The proceedings are
reported in the language in which they were spoken in the
committee. In addition, a transcription of the simultaneous
interpretation is included. Where contributors have supplied
corrections to their evidence, these are noted in the
transcript.
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Dechreuodd y cyfarfod am 09:30.
The meeting began at 09:30.
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Cyflwyniad,
Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
Introduction, Apologies, Substitutions and Declarations of
Interest
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[1]
Dai Lloyd: Croeso i bawb i gyfarfod diweddaraf y Pwyllgor
Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Cynulliad. A gaf i
estyn croeso i’m cyd-Aelodau ac egluro yn naturiol bod y
cyfarfod yma yn ddwyieithog? Gellir defnyddio clustffonau i glywed
cyfieithu ar y pryd o’r Gymraeg i’r Saesneg ar sianel 1
neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2.
A allaf atgoffa pawb i ddiffodd eu ffonau symudol ac unrhyw offer
electronig arall a allai ymyrryd â’r offer darlledu ac,
wrth gwrs, hysbysu pawb, os bydd yna dân, i ddilyn
cyfarwyddiadau’r tywyswyr os bydd y larwm tân yn
canu?
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Dai Lloyd: Welcome to you all to this
latest meeting of the Health, Social Care and Sport Committee here
at the Assembly. May I extend a warm welcome to my fellow Members
and explain that, naturally, this meeting will take place
bilingually? You can use the headsets to hear the interpretation
from Welsh to English on channel 1 or to hear amplification on
channel 2. May I remand you all to switch off your mobile phones or
any other electronic devices that could impair the broadcasting
equipment, and also let you all know that if a fire alarm should
sound, you should please follow the instructions of the ushers?
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Ymchwiliad i
Barodrwydd ar gyfer y Gaeaf 2016/17—Sesiwn Dystiolaeth gydag
Ysgrifennydd y Cabinet dros Iechyd, Llesiant a Chwaraeon a
Gweinidog Iechyd y Cyhoedd a Gwasanaethau Cymdeithasol
Inquiry into Winter Preparedness 2016/17—Evidence Session with the Cabinet Secretary for
Health, Well-being and Sport and Minister for Social Services and
Public Health
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[2]
Dai Lloyd: Felly, symudwn ymlaen i eitem 2 sef yr
ymchwiliad i barodrwydd ar gyfer y gaeaf. Dyma’r sesiwn olaf
yn ein hymchwiliad. Mi fydd Aelodau wedi derbyn papur briffio gan y
Gwasanaeth Ymchwil ac hefyd papur gan yr Ysgrifennydd Cabinet
a’r Gweinidog mewn perthynas â phwysau gofal heb ei
drefnu a pharodrwydd ar gyfer y gaeaf. Felly, gyda’r gwaith
yma y bore yma o gymryd tystiolaeth, bydd ein hymchwiliad ni ar
barodrwydd ar gyfer y gaeaf yn dod i ben.
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Dai Lloyd: So, we move on to item 2
and our inquiry into winter preparedness. This is the final session
as part of our inquiry. Members will have received a briefing paper
from the Research Service and also a paper by the Cabinet Secretary
and the Minister with regard to the pressure of unscheduled care
and winter preparedness. So, with this evidence session this
morning, our inquiry into winter preparedness will come to an
end.
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[3]
Nawr, awr yn unig sydd gennym ni ac
mae yna nifer sylweddol o gwestiynau sydd yn deillio o’r
cyhoeddiad—wel, y mwy nag un cyhoeddiad diweddar—gan yr
Ysgrifennydd Cabinet a hefyd cwestiynau rydym wedi eu derbyn ar
gais rhai o’n tystion eisoes fel rhan o’r ymchwiliad
yma. ‘Anyway’, a allaf groesawu’r Ysgrifennydd
Cabinet, Vaughan Gething, a hefyd Rebecca Evans, Gweinidog Iechyd y
Cyhoedd a Gwasanaethau Cymdeithasol, yn ogystal â Simon Dean,
dirprwy brif weithredwr y gwasanaeth iechyd yng Nghymru, ac Albert
Heaney, cyfarwyddwr gwasanaethau cymdeithasol ac integreiddio, ac
Irfon Rees, dirprwy gyfarwyddwr iechyd y cyhoedd?
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Now, we have an
hour only for this session and we have a number of questions
stemming from the multiple announcements made recently by the
Cabinet Secretary and we have questions that have been suggested to
us by some of the witnesses who’ve been part of this inquiry.
Anyway, may I welcome the Cabinet Secretary, Vaughan Gething, and
also Rebecca Evans, the Minister for Social Services and Public
Health? I also welcome Simon Dean, deputy chief executive NHS
Wales, Albert Heaney, director of social services and integration,
and Irfon Rees, deputy director for public health.
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[4]
Felly, gyda hynny o ragymadrodd, a
gyda’ch caniatâd ac yn dilyn ein trefniant arferol, fe
awn ni’n syth i mewn i gwestiynu, a’r cwestiwn cyntaf,
hefyd yn ôl y traddodiad, yn dod o’r Cadeirydd. A allaf
eich holi chi, felly, a ydych chi’n ffyddiog, Ysgrifennydd
Cabinet, fod y gwasanaethau iechyd a gofal cymdeithasol ledled
Cymru wedi paratoi’n briodol i ymdrin a phwysau’r gaeaf
2016-17?
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So, with those
few words of introduction, and with your permission and according
to our usual practice, we’ll turn straight to questions and
the first question, also according to tradition, comes from the
Chair. May I ask you, therefore, whether you’re confident,
Cabinet Secretary, that the health and social care services across
Wales are adequately prepared to deal with winter pressures for
2016-17?
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[5]
The Cabinet Secretary for Health, Well-being and Sport (Vaughan
Gething): Thank you for the welcome and the opportunity to be
here. The first question, I guess, we rehearsed and answered in the
Chamber this week in my statement. I think that we are better
prepared than last winter and the winter before. I think
we’re as well prepared as we can be, but that does not mean
that I say that the system is in a perfect shape and there is not
further improvement that we would expect to make. In every winter
we learn more and more about the demand that comes through the
door, the preparation for increased demand, what it looks like, and
not just our ability to meet that demand, but about how we need to
continue to shift and change our systems.
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[6]
Our ambition is for more care to be delivered closer to home.
That’s every bit as important in winter as it is throughout
the rest of the year. So, I expect that over the coming winters,
again, you’ll see more of a shift about how to keep people
out of hospital and in their own homes—we’ve got good
examples of that already—in addition to how we get people out
of hospital if they need to go in there as well. That only works if
you do have a health and social care system working together. So,
you’ll continue to hear us talk about a whole-system
approach, but I think we need to front up and say, ‘We think
we’re in as good a position as possible and we can have
confidence going into this winter that services will be as robust
and resilient as possible, but there will, of course, be extremely
difficult days and you and I’ll be very grateful that we are
politicians and not front-line members of staff in various parts of
the service.’
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[7]
Dai Lloyd: Diolch am hynny. Mi fydd yna gwestiynau manwl ar
wahanol adrannau. Awn ni’n syth at Julie Morgan i ofyn
cwestiwn 4.
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Dai
Lloyd: Thank you for that. There will be detailed
questions on different areas. We’ll go straight to Julie
Morgan for question 4.
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[8]
Julie Morgan: Thank you, Chair. There’s an additional
£50 million for winter pressures. I wondered if you could
tell the committee exactly how that money is going to be spent.
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[9]
Vaughan Gething: Thank you for the question. When we
announced the additional £50 million we made clear that it
was to help with winter pressures but also to maintain performance
as well, because you’ll recall that we made, over the last
financial year, a series of performance gains through the system.
Unusually for the national health service, and Members who have
been in and around here for some time will recognise that what
normally happens then is that, through the summer, there’s a
levelling off and things go outwards again before coming back in.
Actually, we haven’t seen a significant move backwards in
many of our headline performance areas, so we want to make sure
that we maintain that particular performance gain, but also that we
go further.
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[10]
If you recall the question from David Rees following the statement
that I made, when he was asking about elective activity, part of
the planning process for winter is that you don’t plan to
undertake the same forms of elective activity because you know that
you’ll have extra unscheduled care demand coming in that will
need bed capacity. But, actually, what we’ve managed to do
through most of the last few winters is to see more activity
nevertheless take place, and we want to see an increase in that
elective activity as well.
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[11]
So, some of the money will go towards maintaining and improving
further in those areas, as well as trying to further support the
additional measures that we know are taken. We talked about
additional capacity in the system, and sometimes it comes with an
additional cost. So, we want to make sure that we are properly
equipping our system to balance both those things: the additional
unscheduled care demand that we know will come through the door, as
well as making sure that we don’t simply compromise all of
our elective activity to be able to deliver that.
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[12]
Julie Morgan: So, it’s not some specific extra thing that
you’re going to do with that £50 million. It’s
keeping things going, basically.
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[13]
Vaughan Gething:
I think the difficulty is, if we say
we’ll allocate all of it to specific areas of activity, we do
need to understand and recognise that there are slightly different
challenges in each winter. Sometimes that’s about the
weather, but we know that there’ll be parts of demand that
come through that we can anticipate—you know, having older,
sicker people coming into our accident and emergency
departments—and equally how we try and plan for potential
additional episodes, so, if flu is worse or better, then that means
we may need to spend more or less money in different parts of the
system. So, some of it is being held, but it is about supporting
performance through winter, both unscheduled care and planned
activity as well.
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[14]
Julie Morgan: And how are you going to measure the success of that
additional money?
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[15]
Vaughan Gething:
Well, we have an awful lot of
measurements within the health service for activity. All the
different measures that we generate, whether it’s about our
unscheduled care activity, but in particular, at the end of the
year, whether you’ll see an increase in the number of people
who’ve been seen in planned care as well. That will be one of
the measures that we’ll look at. Whether it supported a shift
in activity, keeping more people at home, there’ll be a range
of measures that we’ll expect to report on, and, as you know,
we have lots of measures, every month and every quarter, that come
out. And I think that, from the Government’s point of view,
we’ll be able to assess again where we are, and that’s
an important part of our planning process, because in planning for
winter, the first meeting took place in March, so really before
winter had ended, because March was actually what looked and felt
like a winter month this year. Each quarter there have been
set-piece engagements between health, social care and local
authorities and other partners, so we’ll continue to learn
and be able to assess and understand the impact of that additional
resource across the whole system.
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[16]
Julie Morgan: So, you’ll be able to tell us next year how
many people were kept at home because of the extra input
that’s been put in.
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[17]
Vaughan Gething:
Yes, we’ll be able to have a range
of measures for what we’ve been able to do to try and support
people in different parts of the system, and how much additional
elective activity we have or haven’t managed to deliver, and
what our headline performance measures actually look like. For each
of those performance measures, of course, there are people who are
being seen within the system.
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[18]
Part of the thing that is more difficult
to measure, for example, is where we try to prevent and divert
people. So, in the investment that we make in Choose Well, some of
that is about money, and a lot of it is about messaging and trying
to persuade people to behave differently. But I expect we’ll
have some measures about the numbers of people that we think have
been seen in different parts of our whole system.
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[19]
Dai Lloyd: A oedd y Gweinidog eisiau ychwanegu?
Rebecca.
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Dai Lloyd: Did the Minister wish to add
anything?
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[20]
The Minister for Social Services and
Public Health (Rebecca Evans): Yes. Although this is separate to the extra £50
million that the Cabinet Secretary announced, of course we have the
intermediate care fund of £60 million, and the purpose of
that, really, is to build resilience but also to build capacity as
well. We are getting to the point now where we’re able to
really demonstrate and measure the impact that it is having. I can
give the example of the Pembrokeshire Intermediate Voluntary
Organisations Team, which is led by the Pembrokeshire Association
of Voluntary Services. That provides a comprehensive, seven-day
admission-prevention and discharge-support service. To date
we’ve been able to demonstrate that 1,090 bed days have been
saved, and 109 hospital admissions avoided, because of that
particular investment. That’s thanks to the partnership that
we have with Age Cymru Pembrokeshire, the British Red Cross, and
Care and Repair as well.
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[21]
Similarly in north Wales, we have the
step up, step down service, which is avoiding admissions and
facilitating earlier discharge. There we’re able to show that
the services avoided a total of over 5,000 hospital bed days,
equating to avoided costs to the NHS of the best part of £1.5
million. So, we’re gathering these figures and really being
able to demonstrate the value of the intermediate care
fund.
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[22]
Dai
Lloyd: Diolch yn fawr. Mae’r cwestiynau nesaf gan
Lynne.
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Dai
Lloyd: The next questions are
from Lynne, please.
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[23]
Lynne Neagle: I had a supplementary on that.
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[24]
Dai Lloyd: Yes, and then carry on.
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[25]
Lynne Neagle: I just wanted to ask about the £50
million. What will the process be going forward, then, for
allocating that money to health boards, and how will you ensure
that it is to reinforce good practice and not to meet ongoing
budgetary pressures?
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[26]
Vaughan Gething: The £50 million is about supporting
and enhancing activity, and so part of this money will be against
performance actually delivered. So, we’re not going to simply
go through a formula and allocate money out to every health board
regardless of the activity undertaken or planned to be undertaken.
And you can expect that to be part of a feature of our system
moving forward, as well as having money that goes into the bottom
line and goes into formal allocations, as well as the specific
measures that we’ve taken for challenges in two of our health
boards in particular—in Hywel Dda and Betsi—and
recognising the very real challenges that they have, and, actually,
it would not make sense for us to expect them to hit their budgets
this year or next year. We recognise that, but when it comes to
performance and how we use money, some of that money will be
definitely held against delivery. That’s something about
changing and shifting behaviour; it’s also about making sure
that we are getting a return on the money that we deliver as well.
But, you know, health boards will still have significant
allocations that they need to plan for and acquire, as well as an
element that will be against delivery on agreed performance.
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[27]
Lynne Neagle: Thank you.
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[28]
Dai Lloyd: Carry on with your next question.
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[29]
Lynne Neagle: Okay, thank you. I wanted to ask about the
independent care sector and how effectively the Welsh Government
are involving the sector in planning for winter pressures and
whether you think there’s anything more that could be done,
and, also, what specifically the Welsh Government’s role is,
leading on that.
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[30]
Vaughan Gething: I think Rebecca will start on that, but
Simon may want to add something about the planning part of the
whole system as well.
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[31]
Rebecca Evans: I just would start by recognising the
important role that the independent care sector plays in terms of
provision right across Wales. We do engage them very actively and
very directly in terms of the preparation and implementation of the
work under the social services and well-being Act. They’ve
also been involved in the work of the care home steering group. We
have associated work streams there regarding workforce
commissioning and good practice. All of these things together
inform our approach to winter preparedness and preparations to
support the care sector through the winter. There is also a
requirement for the regional partnership boards to have direct
representatives on there from the care sector as well. So, the care
sector should feel that they are directly engaged right at the
heart of service design and delivery right across Wales now. And,
again, the independent sector have been beneficiaries of funding
from the ICF in order to take forward some projects—the
befriending scheme in Powys, for example, the complex discharge
team in Cwm Taf—all of these are delivered through the
independent sector. So, I would hope that they feel fully engaged,
and I would hope that they feel, if they didn’t feel engaged,
that they would be able to come to me with some suggestions as to
how we could strengthen that engagement. But, from my perspective,
they are very much involved and very much valued.
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[32]
Vaughan Gething: Simon, could you say something about
system-wide planning in the independent sector?
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[33]
Mr Dean: Thank you, Cabinet Secretary. Just to reinforce, I
think, the points the Minister’s made, we expect health
boards to engage fully with all of their partners across the
system, which includes the independent sector, local government and
the third sector, as they develop an integrated plans, and
we’ve seen very good examples of that through this year. At
our joint events, we’ve had colleagues from across the system
coming together to talk about plans to learn from each other, and,
at a very practical level, there are some very important
developments with the system, supporting each other—so,
nurses increasingly supporting nursing staff working in
independent-sector care homes, access to training for nurses
employed by the independent sector through NHS-funded training
programmes as well. So, we’re seeing a lot more integrated
planning that is focused on the needs of the patients, wherever
they may be.
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[34]
Lynne Neagle: Thank you.
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[35]
Dai Lloyd: Are you happy?
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[36]
Lynne Neagle: I’ve just got another question, then, on
the way organisations work together, particularly on national
campaigns like the flu campaign. We heard from the Royal
Pharmaceutical Society that they felt that organisations were still
working in silos, in particular in relation to the GP’s role
with flu vaccination and the pharmacist’s role. Do you think
that we doing enough to actually get these organisations working
together?
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[37]
Rebecca Evans: I held a flu summit, a couple of months ago
now at least, with representations from organisations involved in
delivering the flu vaccine—so, health boards, professional
bodies, WLGA, CSSIW and others—and the meeting there really
was focused on partnership working and integrated working in order
to deliver the flu vaccine as widely and as effectively as possible
in terms of meeting our targets, particularly for the at-risk
groups.
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09:45
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[38]
I think I would recognise that, in the past, it has been difficult
in terms of the relationship between GPs and community pharmacies
and the competition, if you like, in terms of delivering those
vaccines. But we did see some really good examples last year of
joint working and partnership working between GPs and their local
pharmacies on a local basis. So, at that meeting I asked them to
look at that good practice and build on it. I know that the chief
medical officer issued guidance at the beginning of this
vaccination period, to build on that practice as well and try to
improve coverage. We’ve asked community pharmacies
particularly to focus on the under-65s with chronic conditions,
because they would be more likely to visit the
pharmacist—probably less likely are the over-65s, who would
be going to the GPs. So, it’s about partnership working and
common sense locally in order to meet our targets.
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[39]
Dai Lloyd: Angela, mae’r llawr i ti.
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Dai Lloyd: Angela, the floor is
yours.
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[40]
Angela Burns: Thank you very much. I just want to
concentrate a little bit more on elderly care. At present, we have,
on average throughout Wales, about 450 people in hospital waiting
for the ability to get out, but they haven’t got their social
care packages in place. I mentioned it briefly on Tuesday. I just
wondered if you could flesh that out a little bit more, because as
we all know, the case mix changes with winter pressures.
We’re going to have more elderly people coming into
hospital—slips and falls and comorbidity—they need to
be able to get out quickly. So how are you going to be able to
tangibly cope with that influx of older people when we’ve
already still got that backlog that runs on a month-by-month
basis?
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[41]
Vaughan Gething:
Yes, delayed transfers of care are a
challenge, both within the NHS system—there are some of those
delays that take place in moving from one part of NHS care to
another—as well as delays that are about releasing people,
either into their own homes with a package of support and care, or
into a different residential facility. So, we recognise it’s
a challenge in our system. What I would say, though, is that, in
terms of our trends we’ve actually seen a downward trend over
the last five years, and a levelling off. Part of the
challenge—because it’s a priority for me, and I
continue to look at the figures each month. I’ve made clear
that I’m not happy with our rate of progress and I expect us
to do more, so there’s more work that is going on that Albert
will be able to talk about more. But last winter, the level of
delayed transfer of care went up at the highest part of the winter
period, so we saw more of our capacity taken up, but actually,
people in an inappropriate part. It would be wrong of me to say
that we won’t see delayed transfers being a feature of the
system in winter. The challenge is how we do more to minimise the
problem they present for the whole system, but importantly, for the
individual who’s in the wrong place. That’s why the
integration between health and local government really
works.
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[42]
So, when I’ve gone after delayed
transfer of care, it’s been a joint conversation with health
and local government, and trying to draw in the independent sector
and housing partners as well. Because if there isn’t that
rounded conversation, then we won’t see activity. Part of the
real issue here is the amount of time and effort you need to spend
on making sure that everyone understands what they’re doing
within the system, and whether they’re on top of what they
need to do.
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[43]
That’s why, in the statement, we
talked about having more social workers within a hospital setting;
that’s a really important part of understanding. But it
starts before people get in through the front door, not after
they’ve got to the front door then assessing them.
That’s why the anticipatory care models that we’ve
talked about really matter. But a feature of our system has been
that we’ve managed to keep a level of patient flow going,
because we’ve had that partnership with social care
that’s improved. It’s because the seven-day working we
talk about is social care as well, because otherwise, if you stop
discharging people on a weekend, you can guarantee your system will
have backed up as well. Albert can give you some more detail on
trends compared to other parts of the UK, but it’s not going
to stop being a challenge for us. It’s not going to be an
area where I expect people won’t start asking questions, or
keep on asking questions that we ask as Ministers as
well.
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[44]
Angela Burns: I totally buy into the concept. I absolutely think
it’s the way forward, and I can see that it works in a lot of
places really well, when the system’s not under pressure. But
when you put that onto one side, and then you think about the fact
that we’ve had a 30 per cent drop in the numbers of district
nurses, when we know we have a shortage of general practitioners
and we’re talking about a winter that’s already just
about here—it certainly was this morning—then what I
can’t understand, what I cannot tie up, is all of that intent
and that strategy and those plans, which are utterly admirable and
I completely support, with the fact that we all know we simply do
not have the resource to go in there. So where are these social
workers coming from? Because I met with the social workers
association and they say that they’ve got a massive
shortage of social workers and they can’t recruit people;
it’s a tough job and it’s quite tricky. Where are the
district nurses going to come from? To make it work, we need more
people and in the short term, I just wonder—. I know we have
long-term plans to recruit and I know it’s a problem
that’s all over the United Kingdom, but I just wonder, for
this particular winter, what else we could possibly do to try to
alleviate that, because that is what’s going to make it
crumble.
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[45]
Vaughan Gething: It’s partly about the commissioning
and the understanding of how care works in different part of the
whole system. It’s also about the need to remodel the whole
system, as well. That’s why, when we talk about anticipatory
care and keeping people well, that really makes a difference. It
really does make a difference to not having people in the wrong
place in the first place. It’s also why, regardless of the
numbers of staff we have, how those staff work with each other
really does make a difference too—
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[46]
Angela Burns: Cabinet Secretary—
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[47]
Vaughan Gething: —and when you talk about district
nurses as an example, actually, we’ve seen an increase in
nurses within the community and that’s part of what supports
people. If you look at the record of last winter as well, the fact
that we didn’t have a larger rise in delayed transfers
actually demonstrates that the system is working at a better level
than before, in the way that we understand how to get people to the
right place and to the right point of care. It’s also why the
joint commissioning between health and local government, and
actually understanding what extra capacity is needed within
residential care as well, to get people out of the hospital,
matters too. Those aren’t necessarily about some of our
longer-term workforce challenges, which, of course, we will return
to at every point within the year, but there can be some confidence
that we will see delayed transfers at a level where the system will
work, but we’ll see real challenge in that, as well.
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[48]
It goes back to my first point that I think we’re in a better
position than last winter, but there’s no pretending that
we’re in a perfect position or that some of the issues
won’t be real and within our system. The challenge always is:
with the resources that we have, not just money but people, how to
make best use of those resources and then learn again what we could
do better than last year. That’s why the example that the
Minister gave earlier about the use of third sector matters too,
because you don’t just look at one part of the system to deal
with this challenge, either. It’s about the whole system and
all of the different actors within it.
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[49]
Angela Burns: To get anticipatory care, which is great, you
have to go through the funnel of the GP, and the GP can then say,
‘You can go to the physio, you can do this, you can do
that’. In my own health board, people cannot get to see a GP,
so how is that elderly woman or man who does not feel really well
going to be able to access that care to be anticipated to stop them
from going into hospital? I hear what you say; I understand the
principle behind it, but on the ground, I don’t see it.
Tomorrow, I’m meeting the chair of Hywel Dda health board to
talk about this. I’m also going out to one of our largest
providers of general practitioners, because they are up against a
wall, to see how it’s going to happen. So, we talk about it
here and we say, ‘Yes, this is okay’; a great
statement, understood it totally, but I really worry about the
reality, because it is my casework file that’s going to just
explode as usual over the winter, because people can’t even
get in to get that first step of care, particularly the
elderly.
|
|
[50]
Vaughan Gething: That’s part of the challenge about
getting people to the right point in the system in the first place.
For some of those people, the GP is the right person, for others,
it’s not. We saw the recent very welcome coverage of the role
of occupational therapists within the system and their role within
it. So, it isn’t always about going to the GP; it goes back
to choices, it goes back to how we help people to make choices and
have people available to then act on those choices. So, GPs get to
do what they need to do and other people can do as well. The
example that I regularly refer to back in Ynys Môn, well,
that works because there’s a partnership with GPs, social
workers and advanced nurse practitioners. That’s what makes
it work. The GPs have confidence in the system and they know they
don’t need to see everyone. They help to identify people at
greater risk, but other people actually undertake that work as
well, so those people don’t need to come in and see the GP,
but if they do, if they do go into care, they then understand what
support they need to go back out.
|
|
[51]
Again, when we look at the whole picture, we recognise that not
every part is perfect. We recognise that some parts have better
practice than others and you can’t take away the reality that
we don’t have automatons working in the system; we have real
people with different needs and different concerns about the way
that their whole system will work and interact with each other. But
we do think that we have advancing and better models of care, and
part of our honest challenge is to make that improvement systemic;
to make sure that we understand our areas of weakness and we can
actually then deliver improved models of care that are appropriate
for them. We know there are lots of really great examples in rural
Wales. We also know that we’ve still got challenges in some
parts of rural Wales as well, just as within Valleys areas and
within urban parts as well. So, we don’t say that our system
is perfect; that every answer exists and that we won’t have
difficult parts of winter ahead, but I do think we’re
genuinely in a better position. We can expect us to be robust and
resilient through this winter and we then need to learn and apply
that learning for winters ahead. But I don’t want to leave
the delayed transfers point. I think Albert will be able to say
something helpful about the approach we’re taking to see some
of the improvement that you refer to as being needed.
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|
[52]
Dai Lloyd: Okay.
Albert.
|
|
[53]
Mr Heaney: Thank you very much, Chair, and thank you, Cabinet
Secretary. Just to make a comment, perhaps, in relation to social
work and social work vacancies, social work is a very skilled,
demanding role, and provides an essential service across our
services in Wales. The ‘Social Work in Wales: A Profession to
Value’ report was produced about a decade ago. That has led
to significant improvements in the recruitment and retention of
social workers in Wales, and there are good data that can be used
to demonstrate that. Social work and social care delays in relation
to delayed transfers of care are just over around a quarter of all
delays relating to assessments and relating to arrangements.
However, critically, when we come to look at delayed transfers,
it’s about a whole-system approach; it’s about how we
all work together as partners and integrate.
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|
[54]
I think it is fair to say that there are
a number of initiatives that recognise the pressures that are there
within the system and the challenges we face, and I’d just
like to highlight—we’ve highlighted today the
intermediate care fund, which is making a significant difference,
trying to move and support our citizens away from ending up in a
hospital setting to a much earlier intervention. The Cabinet
Secretary and the Minister have asked officials to go around each
of the regional partnership boards to hold a direct conversation in
relation to delayed transfers of care. Those conversations have
been taking place; they’re just due to be finalised. And
those conversations have focused in each of the areas on what the
partnerships can do together to work more effectively, and there
are some simple things that can be done as well that will help.
There are some very complex arrangements, but there are some simple
things about when plans are in place, about referral to, perhaps,
an occupational therapist, that those actions are always followed
through in a timely fashion to help the flow in the system. So,
what my message, really, to committee today is: the energy and the
focus upon this in Wales is extremely high.
|
|
[55]
The Cabinet Secretary asked me just to
refer to some of the data trends, and I think, in Wales, what I
would describe at the moment is we have a challenging but resilient
picture. We want to improve and we want to do better. And you will
have had the figures around delayed transfers, and you will know
that they will be updating as we go in terms of reporting, but in
terms of looking at the figures across England, Scotland and Wales,
I have the September figures with me for a number of years, but I
would wish to draw the committee’s attention, perhaps, to the
pressure in the system from 2015-16, because it shows how both
England and Scotland, and Wales, are under pressure, but I think
there’s some learning, and some messages, perhaps, that we
can work together on.
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|
[56]
In England, the figures for September
2015 were delays relating to 5,247; by 2016, due to the pressures
on the system, the delays were 6,777. In Scotland, again,
there’s much good focus in Scotland, focusing on a
whole-system approach, and the delays in 2015, September, that we
have available to us were 1,258; delays in 2016 were 1,524. So,
again, it’s showing a substantial increase in pressure. In
Wales, we have held our ground. We want to do better, we’re
striving to do better, but in Wales, in September 2015, it was 510
delays, and in September 2016 it was 491. Of course, I acknowledge
to the committee today we do want that to be much lower in Wales,
and the actions we’re taking through the regional partnership
boards and other actions are the drivers to help us strategically
move to where we would like to be.
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|
[57]
Dai Lloyd: Ocê. Byddai’n well inni symud ymlaen
nawr i achosion plant. Lynne, ti sydd â’r cwestiwn
nesaf.
|
Dai
Lloyd: Okay. Can we move on, then, please to children’s
issues? Lynne, you have the next question.
|
|
[58]
Lynne Neagle: Can I just ask generally about preparedness for
children’s services, going into winter? We did take evidence
from the Royal College of Paediatrics and Child Health that there
were particular pressures with things like respiratory infections
that affect children in winter, and they were also concerned that
that was compounding the general pressures in paediatric services
in terms of appropriate cover for beds and things. So, can you just
comment on the situation in relation to children?
|
|
[59]
Vaughan Gething:
Yes. It’s part of the future of our
planning for winter as well. In fact, I met the Royal College of
Paediatrics and Child Health this week to discuss a range of
issues. Within winter, again, some of this is about the Choose Well
messages to help and support parents when their child is ill.
Anyone who is a parent knows that children can be ill at any time
of the year, but more likely so in winter, and so it’s
about how we help and support people, and, again, the right place
for them to go—is it a GP, is it a nurse practitioner, or is
it a pharmacy as well?
|
|
10:00
|
|
[60]
For those who do need to go into hospital, actually, within our
whole system we’ve managed to cope, at the paediatric end as
well, but if we did have a significant increase—because, as
you know, very young children are more vulnerable, in the way the
elderly are as well—that’s part of our planning, if we
got a significant surge in demand, how we’d cope and manage
to deliver that. So, it has specifically been taken into account in
planning for winter, and it’s been specifically taken into
account as to how different health boards need to help each other.
You’ll recall that at various points in the year, different
health boards need to help each other on some of our neonatal
provision as well, if there’s a surge in demand or if there
are infections. Some of that is a challenge we still need to deal
with and recognise as an added pressure within winter.
|
|
[61]
I won’t try and soft soap and say this isn’t a problem,
but it’s a challenge we’re well aware of and we think
we’re prepared for, in amongst what we do recognise as being
year-round pressure on a range of services. Again, this goes into
workforce issues, it goes into the use of capital, but it does also
return to the need for a whole-system approach, but where the right
place to care for a child is, and where the parent is worried about
them, and how you meet and deliver against their health need and
support the parents to help look after their own children.
|
|
[62]
Dai Lloyd: Okay. Julie.
|
|
[63]
Julie Morgan: Just as we’re on children, in terms of
the uptake of the flu vaccine in the schools, do we have anything
to report on that for children?
|
|
[64]
Rebecca Evans: This year, we’ve included another year to our
childhood vaccination programme for flu. I think it’s
probably fair to say it’s too early yet in the year to be
able to give any figures, but compared to last year, for the
figures we did have for children then, we don’t have any
cause for concern in terms of a drop-off in uptake this year. But,
as I say, it’s really too early to give the comprehensive
figure for this year.
|
|
[65]
Vaughan Gething:
I know it’s happening, because my
boy’s had his nasal spray as well. He didn’t really
like it, but he got through it.
|
|
[66]
Rebecca Evans: It is an important part of our preventative measures
to support children’s health throughout winter, alongside
which would be programmes such as Healthy Child Wales, for example,
so providing parents with the opportunity to have good advice as to
what signs of concern they should be looking for in their children,
and what the appropriate action would be for them to
take.
|
|
[67]
Dai
Lloyd: Diolch yn fawr. Symudwn ymlaen i gwestiynau ynglŷn ag
adrannau damweiniau ac achosion brys. Jayne.
|
Dai
Lloyd: Thank you very much.
We’ll move on to questions related to accident and emergency
departments. Jayne.
|
|
[68]
Jayne Bryant: Thank you, Chair. Cabinet Secretary, you’ve
mentioned this morning the challenge that people access the right
services. We know that a large proportion of those attending the
emergency departments are deemed to be inappropriate attendees.
Indeed, the committee heard from the Royal College of Emergency
Medicine and the King’s Fund about this. We know it’s
not just about winter preparedness for this, but we know it’s
exacerbated by winter. What evaluations have been undertaken of the
impact of the Choose Well campaigns, both in the way that the
patients choose to access the service and the demands on the
service?
|
|
[69]
Vaughan Gething:
I’ve asked for an evaluation of
Choose Well at the end of this winter, because we don’t have
enough information at this point in time to properly assess its
impact and what we need to do either differently or what we need to
do more of. But we can be pretty confident that without the
campaign to try and help the public to choose well, then
we’re unlikely to see a change in behaviour. We know that, as
I said in the statement, depending on who you’re listening
to, between 9 per cent and 30 per cent of people use A&E
inappropriately, and could be seen outside of A&E. Some
don’t have any healthcare need at all, but they’re
worried, and other people do have a need that could be properly
dealt with somewhere else.
|
|
[70]
The Choose Well campaign matters to us,
so making sure that it works matters to us as well. In the spring,
I’ve asked for a proper evaluation to be undertaken so that
we will then have some learning from it in the summer that could
then apply to next winter’s campaign as well. I think
it’s been helpful, actually, that the Choose Well campaign
has been fronted by the chief executive of the NHS, because there
are times where politicians are the right people to talk about
things and messages, and there are other times where you need
different people doing this as well. So, it’s having the same
Choose Well message go through the service from GPs, to people in
emergency departments, to nurses, to therapists and also to
pharmacies as well. And the fact that we’re investing in
pharmacy as well enables us to do different things as well, and
progressively, again, to next winter we’ll be in an even
better position to deal with many of the common ailments that
people have through the winter in greater number. So, Choose Well
is an important part of where we are. We think it’s
necessary, but when we understand how well it is working,
I’ll have more to be able to tell the committee, after this
winter, when we will have had that rather more formal evaluation
undertaken.
|
|
[71]
Jayne Bryant: Brilliant, thank you.
|
|
[72]
Dai Lloyd: Mae’r cwestiynau nesaf o
dan ofal Rhun.
|
Dai
Lloyd: The next set of
questions are from Rhun.
|
|
[73]
Rhun ap Iorwerth: Diolch yn
fawr iawn. Some questions on matters of capacity in various parts
of the NHS: given that expert groups like the British Medical
Association consider safe bed occupancy levels to be around the 80
to 85 per cent mark, and that figures show not only a decrease in
bed numbers over the past five years or so, but high occupancy
rates—for example, last year, medical acute beds running at
90 per cent occupancy; geriatric medicine at 95.6 per cent
occupancy—would you agree that year-round capacity is already
overstretched?
|
|
[74]
Vaughan Gething:
We know that we have occupancy levels
that are higher than previously, and it depends on who you talk to
as to what is an appropriate level of occupancy.
|
|
[75]
Rhun ap Iorwerth:
I’m happy for you to just answer
that question on whether you agree that capacity is already
overstretched.
|
|
[76]
Vaughan Gething:
Well, asking a complex question and
demanding a simple answer isn’t perhaps a sensible way
through. I’ll answer your question, though. So, there’s
a point about what the right level of capacity and occupancy is,
and, actually, what is more important, we think, is: can it deliver
flow through the system? That, I think, is our biggest
challenge—a flow that’s appropriate, in the sense of
who’s coming into the hospital under the system, and a flow
outward as well, to make sure people are getting appropriate care
and not being kept for a lengthier period of time than is
necessary.
|
|
[77]
Again, we think we’re in a better
position than last year, but we also know that we’ll need
more capacity through winter, and that’s why we’ve got
additional service capacity of more than 300 beds in the system. We
think we can staff that, and we do think that should allow us to
make sure that people are getting the right care in the right
place.
|
|
[78]
Rhun ap Iorwerth:
That’s great. I’ll just ask
that question once more: do you agree that year-round capacity is
already overstretched?
|
|
[79]
Vaughan Gething:
As I said, we don’t think that
there is evidence that year-round capacity is overstretched in
terms of our numbers. We’re always looking, though, at
whether we have got the right level of bed capacity as part of the
system. So, I don’t think it’s a simple
‘yes’ or ‘no’, right or wrong answer,
because you have to understand the demand that comes in, and the
demand that you can anticipate and need to plan for as well. You
also, then, of course, need to be able to staff that capacity as
well, and in many ways, what determines bed capacity and our
ability to actually deliver is not the availability of beds,
it’s the availability of staff and, in particular, nursing
staff.
|
|
[80]
Rhun ap Iorwerth:
I’m not just talking about numbers
of beds. I am absolutely talking about staffing numbers to go with
them. BMA Cymru Wales stated to the committee:
|
|
[81]
‘Once you go above 85 per cent bed
occupancy, you can predict that you can’t cope with
fluctuations. You need about a 20 per cent surplus of beds to cope
with the kind of fluctuations that we’re talking about. When
you’ve got bed occupancies running at 86 or 87 per
cent’—
|
|
[82]
and I’ll remind you the figures for
medical acute were 90 per cent; geriatric medicine, 95 per
cent—
|
|
[83]
‘you start getting C. diff; that
delays the discharge of patients as well.’
|
|
[84]
That suggests to me that BMA Cymru Wales
think the current situation is overstretched.
|
|
[85]
Vaughan Gething:
We recognise there’s pressure in
the system, Rhun. We never try to pretend that there isn’t.
But our challenge is: can we still deliver the right care at the
right place at the right time? Can we still have appropriate flow
through the system to make sure people are going to the right
parts? We do know that there are points in time where, actually,
system pressures mean that we are full. For example, we know that
there are challenges around critical care and intensive care at
different points in the year. In terms of our ability to plan for
winter, though, we do think the additional capacity that
we’re planning to be able to deliver in the system will allow
us to maintain flow across the system. I know Simon’s being
doing work on this in terms of our planning, and can actually give
some more detail on numbers, capacity and flow.
|
|
[86]
Mr Dean: Thank you. If I could draw the attention of the
committee to a recent report from the Nuffield Trust, which looked
at this issue in the English system, it reinforces the point the
Cabinet Secretary has made, because what it demonstrated was that,
actually, some of the best-performing systems were running with
quite high occupancy rates, in the early 90 per cents, and the
whole issue is about flow through the system. So, I think we need
to be careful about placing too much emphasis on a particular
figure. It’s about how the system is working in a way that
optimises the contribution of each part of the system. So, that
includes the elements before people contact the hospital system,
work within the A&E departments, the flow through into the
hospital, and, critically, helping people to move out of the system
at an early stage. So, it’s quite an interesting report that
just reinforces the point the Cabinet Secretary made
there.
|
|
[87]
Rhun ap Iorwerth:
And you’re quite right, which is
why we’re drawing attention to problems of flow through the
system as well, which may be associated, perhaps, with high
occupancy rates. I’d suggest maybe it is. Could you just tell
us a little bit about the modelling capacity that you have
conducted in relation to the winter that is ahead of us, and what
that modelling process has told you about what needs to be done in
terms of capacity over the coming months?
|
|
[88]
Vaughan Gething:
Well, you’ll be pleased to know
that I haven’t personally undertaken the modelling capacity,
but in terms of the planning, again, Simon’s been
leading this work from the Government point of view with different
partners across different parts of Wales. So, I think it would be
most helpful for the committee if Simon actually responds.
|
|
[89]
Mr Dean: Thank you, Cabinet Secretary. As the Cabinet
Secretary indicated earlier, we’ve had a very robust planning
process that actually started in the integrated medium term plan
preparation about 18 months ago now, and then a particular focus on
winter planning from March onwards. As part of that, health boards,
with their partners, have been undertaking their local assessments
of demand and assessing their capacity in terms of people,
infrastructure and beds to respond to that demand and then
developing their plans on the back of that. We have regular contact
with each of the health boards through a number of different
channels of regular meetings, I and my team, talking about
performance and planning. We have a delivery and support unit,
which includes a number of analytical experts who constructively
critique the ways in which individual health boards are approaching
their modelling work. So, we know that health boards have got a
good understanding of likely demand. Now, things can come out of
left field. If we have a major flu epidemic, for example, that will
generate a pressure that it is quite hard to plan for in system
terms and that’s why we need our system to be resilient and
to be adaptable so that it can flex appropriately but from a solid
base. So, that modelling work’s been going on throughout the
year and it has resulted in some of the sorts of initiatives and
developments that the Cabinet Secretary and the Minister have
outlined to you.
|
|
[90]
Rhun ap Iorwerth:
And that suggests you believe you have
adequate up-to-date data in order to flex and respond at the
time.
|
|
[91]
Mr Dean: Yes, we have good understanding of need.
|
|
[92]
Rhun ap Iorwerth:
One quick question from me on capacity,
then, in the social care sector and care homes—given that
Care Forum Wales told us that we’re only one significant
nursing home failure from complete calamity in any part of Wales,
and that they fear we could be approaching that in parts of Wales,
what are your thoughts on the resilience of the system as we
approach winter?
|
|
[93]
Rebecca Evans: Well, we’ve been working hard to understand the
capacity that we have in the sector. We’ve got the care home
steering group, which I referred to earlier, which the independent
sector, Care Forum Wales, do have a voice on. That group provides
the strategic direction for the sector and one thing that they
wanted to do was ask the national commissioning board to undertake
some work to get a complete picture of the state of the market
across Wales. So, we’ve undertaken detailed—or
they’ve undertaken detailed—market analysis of the
care-home sector in every region across Wales. It started in north
Wales, but we’ll be shortly in a position where we will have
a market-position statement for the whole of the care sector. This
will be, I think for the first time, to give us the kind of level
of information and detail about the state of the entire sector that
is in Wales. Also, the regional partnership boards, of course, will
have to work to identify the level of need within their particular
own areas with a view to the joint commissioning of services by
health and social care for adults in residential care by April
2018. So, I think the picture that we have now in terms of
what’s available and where it is, the kind of provision, is
better than it’s ever been, and that enables us to
plan.
|
|
[94]
Rhun ap Iorwerth:
We’ve seen, all of us, I’m
sure, in most of our constituencies, signs of the vulnerability of
the system. I lost, in my constituency, a number of beds very
quickly at one particular care home, which spelled disaster for
many individuals as well as putting pressures on the system, with
people being spread all over north Wales. We already know that
there are problems. Would you agree with that and would you
therefore agree with Care Forum Wales that a major closure in any
part of Wales—whatever work is being done on assessing the
situation formally—and we could be very close to a real, real
problem.
|
|
[95]
Rebecca Evans: I would say you’re correct to say this is about
the individual. The closure of any care home is terrible for the
individual concerned and for their family. Uprooting somebody
who’s a vulnerable person anyway is something that we would
want to avoid and take any steps that we can to avoid. But, in
terms of the sector in Wales, it’s not the same as in
England. The majority of our care homes are actually small. So,
when care homes do close, we do have the capacity and are able to
absorb that impact. Perhaps Albert might say a little bit more
about that.
|
|
[96]
Mr Heaney: Yes, thank you very much, and thank you for the
question. Care Forum Wales are a part of the care home steering
group and very much part of working together with ourselves. The
independent sector provides an enormous quality of care across
Wales and you will be aware of that. However, I would say, from
experience of working both in the sector, and in my role now on
behalf of Ministers, that we are looking to plan more effectively
around strategic commissioning for care homes.
|
|
10:15
|
|
[97]
I don’t agree that we’re one care home away from the
situation you’ve described. However, what I would say is that
each and every care home that closes, if they close in emergency
circumstances, has both an impact on the citizen and an impact on
the professionals working around those individuals. As the Minister
has expressed and explained, we have always, in Wales, responded to
that. Our strategic commissioning emphasis is so that those
situations, when they do occur, if they occur for natural
circumstances—. For example, we have a great deal of
profiling in Wales and the profile of care-home owners in Wales is
more of a small-home ownership rather than a big corporation. So,
there will be times where people will exit and want to exit, but
it’s most important that we plan, because there may well be
other people who want to take over those businesses. The most
important thing is that the independent sector is a sector of value
and is a sector that we’re absolutely committed to working
with to build greater resilience in the care sector. As I said
earlier, I think there’s a lot of good work going on, but
we’re very mindful of both impact upon individuals and impact
upon professionals. We want to get a situation where we have a good
supply.
|
|
[98]
The market analysis work—I won’t take too much more of
the committee’s time, but the market analysis work for Wales,
I think, is really important and to have that clear position. I
know there have been particular challenges in the north Wales area
and we’re very committed—. I’m going up to the
north Wales area at the beginning of December to have a further
conversation as well, on behalf of the Minister, with the
professionals in that area.
|
|
[99]
Dai Lloyd: Reit, mae’r adran olaf o gwestiynau ar
faterion yn ymwneud efo’r gweithlu ac o dan ofal
Dawn.
|
Dai Lloyd: Right, the final section of
questions is related to the workforce. Dawn.
|
|
[100] Dawn
Bowden: Thank you, Chair. I’ll take this out—I can
hear myself. Lots of the evidence that we took was around concerns
over adequate workforce numbers, and we know all the reasons for
that, but the particular concerns were around the levels of
staffing that we would see trying to deal with the particular
pressures in the winter. I thought Adam Cairns actually summed it
up quite well when he said:
|
|
[101] ‘winter is
going to be quite challenging from the staffing perspective, not
because we’re not trying, not because there’s a delay,
not because we’re holding money back, not because we
don’t want to. It’s simply because we simply
haven’t got the workforce presenting itself to us in the
numbers that we need to cover all of the gaps that we’ve
got.’
|
|
[102] So, we know this
isn’t a money issue, this is just about how do we get people
into the system, and that is a long-term issue that we’ve
talked about on many occasions. What is the planning around those
specific pressure points over winter, when we’re going to see
the spikes and we know that’s coming? How are we going to
fill those gaps, particularly in the medical areas around A&E
and general medicine and paediatrics, because that’s kind of
upon us and we know that we’ve still got those gaps? So,
how’s that going to be managed?
|
|
[103]
Vaughan Gething:
It’s part of the planning for
winter. If you’re planning for extra service capacity and
beds, you need to plan for how you’re going to get similar
staff to actually manage that. Some staff will do more through
winter but it’s a short-term point; it’s not a
long-term answer. We also know that we have bank, locum and agency
arrangements as well. There’s always a challenge about
controlling the spend as well. So, we’ve got a range of
different pressure points to manage and it’s completely right
to say—and, as I’ve said in answer to other
questions—we think that actually staffing the capacity is a
bigger challenge than actually identifying what you
need.
|
|
[104]
In terms of where we are, we do think
that people will be under real pressure. Think back to last winter:
the system didn’t fall over but, if you were a member of
staff working within the hospital system or within social care,
you’d have felt that very real pressure. I don’t
pretend to you or to staff within health and social care that it
won’t be really difficult again this winter. The challenge is
that we’ve actually got—. Compared to last winter, we
have got more staff within our system. Think about primary care,
for example: with the investment we’ve made in clusters and
the primary care fund, we’ve got about another 250 people in
primary care across Wales—some GPs, lots of therapists, some
different grades of nurses as well, and lots of extra clinical
pharmacists. So, there are more people within our system. Our
challenge still is: how do we make best use of them and how do we
still plan to get more staff within our system?
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[105] It goes back to some of our recruitment challenges,
rather than training, because, if you think about this winter and
next winter, we’ll have some new people coming along for the
training we’ve already undertaken, but really it’s
about our recruitment profile, which is why yesterday’s
debate in the Chamber, I think, really matters, because
we’re going to be reliant on some returners to
work—people who have left their professions and enabling them
to come back in on different terms if they want to—but also
the honest truth is that, this winter and next, we will be reliant
on recruitment from other parts of the world too as well.
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[106] Now, no part of
our system is relaxed or blasé about that challenge and
there’s huge effort that goes into recruitment. As I say,
though, when it comes to it, we then have to plan to manage with
what we have, and what we reasonably think we’re going to
get, because if we say we’ll plan to have an extra 500 beds
in the system with no idea how many staff we can reasonably
recruit, well, that’s not a plan, that’s a finger in
the wind. That’s why we think we are in a robust and
resilient place, because we think we do have staff to manage the
capacity we have identified, but it reinforces the need to make
sure that we see people in the appropriate part of our health and
care system. Just flooding everyone into a hospital is not great
for the individual and it’s not great for staff and it means
we’ll use our capacity poorly as well, and that probably
means a poorer experience and poor outcomes for patients as
well.
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[107] Dawn
Bowden: Unfortunately, what we know is, despite all the work
going on in a number of these initiatives—and we’ve
talked about Choose Well and the need to evaluate that at the end
of the winter—the fact remains that people don’t always
take the message, so we still see people presenting in the wrong
parts of the service and so on. So, quite specifically, in terms of
staffing around those winter pressures, are you suggesting,
therefore, that what we are going to have to do, to a large
extent—? We’re probably going to have to rely on locums
and agencies to a degree—we can’t avoid that—but
it’s also going to be about moving people around within the
system and perhaps looking at the different skill mixes that
we’ve got, particularly amongst the nursing workforce.
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[108]
Vaughan Gething:
And support workers too and therapists.
It’s about how to make the best use of the staff that we have
and where do they actually provide best value—that is, best
value for the patient, centering around the patient’s needs,
but also it often makes the job of the individual a better job to
do. Think about the ambulance service: we are in a position,
compared to last winter, where we’ve got more paramedics in.
We’re pretty much at full establishment, which is a
remarkable turnaround for that particular service. That means
there’s more capacity to do different things. It means that
there’s capacity within the telephone triage to hear and
treat from the ambulance service. It also means that the ambulance
service can actually discharge people at scene more frequently now
as well, because of the staff that we’ve got in the system.
That’s why we—. As I said, look back at last winter to
see where we are now. We’re in a better place, but no-one
pretends that it’s a perfect place.
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[109]
One of the other things we’ve got
about how we use our staff, another good example, is the piloting
of 111 in the Abertawe Bro Morgannwg area. We’ve been able to
use—we’ve got some additional staff that have gone in
to delivering the telephony service, but actually it’s
largely about the staff that we have. What’s been a really
key feature of that has been the leadership within the GP community
as well to come together to agree on the models of care that are
there, to agree on the directory of services that exist, and how
people are going to be treated.
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[110]
We launched 111 in October and part of
the reason I don’t think you’ve heard much about it is
that there hasn’t been a problem. That’s remarkable. If
you think about the English experience—they had a big bang,
tried to do it right across the country; different models, some
parts of it worked, lots of it didn’t. We’ve taken our
time and we’ve actually bought in and brought staff with us
and that’s meant that we’ve got, I think, a better
system; we haven’t had lots of challenge in it. But it is
making sure that the resource we’ve got in terms of staff is
being used in a different way and it means more people are being
diverted away from the hospital setting in particular. So,
it’s been a real success.
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[111]
The fact that you haven’t had
consultants from hospitals complaining about inappropriate demand
turning up at their doors, the fact that GPs haven’t
complained about it, that nurses and other therapists
haven’t, I think demonstrates that it’s been a
successful addition thus far. The real pressure will come through
the rest of the winter and we’ll know much more about it when
we get to January and February, but, at this point of time,
it’s been a really encouraging start, largely because of that
professional engagement and leadership.
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[112] Dawn Bowden: Thank you, Cabinet Secretary. If I could just have
one follow up question around social care—sorry, this is
still on the workforce, but it’s around social care, because
part of what your strategy is setting out there is that we need to
be getting people away from the acute side of the service, and part
of that is getting people possibly into social care settings. I
just wanted to be clear about the resilience of that in terms of
the workforce to deal with that. We’ve heard a lot of
evidence about care providers struggling to recruit, particularly
care workers, social care workers. Quite frankly, I have to
say, I’m not surprised at that when you can earn more
in Lidl than you can by becoming a social care worker and all the
pressures and the stress that go with that. So, where are we with
that? Are we confident that the social care workforce is going to
be able to deal with those pressures as well?
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[113]
Rebecca Evans: I very much recognise the point that you make about
being able to take a job that is perhaps working in a less
demanding environment for the same kind of money. I do think that
there is a job here for Government in terms of creating the
framework and the climate for good social care and good employment
in social care, and a job for local government as commissioners of
services locally, but there is also a job for the providers in the
independent sector, and for local government as well, and
that’s to create and provide jobs that people want to take.
So, don’t be surprised if you’re offering a zero-hours
contract and your member of staff decides to move on to another job
somewhere else, because we know that turnover in the domiciliary
care field at the moment is at 30 per cent. So, there is a clear
message there to employers as well that they need to step up and
give employees the kind of quality working conditions that they
need.
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[114]
We know, from the research I told you
about last time I was at committee, that the terms and conditions
of the people providing domiciliary care directly impacts upon the
quality of the care that people receive, which is why we’re
taking such a strong interest in this, in the professionalisation
and the resilience of the social care staff themselves, because
they do an incredible job under very difficult
circumstances.
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[115]
So, in terms of professionalising the
workforce, from April 2018, all domiciliary care workers will be
required to be registered. Of course, we’re setting up Social
Care Wales to come into force in April of this year. In terms of
giving domiciliary care workers the kind of standing that they
deserve, I think that’s an important signal. Also, Social
Care Wales will then take responsibility for offering a
contribution to a more focused and positive career progression that
somebody working in social care can expect to have as
well.
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[116]
There’s a lot of work going on.
Every year, we provide £8 million in annual funding through
the social care sector grant in order to provide training and
development. That’s made available in response to regional
training and development plans, which are developed through
regional workforce partnerships as well. So, there is a lot going
on, but I absolutely recognise the concern that we must make social
care an attractive and valued place to work.
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[117]
Mr Heaney: Just to clarify, as the Minister has expressed and
explained, she and Welsh Government are working with the Care
Council for Wales on moving to Social Care Wales, and Social Care
Wales will have a focus on improvement and will have a real focus
on the workforce. The registration itself will open and will allow
the staff time to be able to meet all the standards in terms of
registering as well. So, just to assure you as a committee member
that there will be a very careful process in terms of registration
and assisting the workforce in its professional
development.
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[118]
Dawn Bowden: Okay, thank you.
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[119]
Dai Lloyd: Jayne, a oedd cwestiwn gennyt ti?
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Dai Lloyd: Jayne, do you have a
question?
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[120] Jayne
Bryant: We’re looking at service models. Do you think
that sufficient work is being done to develop new models of care
and the appropriate skills, say, for A&E and emergency
medicine, and is it going at a pace that is sufficient to be
impacted this winter?
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[121] Vaughan Gething: Yes. A really good
example is what’s going on in the Royal Glamorgan with their
acute medicine model. There are good examples. Again, this point
about keeping people away from emergency medicine if it’s not
appropriate, but the challenge is always going to be how we have
that learning spread across our whole system.
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[122]
Last winter, I did a series of interviews
about where we were and one of the lead consultants, who has now
left the Maelor in Wrexham, talked about the fact that a few years
ago they were the highest performing unit in the country; they
hadn’t changed their model of care, but they’d
significantly changed in terms of their performance figures. That
in itself is a story about if you don’t change your model of
care, and if you don’t understand what’s coming through
your door and how you deliver that, then don’t be surprised
if there’s a change in your outcomes and the patient
experience.
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[123] One of the particular parts of work that we’ve
been doing is trying to protect the minor streams of people who
come into an A&E department who actually could be seen in a
slightly different pathway. We’re trying to make sure
that’s protected and insulated, because actually that will be
a better experience for them and they should get seen quicker, but
it also means that for people with much greater need, there’s
a much greater prospect of them being seen by the right people as
well.
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10:30
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[124]
It’s also about how we link up our out-of-hours service, so
that if you go to any major A&E, there’s a proper link
across to out of hours. It goes back to the point that I was making
to Dawn earlier about the 111 service. We do have developing models
and we’ll learn lots from those this year. The challenge then
is about how the service takes those on board and there’s
genuine system-wide learning.
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[125]
Dai Lloyd: Rydym ni wedi rhedeg allan o amser yn anffodus,
gydag ymddiheuriadau i’m nghyd-Aelodau. Efallai y bydd yna
gwestiynau ychwanegol yn deillio o hyn ac fe wnawn ni ysgrifennu
atoch chi efo’r cwestiynau hynny oherwydd prinder yr amser y
bore yma i wneud y craffu fel y byddem ni’n dymuno ei wneud.
Felly, mae’n debyg y bydd yna lythyr i ddilyn. Gyda hynny,
gan fod yr amser ar ben, a allaf i ddiolch i’r Ysgrifennydd
Cabinet a’r Gweinidog am eu tystiolaeth? Ac wrth gwrs, yn
naturiol—fe fyddwch yn gwybod y system erbyn
rŵan—fe fyddwch yn derbyn trawsgrifiad o’r
cyfarfod yma i gadarnhau bod pethau’n ffeithiol gywir. Ond,
gyda hynny o ragymadrodd, a allaf i ddiolch ichi a dyna ddiwedd ar
yr eitem honno. Diolch yn fawr iawn ichi.
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Dai Lloyd: We have run out of time
unfortunately. May I apologise to my fellow Members? Maybe we will
have some additional questions and perhaps we can write to you with
those because time was short this morning to undertake the scrutiny
as we would wish to do. So, it seems likely that there will be a
letter on the way to you. With that, as our time is at an end, can
I please thank the Cabinet Secretary and the Minister for their
evidence? Also of course, naturally—you will know the system
by now—you will receive a transcript of the meeting to
confirm that you’re happy with regard to accuracy. So, thank
you very much and that’s the end of this item. Thank you.
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[126]
Vaughan
Gething: Diolch yn fawr.
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Vaughan
Gething: Thank you very
much.
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10:31
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Papurau i’w Nodi
Papers to Note
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[127]
Dai Lloyd: I weddill y pwyllgor, fe wnawn ni symud ymlaen i
eitem 3. Mae yna bapur i’w nodi. Fe fyddwch wedi darllen y
wybodaeth ychwanegol a gawsom ni gan Ymddiriedolaeth Gwasanaeth
Iechyd Gwladol Gwasanaethau Ambiwlans Cymru mewn perthynas
â’u prosiect galwyr mynych. Cais i nodi’r papur
ydy hwn. Pawb yn hapus? Dyna ni.
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Dai Lloyd: For the rest of the
committee, we're going to move on to item 3. There’s a paper
to note there. You will have read the additional information we had
from the Welsh Ambulance Services NHS Trust in relation to their
frequent callers project. This is a request to just note that
paper. Is everybody happy to note it? There we are.
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Cynnig o dan Reol
Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd o Weddill y Cyfarfod
ac o’r Cyfarfod ar 23 Tachwedd
Motion under Standing Order 17.42 to Resolve to Exclude the Public
from the Remainder of the Meeting and from the Meeting on 23
November
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Cynnig:
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Motion:
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bod y
pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y
cyfarfod ac o’r
cyfarfod ar 23 Tachwedd yn unol â Rheol Sefydlog 17.42(vi).
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that the committee resolves to exclude the
public from the remainder of the meeting and from the
meeting on 23 November in accordance with Standing Order
17.42(vi).
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Cynigiwyd y cynnig.
Motion
moved.
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[128]
Dai Lloyd: O dan eitem 4, fe wnawn ni symud cynnig o dan
Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y
cyfarfod yma ac o’r holl gyfarfod ar 23 Tachwedd, sef yr
wythnos nesaf, hefyd. Pawb yn cytuno? Pawb yn cytuno. Diolch yn
fawr iawn. Fe awn ni i mewn i sesiwn breifat nawr i barhau
efo’n trafodaethau mewnol. Diolch yn fawr.
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Dai Lloyd: Under item 4, we will move a
motion under Standing Order 17.42 to resolve to exclude the public
from the remainder of the meeting and from the entire meeting on 23
November, which is next week, also. Is everyone in agreement on
that? Everyone is in agreement. Thank you very much. We’ll go
into private session now to continue our internal discussions.
Thank you.
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Derbyniwyd y cynnig.
Motion agreed.
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Daeth rhan gyhoeddus y cyfarfod i ben am
10:31.
The public part of the meeting ended at 10:31.
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