not really offer new evidence about the central question: did a child in 2012 do as well as a similarly taught child did in 2011? That is what our report sought to do.
[9] Members will not be aware—but need to be aware—of the issues that we have had to address in respect of Ofqual’s poor understanding of the devolution settlement. In July 2012, Ofqual’s director of regulations wrote to our officials claiming that it had the power to regulate qualifications wherever they were taken, including in Wales. Following discussions with our officials and our lawyers, Ofqual subsequently withdrew that letter. Even on 29 August, the director of regulations at Ofqual said in an e-mail to her chief executive,
[10] ‘I know that we would all like to put the Welsh regulation issue to one side, but we can’t’.
[11] Members will be aware that we had to ask Ofqual’s chief executive to correct evidence that she gave to the House of Commons’ Education Committee, which was wrong.
[12] Members will understandably wish to question us about the key stage 2 predictor issue. We are very happy to answer in detail and to supply copies of correspondence. We regard evidence given by Ofqual to this committee on the key stage 2 issue as incomplete and inaccurate. I can tell the committee that officials told Ofqual by e-mail on 5 April that if Ofqual wanted WJEC to report against key stage 2 predictors, it should send an Ofqual-only letter as
[13] ‘it would be inappropriate for the Welsh Government to be asking for results in Wales to be determined purely on the basis of predictions for English candidates’.
[14] We note that Ofqual’s evidence states that,
[15] ‘The view of the experts is that Key Stage 2 is a better predictor of GCSE achievement at cohort level, than common centres’.
[16] That may or may not be true for England, but it is absolutely not true for Wales. We may, ourselves, have questions about the use of common centres as a predictor, but clearly, the key stage 2 predictor model does not work for Wales.
[17] Finally, Ofqual itself strayed from the original declared position that the reporting against key stage 2 predictors would be ‘for reporting purposes only’ and place all of its reliance on key stage 2 indicators, using them as a device to change results that were already inconsistent with the previous year. I understand that the use of key stage 2 predictor methodology for GCSEs was first proposed by the AQA examining body. Members may wish to reflect on whether Ofqual has been subject to producer capture in its adoption of AQA’s preferred methodology. I have reviewed these issues in detail with my officials and I am confident that the approach that was taken was the only approach that could have been taken in the context of three-country collaboration as it was understood until this year. Members will obviously wish to test that in their questions, and we will be happy to respond and to explain why alternative courses of action would have been unacceptable. In Wales we have acted to put right an unfairness. In England, a court case is pending. I believe that, in a situation that is by no means perfect, the Welsh regulatory system has delivered fairness for Welsh students.
[18] Christine Chapman: Thank you for that, Minister. I will ask the first question, and other Members will have questions that they want to ask you. In the report that you mentioned, dated 10 September 2012, your officials looked at a number of factors that may have affected the grading of the summer 2012 GCSE English qualifications. To give you some examples, there is the possibility that the new, combined English GCSE introduced only in England affected the profile of the cohort and, as a result, made the predictor model unreliable. Also, there could be different approaches and entry strategies towards modular examinations in England and Wales, and there could be significant variations between centres in the approach to controlled assessment. Which of these factors had the most significant impact on the summer 2012 English language GCSEs in England and Wales?
[19] Leighton Andrews: All of them had an impact. It is very difficult to make a judgment as to the relative weighting of each of the factors. As you know, we published our reports and subsequently, last week, Ofqual published its report, and there is material within its report that looks at the different performance of WJEC candidates in Wales compared with WJEC candidates in England. It has some interesting graphs that show a bunching of performance of WJEC candidates in England around the grade boundaries. That graphically illustrates some of these issues. We have said in our report that we regarded the key stage 2 predictor model as being unsafe for a number of reasons, if it was used as a pure determinant—there is a difference between using it as a determinant and allowing it as a factor in reporting. The issue of the different exams that are entered in England is clearly a factor. We have not approved the GCSE English for use in the Welsh education system. We have allowed young people to be entered for GCSE English language or English literature, and the reason very simply is that we do not believe that the GCSE English that is available over the border sufficiently tests the full curriculum. All of these factors have a bearing and it is difficult to make judgments overall as to their impact. As you will know from our report, we have said that there are things that we want our schools standards unit to follow through with schools in respect of performance by particular centres, because clearly there was significant variation, particularly around the issue of controlled assessment.
[20] Jocelyn Davies: You have acknowledged the highly significant variations in performance between centres’ predicted and awarded grades. Were you surprised? What did you do? How do you explain the variation?
[21] Leighton Andrews: Was I surprised when? Do you mean at the point of getting the exam results?
[22] Jocelyn Davies: You have said that there were highly significant variations in performance between centres’ predicted and actual grades within Wales. I am just asking whether you were surprised by that. What did you do when you found out? Can you explain the variation?
[23] Leighton Andrews: Clearly we were surprised, and I think that schools across Wales have been surprised, and many people in the education system have been surprised about the variation in performance. We did not have the full picture until the results were compiled around 22 August, when I was briefed on the GCSE results. The next day I asked for a formal inquiry by my officials, which then produced the report that I subsequently published.
9.45 a.m.
[24] On the basis of that, I took the action of directing WJEC to regrade. However, that report contained a number of other actions, including, of course, the recommendation that our school standards unit worked through with schools the issues that had arisen in respect of controlled assessment. We have subsequently also taken the decision to specify a new standard for the GCSE qualification to be taken in 2014, which has significantly less controlled assessment—it will be 40% rather than 60%—so I think that we have also acted in that regard.
[25] Jocelyn Davies: Can you explain the variation that occurred?
[26] Leighton Andrews: No, not yet. There are still inquiries going on. It is fair to say that, if you look at different schools, you will find that they have taken a different approach, in some cases, to the nature of controlled assessment. We clearly want to ensure that all schools and other centres operate on a level playing field, but also that they are learning from best practice in this regard so that we ensure that Welsh performance is good. From looking at the material that we have received from WJEC—and I think that you have seen it in the evidence that you have received, in our report and in the Ofqual reports—there is some suggestion of earlier entry within the English system, which may well have had an impact on performance. We know that there is more of a re-sit culture in the English system overall. That is slightly separate from the controlled assessment issue, but all of those factors are things that the Welsh education system needs to learn from.
[27] Jocelyn Davies: However, with regard to the variations in Wales, you have said that you do not know yet, but we have had evidence that suggested that perhaps some centres were allowing students to take much more material in with them when they sat their controlled assessment. Do you think that is probably at the crux of it?
[28] Leighton Andrews: That may be one of the factors within it. It is premature to make that judgment, but we certainly know that there is variability between the centres.
[29] Jocelyn Davies: Okay. Ofqual has said that it identified a significant variation—8%, which you have referred to already—in awards achieved between centres in England and centres in Wales. That may be due to the reason that it gave to us, namely policy differences, but what is your reaction to that?
[30] Leighton Andrews: The evidence that has been put to you by Ofqual and WJEC confirms our own emerging conclusions, which go back to what I said in answer to your earlier question. We have evidence that, in England, there are examples of earlier entries. We are aware that there has been more of a re-sit culture in England—I have said that in the Chamber previously in answer to questions on the report that we produced in September. There will also be questions about the nature of the cohorts that were entered for GCSE English in England compared to GCSE English language. Obviously, candidates in Wales do not have the opportunity to enter for GCSE English and it has been suggested that perhaps less able students in England were entered for GCSE English. That, of course, will result in differences overall. So, there is a whole series of factors. I do not know whether Chris wants to add to that.
[31] Jocelyn Davies: I was just referring to the fact that this 8% difference appears to have happened this year, and some of the factors that you mentioned would recur every year, so they would not be—
[32] Leighton Andrews: However, there was a change in specification this year, and I think that is one of the key factors.
[33] Jocelyn Davies: Perhaps you could focus on that, Mr Tweedale, in explaining that significant difference this year.
[34] Mr Tweedale: I would suggest that, whenever you have a big change in specification, such as the one that we saw with the English language course this year, it takes teachers time to understand the new specification. In my mind, that leads me to believe that would give rise to some of the change and the variability between centres, particularly when you had a specification that allowed 60% controlled assessment and 40% of different kinds of assessment. Both our report and the evidence that we have seen in the Ofqual report suggests that the 60% of controlled assessment made a big difference to the way in which we have variability across the system.
[35] Jocelyn Davies: WJEC referred to the regime in Wales. Do you think that there is anything that would affect only candidates in Wales as a result of this ‘regime’ in Wales that WJEC mentioned? You said that you had read the evidence that it gave to us.
[36] Leighton Andrews: One of the things that it clearly said—and this goes back to the question of the early entry—in its evidence to you and in other places is that we have seen candidates in England being entered much earlier. There are very significant percentage differences in the number of early entrants between Wales and England in the reports that have been supplied to you. That in itself means that there will be more opportunities for candidates in England to improve their grades over time. There are a number of factors at play, and that is obviously one of them.
[37] Jocelyn Davies: How long have those significant differences between Wales and England in terms of early entries been going on?
[38] Leighton Andrews: We can certainly do the work on that. We have given some evidence on that. Cassy, do you have it?
[39] Ms Taylor: Early entrants sitting units early in the course, rather than at the end of it, was a new feature of this specification. Previously, specifications have been linear with all assessment at the end of the course. This specification introduced the opportunity to take units early. That opportunity was taken up to a much greater extent in England, therefore enabling them to draw the benefits of a unitised approach to assessment, but not so many centres in Wales took it up. This was the first time that this opportunity had arisen.
[40] Jocelyn Davies: So, that is relevant if they are re-sitting.
[41] Ms Taylor: It is not just relevant if they are re-sitting. If they are taking units early, they are getting them out of the way. They also have the opportunity to know exactly how many marks they need to get in their controlled assessment to get the grades that they are aiming for. WJEC was the only board that did not have any January assessment opportunities for controlled assessment. If you have your January exam results, you know exactly what you need to get with your controlled assessment to get the grades that you are after. There is a difference there that contributes to the benefit of taking exams earlier.
[42] Jocelyn Davies: I think that my last question has been covered.
[43] Aled Roberts: I have a rather keen interest in this, because my son will be sitting controlled assessments before the end of term. Minister, you referred to ensuring that there is a level playing field. We heard evidence that you could take in supporting material in some schools, but, in others, a much more traditionalist approach was applied to the controlled assessment. Has any guidance been issued to Welsh schools to ensure that practice throughout Wales is standardised?
[44] Leighton Andrews: We have offered guidance in the past. Cassy, do you want to give the details?
[45] Ms Taylor: The work that the school standards unit is undertaking is to visit schools that have had good results and good practice, to look at those that are less successful and to draw some lessons together from that. It is just completing that initial stage of work and will be reporting shortly on that.
[46] Aled Roberts: There will be controlled assessments this term and without the guidance being issued this unevenness will continue.
[47] Ms Taylor: As much information as possible will be put out. In the new specification, we have also looked at reducing the ability to take notes in.
[48] Leighton Andrews: It is also the responsibility of the exam board—WJEC—to do this. That is what we would expect it to be doing.
[49] Mr Tweedale: To build on that point, the responsibility for providing guidance on how to deal with the specification is not that of the regulator but the awarding body, WJEC. The work of the school standards unit is to look at good practice from last year and share it around Wales. However, that does not leave WJEC without responsibility for ensuring that teachers understand the specification fully to do the best for the youngsters in their schools.
[50] Jenny Rathbone: Has WJEC not issued clear guidance to all schools for all these students who will now be sitting controlled assessments?
[51] Leighton Andrews: That is a question that you would have to put to it in terms of the detail. In practice, to be fair to WJEC, as we have said, this is a new specification. Mr Tweedale has already explained the difficulties that arise when you have a new specification. WJEC does explain and it has held exam seminars, some of which I am afraid are notorious, which have explained what is allowable practice. There is guidance on WJEC’s website as well. Therefore, I think that that guidance is available.
[52] Angela Burns: Thank you very much for your paper, Minister. I want to talk about the three-country approach, as it gives us some concern going forward as to where we can go forward. Communication between the organisations is not altogether clear. I take your point that you have had many years of discussions with a regulatory body in England. However, I suppose that what the leader of Ofqual was saying was that, technically, Ofqual has not existed since 2010. It was constituted under legislation in 2009, so—
[53] Leighton Andrews: Well, except that, Angela, I have minutes of a meeting in 2008 on the subject of maintaining standards—I am perfectly happy to share them with the committee—and in those minutes it says ‘Representing Ofqual’ and it names a whole series of officials. One of the officials named is a gentleman called Dennis Opposs, whom you will see is the author of one of the letters to WJEC, which was supplied in evidence to you. He, at least, was consistent through that whole period. It is the case, of course, that, following the UK general election 2010, there has been a change in the chair and chief executive at Ofqual.
[54] Angela Burns: I do not doubt the veracity of the documentation that you have. My point is on communication. That is just one small example. She was technically correct to say that Ofqual is only a couple of years old, and you are absolutely correct to say that a process has been around for much longer than that. My concern is whether, in relation to that kind of communication issue or the issues that we had over the exams, there is a way forward for three-country regulation to continue. Can we move past this? I know that there is policy divergence, but this is not just about the English language exam issue. There are other exams too. Where can we go in the future?
[55] Leighton Andrews: We need to separate the issue of communication from the issue of three-country regulation. I do not think that there has been any shortage of communication between my officials and Ofqual, whether that has been in e-mails, telephone conversations, correspondence, or whatever. In terms of whether the three-country qualification has a future, I have to say that the jury is out. In my opening statement, I made reference to the decision by the Northern Ireland regulator to remove its examinations from England, as a result of policy divergence. You will be aware that the Northern Ireland Minister for education and I have had one meeting and a number of telephone conversations about a series of issues. You will be aware that we have a qualifications review that is due to report later this year. You will be aware that the report that I issued in July on the task and finish group on the structure of the qualifications market in Wales made reference to the Scottish system as a potential model for the future—something that the qualifications review should consider. All of these things are currently up for discussion. These are issues to which we will want to return once the qualifications review has reported.
[56] Lynne Neagle: I wish to turn to the use of the key stage 2 predictor model. You indicated in your opening statement, Minister, that you did not feel that it had served Wales particularly well. Could you tell us what your preferred mechanism would be for evaluating award outcomes in Wales?
[57] Leighton Andrews: From our point of view, you need to take into account a number of factors when you are making judgments about overall grade boundaries and the quality of qualifications. You therefore draw on the widest range of statistical material. I will ask Cassy to comment on that in detail in a second. The approach that concerns us specifically in respect of GCSE English is what happens when you have a change of specification. Clearly, you do not want to disadvantage the cohort that is taking the new qualification, compared to the cohort that has taken the previous qualification. That is why we believe that the original intention behind the notion of comparable outcomes, as agreed by the regulators in 2008, was very much to ensure that you did not see radical movements year on year when new qualifications were introduced. The approach that we subsequently took when we reviewed the GCSE in English language and we published our report in September was very much about ensuring that there was an analysis of the performance of the previous cohort, and we did that in some detail. We looked at its performance at key stage 2 and at key stage 3 on teacher assessments and how those compared with the 2011 cohort. That enabled us to make judgments. We have made it clear to WJEC that we do not think that there should be a divergence of more than about 1%. Cassy, do you want to say a word on the detail?
10.00 a.m.
[58] Ms Taylor: Yes. The English language was in the second tranche of qualifications introduced for the new GCSEs. The first tranche, for the non-core subjects, was awarded for the first time the previous year. In that situation, the other predictor model of common centres, which I know that you have talked about with Ofqual and WJEC, was used as the main indicator. We would never support the use of one sole indicator to determine the grade boundaries. That is the difficulty that we have experienced here: the use of one indicator and sticking to that, which must be right, even though it is untried and untested.
[59] With the use of common centres in the previous year, sometimes, the projected results looked a little odd. So, that resulted in what I would call common sense, in that we looked at the straight outcomes for a similar cohort the last time and thought that we should get as close to that as possible within the professional judgment of the examiners on the quality of the work. I have looked with a team of specialists at the work on the grade boundaries that has produced these sets, and our specialist reviewers were broadly content with the levels at which that they were set, and that includes for the regrading. This is not about using one set of data—one prediction based on the ability as defined by key stage 2 in another country—and saying that that will determine precisely where a grade should sit. The degree of precision is not appropriate nor is the use of a single indicator. We would want a range of methods used.
[60] Lynne Neagle: How significant would you say the intention to limit grade inflation was in the design and use of the key stage 2 predictor model?
[61] Leighton Andrews: I think that there has been a change, as I said in my opening statement, by Ofqual in, first, its understanding of comparable outcomes, from what was originally agreed in 2008 to how it was deployed in 2012, and I quoted from the letter of the chief executive of Ofqual to the Secretary of State. There was an equivalent letter from the chief executive of Ofqual a week earlier to the head of Ofsted in England, which made similar points in slightly different phraseology. It is clear that Ofqual, during the course of the last 12 months, has become more focused on the need, as it sees it, to combat grade inflation than, in our view, on ensuring fairness and consistency for candidates. I think that we can bear that out in the evidence that we have. So, the key stage 2 predictor model had started to surface at the beginning of this year, as I think Members are aware. Originally, the intention was that it should be for reporting purposes, as one of the elements in the calculations as examiners came to make judgments around grade boundaries once results came in. However, it clearly became more of a determinant than a factor used simply for reporting.
[62] Lynne Neagle: Finally, what model will be used to determine candidates’ outcomes in Wales and in England in January 2013 and in June 2013?
[63] Leighton Andrews: We are still involved in conversations with the other regulators on this issue. Indeed, there are meetings on this next week.
[64] Mr Tweedale: Could I add one point there? You asked what ‘model’ was going to be used. It is important to get across that there will be no one model. Examiners, when they look at grade boundaries, sit in a room like this and have hundreds of scripts around them. They have done a lot of work on it and they look at where they think the boundary should be by looking at the scripts. They then use statistical predictor models—not one, but several—to consider whether they are about right. They use their professional judgment in combination with statistical measures. So, I would not like anyone to feel that we would just be using one or even a series of statistical models to determine grades. It is much more about using professional judgment and testing with the statistical models.
[65] Simon Thomas: Hoffwn ddweud yn gyntaf, rhag ofn fy mod yn codi unrhyw ysgyfarnogod, fy mod yn cytuno’n llwyr â’ch penderfyniad i gyfarwyddo CBAC i edrych eto ar y ffiniau yn achos yr arholiad hwn. Pryd ddechreuodd y trafodaethau am bennu safonau a ffiniau’r graddau TGAU hyn yr haf eleni, a phryd yn union ddaeth swyddogion Llywodraeth Cymru yn rhan ohonynt?		Simon Thomas: I would like to say first, in case you get the wrong impression, that I agree entirely with your decision to direct WJEC to look again at the boundaries for this exam. When did discussions begin on setting the standards and grade boundaries for GCSEs this summer, and when exactly did Welsh Government officials get involved in the discussions?
[66] Leighton Andrews: I need you to be more specific in what you are asking there, Simon. From my point of view, I became involved in this on or around 30 July, on the detail of the qualification. As for the overall approach to—
[67] Simon Thomas: Let me be more specific, then. In your opening statement, you referred to an April e-mail. I am afraid that we did not have your statement written, so I cannot quote from it.
[68] Leighton Andrews: It was on 5 April.
[69] Simon Thomas: It was on 5 April, and you said that your officials raised doubts or expressed—
[70] Leighton Andrews: I will find my comment and give you it precisely. This was following the 14 March meeting, which I know featured in your earlier meetings.
[71] Simon Thomas: Indeed. From the impression that we got earlier, it seemed that that was when the agreement was made to use key stage 2 predictors.
[72] Leighton Andrews: We need to be very clear about ‘agreement’ here. Ofqual made it clear that it wanted to use key stage 2 predictors for candidates in England. That featured in those discussions at the 14 March meeting, and WJEC made clear its concerns about that. I do not think that our officials who were at the meeting were necessarily impressed with the reasons WJEC gave at that point, but it made it clear, subsequent to that meeting, that there needed to be a further conversation—with Cassy, in fact, who was not at the meeting. That conversation, essentially, took place over e-mail. Cassy can speak for herself, but her e-mail said that it was her view that it should be an Ofqual-only document on the basis that it would be inappropriate for the Welsh Government to be asking for results in Wales to be determined purely on the basis of predictions for English candidates. That has been our position all the way through—
[73] Simon Thomas: Can I just stop you there, please? That is an important point, but we continued, things went on and we reached the end of July and the beginning of August when all this became much more clear. Can I refer to the e-mail of 29 August from Mr Tweedale, which I raised with you yesterday in the Chamber? This has now been published. There are lots of caveats in it, and I accept that, but it is a very clear statement,
[74] ‘It was therefore agreed that for GCSE English and English Language (only), WJEC would report against the KS2 predictions.’
[75] How do we, as a committee, square you telling us that, in April, you e-mailed to say that this was inappropriate for Wales, then there is an admission on 29 August from Mr Tweedale, that, in fact, this was agreed—[Interruption.] Can I just finish? I am sure you will want to come back then. Then, there was your statement to us, as an Assembly, that you thought that the system had failed students in Wales. It seems to me that, at the very least, you let things slip and allowed the situation to develop without being proactive enough to nip this in the bud.
[76] Leighton Andrews: No. Right, this will require a long answer. [Laughter.]
[77] Simon Thomas: That is what you are here for.
[78] Leighton Andrews: Let us be clear about what actually happened in respect of the key stage 2 predictors. At the beginning of the year, Ofqual wanted to use the key stage 2 predictor for all GCSEs, and we were not going to have that. We did not regard that as right. In the case of GCSE English, there is a clear problem: most of WJEC’s candidates are in England, not in Wales. Ofqual, therefore, was determined—regardless of what we thought—that it would use the key stage 2 predictor in making judgments about candidates in England. We cannot stop it from doing that in respect of candidates in England. The issue for us is whether that is the right approach to take in respect of candidates in Wales when we do not have standard assessment tests at key stage 2. Interestingly, by the way, private schools in England, as I understand it, do not have SATs at key stage 2 either, so whether the predictor model works for them is also in question, which may be why—
[79] Simon Thomas: I think that they have other advantages.
[80] Leighton Andrews: Yes, but it may be why so many private schools have joined the court case in England, let me say. That was the situation. After I became involved in this, after 30 July, the question for me was whether I should intervene and, if so, what would be the implication of my intervening. It was a question that I had to think about in early August, but it would have been the same in July, April, March or January. If I were to intervene at that stage, it would, essentially, mean that I would be saying that the setting of grade boundaries in Wales would be done on a different basis from the setting of grade boundaries in England. Now, if I had done that, I would probably have been crucified in the media and, indeed, by Members here, because I would have had very little evidence on which to base that judgment. It was only after we had the exam results that we had the evidence. Even at the stage when I was starting to get involved, on 30 July with briefings from officials on 3 August, I did not have the final results then, so I could not see the impact. This is the first year in which we have to wrestle with this issue, and we have had to wrestle with it, first, because of a change of specification and, secondly, in my judgment, and the judgment of many others, because of a change of approach by Ofqual in respect of comparable outcomes. This is the first time we have had to address that. If you are going to make an intervention as a Minister, you had better have the evidence on which to base it. I did not have the evidence until the officials reported to me, following the review that I asked them to undertake once we had the GCSE English results.
[81] It is also important to get across at this point the fact that there has been a protocol in operation for many years whereby Ministers do not get A-level or GCSE results until the day before they are published. They are sent out in encrypted information to our regulatory officials, and we get a briefing on the understanding that we will not breach the embargo of the qualifying bodies when they issue the results at 9.30 a.m. the next morning. That is how we operate. So, unusually, in this situation, I was alerted at the end of a meeting with WJEC on other issues, when the chief executive of WJEC said, ‘Oh, I’m off to a meeting now to discuss English-language GCSEs, because there are problems’. I am not sure whether he should have told me that, in fact; however, he did, and once I had that information, clearly I had to—
[82] Simon Thomas: That is a bit of a weakness, though, because you are the regulator.
[83] Leighton Andrews: In what way is it a weakness?
[84] Simon Thomas: You are the regulator. You are treated as a Minister in terms of knowing information, but as a regulator, perhaps you should know earlier.
[85] Leighton Andrews: I am not sure that that is right, and it goes back to things that I have already said in the Chamber about the role of the Minister as regulator. It is our view, and it is the approach that we have taken, that Ministers should be brought into regulatory issues when there is a fundamental issue. I have tried to explain how that is operated, with GCSE ICT as an example last year and GCSE English this year. Otherwise, you would essentially have Ministers involved at every stage, every time there is a meeting with regulators. Chris will tell you the number of hours that he spent in conversations with Ofqual the week after the GCSE results were announced. I do not think that that is a sensible role for Ministers. It is entirely right, within the context of the system that we have, that the overwhelming bulk of this work be done by regulatory officials, with Ministers brought in only when there is a particular issue.
[86] Others may want to make a case for a different regulatory model, and that is fair enough, but within the system that we have adopted, that is the approach that we have taken.
[87] Simon Thomas: You said in your opening statement that alternative courses of action would have been unacceptable, but, in effect, at the end of the day, we did have that alternative course of action, did we not?
[88] Leighton Andrews: The alternative courses of action were what I might have done in advance of the results, and I do not believe that any Minister could have done that without the evidence.
[89] Simon Thomas: Do you think that your officials fought hard enough not to use key stage 2 predictors?
[90] Leighton Andrews: Yes, I certainly do, and I commend what they did. What they were trying to do—and this is what is important here—was to operate, very diligently, a three-country model. We have been operating that model reasonably successfully between Wales, England and Northern Ireland for many years. However, there have been very fundamental changes, as I have outlined, in the approach adopted by Ofqual, certainly in the last two years, but most explicitly in the last 12 months. Mrs Burns asked earlier whether the three-country model is capable of surviving. As I say, I think that the jury is out on that.
10.15 a.m.
[91] Christine Chapman: We will have a supplementary question from Suzy Davies and then other Members want to come in. I am conscious that we have about a quarter of an hour left.
[92] Suzy Davies: I will keep it very short, Chair. I want to check something that you said at the beginning of your answer, namely that Ofqual originally wanted the key stage 2 predictor to be used throughout the syllabus, for all subjects. That does not happen in other subjects in Wales. Do we already have a sort of dual system in other subjects?
[93] Leighton Andrews: In terms of the key stage 2 indicator, this year we do. It is this year that this issue has arisen. Ofqual wanted to operate a key stage 2 predictor across all WJEC subjects—
[94] Suzy Davies: My point is that you managed to resist it for everything else, apart from English. I appreciate the point that most of the candidates were in England. However, as you say in your paper, Welsh Government officials take the lead in the regulation of qualifications offered by WJEC. If you had managed to stick to your guns on all the other subjects, why was it so difficult with English?
[95] Leighton Andrews: Think about it for a moment. The reality of the situation is that, once you start with the grade predictions, you then get to the point of setting the grade boundaries subsequently in the summer discussions and clearly the weight is going to be where the bulk of candidates are. Cassy, do you want to explain that?
[96] Ms Taylor: One of the things that is particularly different about English and English language with WJEC is that it is the second largest awarding organisation offering that qualification in England. For other subjects, it tends to be the third or the fourth largest and so is a minority provider. It being the second largest provider of qualifications in England, and with this being such an important subject and the English candidates comprising a significant majority of WJEC’s candidates, I can understand, from Ofqual’s point of view, why it felt that it should be the lead regulator on that. We have other examples of how that working out happens. On relatively minor things—if there is a security breach, say—the protocol that we have established is that the regulator with the most candidates in their country will take the lead on resolving that issue with the awarding organisation. So, it was carrying through, but I think that we have been quite successful in that, in all the other subjects, we have managed to retain the methodology of common centres and a common approach.
[97] Suzy Davies: You must have been confident, however, that you had enough evidence to have this sort of dual system on all the other subjects, so why did you not do that with English? You have had to change it after the results.
[98] Leighton Andrews: Suzy, I think that you need to be very specific and say what you think we should have done.
[99] Suzy Davies: It is not for me to say that. I think that I have indicated what I think should have been done.
[100] Leighton Andrews: This goes back to what I said earlier. I am clear that there were no alternative courses of action. We cannot stop Ofqual saying, ‘We are going to ensure that the candidates in England who are taking English language GCSE are going to be judged against a key stage 2 predictor model’. Ofqual has given you evidence that that is what it regarded itself as doing. How can we stop Ofqual making judgments about the regulation of candidates in England? We cannot.
[101] Suzy Davies: That is my point, really. Why did you not let it get on with doing what it wanted in England and you stick to your guns in Wales?
[102] Leighton Andrews: Because—this goes back to the answer that I gave earlier to Mr Thomas—if I had done that, I would have had to announce in January, March, April that we were going to grade English language GCSEs in Wales on a different basis from that on which they were being graded in England.
[103] Suzy Davies: Like all the other GCSEs—
[104] Leighton Andrews: No, no. I will bring Cassy in to explain the detail of that.
[105] Suzy Davies: I think that this is what I need explaining.
[106] Leighton Andrews: Okay, now I think we are clear on what you want. However, the implication of doing that would very much have been that we would have been acting against the other two countries, probably, in this particular instance, and we would have had no basis of evidence. When we finally acted, we had a basis of evidence. Cassy, do you want to explain that?
[107] Ms Taylor: I realise now what you were asking; I do apologise. All other GCSEs, and all GCSEs up until the point of the regrading, have had the same outcomes for England and Wales. It is the reporting methodology by which those outcomes are reviewed that is different for WJEC’s other qualifications. However, whatever methodology is used, for all the other qualifications—geography, history and so on—the same grades are issued to candidates in England and Wales. There are no different grades.
[108] Suzy Davies: Right—
[109] Ms Taylor: They are just reviewed against a different predictor.
[110] Christine Chapman: We are getting very short of time now, and—
[111] Leighton Andrews: It does get very technical, Chair, so it is difficult to—
[112] Christine Chapman: I think that what we need to do, because it is very complicated, is to possibly have a note from the Minister. I think that that would be very helpful.
[113] Leighton Andrews: If any member of the committee wants a technical briefing on these issues, Chair, we would be happy to give that, because this is immensely technical. I feel that I now know more about some of these technical issues than is good for me. [Laughter.]
[114] Christine Chapman: I will take a quick question from Jenny.
[115] Jenny Rathbone: The Minister has given a really clear explanation as to why he did not get involved until 30 July—he did not have the evidence. However, I am very interested in the e-mail that Cassy Taylor sent on 5 April, making it clear that Wales was unhappy about using the key stage 2 predictions from England for measuring whether this was a fair outcome for candidates in Wales. Despite that, only two weeks later, on 19 April, Ofqual wrote to you saying that it was going to instruct that the key stage 2 predictions for all GCSEs, where more than 500 candidates were from England, were to be used. That would clearly apply to the English results. So, there seems to have been a serious breakdown in collaboration. Despite it having been pointed out that it did not have jurisdiction over Welsh students and that that is the role of the Welsh Government, as it is devolved, on 19 April, Ofqual flew in the face of that and announced that all students were going to have to be marked according to the key stage 2 predictions.
[116] Ms Taylor: To clarify, the request that went out on 19 April was about how WJEC should report its provisional outcomes to the regulators. Ofqual was clear that it wanted WJEC to report outcomes for its English candidates, because it could not compare Welsh candidates with key stage 2 results. It was reporting the outcomes for its candidates in England for English against those indicators only. It could not report the outcomes of the Wales candidates against them, because those did not happen. The understanding was made explicit in the letter to WJEC, which emphasised that it was a reporting mechanism and not a constraint on the outcome of awards.
[117] It is perfectly reasonable to review outcomes against what the predictions might be. It is a different step entirely, and that step that was not taken until July or August, to want to change those outcomes in light of the predictions. Those are two very important and separate steps.
[118] Leighton Andrews: That goes back to what I said in the opening statement. Ofqual, in April, was saying that this was for reporting by the summer, and it, as I said, strayed into ensuring that this was a determinant of the grade boundaries.
[119] Aled Roberts: Rwy’n derbyn yr hyn a ddywedasoch ynglŷn â phryd yr oedd yn briodol i chi ymyrryd. Dywedasoch hynny yn y Siambr rai wythnosau yn ôl, ond roedd Ofqual wedi datgan ei fwriad i newid y ffordd yr oedd yn adrodd ym mis Ionawr. Dywedasoch roedd yn gynnar yn y flwyddyn fod Ofqual wedi mynnu ei fod am newid y ffordd yr oedd pethau’n cael eu rhagolygu.		Aled Roberts: I accept what you said about when it was appropriate for you to intervene. You said that in the Chamber some weeks ago, but Ofqual had declared its intention to change the way that it reported in January. You said that it was early in the year that Ofqual had insisted that it wanted to change how things were predicted.
[120] Rwyf am droi at y cyfarfod ar 14 Mawrth. Dywedasoch eich bod yn fodlon ynghylch y ffordd yr oedd eich swyddogion wedi ymateb i gais Ofqual. Mae e-byst wedi dod allan o dan Ddeddf Rhyddid Gwybodaeth 2000. Mae’n glir yr oedd CBAC yn anfodlon ynghylch cais Ofqual ar y pryd. Hoffwn fynd at yr e-bost rhwng un o’ch swyddogion ac Ofqual sy’n dweud bod CBAC yn anfodlon.		I would like to turn to the meeting held on 14 March. You said that you were satisfied with the way that your officials had responded to Ofqual’s request. E-mails have been released under the Freedom of Information Act 2000. It is clear that WJEC was not satisfied about Ofqual’s request at the time. I would like to turn to the e-mail between one of your officials and Ofqual, which states that WJEC was not satisfied.
[121] ‘Hope you didn’t mind that I kept out of it. I didn’t feel I had anything to add which would have necessarily been helpful.’
[122] Pam nad oedd y swyddog yn mynnu ar y pryd fod Llywodraeth Cymru, fel rheolwr, yn anfodlon?		Why did the official not insist at the time that the Welsh Government, as regulator, was not satisfied?
[123] Leighton Andrews: I think that you should read out the entire e-mail, because I think that you are taking that out of context.
[124] Aled Roberts: Perhaps you would like to read the e-mail.
[125] Leighton Andrews: I think that what he is saying in the e-mail—I am perfectly happy to read it, or put it on record—is that they did not agree, as I mentioned in answer to an earlier question, with the rationale given by WJEC for not reporting, but that there was a need for a further conversation with Cassy, and that she would probably need to discuss it with you, and that is said in the statement there. That then led to the e-mail exchange on 5 April, when Cassy Taylor clearly outlined our position.
[126] Aled Roberts: So, was the only further conversation that e-mail, because I have been through the log, as far as the freedom of information request is concerned, and what concerns me is that in reality, following 14 March, apart from the 5 April e-mail, which I had not noted in the log, there is no evidence that the qualifications and learning division had taken up the issue.
[127] Ms Taylor: I must confess that the e-mail of 5 April was one that was incorrectly filed and which we have found subsequently. I am more than happy to release that.
[128] Aled Roberts: Are there any other communications between the qualifications and learning division and Ofqual regarding concerns that you had?
[129] Ms Taylor: Most of the communication about the concerns was in discussion and telephone conversations and about the link between asking to report on the one hand—. We agreed with Ofqual that it could ask WJEC to report against the predictions. However, the concerns that I raised with it on an ongoing basis were that it was fine to report against this, but I would be very concerned if that analysis of reporting led to requests for the results of Wales’s candidates to be changed subsequently. Most of those discussions were telephone conversations in between meetings, and the main communication of that is through the e-mail of 5 April, which, as I said, we will be very happy to provide to you.
[130] Aled Roberts: Are those telephone conversations logged, in view of the difference in evidence or recollection with regard to what stance was being taken throughout by the two regulators?
[131] Ms Taylor: I can probably find some notes of those. They are not formally logged. Extensive telephone conversations take place all of the time between us. I do not have a systematic log of those.
[132] Leighton Andrews: I do think that you raise an issue. This is one that we need to look at and I will explain why. I think that, up until this year, the three-country model has largely worked, and there have been very few occasions when regulators in the three countries have had difficulties reaching agreements. I have no question in my mind that the nature of what is politely called ‘policy divergence’ between England on the one hand, and Wales and Northern Ireland on the other, now means that we probably need to approach almost every conversation in a much more formal way with Ofqual as a regulator. I say that ‘policy divergence’ is the polite term. I would call it ‘an ideological approach being pursued in England’, if I am to be more honest and open with this committee.
[133] Suzy Davies: By the regulator?
[134] Leighton Andrews: By the regulator as much as by the Government, yes.
[135] Aled Roberts: I recognise the difficulties we have on the policy divergence, but, if we are talking about formality, I will raise another issue as well, because what we are concerned about is the impact that this has on individual pupils and students in Wales and the integrity of the qualification as far as Wales is concerned.
[136] On 9 August an e-mail, again from one of your officials to Ofqual, refers to a meeting that had taken place that morning, obviously to discuss the concerns. There is again no evidence of the meeting in the response to the freedom of information request; we are unable to say what the nature of the meeting was. I am also interested as to the change in August. Everything that I have seen, up until around about 29 August, is between QLD and Ofqual. Then, all of a sudden, there is a different division within the directorate that, from then on in, is basically concerned with this. What is the reasoning behind that?
10.30 a.m.
[137] Mr Tweedale: The reasoning behind that is that, in the early stages of this year, we were working to a protocol that had worked well between the regulators for a decade. That continued through to the point when we had the evidence of the difference in grades for English language in August when the results were published, which was so different to anything that we had experienced before. It was at that point that we realised—well, we had realised before then—that we had talked about the key stage 2 to 4 predictor model being used as a reporting mechanism, and not as a determining mechanism. That determining mechanism changed everything. At that point, when we had that evidence, it became clear that we needed to look at our protocols and the way in which we were working. That was when I became involved. The Minister and I decided that I should get involved with this, and we then ensured that every call was documented to make sure that we had that. As director, that is the way in which I will ensure that we will be working in the future.
[138] Aled Roberts: As far as the director of QLD was concerned—
[139] Leighton Andrews: It is the head of QLD.
[140] Aled Roberts: Right. Okay.
[141] Julie Morgan: I am aware that we have run out of time, but as a final question, in looking back at everything that has happened, do you think that anything more could have been done, and by whom, to prevent the regrading from happening in the summer?
[142] Leighton Andrews: The only way that you could have avoided the regrading in the summer would have been if I had taken a decision earlier to intervene and to dictate to or direct WJEC that we would follow a different grading model for Wales, as distinct from England. I have already explained in evidence to the committee that I do not think that any Minister would have done that, because we did not have the evidence to justify that decision; it was only when we had the examination results that we were able to instigate the kind of inquiry that led to the September report.
[143] While I think that there are lessons to learn from this year, they relate to the relationships between the regulators. We have seen that those changes have occurred not just in terms of relationships between Wales and England, but also between Northern Ireland and England in the way that I explained, regarding the withdrawal of Northern Irish exams from England. This is a serious moment in three-country qualification. I regret to say that I think that Ofqual is in the grip of an ideological spasm.
[144] Christine Chapman: On that note, I thank you and your officials for attending this morning and for answering Members’ questions. The committee will now break until just before 10.45 a.m..
Gohiriwyd y cyfarfod rhwng 10.33 a.m. a 10.47 a.m. The meeting adjourned between 10.33 a.m. and 10.47 a.m.
Materion Iechyd Plant Child Health Issues
[145] Christine Chapman: I welcome Dr Ruth Hussey, the new Chief Medical Officer for Wales, and Dr Heather Payne, the senior medical officer for maternal and child health. Welcome to you both; we are very pleased to see you. I thank you for providing a paper in advance. Members have read it and they will have specific questions for you. However, Dr Hussey, would you like to say a few words first about how you see your role as far as children are concerned?
[146] Dr Hussey: Bore da. Diolch yn fawr iawn am y cyfle i gael siarad â chi heddiw. Rwy’n falch iawn i fod yma.		Dr Hussey: Good morning. Thank you very much for the opportunity to come to speak to you today. I am very pleased to be here.
[147] I am delighted and honoured to be in the role of chief medical officer and medical director. In general terms, it is important to see the role as one that stretches from the causes of poor health right through to the quality of care for people and families. So, it is a very broad role and it therefore requires me to be very focused on achieving outcomes—the best health and wellbeing that we can achieve for the people of Wales and, today, in this context, children and young people.
[148] We are seeing a massive change in society. There are rapidly changing patterns with regard to the population, which is rapidly ageing. So it behoves us to be very conscious about the different groups in society—children and young people, those of working age, and older people—ensuring that, as we design services and respond to health problems, those services meet the needs of those particular communities of interest. So, it is a broad role. Many things are happening that are affecting our ability to improve health and wellbeing: the economic position, technological changes, the rapidly changing pace of certain aspects of society and, indeed, demographic changes. They all come together, and I think that there is a growing interest in creating wellbeing as the unifying thing that we need to do alongside protecting our environmental resources and developing the economy. So, there is a real sense that those three things come together.
[149] Briefly, in terms of children, the first thing that I would say is that it is important that we do not just talk about children as one group of the population. There are very distinct stages in their lives, from the importance of early years through to teenage years and the transition to adulthood. Policies have to be sensitive to the different issues that play out.
[150] The second point that I would make is on the balance between universal approaches that benefit all children and young people and the need for targeted solutions for particular needs or aspects where we have failed to address their rights.
[151] The third thing is the importance of voice. There is a growing understanding, across delivery of public services, of the importance of listening to people and responding appropriately to their concerns, and their right to participate in the design of services. For children and young people it is as important as for anyone else. How do we ensure, in the context of the rights of the child and the UN convention, that we do that well and systematically, and that there is good evidence of work around that?
[152] I have two final points. The first is the importance of a cross-Government approach. All sorts of things are affecting children, young people and their families, and making sure that we take that unified approach with a holistic, integrated style is critical. Finally, you will see from the paper that I have highlighted the important work that happened through the national service framework, and it is probably time now to look at all the different policies and things that have changed, build on the success that has been achieved there, and start to develop a new framework as we go forward. I am happy to talk a bit more about that.
[153] Embedded in everything that I want to do are two words: prevention and quality. I am happy to discuss different aspects of that.
[154] Christine Chapman: Thank you, Dr Hussey. I know that Members will want to explore some of these issues in further depth. I ask Lynne Neagle to ask her question first.
[155] Lynne Neagle: I wanted to ask about the national service framework. You have been quite positive about the NSF in your paper, highlighting the good progress that you feel has been made, but the Children’s Commissioner for Wales was quite critical of that in his recent report. I wondered if you would comment on that and say a bit more. You have referred to where the progress has been, and how that has been monitored by the Welsh Government, but you have also indicated that, in five key areas, things have deteriorated. Could you say which areas those were?
[156] Dr Hussey: Thank you for that question. Yes, it is my understanding that it is being very closely monitored on a self-assessment basis, which is very detailed, with every single issue assessed and judged as to whether sufficient progress has been made. So, we should not diminish the impact that that has had in improving a whole range of issues. However, not everything has improved in the same way, and there are some areas around mental health and inter-agency work where there are a few issues. I understand that there are also some transition issues where more progress is needed. You will be aware that ‘Together for Mental Health’ has recently been published, and that has really focused on one of the areas that needed further progress, so I am pleased that we have that as a platform to take work forward around building on the NSF. Also, you may be aware that the continuing care guidance is about to be refreshed and is imminently due for publication, so again, these are areas where we can make more progress. Given all the incredibly positive things that have happened for children and young people over recent years, in terms of initiatives and development—[Inaudible.]—refreshed in a holistic way and bring the things that need further attention into a wider approach.
[157] Lynne Neagle: I hear what you are saying about the need to refresh it. Do you know if the Welsh Government has any concrete plans to take that work forward and, if so, do you have any idea of what the timescale is? Just in terms of the monitoring that you referred to, are you content that self-assessment is a sufficiently robust way of monitoring delivery in this very important area?
[158] Dr Hussey: On that second point, it is terribly important that people own the responsibility for taking action, so self-assessment is a good basis, but I am assured—although I have only been in post for eight weeks—that in reviewing the self-assessment there has been validation of what people have been saying. So, it is important to be confident and assured that what is being said is the reality. I do not know whether my colleague Dr Payne wants to add anything, given that she has led much of this work.
[159] Dr Payne: I am happy to add a little to that. Self-assessment is the mechanism whereby people address the standards. They are signed off at a very high level within health boards and local authorities, and they have, up to now, been reporting into the children and young people’s partnerships. That structure will change with the single integrated plan, so we are currently addressing within the Welsh Government exactly how those messages, given the changes, will continue to be received and not lost. So, there is a period of tremendous transition. Dr Hussey has explained the areas where we know that there has not been an improvement or that have stood still. Some of the areas that have not seen improvement are those at the top level 6, so they have reached the standards.
[160] So, we have this law of diminishing returns as time goes on and that is why, even though it was set out to be a 10-year plan, after seven years, we found that the bits that still need work probably need a slightly different approach. The thing is that the areas—and I have them here if you want to see them in detail, and they are also published on the local government’s Data Unit Wales website for everyone to access—where there has been no progress or where there has been a slight decline since the NSF was put in place are all inter-agency areas. So, that tells us something about what our approach needs to be to improve them. The whole point about the NSF was that it was about the child. It was about services combining to get better outcomes for the child. However, as we refresh it, we may need to move on to a slightly different focus and do things slightly differently.
[161] Dr Hussey: I want to pick up the point about the new outcomes approach. What Heather said is terribly important in setting the way that we need to go forward with this. So, one of the first things that I need to do is to have the cross-departmental conversation about how best to position a new approach, so that it is not seen as one initiative in one part of the Welsh Government and that we have a shared approach to this. So, my intention is to identify a programme of work going forward. Do I have a specific timetable today? No, I do not, but I have seen it clearly as an area of work that we need to pick up. It was one of the conversations that I had when I started, during which it was identified as an area for which we needed to put a programme of work in place. I am happy to keep the committee informed as that thinking develops, and I welcome your views on the scope and shape of that as we go forward. It is critical that there is a cross-Government approach and a participative approach as well.
[162] Jocelyn Davies: I am pleased to hear that. I hope that the child and adolescent mental health services will come under your focus fairly early on, because the evidence that we have received from CAMHS is that it fails to provide early intervention. It is stated in ‘Together for Mental Health’ that early intervention is a key priority. However, we heard that it does not do that, that practitioners have an overwhelming case load—twice as much as is recommended—and that it has only 50% of the spend per head that England has and 70% of the staff. You mentioned health outcomes and, of course, somebody blighted from childhood with a mental health issue will carry that through to their adult life and therefore their whole life might be blighted. So, I hope that you will look at that.
[163] One thing that we heard that surprised us all was the huge percentage of referrals to CAMHS that are rejected by the service and the fact that those young people do not always know that their referral was rejected and families think that they are on a waiting list for something that will never come. I hope that you will be prepared to have a look at that. Your views on CAMHS would also be very welcome. The other thing that we heard is that, across Wales, it is inconsistent and patchy and, in some areas, it is very difficult to recruit professionals. I know that I have not actually asked you a question, so I think that I will just invite you to agree with me—[Laughter.]—that this needs to be looked at urgently, particularly if the focus is on outcomes.
11.00 a.m.
[164] Dr Hussey: Obviously, I am not in a position to comment on the detail, but I take on board exactly the point you are making that we need to look at the whole child and at a preventive approach, really building on the early parenting opportunities and the initiatives around that right through to the school context. We have a big capability around the healthy schools scheme and there have been some really strong initiatives around the school counselling services. It is important to look at the whole spectrum because the sooner we intervene to support a child to be healthy, happy, content and able to deal with the emotional and circumstantial issues that lead to distress the better. We have got put those things in place, so the earlier we can identify those needs the better. My view of an outcomes-based approach is embedding that whole understanding.
[165] However, I take on board what you are saying about children and young people finding themselves in difficulty and in need of further services. I am aware that there has been a refreshing of the approach, resources have been made available, there is a delivery assurance group looking at this and CAMHS networks have been established. I will take away what you have said and work with my fellow directors who are working on this area to look at whether we have the whole thing lined up in a way that meets the level of concern of families and children and young people. I am very grateful to you for raising that as part of the context that we are operating in. The emotional development of children is absolutely critical; it affects their learning, their life chances and so on, so I am very passionate about the importance of supporting strong and resilient children and young people.
[166] Christine Chapman: Before I bring in Rebecca Evans, I want to reinforce what Jocelyn Davies is saying. The concerns that we have about CAMHS seem to have run like a thread through a number of the inquiries that this committee has undertaken and the evidence that we have taken. I think that we all share those concerns.
[167] Rebecca Evans: In your opening remarks, you referred to the impact of the economic situation on health. Some recent research has shown that young people have a particularly bleak outlook on the future now. What impact do you think the economic situation is having on the mental health of young people in particular and what extra support might be necessary?
[168] Dr Hussey: In the direct sense, the economic position is clearly affecting the opportunities for young people who are leaving school and looking for employment. However, we need to look right across the spectrum. The evidence of health inequalities that come from the socioeconomic gradient, if I can describe it like that, is profound. The work of Michael Marmot and others has repeatedly documented the importance of looking at the gradient from rich to poor in terms of the health experience. Therefore, the policy response is incredibly important right through the course of a person’s life in counteracting the health inequalities that children experience in the early years and right the way through their lives.
[169] We need to be thinking about how best we fundamentally build an approach that tackles health inequalities right the way through a person’s life. The tackling poverty programme gives us the opportunity to do that, to ensure that the health elements are played into the more socioeconomic part of that situation. Again, I want to ensure that the health outcomes are driven by the health parts of that as well, so that we are contributing to the key social outcomes that we want to see, which are good school-readiness, good experience through adolescence, and opportunities to get beyond education and training into employment. We need to look at how the health sector best contributes to supporting that wider social context.
[170] Personally, I do not have any specific data relating to child and health trends relating specifically to the immediate economic situation. However, you will see from the paper that there are some health trends that have been of concern for some years. The pattern of the health and lifestyles of children and young people is a cause for concern. We have seen that, for many of these issues, and in terms of the pattern of social continuum, the more well off that families and children are, the more able they are to choose alternative lifestyles. I think that a theme that we need to look at is how we can take a universal approach but also target action to support those who are most affected by lifestyle choices. I can talk a bit more about specific examples. In my view, it has to underpin everything that we think about.
[171] Julie Morgan: Going back to the issue of mental health, obviously there is still an enormous amount of stigma and negativity about it. How do you see that actually being changed? What are your plans to do something about that? I know that the Time to Change Wales campaign was launched earlier this year, but I do not know whether that is having any effect.
[172] Dr Hussey: Mental health problems are common. One in four of us will be affected at some point in our lives. That whole sense of de-stigmatising this—that it is something that we cannot talk about, or that it is different—is incredibly important. The Time to Change Wales campaign is built on the evidence as to how you create a change in attitudes. The two strands are raising awareness and then reinforcing positive behaviours. These are very early days. Behaviour change takes time. There is an evidence base about how to create behaviour change. The important thing that we have to do is to commit to raising awareness and trying to influence behaviour, and then constantly reflect on how that is going, test out whether we are shifting outcomes and modify the approaches as it evolves. The worst thing that we could do would be to expect to see it changed overnight. These are early days and there is a three-year programme of work around leadership projects and so on.
[173] We all play a role in this. It is terribly important to walk the talk, which is the best phrase that I can think of. It is a matter of how we embed, in all that we do, an awareness of some of these key issues in society, and how we demonstrate healthy behaviours, which include supporting emotional wellbeing. It is a large-scale change process. It is too early for me to comment on whether this particular approach is having an effect. It will take time.
[174] Julie Morgan: What is the role of the Welsh Government in the policy?
[175] Dr Hussey: It is a leadership role. It is a matter of setting the policy and then following it through the whole system to ensure that the policy is being implemented. I was very interested to hear about this: I know that the Welsh Government as an employer itself has actually been behind this programme and has done a range of initiatives. I would be very keen to give my own support to this, as I am sure that you have and will be doing. We must all get behind campaigns like this to demonstrate that we mean it and that it will be followed through.
[176] Suzy Davies: Sticking with mental health, if that is okay, I would like to ask a few questions about transition and the gaping hole, if you like, between services for 16 to 19-year-olds. I am pleased that the NSF has made provision about how this is to be dealt with now and in the future, but a part of that caused me some concern, and that is the draft guidance that the Welsh Government has now issued, which states that,
[177] ‘LHBs should play a full role in transition planning, including where the young person has health needs that do not qualify for continuing care.’
[178] How seriously, do you think, will local health boards be able to take that obligation, considering all the other demands on their services?
[179] Dr Hussey: This has been an area where there has been quite a bit of development and recognition that that period from 16 to 18 was important in supporting transition, which is why I emphasised transition as a key stage in my opening remarks. My sense is that resources have been put towards this, there will be follow-up, and there are these delivery assurance groups and networks put in place to try to promote the standards; so, I think that the spotlight is already on this area of concern, and I would hope that, whatever needs are identified in transition, people are responding appropriately. You are highlighting a concern that, along with the comments made earlier, makes me think that we need to look at this to make sure that it is being followed through. However, the role of health boards is to work from population needs through to the care that is required to meet those needs in order to get the best outcomes. So, we will continue to promote the achievement of the best outcomes for everybody.
[180] Suzy Davies: To clarify, LHBs may know fully what expectations there are of them, but what I think that I am trying to establish is where the buck stops. Even if they know about these responsibilities, among the myriad of other things that they need to help with, if they decide that that priority slips down the list a little, who is responsible for making sure that it goes back to the top of the list of priorities?
[181] Dr Hussey: You are talking about the continuing care of people in their care in the current care system. So, I would hope that this is not about attention and priorities in certain key topics slipping, but more about excellence in care.
[182] Suzy Davies: I appreciate the ambition, but I am specifically asking about the health needs of young people who do not qualify for continuing care. The draft guidelines say that they should be included in an LHB’s considerations. If they do not qualify for continuing care, are they not likely to lose their importance in the system?
[183] Dr Hussey: I would hope not, because my understanding of continuing care is that there are particular needs that need a particular approach. That does not mean that because there is not quite that level of need it is not important; it means that it does not go down a particular pathway. However, the quality of care should be appropriate regardless of whether it falls into a particular category of definition. They still have needs, which need to be addressed by the mainstream health system. However, I will take that question away to look at it and pursue it.
[184] Suzy Davies: I appreciate that the LHBs are only one player in a multi-agency arrangement, but I am a bit worried about that element. Finally, do you think that it would help young people in the 16-19 category if they had greater access to independent advocacy services?
[185] Dr Hussey: That is a good question. My first response would be to ask whether what is in place now is sufficient. We have an active children’s commissioner in Wales and other types of patient representative organisations, such as community health councils and so on. So, rather than say ‘yes’, I would first need to see what we have in place. The second thing is to talk to children and young people to find out what their views are as to what they need. Sometimes, our solutions may not be theirs. I would want to look into it a bit more, but I know that we need to support children and young people’s voices, as I said at the outset.
[186] Suzy Davies: That is a perfectly fair answer, thank you.
[187] Christine Chapman: I want to move on to another area that I know that Members have been quite concerned about, which is childhood obesity. I call on Jenny Rathbone to ask the first questions.
[188] Jenny Rathbone: Good morning. In your paper, you state that one third of all our children are overweight and only half are doing the recommended amount of daily exercise. I think that we can agree that we have a bit of a public health emergency. There are three particular areas that I would like to ask you about, the first of which is breastfeeding. Although we have pockets of excellent practice, they really are pockets. If we could get every child breastfed, we would prevent four-month-olds from being fed crisps, which is something that happens. So, what are we doing to ensure that mothers are being supported systematically by midwives, health visitors and other people to continue breastfeeding, and to ratchet up the breastfeeding rates?
[189] Secondly, unfortunately, in Wales, we are slightly behind the curve on school meals and healthy eating in schools. In secondary schools, we are still allowing junk foods to be sold and some schools unfortunately are still doing that. The healthy eating in schools regulations for secondary schools do not come in until next September, so what children are eating at school is of concern, although schemes like the healthy breakfast are excellent ways of countering some of that. The third issue is the adulteration of food for profit. This is about people being encouraged to buy processed food instead of the honest carrot and potato, and how we change attitudes to food and its purpose.
11.15 a.m.
[190] Dr Hussey: I share your concern. It is important to reflect that a number of lifestyle issues, as I said earlier, are increasingly demonstrating social gradients. So, we need to be mindful that any actions we take are addressing the inequality that is emerging around the opportunity to have good health and healthy lifestyles. Regarding obesity as a specific concern, you highlighted a number of areas. Underpinning what you are saying is the importance of the person and the context and environment—the cues that people have and their opportunities to make the healthy choice. You will be aware of the Foresight report, which mapped out some years ago all of the influences on obesity. It was a huge, complex, wiring diagram of different influences. We are not alone; this is not particular to Wales. The challenge is how we counteract some of the trends that are happening, in terms of not promoting physical activity and the nutritional choices that are being made.
[191] Looking specifically at the three issues that you highlighted, my sense is that there is quite a lot of work in place around promoting the national breastfeeding programme and the baby-friendly hospitals initiative. So, on the point of initiating breastfeeding—and Heather might want to join in on this issue—I understand that this has been heavily promoted and taken up in parts of Wales.  My experience from elsewhere has suggested that getting over the idea that it is not the norm is at the heart of this. I have seen some very successful initiatives prompted by peer-to-peer initiatives in communities. There has been a whole range of initiatives led by young mothers themselves, promoting this on a peer-to-peer basis. We have seen some really strong results around that sort of approach. I am not in a position to know whether we have lots of that happening in Wales, but that is the sort of area where issuing guidelines is not going to shift social aspects. So, it is about finding ways of mobilisation. The third sector is very effective in working with communities, changing perceptions and campaigning for facilities to make it easy and make it the norm. So, I suspect that this is about working those sorts of approaches. The professionals can set a context, helping the initiation, the follow-up and the education. However, the day-to-day reinforcement of changing norms about breastfeeding is really important. I will pause here in case Heather would like to add anything about what has happened.
[192] Dr Payne: Yes, I would. You are right to say that, with breastfeeding, if you start well, you have all of the advantages and much less risk of being overweight or obese later in life. Yes, this is absolutely vital, and yes, we are using evidence-based interventions, in that midwives are routinely asking women about their plans for feeding. They are not advising them, because that does not work. It is about having cultural support for a preferred activity, and that is the way in which it works best. The other thing is to measure breastfeeding. We are looking at Wales-wide reported figures, and close examination has led to the finding that there are some quite big discrepancies in different parts of Wales, as has been said. We have gone back to see whether that is to do with the way in which the data are collected or reported, and we are sorting that out, to ensure that the data will be more robust in future. This is very much in our sights, and we are hoping to be able to show some progress on it in the next round of figures.
[193] Christine Chapman: Before you continue, Jenny, I would like to ask Julie to come in here.
[194] Julie Morgan: I have a question on that particular point: is there socioeconomic evidence that poorer families are less likely to breastfeed?
[195] Dr Payne: Yes, it has a socioeconomic gradient like weight, smoking, diet and exercise—the usual suspects. I am afraid that that is the case.
[196] Simon Thomas: Is there an ethnic minority aspect to that?
[197] Dr Payne: Not that we can detect in the figures that we have at the moment. However, I will say that promoting breastfeeding is very much a part of Flying Start, so that will address the inequalities.
[198] Christine Chapman: Jenny, did you want to—
[199] Dr Hussey: Sorry, but I have another point to make. I will be brief. The Healthy Eating in Schools (Wales) Measure 2009 is critically important, and it needs to flow right through that whole reinforcement of healthy choices. You can undo all the health education by prompting children to buy crisps and sweets and so on. This is about being consistent in our approach right through our public services. Are we inadvertently reinforcing the slightly unhealthier approach at the expense of the one that would be healthier? So, on healthy eating in schools, every element of what we do must keep reinforcing that approach and making it the easy choice. So, we are keen to see that we promote standards around that.
[200] On the processed food issue, this is a complex area, is it not? In the case of less well-off people, we know that the ability to feed a family is driven more by the price and the availability of food. We know that many of the products with a high fat, sugar and salt content can be the cheaper products. So, I do not have an easy answer to that. There is no quick way to suddenly turn that around. However, we need to raise awareness of this and find ways to promote alternative approaches, but it is an area that we need to consider in terms of how we can enable people to make the healthier choices.
[201] In my view, we have to use a cross-governmental approach. I am pleased to hear that, on the physical activity side, Baroness Tanni Grey-Thompson is looking at physical activity in schools. We are not talking about high levels here, but about supporting people to be physically active every day and embedding it in our daily lives. Every policy that we have has the opportunity to drive that home—that is probably an inappropriate metaphor—or to encourage physical activity as the option in terms of doing small amounts every day. So, we should think about urban design, community safety, green space and street lighting—everything. Is all of that giving everyone the opportunity to make walking the easy option? Again, as you can tell, I am passionate about this. Physical activity is a positive thing that we can undertake. As you will know, it is one of the five ways to wellbeing for positive mental health. So, of all the things that we need to focus on, physical activity is one that we can get such a benefit from and it opens doors to exercising and doing things with others and to social support networks—a range of things come from it. In my view, that is a strong element. Instead of telling people what they cannot do, it encourages people to do things that they can do and enjoy them.
[202] Jenny Rathbone: Although we are not alone in Wales in having this problem, unfortunately our statistics are even worse than those of most other countries around us and that is why it is a particular problem that we have to face up to. I do not know if you have had the opportunity to look at the MEND programme and to consider whether that formula will work for the seven to 13-year-olds and their families. If so, how can we make that more widely available? Is that what is making the difference?
[203] Dr Hussey: We talked earlier about universal and targeted support and what we are seeing here is potentially a universal problem. The influences that are creating the overweight, obesity and low physical activity levels do not relate to a small group of people, so our response has to be comprehensive. However, there may be some people within that group who need targeted support. So, I see the MEND programme as an opportunity to help particular individuals and groups. Partly, it helps to shift the norm for others and it is partly about the particular needs of those individuals and families. However, we need ‘both and’. To scale up a MEND programme to everyone who might benefit would be enormous when perhaps the solutions are more about the environmental cues and the wider environmental opportunities to shift behaviours. So, I think it is a ‘both and’ approach. I will look into MEND in more detail; it comes as an evidence-based programme and it is targeted at 1,500 children and their families, so it is very much a family programme, which is important. We will learn from that and see what impact that is having as we go along. You rightly highlighted the fact that the population level indicator needs a wider approach at the same time.
[204] Jenny Rathbone: Do you think that there are regulatory issues that we should be thinking about to try to countermand these commercial cues that you are talking about?
[205] Dr Hussey: You will be aware that in New York, for example, a policy has been introduced around restricting fizzy drink sizes, and there has been a strong negative reaction to that proposal. What we have just talked about suggests that it is not just about fizzy drinks; it is about a whole set of issues. A broader approach might be to look at the opportunities that we might have with the forthcoming Green Paper and the consultation on whether or not we should have a public health Bill. That will be a consultation about whether we should use the law to influence health in its broader sense. I would not want to pre-judge that consultation. The example that I have given is a fairly narrow intervention, and that will not be the whole story.
[206] For me, it is about whether, as a country, there is a way in which we can shift the norm within our powers to enable good health to be the product of our policies, our decision-making and our services. The Green Paper, and the consultation on the public health Bill, will be an opportunity to rehearse that. However, I also hope that it will enable a conversation to take place with the public in Wales, asking people to look at the situation that we are in and at whether we need a law, or whether there are other things that we should be doing, and could be doing, that would help us have a better health outcome for our children and young people. It is a great opportunity to think this through.
[207] Rebecca Evans: What has been done to address the gender gap and the amount of time that boys and girls spend doing physical activity, particularly girls of secondary school age?
[208] Dr Hussey: There is a difference. We know, from patterns of behaviour as children go through adolescence, that there are different preferences. There are lots of school-based programmes in place and, as I have mentioned before, there is a review of physical activity in schools, which will provide an opportunity to address gender differences. For me, it comes back to working with the children. It is not about selling a particular type of activity to children and young people; it is about listening to what they like doing. It may be that some of the things that are offered are not what they want to do. The general message is that walking is the physical activity that we are talking about, and it is about finding ways of encouraging that. It might be linked to doing something that is social, or it might be linked to dance classes, for example—there is a whole range of things. Children of different genders have different interests. The stereotypical one is football for boys, but some girls will want to do football as well, so are we making that easy for them. It is about starting from an understanding of what is going to encourage children and young people to be physically active and then trying to design initiatives and processes that enable them to do that. I noted that, within the programmes, there are leadership courses for sports development and so on, and it was interesting that quite a lot of young girls are coming through that process. So, let us not make any stereotypical assumptions about what people want to do. Let us really work with them and be flexible about enabling them to exercise their choice, if I can use that phrase.
[209] Rebecca Evans: You refer in your paper to the child measurement programme for Wales. When will the results will be published and a decision made about whether to extend the programme to cover children in year 4?
11.30 a.m.
[210] Dr Hussey: This is really important. You might think, at one level, that it is a very technical thing to do, to collect the data, but I am a strong believer in driving for results. To do that, you need to know where you are starting from and what your actions are doing, in terms of impacting on that starting point. I see this as a really important piece of work. The timetable, as I understand it, is that we will have the results of this first approach in spring 2013. So, I will be the first to have a look at those and really get underneath them to understand the patterns, to see what programmes we need to tailor, what we need to do before that age group and then what might come afterwards. To answer your question on whether we extend it, I would like to see the results that we get and then take stock of the overall approach, in the context of being driven by good information.
[211] Christine Chapman: We now move to another really important area for Members. Simon Thomas has the next question.
[212] Simon Thomas: Rwyf am ofyn ychydig o gwestiynau am gamddefnyddio cyffuriau, o bob math—rhai cyfreithlon ac anghyfreithlon. Fodd bynnag, cyn gadael pwnc gordewdra, a ydych yn credu bod gan y Llywodraeth rôl o ran cyfyngu ar ddewis pobl o beth i’w fwyta?		Simon Thomas: I want to ask a few questions about the misuse of drugs, of all kinds—both legal and illegal. However, before leaving the subject of obesity, do you believe that the Government has a role in restricting people’s choice of what to eat?
[213] Dr Hussey: As I said, the law has a role in influencing the choices that we make. The dietary choices that children, young people and adults make are so complex that I certainly would not rush in to pick out one or two things and say ‘If only we change that, it will solve everything’. I would be very cautious about that. The consultation about whether the public health Bill should play a part in shaping choices in our lives is the opportunity to have a conversation about how we can influence choices and how much the public would accept that. This is very much a conversation with the public to determine how much the law should shape people’s personal choices. However, we know that there are powerful forces and that this is not unique to Wales. It is about how we can use the law to work with the public to help to support that healthy choice-making. So, I am not rushing to say that it is the right answer. It is a complex area, which needs working through with the public.
[214] Simon Thomas: Maes arall sy’n hynod gymhleth, a lle mae nifer o ffactorau, yw camddefnyddio alcohol a chyffuriau o bob math—cyfreithlon ac anghyfreithlon—ac ysmygu ac ati gan bobl ifanc. A allwch esbonio eich rôl chi o ran ceisio hybu gwybodaeth ymysg pobl ifanc ynglŷn â pheryglon rhai o’r sylweddau hyn?		Simon Thomas: Another area that is highly complex, and where there are a number of factors, is the misuse of alcohol and drugs of all kinds—legal and illegal—and smoking and so on among young people. Can you explain your role in trying to promote understanding among young people of the dangers of some of these substances?
[215] Dr Hussey: As the medical adviser to the Welsh Government, my role is to identify the threats to health, if I can put it like that, and to give advice on policies and processes that might help to change those threats. You will be well aware that, each year, reports are published that set out the issues that affect the health of children, young people and others. Clearly, where new threats emerge, we have a role in, hopefully, anticipating and spotting things, being aware of trends and then highlighting those and recommending appropriate action, based on whatever evidence is available. In terms of tobacco, we know that there has been a massive effort to curb the impact of cigarette smoking—to good effect, so far, but there is more to do; as you know, there is a campaign around smoking in cars and a UK-wide plain packaging approach. It is about refreshing thinking and always looking ahead to see what we can do. With alcohol, concerns have been raised and trends have been articulated clearly. We need to be mindful of the conditions that are creating the pattern of alcohol consumption among young people. I am very concerned that we do not demonise young people, because circumstances have been created where this is seen as the norm. So, I have a role in ensuring that the public has information, through colleagues in Public Health Wales and other agencies, and that we also look at new ways of helping to change the circumstances that we are in.
[216] Simon Thomas: On alcohol, do you believe that there is there any way that you can work with families on the drinking of alcohol in the home? Is there discernable evidence regarding a safe approach to drinking alcohol in the home?
[217] Dr Hussey: You will be aware that the former Chief Medical Officer for England, Sir Liam Donaldson, looked at this issue not so long ago. There was a growing sense that the age at which children are given the opportunity to drink is important. He issued guidance around that. The other thing that we need to think about is not whether children are allowed to drink in the home, but what they are experiencing of the norm around alcohol. I am aware of a small piece of work that looked at asking young children what they thought a normal pattern of drinking might be. Some of the answers that came back were levels of consumption that were technically binge consumptions. Therefore, as adults, there is a question about not only whether we should allow children to drink in the home when they are underage but also whether our own behaviours are inadvertently having an impact. We know from cigarette consumption patterns that the influences on children are the family and peer groups. I do not have any easy answers and it comes back to the question about the role of the law and how far we work with the public to determine whether laws should be passed around these sorts of issues and how much of it is about parental awareness, parental choice and—
[218] Simon Thomas: Good role modelling, too.
[219] Dr Hussey: Yes, good role-modelling. We are powerful influences on our children. These are issues to discuss with the public and about which to provide information.
[220] Simon Thomas: You mentioned new trends: being aware of them and dealing with them. An example that my office has been dealing with quite a lot is the mephedrone problem in Llanelli, which has been identified recently by South Wales Police as a hotspot for that particular drug. Drugs come into fashion and go out of fashion, and are associated with different trends. One thing for Government is that there is a health response to this, but there is also community safety response, which is divided between Ministers. What is your role in getting that clear message out? Is the law the way to deal with this, when people are experimenting as they grow up?
[221] Dr Hussey: My role is to offer advice on the potential harms, to work with other agencies to identify the patterns of consumption that might be emerging and to work across Government. You will have already gathered that I am aware of the importance of a cross-Government approach to a number of issues. I do not think that there is a single person who can solve many of these problems. We have a role in identifying harms that might emerge and making people aware of them, which may then change a policy response in another department. That is what I see as my role. Again, it depends on the issue. I would not want to generalise. Some of these things come and go so quickly that solutions are more immediate, but with other things, if you think that there is a growing trend and that there is a pattern, and that there is something that the law can offer, they need to be explored. Sometimes it is about delivery on the ground and front-line responses to things. Each of these things need an overview approach and we have a role in encouraging that and setting that context.
[222] Simon Thomas: To reflect the earlier discussion on obesity, when you take all this together—alcohol and drugs of all kinds—is there a gender difference in the way that boys and girls use or do not use alcohol or drugs? If so, does that mean that we need different ways of targeting the messages?
[223] Dr Hussey: There is a bit of a difference. Age groups differ too. It comes back to social norms and influences, and getting underneath the information to undertake the universal approach that I talked about and the targeted approaches. In some communities, different patterns of behaviour will emerge.
[224] Julie Morgan: I wanted to ask you about the use of the law, because it seems to me that there is reluctance, generally, to use the law, and a feeling that we should hang back a bit before we use it for issues such as this. I was just thinking of the great success of no smoking in public places. It was a long time before we did that, although there was evidence for it a long time before. Now, we have the consultation on smoking in cars with children, and, to me, it seems quite clear that we should legislate on that. I wonder if you could comment on the fact that there is some reluctance to use the law.
[225] Dr Hussey: The important issue is working with the public to prepare the ground for it, because, at the end of day, you want a law that is useful and used. So, going back to the whole seat belt legislation, there was a precursor period building up to the point when that was introduced and was successful. It was similar with tobacco, there was a whole engagement process, talking about the issue, encouraging people to think about it, and to develop an acceptance that it was the right thing to do. That took time to build up. I guess that I am straying into your territory, but we need to work with the public to make the case to say, ‘Actually, we have now gotten to the point where we need the law to change this, and to codify it in that way’, and it takes a bit of time to build up public acceptance that that is needed.
[226] There is a framework called the Nuffield ladder of intervention, which looks at when you would resort to different types of intervention at different stages. I do not have all the detailed components in my mind just now, but it is about a balance, and it builds up a case from the scale and spread of the problem and so on, to tell you when you have got to the point at which the law is needed to reduce potential harm or to change behaviour in some way.  So, again, the public health (Wales) Bill is an opportunity for us to talk about this and about what should be our approach in certain circumstances. Should we have an agreed way in which we introduce things, and when would we do that?
[227] Aled Roberts:  Rwyf eisiau symud ymlaen i drafod anghydraddoldeb iechyd, ymhlith plant a phobl ifanc yn benodol. Mae ‘Law yn Llaw at Iechyd’ yn rhoi targedau penodol i fyrddau iechyd o ran delio â’r broblem hon. Rwy’n derbyn eich bod ond wedi bod yn y swydd am wyth wythnos, ond a ydych yn fodlon bod y byrddau iechyd yn ymwneud â’r targedau cywir a bod digon o lwyddiant, o ran y mesurau y maent wedi penderfynu eu gweithredu ers i’r ddogfen gael ei derbyn?		Aled Roberts:  I would like to move on now to discuss health inequalities, specifically among children and young people. ‘Together for Health’ sets specific targets for health boards in dealing with this issue. I accept that you have been in post for only eight weeks, but are you satisfied that the health boards are working to the correct targets and that there is enough success in the measures that they have decided to undertake since the document was accepted?
[228] Dr Hussey: I have to start by saying that I am absolutely passionate about tackling health inequalities, and I know that we must monitor progress on this. It is not something that you just speak about and then hope that something happens. I am aware that there are comprehensive programmes in place, such as tackling poverty and Flying Start. There are initiatives in place that we need to monitor to make sure that they are driving through to the impacts that we are looking for. Part of the reason for suggesting that we need to develop a children and young people outcomes framework is to make sure that we have embedded in our health response the specific things that we need to focus on as part of that wider cross-Government approach to tackling inequality.
[229] So, I am not in a position to give you a detailed account today of what progress each health board is making. We have indicators, and part of the work that we need to do in preparing the ground for an outcomes framework is to look at what the issues are, where we need to put some focus, how we do that across Government, and what the health contributions are specifically that we can then follow up. So, I take this as an incredibly important part of what we need to do. I do not know whether Heather wants to add anything about progress so far.
11.45 a.m.
[230] Dr Payne: I will just reinforce the fact that I agree absolutely that it is the outcome that matters, and health inequalities, the difference in them, are a key aspect of what we are doing. It is not just about getting people better; it is about getting poorer people better quicker. Otherwise, if we just offer interventions, we know that ‘the worried well’, the educated middle classes, would take up those services and we would make inequality worse. So, it is about having a clear focus on the outcomes and saying that, as well as getting people better, we need to reduce inequalities. That is written into the outcome indicators and the way that they are looked at, so we have already identified that. The gap in life expectancy between the most and least affluent is a programme for government tackling poverty outcome indicator, so everything works towards delivering on that.
[231] Aled Roberts: On the tackling poverty action plan, are you satisfied with the outcomes that have been chosen for that? In addition, given the comments on breastfeeding, do you have any concerns about the patchiness of performance? I know that you said that you would not be able to discuss it, but perhaps you could come back to us with any concerns you might have about patchiness across Wales and the effectiveness of some of the strategies within different health boards.
[232] Dr Payne: When we have the right figures, we will be able to see whether or not that is real.
[233] Dr Hussey: To come back to the point about breastfeeding, it looks like we have not been validating the data to make sure that we have the right picture. Only in the last few days, there has been involvement around the tackling poverty action plan and making sure that health is really embedded in those issues. We have to be clear how we can contribute as a health sector to achieving that overall goal. It is a very active piece of work at the moment, so we will certainly take that away as well.
[234] Christine Chapman: I would like to ask a particular question—and there may be others, if we have time—on workforce planning. This has come up within this committee. We recently undertook an inquiry into neonatal services, and there were some issues there in that regard. Would you give your views on that? What work has been undertaken by reconfiguration leads and the Wales Deanery to ensure that there is an adequate workforce with the necessary skills for paediatrics and neonatal services in the short, medium and long term?
[235] Dr Hussey: I will kick off, but I know that Dr Payne has been heavily involved in some aspects of this. Medical workforce planning in its entirety is about predicting, as you know, the likely need for particular specialist areas, and then the lead-in time to having those specialists up and running and ready to go is quite a long period. Much of that is done as a UK-wide approach, so there is a shared understanding of the likely trends, but they are high-level trends. That is the first thing. The second thing is that that then informs how many juniors are required in those sub-specialist areas to make sure that we have replacements or either a growth or diminishment in the consultant numbers over the years.
[236] The work that has been going on in this area is very focused on looking at what we need in Wales to maintain an effective approach to paediatrics and neonatology. I am aware that quite comprehensive work is under way with the deanery. It is important to understand that the deanery is there to provide or ensure excellent postgraduate training. It is accountable for making sure that the package of training is of the highest quality. Therefore, it has to make choices about location, the numbers of juniors and the way in which they play out across the system. One of the challenges that we are now experiencing is that, if there is a certain number of certain junior doctors globally and that is how many we need to keep the supply chain going, it can have an impact on local services. The answer is not to have lots more junior doctors in that specialty, because you are not doing them any favours because the pipeline does not need them in future years as consultants. So, that is where we find the imbalance between the service that wants maybe more junior doctors and the training needs that we do not need to grow those numbers to that level. It plays out, then, in how services need to be designed increasingly to be driven or delivered by a consultant-type model of service. Then you need a critical mass of services to ensure an appropriate level of resource. So, that is the context-setting. I am aware that there is a substantial amount of work to be done in looking at what we need in Wales. Perhaps Heather would like to add something on this.
[237] Dr Payne: Yes, as well as our outcomes for patients and service users—the consumers of our service—it is vital that doctors have high-quality training experiences, not only for their skills and experience, but to guarantee the quality of the service that they then provide where they work, and also to attract future trainees to Wales. Those are all important indicators of how well we are doing. Medical training is quality-assured by the General Medical Council. That is an important aspect. If it is not good enough, it will not get approved. So, we have to be cognisant of that. That is one of the important drivers in making decisions about how trainee rotas work. Briefly, for medical trainees, there must be 11 people on a rota and they have to have a certain throughput of cases. You have to put all those in a bag, shake them around, and come up with the number of trainee rotas that Wales can sustain. The postgraduate deanery has been very clear about that. That is a piece of information that everyone has to work with.
[238] On nurse staffing, for maternity services, Birthrate Plus is the measure that everyone agrees. That is in use and, generally speaking, well adhered to. For neonatal nursing, the national perinatal standards are set, and are used by the neonatal network. The shortfall against those has been identified. As you will know, a lot of work has been going on to do with that, and many nursing staff establishments have been increased around Wales to get closer to those standards. Clearly, that will also be affected by any decisions on future plans and the future configuration of services. However, the medical and nursing areas, which are the big areas, are very much in focus. As you will know, the plans are at different stages, but there has been a distinct improvement in the nursing establishments. We know where we have to get to for medical postgraduate training. It is just a matter of how that works through in everyone’s planning processes.
[239] Christine Chapman: A number of Members want to come in on this. I see that Aled, Jenny and Suzy are indicating that they have questions. Aled, do you want to start?
[240] Aled Roberts: May I just challenge you on the monitoring of these guidelines? The British Association of Perinatal Medicines guidance was effective from 2008. As far as north Wales is concerned, as that is where I am particularly interested in, the proper staffing complement should have been seven neonatologists, but they only ever employed one and a half. So, why did the Welsh Government not pull them up on this before now? You mentioned the nursing guidance. Even following recruitment this year, north Wales is still 27% below the standard on the nursing ratio. What will be done about that situation?
[241] I accept fully what you say about the deanery, but some of us attended public consultation meetings in north Wales when the reconfiguration plans were announced, and senior managers were unaware of an announcement from the deanery that it would not allow training to go ahead in neonatology services where there was no level 3 provision. In effect, if the health boards’ preferred course of action goes ahead, that will mean that no training will be provided in the north Wales region. Given the levels of reliability as far as the rotas are concerned for trainee doctors, I find this situation staggering. You talk about lead-in periods for seeing these doctors through; is there not a lead-in period for discussions as to what the deanery is intending to announce with the health boards?
[242] Dr Hussey: Obviously, I cannot comment on what conversations took place. My understanding is that there is close working and that work has been going on for many months, and longer, about this particular workforce. Obviously, I am concerned to hear that there is a view that there was a lack of awareness of that. It is important that they work together. My understanding is that the service and the deanery do work together. So, I will certainly follow that up.
[243] Dr Payne: I would just like to add that those criteria were discussed at a meeting, at which I was present, with all of the Wales paediatricians and the deanery a year ago.
[244] Christine Chapman: Perhaps you could write to us on that. It would be useful if you could get back to us. Thank you.
[245] Jenny Rathbone: My question is on dentistry, but I know that Suzy wants to continue with this.
[246] Christine Chapman: Suzy, was this on the—
[247] Suzy Davies: It is, broadly, actually. It is a similar question. In the region that I represent, we have had a service withdrawn from a local district general hospital because of training issues, the point being that it was not a suitable training arena for acute medicine because there were not sufficient senior doctors in that specialism to give the training cover. I am stuck with a chicken-and-egg question here, therefore. If we are saying that we do not want too many junior doctors going into a specialism because there will not be the space for them in the future, how does that marry up with the assertion that there are not enough consultants in some specialisms to train up junior doctors in the spaces that we do need and where we do need them?
[248] That is one question. My second supplementary question is about the fact that I am still struggling to discover the level of influence that the deanery has on influencing how junior doctors progress in their future career paths. My local health board has indicated that it has junior doctors coming to it who all want to do something that is very flashy, sexy and fashionable at the moment and who may not be very interested in other disciplines where, actually, a future need is starting to be identified. Where does the deanery fit in on that?
[249] Dr Hussey: Perhaps I can start with that question and come back to the point about the organisation of training. This starts from the undergraduate level. What are the future patterns of need that medicine will be dealing with as we go forward? I mentioned earlier that we have a massively changing demography. Increasingly, the main bulk of general medical care in hospital is for older people and very elderly people. While there is also the need to have the highest research and development, the highly specialised and cutting-edge new skills, we need a workforce that is fit for both of those aspects of complex general health problems and multiple health problems. People do not fall into a single category of that particular specialty. So, we need ‘both and’: we need a generalist capability for the future and we need a workforce that can be highly specialised and innovative.
[250] A UK-wide review of medical training has been established, the Greenaway review, which is called a review of the shape of medical training. Its purpose is to ask whether we have the right mix for the future. I think that it gives us the opportunity to have that conversation right through from day one, when someone decides that they wish to become a doctor. The pattern of specialties and the type of work that we need for the future is constantly changing. If you talk to clinicians, you will find that what they do today is probably not exactly what they were trained to do 10 years ago. Medical practice is changing apace. So, it is not only about conversations with undergraduates as they are influenced, going through their training.
[251] The question was about the role of the deanery in this. It is part of a wider healthcare system, and you will be aware that we have established a medical and dental academic board, chaired by Baroness Finlay, which looks at the whole area from undergraduate to postgraduate training, looking ahead and asking, ‘What are the things that we need in place for the future, bearing in mind that these changing patterns of need and changing medical practice?’ That will influence the way in which junior doctors look at what they want to do. Senior leaders in the profession will have a role in helping juniors to do that, but the deanery is one part of that. I think that we all have a role in that.
12.00 p.m.
[252] In terms of your question about units that do not have enough senior people to ensure high-quality training for juniors, quite often these are services—and I am not commenting on the specific example that you gave—where the workload is sufficient for two senior doctors. The colleges set out guidelines as to what they need and about what good quality training is, and the GMC inspects the training and so on. If, for instance, there is a need in a particular speciality for staff to be exposed to a whole range of different elements of training and they cannot get that because the unit is small and has a limited workload, the answer is not to get more senior people in, because there will not be the caseload and the breadth of service to justify that. The reaction, therefore, is that people look at training in units that have a breadth of workload, a range of experience and opportunities to get a broader experience.
[253] What we always need to try to do is to look at solutions to those issues in a way that supports local services, but ensures that we give people the right quality training at the same time. There is no easy answer to it. In those particular smaller services, the answer is not just to recruit more senior doctors. They are perhaps small because that is the level of need for that particular service. Does that answer your question?
[254] Suzy Davies: I have supplementary questions, but time is against me and I am aware that Jenny needs to ask a question.
[255] Christine Chapman: Jenny, could you keep it brief, because we have to finish shortly?
[256] Jenny Rathbone: One of the issues with ‘Designed to Smile’ was that there were not enough paediatric dentists in some places. I remember that, in west Wales, children with cerebral palsy had to travel all the way to Cardiff to have basic examinations, given that it was a specialist area. So, could you look at that when you are reviewing?
[257] Dr Hussey: As it happens, I have had a conversation with the Chief Dental Officer for Wales about this very issue and the beneficial impact so far in developing community-based dental services. So, it is an area that I have started to explore. Thank you for that.
[258] Christine Chapman: I apologise to Members for cutting things short. It has been a very interesting session and I am sure that we will return to some of these issues in future meetings. I thank you both for attending this morning and, Dr Hussey, I wish you well in your new role. As I said, the committee will probably want to return to some of these issues in future meetings. We will send you a transcript of the meeting, so that you can check it for factual accuracy.
[259] Dr Hussey: Thank you very much.
[260] Christine Chapman: Before I close today’s meeting, I want to advise Members that the next meeting will take place next Wednesday, 14 November, when we will be considering amendments to the Schools Standards and Organisation (Wales) Bill. I also remind you that we have the official launch of our adoption inquiry report at 12.30 p.m. Thank you.
Daeth y cyfarfod i ben am 12.03 p.m. The meeting ended at 12.03 p.m.