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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[5]
Dai Lloyd: Dyna chi, diolch yn fawr iawn am yr ateb
cynhwysfawr yna. Bydd yna ddigon o amser nawr i Aelodau ddrilio i
lawr am y manylion roeddech yn sôn amdanyn nhw. Fe wnaf i ofyn
i Caroline Jones ofyn y cwestiwn nesaf. Caroline.
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Dai Lloyd: There we are, thank you very
much for that full answer. There’ll be plenty of time now for
Member to drill down for the details that you mentioned. I’ll
ask Caroline Jones to ask the next question. Caroline.
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[6]
Caroline Jones: Yes. You have the pilot scheme that’s
been extended further. I’m looking at the 65 per cent target.
Do you think that the 65 per cent target is ambitious? Do you have
any detail regarding the 35 per cent of that target that is not met
and how it has affected patients and, possibly, the families?
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[7]
Ms Myhill: I’ll start and then I’ll ask Richard
to add, if I can. I think the 65 per cent target for red
calls—. I’m sure you’re aware that the difference
in the model now means that those red calls are 5 per cent of our
work. They really are the most immediately life-threatening calls.
We’ve been able to achieve that target now for 11 months.
We’ve been improving our ability to achieve that target, not
just at a Welsh level, but across the whole of Wales. So,
it’s probably not ambitious enough, but I think it will
really be tested now over the next six months. This is the time of
the year, we know, between October and March, sometimes even beyond
March, where we will test that target. But we are planning to meet
that target through the winter. If you look at the figures last
year, we did, but only just, particularly in March, which was a
very challenging month for us last year. So, I think it’s the
right target at the moment, but in time I think we would want to be
more ambitious than that.
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[8]
Dai Lloyd: Rhun.
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[9]
Rhun ap Iorwerth:
Just a supplementary on that, it’s
five—
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[10]
Dai Lloyd: Oh, yes. Sorry, Richard, did you want to
add?
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[11]
Mr Lee: Sorry—
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[12]
Caroline Jones:
[Inaudible.]—up from the
other 35 per cent that wasn’t met.
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[13]
Mr Lee: I think it’s important to reassure the
committee: we don’t plan our services to reach 65 per cent of
red calls and then stop. As you see, we are increasing the element
by which we overachieve against the 65 per cent target. The
ambition of my operational teams is to get to as many of these
life-threatening calls as quickly as possible. So, the 65 is the
target, but as you can see, we are overachieving on that by some
margin and we will continue to do that across the winter, as far as
we can.
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[14]
As far as the effect on patients, we know
that, for patients in cardiac arrest, their chance of survival
reduces by 10 per cent per minute before a defibrillator is applied
to them. We know that waiting for an ambulance is a very
frightening experience—minutes seem like hours when
you’re waiting. So, as well as recording our performance
against the 65 per cent target, we also measure our performance
minute by minute. At 10 minutes, we are at around 85 per cent to 90
per cent of calls—it varies slightly, month to month. So, our
10-minute performance is better than our 8-minute performance, and
our 15-minute performance is better than our 10-minute performance.
There will always be a tail-off in response, especially in very
sparsely populated areas. One of the very important things about
the way we are managed is that the target is universally applied
across Wales—there are no geographical distinctions—and
that’s really important as far as equity goes.
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[15]
To take the second part of your question
about clinical information, last year, we were lucky to receive
investment for a new system of digital pens. So, our ambulance
crews record information on patient report forms and that now feeds
into a database, so we can extrapolate much better information. Two
of the key indicators that we look at are stroke and heart attack,
where we look at actual whole-system data. So, we don’t just
look at what was the ambulance component, we look at when you got
to hospital, what happened to you in hospital and what was your
outcome sometime later. So, I think we’re able to be quite
reassured that the whole-system data support the fact that
we’re playing our part in the system.
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[16]
Dai Lloyd: Ocê, diolch yn fawr. Rhun.
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Dai Lloyd: Okay, thank you very much.
Rhun.
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[17]
Rhun ap Iorwerth:
Red calls are 5 per cent, you say, of
your total calls. So, there are no targets, by now, for 95
per cent of the calls that come in. How do you measure your
performance within that 95 per cent?
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[18]
Ms Myhill: It’s quite interesting, because the reason
that 5 per cent of the calls are based on a time target is because
the clinical evidence is that for that category of call, time is
absolutely critical—those minutes, as Richard has said. So,
for the rest of the work that we do, we’re not measuring time
where time doesn’t have a discernible impact on the
outcome—what we’re measuring is patient experience and
clinical indicators. Richard has mentioned stroke—if
you’ve had a stroke, we want to make sure we get you to the
right unit in the time that you need to be in the unit, which is
usually an hour, to receive what you need for your condition. So,
we’re measuring more information on that 90 per cent that
you’ve noted than we’ve ever done before. So, the
ambulance quality indicators that you might have seen that we
publish now every quarter at each health board level, as well as at
a Welsh level, give a whole raft of information about the service
that we provide to the bulk of our work.
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[19]
Rhun ap Iorwerth: You could see targets as benchmarks as
well, of course. How do you benchmark those performance
indicators?
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[20]
Ms Myhill: In terms of the time target, the system that we
have is probably unique, actually, at the moment, in terms of the
clinical response model that we are operating—it’s
being watched by people across the bridge and across the world. So,
we haven’t got exactly the same systems, but there are ways
of benchmarking, particularly those very, very severe calls. The
system in England, for example, has got a red 1 and a red 2, so we
will look at what we do compared to the red 1 category in England.
But, again, the systems are slightly different.
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[21]
Rhun ap Iorwerth: But you will publish time figures as
well.
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[22]
Ms Myhill: Sorry?
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[23]
Rhun ap Iorwerth: You will publish data on time as well as
clinical outcomes.
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[24]
Ms Myhill: We publish data on the amber calls, which is
about 60 per cent of our work. The main measures there are about
patient experience and outcome, but we still need to keep an eye on
time, because that’s quite important. So, internally, we will
measure 20 minutes on those amber calls.
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[25]
Rhun ap Iorwerth: And they are published then.
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[26]
Ms Myhill: They are published, yes.
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[27]
Mr Lee: In the monthly statistical release, similar to the
one that was released yesterday, there is time-banded performance
for amber calls—it’s not a target, but it’s
information that we publish because it’s important. As I say,
waiting for an ambulance is a desperate time. Just to back up what
the chief executive said, our previous obsession with time targets
in the UK for ambulances actually drove poor behaviour by ambulance
services. So, if somebody in your constituency is having a stroke
or a heart attack, us sending a paramedic in a car to help them
does not actually help them get the definitive treatment, get them
well and get them home again to the community in a good functional
state.
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[28]
There are a really small number of emergencies—the 50 that we
attended yesterday; the 50 red calls yesterday—where minutes
really did make a difference between that person living or dying.
For the rest of the calls, it’s far more important that we
send the right thing—the right people in the right
vehicle—to do what’s needed for that patient and take
them to the right treatment.
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[29]
Heart attack patients—when I was first a paramedic in the
mid-1990s, we were thrombolysing, we were taking them, they were
spending two weeks in hospital and they were being discharged with
heart failure. We’re now taking those patients direct to a
catheter lab and three days later they’re back home better.
So, the system is much less now about how quickly we get to
people—it’s much more about sending the right thing.
So, one of the things we do benchmark is who we send to
emergencies. We are trying to reduce the number of occasions where
we send a paramedic in a car and increase the number of occasions
where we send an ambulance with a paramedic in it who can look
after the patient’s whole needs.
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[30]
Dai Lloyd: Good. Julie.
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[31]
Julie Morgan: Yes, thank you very much. I think this is the
right move—to reach the people who are most urgent and need
the time is absolutely right. But I do think that the amber area is
the area that does produce most controversy and concern. As you
know, I’ve had a number of patients who’ve had to wait
a long time for an ambulance, and they were not classed as red. My
fear was that the experience of waiting so many hours may, perhaps,
make them red in the end. So, I really think it’s very
important, as Rhun has said, that we do have an analysis of
what’s happening with the amber calls.
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09:45
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[32]
I’d also like to say that I think your response has been very
good to the complaints that I’ve put in about them.
You’ve been very direct with the patients, offering to go to
see them personally, and sending a lot of people to see me
personally, because I had a little run of people. I think
it’s really important that we do avoid that. So, could you
tell me what your actual plans are to make it less likely that
people in the amber category who appear to be not life-threatening
don’t wait for hours and hours, which, as they’re often
elderly, is very concerning?
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[33]
Mr Lee: Absolutely. So, we are doing two pieces of work at
the moment. One piece of work, which comes to an end in October, is
in association with the Association of Ambulance Chief Executives,
which is the UK body. We are undertaking a demand and capacity
analysis, and that’s specifically looking at the level of
resourcing we require to send the ideal response to every emergency
call. We have put some notional time boundaries in that to do the
analysis against. So, that piece of work is going on at the moment,
health board by health board area, and the information will be
available to us and our commissioner in late October.
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[34]
That’s the strategic piece of work. The local piece of work
and the tactical piece of work is about looking at the amber
patients and being quite relentless at analysing the tail of
responses. One of the advantages of the new model is that we can be
much better at looking at the red incidents. So, every red call
that we don’t get to in eight minutes every day is now
reviewed on a case-by-case basis. In the previous model, we
couldn’t do that because there were so many of them. It would
have been an industry in itself. For the amber calls, we know that
the heart attack and stroke patients wait the shortest amount of
time because they are the highest priority within the amber group,
and we have identified some categories of amber patients who are
sometimes waiting longer than they should. Some of those are
elderly people who have fallen, and some of those are people with
isolated limb injuries; so, people who have broken their arm,
people who have broken their leg.
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[35]
Now, it’s not right that anybody waits too long for an
ambulance, but it is reassuring that we’re getting to the
heart attack and stroke patients quicker than we’re getting
to somebody with a broken arm. That is good news, and that shows
that the model is doing what we thought. So, as part of our winter
plan, you’ll see that we’re looking at new ways of
managing patients, especially elderly fallers. One of the things
we’re doing—you’ll have read in our evidence
about our clinical support desk. So, we now have a team of 18
paramedics and nurses who assess patients over the telephone and
provide alternatives to us sending an ambulance. Last month, 907
ambulance dispatches were prevented by the nurses and the
paramedics on that desk. That means that there were 907 ambulances
available to go to amber calls that previously weren’t
available.
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[36]
We know that elderly fallers can’t be managed over the
telephone because they’ve fallen and they need help. So, we
have equipped 15 of our community first responder teams with the
necessary equipment to lift patients from the floor. That’s
really important because when we talk to our community first
responders, they say to us, ‘We’re really happy to go
to the red calls in our community and save life, but, actually, we
hear, when we go into the Spar shop in the village, somebody saying
to us, ‘Where were you the other day when my mum fell over
and we waited 45 minutes for an ambulance?’ Well,
historically, we’ve not used CFRs for that, and we’re
going to this winter.
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[37]
So, the clinical desk will provide some initial safety-netting, and
once the clinical desk are happy that the patient isn’t
injured, the community first responders will attend to help the
patient off the floor, and then the clinical desk will then provide
a follow-up assessment and a referral by telephone on to the local
falls service. That is going to transform the experience of those
fallers. It’s also going to give us more ambulances available
to go to other amber calls, where it is not acceptable to send a
first responder because the patient’s going to need something
more than a first responder can offer.
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[38]
There’s also some work going on about our ambulance
availability. We know that our peak demand now starts at 10
o’clock in the morning. Historically, we thought our demand
peaked up about 2 o’clock in the afternoon and went through
to the early hours. The demand and capacity work we’ve done
already has shown us that, actually, we are at peak demand from
about 10.00 a.m. onwards. So, we’re looking, at the moment,
at what we can do about moving our peak staffing forward into the
early part of the day, not the late part of the day.
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[39]
Lastly, I think you’ll have seen from our plan that a huge
part of our plan is about returning capacity to the front line. So,
for managers, like myself, who are paramedics, part of the winter
plan is about putting us to do some clinical work for some of the
time, which will increase the ambulance availability and will
reduce the amber waits.
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[40]
Julie Morgan: Can I just ask about the falls and elderly
people having to wait? Do those increase in the winter? Do you have
any evidence?
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[41]
Mr Lee: Yes, they do. What we find, in the winter—. If
you look at last winter, for our call volume on all 999 calls, on a
month-by-month basis, there was a variance of about 3,000 calls
between the quieter months and the busier months. So, there’s
not a massive—you’re talking about 100 incidents a
day—spike in demand. What we find is the acuity changes. So,
the number of calls that are red stays the same—people
don’t become more life-threateningly ill in the winter. What
happens is that our green calls, the very minor calls, reduce, and
the amber calls in the middle increase. Most of those are either
people who’ve fallen or people with respiratory conditions
who maybe in the warmer months would have been categorised as a
green call and been suitable for telephone assessment, but in the
winter, the person now has a chest infection and is septic and
requires an ambulance response. So, that’s the pattern that
we see.
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[42]
Dai Lloyd: Okay. Lynne.
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[43]
Lynne Neagle: Thanks, Chair. I’m really pleased to
hear that the work is ongoing with the fallers—as you know
it’s been an area of concern for me, and I think that’s
really positive that you’re looking at innovative ways to
deal with it. I just wanted to ask about the capacity and resource
review—I’m waiting with bated breath to see what it
comes up with for Torfaen. I just wondered, if that review finds
that you do need significant extra resource, will it be the
intention of the commissioners to go to Welsh Government to ask for
more money?
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[44]
Ms Myhill: We’re doing this in conjunction with the
commissioners—so the emergency ambulance services committee,
which is made up of all the chief execs, as you know, commission
the ambulance service from us. So, we’re doing that together,
and they’re involved in the review, and we will collectively
consider the outcomes from the review. I’m confident that the
review will also show us where we can be more efficient. So,
it’s not just going to be about, ‘We’ve got gaps
and we need more’. I’m sure there will be some advice
for us where we can be better at what we do with what we’ve
got. If we see, through that review—. What we’re hoping
the review will tell us, to achieve certain outcomes and to achieve
certain performance—it will tell us what we need where.
We’re doing it at very local level, as you know. So,
it’s not a national picture, it will be local level and
building that up. Then we will have those conversations in terms of
how we move from where we are to where we need to be—I would
suspect, over time, as opposed to immediately—if there are
areas where we’ve got gaps. It will help us prioritise also
where we need to maybe shift resource or invest resource in the
future.
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[45]
Dai Lloyd: Okay. Angela, did you want to ask at this
point—? I’ll give you the floor for a couple of
microseconds.
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[46]
Angela Burns: Thank you. I wanted to ask a couple of
questions on your paper. I couldn’t have agreed more about
your commentary on the resilience of the wider unscheduled care
system and particularly your view that pumping more money into the
NHS isn’t necessarily the answer, but it’s about making
sure that that network and web is entirely in place. You talked in
your paper about being an integral part of the unscheduled care
services with the local health boards, and I think, Tracy, you
mentioned the fact that you have integrated plans with each and
every health board. Nothing in life is perfect, though—where
are the holes?
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[47]
Ms Myhill: I think there are challenges that you will know
and you will have seen and you will have heard. So, yes,
we’ve got integrated plans with all of our health board
colleagues and I know that our health boards are also working
across the system with social care and others. So, the plans are
definitely more joined up than they’ve ever been. That
doesn’t mean that there aren’t pressures and we do have
pressures in certain parts of Wales. North Wales is a pressure
point for us on times, and you’ll see that again from some of
the published performance—
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[48]
Angela Burns: My apologies. I wasn’t trying to get you
to name and shame any other LHBs, I was thinking more about holes
in the integration, in terms of—. So, for example, when
you’re trying to refer someone—when the ambulance has
arrived there and you’re saying, ‘Well, actually, I
don’t think you need to go to hospital, you need to go and
see somebody else’—are you finding those
‘somebody elses’? Is there good accessibility to other
services, to be able to signpost people? Sorry, I meant more those
kinds of gaps in the system.
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[49]
Ms Myhill: Yes, okay, thank you. So, we would call that
alternative pathways in terms of the way that we would describe
that work. So, there are a number of alternative pathways that
we’ve been developing collectively with health boards to help
us avoid taking patients to emergency departments where emergency
departments are not the right place for them anyway, but also it
just potentially adds to the pressure. So, there are a number of
common pathways that we have—falls is an example, diabetes is
an example, and epilepsy is an example that we’ve got across
the whole of Wales.
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[50]
Another example of a pathway we’ve got in Cardiff and in some
other health board areas is mental health. So, if you’re in
mental health crisis, the last thing you need is to go to an
emergency department. It’s just not good for you, is it, as a
patient, and it takes so much longer to get you the right care you
need if you go through that route. So, in Cardiff, for example,
we’ve got direct access to a mental health crisis team, so
our people can refer directly to that team, and we have seen the
hours that that has taken off some patients’ journeys because
they’re getting the right expertise. We’re looking to
develop a few more in the winter now; diarrhoea and vomiting is
another example, and flu. So, we are working across Wales to get
direct access to district nursing, which is another example. So,
there are good examples.
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[51]
There are some that are happening everywhere, there are some that
are happening in some parts of Wales and not everywhere, and
through our work with the commissioner and the emergency ambulance
services committee we have an opportunity to say, ‘That is
really working there’. So, the Cardiff mental health pathway
is not perfect either—we could still improve it—but
that’s a good pathway; let’s move that and share that.
We’ve done that with Aneurin Bevan, we’ve done it with
ABMU in Swansea. So, we’ve got an opportunity through the
system to share so that, where it works, we do it once for Wales
wherever possible.
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[52]
Angela Burns: Thank you. The interest that I have is in how
we might be able to stop people getting to the front door of the
hospital—so, looking at all of the different alternatives.
Obviously, as the first responders and as trusted professionals,
you’re going to be somebody that—. Your organisation is
going to be an organisation that a potential patient will listen to
and will follow your advice. So, I’m kind of interested in a
few other things in that same area. Does the ambulance service just
deal with a patient and that’s it—their data, if you
like, are dead to you? I notice you mentioned frequent callers, but
do you have any data that can indicate the revolving door syndrome,
where you’re taking patients up to the front door and
they’re going in for a few hours, and then you’re
having to take them back out again, which of course is a huge drain
on your resources? Do you have any data that might indicate what
they do in those few hours, and is there anywhere else that we
could be putting them rather than in a hospital? I’m
interested in that whole short-term revolving door syndrome, and if
you have any data, information or just any intuition that you could
share with the committee on that.
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[53]
Ms Myhill: I think—you can add a bit more detail,
Richard, if you would—but I think generally where we have
been historically is we’ve been very insular, so our data
have been our data and they’ve been recorded manually across
the whole of Wales. It’s been very difficult to join that up
with the rest of the care system. So, our data—Richard
mentioned digipens—are now digitalised, which makes it much
easier for us to do a clinical audit or to work with our staff to
understand what’s happening. We are working in conjunction
with health boards and Welsh Government to join up the system so
that we can follow the patients right through the system. Quite
often, for our crews—and I go out with crews regularly;
people will know that I do that, and I say, ‘What’s
happened to Mrs Jones?’ and they say, ‘Well, we
don’t know’, and I say, ‘Well, I want to know. I
want to know what happened to her once we took her to the
hospital’. So, there’s definitely a system piece of
work that we are doing to try and join that up.
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[54]
In terms of the reality on the ground now, and intuition and
feeling, you could probably say a bit more on that.
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[55]
Mr Lee: If you look at our whole 999 workload, we take about
63 per cent of the people that dial 999 to hospital, and some of
those patients are helped over the telephone, so once you take away
the ones that were helped over the telephone, we take about seven
out of 10 people that we actually go and see face to face
somewhere. Not all of those patients go to the emergency
department. We’re increasingly taking people to other parts
of the hospital, so we take pregnant ladies direct to maternity, we
might take mental health patients to a mental health clinic, and we
might take patients with a fractured neck of femur to a trauma
ward, directly bypassing the emergency department.
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[56]
In terms of your question about the gaps, the big gap is the use of
our service by care homes. So, we have lots of calls to nursing
homes to attend to patients, and there are registered nurses in
nursing homes, and I think there’s more work for us to do as
a system to keep people in their nursing home. That is, after all,
their home; that’s where they live. If I was living in a
nursing home, I’d want to live there. So, it’s about
keeping those people there and finding strategies. So, we’re
looking at the moment at developing community paramedics that will
work in an area and will work alongside the district nursing team
and alongside falls teams to maybe provide a bit more of a virtual
ward system. So, instead of you being taken to hospital, they might
pop in and see you a couple of times and just see how you are.
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[57]
The other issue you raised about people going in and coming out
again, that’s a real problem, because we don’t bring
people home from hospital anymore. We used to; we don’t do
that anymore. So, if we take somebody to hospital and then they
need to come home again, quite often, getting them home is quite an
art. So, we have to find new ways of not repeatedly taking people
that don’t need to go to hospital. So, our frequent-caller
programme at the moment is looking at our top-10 frequent callers
in each health board area, and is helping literally hundreds of
patients—there are 400 and something patients in the
programme at the moment. And it’s not about—.
You’ll have read in the paper that two people have had a
custodial sentence for abusing our service, but the vast
majority—all except two of the patients in the
programme—have had individual care plans agreed. So, we will
talk to their GP. The GP, quite often, is unaware that their
patient is calling an ambulance every day. We’ll talk to the
district nursing team, we’ll talk to the falls team, and this
then allows us to have an individual treatment plan, which means
that that patient doesn’t end up in that revolving door
arrangement.
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10:00
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[58]
Julie Morgan: Can I just follow that up?
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[59]
Dai Lloyd: Sorry, everybody’s—.
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[60]
Angela Burns: [Inaudible.]
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[61]
Dai Lloyd: If it’s still on this point, yes.
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[62]
Julie Morgan: It was just particularly on frequent
callers—
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[63]
Dai Lloyd: Go on, then.
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[64]
Julie Morgan: --because I was coming to that later on. I
think you said—did you say had 400 people who were
on—?
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[65]
Mr Lee: There are 400 people in the programme at the moment,
but the thousands of ambulance journeys—3,000
hours—
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[66]
Julie Morgan: Yes. I’ve experienced a lot of this in
my area, and, again, your response and explanations have been very
good. But how many are you not reaching who are doing the frequent
calling, because I’m getting repeated complaints from
neighbours saying the ambulances are there every night, twice a
night? And this, in one case, has gone on for two weeks. So, I
wondered at what point do you intervene and are able to try and
address the real needs of the person who’s calling the
ambulance.
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[67]
Mr Lee: So, we intervene at four calls in a month, or five
calls over a two-month period. And the reason for that is that
there are sometimes patients, especially end-of-life patients
maybe, who become a super-user of ambulance services for a couple
of weeks, and that is unavoidable. Or we find patients who are
usually cared for by their family, and maybe the family go on
holiday, and we have to fill a gap for a couple of weeks while that
person’s family aren’t around. And, sometimes, people
that aren’t very well, especially older, frailer
people—we may find we go to the same patient two or three
times in a week, and help them while they’re unwell and then
they get better and we don’t hear from them again.
|
|
[68]
The triggers we use to do the frequent-caller work: we’re
part of a national UK network of ambulance frequent-caller work,
and the triggers are UK-agreed. I should say that one of the
advantages of NHS Wales, with us being in this integrated system,
is that our plans are much more whole-system plans, involving the
GP and other services, where in England, the frequent-caller work
tends to be that the ambulance service writes to the GP or writes
to the community service, saying, ‘This patient is now a
frequent ambulance caller.’ We don’t do that; we get a
multi-disciplinary team together, because we’re integrated,
and actually come up with a plan and a solution.
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|
[69]
Julie Morgan: Thank you.
|
|
[70]
Ms Myhill: There’s some real data on that that we can
share that show the significant reduction. In January, for example,
71 patients called us over 400 times in that month—the same
patients. We did this work across the system, as Richard has
described, and by April the same 71 patients called us 100 times.
So, a significant reduction in trying to access our services.
|
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[71]
Dai Lloyd: On that point, Rhun, and then Angela.
|
|
[72]
Rhun ap Iorwerth: Is there a peak in the incidence of
frequent calls over winter?
|
|
[73]
Mr Lee: No. The call volume rise is to do with that shift in
acuity, as I said, so the people that in the summer are green calls
become amber calls in the winter.
|
|
[74]
Dai Lloyd: Angela.
|
|
[75]
Angela Burns: Two quick questions on winter pressures. The
first, actually, Chair, is slightly to you, which is the point you
made about the care homes, because of the fact that, during the
winter, more people slip, particularly the elderly, and go into
hospital, one of the big worries is that a number of those people
will have some form of dementia. And I think the evidence very
clearly shows that once you take someone out of their established
routine and put them into hospital, their dementia increases
exponentially and it’s very hard then to row back and get
them back into—. So, then we have all those other ongoing
social areas. So, I just wonder if our winter pressures inquiry
ought to just have a quick look at the care home element of what we
might be able to do, or see how prepared they are for winter
pressures.
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|
[76]
Dai Lloyd: And possibly invite the umbrella organisation for
care homes, yes. Okay.
|
|
[77]
Angela Burns: Yes. But the other question I wanted to ask
was about—. You’re setting up a specific, or have set
up a specific, call centre in Llanfairfechan to deal with the
police, calls from the police.
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|
[78]
Mr Lee: Yes.
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|
[79]
Angela Burns: Is that actually a direct result of the
festive season or was that—? I wasn’t quite clear from
the paper whether it was a specific response. Is that because the
calls from the police specifically tend to be of a certain type of
nature, or what?
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|
[80]
Mr Lee: So, I talked about the secondary triage team, our
team of nurses and paramedics who provide help over the
telephone—18. So, we have put four posts up in north Wales.
The police are a super-user of ambulance services. The police call
the ambulance service 25,000 times a year and we know from test-bed
work that we’ve done that, by putting a clinician in the
police control room, we can halve the number of ambulances that we
send to the police. That’s really important because it means
that fewer people go to hospital; it means that we dispatch fewer
ambulances—so we’ve got more ambulances for our amber
calls that predominantly need an ambulance—but it also means
that police officers can go off and be police officers again,
rather than waiting for us to attend to someone with a minor injury
or a minor health problem that they’ve come across in the
course of their duties.
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|
[81]
It is a piece of work that we’re leading in Wales and our
intention is to do it with all police forces, but we’re
starting it in north Wales and that will be live as part of our
winter plan. There are some spikes to it. So, obviously, in the
night-time economy in the run-up to Christmas and the new year
period, the police come across more people with minor injuries
during that period, but although we’re starting it because
it’s a good thing to have in our winter plan because it will
help, it won’t stop at the end of winter—it will be a
365 provision.
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|
[82]
Angela Burns: I just wanted that clarification. Thank you
very much.
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|
[83]
Dai Lloyd: On this point, Caroline, before we move on to
Jayne.
|
|
[84]
Caroline Jones: It’s on lost ambulance hours. Is that
all right?
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|
[85]
Dai Lloyd: Where’s that now?
|
|
[86]
Caroline Jones: Lost ambulance hours—knowing that
there will be an increase this winter of probably 4 per cent,
again, as there has been previously, you can’t respond then
to other calls if the ambulances are outside the hospitals. So, can
you please tell me what plan you have for this eventuality, really,
to improve the situation, if you like?
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|
[87]
Ms Myhill: We’re not planning this winter on the basis
that we don’t think there’ll be pressure, I think is
the first thing to say. So, we know that there will be pressure and
we know there’ll be pressure for us and there’ll be
added pressures across the system because that’s what
happens. I know people say that winter is all year round, but there
are certain things that do happen. So, our plan is not predicated
on there being no delays because I think that that would be a plan
that would fall down very, very quickly. So, we are anticipating
that there will be pressure and we are anticipating that hospitals,
us, GPs—that we will all have added pressure as a consequence
of the winter.
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[88]
The 4 per cent increase that you mention is about demand, not
necessarily hours lost. It’s a 4 per cent increase in demand
that we are seeing year on year. But we are working very hard, as I
said at the beginning, with our health boards to do everything we
can to keep the flow of patients through the system. A lot of the
examples that Richard has talked about in terms of the clinical
desk, triaging people before and reducing 900 ambulances in one
month—all of those things will reduce the number of
ambulances that we take into hospitals.
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|
[89]
We are also working very hard with our staff to make more decisions
at scene so that our staff have more confidence to make clinical
decisions and not take people to hospital where they don’t
really need to—not taking people to hospital for just a
double check or a look-over. So, everything we’re doing is
focused on reducing the demand and then we are talking with our
health board colleagues at the moment about, in the event that we
do get significant pressure, what we will do to prevent ambulances
queuing outside hospitals.
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[90]
There’s a national Welsh Government circular that’s
been issued at the end of winter, which is quite strict in terms of
what you do at certain points of delays in terms of clinical
assessment and escalation. We’ve got our own escalation
processes this winter, which are much better than we had last year,
and, again, we’ve got that jointly with the health boards. We
are looking at the potential for extra capacity that we can put in,
in the event that we’ve got huge delays outside our hospitals
and patients in the community needing care. There is a potential
that we will be able to provide some mobile support that can move
to areas of greatest pressure. So, we’re working that through
with the health boards at the moment.
|
|
[91]
Dai Lloyd: Ar y pwynt yna, mae
yna gwestiwn gyda Jayne hefyd.
|
Dai Lloyd: On that point, Jayne has a
question.
|
|
[92]
Jayne Bryant: Thank you, Chair. I’d just like to say
that I found your paper very helpful, actually, so it was very
useful reading through that. I’d like to take us into
handover issues now, and I notice in the paper that you say that
there’s a direct correlation between handover delays, the
availability of emergency ambulances, and the risk to patients.
With that in mind, I was just wondering what you think the reasons
are for such a significant difference between local health boards
in these handover times, and are there examples of good practice,
like the one in Cwm Taf, perhaps, that we could follow.
|
|
[93]
Ms Myhill: There are differences. Sometimes, the difference
is the population and the demand, because our hospitals are
different, clearly. So, the University Hospital of Wales will see
patients very differently to some of our smaller hospitals. So, the
demand profile is definitely different. There is something about
approach as well. Cwm Taf is an example that you’ve used. We
have very few delays, if any, if you look at the data, in relation
to Cwm Taf. Some of that is about the model that they operate: the
direct access to medical wards, which we don’t have in all
hospitals, means that we can get in and out much more quickly. Some
of it is about clinical leadership and leadership in that
there’s a no tolerance, really, to ambulances
waiting—so, they’re trying to push us away before we
want to go, almost, in some of those areas. That is something that
genuinely does really help. But the pressures are different.
It’s not the same everywhere, but there is good practice and,
through the Chief Ambulance Services Commissioner, who works on
behalf of all the health boards, we try to share that. The systems
are different; you know, the social care is different in different
parts of Wales, the support infrastructure is different in
different parts of Wales. Unfortunately, it’s not one
solution for all but, where we can, we will share that practice. I
don’t know if you want to add anything to that.
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|
[94]
Mr Lee: Absolutely. Patients flow through the emergency
department into the hospital, into the wards, have some treatment
and then flow out of hospital back into the community. So, the more
people we can keep in the community, the fewer people we take to
hospital, the fewer ambulances there are outside. But, actually,
flow within the hospital is probably the difference in the
different parts of our system. How quickly can a hospital get,
especially, a frail elderly patient back into their home with a
homecare package that works? How often do those homecare packages
fail and the patient comes back? And the systems within the
hospital, as Tracy said—. The more often we can take a
patient somewhere other than ED—. In the same way that us
sending an ambulance to you in eight minutes is only beneficial to
a very small number of patients, a lot of patients that go into the
emergency department are seen in the emergency department but their
actual treatment is given by other specialisms within the hospital.
So, the more often we can bypass the emergency department and take
those patents directly to the speciality, the more room there will
be in the emergency department, the quicker our ambulances will
turn around, and the quicker we can deploy the ambulance to the
next call. Sometimes, people imagine the halcyon days of ambulances
doing a call and then going back to the ambulance station and
sitting watching the telly for a bit and then going out again.
It’s not like that. Our ambulances go from call to call to
call. That’s the pressures of the system that our staff work
under. So, we need the ambulance availability to make sure patients
like those Mrs Morgan referred to get an ambulance as quickly as we
would like.
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|
[95]
Dai Lloyd: Cwestiwn olaf—Rhun.
|
Dai Lloyd: Final
question—Rhun.
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|
[96]
Rhun ap Iorwerth:
I’ll squeeze two questions into
one, then. [Laughter.]
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|
[97]
Dai Lloyd: Well, brief answers, then.
|
|
[98]
Rhun ap Iorwerth:
Leading on from that, there’s real
concern in my constituency, the Isle of Anglesey, and among
paramedics on Anglesey, about the amount of time that they’re
spending away from the island. The consequence of that, of course,
is it takes longer when they’re away—which is most of
the time, it seems—for calls to be responded to on Anglesey
from ambulances elsewhere in the north-west of Wales. They spend a
lot of their time down on the north-west coast. What is being done
to try to address that? What lessons, particularly from Explorer
Cwm Taf, perhaps—? Given that much of the time, or a not
insignificant amount of time, is spent transferring trauma patients
from Ysbyty Gwynedd to Stoke, as the trauma centre, what thought
has been given to a dedicated fleet of emergency-transfer,
intra-hospital transfer vehicles in order to take off the
pressure?
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|
[99]
Ms Myhill: Just a general comment from me in terms of our
ability to respond in Anglesey—we’ve spent time
ourselves there, obviously, and we’re back up there in a
couple of weeks, working with crews—we recognise the drag,
almost, and the challenge that has. The geography is clearly a
challenge in terms of distances to travel. But what we’ve
been looking at through our new model is—because,
particularly, the red calls are low in number now, we can look at
every single one, as Richard has said, and we look down to the
lowest level we possibly can. It’s really encouraging to see,
particularly in Anglesey, that in four of the last five months we
have achieved above the target. That is significantly different
from where we were. There’s no doubt about that. If we
were talking a year ago, we’d be having a different
conversation, because it was shining out to us that we needed to do
something different. So, we have been trying to do that to make
sure we look after the local population. That’s what our
crews want to do; they want to look after their neighbours, they
don’t want to be stuck somewhere else. But we are doing some
work on cross-border flows and maybe, Richard, you could add a bit
more about that, particularly into England, which is much more
prevalent in north Wales, clearly.
|
|
10:15
|
|
[100] Mr Lee:
So, the emergency medical retrieval transfer
service—EMERTS—the air ambulance service, which
we’ve been augmenting with doctors, now undertake a number of
the critical transfers for neuro and for trauma into England from
north Wales, but there are still those that we have to do.
Unfortunately, there aren’t enough of them to support a
dedicated resource. They are a daily occurrence, but there
aren’t enough of them. When we’ve looked at the data,
it wouldn’t keep a dedicated service busy.
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|
[101] The
return-to-area arrangements are quite important to us. You know I
talked about equity earlier. It’s not right that, if you live
in one part of Wales, you get a different service to somewhere
else. It might be delivered slightly differently, because
localism’s important, but the standard should be the same.
So, we’ve got a process now that we were trialling between
the borders of ABMU and Hywel Dda, so in the Carmarthen-Swansea
corridor and in the south Powys and ABMU corridor, where, if a
Powys ambulance has ended up at Morriston because it’s taken
a heart attack patient there, which is the right thing to do,
unless there is a red call or a very high priority amber call
outstanding in Swansea when that vehicle becomes available,
it’ll be sent back to south Powys. That has improved—.
Members will have noted the improvement in performance in Hywel Dda
and the improvement in the performance in south Powys over recent
months. That’s down to those arrangements—and the hard
work of the staff, but down to those arrangements. So, we will roll
those arrangements out now across the winter, across Wales. That
will lead to some patients with green emergencies waiting slightly
longer for an ambulance, but what it will do is it will allow us to
provide equity of cover across what are predominantly rural
communities where there will always be a pull of resource out. So,
it allows us to maintain a service in a rural area.
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|
[102]
Rhun ap Iorwerth:
Before this winter?
|
|
[103]
Mr Lee: Going on now, so, yes. Yes. Before
Christmas.
|
|
[104]
Dai
Lloyd: Diolch yn fawr. Tri chwestiwn mewn un yn fanna, rwy’n
credu, Rhun, ond dyna fe. Reit. Diolch yn fawr iawn. Mae amser y
sesiwn yma wedi dirwyn i ben. A allaf ddiolch i’n tystion am
eich tystiolaeth fendigedig y bore yma, mae’n rhaid imi
ddweud—tystiolaeth arbennig o dda? Diolch yn fawr i chi am
ateb y cwestiynau mor fanwl a mor drylwyr. Felly, i weindio i fyny,
diolch swyddogol, felly, i wasanaethau ambiwlans Cymru, i Tracy
Myhill, prif weithredwr ac i Richard Lee, cyfarwyddwr
gweithrediadau. A allaf hefyd eich hysbysu bydd trawsgrifiad
o’r cyfarfod yma’n cael ei anfon atoch chi i chi gael
ei wirio os bydd angen i wneud yn siŵr ei fod yn ffeithiol
gywir. Gyda hynny o eiriau, a allaf eto ddiolch ichi am eich
presenoldeb a’ch tystiolaeth? Gallaf ddatgan bydd egwyl fer rŵan
i Aelodau gael paned byr o goffi cyn dod nôl yma o fewn saith
munud. Diolch yn fawr i chi.
|
Dai
Lloyd: Thank you very much.
There were three questions in one, I think, there, Rhun. Thank you
very much. This session is now drawing to a close. May I thank our
witnesses for your wonderful evidence this morning—excellent
evidence? Thank you very much for responding to our questions in
such great detail and so thoroughly. So, just to wind up, I’d
like to officially thank the Welsh ambulance service, Tracy Myhill,
the chief executive, and Richard Lee, the director of operations.
May I also inform you that a transcript of this session will be
sent to you so you can check it for accuracy? With those few words,
may I thank you once again for your attendance and your evidence? I
can now state that there will be a brief break for Members to have
a coffee before returning in seven minutes’ time. Thank
you.
|
|
[105]
Ms Myhill: Diolch.
|
Ms
Myhill: Thank you.
|
|
Gohiriwyd y cyfarfod rhwng
10:18 a 10:26.
The meeting adjourned between 10:18 and 10:26.
|
|
Ymchwiliad i Barodrwydd ar gyfer y Gaeaf
2016-17—Sesiwn Dystiolaeth gyda Choleg Brenhinol yr
Ymarferwyr Cyffredinol (RCGP) a'r Gymdeithas Fferyllol Frenhinol
(RPS)
Inquiry into Winter Preparedness 2016-17—Evidence Session
with the Royal College of General Practitioners (RCGP) and the
Royal Pharmaceutical Society (RPS)
|
|
[106]
Dai Lloyd: Diolch yn fawr i chi i gyd a chroeso i’r
sesiwn nesaf o’r Pwyllgor Iechyd, Gofal Cymdeithasol a
Chwaraeon. Beth sydd gyda ni gerbron ydy eitem 3 ar yr agenda
nawr—ymchwiliad i barodrwydd ar gyfer y gaeaf. Rŷm ni
wedi bod yn cymryd tystiolaeth eisoes y bore yma gan y gwasanaeth
ambiwlans, nawr mae’r sesiwn dystiolaeth yma gyda choleg
brenhinol y meddygon teulu a hefyd gyda’r Gymdeithas
Fferyllol Frenhinol.
|
Dai Lloyd: Thank you all very much and
welcome to this next session of the Health, Social Care and Sport
Committee. Next is item 3 on our agenda, which is our inquiry into
winter preparedness. We've already taken evidence this morning from
the Welsh ambulance trust, and this session will concentrate on the
Royal College of General Practitioners and the Royal Pharmaceutical
Society.
|
|
[107]
Felly, mae pedair yma. A allaf
groesawu, felly, Dr Jane Fenton-May a Dr Isolde Shore-Nye o goleg
brenhinol y meddygon teulu a hefyd Suzanne Scott-Thomas, cadeirydd
bwrdd fferylliaeth RPS Cymru, a hefyd Mair Davies, cyfarwyddwr RPS
ar gyfer Cymru? Felly, croeso i’r pedair ohonoch.
|
So, we have four witnesses. May I therefore
welcome Dr Jane Fenton-May and Dr Isolde Shore-Nye from the Royal
College of General Practitioners and also Suzanne Scott-Thomas,
chair of the Royal Pharmaceutical Society Wales, and Mair Davies,
RPS director for Wales? So, a very warm welcome to all four of
you.
|
|
[108]
Fel y byddwch chi’n ymwybodol,
ymchwiliad i barodrwydd ar gyfer y gaeaf ydy hwn. Rŷm wedi
gweld ac wedi darllen eich adroddiadau bendigedig chi—diolch
yn fawr iawn ichi ymlaen llaw. Mae yna gwestiynau y mae Aelodau
eisiau eu holi, a gyda cymaint â hynny o ragymadrodd, fe awn
yn syth i mewn i’r cwestiynau, os yw hynny wrth eich
bodd?
|
As you are aware, this is an inquiry into
winter preparedness. We’ve read your wonderful papers, so
thank you in advance for that evidence. There are some questions
that Members will want to ask and, with those few words of
preamble, we will move immediately to questions, if that suits
you.
|
|
[109]
A allaf i ddechrau, felly, gan ofyn a
ydy gwasanaethau gofal cynradd yn barod am y gaeaf? Fe allai hynny
fod o ochr y meddygon teulu ac o’r ochr fferyllol. Nid
wy’n gwybod pwy sydd eisiau dechrau ateb.
|
May I start, therefore, by asking whether
primary care services are prepared for the winter? We could hear
from the GPs and the pharmacists. I don't know who wants to
actually kick off.
|
|
[110] Ms
Scott-Thomas: I think pharmacists are in different sectors of
the health professions. We have recently, since 2015, had
pharmacists working in a new sector, which is across GP clusters,
working in GP practices. I think that introduction—the
emerging evidence is that they have contributed very positively
into that environment and certainly have improved patient care in
terms of managing medicines. But more importantly, perhaps, the
evidence is starting to emerge of freeing up GP time with increased
appointment times and enabling GPs to see the more complex
patients, which I think will put the GPs that have them in a better
place for the winter pressures. Now, not all clusters have cluster
pharmacists, as we call them, and that’s their choice, some
of them. But I’m also aware that we have about 60 pharmacist
posts, full-time equivalent posts, in Wales at the moment, but I
think that, in terms of sustainability and increasing that, we
perhaps need to look at more workforce planning, because it’s
starting to emerge now that there are difficulties in recruiting
those posts now. I think that we need to look at that for the
future sustainability of that model.
|
|
[111]
Dai Lloyd: Grêt, diolch yn fawr am hynny. Nid
wy’n gwybod a yw’r meddygon teulu eisiau ychwanegu at
hynny. Jane.
|
Dai Lloyd: Thank you very much for
that. I don’t know if the GPs have anything to add to that.
Jane.
|
|
[112] Dr
Fenton-May: The general practice, as I’m sure the
Assembly has heard in several of the Plenaries, is currently under
severe pressures already. There is a big recruitment—mostly
in the more rural areas in the north and west of Wales, but also
even in Cardiff there’s difficulty getting doctors.
|
|
10:30
|
|
[113] So, adding the
winter pressures onto the problems is very difficult, because we
have the increase in flu and respiratory-type acute diseases, which
makes the care of chronic disease patients much more difficult,
added to which there’s more falls and injuries if the
weather’s icy or snowy. Sometimes, these patients then
can’t get the care they need or carers getting to them. Very
often, we have patients that are pushed in and out of hospital and
they are not ready for discharge, they haven’t got the care
and the support and they haven’t been stabilised, and that
increases the workload for general practice. We’re already,
in the winter, managing these acute respiratory things by
nebulising patients in the surgery and also getting patients seen
in out-of-hours by GPs.
|
|
[114] We need to look
at this in a more robust way. Some of the health plans last year
said, ‘Well, the GPs need to do more work to stop patients
going into hospital’, but if the GPs are already on their
knees, then it is difficult for them to do more work. Alongside
looking at some of the problems, we need to make sure that
we’re getting some robust evidence coming out of how we
manage this, so we need to support our academic, general practice
and primary care colleagues to do more work to look at the issues
around some of this problem.
|
|
[115] We’ve
spoken about getting more pharmacists and other care people and we
are looking at how we change the way GPs work to free up the actual
GP need for the service, but, in fact, there aren’t some of
these additional people available. As their roles become more
complex—when I first started you didn’t need to train
to be a GP—these people will need to train to become primary
care general practice workers. So, the pharmacists and the
paramedics are very well trained but they are not—and the
nurses—not necessarily importable from other services into
primary care and general practice.
|
|
[116] Dai
Lloyd: Ocê, diolch am hynny.
Mi fydd yna gyfle i fynd i mewn i hyd yn oed fwy o fanylder nawr
wrth i ni fynd ymlaen drwy’r sesiwn yma. Julie Morgan sydd
efo’r cwestiwn nesa, rhif 11. Julie, os wyt ti eisiau mynd
amdani, ac wedyn Caroline.
|
Dai Lloyd: Thank you for that. There
will be an opportunity to go into even greater detail now as we
proceed through the session. Julie Morgan has the next question.
Julie, if you want to take question 11, and then Caroline.
|
|
[117] Julie
Morgan: You did say that there needs to be a more robust
approach. How much planning has there been with the local health
boards and with the ambulance service in developing plans for this
winter now that’s coming ahead—have you had any
discussions with clear plans?
|
|
[118] Dr
Shore-Nye: What I would like to say is: I’m a GP in
Aneurin Bevan health board and, as such, I’m not aware of any
discussions with GPs on the ground about 2016-17 winter
preparedness.
|
|
[119] Julie
Morgan: Is anyone aware of any discussions on the ground?
|
|
[120] Ms
Scott-Thomas: I think planning is going on and people are
looking at how we can do things differently. My day job is in Cwm
Taf health board, and so I’m aware that there is work going
on to look at how you can support patients to avoid admissions and
cope with them better in the community through increased social
care and district nursing. An element of that is medicine support
as well—so, looking at how patients manage their medicines
better in the home, because about 10 per cent of admissions are
related to medication use or misuse. I think that is a plan that
will be emerging, probably, from January on. So, people are looking
at this, but unfortunately—it is all down as well—one
of the barriers is recruitment, and the plans may be there on the
table but putting them into reality is about getting the right
people in the right place at the right time. So, it does come back
to this issue around the bureaucracy of recruitment but also,
‘Are the people there in Wales?’ I know it has been
said in other parts of the country that there is perhaps an
oversupply of pharmacists, but it’s not in Wales. I think it
may be in pockets, in perhaps England and the higher-populated
areas, but it certainly isn’t in Wales. We do have an issue
in drawing all healthcare professionals into
particularly—Isolde and I were just talking, Isolde works in
the top of the Rhymney and I actually live in Merthyr—we do
have an issue in drawing them up into those particularly
hard-to-recruit areas. So, the plans may be there, but putting them
into fruition can be a problem.
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[121] Julie
Morgan: In terms of the shortage of pharmacists, have you got
any figures for that? How many, in terms of Wales?
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[122] Ms
Scott-Thomas: No, and that is one of the issues in terms of
workforce planning: we don’t know. That is something that we
need to commission: better workforce planning and knowing what our
baseline is to know how to go forward. So, that is something that
we do need to address quite urgently.
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[123] Julie
Morgan: So, it’s based on local knowledge.
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[124] Ms
Scott-Thomas: Yes.
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[125] Julie
Morgan: So, you think the plans are on the table, but
they’re difficult to actually carry out.
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[126] Ms
Scott-Thomas: I’m not saying it’s not going to
happen—it will happen—but there are some barriers.
There is a will to do more, but it is about getting the right
people, and I think that’s across all disciplines, to be
fair.
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[127] Julie
Morgan: Right. Is there a forum where these issues are thrashed
out?
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[128] Ms
Scott-Thomas: A national forum, or what?
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[129] Julie
Morgan: The local health board areas, for example.
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[130] Dr
Shore-Nye: What I would say within local health boards, and
certainly within the cluster system that has developed, is that we
do discuss recruitment workload issues as part of the general
health board priorities. I think that was more what you were
specifically talking about than specifically about winter
preparedness, but it is an issue within health boards and we do
liaise with pharmacists within that.
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[131] Ms
Davies: I think there’s also an issue—we’ve
got new models of care emerging, but the professions are still very
much in their silos. We talk about multidisciplinary work, but,
actually, are we putting it into practice? I don’t think we
really have the evidence to show that it’s rolling out,
certainly not across the whole of Wales. New models of
care—we’ve got 716 community pharmacies, for instance.
Are we utilising the skills of those pharmacists the way we should
be utilising them? There is a scheme that’s been
evaluated—the common ailment scheme around Choose
Pharmacy—but it hasn’t been commissioned by all health
boards across Wales. Also, if we want public behaviour to change,
there needs to be a campaign to change their behaviour. At the
moment, the only person they still want to see is the GP. The
evidence is there that, yes, if they go, for a minor ailment, to
the pharmacies—this has happened without any promotion or
campaign—it’s saving quite a lot of GP time. So, there
needs to be a much more national-systems approach across all
professions.
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[132] Julie
Morgan: Is there any evidence of how many people—what
percentage—are now actually going to pharmacists rather than
GPs for minor ailments? Do we have any evidence about that?
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[133] Ms
Scott-Thomas: The evidence is there for the two pilot schemes
that were run in very small localities in Cwm Taf and in north
Wales. So, the evidence has been published for that. I
haven’t got the figures with me. For a very small pilot in
very small localities where there wasn’t a national campaign,
I think it did really well. But, the key to it was the
collaborative working with the GP and where there was collaborative
planning so that the GPs actively triaged patients who rang up, as
well, to the pharmacy—that’s when it worked really
well. There is a plan to roll out the IT platform across Wales that
supports that service, but it’s then got to be commissioned
by each health board. I think we need a bit more of a national
campaign—that that is going to be commissioned by each health
board, and that it’s underpinned by a national campaign to
change people’s behaviours and change the patient pathway,
perhaps, away from the GPs so that the community pharmacist is more
of a first port of call.
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[134] Julie
Morgan: So, we have individual examples of good practice.
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[135] Ms
Scott-Thomas: Yes, we have the evaluation.
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[136] Julie
Morgan: We know what should be done—
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[137] Ms
Scott-Thomas: I’m happy to send that. I haven’t got
the details with me.
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[138] Julie
Morgan: —but need a national move. Thank you.
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[139]
Dai Lloyd: Ar y pwynt yma, Angela nesaf.
|
Dai Lloyd: On that
point—Angela.
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|
[140] Angela
Burns: Thank you. I just wanted to pick up on a point that you
made, Dr Shore-Nye, because we are talking about winter pressures.
Whilst I totally appreciate the long-term planning you’re
talking about, you actually said, if I heard you correctly, in
answer to Julie Morgan, that you hadn’t been consulted at all
about the current winter pressures, and I believe your colleague
was also saying that. Could you just explain that? Because our
inquiry is about how prepared the NHS is for the current winter
pressures that will be coming up in the next four or five months. I
have to admit to a slight frisson of concern that you’ve not
been involved in anything.
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[141] Dr
Fenton-May: As the representative of the Royal College of GPs,
I think this inquiry has been the first time we have been made
aware of somebody looking at winter pressures. As a working
GP—I apologise, I am retired now, two years, but I used to
work in Butetown—the first thing you’d know that there
was some pressure in the hospital was some red alert coming through
saying not to admit patients, which is a little bit difficult when
you’re sitting with somebody who’s got severe
pneumonia, hasn’t got a carer and needs intravenous
medication, and you haven’t got any district nurses to help
support the patient. You have to kind of sit there and say,
‘Well, I’m sorry, I can’t send you to hospital in
this area; maybe we could send you to Newport or somewhere if
there’s a bed that we can find.’ So, it is very
difficult. I don’t think the GPs—. The clusters
potentially could be involved with that; I don’t think that
that is the prime focus of the clusters. And any money that’s
coming through the cluster system seems to be really very slow in
actually making any difference to most of the practices. The way
that the clusters work is very varied across Wales, so that is
putting increased inequalities into the system. Those who shout the
loudest get the most, and those that just opt out of being involved
in the clusters are not getting any support. So, that actually has
an impact on patients.
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[142] Dr
Shore-Nye: Yes, I’d agree. Obviously, representing the
RCGP, I know that this is the first time we’ve been
specifically asked about winter pressures. I’ve worked in
Aneurin Bevan health board for the last three and a half years, and
Dr Fenton-May is very accurate in that the response we seem to get
is that the hospital is under the pressure—but no survey as
to how much pressure the practices within the areas may be under.
Obviously, I can’t comment on whether there are more detailed
discussions going on within health boards at a higher managerial
level, but certainly, as an independent contractor, we’re not
specifically surveyed on how we might prepare for increasing winter
pressures.
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[143] Angela
Burns: That gives me a degree of concern, Chair, because they
are the front door.
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[144] Dai
Lloyd: Duly noted.
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[145] Caroline nesaf,
ac wedyn Rhun, ac wedyn Lynne.
|
Caroline next, then Rhun, and then Lynne.
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[146] Caroline
Jones: Diolch, Chair. I was going to ask: have we analysed or
taken into account previous data on where the pressure points are
likely to be, including the current workforce, the skills and
resources, and what action is needed, and indeed being taken, to
address any issues that we have? I don’t suppose you can
answer that if you—.
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[147] Dr
Fenton-May: I don’t think we’ve got the figures
that relate to the winter pressures. We have got figures to show
that it is very difficult to recruit GPs. The actual numbers of
GPs, as was discussed in Plenary, may have increased, but the
whole-time equivalent of GPs, which is much more important, has not
increased. We do have a lot of GPs now that work part-time for
whatever reasons; some of them because they’re doing other
things in the health board, or working propping up something like
the cardiac service or the dermatology services in the hospital, or
doing managerial-type jobs. But you could potentially say in the
winter you might get those doctors to increase the amount of work
they’re doing, but there are issues around indemnity and the
amount of time that you can work as a GP. That is one of the issues
that the college of GPs have brought to the attention of the
Assembly—that it costs a huge amount.
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|
[148] I might have
decided when I retired, for an example, that I would go on the
locum round as a GP, but I’d have to pay my indemnity fees
upfront, and they’re a few thousand pounds. Do I really want
to pay a few thousand pounds out in the hope that, in the winter, I
might get asked to go and do a locum because somebody was under
pressure, and I have to do all my appraisal and my CPD et cetera,
which I’d have to pay for? So, we are losing GPs at the top
end, who are nearing retirement, or getting to retirement, or
women, or men as well, who have got other commitments, who just
think ‘Well, it’s just too much of an effort to do
that.’ We need to do serious things—. I’m
straying into workforce issues now, I realise, but we need to do
serious things to try and encourage people to work. It’s the
same for other health professionals—the nurses, the
pharmacists, et cetera; they have the same issues.
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10:45
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[149] Ms
Davies: If I may, I think you’ve identified the crux of
the matter. We may well have some solutions, but if we’re not
involved in the planning, we can’t offer those solutions.
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|
[150] Caroline
Jones: I was going to say that communication, here, is
obviously the main key—you know, the communication between
the health boards, the primary care doctors and so on. There
doesn’t seem to have been the communication to put together
where there are no plans. You said there are no plans for winter
preparedness—winter pressure—and that is a cause of
concern. I’m wondering if there’s been a lack of
communication.
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|
[151] Ms
Davies: The one thing I can say, having been a community
pharmacist, and having had my own pharmacies in the past, is that
as individual pharmacists, yes, we do prepare for winter pressure,
obviously, but we’re not part of the plan, which could really
make a difference, not only to our practice but to the way patients
behave and to the workload on, particularly, GPs.
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|
[152] Caroline
Jones: How can we improve things for the future?
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|
[153] Dr
Shore-Nye: Could I just add that, actually, as GP practices,
it’s exactly the same? In my practice we are preparing for
winter pressures. So, it’s not that there’s no
preparation going on.
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|
[154] Caroline
Jones: No, no, are you planning, though, in
isolation—each person having their own little
piece—instead of there being an integrated approach, really?
Is this what we could improve on? That’s what I’m
asking.
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|
[155] Ms
Davies: One of the things that I’d like is that
facilitation, be it by Government, or particularly by the health
boards, to bring practitioners together.
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|
[156] Caroline
Jones: To bring everyone together.
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|
[157] Ms
Davies: It’s how you can solve this problem between
you.
|
|
[158] Caroline
Jones: Yes, exactly.
|
|
[159] Ms
Davies: We need to be working together, not pulling against
each other, and everybody’s in isolation at the moment.
|
|
[160] Caroline
Jones: That’s why I’m looking at the communication
issue here and everyone needs to be in—there needs to be an
integrated approach. Thank you.
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[161] Dai
Lloyd: Okay, Jane on this point.
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|
[162] Jane
Bryant: I just wanted to come back to Dr Fenton-May, if I can.
You talked about the workforce—I know that we’re
straying a little bit into workforce planning here. How are we
using GPs before they retire? Are there any programmes in terms of,
perhaps, looking at reduced hours before they retire? How are we
making sure that we’re using all of their experiences before
they do actually retire and passing those on to new GPs? Is that
effective enough at the moment?
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[163] Dr
Fenton-May: I don’t think there’s any effective
plan. Basically, the majority of GP practices are small businesses,
and it’s up to the partners in the practice what arrangements
they make with the partners who are looking at retirement. It is a
complex issue, and, as I said, there are various things, like
indemnity, pay and how you employ people, involved in that. Some
doctors will have retired from practice and will go on to do more
administrative-type jobs, but that isn’t what everybody wants
to do.
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|
[164] Jane
Bryant: It just feels that we lose a lot of experience. Once
people retire, they retire and it’s unfortunately a resource
that we’ve lost. Just quickly on practice nurses, I was just
wondering how we’re using those in GP surgeries to help and
support, particularly when there are winter pressures. Are we
effectively using those?
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[165] Dr
Fenton-May: I think that when you’ve got good practice
nurses in the practice, they are being used very effectively, but
the problem is that many of the current well-trained practice
nurses have learned on the job over the last 20-odd years. Before
that, we didn’t really have practice nurses. The new nurses
that come from secondary care are not necessarily fit to work and
do the very high-skilled jobs that the practice nurses
do—they need training. We haven’t got adequate
training. If you do get somebody like that, you then have to lose
them from the day job at the coalface to go off to do training, so
you haven’t got that session filled to do the work, because
they’re doing their continuous professional development, so
you’re down a nurse for the day. So, we need better training
programmes for practice nurses as well, and we need to be enabled
to attract them into practice. At the moment, they’re not
being very well attracted into practice, I don’t think,
because of some of the issues around how they work.
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[166] Jane
Bryant: What do you think about, when nurses do their training,
perhaps having a session or time working in a GP practice? Do you
think that would be useful?
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[167] Dr
Fenton-May: I think all health professionals should have time
spent in general practice during their training. There are issues
about how you fund that, because if you’re training somebody
in your GP practice, whoever it is, it takes you away from dealing
with the patients, so you need more people working in the general
practice, and so you need to fund that somehow to enable those
people to do more work in the practice to do the training.
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|
[168] Dai
Lloyd: Okay. Suzanne, always cognisant of the fact we are
trying to talk about winter pressures, as always.
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[169] Ms
Scott-Thomas: Yes, I think workforce is fundamental, and
actually recognising that primary care is a huge part of where
healthcare is given, and training has historically been in
secondary care. As I said, cluster pharmacists are a new model of
working, and it’s been recognised that we are now starting to
move our pre-registration into an integrated pre-registration for
pharmacists. We’re starting in north Wales this year as a
pilot, where pharmacists will train for a significant time in
secondary care, in community pharmacy and in primary care. So, we
are trying to provide that sort of portfolio experience so that
when they are hopefully to go into primary care, at least they can
hit the ground running to some extent. But that will take a little
while to filter into the system.
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[170] Dai
Lloyd: Mair.
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|
[171] Ms
Davies: We were talking about winter pressures, and one of the
things that we’ve identified—. The BMA, to quote them,
say in their submission
|
|
[172] ‘the sheer
scale of the annual influenza vaccination campaign, leads to
increased pressures on the health service during the winter
season.’
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|
[173] Now, we’ve
currently got GPs giving flu vaccinations, we’ve got some
community pharmacists, but actually there’s tension between
those two professions on who’s going to deliver that. I would
think that one of the urgent things that needs doing is some sort
of facilitation so that those two contractors are pulling together
to make sure that the targets are reached, and there is nothing
happening there. That is definitely one of the solutions. If we
could get those vaccination targets up by using everybody
who’s available to inject the population, and have access to
all the population—you know, that is a solution that
nobody’s addressing at the moment.
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|
[174] Dai
Lloyd: There are some complicated answers to that one, but
I’ll come back to that. Rhun and then Lynne.
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|
[175]
Rhun ap
Iorwerth:
Rydw i’n meddwl y byddwn ni
eisiau dychweled at y pwynt yna yn benodol ynglŷn â
brechiad y ffliw. Rydw i’n eich addo chi ein bod ni fel
pwyllgor yn cydymdeimlo yn llwyr â’r pynciau yr ydych
chi yn eu codi o ran y pwysau sydd ar eich gwasanaethau chi
trwy’r flwyddyn. Ond i ddod yn ôl at y gaeaf a’r
pwysau yn y gaeaf, rydw i’n meddwl ein bod ni wedi symud
ymlaen o ran yr hyn yr ydym ni’n chwilio amdano fo bore yma
yn eich ymateb chi i gwestiynau Caroline Jones—eich bod chi
wedi cyfaddef, fel dau grŵp, oes, mae yna bwysau yn y gaeaf.
Nid oeddem ni’n siŵr yn gynharach, o bosib, i ba raddau
yr oeddech chi’n dweud bod y pwysau yna yn ychwanegol, ond yn
yr un ffordd yr oedd y gwasanaeth ambiwlans yn gallu dweud wrthym
ni yn gynharach heddiw, ‘Mae yna bwysau penodol yn y maes yma
oherwydd afiechydon respiratory ac yn y blaen’, a
allwch chi roi eglurhad i ni o beth yn union sydd yn
ychwanegu’r pwysau mwyaf arnoch chi dros fisoedd y gaeaf yn
benodol, a hefyd beth ydych chi’n ei wneud fel ymateb i
hynny? Hynny ydy, a ydych chi’n gallu, mewn rhyw ffordd,
ychwanegu capacity? Rydw i’n amau nad ydych chi. A
ydych chi’n cyflwyno ffyrdd newydd o weithio? A ydych chi yn
clicio i mewn i ryw mode gaeaf, mewn rhyw ffordd, a beth
ydy’r mode hwnnw?
|
Rhun ap
Iorwerth: I think we’ll want to return to
that point specifically regarding the flu vaccine. I promise you
that as a committee we sympathise completely with the issues that
you’re raising in terms of the pressures that are on those
services throughout the year. But to come back to the winter and
the winter pressures, I think we’ve moved on in terms of what
we we’re looking for this morning in your response to
Caroline Jones’s questions, in that you have admitted, as two
groups, that, yes, there is pressure in the winter. We
weren’t sure earlier, perhaps, to what extent you were saying
that that pressure was additional pressure, but in the same way as
the ambulance service could tell us earlier today, ‘There is
specific pressure in this field because of respiratory diseases and
so forth’, can you provide us with an explanation of what
exactly is adding to that pressure on you during the winter
specifically, and also what you are doing as a response to that?
That is, can you in any way add capacity? I suspect you
can’t. Are you introducing new ways of working? Are you
clicking into some winter mode, somehow, and what is that mode?
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[176] Dr
Shore-Nye: Can I answer specifically about whether there are
increasing pressures? I can basically give you an example from this
week. As you know, I’m a practising GP, and certainly from
the end of last week to this week, we have noticed at least a
doubling if not a tripling of children with fever, and respiratory
illness, for which I think it’s perfectly understandable for
parents to maybe access their GP service rather than deal with it
at home. That’s been exceedingly noticeable over this last
week, and that is a very large proportion of an increase in winter
pressures. Other examples might be of someone with a chronic
respiratory illness. You mentioned respiratory pressure on the
ambulance service—there are those who are managing very well
at home with occasional visits, or are managed by the practice
nurse.
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|
[177] We mentioned
flu, and I know that that may be a hot topic, but not just
influenza, but other respiratory illnesses will mean that the
demand of these people with chronic illness increases. That will
increase their attendance at general practice and will increase the
need for home visiting, which we know takes more of a period out of
our time than people coming to see either doctors or other
healthcare professionals and actually increases demand on hospital
services, discharge planning, and then looks forward towards
increasing pressure on social care and then managing those people
at home. So, they are definite increases that we see throughout the
winter.
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|
[178]
Rhun ap Iorwerth:
And the mode that you click into in order
to deal with that, seeing as you know it’s coming?
|
|
[179]
Dr Shore-Nye: It’s difficult to explain from a broad point of
view because I only know from my own personal practice. The way we
manage it would be to have to change the way in which we work, in
that these chronic-disease clinics may have less input from medical
professionals to make up for the on-the-day or urgent demand that
is coming from winter pressures. I suspect that’s also what
happens in hospital and social care and pharmacies and all other
professions.
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|
[180]
Rhun ap Iorwerth:
And what about public-awareness campaigns
to try to keep people safely away from your door by perhaps sending
them over there?
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[181]
Dr Fenton-May: I’m not really convinced that most of the
public-awareness campaigns keep people away. They usually get some
awful thing on the thing that there’s more of A or B in the
community, so they come and knock on your door in more
numbers—
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|
[182]
Rhun ap Iorwerth:
But it could be somebody else’s
door.
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|
[183]
Dr Fenton-May: Well, they usually come to the GP. There was a
campaign that, you know, if you’ve got a cough for three
weeks, you need to see your doctor, and you get lots of people
coming with a very mild cough, which was not necessarily
significant, saying, ‘Well, I had to come because I’ve
had it for three weeks, doctor’. What you don’t get are
the people who’ve probably got lung cancer coming in because
they’ve had a cough forever and they don’t actually
turn up because it’s changed in its nature. It’s a very
complicated thing, but we do need some sort of public health thing.
I don’t think there’s very much now very evident about
things like flu jabs and things like that. I think that pharmacists
do a lot of advertising of the flu jab. Every time I listen to the
radio, it says to go to some pharmacy and pay for your flu
jab.
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|
[184]
Rhun ap Iorwerth:
They’re not allowed to say that,
are they?
|
|
[185]
David
Lloyd: Roedd Mair eisiau dod i mewn.
|
David
Lloyd: Mair wanted to come
in.
|
|
[186]
Ms Davies: I think we’re using the terminology
‘raising awareness’, but that’s not
enough—we need to change behaviour. The principles of
changing behaviour are very different to just raising awareness. I
think that if Government are going to do public awareness, they
need to say, ‘What is the outcome I want?’ We need
people to change their behaviour. We’re talking about the
increased pressures in the winter. I don’t actually know if
dispensing figures are up because in the summer, we’ve got
similar pressures with hay fever et cetera. There’s always a
pressure, quite frankly, but they do go up in the
winter.
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|
[187]
The big thing at the moment now is that
we’re also trying to deal with anti-microbial resistance. So,
with a lot of the people we tell to come to us don’t actually
need an antibiotic and it takes much longer to go through that
conversation—and I’m sure it’s the same for
GPs—than writing a script. So, there are other pressures as
well as winter pressures, because when everybody thinks, ‘Oh,
gosh, I’ve got a cough, I need an antibiotic’, that
consultation, to address anti-microbial resistance, takes even
longer than the writing of the script.
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|
[188]
Dai Lloyd: Lynne, the floor is yours.
|
|
[189]
Lynne Neagle: Shall I do my questions as well?
|
|
[190]
Dai Lloyd: Go for everything you want.
|
|
[191]
Lynne Neagle: Okay, marvellous. I just wanted to ask about the
minor-ailments scheme first because I do think that’s got a
lot of potential to ease pressure on GPs, but the roll-out of it
does seem to have hit a block really—nothing seems to have
happened for a long time on that. Why do you think that
is?
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|
[192]
Ms Scott-Thomas:
I think the roll-out is happening. The
service is dependent on an IT system called the Choose Pharmacy
system. I’m aware that Welsh Government have provided funding
to roll that system out and NHS Wales Informatics Service are in
the throes of doing that at the moment, so it is being rolled out.
When we’re rolling IT systems out, as you know, it can take a
little time, but areas have been prioritised and health boards have
their plans in place to implement the IT system.
|
|
11:00
|
|
[193]
So, the IT system will be rolled out, I
think, to 400 community pharmacies of the 715 in this NWIS
plan, and I think their timescales are over the next three
years, but don’t quote me on that; I may be slightly wrong.
So, it is happening, but I’m not sure whether that pace could
be increased—that’s something that you would have to
ask them.
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|
[194] Lynne
Neagle: So, we won’t see any new minor ailment schemes in
time for this winter, then.
|
|
[195] Ms
Scott-Thomas: You may see one or two in certain localities. I
know, within my own health board, we are looking to put it into the
Rhondda by the winter. So, that’s our priority area, because
of the issues there. So, it is happening. Personally, I would like
to see a quicker pace and, certainly, we would like to see that
this is regarded as phase 1 of the 400 of 715 and phase 2 is to
complete the total number of pharmacies in Wales.
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[196] Dai
Lloyd: Jane.
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[197] Dr
Fenton-May: Can I just remind you that—what you said
before—it is important that it is done with the collaboration
of the local GPs with the pharmacists? So, it’s again talking
to each other and collaboration across services, because that is
how it has worked best in the areas in the pilot. Because it
hasn’t worked very well in some of the areas, to be fair.
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|
[198] Dai
Lloyd: Okay. Lynne.
|
|
[199] Lynne
Neagle: I was going to go on to the flu, if that’s okay.
The immunisation rates dropped slightly last year under the flu
programme, despite more people being eligible for it. Why do you
think that is?
|
|
[200] Dr
Fenton-May: My understanding was that the percentage of people
fell because there were more elderly people and more people with
chronic diseases who should’ve had the flu jab. So, we were
vaccinating the same numbers, but there were more eligible people,
so the actual percentages didn’t look so good. So we need to
just keep flagging this up and the more people who can advertise
that flu vaccinations are beneficial is helpful.
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[201] We also need to
make sure that we get private organisations like the care homes to
be vaccinating their people, because we have seen problems in a
number of care homes where the carers haven’t been able to go
in because there’s flu in the home, and they have been a
little bit reluctant to take that up, because they’re private
organisations and there’s a cost involved. So, we are able to
vaccinate carers who are family members and we can vaccinate people
who are volunteers for charities as well. That has been seeing an
increase over the years. I think it was only last year or the year
before, but the numbers have increased for those groups. But there
are lots of groups that need vaccination. Hospitals are a big
issue—that the staff are not being vaccinated in the
hospital.
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[202] Talking about
collaboration, there have been some trials in things like
respiratory clinics to increase vaccination actually in the
respiratory clinic, so, instead of people having to go to the
pharmacy or to the GP, if they’re recurrently going to see
the respiratory nurses, the respiratory nurses might give them the
vaccinations, and that’s worked quite well up in some areas.
But, basically, some of these groups—. Sometimes, we’re
trying to catch the same patients and the most effective way to
vaccinate patients is, when they walk in the door, you say,
‘While you’re here, I will give you a
vaccination’. That is the much most effective way to do it,
because there will be some people who dissent, but you’ve got
them there and they don’t have to make a special
appointment.
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[203] Ms
Scott-Thomas: I think the collaborative approach, and, wherever
patients are, you look at every opportunity to give them a flu
vaccination—I think that’s a principle that we need to
use more of. So, whoever has the opportunity to give them a flu
vaccination, you use that opportunity and you use it well.
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[204] Lynne
Neagle: You’ve expressed some frustration in your paper
that not all pharmacists are able to give the flu jab. What do you
think the barriers to that are and how should we address those?
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[205] Ms
Scott-Thomas: I think it comes back, perhaps, to some
sensitivities around GPs, and it’s seen, perhaps, as not
working in collaboration with their local community
pharmacists—not all; I think it is getting less. We need to
look at a more collaborative way of working across primary care
clusters. We have these clusters now and I think we need to
maximise how clusters work. I’m sure Isolde can tell us more
about that. Some are at a different maturity to others, but,
certainly, it’s recognising that they are primary care
clusters and using all the available healthcare within that primary
care, not just everything coming down to sit with the GP. I think
there is a better way of doing things.
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[206] Lynne
Neagle: A lot of people would prefer to go to the pharmacist
because it’s more convenient with work. I always get mine
done at the pharmacist.
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[207] Ms
Scott-Thomas: I think it is about having more access and
appreciating what patients want.
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[208] Ms
Davies: It’s outside the realms of the Royal College to
speak about our contracts, but one of the big problems that we have
is community pharmacists have a contract, GP practices have a
contract, and they’re pulling against each other and not
pulled together.
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[209] Lynne Neagle: Okay. In the light of that,
is there anything more, then, that you think the Welsh Government
should be doing this year to increase the uptake of the flu
vaccine?
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[210] Ms
Scott-Thomas: I think there are a number of patients who, for
whatever reason—and perhaps you can say it’s myths
around the vaccination—will never have that vaccination.
Whether there is something to be explored about dispelling those
myths, because I think there is a significant rump of patients, if
I can use those words—of the public; they’re not just
patients—who have this myth around the vaccination, that it
actually causes flu. I think there is some work to be done in
trying to understand that behaviour and trying to change that
behaviour, and then having that more of an open access to the
opportunity to have the vaccination wherever it suits the
patient.
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[211] Dr
Shore-Nye: Yes. It is community awareness. However, I am aware,
living within a community, that there is a lot of advertising,
there is a lot of media, there is already—and has been last
year—a lot of promotion of the flu vaccine with risk groups,
within carers and within healthcare professionals. Certainly, it
has to be a collaborative approach, acknowledging the
difficulties—and, certainly, the RCGP don’t
particularly want to get into contractual discussions, but it is to
put forward a collaborative approach, and immunising people in a
place that is right for them has to be the way forward. For a lot
of people that may be a community pharmacy, but, for a very large
number, that is still their GP, and that is very often the first
place they will contact to ask either whether they’re
eligible for a flu vaccine or whether they can have their flu
vaccine. I think there is a role also to widen that out amongst
voluntary agencies and the third sector to promote flu vaccine
amongst people who, maybe, don’t engage with either community
pharmacy or general practitioners, to make people aware that they
are eligible for flu vaccines as well—people who may not see
the awareness and promotional campaigns that are evident.
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[212] Dai
Lloyd: Rhun.
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[213]
Rhun ap Iorwerth:
Just to hammer the point home further, it
may well be that people choose to go to see their GP initially to
ask about the flu vaccine, but, in the context of hearing pretty
often that general practices are under strain, the high-street
pharmacy with a stockpile of flu vaccines and plenty of capacity is
not allowed to put a sign up outside saying, ‘Come in here
for your flu vaccine’. Does that have to change?
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[214] Dr
Fenton-May: I thought that they do, because I’ve seen the
adverts outside in Tesco and Sainsbury’s. We’re not
allowed to advertise, but I have heard adverts on Classic FM
for—
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[215] Rhun ap Iorwerth: For the NHS vaccine, I mean.
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[216]
Dr Fenton-May: Yes, yes.
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[217] Rhun ap Iorwerth: They can go in and pay
for it, yes, absolutely, but they get it for free through
their—
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[218] Dr
Fenton-May: No, no, but they have signs saying, ‘Ask the
pharmacist if you’re eligible for an NHS
vaccination’.
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[219] Dr
Shore-Nye: Yes. I know Sainsbury’s—sorry, I
shouldn’t mention brands—advertise.
[Laughter.]
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[220] Dai
Lloyd: It might be worth just delineating the at-risk groups
who should be having a flu jab, and also dispelling a couple of
those myths that you’re on about, like patients who say,
‘I always catch flu after I’ve had the flu jab’.
So, let me give you the floor to do that.
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[221] Ms
Davies: I think the one thing about at-risk groups is, even if
their condition is stabilised, they will visit a pharmacy once a
month—or somebody will visit that pharmacy. So, there’s
that opportunity. I don’t mind where people get their
vaccination, quite frankly; I just want to sort out how we do this
together to make it work. But, even when they’re well, for
long-term conditions, particularly respiratory, they will be seen
once a month in a pharmacy. So, there is an opportunity there that
we need to embrace, and I don’t think we probably do to the
level we should. I do believe that it should be Government-led.
This should be the NHS in Wales pushing these patients, getting
their behaviour to change and making them realise why they need to
do this. It shouldn’t be seen as a commercial—that
pharmacies want to do this because they get money and that’s
over the GPs. We need to get away from that. We need to be actually
thinking about the care of patients—a very different
approach.
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[222] Dr
Fenton-May: Can I add there? I think one of the problems is
some people who have long-term chronic conditions don’t
realise they’re actually eligible. They say, ‘Oh,
I’m a diabetic, I’m fit, I’m taking my
medication’ and whatever it is, and they don’t think
that they fit into that group of people who have a chronic
condition. So, we need to actually spell it out to some of these
people that, actually, they are the people who are eligible. So,
that is a big problem.
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[223]
Dai Lloyd: Unrhyw gwestiynau eraill cyn i fi ddod
â’r sesiwn yma i ben? Na, pawb yn hapus. Felly, a gaf i
gyhoeddi bod y sesiwn yma ar ben? A allaf i ddiolch yn fawr iawn
i’r pedair ohonoch chi am eich tystiolaeth a hefyd am y
papurau ysgrifenedig y gwnaethoch chi eu cyflwyno ymlaen llaw?
Diolch yn fawr am rheini i gyd. A allaf i jest gyhoeddi y bydd yna
drawsgrifiad o’r cyfarfod yma’n cael ei anfon atoch chi
i gael ei wirio i wneud yn siŵr ei fod o’n ffeithiol
gywir? Wedyn, gyda hynny o ddiolch, a gaf i ddiolch yn fawr iawn
i’r pedair ohonoch chi? Cawn ni doriad bach am y tro a dod
nôl mewn 10 munud. Diolch yn fawr i’r
Aelodau.
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Dai Lloyd: Any other questions before I
bring the session to close? No, everybody’s content. May I
announce, therefore, that this session is now closed? May I thank
the four of you for your evidence and for the written papers that
you submitted beforehand? Thank you very much for all of that. Can
I just announce that there will be a transcript of this meeting
sent to you for checking, to make sure that it’s factually
correct? Therefore, with that, may I thank you very much?
We’ll have a short break now and return in 10 minutes. Thank
you to the Members.
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Gohiriwyd y cyfarfod rhwng 11:11 a
11:22.
The meeting adjourned between 11:11 and
11:22.
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Ymchwiliad i Barodrwydd ar gyfer y Gaeaf
2016-17—Sesiwn Dystiolaeth gyda Choleg Brenhinol y
Seiciatryddion a Choleg Brenhinol Pediatreg ac Iechyd Plant
Inquiry into Winter Preparedness 2016-17—Evidence Session
with the Royal College of Psychiatrists and the Royal College of
Paediatrics and Child Health
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[224]
Dai Lloyd: Croeso nôl i chi ar ôl toriad
diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn
y Cynulliad, a chroeso i’n tystion diweddaraf ni. A gaf i
eich croesawu i’r sesiwn yma ynglŷn â’n
hymchwiliad ni i barodrwydd ar gyfer y gaeaf? Dyma sesiwn
dystiolaeth gyda Choleg Brenhinol y Seiciatryddion a Choleg
Brenhinol Pediatreg ac Iechyd Plant. Ac, felly, o’n blaen, a
gaf i groesawu’r Athro Tayyeb Tahir o Goleg Brenhinol y
Seiciatryddion—bore da i chi—a hefyd, Dr Mair Parry, o
Goleg Brenhinol Pediatreg ac Iechyd Plant? Bore da i chithau
hefyd.
|
Dai Lloyd: Welcome back after the
latest break of the Health, Social Care and Sport Committee here in
the Assembly, and I welcome our latest witnesses. May I welcome you
to this session on our inquiry into winter preparedness? This is an
evidence session with the Royal College of Psychiatrists and the
Royal College of Paediatrics and Child Health. Therefore, before
us, may I welcome Professor Tayyeb Tahir from the Royal College of
Psychiatrists—good morning to you—and, also, Dr Mair
Parry, from the Royal College of Paediatrics and Child Health? Good
morning to you as well.
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[225]
Dr Parry: Bore da.
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Dr Parry: Good morning.
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[226]
Dai Lloyd: Nawr, rydym ni wedi darllen eich papurau
bendigedig, sydd wedi’u cyflwyno eisoes gerbron, ac felly, yn
sylfaenol, awn yn syth i mewn i gwestiynau, os yw hynny’n
iawn gyda chi. Dyna beth mae’r tystion eraill wedi cael ac mi
wnawn ni drin pawb yr un peth. Felly, mi wnaf i symud ymlaen
efo’r cwestiwn cyntaf, a chwestiwn cyffredinol i’r ddwy
ochr, a gofyn: a ydy’r Gwasanaeth Iechyd Gwladol yng Nghymru
wedi paratoi’n ddigonol, fuasech chi’n meddwl, ar gyfer
y gaeaf yma sydd ar fin digwydd, o ran rheoli derbyniadau ymysg
plant a’r rhai efo problemau iechyd meddwl? Nid wyf i’n
gwybod pa un ohonoch sydd eisiau mynd yn gyntaf.
|
Dai Lloyd: We have read the wonderful
papers that you’ve submitted already, and therefore,
basically, we’ll go straight into questions, if that’s
okay with you. That’s what the other witnesses have had and
we’ll treat everybody in the same way. So, I’ll move on
with the first question, which is a general question for both
sides, and ask you whether the NHS in Wales is adequately prepared,
in your view think, for the winter that’s about to happen, in
terms of managing admissions amongst children and those presenting
with mental health problems. I don’t know who wants to go
first.
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[227] Dr Parry:
Shall I start? Okay.
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[228]
Diolch yn fawr. Hyd yn hyn, rydw
i’n meddwl mai’r ateb yn gryno ydy, ‘Na, nid ydym
ni cweit yn barod’. Rydw i’n meddwl bod yna welliannau
wedi’u gwneud yn y gorffennol. Rydym ni o’r coleg
iechyd plant a phediatreg yn eithaf siomedig, yn y gwelliannau sydd
wedi cael eu hawgrymu yn y gorffennol, nad oes cyfeiriad penodol at
blant neu at anghenion plant. Un o’r pethau glywch
chi’n aml gennym ni sy’n gweithio efo plant ydy,
‘Nid oedolion bach ydy plant, ond plant ydyn nhw’. Mae
eu hanghenion nhw’n wahanol. Mae heintiau’n effeithio
arnyn nhw’n wahanol. Mae’r triniaethau’n wahanol,
a fedrwn ni ddim darparu ar gyfer oedolion a disgwyl medru
defnyddio’r un strwythurau i wella plant. Nid ydyw’n
mynd i weithio. Felly, rydym ni wedi bod yn eithaf siomedig yn y
gorffennol, ac, unwaith eto, nid oes yna lot o sylw i blant yn
benodol ac mae’n wardiau ni yn orlawn yn ystod y gaeaf efo
heintiau gwahanol mewn plant. Hefyd, nid yn unig bod yna fwy o
blant, ond mae’u hanghenion nhw’n wahanol, yn fwy dwys,
yn y gaeaf, ac nid ydym ni’n barod am hynny eto.
|
Thank you very much. To date, I think the
succinct answer is, ‘No, we’re not quite ready’.
I do think that improvements have been made in the past. We as the
royal college of paediatrics are a little disappointed that the
improvements that have been suggested in the past haven’t
made specific reference to children or the needs of children. One
of the things you will often hear from us is that children are not
small adults; they are children. Their needs are different. The
illnesses affect them in a different way. The treatments are
different, and we can’t make preparations for adults and
expect to use the same structures for children. It simply
won’t work. So, we’ve been quite disappointed in the
past with that, and once again, there hasn’t been a huge
amount of attention paid to children specifically and our wards are
packed during the winter months with different illnesses among
children. Also, not just that there are more children, but their
needs are different, more intense, during the winter, and
we’re not currently prepared for that.
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[229] Dai
Lloyd: Diolch yn fawr. Yr Athro Tahir.
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Dai Lloyd: Thank you. Professor
Tahir.
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[230] Professor
Tahir: The answer is, perhaps, a ‘yes’ and
‘no’—both [Laughter.]
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[231] Dai
Lloyd: That’s my sort of answer.
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[232] Professor
Tahir: First of all, thank you for this opportunity, because it
gives us an opportunity to bring forward a number of issues that
affect people with mental illnesses not just in Wales, but across
the UK. We’ve learnt a lot from evidence that’s there
across the board. I say ‘yes’, because, on a positive
note, we’ve had ring-fenced mental health funding; there has
been investment in the area where I work. I’m a liaison
psychiatrist and I work in general hospital and I have done so for
the last 15 or so years in the University Hospital of Wales. We see
pressures across the year and not just in wintertime. So, thanks
for the investment in liaison psychiatry, but that funding has gone
specifically towards emergency medicine and also the interface
between people over the age of 65 presenting to the emergency unit.
So, there has been a development in old-age liaison services across
Wales. As chair of the faculty for liaison psychiatry for the Royal
College of Psychiatrists, we have recently approved six or seven
posts across Wales So, ‘yes’, there is an investment,
and, ‘no’, because we need to see the impact of that
investment, and it would be important to see how those services are
developed in different health boards across Wales.
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[233] From the Royal
College of Psychiatrists, we don’t want to be prescriptive,
but then there are certain standards that we would want the
services to adhere to and, hence, we’d want them to develop
services that are effective for patients in those areas, rather
than a model that’s good for Betsi but not good for Hywel
Dda. So, we want them to look at their own services, but
we’ve got a meeting coming up in December in mid Wales, where
we’re going to talk about how those standards should be for
each service, so we’ll be able to report later.
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[234] Dai
Lloyd: Grêt. Mae’r cwestiwn nesaf gyda Caroline
Jones.
|
Dai Lloyd: The next question, Caroline
Jones.
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[235] Caroline
Jones: Thank you, Chair. Good morning. The British Medical
Journal research suggests that the increase in very short-term
admissions of children with common infections suggest systematic
failure in primary care and in hospital in the assessment of
children with acute illnesses that could be managed in the
community. Solving the issue is likely to require restructuring of
the way paediatric care is delivered. Is there appropriate and
sufficient training across the whole healthcare spectrum to enable
staff to respond appropriately to the needs of children and,
indeed, people with mental health issues in ensuring that prompt
access to assessment by the appropriate practitioners and
professionals is available?
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[236]
Dr Parry: Fe wnaf i ateb gan mai fi sy’n gweithio
â phlant ac rwy’n fwy cyfarwydd efo’r wybodaeth.
Rydych chi’n hollol gywir, ac mae hefyd yn un o’r
pethau a ddaeth allan—. Fe wnaeth y
coleg paediatrics adroddiad y llynedd, ‘Why Children
Die’, ac un o’r pethau mawr a ddaeth allan o’r
adroddiad hwnnw yng Nghymru oedd bod yna wahaniaeth anferth o ran
marwolaethau a bod yn sâl rhwng ardaloedd tlotaf Cymru ac
ardaloedd cyfoethocaf Cymru. Roedd hwnnw’n wahaniaeth mawr,
ond y gwahaniaeth arall a ddaeth allan, neu’r mater arall a
gafodd ei godi yn yr adroddiad hwnnw oedd bod yna broblem efo asesu
plant sydd yn wirioneddol sâl—y cyswllt cyntaf efo
rhywun sy’n gweithio i’r gwasanaeth iechyd ac adnabod
pa mor ddifrifol sâl yw’r plentyn a’i yrru i
mewn. Mae ar fy rhestr i,
felly rydw i’n falch eich bod chi wedi gofyn.
|
Dr Parry: Shall I answer, as I work
with children and I’m aware of the information? You’re
completely right, and this is one of the things that came
out—. The paediatrics college produced a report last year,
‘Why Children Die’, and one of the big issues that came
out of that report in Wales was that there was a massive difference
as regards deaths and being ill between the deprived areas of Wales
and the most advantaged areas. That was a big difference, but one
of the other issues that was raised in that report was that there a
problem with assessing children who are really ill—that first
contact with somebody who works for the NHS and recognising how
seriously ill those children are and sending them in. That is on my
list, so I’m glad that you asked that question.
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[237]
Mae’n broblem rydym
wedi’i gydnabod ers yn hir iawn, efo plant. Jest i roi tipyn
o gefndir i chi, mae’r rhan fwyaf o blant yn mynd yn sâl
yn y gaeaf oherwydd bod yna lot o annwyd o gwmpas ac mae yna lot o
viruses. Rydym ni i gyd yn gwybod, os oes gennym ni blant,
eu bod nhw’n mynd yn sâl yn sydyn iawn a’u bod nhw
hefyd yn gwella’n sydyn iawn.
|
It’s a problem that we’ve
acknowledged for a while with children. Just to provide you with
some background, the majority of children become ill during the
winter because there’s a lot of colds and viruses around. We
all know, if we have children, that they can get ill quite quickly
but that they also improve quickly.
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11:30
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|
[238]
Mae’r rhan fwyaf o blant, i
ddweud y gwir wrthych chi, lle rydw i’n gweithio—rydw i
yma heddiw ar ran y coleg, ond yn fy ngwaith bob dydd rydw
i’n ymgynghorydd ym Mangor, yn Ysbyty Gwynedd, felly mae gen
i brofiad diweddar iawn o beth sy’n digwydd ar ein wardiau
ni—yn ein hadran ni, mae 80 y cant o blant yn mynd adref mewn
llai na 24 awr o ddod i mewn i’r ysbyty ac mae canran uchel
iawn yn mynd adref mewn llai na chwe awr.
|
The majority of children, really, where I
work—I’m here today on behalf of the college, but in my
every day work I’m a consultant in Ysbyty Gwynedd in Bangor,
therefore I have recent experience of what’s happening on our
wards—in our department, 80 per cent of children return home
in less than 24 hours of being admitted into hospital and a high
percentage go home in less than six hours.
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|
[239]
Rydych chi’n hollol
gywir—yn achos lot o’r plant sy’n dod un ai
i’r syrjeri ac wedyn yn dod i mewn atom ni, neu’n dod
i’r adran frys, nid oes wir ddim angen iddyn nhw fod yna.
Ond, lle nad ydym ni’n dda iawn yn sortio hyn allan—a
dyma pam rydw i’n dweud nad ydym ni cweit yn barod am y
gaeaf—ydy nad oes gan y rhieni y wybodaeth na’r hyder i
ddweud, ‘Na, mae’n sâl, ond os cadwaf i o adref a
gwneud hyn a rhoi hwn iddo fe, mi fydd o’n iawn’. Nid
oes ganddyn nhw hynny. Felly, rydym ni angen gweithio ar hynny fel
gwlad, fel cymuned, fel cymdeithas. Rydym ni angen medru galluogi
rhieni i fod yn hyderus, iddyn nhw wybod beth sy’n addas
i’w gadw adref.
|
You’re quite right— with a number
of the children that either go to the surgery and then come in to
us, or go to the A&E department, there’s really no need
for them to be there. But, where we are not very good in sorting
this out—and this is why I’m saying that we’re
not quite ready for winter—is that parents haven’t got
the information or the confidence to say, 'No, he's ill, but if I
keep him home and do this and give him this, he’ll be
fine’. They don’t have that. So, we need to work on
that as a country, as a community, as a society. We need to be able
to enable parents to be confident, and to know when it’s
suitable to keep a child at home.
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|
[240]
Rydym ni hefyd angen, o ran pawb
sy’n ymweld â phlant ym myd iechyd—nyrsys a
meddygon, allan yn y syrjeri ac yn yr ysbyty—gwneud yn
siŵr bod ganddyn nhw hefyd set o sgiliau sy’n ei gwneud
hi’n hawdd iddyn nhw fedru asesu, ‘Na, os gyrra i hwn i
mewn, fe rôn nhw driniaeth am dair neu bedair awr a’i
yrru adref. Mi fedraf i roi’r un driniaeth i’r plentyn
allan yn y gymuned—adref, hyd yn oed, efallai—a gweld y
plentyn eto mewn tair neu bedair awr’, a chadw’r
plentyn allan o’r ysbyty.
|
We also need to make sure that everybody who
sees children in the medical world—nurses and doctors, out in
the surgeries and in the hospitals—have a set of skills that
makes it easy for them to assess, ‘No, if I send this child
in, they will be treated for three or four hours and then home. I
can provide them with the same treatment in the
community—even at home, perhaps—and see the child once
more in three or four hours’, and keep that child out of
hospital.
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|
[241]
Beth rydym ni’n trio gwneud yw
rhoi’r gofal cywir i’r plentyn yn y lle cywir, boed
hynny yn yr ysbyty neu adref, neu efallai yn un o’r ysbytai
bach sydd gyda ni allan yn y gymuned yng Nghymru—y gofal
cywir yn y lle cywir gan y person cywir. Felly, mae angen i’r
person cyntaf y mae’r teulu yna’n ei weld fod yn gymwys
ac yn hyderus ei fod yn mynd i fedru dweud y gwahaniaeth rhwng y
plentyn sydd angen dod i mewn ataf i yn yr ysbyty a’r plentyn
sy’n gallu mynd adref efo’i fam, sydd hefyd yn hyderus
ac yn gymwys i edrych ar ei ôl. Mae’n beth mawr
yma.
|
What we’re trying to do is provide the
correct care for the child in the right place, whether that be in
hospital or at home, or perhaps in one of the small hospitals that
we have in the community in Wales—the right care from the
right person and in the right place. The first person that that
family will see should be competent and confident that they can
tell the difference between a child who needs to come in to me at
the hospital and a child who can go home with his or her mother,
who is also confident and competent to look after them.
That’s a very big thing.
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[242]
Mae’n ddigon hawdd chwerthin,
‘O, nid oedden nhw angen mynd—gwneud ffỳs’.
Ond, a dweud y gwir wrthych chi, mae’r pethau yma sydd yn
ddiangen, sef y tripiau diangen i’r syrjeri ac i’r
ysbytai, yn gostus, yn un peth—rydym ni’n dal i orfod
staffio’r llefydd i’w gweld nhw—a, hefyd, maen
nhw’n achosi pryder. Mae’r teuluoedd yma’n gorfod
cael rhywun i warchod y plant eraill ac yn gorfod dod i
mewn—cael car, cael bỳs, cael y bygi ar y bỳs.
Maen nhw’n gostus ac maen nhw’n achos pryder. Rydw
i’n meddwl bod yna ddyletswydd arnom ni i gymryd pob cyfle y
medrwn ni i drio galluogi rhieni i fanejo hyn adref.
|
It’s easy to say, ‘Oh, they didn't
need to go to hospital—just making a fuss’. But, to be
honest, these unnecessary trips to the surgery and to the hospital
are costly, for one thing—we still have to staff these places
to see them—and they also cause concern. These families have
to get somebody to look after the other children and have to find a
way in—get a car, get a bus, get the buggy on the bus. They
are costly and they do cause concern. I think there is a duty on us
to take every opportunity available to encourage parents to manage
this at home.
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|
[243]
Achos, os ydyn nhw yn dod i mewn
i’r ysbyty ac yn aros mewn dros nos bob tro y mae rhywbeth
eithaf bach yn bod ar y plant, dyna wnân nhw y tro nesaf
a’r tro ar ôl hynny a’r tro ar ôl hynny,
oherwydd maen nhw’n dysgu o’r profiad blaenorol, onid
ydyn? Felly, mi rydym ni i gyd fel cymdeithas angen derbyn hyn ac
angen gweithio ar sut rydym ni’n mynd i ddelio â’r
peth.
|
Because, if they do come in to hospital and
stay overnight every time something small is wrong with the
children, that’s what they’ll do the next time and the
time after that, because they learned from their previous
experience. So, as a society as a whole, we all need to accept this
and need to work on how we’re going to deal with it.
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|
[244] Caroline
Jones: Yes. Thank you.
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|
[245]
Dai Lloyd: Diolch yn fawr am yr ateb cynhwysfawr yna.
Rwy’n meddwl yr oedd yna gwestiwn tebyg gyda Julie, ond
efallai bod yr ateb eisoes wedi dod gerbron, gan mor gynhwysfawr
oedd—
|
Dai Lloyd: Thank you for that very
comprehensive answer. I think Julie had a similar question, but
perhaps you’ve already answered that, given the comprehensive
nature of your response.
|
|
[246]
Dr Parry: Sori, rydw i yn siarad.
|
Dr Parry: Sorry, I do tend to talk too
much.
|
|
[247]
Dai Lloyd: Na, roedd popeth yn effeithlon iawn.
Julie.
|
Dai Lloyd: No, it was very effective
and efficient. Julie.
|
|
[248]
Julie Morgan: Yes. My question was really about children and the
common reasons that they would need to go into hospital. For
example, you’ve talked about colds and the temperatures at
this time of year. Could you tell us any other general reasons why
parents would be looking for help?
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|
[249]
Dr Parry: Mae yna lot o bethau, a dweud a gwir. Yn y
gaeaf, fel arfer, pethau argyfyngus ydy’r
broblem—pethau lle mae plant yn mynd yn sâl yn sydyn
iawn, nid pethau sy’n gallu dod i’r clinig o fewn tair
wythnos i weld meddyg—a phethau lle maen nhw eisiau cael eu
gweld heddiw.
|
Dr Parry: There are a number of things,
truth be told. In winter, it’s critical issues that tend to
be the problem—things where children fall ill very quickly,
not things that could go to a clinic in three weeks’ time to
see a doctor—and things that need to be seen today.
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|
[250]
Y ddwy her fawr i ni yn
paediatrics, buaswn i’n dweud—un y byddwch
chi’n gyfarwydd iawn efo, sef ffliw. Mae plant, yn enwedig
plant sydd efo cyflyrau tymor hir—nid ydyn nhw’n gallu
delio efo ffliw yn yr un ffordd ag y byddai plentyn holliach.
Felly, mae ffliw yn broblem fawr i ni.
|
The two major challenges for us in
paediatrics, I would say—one you’ll be very familiar
with, which is flu. Children, particularly children with long-term
chronic conditions—they can’t deal with flu in the same
way as a healthy child would. So, flu is a major problem for
us.
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|
[251]
Mae yna gyflwr arall, rhywbeth
o’r enw bronciolitis, a fyddai, ynoch chi neu fi, yn achosi
annwyd. Ond, mewn babanod i fyny at flwydd, mae’n gallu
achosi iddyn nhw fod yn sâl ofnadwy. Mae’n feirws
penodol. Mae’n dŵad mewn ton, o’r dwyrain. Rydym
ni’n ei weld yn dŵad, ac mae plant yn gallu mynd yn
sâl iawn, iawn efo fo. Mae hwn yn faich mawr arnom ni yn ystod
y gaeaf, nid oherwydd niferoedd, er bod niferoedd yn broblem, ond
oherwydd, o’r plant sy’n gorfod dod mewn i’r
ysbyty efo bronciolitis, nid ydyn nhw’n debygol iawn o fod o
fewn yr 80 y cant yna sy’n mynd adref o fewn 24 awr. Os ydyn
nhw, maen nhw’n debygol iawn o ddod yn ôl. Felly, nid
ydym ni’n elwa o’u gyrru nhw adref yn rhy fuan, a dweud
y gwir. Maen nhw’n debygol o fod i mewn am gyfnod hir, felly rydym angen medru edrych ar
eu holau am gyfnod eithaf hir, ond maen nhw hefyd yn fwy tebygol o
fod angen gofal arbennig—high-dependency
care—neu hyd yn oed gofal dwys—intensive
care—ac mae hynny’n cael effaith ar yr holl ffordd
rydym ni’n medru rhedeg y wardiau yma.
|
There is another condition, called
bronchiolitis, which, in you or I, would cause a cold. But, in
babies up to a year old, it can cause serious problems. It’s
a very specific virus. It comes in as a wave, from the east. We see
it coming, and children can fall very ill with that. This is a
great burden on us during the winter months, not because of the
numbers, although the numbers are also a problem, but, of the
children that have to come into hospital with bronchiolitis,
they’re not very likely to be in that 80 per cent that will
return home within 24 hours. If they do, then they’re very
likely to come back. So, we don’t benefit from sending them
home too soon, truth be told. They’re likely to be in for a
long time, so we need to be able to look after them for an extended
period of time, but they are also more likely to need
high-dependency care or even intensive care and that is having an
impact on the whole way we're able to run our wards.
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|
[252]
Ar bronciolitis, i ddweud y gwir
wrthych chi, os oes gennym ni ddau faban sydd angen gofal
arbenigol— high-dependency care—mae
hynny’n meddwl ein bod ni angen dwywaith gymaint o nyrsys i
edrych ar eu holau. Rydym yn landio i fyny ar adegau yn gorfod
nyrsio’r plant yma ar ward agored, sydd yn effeithio ar y
gofal y mae’r nyrsys hynny’n medru rhoi i’r plant
eraill, oherwydd mae’r plant yma, wrth reswm, yn gorfod tynnu
mwy o’u sylw nhw ac maen nhw angen mwy o nyrsio.
|
On bronchiolitis, to be honest, if we have two
babies who need specialist high-dependency care, then that means
that we need twice as many nurses to look after them. We find
ourselves, at times, having to nurse these children on an open
ward, which impacts upon the care that those nurses can provide to
other children, because these children necessarily have to take
more of their time and they need more nursing care.
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|
[253]
Hefyd, mae yna
broblem—mae’n rhaid i ni fod yn ofalus iawn oherwydd
mae bronciolitis yn haint sy’n gallu mynd trwy ward fel
slecs. Felly, rydym ni’n gorfod bod yn ofalus iawn efo
cadw’r plant yma ar wahân, sy’n ei gwneud
hi’n anodd i un nyrs nyrsio dau neu fwy ar unwaith, oherwydd
yn ddaearyddol, mae’r ffordd mae’r ciwbiclau wedi cael
eu rhannu allan ar y ward yn ei gwneud hi’n anodd iawn.
Felly, buaswn i’n dweud mai dyna yw’r ddau beth
sy’n fwyaf o her i ni—nid y ddau beth mwyaf cyffredin,
efallai, ond dyna ydy’r pethau mwyaf heriol i ni dros y
gaeaf.
|
There’s also a problem that we have to
be very careful with, because bronchiolitis can go through a ward
like wildfire. So, we have to be very careful with keeping these
children in isolation, which makes it difficult for one nurse to
nurse two or more patients at once, because geographically, the way
the cubicles are separated on the ward makes it very difficult for
that to happen. So, I would say that those are the two things that
are most challenging to us; they are possibly not the most common
issues, but they are the most challenging issues during the
winter.
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[254]
Rwy’n meddwl ein bod ni angen
meddwl am niferoedd nyrsys. Rydym angen i’r gwasanaeth iechyd
fod yn fwy hyblyg, oherwydd yn yr haf, i ddweud y gwir wrthych chi,
nid ydym angen staffio chwe gwely gofal dwys ar ward yn yr ysbyty
lle rwy’n gweithio. Ond, yn y gaeaf, mi rydym ni, ac rydym ni
angen medru bod yn hyblyg ac yn ystwyth er mwyn newid yn ôl y
tymor. Rydym angen hefyd bod yn eithaf gwydn, oherwydd dim jest y
gaeaf yma y mae bronciolitis yn broblem; bydd yr un broblem y gaeaf
nesaf a’r gaeaf wedyn. Felly, rydym ni angen medru cynnal
blwyddyn ar ôl blwyddyn a dim jest rhoi rhywbeth i
mewn—nid ydym angen one hit wonder fan hyn; rydym
angen rhywbeth sydd yn mynd i gynnal a bod yn gynaliadwy dros y
blynyddoedd i ddod hefyd.
|
I do think that we need to think about nurse
numbers. We need the health service to be more flexible, because in
the summer, we don’t need to staff six intensive care beds on
a ward in the hospital where I work, but in the winter, we do, and
we need that flexibility in order to respond to the season. We also
need to be quite robust, because it’s not just this winter
where bronchiolitis will be a problem; it’ll be the same
problem next winter and the winter after that. So, we need to
maintain this year on year and not just produce something for the
short term—we don’t need a one hit wonder; we need
something that’s going to be sustainable over years.
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[255]
Dai Lloyd: Dyna ni.
|
Dai Lloyd: There we are.
|
|
[256]
Julie
Morgan: And as things stand,
there are not enough cubicles, for example.
|
|
[257]
Dr
Parry: Nid bod yna ddim digon o giwbiclau; nid oes dim digon o nyrsys
i staffio’r gofal dwys. Mae yna safonau rydym ni’n
gorfod cadw efo nyrsys, ac oes os gennych chi blentyn sydd ar ward
agored, er enghraifft, sydd ddim angen gofal arbenigol—ac
rwy’n meddwl high-dependency care—fedrwch chi gael pedwar plentyn i un nyrs.
|
Dr
Parry: It’s not that
there aren’t enough cubicles, but there aren’t enough
nurses to staff that intensive care. There are standards that we
have to maintain with nurses and if you do have a child who’s
on an open ward and doesn’t need specialist care—and
I’m talking about high-dependency—care, then you can
have four children to one nurse.
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|
[258]
Efo plentyn sydd
efo bronciolitis, sydd yn aml yn gorfod cael ffordd benodol iawn o
roi ocsigen iddyn nhw er mwyn eu cynnal nhw—ac am gyfnod hir
o dri, pedwar neu bump diwrnod—rydych chi angen un nyrs i
ddau blentyn. Felly, mae’r niferoedd o nyrsys yn gorfod mynd
i fyny. Os ydym ni wedyn yn ffactorio i mewn y ffaith bod un
plentyn yn y fan hyn a’r llall yn fanna, mae’r nyrs yn
treulio amser yn y canol a ddim yn edrych ar ôl y plentyn.
Felly, mae eisiau meddwl am sut rydym yn cynllunio ein hysbytai yn
ogystal â sut rydym yn staffio ein hysbytai.
|
With a child with
bronchiolitis, who will often need a very specific way of
delivering oxygen to sustain them— and that can be over a
longer period of three, four or five days—then you need one
nurse to every two children. So, the nurse numbers have to
increase. If we then factor in the fact that one child is here and
the other is elsewhere, then the nurse will spend her time between
those two rather than look after the children. So, we have to think
about how we plan our hospitals as well as how we staff our
hospitals.
|
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[259]
Julie Morgan: Can I ask one more question very quickly?
|
|
[260]
Dai Lloyd: Go on, Julie.
|
|
[261]
Julie Morgan: In your response to an earlier question, you said
that some children do go into hospital unnecessarily for six hours
or something and that you were able to do the same treatment
without them going into hospital. So, do you tell this to the
parents and then they still insist on going to hospital? How does
that work?
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|
[262]
Dr
Parry: Rydym yn trio. Mae’n anodd iawn. Mae eisiau newid yr
holl feddylfryd, onid oes? Yn anffodus, rydym ni wedi, dros y
blynyddoedd, trwy efallai bod yn rhy agored ein breichiau, derbyn
pawb i mewn i ysbytai. Rydym wedi dysgu pobl, ‘Os nad ydych
yn dda, rydych chi angen bod mewn ysbyty.’ Nid yw
hynny’n wir; nid oedd erioed yn wir. Ond rŵan,
efo’r cyfyngiadau sydd arnom ni, mae’n rhaid inni
ymateb i hynny. Ydyn, mi rydym ni’n trio dweud wrth y
rhieni—. Gyda’r rhan fwyaf o’r rhieni, os ydyn
nhw’n hyderus ein bod ni’n gwybod beth yr ydym
ni’n ei wneud, medrwn ni gael perthynas efo nhw a medrwn ni
ddefnyddio pob math o strwythur i gefnogi hyn: beth rydym
ni’n ei alw’n ‘safety netting’.
Rydym yn aml yn dweud wrthynt, ‘Os yw’n sâl yn y
24 awr nesaf yma, peidiwch â mynd i chwilio am GP na mynd i
casualty—dewch yn syth i’r ward; ffoniwch ni a
dewch yn syth i’r ward.’ Rydym yn eu gadael nhw efo
pethau fel open access. Felly, rydym ni’n trio
hyrwyddo’r neges yma nad oes angen bod yn yr ysbyty pan
rydych yn sâl, a trio, fel rwy’n dweud, rhoi’r
hyder i’r rhieni i fedru dweud—. Mae hynny
weithiau’n cynnwys rhoi darn o bapur iddyn nhw efo rhestr yn
dweud, ‘Dyma’r pethau i edrych allan amdanyn nhw. Os
welwch chi un o’r pethau yma, ffoniwch ni’n syth
bin.’ Weithiau mae o’n dangos iddyn nhw sut i roi
meddyginiaethau—y pethau mwyaf amlwg ydy inhalers a
phethau ar gyfer asthma ac felly. Mae’n anodd eu rhoi nhw i
blentyn sydd ddim eisiau eu cymryd nhw. Os ydych chi’n methu
ag anadlu, yn oedolyn, ac y mae rhywun yn dod atoch chi efo mwgwd
a’i roi ar eich ceg chi, rydych chi’n gwybod,
‘Mae’n iawn; nid yw’n neis, ond fyddai’n
well os cymera i o.’ Fedrwch chi ddim rhesymu, fel yna, efo
plentyn dwy oed. Mae rhieni yn ei ffeindio’n anodd—maen
nhw o dan bwysau, mae eu plant nhw’n sâl a maen
nhw’n poeni. Felly, rydym ni’n trio cymryd y cyfleon
i’w haddysgu nhw a’u gwneud nhw ychydig bach yn fwy
hyderus i edrych ar ôl y plant yn eu cartref, ond maen nhw
angen y gefnogaeth.
|
Dr
Parry: We do try. It’s
very difficult. We need to change the whole mindset, don’t
we? Unfortunately, over the years, through perhaps being too open,
in taking everyone into hospitals, we have taught people that if
you’re not well, you need to be in hospital. That simply
isn’t the case; it never was the case. But now, given the
limitations upon us, we have to respond to that problem. Yes, we do
try and explain to parents—. With most parents, if they are
confident that we know what we’re doing, then we can have a
relationship with them and we use all sorts of structures to
support this: what we call ‘safety netting’. We often
tell them, ‘If he’s ill in the next 24 hours, then
don’t go in search of a GP or go to casualty—come
straight to the ward; give us a ring and come straight here.’
We have things such as open access. So, we do try and promote this
message that you don’t necessarily need to be in hospital
when you’re ill and try to give parents the confidence to
say—. On occasion, that’s a matter of giving them a
piece of paper with a list of what to look out for, stating,
‘If you experience one of these things, then give us a ring
immediately.’ Sometimes, it shows them how to administer
medicines, such as inhalers for asthma and so on. It’s
difficult to give them to a child who doesn’t want to take
them. If you can’t breathe as an adult and someone places a
mask on your mouth, then you know, ‘Well, it’s fine;
it’s not nice, but I’ll be better.’ But you
can’t reason like that with a two-year-old and parents find
it difficult—they’re under pressure, their children are
ill and they’re concerned. So, we do try and take the
opportunities to educate parents and to give them confidence in
looking after their children at home, but they need that
support.
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|
[263]
David
Lloyd: Lynne sydd â’r cwestiwn nesaf.
|
Dai
Lloyd: Lynne has the next
question.
|
|
[264] Lynne
Neagle: Thanks, Chair. I’ve got a couple of questions.
The first was on this issue of the lack of—or, you feel, a
shortage of—high-dependency beds and intensive care beds.
Your paper says that the same pressures exist in that area with no
mitigation. So, I wanted to ask: are there any parts of Wales where
they’re actually looking at increasing the number of HDU and
intensive care beds, or is that generally the pattern across
Wales?
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|
[265] Dr
Parry: Mae’r un patrwm
â—. A gaf i jest ei wneud o’n glir—? Nid
wastad diffyg gwlâu ydy o, ond diffyg nyrsys i staffio’r
gwlâu ydy o. Fe fedrwn ni gael gwlâu gwag, ond fedrwn ni
ddim rhoi plentyn ynddyn nhw os nad oes nyrs. Felly mae o’n
gyfuniad o’r ddau beth, i ddweud y gwir wrthych chi, nid jest
y gwely ei hun. Mi ydym ni, ar bapur yn aml—os na fuasai neb
o’r staff yn mynd yn sâl, yn mynd ar gyrsiau, yn cael
babis ac yn mynd i ffwrdd, mae’n bosib iawn, ar bapur, ein
bod ni’n edrych fel ein bod ni’n gallu staffio. Ond yn
y byd go iawn—a dyna lle ydw i’n gweithio—yng
nghanol gaeaf, mi ydym ni’n ffonio a ffonio a ffonio yn trio
cael mwy o staff i ddod i mewn drwy’r amser. Ac rydym
ni’n gwario ffortiwn ar nyrsys banc, ar nyrsys o
agencies a phethau, a’r un peth efo meddygon. Mae yna
brinder meddygon ar bob lefel yn iechyd plant, ac mi ydym
ni’n gwario ffortiwn er mwyn cadw pethau i fynd yn lle
chwarae’r gêm hir, fel petai. Beth y mae angen i ni ei
wneud, a dweud y gwir, ydy tyfu ein nyrsys ein hunain a thyfu ein
meddygon ein hunain yng Nghymru, ac mae hynny’n gorfod
dechrau efo plant ysgol. Rydym ni’n gorfod gwneud y swyddi
yma’n ddeniadol—eu bod nhw’n gweld pobl bositif
yn gwneud y swyddi, yn mwynhau, yn role models positif yn
ein cymdeithas ni—bod ein hysgolion ni yn ddigon da iddyn nhw
gyrraedd y safonau i gael mewn i brifysgol neu goleg nyrsio,
a’u bod nhw wedyn yn mwynhau, bod ein colegau ni’n
ddeniadol, eu bod nhw eisiau mynd i fan yna yn hytrach nag i rywle
arall ac wedyn bod Cymru’n lle da i weithio a’u bod
nhw’n aros yma, a’n bod ni’n elwa o’u
sgiliau nhw ac o’r buddsoddiad o’u hyfforddi nhw yn y
lle cyntaf.
|
Dr Parry: It’s the same
pattern—. Can I just make it clear—? It’s not
always a lack of beds, it’s a lack of nurses to staff those
beds. We can have an empty bed, but we can’t place a child in
it if the nursing staff aren’t there. So, it’s a
combination of both, really. Not just the bed itself. On paper
quite often—if none of the staff were ill, or went on courses
or had babies, it’s possible on paper that we look as if we
can staff. But in the real world—and that’s where I
work—we are, in the middle of winter, phoning and phoning and
phoning to try and get more staff in all the time. We spend a
fortune on bank nurses, agency nurses and it’s the same with
doctors. There’s a shortage of doctors on every level in
child health and we spend a fortune in order to keep things going,
rather than playing the game for the long term. What we need to do
is to get nurses and doctors ourselves in Wales. It starts with
children in school. We need to make these jobs attractive, we need
them to see positive role models in our society. We need to ensure
that our schools are good enough for the children to get those
standards to go into medical school and colleges, and that our
colleges are also attractive and that they want to go there rather
than elsewhere, and that Wales is a good place to work and that
they stay here, and that we benefit from their skills and the
investment in them in the first place.
|
|
[266] Lynne
Neagle: Thank you. Your paper also says,
|
|
[267] ‘It is
disappointing that many of the recommendations designed to ease the
pressures have not been acted upon and we are not aware of any
specific action taken in relation to children.’
|
|
[268] Can you pinpoint
exactly what the recommendations are that you feel should have been
acted on that haven’t been?
|
|
[269] Dr
Parry: Un o’r pethau mawr
ydy nyrsio plant. Beth rydym ni’n trio ei ddweud ydy: mae yna
lot o sôn am yr henoed yn ystod y gaeaf, ac eto mae 20 y cant
o’n poblogaeth ni yng Nghymru yn blant o dan 18 oed. Mae
plant o dan 18 oed yn cymryd 25 y cant o amser meddygon teulu,
felly maen nhw’n defnyddio mwy ar y gwasanaeth na’r
niferoedd o blant, os ydych chi’n dallt beth rydw i’n
ei feddwl. Mae plant o dan 18 oed hefyd yn cymryd dros 25 y cant o
ymweliadau ag unedau brys yng Nghymru, felly eto, maen nhw’n
defnyddio’r gwasanaethau yna yn fwy. Eto, nid oes yna ddim
sôn amdanyn nhw fatha rhywbeth gwahanol i’r oedolion.
Rŷm ni o hyd yn dweud hyn—dyma beth mae
paediatricians yn ei ddweud ar draws y wlad: bod plant yn
wahanol, mae’r cyflyrau’n wahanol. Mae yna lot o
sôn am ffliw yn yr henoed, ond nid oes yna ddim sôn am
ffliw mewn plant. Ac eto, mae ffliw yn effeithio ar blant mewn
ffordd wahanol ac mae’r triniaethau’n wahanol—yn
union yr un peth â bronciolitis. Mae bronciolitis yn broblem
anferth i ni bob gaeaf. Chlywch chi ddim sôn amdano
fo—dim byd mewn argymhellion parodrwydd gaeaf, ond fe ddylai
o fod yna oherwydd mae o mor dymhorol, fel yr oeddwn i’n ei
ddweud. Mae’n dŵad mewn ton ddechrau mis
Hydref—mae’n dod mewn ton o’r dwyrain ac
mae’r ward yn llawn o blant bach yn tagu, a babis bach yn
tagu. Felly, mae yna ambell i gyflwr penodol—os nad ydym
ni’n ei drafod o’n benodol mewn plant, ni chaiff o ddim
ei drin mewn ffordd addas, a dyna ydy fy mhoen i.
|
Dr Parry: One of the major things is
paediatric nursing. What we’re trying to say is that
there’s a great deal of talk about the elderly during the
winter months, but 20 per cent of our population in Wales are
children under 18. Children under 18 do take 25 per cent of GP
time, so they use more of our resource than the number would
suggest, if you understand what I mean. Children under 18 also take
more than 25 per cent of visits to A&E in Wales, so again,
they’re using those services more. But again, there is no
mention of them as being different to adults. We’re
constantly banging on about this—this is what paediatricians
are saying across the country: that children are different, the
conditions are different. There’s a great deal of talk about
flu among older people but not among children, and flu affects
children in a different way and the treatments are
different—exactly the same as bronchiolitis. Bronchiolitis is
a huge problem for us every winter but you never see it mentioned
in any of the winter preparedness recommendations, but it should be
there because it is so seasonal. It comes in a wave at the start of
October—it comes in a wave from the east and then the ward is
full of babies who are finding it difficult to breathe or choking.
So, there are a few specific conditions and if we don’t
actually discuss it specifically among children then it won’t
be treated appropriately. That’s my concern.
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[270] Dai
Lloyd: Dyna ni. Diolch am hynny.
Rhun, efallai ein bod ni’n mynd i sôn am iechyd meddwl
am ychydig bach.
|
Dai Lloyd: Thank you for that. Rhun,
we’re going to talk about mental health.
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[271] Rhun
ap Iorwerth: Ie. Fe wna i aros
efo plant a phobl ifanc, ond os caf i ofyn i chi pa mor effeithiol
ydy’r gwasanaethau ar gyfer plant a phobl ifanc sydd yn dod
atoch chi fel achosion brys efo problemau iechyd meddwl, o ran
effeithlonrwydd yr asesu a sicrhau bod y gofal iawn ar eu cyfer
nhw. A gan eich atgoffa mai edrych yn benodol ar y gaeaf yr ydym
ni, a oes yna bwysau penodol yn codi dros gyfnod y gaeaf yn y maes
yma?
|
Rhun ap Iorwerth: I’ll stay with
children and young people. If I could ask you how effective the
services are for children and young people who come to you as
emergency cases with mental health problems, in terms of the
effectiveness of the assessment and the treatment. And reminding
you that we’re looking at winter specifically, is there
additional pressure in this field in the winter?
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[272] Dr Parry:
Do you want to go first on this?
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[273] Professor
Tahir: It is winter specific, but what we see year round is
that one of the major reasons why mental health gets involved with
children is self-harm. With the crisis teams and lack of crisis
teams and lack of liaison psychiatry teams in children, we have to
keep kids waiting for an assessment, and that takes the pressure
onto their physical health issues and a bed would be blocked.
Hence, there is a need for looking into that area.
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11:45
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[274] Then there is
the other issue that was talked about earlier: first contact
matters a lot, and if we do not have the right people, fully
trained professionals, assessing kids and their families early on,
we’re not going to have a good impact later on, and those are
the children who’ll perhaps graduate into, later on, adults
with mental health problems, alcohol/substance misuse, behaviour
issues and more serious and enduring mental illnesses. So,
that’s why first contact matters a lot. I know, for
specifics, in certain areas, a lack of crisis teams in CAMHS has
led to people being in hospital for 48 hours longer than they
should have been, and that is not up to standard.
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[275]
Dr Parry: O ran fy ochr i, yn gweithio ar ward lle mae
plant efo pob mathau o gyflyrau yn dod i mewn, mae’n rhaid i
mi ddweud rwy’n eithaf hapus am rai agweddau o CAMHS. Nid wyf
i’n cwyno am bob dim, ylwch, rwy’n hapus am rai pethau.
Mi ydym ni yn barod—rydych chi i gyd yn gwybod, rwy’n
siŵr—wedi cael mwy o arian i redeg gwasanaethau
CAMHS ac rydym ni’n gweld hynny’n barod ar y wardiau, i
ddweud y gwir wrthych chi.
|
Dr Parry: From my perspective, working
on a ward where children with all sorts of conditions come in, I
have to say that I am quite content about some aspects of CAMHS.
I’m not complaining about everything, you see; I’m
happy with some things. But, as I’m sure you already know, we
have been given more funding to run CAMHS services and we see the
impact of that already on the wards, if truth be told.
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[276]
Ein problem ni fel meddygon
sy’n edrych ar ôl plant efo salwch corfforol yn hytrach
na meddyliol ydy bod dal trafferth ymateb i anghenion y plant yma
sy’n dod i mewn, yn enwedig plant sydd â hunan-anafiadau
a phethau. Ar y funud, cyn ein bod ni wedi cael mwy o bres yn yr
uned lle rwyf i, ac rwy’n gwybod ei bod hi’n debyg iawn
ar draws Cymru—. Mi ydym ni wedi medru, yn sydyn iawn,
ehangu’r gwasanaeth CAMHS sydd ar y ward o bum diwrnod yr
wythnos i fyny i saith diwrnod, sydd yn grêt. Rwyf wrth fy
modd efo hynny, oherwydd yn y gorffennol os oedd plant yn dod i
mewn ar nos Wener ac wedi hunan-anafu, roedden nhw i mewn tan ddydd
Llun os oedden nhw’n holliach neu beidio. Trwy eu cadw nhw i
mewn yn disgwyl am CAMHS, rydym ni’n eu tynnu nhw oddi wrth
eu ffrindiau ac oddi wrth eu teuluoedd—rydym ni ond yn gwneud
pethau’n waeth. Rydym ni’n gwella dim arnyn nhw drwy eu
cadw nhw yn yr ysbyty jest yn disgwyl am rywun penodol. Felly, mae
hynny wedi gwneud byd o wahaniaeth, ond mae dal yn broblem. Nid oes
digon o bobl wedi eu hyfforddi yn CAMHS; nid oes digon ar ddydd
Sadwrn a dydd Sul. Nid ydy o’n ddim byd y dyddiau yma, hyd yn
oed mewn uned eithaf bach fatha’r un rwy’n gweithio
ynddo, i ni gael pump, chwech neu saith o blant ar nos Wener a nos
Sadwrn wedi hunan-anafu. Fedr un person ddim gweld gymaint â
hynny o blant a gwneud asesiad trylwyr ac addas mewn un
diwrnod—mae’n amhosib. Felly, maen nhw dal yn aml yn
gorfod disgwyl diwrnod neu ddau yn hirach.
|
Our problem, as doctors looking after children
with physical illnesses, rather than mental illnesses, is that
there is still some difficulty in responding to the needs of these
children who come in, particularly those who are self-harming and
so on. Now, before we received the additional funding, in the unit
where I work, and I know that the situation is similar across
Wales—. We have very suddenly been able to expand the CAMHS
services on the ward from five days a week up to seven, which is
wonderful. I’m delighted with that, because, in the past, if
children had come in on a Friday evening having self-harmed, then
they’d be there until Monday, whether they were healthy or
not. By keeping them in, waiting for CAMHS, we are taking them away
from their friends, their families—we’re only making
things worse. We’re not doing them any good by just keeping
them in hospital waiting for a specific individual. So,
that’s made a world of difference, but it is still a problem.
There aren’t enough people who are trained in CAMHS; there
aren’t enough available on Saturdays and Sundays. It’s
nothing, even in quite a small unit like the one where I work, for
us to have five, six or seven children on a Friday night or a
Saturday night to have self-harmed. One person simply can’t
see that many children and carry out a thorough, appropriate
assessment in one day. It’s impossible. So, they often have
to wait a day or two longer.
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[277]
O’r holl blant sydd gennym ni,
a phobl ifanc, ar y ward—. Efo’r henoed mae yna lot o
sôn—ac mae’n gas gen i’r dywediad—am
‘bedblocking’. Maen nhw angen gwely, yn amlwg,
achos nid oes unlle arall iddyn nhw fynd. Ond, efo plant, nid ydym
ni’n cael trafferthion efo gyrru plant adref fel arfer.
Mae’r rhan fwyaf o blant yn dod i mewn efo un neu ddau ofalwr
cymwys, i ni fedru eu gyrru nhw adref. Ond efo plant CAMHS a phobl
ifanc CAMHS, mae o’n gallu bod yn broblem, oherwydd nid
yw’r gwasanaethau arbenigol efo unedau inpatient
CAMHS—nid oes llawer o’r rheini. Mae’r rheini
sydd gennym ni yn llawn dop trwy’r amser, ac rydym ni yn cadw
plant am wythnosau maith weithiau ar ward yn disgwyl am lefydd mewn
unedau arbenigol os oes ganddyn nhw rywbeth sydd tipyn bach yn fwy
arbenigol na fedr ein psychiatrist ni ddelio â fo.
Rydym ni’n gorfod disgwyl am wythnosau.
|
Of all the children and young people we have
on the ward—. With older people, there’s a lot of
talk—and I hate this phrase—about
‘bedblocking’. They need a bed, obviously, because
there’s nowhere else for them to go. But with children, we
don’t have those problems with sending children home,
usually. Most children come in with one or two suitable carers, and
we can send them home with those carers. But with CAMHS children
and young people, it can be a problem, because the specialist
services with inpatient units—there aren’t too many of
those for CAMHS. Those that we have are full to overflowing all the
time, and we do keep children for many weeks, occasionally, on
wards awaiting places in the specialist units if they have
something a little more specialist than our psychiatrist can deal
with. We have to wait weeks.
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[278]
Mae hynny’n
amharu—mae’r plant yma a’r bobl ifanc yma’n
tueddu i gymryd lot o sylw’r nyrsys. Mae’n amharu ar y
gofal rydym ni’n medru ei roi i’r plant eraill,
fatha’r plant gofal dwys. Mae lot o bobl ifanc CAMHS yn ofal
dwys yn eu hunain. Efallai nad ydyn nhw ar ocsigen neu ar
ventilator, ond maen nhw angen un i un yn aml, ac mae
hynny’n tynnu oddi wrth y gofal fedrwn ni ei roi i’r
plant efo heintiau sy’n dod i mewn yn ystod y gaeaf. Felly,
dyna sut mae’n effeithio arnom ni. Nid ydy o’n dymhorol
yn ei hun, ond oherwydd ei fod o’n eithaf cyson, pan mae
pwysau tymhorol eraill yn dod ar ei ben o, nid ydym ni’n
gallu manejio.
|
These children and young people tend to take a
great deal of nurse time. It affects the care that we can provide
the other children, such as the intensive care children. Many of
these CAMHS patients are intensive care themselves. They need one
to one; they may not be on oxygen or ventilators, but they do need
that care and that actually removes capacity to deal with other
children who come in with infections during the winter.
That’s how it impacts us. It’s not seasonal in and of
itself, but because it is relatively consistent, when other
seasonal pressures come on top of that, we can’t manage.
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[279]
Rhun ap
Iorwerth: Dyna fo, a dyna oedd fy ail gwestiwn i’n mynd i fod. A
fyddech chi’n cytuno â hynny hefyd? Buaswn i hefyd wedi dyfalu
na fyddai yna sbeic mawr o ran achosion brys iechyd meddwl yn y
gaeaf, ond bod yna bwysau ar y gwasanaeth rydych chi’n gallu
ei ddarparu iddyn nhw oherwydd y pwysau mewn rhannau eraill
o’r gwasanaeth.
|
Rhun ap
Iorwerth: That was going to be
my second question. Would you agree with that as well? I would also
have guessed that there isn’t a big spike in terms of
emergency cases, for many people with mental health problems in the
winter, but there’s pressure on what you can provide for them
because there’s pressure on other areas of the
service.
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[280] Professor
Tahir: That’s absolutely correct. In fact, for mental
health, there is a dip in self-harm from November onwards, until
about January or February time, and then it peaks again. The rates
of self-harm and suicide are higher in spring and summer, and in
the elderly it is more towards late summer. So, that’s not an
issue as far as wintertime is concerned.
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[281]
Dai Lloyd: Diolch am hynny. Jayne, a oeddet ti eisiau gofyn
cwestiwn 24?
|
Dai Lloyd: Thank you for that. Jayne,
did you want to ask question 24?
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[282] Jayne
Bryant: Just to follow on from that, I think. Professor Tahir
just mentioned having the right people seeing the people at the
moment when they come into the service—having the first
contact; sorry—but do you think there’s appropriate and
sufficient training, particularly when we’re talking about
dementia and winter pressures, with more people coming in, perhaps
through falls? Do you think that’s a problem?
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[283] Professor
Tahir: One of the beauties of psychiatry is that we work
laterally, not hierarchically. Our senior nurses are very well
trained and very much respected. For me, in my team, they are my
eyes and ears in a general hospital, but that’s where
training is concerned. While there’s some improvement in the
split between registered mental health nurses and general nursing,
nurses who are trained in mental health will specifically go on to
work—some of them—on old age. Working in a general
hospital is a different environment altogether, because there are
people with co-morbid, physical and mental health problems, and
therefore the parity of esteem between physical and mental health
is very important. That’s the sort of thing that needs to be
part of the training.
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[284] At the front end
of the hospital, in an emergency unit, there is a lot of pressure
on nurses and their time. Dealing with mental health sometimes is
not the first thing that comes to mind as far as training is
concerned, and that’s why there’s a need to train
general nurses working in general hospital, because sometimes the
first point of contact is a general hospital. It’s the front
end of the hospital rather than a psychiatry clinic, or the GP
clinic, and that’s where bringing that gap between mental
health and physical health closer is very important at training
level, not only for the nurses, but for doctors and medical
students. There needs to be a much more integrated curriculum for
mental health and physical health. In Cardiff University, that
change has been made, but still there’s a lot of work that
needs to be done.
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[285] Jayne
Bryant: I suppose the time for refreshing, or refresher
courses, is important as well.
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[286] Professor
Tahir: Yes. It’s important to remember that the turnover
of staff in emergency units and general hospital, for junior
nursing staff, is very rapid. That’s why they would come in
and get trained and then move on to a different job. Then we need
to get the training for the new batch of nurses. That’s why
it’s important that it’s an ongoing process. The
problem is that there are very few liaison psychiatrists working in
general hospital and psychiatrists within the community. Community
mental health teams are swamped with work within their catchment
areas. As you would know, psychiatry works in every area in
regions. For them to move out of their CMHTs and go and do training
for general nurses, there needs to be more investment in getting
the training up and running, and a regular turnover of
training.
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[287]
Dai Lloyd: Dyna ni. A’r cwestiwn olaf gan
Angela.
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Dai Lloyd: The final question from
Angela.
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[288] Angela
Burns: Professor Tahir, I just wanted to clarify your comment
about the winter pressures because, in the paper, it says that:
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[289] ‘the
prevalence of self-harm and suicide attempts and completions
decreases prior to Christmas; this trend is reversed immediately
after Christmas and should be cause for concern for psychiatric
services.’
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[290] To me, that
sounds like it does have an impact on winter pressures. I just
wasn’t quite sure that that was what you just said. So, I
just wondered if you could clarify that.
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[291] Professor
Tahir: So, research across the world, and not just our own
local data, shows very clearly that there is a decrease in
admissions and presentations for self-harm in hospitals. Then,
after Christmas and the new year, come February time, the rates
start increasing again. From our data at the poisons unit in
Cardiff, we know very well that, in a year, more than 1,200
patients are admitted to the poisons unit every year. Of those,
about a third of them are seen by a psychiatrist or psychiatric
nurses. But, you’re correct; my reflection on that is that,
yes, the rates decrease in wintertime for self-harm, but it does go
up occasionally—
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[292] Angela
Burns: Immediately afterwards, which is what it says. Do you
have enough data to be able to—? Do you have enough empirical
evidence that we can use to persuade Government that this might be
an area where we need to reassess our funding levels, or our
staffing levels?
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[293] Professor
Tahir: So, like I said earlier, investment has come into
liaison psychiatry for the elderly. My team in Cardiff and Vale,
apart from a part-time post in Swansea, was the only team for
working-age adults for the last 10 or 12 years, and there needs to
be investment in those under the age of 65 as well. And, yes,
I’ve got data that, year-on-year, my team sees about 2,500
patients and about 1,000 of them are seen in the emergency unit
every year, and this would be 24 hours. There are models that the
Royal College of Psychiatrists has worked on—basic liaison
psychiatry, core 24 and a comprehensive 24-hour service—and,
yes, there is a lot of data, not only from local services, but also
from across the bridge in England that we can use to persuade.
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[294] Angela
Burns: Chair, would it be at all possible to ask Professor
Tahir, if you have the time to—. There are two bits of
information I particularly would like to understand, if at all
possible. First of all, as we know, more elderly people get
admitted during the winter period because they get things like
influenza, slips and falls, et cetera, and if they have some form
of dementia, once they’re in through the doors of the
hospital, they tend to go over the cliff and become very poorly
very quickly and it’s very hard to bring them back. So, I
wondered if you had anything on that, that you might be able to
give us a comment on.
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[295] And the second
area I wanted to ask about was if you have any comment on, during
the winter period, in psychiatric illnesses, whether there’s
a particular increase. I would imagine—I’m talking off
the top of my head here—that, say, something like psychotic
illnesses are pretty standard all the time, but I wondered if there
might be an increase in depression and anxiety throughout the
winter periods, and that that may be an area where we might have to
look at trying to support that particular element during the
winter. So, anything like that that might be able to help us just
to have a better understanding of the splits within mental
health.
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[296] Professor
Tahir: I know particularly that Julie Morgan has been to visit
the response enhancement assessment and crisis and treatment
team.
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[297] Julie
Morgan: I was just going to mention it.
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[298] Professor
Tahir: REACT is more in the community. For dementia sufferers
who are in nursing homes, when they come into hospital, it could be
for various reasons, for example, a fracture of the neck or femur,
or as simple as a urinary tract infection or an upper respiratory
tract infection, and they would then develop delirium. It is very
well known that after an episode of delirium, the dementia suddenly
worsens, and there’s plenty of information around that. In
Cardiff, we have done a trial on delirium, and the treatment and
management of delirium. In 2010, that was published, and we know
that the recognition of delirium in general hospitals is not too
great, because people who come into a hospital might have
hyperactive delirium, and they would get referred to psychiatry
services very quickly, but those who have a hypoactive delirium,
they would be pleasantly in a bed—I can tell you a number of
such stories—confused, and thought of as depressed, and those
are the areas that could be part of training in general
hospital.
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[299] So, with upper
respiratory tract infections in winter, that is an issue. Our REACT
team has shown some—. I was on call last week, and there was
an elderly lady who had taken an overdose, and if we didn’t
have the REACT team, perhaps we would have had to bring her into a
psychiatric unit, but with the REACT team, we were able to prevent
an admission.
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12:00
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[300] But that’s
something that happens across the year and not just in the
wintertime. For psychiatric illnesses, people who suffer from
severe mental illnesses like schizophrenia and bipolar affective
disorder, for them, it is very important that they are well
supported throughout the year and especially at critical times such
as winter. People who have got schizophrenia are particularly at
risk of developing physical health problems. People with general
physical morbidity, multiple physical morbidity or with long-term
conditions like diabetes, heart conditions and arthritis are
particularly vulnerable to developing psychiatric illnesses and
that’s where we need to bring in a lot of resources to help
those people.
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[301] We’ve
collected data in the University Hospital of Wales for about 600
patients. About 30 per cent of those who come to our out-patient
clinics have got a depressive illness in particular. So, yes,
there’s a lot that can be done for patients with multiple
morbidities. Medically unexplained symptoms—and I know, in
general practice, that people do see that 30 to 40 per cent of
their workload is medically unexplained symptoms—that draws
in a lot of resources with multiple investigations and, again, the
issue of training is important there, and working with those people
to prevent admissions into general hospital for physical
investigations is important. Support for the psychological: in my
team, to see a psychologist it takes about eight months, and that
could take pressure off general hospitals. I’ve got a
part-time cognitive behavioural therapist; if I had a full-time
one, from eight months we could reduce the waiting time to four
months. That’s the nature of psychology services across
Wales.
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[302] Can I mention
some other things, if you’ll allow me? Neuropsychiatry;
young-onset dementia. They are the stories that are heartbreaking
to deal with. I’ve got a gentleman on a neurosurgical ward
who has had bifrontal surgery, and I’m dreading the time when
he’s ready to go out into the community. Where is he going to
go? He’s a young man in his 40s, he would need a lot of care
and there aren’t enough places, and, unfortunately, I hate to
use the word ‘bedblocking’ myself, but that is how he
would be—in hospital where he’s inappropriately placed.
Someone with neuropsychiatric conditions or someone with
young-onset dementia—. Cardiff is the only place where
there’s a young-onset dementia service and we’ve got
very limited resource with those people in hospital. There is
hardly anything in the community to work with them. Those are the
ones who are particularly at risk in winter as well.
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[303]
Dai Lloyd: Julie, i orffen.
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Dai Lloyd: Julie, to finish.
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[304] Julie
Morgan: I wanted to raise the REACT scheme, because I was very
impressed at the visit, where it was described as the hospital
going to the patient in the home and providing a multidisciplinary
team, and with really striking numbers about how many people had
actually been kept out of being admitted to hospital, because of
the intervention of REACT. So, how could we get a scheme like that
much more widespread? I think that’s the key issue. It seems
to be a star scheme and I think it would be wonderful, actually, if
people could visit it from this committee. But, how do we spread it
out?
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[305] Professor
Tahir: In Birmingham, the first team that was set up was the
rapid assessment, interface and discharge team, which is from 16
onwards, across ages. I’m one of the very few people who are
trained in adult old-age psychiatry and liaison psychiatry. I think
there are about 14 of us in the whole of the UK. There needs to be
training in those areas, first of all, as medical leadership, for
us to lead teams like that. The REACT team is only specific to
old-age psychiatry, so we need to broaden the remit of that and we
know that the RAID team in Birmingham has shown that for every
pound invested, there is anything between a £4 and £6
saving. That’s a model that works with prudent healthcare as
well; it works across—. It’s not only for crises, but
it’s also working through the rehab phase and the recovery
phase. So, we need resources, we need training and we need to
attract colleagues from other areas to come and work in Wales, and
one of the areas the Royal College of Psychiatrists is very keen on
is recruitment and retention. I have trained three specialist
registrars in liaison psychiatry and because of no jobs in Wales,
they have gone elsewhere to work. So, we need to set up those
services and attract those people to stay in Wales. I came to Wales
22 years ago, and I’m an example—I’ve not left,
despite having offers from other places, because this is where we
can make a difference. We are very fortunate to have health boards,
where we can work across physical health and mental health areas.
We are fortunate to have this interface with the Welsh Assembly
Government, and that is very fortunate. So, the resource is there,
the networks can be developed, but we need—
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[306]
Julie Morgan: Personnel.
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[307]
Professor Tahir:
We need personnel. We need to keep them
in Wales to work in these areas, and especially in west Wales or
north Wales. We need to develop those services with a focus on
rural psychiatry as well, because some people are quite isolated,
especially people with mental illnesses.
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[308]
Dai Lloyd: Ocê. Diolch yn fawr iawn. Dyna ddiwedd
sesiwn y bore. A gaf i’ch llongyfarch chi eich dau, yn wir,
am gyfoeth y dystiolaeth gerbron, yn ysgrifenedig ac ar lafar?
Llongyfarchiadau mawr i chi—er mwyn y record—yr Athro
Tayyeb Tahir, Coleg Brenhinol y Seiciatryddion, a hefyd Dr Mair
Parry, Coleg Brenhinol Pediatrig ac Iechyd Plant. Diolch i’r
ddau ohonoch chi. A allaf i jest cyhoeddi y byddwn ni’n anfon
trawsgrifiad o’r cyfarfod yma i chi er mwyn i chi ei wirio
fo—ffeithiau yn unig; ni fedrwch chi newid eich meddwl neu
eich agweddau ar stwff, ond gallwch ei wirio fo o ran bod yn
ffeithiol gywir. Felly, diolch yn fawr i chi. A allaf i gadarnhau,
felly, bod sesiwn y bore o’r pwyllgor yma wedi dod i ben?
Diolch yn fawr am eich presenoldeb.
|
Dai Lloyd: Okay. Thank you very much.
That brings us to the close of our morning session. May I
congratulate you both, certainly, for the wealth of evidence that
you’ve given us, both in written form and orally? Many
congratulations for that—for the record—Professor
Tayyeb Tahir, from the Royal College
of Psychiatrists, and also Dr Mair Parry, from the Royal
College of Paediatrics and Child Health. Thank you both very much.
May I just announce that we will be sending you a transcript of
this meeting so that you can check it for factual issues? You
won’t be able to change your mind about anything, but you can
check it just to make sure it’s factually correct. So, thank
you very much. May I confirm that this morning’s session of
the committee has come to an end? Thank you for your presence.
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[309]
Gohiriwyd y cyfarfod rhwng 12:07
ac 13:04.
The meeting adjourned between 12:07 and 13:04.
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|
Ymchwiliad i Barodrwydd
ar gyfer y Gaeaf 2016-17—Sesiwn Dystiolaeth gyda Chymdeithas y Cyfarwyddwyr
Gwasanaethau Cymdeithasol
Inquiry into Winter
Preparedness 2016-17—Evidence Session with the Association of
Directors of Social Services (ADSS)
|
|
[310]
Dai Lloyd: Croeso i chi gyd i sesiwn y prynhawn o’r
Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon. Byddwch yn
ymwybodol—y nifer sylweddol ohonoch chi sydd wedi bod yn
gwylio’r trafodaethau hyn drwy’r dydd—ein bod ran
o’r ffordd drwy ymchwiliad i barodrwydd ar gyfer y gaeaf.
Rŵan, mae gennym sesiwn dystiolaeth gyda Chymdeithas y
Cyfarwyddwyr Gwasanaethau Cymdeithasol. Felly, croeso i Neil
Ayling, Llywydd ADSS Cymru, a phrif swyddog gwasanaethau
cymdeithasol Cyngor Sir y Fflint, a hefyd Claire Marchant,
cyfarwyddwr arweiniol gwasanaethau newydd a phrif swyddog iechyd a
gofal cymdeithasol Cyngor Sir Fynwy. Croeso i chi’ch dau
i’r pwyllgor.
|
Dai Lloyd: Welcome to you all to this
afternoon session of the Health, Social Care and Sport Committee.
You will be aware—the substantial number of you who have been
viewing these discussions throughout the day—that we are
halfway through an inquiry into winter preparedness. Now, we have
an evidence session with the Association of Directors of Social
Services. Therefore, welcome to Neil Ayling, president of ADSS
Cymru, and chief officer of social services at Flintshire County
Council, and also Claire Marchant, lead director of new services
and chief officer of social care and health at Monmouthshire County
Council. Welcome to both of you to this committee.
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|
[311]
Rydym ni wedi darllen y papur
gerbron, ac felly fe wnawn eich trin chi fel rydym ni wedi trin pob
un o’r tystion eraill heddiw: awn yn syth i mewn i’r
cwestiynau. Fel rydych chi’n ymwybodol, ymchwiliad i
barodrwydd ar gyfer y gaeaf ydy hwn. Fe wnaf ofyn cwestiwn
cyffredinol i ddechrau: a ydy’r gwasanaethau cymdeithasol
ledled Cymru wedi paratoi yn ddigonol ar gyfer gaeaf
2016-17?
|
We have read the paper that’s before us,
and therefore we’ll treat you as we’ve treated each of
the witnesses today: we’ll go straight into questions. As you
are aware, this is an inquiry into winter preparedness. I’ll
ask a general question to begin with: are social care services
across Wales adequately prepared for winter 2016-17?
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|
[312] Mr
Ayling: Thank you, Chair. Thank you for the question. As you
kindly said, I’m Neil Ayling, the director of social services
in Flintshire and president of ADSS Cymru. Can I just initially say
we are extremely pleased and honoured to be asked to give evidence
to the committee, and clearly we would want to respond positively
to that request?
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|
[313] I would say that
social services are very prepared across Wales in relation to the
pressures of winter, and indeed the pressures throughout the year
in relation to hospital interface. I think it is a key priority for
social services in relation to that response, both at the hospital
interface and in the community. I think we all know that, at times,
in the past, there have been periods in the winter when services
maybe have had a winter break. Those times are well behind us,
certainly in terms of Christmas, in terms of a Christmas break.
Services are available throughout the winter period and, indeed,
many of our services are 24 hours, seven days a week in relation to
supporting people at home in the community.
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|
[314] So, yes, we are
prepared. One thing I would say is that, quite clearly, we
acknowledge we are a key part in a whole system of provision across
services, and we, our independent sector colleagues who work with
us, our voluntary sector colleagues, and obviously health,
ambulance and other partners are a key part in that provision of
service. So, we recognise that we need to play our full part in
that provision throughout the winter period—indeed,
throughout the year, but particularly during the pressures of
winter—and we acknowledge that we need to give thought to
preparing for that. I know that Claire and I will do that in our
local networks at a regional level, in north Wales for myself and
in the county of Flintshire, to actually prepare for that. I can
clearly say as much as you would like me to, but it’s an
introductory question, so I’ll maybe keep it quite brief, if
that’s okay, Chair.
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[315]
Dai Lloyd: Bydd mwy o gwestiynau i ddilyn. Diolch yn fawr
am yr ateb cychwynnol yna. Fe gawn ni’r cwestiwn cyntaf gan
Lynne Neagle.
|
Dai Lloyd: There’ll be more
questions to follow. Thank you very much for that initial response.
We’ll have the first question from Lynne Neagle.
|
|
[316]
Lynne Neagle: Can I ask what you think the key pressures are, then,
that face social services departments in Wales as you’re
going into this winter period?
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|
[317]
Mr Ayling: Okay. The key—. I suppose I started off by
saying that we are a key part of a whole system of service
provision, and I suppose that’s a theme we’ll come to
throughout our evidence, because it’s all about providing the
best outcomes for people, and outcomes for people require
intervention from different parts of the service—health,
voluntary and social care, and indeed other services that local
authorities provide, such as housing, quite clearly.
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[318]
The key pressures for social services is
in relation to capacity in some areas. I’m not talking about
capacity of professional social workers or people who assess for
services; I’m talking about capacity—shortages of
domiciliary care provision in some parts of Wales, and in some
areas, some specialist areas of care home provision are quite
strained, particularly around dementia. You will find that those
areas are not as available as we’d like them to be. There are
fundamental, long-term issues regarding that that aren’t
around winter or summer or anything else. They’re to do with
key issues in terms of priorities for resources, key pressures, key
cost pressures for the organisations providing those, and in many
ways challenges to the workforce in those providers being able to
attract enough good-quality staff to be motivated to work in those
areas of the social care sector. So, those are the key pressures
that we face.
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[319] Quite clearly, I would say that many of the
investments that have taken place in Wales of late, particularly
around the intermediate care fund, have been hugely important in
actually strengthening and reinforcing some of those sectors. So,
in a sense, as we provide in our evidence, the use of step-up,
step-down beds in care homes, the use of preventative
schemes based in people’s homes and the use of therapy
services to actually help provide greater intense care for those
areas is important. But it would be remiss of me not to say that
those long-term pressures of resources are there for the sector. I
do note from reading the evidence that other colleagues have
provided to this committee that there’s clear evidence that
some of those pressures are evident from colleagues who’ve
submitted evidence—from surgeons to nurses to the voluntary
sector. That was notable from reading the evidence across the
board, for me. So, that would be an initial response. Claire, would
you—?
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[320] Ms
Marchant: Just to echo what Neil has said there, really, good
community care services are the bedrock of any whole system. When
those services aren’t right—when they’re not
available in the right quality or quantum or in a timely
way—that causes issues across the whole system. I think that,
as you’ve seen from other submissions, and as you’ve
seen from our submission, we have concerns about the fragility,
particularly, of the domiciliary care sector.
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[321] One of the
successes of social care in policy and practice in recent years has
been the reduction in the reliance on care home placements, but
what that means is that people who are in care homes are very
frail. The complexity of need that care homes are managing has
increased, and the requirement, then, for a quality and quantity of
domiciliary care has really increased. The business models and the
ways of commissioning domiciliary care over the years—a
task-and-time approach to that—we understand are broken, and
we’re working, and actively working, to change that. So, I
think that that is well understood. We manage, and we manage crises
in providers on a daily or weekly basis. We’ve also been able
to assume and subsume that in the whole system and quantum of
capacity.
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|
[322] But there are
significant issues, really, in terms of the funding of the sector,
going forward. We operate in Wales with that £60 cap, in terms
of people paying for their community care. That places pressures on
us, as commissioners of service, around the sustainability, really,
of the funding model. There are some really good examples of
starting to do things differently. Within the authority in which I
work, in Monmouthshire, we’ve got the roll-out of something
called the Raglan project, which is a relationship-based model of
care and support, and we’re looking now—and actively
working—at how that can be applied to the independent sector
and our partners. So, commissioning needs to change quite
significantly, really.
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[323] Critical to all
of this is a point that Neil has already made around the workforce.
I know there’s a separate inquiry about the workforce that
this committee will be undertaking. Recruiting the right quality of
staff with the right vocation for care, and being able to really
train them and make sure that we’re not robbing from one part
of the sector for another part of the sector, and working together
in an integrated whole-system approach around that, I think, is
something that is a real priority for us.
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[324] Lynne
Neagle: Thank you. You referred to resources. Of course, the
Welsh Government has, thankfully, protected social services in
Wales much more than has been the case in England, and has put in
very welcome extra funds this year. How critical will it be, as we
go into this budget round, that, in looking to future winters, we
continue to have that protection for social services?
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[325] Mr
Ayling: I think it’s hugely critical and can’t be
understated in terms of its importance. As you say, the experience
in England is not good in relation to the erosion of some care
services. Claire and I were just discussing a recent report
that’s come out from the King’s Fund just very
recently, in the last month, regarding social care in
England—I think the word is some ‘Home Truths’.
What it’s saying is that there’s been a real erosion in
some areas of service—that, actually, you’re looking at
a very patchy provision and you’re looking at provision only
for those who actually need it, so most people can’t actually
access that service. In Wales, we’ve maintained that priority
in terms of social care, and it’s absolutely evident.
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|
[326] As Claire has
said, the resource pressures for the sector are significant.
It’s been great that we’ve had that protection in
Wales, and we need that to continue. The cost pressures for the
sector, because of reasonably good increases in the living wage and
in quality and pensions, are about 5 per cent to 7 per cent a year.
So, in a sense, with those increases, we absolutely need the
protection in terms of care, and I guess we need to actually have a
debate about the choices that we as a nation need to have.
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13:15
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[327] How much can we
pay for a care service which we all can rely on? Because,
obviously, the domiciliary care cap, as Claire has said, is
something that is valued by many and, clearly, we respect that as
an association, but it does mean that additional resource needs to
be found somewhere for the system to make it work. And so the
protection and the safeguarding of funding for social care is very
much paramount.
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[328] From reading the
evidence presented to this committee, it’s quite clear that
the shortages are not just in social care. Some of the shortages in
primary health and community nursing are key things that we see on
a daily basis, and that was reflected in the evidence. So, I
wouldn’t want to give the impression that it is purely about
providing resource for social care, but we are a key part of the
whole system in terms of responding to the different parts of
people’s lives.
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[329] I suppose that
one thing I would say in finishing is that we all recognise that
informal support for carers and for organisations is a key part of
what we need to provide as a public service, and actually
protecting the services to third sector organisations in a way that
they can support people caring for themselves, and actually taking
care of their own health and social circumstances, is a key area
that we would want to join Welsh Government in supporting. Thank
you.
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[330] Lynne
Neagle: Okay, thank you. If I can just ask two other quick
questions—.
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[331] Dai
Lloyd: Go on, then.
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[332] Lynne
Neagle: Your paper refers to the importance of the intermediate
care fund and the contribution that that makes to reducing
pressures. How satisfied are you that social services departments
are getting enough of a say in the use of that money, because I
know that my own department was a bit concerned that it was a bit
too health-driven?
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[333] Shall I ask my
other question as well?
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[334] Dai
Lloyd: Crack on. You’re on a roll now.
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[335] Lynne
Neagle: In terms of the workforce issues, we’ve talked
this morning about flu vaccination. Of course, it’s just as
important for domiciliary care workers to have the vaccination.
Some of them are in-house and some of them are contracted. What are
we doing to actually make sure the workforce is vaccinated as much
as possible?
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[336] Mr
Ayling: Around the vaccination point, certainly we have flu
vaccination programmes for our in-house staff and for our
commissioned staff—the independent sector colleagues that
work with us. I don’t know—
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[337] Ms
Marchant: Yes, that would be the case across Wales.
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[338]
Lynne Neagle: Okay, good.
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[339]
Mr Ayling: And your first question—
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[340]
Lynne Neagle: About the ICF—whether social services are
having enough of a say.
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[341]
Mr Ayling: In my region, we have complete openness in terms of
discussing the priorities throughout the ICF in north Wales. And,
actually—certainly, from a social services point of
view—I have no concerns that we don’t get our fair
crack of the whip in relation to investment of ICF.
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[342]
Ms Marchant: I’d echo that from a greater Gwent perspective.
The way that the ICF policy has been administered is that
it’s administered through health, but it’s got to be
agreed through the regional partnership fora, and that works quite
well. I guess—at this point, we’re three years into the
intermediate care fund—it’s a plea, really, for it to
be put on a sustainable footing going forward. We have some
recurring moneys that have come back into year three; there are now
new moneys coming out, but those need to be spent by 31 March next
financial year. And, obviously, it’s very difficult to put in
place sustainable solutions if you’re looking at recruiting
workforce on a short-term basis—you’re either taking
from your current services or you’re looking for people who
are willing to take on short-term contracts. So, if we could make a
plea that we know what works now—it’s all
well-evaluated in terms of the development of intermediate care
services, for example. What we need to make sure is that
we’ve got the right capacity in those services going forward,
and that means sustainable long-term investment.
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[343]
Lynne Neagle: Thank you.
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[344]
Dai Lloyd: Jayne.
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[345]
Jayne Bryant: It’s just a small point to come back in on what
Lynne has said. Do you have any figures around take-up of staff of
the flu vaccine? Do you have any information on that,
statistics?
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[346]
Mr Ayling: I don’t have to hand, but we can provide those
to the committee subsequently.
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[347]
Jayne Bryant: I would just be interested to see what the take-up is
and if it’s gone up.
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[348]
Mr Ayling: To be honest with you, I think it’s probably
greater in-house than in the independent sector, and I think
we’ve got a way to go to actually make sure that the take-up
in the independent sector is as strong as it is for both local
authority and for NHS staff. We’re on a journey on that, but
certainly we can provide figures subsequent to the committee.
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[349]
Dai Lloyd: Rhun.
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[350] Rhun ap Iorwerth: Just on the intermediate care fund again, is
there any evidence of a
focusing of that resource on the winter period in
particular, and using it as a means to tackle the spikes that do
happen within the health service over the winter?
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[351]
Mr Ayling: I think the intermediate care fund has been
fundamentally important at focusing on the areas that are critical
to supporting how the health and social care system works together;
how people are effectively supported in the community to prevent
them going into hospital unnecessarily, and actually how people are
effectively supported in hospital to sort of reach in and actually
support them well, so that actually they have good outcomes at
home. Because obviously one key thing that we haven’t said is
it clearly isn’t all about speed; it is about doing things
the right way, and actually giving people a good outcome when
they’re at home. It’s in no-one’s interest if,
when they’re assessed to leave hospital, they’re
actually in a care home when they shouldn’t be in a care
home, or they’re in an environment where they’re
actually reliant on home care when they don’t need to be
reliant on home care.
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[352]
I think we have used the investment year
round, but I think it’s been particularly important to
actually strengthen pressure during the winter period. I think
the—
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[353]
Rhun ap Iorwerth:
How?
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[354]
Mr Ayling: How?
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[355]
Rhun ap Iorwerth:
Yes.
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[356]
Mr Ayling: Because, when there’s been real pressure on
district general hospitals in north Wales, the ICF has
fundamentally helped in actually seeking to relieve that pressure.
So, for instance, if people are on wards and there isn’t a
particular care home for them to go to, we actually use ICF funding
for step-down beds for them to go and actually have a reablement
package. That is probably more—. Your point is: is it
particularly around the winter? It is year round, but those
pressures in terms of admissions tend to be greater in the winter
than in the summer period.
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[357]
Rhun ap Iorwerth:
Because what we’re interested in,
in a way, is seeing how resilient health and social care can be
year round, which in some way must include a mechanism for
concentrating resource over a particular period of the year because
of additional demand. Do you have evidence to show that, yes,
we’re able to help this many people stay in their homes, and
therefore keep this many people out of hospital, over that winter
period?
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[358]
Mr Ayling: The demand on social care services is consistent
throughout the year. We have spikes and we have peaks throughout
the year. There are some spikes in the winter period, but there are
actually some spikes in other parts of the year.
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[359]
Rhun ap Iorwerth:
But, in an integrated system, you would
be doing everything you can to take the pressure off where there is
a spike, and that is in the hospital.
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[360]
Mr Ayling: Absolutely.
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[361]
Rhun ap Iorwerth:
Are you able to do that?
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[362]
Mr Ayling: We are able to do it, and the services that ICF have
supported us to do that, have enabled that. So, I suppose your
question is: are we able to react in terms of the—? Because
we have excellent relationships at ward level. Having social
services staff based in the hospitals is key to actual success, and
actually having those relationships build up. We have very good
relationships at our level in the sense of actually having those
abilities to prioritise services if we actually need to, and we
have those regional and sub-regional partnerships to have those
discussions about planning for the year ahead, for the season
ahead, and for longer periods.
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[363]
Rhun ap Iorwerth:
Again, can it be evidenced? Can you show
when that is happening—
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[364]
Mr Ayling: We can show evidence the ICF has been effective in
terms of actually managing that demand. Absolutely we
can.
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[365]
Rhun ap Iorwerth:
And if that something that could be
shared, obviously, with the committee we would appreciate
it.
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[366]
Mr Ayling: Yes.
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[367]
Ms Marchant: I think it’s that ability to flex up, and where
ICF has been particularly effective, as Neil has said, is those
type of services that are at the interface of health and social
care. So, the step-up, step-down beds, the in-care facilities, the
expansion of those reablement-type services, the—I call them
rapid response domiciliary care provision, which tends to be
in-house services that can be put in place on a short-term,
bridging basis, while the long-term services—. Where we
struggle as a social care system, which isn’t particularly
related to the ICF question, is around the quantum of capacity
that’s out there in the core community services. Neil quite
rightly picked up the issue of community nursing and primary care
in addition to domiciliary care and those services that we
commission and provide as social services. Even where we want to
try and put more investment into those services, sometimes there is
an issue in terms of recruitment of workforce and the ability to
get that workforce in quickly. So, there are issues in core that
sometimes will mean we experience a delay in a transfer of care
from those intermediate services into those core community
services.
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[368]
Rhun ap Iorwerth:
And, not another question, but just a
point: I appreciate that point, and please be honest, as honest as
you can be, in terms of where the blockages are to you being able
to do more, because that’s what we’d like to highlight
in this report.
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[369]
Mr Ayling: Just to pick up on that briefly, if I may, Chair, the
blockages have been around the availability of direct care, okay?
It’s not around professional assessment and around actually
having those networks to give people—it’s around direct
care, be it reablement or be it in longer term support. So, in my
authority, this winter and longer than that, we’ve had
sessions where we’re meeting with health colleagues weekly or
twice weekly to actually say who are the people for whom we need to
expedite those blockages, and how we can actually build more
capacity into the market so that there are provisional domiciliary
care agencies in rural area or there’s some choice about
dementia support in terms of residential care, because some of
those shortages are very real. I know you will know of those from
your constituency work. We have noticed a real increase in the
intensity of those blockages in the last year, undeniably
so.
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[370]
Rhun ap Iorwerth:
Can you expand on that, because
that’s a key point?
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[371]
Mr Ayling: Yes, well, to some degree it relates to what I was
saying earlier about the whole system and it relates to what we
said about workforce. In some areas, domiciliary care agencies,
including local authority, have not been able to attract staff to
work and provide care. My authority, Flintshire, is a border
authority, and there are alternatives for people in terms of work.
I suppose there’s a real challenge for all public bodies, I
believe, to actually up our game in terms of the prominence of the
social care economy and the social care sector. How important is it
for us? Clearly, we’re all deeply committed to all sorts of
industries in our communities, and many of those are in Wales, but
the social care sector—we don’t know the exact figures,
but, certainly, looking at authorities, I’m sure there are
30,000 people working in the social care sector in Wales. We need
to protect, build on and, actually, support that sector in the same
way that we do other sectors.
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[372]
Rhun ap Iorwerth:
Thank you.
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[373]
Dai Lloyd: Julie.
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[374]
Julie Morgan: Just following up that point for a moment, are many
of the workers in the social care sector from other parts of the
EU? Have you got any analysis of that?
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[375]
Mr Ayling: There are surveys in relation to the social care
workforce that give some breakdown in terms of nationality, and we
can seek to provide that. I think we know that the care home sector
has a significant number of people from the EU and from further
afield in relation to that, and the domiciliary care sector,
similarly. There are many people who come from the EU who work in
that. I think, without getting into political water that I
shouldn’t get into as an officer—
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[376]
Julie Morgan: I just wanted facts—
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[377]
Mr Ayling: No, okay. Definitely a proportion of them do come. I
don’t know if you’ve got any specifics,
Claire.
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[378]
Ms Marchant: I don’t know the specifics, but, certainly,
when we look at the workforce, particularly within the independent
sector rather than the directly employed within the authority
sector, yes, there’ll be significant proportions within care
homes and domiciliary care providers.
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|
[379]
Julie Morgan: Thank you. The other question I’d wanted to
ask, which was to pick up on something you were saying earlier,
both of you referred to this £60 cap on the domiciliary,
at-home fees. It sounded as if, when you both said it, it was a
problem, and I just wondered if you could expand on what you were
saying about it, really.
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[380]
Mr Ayling: I think I was saying that, in relation to my
authority, the £60 cap means that there’s less money to
actually fund the overall system. The additional demand
that’s created by the £60 cap—there’s
additional demand for homecare services in my authority as a result
of the domiciliary care cap. We accept that we had support from
Welsh Government to support local authorities in terms of
transition, and I was certainly there and involved in those
discussions. But I think, for my authority, it means that,
probably, there’s over £1 million per year, which is
having to be funded elsewhere within the public sector to
provide the same level of domiciliary care.
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13:30
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[381] I suppose
that’s the problem about it; it’s certainly not a bad
thing in terms of limiting the amount that people pay, but,
clearly, the fact that the people pay that maximum regardless of
their income means that there’s potentially lost income
coming into the social care system. So, I guess that’s what I
was meaning in terms of saying it presented challenges to us. When
we’re looking at ways of funding health and social care when,
obviously, resources are tight, that is one thing that we should
consider is what we were suggesting, I think.
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[382] Ms
Marchant: Yes. It’s certainly not making any points about
whether that’s a really positive policy to be in place in
terms of the impact on the people who’ve benefited from it,
but it is a reality that people who were accessing and paying for
their own care outside of coming through the local authority prior
to the cap coming in, are now coming in via the local authority
and, along with others, are benefiting from that cap being in
place. One of the points—
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[383] Julie
Morgan: So, are you saying that the imposition of the cap meant
that more people started to claim services?
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[384] Mr
Ayling: Yes, because some people would’ve made their own
arrangements previously, and when there’s an actual cap on
domiciliary care, they actually refer for services. So, yes.
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[385] Julie
Morgan: I suppose you could look at that to say that those are
people who needed services and who were only able to have them
because there was a cap.
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[386] Mr
Ayling: You could.
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[387] Julie
Morgan: Sorry, I interrupted you.
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[388] Ms
Marchant: Just to make a point, which is, I suppose, allied to
that. One of the points I made is I think it is a huge success of
policy and practice that people are now being supported in their
own homes, who, five or ten years ago, would’ve been in a
care home setting. They’re being supported in their own homes
with the cap in place, and the cost of the equivalent and what they
would’ve been paying for the equivalent care home placement
was obviously far higher than what they’re now contributing
within the community. Doing the right thing, that’s what
we’re there to do as practitioners and directors of social
services—the right thing for the person. That’s the
frame through which we must see everything. But we also have to be
cognisant of the financial implications of that and the level of
support, which, for some people who are having to remain within
their own homes, is very significantly more than the cost of what
the equivalent care home placement would’ve been.
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[389] Dai
Lloyd: Okay. Caroline Jones.
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[390] Caroline
Jones: Thank you, Chair. Communication and planning are of
paramount importance in the management of unscheduled care
pressures. Can you tell me, please, how effective the local
authorities have been in both communicating and planning with local
health boards?
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[391] Mr
Ayling: We have a range of networks for doing that. I meet with
my equivalent in health, the area director in Betsi Cadwaladr
university health board on a regular basis and our teams also meet.
The communication, as I said, on the front line, is hugely
impressive; our managers work in hospitals and actually provide
that communication. Obviously, on a senior level, I, the chief
executive, the leader of the council and the cabinet member of the
council meet regularly with colleagues in BCU to actually discuss
those issues.
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[392] Obviously, we
are all doing that, in a way, to actually ensure that communication
is working well and to ensure that, if there are any barriers or
any things that we can solve internally within our organisations to
actually expedite problems and ensure that those linkages are
effective, we do it. So, I would say that they’re very
positive, and I think, obviously, the establishment of the Part 9
partnership boards under the social service and well-being Act is a
further strengthening of that, and that is growing and developing
in terms of maturity and will provide a further emphasis. Of
course, we shouldn’t forget that the public service boards
are still a key part of that communication as well, Certainly,
health, social care and well-being is of fundamental importance
within the public service board that I work in in Flintshire and I
know from colleagues that that’s the case in other
authorities across Wales.
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[393] Ms
Marchant: Just to echo that, really, in the authority I work
in, on the ground, we’ve got integrated teams, so we’ve
got integrated health and social care teams, which is part of the
same service; they assess people once, they care-plan once and that
reflects in the way that they work with the hospitals locally. At
senior levels, one of the things, in addition to all those formal
partnership structures that Neil has described, I think, which has
really improved over the last number of years, is the fact that we
just expedite things daily. So, if it’s running hot within
the hospitals, we know about it from the chief operating officer or
their equivalents. At the same time as they’re managing the
problem, we’re in there trying to work with them and to solve
the problem with them. So, I think that ability to expedite and to
escalate quickly is something that has really improved in recent
years.
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[394] Caroline
Jones: Yes. So, the communication is there. What about the
planning for the unscheduled pressures? Hotspots and—.
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[395] Ms
Marchant: That happens all the time. We’ve got our formal
winter plans. We’ve submitted those to Welsh Government.
We’ve been part of all those sorts of planning sessions. I
think the important bit, looking forward, is the intelligence
across our health and social care communities, about where our risk
issues are, where our capacity points are—it might be around
community nursing, it might be around primary care, it might be
around domiciliary care and the care home sector in parts of, with
us, the greater Gwent area—and then using the resources that
come in. So, there is the new intermediate care funding, for
example, that we’ve had for this year to try and
strategically put in place solutions together, which makes sense to
all of us. So, that is there, in the planning sense, and it’s
really supported by the statutory partnership arrangements.
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[396] Caroline
Jones: Thank you.
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[397] Mr
Ayling: Again, it’s at different levels. We have a
regional plan in relation to these issues across north Wales. In
Flintshire, one of the two key priorities on the public service
board is in relation to health and social care and those workers so
that there’s a plan that lays out that in the long term. That
responds to winter pressures, amongst other issues. Clearly, some
of these issues we’ve talked about, about the pressures in
the sector and the need to actually respond to those are key
elements of those plans.
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[398] Caroline
Jones: Thank you.
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[399] Dai
Lloyd: Lynne, you had a question.
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[400] Lynne
Neagle: It was just to return to this issue of the cap, because
I think it is important in terms of the pressures that you’ve
highlighted. Now, that the transitional funding has ended, the
Welsh Government would say, ‘Well, the money is going into
the rate support grant’. Is it your contention that that
isn’t being properly compensated for in the rate support
grant, or have we got a problem with local authorities not passing
that money on to social services departments?
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[401] Mr
Ayling: No. The local authorities have passed it on to social
service departments, so that money is in my authority, but
there’s been additional demand on top of that in relation to
the implication of the cap, which we’ve described, which is
over and above the amount that came in from Welsh Government around
the transition.
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[402] Lynne
Neagle: It was an unfunded pressure, then.
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[403] Mr
Ayling: Yes.
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[404] Lynne Neagle: Okay, thank you.
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[405]
Dai Lloyd: A oes yna unrhyw gwestiwn arall cyn i mi ofyn yr
un olaf i gloi? A allaf i jest gofyn yn gyffredinol—? Mae yna
ddeddf newydd yn y maes, wrth gwrs—Deddf Gwasanaethau
Cymdeithasol a Llesiant (Cymru) 2014. A allech chi jest olrheinio
effaith y ddeddf honno ar y galw am wasanaethau a’r ffordd o
ddiwallu anghenion, yn enwedig yn ystod y gaeaf?
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Dai Lloyd: Are there any further
questions before I ask the final question? Could I ask,
generally—? There is new legislation in this area—the
Social Services and Well-being (Wales) Act 2014. Can you just tell
us the impact that that Act has had in terms of the demand for
services and meeting needs, particularly during the winter
months?
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[406] Mr
Ayling: The Social Services and Well-being (Wales) Act
has—. One of the fundamental changes around it was actually
changing the relationship with people that use services, with much
more control and much more independence in the hands of people that
use services rather than being people that are passive recipients
of services. So, quite clearly, one of the implications of the Act
is that our services have followed that philosophy. So, for
instance, our initial access services, which we in north Wales call
single point of access, or SPOA, actually run along those lines. We
actually have an IT service called Dewis Cymru, which I hope
you’ve heard of, which is a way that people themselves can
actually find information about the services in their area and
respond to those themselves in terms of information about different
providers, how they might get in touch with the third sector.
Single-point-of-access services seek to actually find out what the
issue is that the person themselves perceives, rather than
traditional approaches like, ‘Do you require assistance with
activities of daily living?’, and respond to that issue.
Those approaches, where you’ve got local authority, health
and third sector colleagues working alongside each other, have been
really quite transformational in terms of actually changing our
service offer at the front door to try and actually manage some of
the services that are actually presenting on us. If you’re
asking me, ‘Has that meant that we’ve freed up
capacity?’, I would say, ‘No, it has not’,
because, actually, if you look at the demand on services and the
demographic increases that we all are actually facing in Wales, it
means that that is a way of actually managing the demand that will
be there anyway. But, certainly, it’s had that positive
impact in terms of quality, and, if done well, quite clearly,
it’s a very resource-effective way, as well as a good-quality
way, to respond to people, where they keep control and they
actually are enabled and supported to find their own solutions.
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[407] Ms
Marchant: I echo all of that. Fundamental to the social
services and well-being Act are the duties around well-being. One
of the points we really wanted to get across, alongside all the
talk about service solutions, is the absolute importance of
addressing loneliness and social isolation and putting in
place—and the ICF has been fundamental in this as
well—those sort of community connections and local area
co-ordination approaches, which the third sector is so important in
providing. The investment in those sorts of approaches, which are
fundamental to the Act, is enabling us to manage demand, if I can
put it that way, far more effectively than we otherwise would.
People might still need an element of care and support, but their
social needs, and their needs for continued connection, are being
met as well. The evidence is clearly there that loneliness and
social isolation is a bigger scourge and a bigger problem for
people and cause as many pressures on health services as obesity,
for example. So, it is absolutely fundamental, and that’s
completely there within the Act.
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[408] It’s still
early days, in terms of the Act itself, and a lot of the changes
around trying to be more outcome focused in assessments and asking
those ‘what matters’ questions—some of those
happened in advance and those changes, in practice, will continue
to progress. Then, obviously, the Act gives us duties as well about
promoting alternative models of provision, and when we’re
talking about those radical and different solutions for things like
domiciliary care, that may take us to different places over time.
It’s important that we’re putting the effort into those
commissioning responsibilities—obviously, part 9 we’ve
talked about—and absolutely embedding partnership and
integrated working. So, it’s early days in terms of the Act
itself, but it’s in the right direction, I think, in terms of
the approaches we’re trying to take.
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[409]
Dai Lloyd: Ocê. Pawb yn hapus? Pawb yn hapus.
Rhyfeddol. Diolch yn fawr iawn ichi am eich tystiolaeth ac am eich
presenoldeb—cyflwyniad graenus iawn oddi wrth y ddau ohonoch
chi. Jest i gadarnhau, ar gyfer y record, diolch yn fawr i Neil
Ayling, llywydd ADSS Cymru a phrif swyddog gwasanaethau
cymdeithasol Cyngor Sir y Fflint, a hefyd i Claire Marchant,
cyfarwyddwr arweiniol gwasanaethau newydd a phrif swyddog iechyd a
gofal cymdeithasol Cyngor Sir Fynwy. Diolch yn fawr iawn i
chi’ch dau. Fe allaf gadarnhau hefyd y byddwn ni’n
anfon trawsgrifiad o’r cyfarfod yma atoch chi er mwyn ichi ei
wirio i wneud yn siŵr ei fod yn ffeithiol gywir. Hynny yw, ni
allwch newid eich meddwl ynglŷn â rhywbeth rydych wedi ei
ddweud, ond gwnewch yn siŵr ei fod yn ffeithiol gywir gogyfer
â’r cofnodion. Diolch yn fawr iawn i chi.
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Dai Lloyd: Okay. Everybody content?
Everybody is content. Amazing. Thank you very much for your
evidence and your attendance—a very polished performance from
both of you. Just to confirm, for the record, thank you to Neil
Ayling, president of ADSS Cymru and chief officer of social
services at Flintshire County Council, and Claire Marchant, lead
director of new services and chief officer of social care and
health at Monmouthshire County Council. Thank you very much to you
both. I’ll confirm as well that we’ll be sending a
transcript of this meeting to you for you to check the factual
accuracy. You can’t change your mind about something that
you’ve said, but you can make sure that it is factually
correct for the record. Thank you.
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[410] Mr
Ayling: Thank you very much.
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[411] Ms
Marchant: Thank you. Diolch.
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13:43
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Cynnig
o dan Reol Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd o’r
Cyfarfod
Motion under Standing Order 17.42 to Resolve to Exclude the Public
from the Meeting
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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 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 in
accordance with Standing Order 17.42(vi).
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Cynigiwyd y cynnig.
Motion moved.
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[412]
Dai Lloyd: Rŵan, o dan eitem 6, rwy’n cynnig, o
dan Reol Sefydlog 17.42, i benderfynu gwahardd y cyhoedd o weddill
y cyfarfod a mynd â’r trafodaethau i fod yn breifat.
Diolch yn fawr.
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Dai
Lloyd: Now, under item 6, I propose, under Standing
Order 17.42, to resolve to exclude the public from the remainder of
the meeting and for proceedings to be private. Thank you very
much.
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Derbyniwyd y cynnig.
Motion agreed.
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Daeth rhan gyhoeddus y cyfarfod i ben am
14:43.
The public part of the meeting ended at
14:43.
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