The proceedings are
reported in the language in which they were spoken in the
committee. In addition, a transcription of the simultaneous
interpretation is included. Where contributors have supplied
corrections to their evidence, these are noted in the
transcript.
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Dechreuodd rhan gyhoeddus y cyfarfod am
11:30.
The public part of the meeting began at 11:30.
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Cyflwyniad, Ymddiheuriadau, Dirprwyon a Datgan
Buddiannau
Introductions, Apologies, Substitutions and Declarations of
Interest
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[1]
Dai Lloyd: Croeso i chi i gyd i gyfarfod diweddaraf y
Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Cynulliad.
A gaf i groesawu fy nghyd-Aelodau yn ôl? Geiriau cyffredinol
i ddechrau: a allaf i estyn croeso i bawb ac fe wnawn ni fanylu
ynglŷn â’n holl westeion nawr yn y foment? A allaf
i egluro hefyd fod y cyfarfod yma’n ddwyieithog? Gellir
defnyddio clustffonau i glywed cyfieithu ar y pryd o’r
Gymraeg i’r Saesneg ar sianel 1 neu i glywed cyfraniadau yn
yr iaith wreiddiol yn well ar sianel 2. A allaf i atgoffa pobl i
ddiffodd eu ffonau symudol ac unrhyw offer electronig arall a allai
ymyrryd â’r offer darlledu? Nid ydym yn disgwyl
tân y bore yma na larwm tân, felly os ydym yn clywed
larwm tân, dilyn cyfarwyddiadau’r tywyswyr a
fyddai’n dda, ac fe wnawn ni eu dilyn nhw heb ddim elfen o
banig.
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Dai Lloyd: Welcome to you all to the
latest meeting of the Health, Social Care and Sport Committee here
at the Assembly. Could I welcome my fellow Members back? Just a
general introduction: I’d like to welcome you all and we'll
go into detail about all of the guests in a minute. This is a
bilingual meeting. You can use the headphones on channel 1 for
interpretation or amplification on channel 2. Please switch off
your mobile phones and any other electronic equipment that could
interfere with the broadcasting equipment. We don’t expect
any kind of fire this morning, or a fire alarm alarm, so if we do
hear a fire alarm, please follow the instructions of the ushers,
and we’ll follow the guides without any kind of panic.
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11:31
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Craffu ar Gyllideb Ddrafft Llywodraeth Cymru ar
gyfer 2017-18
Scrutiny of the Welsh Government Draft Budget 2017-18
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[2]
Dai Lloyd: Felly, gyda’r rhagymadrodd yna, fe wnawn
ni droi at eitem 3, a chraffu ar gyllideb ddrafft Llywodraeth Cymru
ar gyfer 2017-18. Rydym wedi gweld y papurau gerbron. A gaf i
groesawu’r tystion? Yn gyntaf, Vaughan Gething, Aelod Cynulliad ac Ysgrifennydd y
Cabinet dros Iechyd, Llesiant a Chwaraeon—bore da—a
hefyd Rebecca Evans AC, Gweinidog Iechyd y Cyhoedd a Gwasanaethau
Cymdeithasol, yn ogystal ag Alan Brace, Andrew Goodall ac Albert
Heaney. Croeso a bore da i chi i gyd.
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Dai Lloyd: So, without any further ado, we’ll turn to item
3, scrutiny of the Welsh Government draft budget for 2017-18. We
have had the papers that have been submitted. Could I welcome the
witnesses? First, Vaughan Gething, Cabinet Secretary for Health,
Well-being and Sport—good morning—also Rebecca Evans
AM, Minister for Social Services and Public Health, as well as Alan
Brace, Andrew Goodall and Albert Heaney. Welcome to you
all.
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[3]
Gyda’ch caniatâd, ac fel
sy’n draddodiadol nawr, fe awn ni’n syth i mewn i
gwestiynu yn lle unrhyw gyflwyniadau. Hefyd, fel sy’n
draddodiadol, fe wnaf i ofyn y cwestiwn cyntaf. Ynglŷn â
chyflawni cydbwysedd ariannol yn y gwasanaeth iechyd gogyfer
â’r flwyddyn 2016-17, pa mor hyderus ydy Llywodraeth
Cymru y bydd byrddau iechyd lleol yn cyflawni cydbwysedd ariannol a
sut y bwriedir mynd i’r afael â’r problemau
ariannol presennol sy’n wynebu nifer o fyrddau iechyd lleol?
Rwy’n ymwybodol, yn naturiol, o beth sydd wedi cael ei
gyhoeddi’r bore yma, ond efallai y byddwch chi eisiau
amlinellu hynny hefyd. Felly, Vaughan.
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With your
permission, and as is traditional now, we’ll go straight into
questions rather than any introductions. Also, as is traditional,
I’ll ask the first question. Regarding achieving financial
balance within the NHS for 2016-17, how confident is Welsh
Government that local health boards will achieve financial balance
and how is it intending to address immediate financial issues
facing a number of these local health boards? I am aware of what
has been announced this morning, and perhaps you will want to
outline a little bit about that as well. So, Vaughan.
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[4]
The Cabinet Secretary for Health, Well-being and Sport
(Vaughan Gething):
Thank you, Chair. I’m happy to
start on this subject and differentiate between the system as a
whole and the challenges that we know individual health boards are
facing. This should give people some confidence about the system as
a whole: last year the system was in balance as a whole and we
lived within our means within the whole budget. The challenge,
though, is different in different parts of the system.
There’s recognition of that both from last year and from the
decisions we’ve taken around planning and the decisions
we’ve taken around targeted intervention on the budgetary
challenge.
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[5]
There are two organisations that we
don’t think there’s any prospect that they will come in
on budget, and that’s not a secret. That’s why
we made the announcement today that we’ll hold money
centrally for Betsi Cadwaladr and Hywel Dda in particular. The
challenge there is about not just supporting those organisations
for this year and into next year, but about the support that we
continue to provide to try and get them into balance in the future,
so that this isn’t a continual exercise for the rest of this
term but, at some point in this term, that we see a turnaround that
means they can work within balance. So, there’s something
about improvement there, which is important. There’s also
something about recognising if there’s a particular context
that needs a different sort of recognition.
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[6]
If you recall—whilst I know you weren’t in this place
last term around, I know that you’ve had a close eye on
everything that happens within the health world—we had a
conversation with Powys about trying to recognise their ability to
run the services and whether there was a broader problem. We worked
with them, we recognised part of the challenge that they had and we
also recognised that part of the challenge was in their own hands.
They’re now an organisation in balance. So, this is
achievable, and that’s the point about the conversation that
we should have with each organisation about where it is.
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[7]
There are pressures in other health boards too, but we think those
pressures should be eminently manageable. That’s our
expectation across the system. We expect that the announcements
that we’ve made throughout the budget process, and the
additional announcements today about reserves, should allow us to
be in a system where, at the end of the year, we do expect the
whole system to balance. But we do recognise that those two
organisations in particular have challenges that are unlikely to be
met. That’s why we’re holding an extra reserve against
those two organisations.
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[8]
Dai Lloyd: Diolch yn fawr.
Bydd yna nifer helaeth o
gwestiynau y bore yma a fydd yn mynd i mewn i fanylder, wrth gwrs,
wrth inni fynd ymlaen. Mae’r cwestiwn nesaf oddi wrth Julie
Morgan.
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Dai Lloyd: Thank you very much. There
will be a number of questions this morning that will go into
detail, of course, as we go on. The next question is from Julie
Morgan.
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[9]
Julie Morgan: Thank you very much, Chair. Could you give us
your views on how successful you think the planning system is, now
that you’ve got the three-year planning, and how has that
worked out?
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[10]
Vaughan Gething: Perhaps if I start and then I think it
would be useful to hear from Andrew as well about the system
perspective in looking backwards as well as forwards. We introduced
this to look at planning overall in an integrated way and finance
is part of that, so we’ve seen a range of organisations that
have lived within their means, that have met their duties, and
it’s been a much more sensible way of planning, both in an
integrated way but in financial planning too, so we’ve gone
away a fairly difficult and perhaps not a helpful way of rushing to
the end of year to try and meet targets. I don’t think that
sensible decisions were made and I’m actually pleased that
the Assembly as a whole, across all parties, recognised we needed a
different approach.
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[11]
But in doing that, we do honestly recognise that planning is a
moving target—it’s about understanding your health need
but equally about understanding the growing and developing maturity
within the system, and that’s at different points and
different parts of the system as well. It’s important to
recognise that, too, and not to run away from that reality. So,
some health boards have managed better than others. We have seen, I
think, progress across the team here in Wales, both the seven LHBs
and the three trusts. For example, the ambulance trust is a really
good example of an organisation where it had a real challenge about
managing its books as well as managing its ability to turn out a
service that people could understand and developing that for the
future. It now has an approved plan, where it simply was not in
that position—you could not have anticipated it would be a
year and a half ago. So, that’s again a sign of real progress
and ability within the system.
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[12]
I think we’ve made real gains, there’s more to come,
but don’t be surprised if there are still some bumps in the
road—because when you’re managing something this
complex, and the interaction that needs to takes place as we expect
the system to do even more in an integrated way, I think we could
and should expect to see further improvement, not just from those
organisations that are either in special measures or targeted
intervention, but from those that still have approved plans as
well, because the challenge won’t lessen as we move forward.
I don’t know if Andrew wants to say something about where we
are specifically on the planning maturity process.
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[13]
Dr Goodall: Obviously, we’re coming to the end of the
first three-year cycle with organisations, so we’ve had
organisations who’ve been able to achieve approval throughout
that period of time, so, for example, Cwm Taf and Velindre, in
terms of their own approaches. I think it’s important to show
progress over that time, so in the first year when Ministers were
looking to approval, it was only four organisations who had an
approved plan—that moved up to seven last year. I think this
year, actually, was a particular test for us. It’s
important—although we would like to have every organisation
in Wales approved—that actually there is ongoing discipline
within the system. We’ve maintained the standards and the
criteria in place and the number of organisations did drop, with
two organisations losing their status this year. I think maybe in
previous years that wouldn’t necessarily have happened, but I
think it’s the guidance and the discipline in place that has
allowed us to move that. It also requires us to then get alongside
those organisations to work differently. I just think that approval
status needs to mean something, and certainly for organisations
who’ve managed to achieve it, it does allow us to afford some
greater levels of flexibility for them, even choices around, for
example, use of capital funding, which means that they can operate
slightly more autonomously.
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[14]
Julie Morgan: So, you think the targeted interventions that
you’re taking are proving successful.
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[15]
Dr Goodall: I think there are two processes in place.
There’s the planning approval mechanism and then, I think,
the escalation framework that is in place really does complement
it. The targeted intervention approaches that we have put in place
do clarify organisations that have given us some concerns, maybe,
about the clarity of their plans over the next three-year period,
but we think that we can look to get those back on track, but
equally highlight some issues of managing within the resources that
they’ve got available. Certainly, those currently on targeted
intervention—we’re working very closely with them to
the end of this financial year, but the real challenge, I think, is
to take the progress into subsequent years—it’s not
just trying to get them over the line in one individual financial
year.
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[16]
Julie Morgan: But do you anticipate they will get out of
targeted measures at the end of the year?
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[17]
Dr Goddall: Absolutely. The intention is to make sure that
we make progress on all of those. The ultimate aim is to have 10
organisations who are able to have an approved status. We think it
will probably take us still a bit longer in terms of Betsi
Cadwaladr, not least recognising their special-measures status. We
probably wouldn’t expect that to come through maybe until
March 2018 at the earliest, and maybe, in respect of Hywel Dda, it
may just take a little bit longer because of the need to really
clarify some of their local clinical services strategies.
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[18]
Vaughan Gething: It’s important to recognise that
targeted intervention recognises the challenges that that health
board has, so there are different issues in each of those health
boards. So, we’ll have more to say about target interventions
later in the year, both the work that’s been done and our
expectations for each health board, that will be understanding in
addressing those particular concerns for that particular health
board, both for work that’s being done and our expectations
for each health board that will get understanding in addressing
those particular concerns for that particular health board. So, it
isn’t a one size fits all; it really is about what the
particular challenges are here that meant that I made a decision to
go into targeted intervention, how that’s being addressed,
what confidence we can have and in what timescale we think that
approval will be made.
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[19]
Julie Morgan: And I wanted to ask you at an early stage,
really, of this questioning, talking about planning ahead: how do
you take into account the particular needs of children in your
financial planning?
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[20]
Vaughan Gething: Well, it’s not just financial
planning where we take into accounts the needs of children.
It’s part of that whole integrated planning process. And the
money has to lead to outcomes. I think that the challenge always is
whether we simply focus on the sum of money in a particular part of
the service, and sometimes it can be difficult to level out and
just break out sums directed at one particular group, whether
children or older people, or other particular groups that we know
that the service as a whole has to serve. I think it’s really
about understanding: are we achieving outcomes that are acceptable
and are we seeing improving outcomes? And that’s got to be
the focus of how we then use the money. And that is an aspect
that’s taken into account when looking at
organisations’ medium-term plans. It is an aspect of the
accountability mechanism that we have, both in my direct
conversations with chairs, as well as in the joint executive team
meetings that take place between Welsh Government officials and
health boards and trusts as well.
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[21]
So, when I go through appraisal settings, then this does turn up. I
think that it’s a regular part of our conversation. I think
that that’s the important point—we don’t just
focus on adult and older people services. It’s about the
whole service and we expect to see funding allow us and enable us
to do that, and every organisation are told very clear that they
are expected to be held to account for doing that as well.
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[22]
Julie Morgan: I accept the fact that if you successfully
treat a mother, that helps a child. So, the funding is that sense
is overall. But it is helpful, I would have thought, to know how
much money, for example, was spent directly on children. Do you
have those figures?
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[23]
Vaughan Gething: Well, no, but then part of the challenge
is, when we talk about spending money directly on children, for
example for cancer—this spending money in a certain
way—
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[24]
Julie Morgan: We’ll be going on to that later on.
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[25]
Vaughan Gething: We have specialist paediatric services that
spend money in a certain way. But trying to unparcel, for example,
how much in primary care is spent on children would be difficult,
and I’m not sure it would be very helpful either. I’m
rather more interested, actually, in—can we demonstrate that
outcomes are right, that outcomes are improving, and that
we’re directing resources in a smart way, not just with the
amount of money but in the use of that money as well to deliver
improved outcomes? And you’ll know that we’ve got
formal architecture around decision making, and the UN convention
that does play a part, and an important part, in how we make
decisions across Government. But, for me, it’s got to be
about the outcomes—how do we demonstrate across the whole
portfolio, in health and social services, that we’re
improving outcomes for children? That means that it leaks into the
very direct and regular conversations that the Minister has with
Carl Sargeant and his portfolio as well. So, I really don’t
want to get drawn away for the outcomes focus, and make sure that
resource allows and enables us to see those outcomes improving.
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[26]
Julie Morgan: So, every decision you make about spend, you
take into account children.
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[27]
Vaughan Gething: Well, it can’t be on every decision
because if I’m making a decision, for example, about spending
on a particular service for older people, I’m still going to
say, ‘How I take into account the needs of children within
this?’, but when we look at the whole system, we do take into
account the needs of adults, whether they are older adults,
middle-aged adults, younger adults, and we take into account the
needs of children, including, importantly, transition services as
well, which are often overlooked and are a cause of real difficulty
in themselves, not just for the children but their families too.
And that’s particularly important, for example, in
end-of-life care. When we know that children and young people live
longer now, and there are real challenges about moving from a
paediatric and children’s-based service into an adult-based
service when you know that someone has a life-limiting condition.
So, that’s part of the complexity, which is why I really do
want to focus on outcomes and make sure that we get the outcomes
right for people and see them in the whole context. You don’t
just see a mother on her own, you see the mother in her whole
context, you don’t see the child on their own, you see the
child in the whole context—their family and social group as
well.
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[28]
Julie Morgan: This is the last question now,
really—obviously, we do have a duty, under the United
Nations, to consider children in every decision that we make. And
even if it means—. You look at an older person and you make
your decision then. I just want to be sure that that is happening
in your department.
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[29]
Vaughan Gething: As we take decisions, we do take into
account the needs of children in the decisions we make. I just
don’t want to overstate the fact that there will be sometimes
specific decisions that you make that are about that individual
service in a particular specialist area, for example we’ll
get on to talking about gender identity services later
on—there are real issues there for children and young people.
But in particular choices we make, some of that you can’t
bend just to lever in and say, ‘Actually, I can demonstrate
here an additional way to say that children have been specifically
taken account of in this particular part of the decision
making.’
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11:45
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[30]
But in the overall suite of what we do, we certainly do take into
account the impact on children, and the
services for children, and then that whole context in which
children live—in their family, in the street they’re
on, and the wider community they’re in as well. So, that is
very much part of it, not just in this department, but across
Government too.
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[31]
Julie Morgan: Thank you very much.
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[32]
Dai Lloyd: Ocê. Diolch Julie. Mae Rhun yn mynd i ddod
i mewn, ac wedyn Angela.
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Dai Lloyd: Okay. Thank you, Julie. Rhun
will come in and then Angela.
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[33]
Rhun ap
Iorwerth: Rydw i’n meddwl ei bod hi’n bwysig ein bod ni yn
dod yn ôl at yr arian ychwanegol sydd wedi cael ei neilltuo
ar gyfer Betsi Cadwaladr a Hywel Dda. Eto bail-out ydy hwn,
ac mae’n siomedig bod hyn yn gorfod digwydd. Dyma oedd union
y math o beth oedd i fod i gael ei atal, wrth gwrs, gan Ddeddf
Cyllid y Gwasanaeth Iechyd Gwladol (Cymru) 2014. Rydw i’n
edmygu eich optimistiaeth chi y bydd pethau yn gwella yn y ddau
fwrdd yna. Ond, o ystyried bod ymateb i ymyrraeth wedi’i
thargedu ac ymateb i fesurau arbennig yn golygu ffactorau eang iawn
ar draws gwaith y byrddau hynny, a allwch chi ddweud mwy wrthym ni
am y camau, yn benodol, fydd yn cael eu cymryd rŵan i wella
rheolaeth ariannol o fewn y byrddau iechyd yna? Achos mae’n
rhaid i ni ddod allan o’r seicl yma lle mae bail-outs
fel hyn, unwaith eto, yn digwydd pan fo yna ddeddfwriaeth i fod i
atal hynny.
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Rhun ap Iorwerth: I
think it’s important that we return to the additional funding
that has been set aside for Betsi Cadwaladr and Hywel Dda. Once
again, this is a bail-out, and it’s disappointing that this
has had to take place. This was exactly the kind of thing that was
meant to be prevented by the National Health Service Finance
(Wales) Act 2014. Now, I admire your optimism that things will
improve in both boards. But, having considered that the response
that there has been to a targeted intervention and the response to
special measures means that there are very broad factors across the
work of those boards involved, can you tell us a little more about
the specific steps that will now be taken to improve the financial
management within those health boards? Because we have to get
ourselves out of this cycle where such bail-outs are once again
taking place when the legislation was meant to stop that from
happening.
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[34]
Vaughan Gething:
Okay. I’ll happily start off, and
then I think it might be helpful if either Alan or Andrew come in
on some of the specific measures and work being done with the two
boards that you focus on. It’s inevitable, of
course—and I understand this, being a party politician
myself—that, when you announce additional money in-year for
organisations, it’s entirely possible that people either say,
‘I welcome this, and I welcome the fact that there’s a
recognition of the context in which this service is being
provided’, or the alternative is that people say,
‘It’s a bail-out, and this is shocking.’ Well,
that’s the honest reality of where we are, as politicians in
different parties and our different perspective on it. I just
don’t think it’d be helpful to get to the end of this
year and then say, ‘Well, blow me down, Betsi Cadwaladr and
Hywel Dda haven’t lived within their means.’ So,
it’s a recognition at this point and it’s important
that we do this at a time that allows the organisation to plan and
manage and know there is going to be the potential for
support.
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[35]
And it’s held centrally, against
what they’ll do. We still have real discipline in the system,
and an expectation that they will examine critically what they
currently do and what they can improve upon as well. That
expectation has to be real. We’ll need to recognise that you
won’t resolve this all in one year. Those organisations are
in a different place, and it’s really important as a system
that we recognise organisations are at different stages and in
different places. We would not and should not take the same
approach with Cardiff and the Vale as we would with Hywel Dda or
Betsi. Otherwise, we’re going to try and manage the system in
a way where we can guarantee there are interventions, which could
make things worse rather than better. So, the work’s already
ongoing with targeted intervention and special measures.
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[36]
I’ll hand over to Andrew in a
minute, but I just want to make that broad point that I think this
is a good thing, to recognise, within the year, that there are
challenges and pressures that are unlikely to be met, to recognise
our ability to cover those off, but also to be clear that there is
a time-limited amount of support. We do expect, within the course
of this term, that those organisations will find themselves in
balance financially, but also delivering the sort of quality of
care and services that all of us would expect, within their
means.
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[37]
Dr Goodall: And we do have examples of organisations who’ve
been able to demonstrate—despite having a broad and large
population and health responsibility working as health
boards—that they can actually manage within their means.
We’ve had organisations, such as the Welsh ambulance service
trust and Powys, demonstrating that they’ve been able to
improve a position where there’s been a lack of a plan and a
difficulty around their financial resources, and we’ve got
them to be improved. But I think there are relevant issues for
those two organisations, and they are different.
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[38]
It was quite clear, when we gave advice
for Betsi Cadwaladr to be put into special measures—and that
was accepted by Ministers—that they had a very difficult set
of circumstances. We have not wanted them to make the wrong kinds
of decisions as an organisation in the financial context of leading
to difficulties around safe services locally or reducing access.
We’ve wanted them to be able to maintain it, but we do have
an expectation over time that they need to be recovering within the
budgets that are announced, and we’ll all be working with
them alongside it. Some of this is about recognising some of those
pressures—you know, in particular, mental health as an area.
That has required some recognition of additional resources into the
system, because we’ve wanted to maintain the local access for
that facility.
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[39]
I think, for Hywel Dda, it just feels
that there’s been a more long-standing issue over many years
that we need to help the organisation with. There are some question
marks about the spread and distribution of services. To some
extent, there’s the context of what remoteness and a growing
older population can actually cause as a cost in the system, and I
think we actually need to understand that better, in terms of the
balance of services. The targeted intervention, and aligning this
support this year, which is held centrally rather than for the
organisation itself, I think allows us to try to get them on an
even keel for the first time. But I would hope as well, Minister,
that they can also learn from the experiences of what we’ve
done with some of the other organisations in Wales too. Their plans
I don’t think will be able to be put up for advice to
be signed off until at least March 2018. It will be nice to feel
that we can make some good progress on that. But the reality is
that I think they’ve got some longer-standing problems that
we’ll need to work through. And, if they can get there
sooner, that will be a positive, but I think it will be a longer
period of time.
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[40]
Dai Lloyd: Fe fydd yna gwestiynau mewn manylder ar
bethau fel iechyd meddwl a CAMHS ac ati yn nes ymlaen.
Felly, gwnawn ni gadw pethau yn sych tan hynny.
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Dai Lloyd: There will be detailed
questions on things like mental health and CAMHS later on. So,
we’ll keep our powder dry till then.
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[41]
Angela nesaf.
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Angela
next.
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[42]
Angela Burns: Yes,
thank you very much and thank you for the papers that came with
further explanation. But I’d just like to—. My series
of questions are all about whether or not we’ve got enough
money going into the NHS in the forthcoming budget. But, to do
that, I have to go back to last year’s figures as well. Given
the deficits in the health boards for 2016-17, how confident,
Cabinet Secretary, are you that the 2017-18 budget settlement is
sufficient to meet the financial challenges of the NHS? I just
wondered if you could also just explain on the record—we
talked about the system was in balance and I appreciate that both
Betsi Cadwaladr and Hywel Dda have got financial deficits. But we
also have in the integrated medium-term plans financial deficits
being forecast for Abertawe and for Aneurin Bevan. Between the two
of them, that’s another £35 million, possibly £40
million. So, you know, there is still money out there that’s
not sort of—. And I appreciate, I understand, that’s
not necessarily revenue deficit, but, nonetheless, it’s still
a deficit. So, how does all of that impact on whether or not we
actually have enough money going into the NHS for this coming year,
given that backlog that I assume we will have to make up across the
piece?
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[43]
Vaughan Gething:
It’s a really important question
that is not just for the health part of the budget, but it’s
part of the context for the whole Government. Everyone knows that
we have less money to work with from a revenue point of view.
We’ll have our arguments in parties about how and why that
is. But it’s a fact that we have to deal with. And
you’ll have heard from local government colleagues their
concern about the number of jobs that have come out of local
government and the partnership that we need to have to deliver
health and care within our context, and the concerns about whether
the Government becomes a large health authority with other things
added on. Within that context, health has still got an additional
cash boost, which meets the gap that has been predicted by Nuffield
previously, and recently by the Health Foundation too.
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[44]
So, the recognition of the potential gap
that existed in the recent Health Foundation work has been covered
by this budget settlement. And so there are real grounds for
cautious optimism about the future. And there always has to be an
element of caution, because we know that, even with that additional
funding having been found at real cost to other budgets within the
Government, that money having been found gives a real prospect of
the system being within balance and living within its means again,
and, at the same time as living within its means, of being able to
change and improve services within that context too. But this does
not mean that the national health service is awash with
money—far from it; they’re not. But I think it
reinforces the need for the health service, with its partners, to
drive real value out of the money that is spent. That will mean
doing things differently, but I think that we should have a level
of confidence that the changes, with savings in some parts of the
service, can be achieved, because we’re seeing some progress
made on that already. But the changes will be made with a
recognition by the partners that health has got a settlement that
it can work with, and can live within its means. And I think that
there’s a sense of real encouragement, because the challenges
we have are not unique to Wales. You look at England, Scotland, and
Northern Ireland: lots of the same contexts exist in those other
parts of the system. And there are different challenges in other
parts of the UK, and, actually, within England, they’re
forecasting a £2.5 billion deficit at this point in the year.
Last year in England, two thirds of hospital trusts came in with a
big deficit as well. In Wales, eight out of ten organisations came
in on budget.
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[45]
So, despite the fact that we do have very real pressures and real
challenges, there should be, bearing in mind that performance and
the budget settlement that we have achieved within the Government,
the political priority that the NHS is—but the practical
ability to live within its means is there. But I won’t
pretend to you today or on subsequent occasions that this somehow
means it’s easy and we’re all home and hosed.
It’s far from that; there are difficult choices to be made.
But there’s real potential in making those choices to drive
greater value from the money that we’re spending within the
service.
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[46]
Angela Burns: Okay. So, you said that two didn’t come
in on budget, Betsi Cadwaldr and Hywel Dda. Can you explain to us,
though, what exactly is the deficit for for Abertawe, which is
actually £20.1 million, and for Aneurin Bevan, which is
£12.8 million? So, they’re going to go into the 2017-18
budget with that shortfall. What is that shortfall, and do they
have to make that up, because there’s obviously no
recognition that there is a shortfall there.
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[47]
Vaughan Gething:
There’s something about the duty
going over more than one year, which we touched on earlier, and
there’s also something about an organisation in targeted
intervention within that. But we don’t think that the level
of forecast deficit that they have at present is really where
we’re expecting them to be at the end of the year. But I
think, to give you some proper detail, it would be helpful if Alan
goes through the work he’s doing with the organisations that
you’ve mentioned, as well as more generally across the
system.
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|
[48]
Mr Brace: Yes, if I could just pick up on this year, I guess
the last reported position from the NHS at the end of September was
a £95 million overspend, but £52 million of that was in
the two organisations we just referred to—Betsi Cadwaladr and
Hywel Dda. So, really, that left a residual pressure across all of
the remaining organisations of £43 million. I guess, if you
look back to the year before, there still remains plenty of
opportunity, and I guess a track record that the NHS has been able
to manage some of those pressures. So, at the moment, I think we
probably remain confident that the overall main expenditure group
will get into balance for the end of this year, and the
organisations that are reporting a deficit, and are at deficit at
the end of September, will continue to make progress.
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[49]
If I take Aneurin Bevan, because two
months ago I was the finance director and deputy chief exec there,
there remain plenty of opportunities for improvement, and probably
that forecast is more at the worst-case end, but on the assumption
that they won’t make progress. So, we remain confident that,
this year, the MEG will come into balance and further progress will
be made in the NHS component of that, particularly starting to have
some certainty over those two organisations that were, at the end
of September, over 50 per cent of the problem across the NHS
anyway.
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[50]
If we go into next year, and I think you
take the work of Nuffield and the Health Foundation and their
assessment that, to continue to deliver the NHS, we’ll need
about 2.2 per cent real-terms growth and continue to deliver about
a 1 per cent efficiency saving, this settlement certainly gives us
the growth that is required in real terms in the NHS, and, looking
at the track record of the NHS, 1 per cent efficiency savings
remain achievable, although some of the work of the new efficiency
board is starting to think about how we can take a broader approach
to efficiency than just the normal, more technical efficiency,
where you try to do more for less, or you try to do more for the
same. So, I’m more than happy to talk about some of that
development.
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[51]
Angela Burns: Can I ask you, then, to just develop that argument a
little bit more? Because, of course, one of the conclusions that
came out of your paper quite strongly was that the low-hanging
fruit, in terms of efficiency savings, has gone. The reports that
you’ve referred to, particularly the Health Foundation
report, say that NHS Wales must deliver at least £700 million
to close the projected funding gap by 2019-20, which is almost 10
per cent of current NHS Wales spending. I’ve worked in
organisations before, and I do understand how complicated and how
difficult it is to get a true efficiency saving. It’s very
easy to make it look like an efficiency saving, but, if you
actually want one that delivers the cash—. With that
low-hanging fruit gone, how confident are you, then, that the
funding you’re putting into the NHS in the coming financial
year will actually be enough to enable it to sustain and develop
where it needs to, but will still give that room that will allow
the organisation to deliver that efficiency saving? Because you
can’t actually deliver an efficiency saving if your back is
up against a wall. As I’m sure you all know, from an
operational point of view, you’ve got to be able to have that
wiggle room to spend to deliver that efficiency saving. So,
that’s what I’m really trying to understand.
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[52]
Vaughan Gething:
But with the budget settlement that we
have, it meets the gap identified by Nuffield and it meets the gap
identified by the Health Foundation. That other work ongoing about
delivering that efficiency is part of where we are. As Alan said,
there are still opportunities for some other technical savings,
other than those that have been made, but the point about future
savings is that it comes through the work of the efficiency board
that Andrew Goodall is chairing, but also comes through a different
approach around savings and around efficiency, and about generating
extra value from working in a different way as well. Now, that will
require some systems analysis and system reform as well, but,
actually, that, I think, is the real prize. But the NHS I do think
recognises it’s not just possible, but there’s a
responsibility, to go at it in a different way. Alan has led on
this not just within Aneurin Bevan, but has seen this across
different healthcare systems as well, so there are real
opportunities in going after what—. Alan will talk to you at
length, if you like, about allocative efficiency as well.
[Laughter.] But the point to make is that there is a real
opportunity to do this. There’s a recognition within the
whole system that it needs to happen.
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|
12:00
|
|
[53]
We’re meeting the gap identified by
the Health Foundation and by Nuffield previously, but it does mean
that—. Difficult choices are there, but these are entirely
possible choices as well. We have the opportunity to have a system
in balance, and if you ask the Health Foundation, they don’t
think that’s a position in other parts on the UK.
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|
[54]
Angela Burns: I do listen to what you say. This is an area that I
don’t feel satisfied that we’ve explored enough, but I
don’t propose to it now because I am really aware that the
Chair gave us very strict rules about questions, because there are
a lot to ask you in this very short session. So, can I just—?
I do understand how difficult it is to achieve true value for money
through efficiency savings. Can I just perhaps ask my final
question, which would be: the extra money that you’ve put in
towards the NHS—the £240 million, for example, and the
other smaller sums of money that you’ve popped in here and
there where you’d like to add to programmes, and the changes
that you’ve made—how confident are you that that sum of
money would be enough to enable you to have that room to drive
forward the service reforms that you want, the efficiency savings
that you want, and in the meantime to continue to drive an upward
trajectory on improvements in delivery?
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|
[55]
Vaughan Gething:
I think I’ve given a really clear
and consistent message to the service, both before the election and
a since my confirmation in this post, about where I expect the
service to be in terms of delivering some of that headline
improvement, and at the same time, being really clear that new
money coming into the NHS budget—there’s going to have
to be something for something in that, in the sense of:
there’s got to be proper service reform to deal with some of
the change and transformation we know needs to take place.
We’ll have more to say in the new year about an approach on
how we’ll make use of that money, but this won’t be a
surprise to health boards and trusts here in Wales. They know
that’s our expectation and they know that that’s the
way that chairs and chief execs will have a very high level of
expectation and accountability in using that money in a different
way to change and transform services. So, it won’t simply be
going into things as we do now—just put the money into the
bottle and do what you want with it. There will be a an approach
about tying additional investment into service reform and
improvement, and demonstrating that’s actually going to
benefit the citizen in the way that they receive and take part in
the service.
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|
[56]
Dai
Lloyd: Diolch, Angela. Fe wnawn ni symud ymlaen. Mae’r gyfres o
gwestiynau nesaf o dan ofal Dawn Bowden.
|
Dai
Lloyd: Thank you, Angela. Dawn
Bowden has the next set of questions.
|
|
[57]
Dawn Bowden: Diolch. Thank you, Chair. Minister, I wanted to pick
up a couple of the—much of it you’ve already covered in
response to Angela, around NHS efficiencies. Can I just put it to
you that, although the report does talk about, you know, most of
the low-hanging fruit as already being dealt with, there are still
huge inefficiencies in the system that need to be addressed? When
you and I were working in a different life, we talked about
this—as I did with Andrew in the joint consultative groups
and so on—and there seemed to be an awful lot around IT and
around procurement, and about wastage around drugs and all of that
kind of thing, which appear to be low-hanging fruit and should have
been dealt with, but actually, there are still huge inefficiencies
in the systems around that. So, what steps are you taking to
address some of those areas? Are you confident that we’re
going to be able to deliver those very clear efficiencies that
still need to be tackled?
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|
[58]
Vaughan Gething:
Yes, and I think people that are
supporters of the national health service should not be shy to say
that we expect it to become more efficient, and to recognise where
it can drive greater value in what it does. I’d agree with
you that there is more that could and should be done in areas that
would still be considered to be low-hanging fruit, and some of it
will take a little more time. I’ll ask Andrew to talk about
the efficiency board, because it’s something we’ve
introduced, led by the chief exec of NHS Wales, to make sure that
there is a drive about some of that central efficiency. Because I
don’t accept that we’re at a point where everything is
too difficult to achieve. There’s lots for us to go at, and
that’s an optimistic perspective to take, because it means
that there’s further improvements we can make within the
system. The new money should unlock some more of that as
well—going back to the point you made about whether
there’s the room and the space to do that. But perhaps you
wanted to say something about the new board, Andrew.
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|
[59]
Dr Goodall: I think we should give some credit to the NHS,
because over time it’s continued to be able to demonstrate a
level of efficiency savings, through both innovative and
traditional routes. So, that has helped us over the last five
years, for example, and over the last 10 years, and I know
it’ll help for the future. But I think we can also help the
understanding with individual health boards by work that
we’re holding nationally. So, we do now have an efficiency
board in place, and I’ve been chairing it. We’ve been
working our way through a number of areas: information and data
around productivity and efficiency, challenging ourselves on
medicines management, looking at whether we can organise
theatres in a better way, taking account of the Health Foundation
work. Our next meeting, which is actually happening on Friday of
this week, is looking at some of the emerging work that’s
come through from recent assessments by the Wales Audit Office on
medicines management, although we still require that with their
local plans as well. We’re trying to ensure that we can lay a
level of expectation centrally that we expect people to be chasing
down some of those numbers on behalf of patients, and on value for
money and on outcomes as well. But also they should be drawn into
the local plans for organisations as well. So, there’s an
aspect of support, but there’s also an expectation of some
compliance with some of these areas. I think it would be right to
expect, on an ongoing basis, that we continue to
go—obviously, in some of the traditional areas—but I
genuinely feel that our opportunity in Wales is that we can look at
things through a slightly different lens and be more innovative on
our thinking about the value and some of the variation that we see
across the different organisations and areas of Wales as well.
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|
[60]
Dawn Bowden: I think that that’s very
welcome—the innovation. Can I just ask: is part of the work
of the efficiency board actually talking to the staff on the ground
that are working? Because it seemed to me that staff were often
throwing up all kinds of issues and ideas around the way in which
front-line services could be more efficient. Quite often that
seemed to be overlooked. It seemed to be that there was a kind of
top-down approach to efficiency, instead of actually talking to the
people who are delivering the job.
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|
[61]
Dr Goodall: I would personally expect organisations to
absolutely listen to their staff. I certainly did that myself as a
chief executive out in the service within health boards in terms of
their own reflections on areas that either they were frustrated
about or they felt could actually help with resources. We’ve
probably not drawn in specifically the staff perspective around the
current discussions. We’re also reviewing areas like the
Carter review that took place over the border in England, and
making sure that we do our own assessment, but my
proposal—and I’ve shared this with the partnership
forum—is to use that as the committee that can have an update
and an overview of some of the areas that are highlighted here. But
I would expect local health boards and trusts themselves to
absolutely be drawing in their staff reflections because they
understand what it means on the front line.
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|
[62]
Vaughan Gething: It might help to have a reflection, a
recent one, from Alan as well on how that can be addressed through
our national approach too.
|
|
[63]
Mr Brace: If you look at a lot of the work of people like
the Health Foundation, although they’ll talk about 1 per cent
efficiency, they’ll also talk about significant variation
within organisations around that. I think that probably points to
some of your question around—there seems to be some
organisations that are more capable of engaging with people who can
help them with that efficiency debate rather than trying to issue
it as a target that people respond to. If you look at the very
practical level with some of the things that we’ve now put in
place, we’ve got some unique advantages in Wales, I think.
We’ve got a shared service. They run most of our procurement.
We’ve established a clinical procurement board, chaired by a
medical director. They are really bringing clinicians in to say,
‘Why do we need to use so many different products?’. If
we could just think about standardising—but standardising on
products that drives the right outcome for patients—and then
just let’s maximise the benefit of the purchasing power that
we would have by concentrating on a narrower range of products that
we all agree are the best to use—clinically safe and
clinically appropriate. So, there are now more and more mechanisms,
I think, where people are being drawn in. As Andrew said, I think,
increasingly—and certainly we have benefited hugely in
Aneurin Bevan—things like the trade union partnership forum
give you a real insight into what’s going on. So, you can sit
at the board level and think that you’re tackling some of
these sorts of issues. You get some really almost-live feedback
through those types of mechanisms about where things need to change
and where opportunities exist. I think Wales now, with a smaller
number of organisations doing much more centrally, but also
engaging a lot more within individual organisations, will allow us
to have a bit more confidence that greater than 1 per cent will be
achievable, even on just the basic technical efficiency.
|
|
[64]
Dawn Bowden: That’s helpful, thank you. Can I just
very briefly ask a couple of other questions, just around
efficiencies on staffing, really, and how you feel the balance is
going to be struck between maintaining what is effectively a tight
pay policy with the dilemma that that presents in terms of
recruiting staff—how you maintain that and that efficiency,
but also, at the same time, recruit and retain staff, particularly
given that you’re going to have to think about as well now
the new rate for the living wage that has been announced and at
what point that will be implemented and so on? So, you know, how
are you going to manage all of that?
|
|
[65]
Vaughan Gething: They’re honest and really difficult
challenges for us. As you’ll know, Dawn, there’s the
challenge about the NHS being perhaps the one big block of the
public sector where people still expect more staff to be recruited.
I don’t think I’ve ever had a question session in the
Chamber or in committee where people have said ‘You need less
staff’. It’s always about needing more staff, and
always the bids come in for that. So, that’s part of the
pressure that we need to manage and, at the same time, we have got
a very tight settlement. And you know, there’s a UK
perspective and a policy perspective that is being driven by
central Government that means that pay restraint is a real
challenge, and it means that some workers have not had real-terms
pay increases for some time. I don’t shy away from that. If
we had a completely free hand, and different sums of money, then
we’d take a very different approach. But there’s
something about the pragmatism of those different groups, and the
principle point of view as well, and about wanting to make sure
that lower paid workers are not left behind. That’s why we
took the decision on the living wage—and of course, you had
an interest in that in a different life—and about wanting to
see how we maintain our commitment to low-paid workers, how we make
sure that we maintain the pay structures we have and, equally, how
to maintain the bargaining arrangements.
|
|
[66]
So, we’re going into now the pay review body
evidence—and we’ll wait to see what those reports look
like—as well as the negotiations we’ll need to have
with colleagues in the BMA, because we still don’t have a
clear position on what the junior doctor contract looks like in
England. That’s a real pay pressure and a challenge for us as
well, but we do have sensible and constructive relationships and
we’re starting the negotiation round on the next GMS contract
as well. So, all of these things are with us, and are very real
pressures, but what I would say—and perhaps it will give some
confidence not just to Members here, but outside as well—is
that I recognise there’s a real challenge between the pay
line moving upwards and the head count as well, and that’s a
difficult conversation to have. But I also recognise that
we’re in a fortunate position here in Wales to still be able
to have a conversation—and that does not mean we always agree
on every single part of it—that is constructive and
respectful, with each of those different parts of the workforce and
their representatives. But I don’t pretend it will be an easy
next few months. We’re going to have to deal with the
practical challenges of all those choices, and the fact that we do
some of that despite having a good settlement, I think, within a
budgetary context, from the Government, for the NHS, but it’s
still a challenging one to meet all those different pressures.
|
|
[67]
Dawn Bowden: Okay, thank you. Just a final brief question,
perhaps to Andrew, if I may. There was a considerable piece of work
going on around how we were going to deal with agency costs,
particularly around nursing, because I think, in the last couple of
years, it was the first time that nursing agency costs has actually
overtaken medical agency costs. So, can you perhaps just give us an
update in terms of where we’re at with that piece of
work?
|
|
[68]
Dr Goodall: We continue to have the group in place, which
you were probably aware of previously, and, yes, we’re taking
a number of approaches, some of which are national, and some of
which are through more regional arrangements across organisations.
We’ve tried to, on an agency perspective, limit some of the
use of agencies, so making sure that there’s a focus, of
course, on existing contractual relationships, rather than through
exceptions. A lot of this, though, of course, is about how we steer
staff numbers on the ground, and, inevitably, in our system,
probably around 4 per cent of our pay budget goes currently on
agency and locum use. We, of course, want to convert that to
substantive staff as much as possible and work it through. We have
other pressures coming through like the more staffing arrangements,
for example, that we need to balance.
|
|
[69]
We have got more staffing in place—about 8 per cent more than
10 years—ago, so it’s important to recognise that
we’ve been making some progress, but we also need to keep
ahead of these pressures. I think, for an expectation for the
system, we need to keep expecting that there should be a
stabilisation first, and then a recovery around the current agency
and locum spend in the system. But, what we can’t stop is
that there will be moments when these staff need to come in for
safety reasons, not least for local services at this stage.
|
|
[70]
What I would like to see, though, is perhaps a better understanding
about where we make decisions on locum use, for example, for the
right kinds of reasons. So, mixed up within some of those figures
are some decisions taken to stabilise services where they are
planned decisions, rather than exceptional. So, for example, in
north Wales, the maintenance of maternity services require Betsi
Cadwaladr to recruit a whole number of locum consultants in place.
We had our mid-year review with Hywel Dda yesterday, and they were
outlining that, actually, in their local services, they had 17
recent locum consultants who were in post. That secures the service
on the one hand, but actually, for them, it does allow them to
potentially recruit, and I was really pleased to hear that some of
those individuals are actually interested in taking up substantive
consultant posts in that area as well. So, sometimes, a locum spend
may sound as though it’s the wrong kind of spend, but it can
sometimes attract in future substantive staff.
|
|
[71]
Dawn Bowden: Okay. Thank you.
|
|
[72]
Dai Lloyd: Y cwestiwn nesaf gan Caroline Jones. Cwestiwn
10, Caroline.
|
Dai Lloyd: The next question is from
Caroline Jones. Question 10, Caroline.
|
|
[73]
Caroline Jones: Diolch, Chair. Regarding maintaining NHS
performance, I’d like to ask whether the funding will enable
the NHS to meet key performance indicators, which are currently
proving difficult to achieve.
|
|
12:15
|
|
[74]
If we look at waiting times for treatment, access to diagnostic
tests, access to mental health services, and also child and
adolescent mental health services, waiting times in A&E, and
delayed transfers of care, how confident are you that the level of
funding will help us achieve these key performance indicators and
meet the targets?
|
|
[75]
Vaughan Gething: I expect that we’ll see improvement
across the system through the year. We’re about to come into
winter where actually emergency pressures and unscheduled care are
always facing a significant challenge. And part of my challenge in
managing that time of year—and I know that I’m going to
come to committee in a couple of weeks to talk about that at some
more length—is the balance between unscheduled care and
elective care as well. So, that’s an important planning
aspect.
|
|
[76]
If you look at the history of the national health service within
the last five years and more, what you typically see is that, at
the start of the financial year, there’s a relaxation and a
ballooning out of a range of these measures and you need to see if
you can come back in the second half of the year. On waiting times,
what we’ve actually seen is a level of real stability through
this year. And I still expect that we’ll see an improvement
in the second half of this year in those headline performance
figures, despite the fact that we’re going through the winter
period.
|
|
[77]
On cancer, for example, we know that there have been challenges
about whether the level of resource allows us to do that. Actually,
in that circumstance, it’s often more about how the service
is organised. Now there’ll be difficult choices again in this
area about what we do and how we do it. Some of the new diagnostic
investment will help us with that. But an awful lot of this is
understanding whether the right pathways are in place, and
understanding how and where people flow between different health
boards at different stages of their treatment.
|
|
[78]
So, what I think you’ll see is a system that will continue to
improve through the second half of this year, and that’s
really important. But in terms of the headline measures that we
currently have, I don’t think we’ll hit all of those
through this year, and I won’t try and pretend to you that we
will. But I do think that you’ll see a real improvement
across a range of those measures, which is good news for patients,
but also it then goes back to the transformation points that came
from earlier questions about not just using the money to buy
performance in the short term, but about how we see a genuine
transformation in the way that services are configured. So,
we’ve directed people to different parts of the system, but
are those different parts able to cope and provide a service that
the citizens need as well? So, I think that there can be some
optimism about the real level of improvement that you are likely to
see in the second half of this year.
|
|
[79]
Caroline Jones: Okay.
|
|
[80]
Dr Goodall: And I think there are some foundations here in
place, you know, just on diagnostics for example. And the figures
are 42 per cent better than the same time last year. All these
figures were actually the lowest that they’ve been since
2011. Our referral-to-treatment time position is actually 24 per
cent better than last year. And we need to keep on some progress.
You highlighted some other areas. On the mental health side,
we’ve had 110,000 people though the primary care mental
health teams and we’ve seen improvements on the mental health
targets in place despite the fact that we’ve actually reduced
the time target, so, we’re already meeting 75 per cent on the
intervention target, for example. And even on primary care, we know
the latest figures for the QOF assessment, that’s the quality
and outcomes framework for GPs, again shows a very high performance
across our system. And access hours have continued to expand and
increase too. So, I don’t think that any of those are about
saying that we’re complacent about performance, but I do
think that we’ve got a foundation to keep pushing on and not
least through the next number of months and into next year.
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|
[81]
Dai Lloyd: Ocê,
mae’n amser symud ymlaen i sut rŷm ni’n ariannu
llywodraeth leol, ac mae’r cwestiynau nesaf hefyd gyda
Caroline Jones.
|
Dai Lloyd: Okay, we’ll now move
on to how we fund local government. The next question is also form
Caroline Jones.
|
|
[82]
Caroline Jones: Diolch, Chair. Thank you. What is the
process for determining the level of funding for social services
provided through the revenue support grant to local authorities for
social services in 2017-18, and will this keep pace with the
additional demands on social care, as identified by the Health
Foundation?
|
|
[83]
Rebecca Evans: Thank you for the question about funding for
social care to local government. Essentially, the decision as to
how funding to local government is taken forward is one for the
Cabinet Secretary for Finance and Local Government, but the money
does go through the revenue support grant. The revenue support
grant recognises the many functions of local authorities, including
social care, but the funding within it for social care isn’t
hypothecated, so, it does give local authorities a certain freedom
in order to try and meet the local needs that they identify, which
will vary depending on the local populations across Wales. The
overall settlement to local authorities, as you know, is £4.1
billion. There was additional funding of £25 million this
year for local authorities, in specific recognition of the
importance of strong social services, alongside additional funding
of over £4 million to fund our pledge on doubling the capital
limits—we’ll be taking that up to £30,000 next
year—and additional funding again for the pledge we had on
the full disregard of the war disablement pension, which I’m
really pleased to say is going to come into force in April of next
year.
|
|
[84]
Caroline Jones:
Okay. Thank you.
|
|
[85]
Dai Lloyd: Mae’r cwestiwn nesaf dan ofal
Lynne
Neagle.
|
Dai Lloyd: The next question will be
asked by Lynne Neagle.
|
|
[86]
Lynne Neagle: Thank you for your answer to Caroline Jones. Of
course, we know that local authorities are under tremendous
pressure, and they have received a slight decrease in funding
overall, so I think there will be a natural temptation to want to
use some of the social services money on other things. What steps
is the Welsh Government taking to ensure—and to
monitor—that appropriate levels of funding are actually spent
on social services? Can I also ask about some specific pressures?
Obviously we know that things are in the pipeline, such as changes
to domiciliary care staffing that are really welcome—that
we’re looking at ending zero-hours contracts, and things like
that—but that could potentially have a significant
commissioning cost for local authorities. What assurances can you
offer that the money that has gone into the RSG is going to be
adequate to meet those needs?
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|
[87]
Rebecca Evans: Thank you for those questions. I meet very regularly
with representatives of the WLGA, both in terms of social services
and the responsibilities I also have for community sport as well,
to discuss the pressures. I have to say that they’re not
backwards in coming forward in describing the kind of pressures
that the sector is facing at the moment. They’ve described
the settlement as challenging but fair, which I think is probably
an accurate way to describe things given the current financial
situation and the pressures facing the sector. But I think that
funding for local government is only part of the picture in terms
of the picture for domiciliary care staff, because
professionalising and making the sector more sustainable is really
at the heart of what I’m trying to achieve. To do so,
we’ve undertaken a large piece of work that has looked at the
views of people in the domiciliary care sector to better understand
what is preventing career progression, and what is preventing
people coming into the industry, because we know that there’s
a turnover of 30 per cent, and every time you recruit a new member
of staff in the domiciliary care sector, the cost to the business
is £3,500 in terms of training and so on. So, if we take
steps such as ending the abuse of zero-hours contracts to support
staff in the sector and to make the sector more sustainable and
more attractive for people to enter, then I think that will
certainly be really helpful to local authorities as
well.
|
|
[88]
Dai Lloyd: Jayne Bryant efo’r cwestiwn
nesaf.
|
Dai Lloyd: Jayne Bryant has the next
question.
|
|
[89]
Jayne Bryant: Thank you. I was very pleased, just to come in
on the back of what Lynne has said, to see your recognition of the
pressures on local authorities with regard to social services.
Perhaps you could just outline a little bit more how you envisage
that additional funding of £25 million for social services,
and how that will be used.
|
|
[90]
Rebecca Evans: Well, this would be a matter for individual local
authorities to decide. I don’t really want to direct local
authorities as to how they would want to spend that funding, other
than to spend it on ensuring that we have strong, sustainable
social services for the future, because as I said, the pressures
will vary from local authority to local authority. There might be
pressures, for example, relating to the national living wage
introduction, or the increase of that next year, which they might
want to consider. But it will be about meeting the pressures
locally.
|
|
[91]
Dai Lloyd: Nôl i Lynne Neagle am y cwestiwn nesaf.
Lynne.
|
Dai Lloyd: Back to Lynne Neagle for the
next question. Lynne.
|
|
[92]
Lynne Neagle: Thank you. You mentioned the announcement of the
extra funding to enable the commitment to increase the capital
limit for residential care to be met. Have you made any assessment
of how many people will be beneficiaries of that in this first
implementation stage? Also, you mentioned the very welcome
disregard for the war disablement pension. How many people do you
anticipate are likely to benefit from that disregard?
|
|
[93]
Rebecca Evans: Well, in terms of the independent research that we
commissioned to look at the state of the sector, particularly
regarding those who pay for residential care themselves, we know
that there are up to 4,000 care home residents who currently pay
the full cost of their residential care. So, increasing the capital
limit from its current level of £24,000 to £50,000 has
the potential to benefit around 1,000 of these, and increasing it
to £30,000, as we will as of April next year, will benefit in
the region of 250 people.
|
|
[94]
Dai Lloyd: Diolch yn fawr. A’r cwestiynau nesaf, ar
atal, o dan ofal Dawn Bowden.
|
Dai Lloyd: Thank you very much. The
next questions, on preventative measures, are by Dawn Bowden.
|
|
[95]
Dawn Bowden: I didn’t have the translation on then,
Dai, sorry. Okay, a couple of questions around prevention, please,
if I might, and whether you believe that funding for the
preventative services is sufficient, well-targeted and able to
demonstrate clear outcomes, and to identify whether there’s
any tangible evidence of seeing benefits from preventative
initiatives. So, there we are, I’ll leave it at that.
It’s a fairly clear question.
|
|
[96]
Rebecca Evans: I’ll start with this. As we said in our
evidence paper to you, representing preventative spend in our
resource allocation is actually highly complex because they can
take a variety of forms—it’s not easily separated from
other forms of spend. For example, on spend in primary care, much
of that will be focused on preventative measures. But in terms of
the actions that we’re taking, we have a wide, wide range of
preventative actions that we support, for example, investing in
evidence-based preventative healthcare interventions, such as our
immunisation screening programmes as well as settings-based
approaches to improving public health, so the work that we’re
doing on healthy workplaces, for example.
|
|
[97]
We’re also seeking to improve
health literacy and support individuals to take greater
responsibility for their health because we know that this is one
area in which Government can’t do things alone. Actually,
Government can do a great deal, but it will take the individual,
local authorities, education and the third sector all to work with
us to address these challenges. We can also take legislation
forward in order to address public health challenges as
well.
|
|
[98]
I’m pleased to say, as you will
know, that I’m introducing the Public Health (Wales) Bill to
the Assembly on Monday of next week, with the opportunity for
Members to scrutinise it on the Tuesday. We also want to work with
the broader public sector and others in promoting health and
well-being, which is why we’re looking at models for social
prescribing, which I think is a turning point, I suppose, in the
way that we support people to look after their health and meet
their healthcare needs, rather than a pill being for
everything—actually, there are other things that can help a
great deal. That really recognises the importance of good mental
health.
|
|
[99]
Finally, as well, we’re setting a
framework and providing assurances over our preparedness to deal
with infectious disease outbreaks, environmental hazards and
significant health emergencies and so on, such as a pandemic flu
outbreak, for example. We would be prepared for those
events.
|
|
[100]
Dawn Bowden: Can I just take you back to the point you made then
about sport being used in the preventative measures and how you
think that an investment in sport can be targeted, particularly to
support the public health agenda?
|
|
[101]
Rebecca Evans: I think there are two sides to this: there’s
sport and physical activity as well, because I think there’s
always been quite a focus on sport previously, which has led us to
think of sport very much in elite terms, but actually, this
Government now is bringing back a focus to community sport and to
physical activity as well, because sport is only 30 per cent of
physical activity. So, the majority of our work that we do on sport
is done through Sport Wales. Sport Wales take up the vast amount of
the sport budget. I’ll be agreeing their allocation after
I’ve received a copy of the chair’s review, which is, I
understand, coming to a conclusion at the moment, so I look forward
to seeing that. The chair’s review will be looking at how the
organisation can best support Welsh Government aims, particularly
with regard to our interest in expanding our physical activity
agenda as well. So, I’ll be agreeing Sport Wales’s
budget as soon as I’ve had the opportunity to consider the
chair’s report. But, of course, there are other ways in which
we’re supporting things, for example, through our Active
Travel (Wales) Act 2013 and financial support for that through Ken
Skates’s department, for example.
|
|
[102]
Dai Lloyd: Rhun, roedd gen ti gwestiwn atodol ar hyn—un
byr.
|
Dai
Lloyd: Rhun, you had a
supplementary question on this—a brief one.
|
|
[103]
Rhun ap Iorwerth:
Dau byr. Un, pa
asesiad sydd wedi ei wneud o’r cyfraniad o gyllidebau
adrannau eraill yn y Llywodraeth tuag at yr agenda atal afiechydon?
Yn ail, pa arloesi mae’r Llywodraeth wedi, neu yn, ei wneud i
chwilio am ffyrdd newydd o gyd-gyllido rhwng cyllideb yr adran
iechyd a gofal cymdeithasol ac adrannau eraill er mwyn hybu'r
agenda?
|
Rhun ap
Iorwerth: Two brief ones.
First, what assessment has been undertaken of the contribution from
the budgets of other Government departments towards the agenda to
prevent diseases? Secondly, what innovation has the Government, or
is the Government, undertaking to seek new ways of having pooled
budgets between the health and social care budgets and other
budgets in order to promote this agenda?
|
|
[104]
Rebecca Evans: If I can begin with the issue of pooled budgets,
under the Social Services and Well-being (Wales) Act 2014,
there’s a requirement on local health boards and local
authorities to establish pooled budgets to meet the needs of people
in residential care by April 2018.
|
|
12:30
|
|
[105] Today,
there’s an event with all of our regional partnership boards
attending, looking at what support they might need from Government
in order to get them ready for that. Because, obviously, planning
has to start now, because pooling budgets is obviously a complex
matter. So, we’re certainly addressing that through
legislation under the Social Services
and Well-being (Wales) Act 2014.
|
|
[106]
Vaughan Gething:
In terms of the way in which we work with
other departments, I hope you’ve seen, not just in
conversations we’ve had since coming into office, but,
actually, really recently, in the Public Health Wales conference.
They don’t just talk to public health professionals,
they’ve got links to Community Housing Cymru, and a range of
others, including police and crime commissioners as well. So, it
does cut across devolved areas and non-devolved ones too. You can
think about the partnership we have with Carl Sargeant’s
department, where we recognise that, actually, having high-quality
housing makes a really big impact on someone’s health and
health outcomes. So, if we’re going to look at how we improve
health outcomes in the future, it will require that
cross-Government approach.
|
|
[107]
Again, education is another really good
example. If we look at our Healthy Child Wales
programme—actually, that’s got to link into and talk to
education. We’ve got to find a way to make sure that
information that is useful goes from the family and the child into
the school setting, their early learning years and other childcare
offers—lots of different conversations within the Government
that need to take place to improve those health outcomes. The
recent, and I think very welcome, focus on adverse childhood
experiences demonstrates that lots of those are outside the health
field, but they have a very real impact on people’s health
outcomes, and, actually, their whole life outcomes too. So,
it’s absolutely the approach we take within
Government.
|
|
[108]
So, regardless of all the allocations of
the financial part of the budget scrutiny, when we all have the
sums of money, actually we’re still going to have to focus
back on, ‘And how do we deliver real value for this money
across the whole Government, as well as within our part of it as
well?’ So, you’ll see more and more work, I think, in
the future, between this department, housing and education in
particular, but it isn’t just those areas and it isn’t
just devolved services either.
|
|
[109]
I could go on and on and on, but, you
know, the police service in particular are really important
partners for us on a whole range of these things, whether
it’s about domestic violence, or whether it’s actually
about getting into schools again, and having a message that the
police buy into as well about different forms of behaviour. So,
there’s an awful lot that we could do—we could have a
whole session on it if you wanted to. But there should be some
confidence from them, as part of what goes into both the budget
strategy and then the expectations of how Government will deliver
with our partners outside Government, not just in this term, not in
this year, but in the future too.
|
|
[110]
Rhun ap Iorwerth:
Confidence is all very nice; I’d
rather have the evidence. Hopefully, we will be able to return to
this.
|
|
[111]
Dai Lloyd: Rebecca, oedd gen ti bwynt?
|
Dai
Lloyd: Rebecca, did you have a
point?
|
|
[112]
Rebecca Evans: I just wanted to add that, as part of the public
health Bill, which will be introduced to the Assembly next week,
there will be the creation of powers to require health impact
assessments from all of the bodies in certain circumstances, which
are covered under the Well-being of Future Generations (Wales) Act
2015, and that will help us move towards that health in all
policies aim that we have.
|
|
[113]
Dai
Lloyd: Diolch yn fawr. Symudwn ymlaen nawr i sôn am y gronfa
gofal canolraddol, ac rydw i’n edrych ar Jayne Bryant i ofyn
y cwestiwn nesaf.
|
Dai
Lloyd: Thank you very much.
We’ll move on now to talk about the intermediate care fund,
and I look to Jayne Bryant to ask the next question.
|
|
[114]
Jayne Bryant: Thank you, Chair. With the intermediate care
fund’s clear objective, which is prevention and to reduce
unnecessary admissions to hospital or residential care, what
outcomes have been secured from the extra money?
|
|
[115]
Rebecca Evans: Well, the key outcome, fortunately, meets the aim in
terms that we’ve been able to support more older people to
maintain their independence and stay at home and receive care in
their own home, and prevent admissions to hospital. In the evidence
paper I’ve provided, I offered some examples of how our
revenue fund has been able to do that in different circumstances
across Wales. Within that, actually, we’re able to
demonstrate now the number of bed nights saved to the NHS, for
example, and I think that that is quite compelling evidence that
the ICF is making a real difference. That’s certainly the
feedback that we’re getting from people, both working in the
ICF arena, but also from people who are on the receiving end of the
care as well.
|
|
[116]
Jayne Bryant: So, that will continue to be evaluated in the same
way that you’ve been doing it this time, in the future, will
it, or—?
|
|
[117]
Rebecca Evans: Well, actually, we’re increasing the evaluation
of it from this year forward. Perhaps Albert would like to say a
little bit about that?
|
|
[118]
Mr Heaney: Thank you, Minister. We’ve been evaluating. As
you know we’re in the third year of the intermediate care
fund—very popular with both practitioners and people
receiving services, but as we’ve developed we’ve
realised that we need to get enhanced strengthening around the
outcomes that come in to us. So, we’ve revised the template
that we currently use. That focuses much more on outcomes and
expenditure value for money. We have been continuing to work with
the regions and the regional partnership boards, and there’s
been a number of site visits to actually see the services,
and I know that many of you in the room as well have been out to
some of those services. So, we’re using that intelligence to
actually enable us just to build and to clarify. What we will,
therefore be, doing at the end of each quarter—we will be
writing back to each regional partnership board, with feedback, in
response, so we’re able to share intelligence across Wales
smarter and quicker, to enable us to be much more effective.
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|
[119]
Dai Lloyd: Ocê, diolch yn fawr.
Symudwn ymlaen nawr i ofal sylfaenol, ac mae yna ddau gwestiwn gan
Caroline Jones ar y mater yna.
|
Dai Lloyd: Okay, thank you. We’ll
move on now to primary care, and there are two questions from
Caroline Jones on that matter.
|
|
[120] Caroline
Jones: Thank you, Chair. Could you tell me, please, what
outcomes have been secured with the additional moneys, over
£40 million, invested in primary care in 2015-16? And what
outcomes or changes do the Welsh Government intend to secure if
this funding is continued in 2017-18?
|
|
[121]
Vaughan Gething:
Well, I’m happy to confirm that the
additional investment that we made in primary care is going to
continue—it’s a recurrent commitment, so it isn’t
a one-off addition. And our challenge, then, is about how we
continue to invest with, and for, primary care, to deliver improved
outcomes. But you’ll see that a range of different and new
staff are now in primary care as well. One of the big stories,
actually, has been the number of GP clusters—well, primary
care clusters—that have actually invested in pharmacy
services. There are over 240 extra people employed within the
primary care system now as a direct result of this investment. And
you can see the way in which that’s led to
people—it’s important that they’re getting the
right care, and at the right time, and in the right place, and in
primary care that isn’t always about going to see the GP. So,
lots of this is about moving people to see an appropriate
professional, who could be a physiotherapist, could be an
occupational therapist, or could be a different kind of
nurse—there are lots of advanced nurse practitioners in the
mix now, compared to five years ago. And that gives better access
for lots of people to the appropriate care, and it means those
people who need to see a GP are much more likely to see that
happen.
|
|
[122]
And, in fact, in the recent day, I
convened a national event on primary care to look at the progress
we’ve made in primary care clusters. So, each of the health
boards came and presented, both on where they had real opportunity,
real achievement, but also I was really clear with them that I
wanted to understand what hadn’t worked as well, to try and
understand why things weren’t working, or why they’d
stopped doing things as well. It was actually a very positive
conversation about real improvement, and real enthusiasm from
different parts of our primary care community. That’s been
built upon the approach of investing in primary care, the
investment that will continue, but, importantly, in the way that we
gave primary care clusters—each one of the 64 of
them—the opportunity to determine and decide for themselves
their own priorities for the populations that they served. And
that’s actually provided a real element of confidence,
because, sometimes, when you announce an investment, people in the
field will think, ‘That’s got nothing to do with me,
and I won’t believe it, because I won’t see
it—the decision will be taken somewhere else.’ But,
actually, having a very direct input into how that money has been
spent has been really helpful, and it’s changed relationships
between people within clusters, so more GPs talk to each other,
more GPs talk to other primary care professionals, and it’s
changed the nature of the conversation in a helpful way, between
health boards and those primary care clusters too as
well.
|
|
[123]
So, I’m really encouraged about the
progress that we see in this area, and I think Members could and
should expect to see more in the future, because I certainly do
from my position. I expect to see a greater improvement again in
the way that primary care works and delivers even more services,
and then how we make sure that the resource follows the service, to
make sure that delivery is still of high quality for the
system.
|
|
[124]
Caroline Jones:
So, communication has been of paramount
importance then. Can you tell me how GPs are communicating with
other therapies, to bring on board other therapies that they can
use—physiotherapy, for example—as opposed to an ongoing
visit with a GP?
|
|
[125]
Vaughan Gething:
This has been part of desire, so GPs do
talk to other professionals, they talk to each other in the
clusters, to design and deliver what they think are their
priorities. Some of them—lots of them—have chosen
physiotherapy and pharmacists—they would probably be the two
most popular choices—about bringing in additional capacity.
And there’s a really good and strong evidence base about not
just how that that’s meant that there’s more time for
the GP to see whoever they need to see, but also a better outcome
for the citizen as well, so they get quicker access to the right
service as well.
|
|
[126]
We mentioned earlier about medicines
management, and that’s been a real positive engagement
between pharmacists and those clusters, too, on improving medicines
management. We have lots and lots of people who have multiple
chronic conditions that they’re managing and dealing with,
and, actually, those medication reviews, and that input from the
pharmacist, have been really important for the individual, who has
been going and taking part in that treatment, as well as from the
GP as well, and understanding how those different choices work. So,
you can see also that it’s not just physios and pharmacists,
but a range of other people being brought in as well. And the
challenge is how we make sure and
continue to learn from the most successful clusters, and how we
make sure that we understand why the clusters that aren’t as
successful—understanding why that is. That’s what part
of the national day that we had was about—about taking that
learning and putting it into the system. So, I really do think that
you’ll see change again over the next year in the way those
clusters work, but also in the choices they make about how to meet
the health needs of their local population.
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|
[127] One of the most
encouraging things about the day was that people didn’t just
turn up and say, ‘Everything’s fine’, because the
easiest thing is to say, ‘Here are six examples of good
practice and now we can get out and leave the room.’ There
was an honest engagement about the improvement that’s needed
in health board areas and how they want to work with their local
professionals to actually see that delivered. There’s lots of
really exciting things to happen but some of this is necessary as
well, because just running our current system on our current model
won’t deliver against the real demands that we have in
primary care and the wider system. So, there will be remodelling,
but it’s important that local practitioners take charge of
that. That’s why we’ve seen a different model in
Bridgend, for example, with the federation. It’s why
you’ll see not just independent contractors delivering the
majority of our care, but you’ll see different models
happening as well. And that mix of different ways of delivery with
different professionals will be an important part of the future
that I’ll think you’ll recognise, not just this year,
but next year and the one after that.
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|
[128] Dai
Lloyd: Ocê. Mae amser yn
carlamu ymlaen, so bydd rhaid inni symud ymlaen ar yr adeg hon. Ac
o hyn ymlaen, cwestiynau byr ac atebion byr—nid fy mod yn
edrych ar Jayne Bryant, ond rŷm ni’n mynd i sôn am
drawsnewid gwasanaethau ac mae’r cwestiynau yn dod oddi wrth
Jayne.
|
Dai Lloyd: Okay. Time is getting on, so
we’ll have to move on now. So brief questions from now on,
and brief answers—not that I’m looking at Jayne Bryant
specifically, but we are going to talk about service transformation
and the questions comes from Jayne.
|
|
[129] Jayne
Bryant: I think that I’m doing well on being brief.
[Laughter.] Thank you, Chair. How well do you think service
transformation in health and social care is being achieved, both in
terms of the extent and the pace of change?
|
|
[130] Vaughan Gething: Perhaps the Minister
could say something about the transformation that she’s
looking to oversee in social care and the partnership between
health and social care. I think the honest perspective is that
we’ve seen real change in service transformation across the
health sector but we’ll need to see a lot more, and part of
my frustration is the pace of that change—I don’t think
it’s where it needs to be. And I’m really looking for a
significant step forward in the pace of that change. It’s
why, for example, in the planning frame, which we talked about
earlier, I’ve been really clear, not just in the document
that’s gone out, but in the direct conversation with health
boards, about the fact that I expect to see more happen on
transforming services. And I expect to see that wider conversation
take place, not just within health boards but with all the
different actors within health and social care, but also between
health boards as well. Because the range of our really big services
are not just emergency services but they will go across health
board boundaries. And in primary care we all know that there are GP
surgeries, GP practices, that work across health board boundaries,
so people need to talk at the margins. But on some of the big
elective, planned care services as well, I’ve been really
clear that there needs to be a change in approach—that means
organisation across different health board boundaries. So, the
acute alliances that are going to be delivered with the south Wales
programme, they need to work and the services need to be developed
and delivered in a certain way to make sure that they’ll
deliver the efficiency that we want to see, which we talked about
earlier, but also a real improvement in outcomes.
|
|
[131] So,
there’s plenty that’s been done, but I expect much more
to be done and I really do expect to see that, over the next year,
there’s a real step up in the pace of that as well.
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[132] Jayne
Bryant: Do you think there’s sufficient capacity within
the health and social care sector to support the drive and change
that’s needed?
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[133]
Vaughan Gething: Our expectation is that that capacity does exist,
and where it doesn’t, that we can try and find support around
it. Part of the reason for the challenge and accountability
mechanism we have is to really understand whether health boards can
deliver, and if not, that we understand at an earlier stage whether
they can do. And it’s the planning, it’s the
accountability, and it’s also the escalation frame that
allows us to try and understand and do that.
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|
[134] Part of the
challenge that still exists is whether that capacity is where it
needs to be. But that’s also why health boards need to work
together to pool their resources, to understand the shared
challenges that they have and about how those patient flows will
work, because every health board trying to do everything on its own
isn’t going to deliver the sort of outcomes that we want to
see, and it won’t deliver the best use of money and it
won’t make the best use of the staff resource we have as
well.
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|
[135] So, I think that
there’s real opportunity to improve that, but I think that
there’s got to be an improvement too. As I said, the Minister
might want to say something about the improvements in integration,
but also the moving forward on social care as well.
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|
[136] Rebecca
Evans: Thank you. With regard to the social services and
well-being Act, as you know, it’s only been in force for six
months, but, actually, there’s, I think it’s fair to
say, a real buzz in the sector. People who are working on the front
line in this field actually feel that there is a real change in
terms of the way that we are seeking to transform the care that we
deliver to people, and it’s quite exciting to talk to people
who are working in the field. It seems like they’ve been
waiting for this a long time. There’s quite a relief,
actually. People do genuinely say to me all the time,
‘I’m so glad that I work in Wales with the social
services and well-being Act, as opposed to across the border. So,
that’s really heartening.
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12:45
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[137] But I also
wanted to draw Members’ attention to the Welsh community care
information system, which is something that the Welsh Government
has invested heavily in. We’ve provided £6.7 million of
capital funding for the initial set-up costs and for the all-Wales
licence, and that basically is an IT system that integrates health
and social care by providing for a shared record of care for
somebody who’s receiving both health and social care. So,
we’ve confirmed as well that we’ll add an additional
£2 million from the intermediate care fund for that for this
year, but also for next year, to see it rolled out across further
counties as well.
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|
[138]
Dai Lloyd: Diolch yn fawr. Mae’n dod â ni yn
neis ymlaen i sôn am integreiddio iechyd a gofal
cymdeithasol, ac rwy’n credu bod rhai o’r cwestiynau
yma eisoes wedi cael eu hateb, Dawn—ond y ddau gwestiwn
cyntaf beth bynnag. Dawn.
|
Dai Lloyd: Thank you very much. That
brings us neatly on to talk about integration between health and
social care. Some of these questions have already been answered,
Dawn, but the first two anyway. Thank you.
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|
[139] Dawn
Bowden: Thank you. I will just follow on from Jayne’s
question, really, and your answer there, Rebecca, in terms of
integration, and whether you think the budget is sufficiently
incentivised to encourage integrated working across health and
social care, including the independent sector. Could we just deal
with that bit first—on the budget?
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|
[140]
Rebecca Evans: Well, I’m really pleased that, again, this
year, we’ve been able to allocate for next year £50
million revenue and £10 million capital for the intermediate
care fund, and obviously this meets one of our programme for
government commitments, to maintain our support for it.
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[141]
The changes in the ways of working and
the improvements that have been seen under the intermediate care
fund actually are things that you don’t just have to do under
the intermediate care fund. I think, when health and social care
are working very closely together and realising these benefits,
actually, these things can be done outside of the intermediate care
fund. This is pump-priming money for innovation and innovative ways
of working. When you see the benefits to the NHS and to the
individual concerned in terms of their outcomes, and so on, then
actually there’s a compelling case for local authorities and
social services to work more closely together, beyond the formal
scope of the ICF.
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[142]
Dawn Bowden: So, are you happy with the pace of integration, or do
you think, potentially, that there’s a greater role for
Government in pushing the pace of integration and possibly looking
at some of these areas where we’ve seen integration? I
wouldn’t call them pilots because, actually, they’re
working properly, but where we’ve got integrated services
working really well, whether they could be used as a kind of model
to roll out in other areas. Do you see a role for Government in
maybe facilitating that?
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[143]
Rebecca Evans: I think the ICF certainly gives us the opportunity to
test innovative models and new ways of working, and certainly
there’s a compelling case then to roll out models that are
working and are delivering not only improved outcomes for
individuals, but cost savings to the NHS as well.
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[144]
In terms of the role of Government, as I
mentioned earlier, under the Social Services and Well-being (Wales)
Act 2014 we are requiring joint commissioning for care home
placements as of April 2018, and, obviously, we’ll provide
the guidance and support that local authorities and health boards
might need in their regional partnership boards to make that
happen. But that’s a clear sign from Government that we need
to see further integration as well.
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[145]
We are seeing lots of innovative new ways
of working. I did provide in the evidence paper some examples of
the capital improvements that we’re seeing. In Cardiff and
the Vale, for example, capital funding has allowed the setting up
of step-down accommodation, which facilitates earlier discharge
from hospital, and new respite units for people with learning
disabilities and complex needs as well. So, they are meeting those
needs locally. In Western Bay, which is Neath Port Talbot and
Swansea, for example, we’ve got closer-to-home and supported
housing, and that helps the local authorities to find placements
for people with quite complex needs closer to where they live. So,
that’s good for the individual in terms of maintaining their
networks and so on, but also is money saving as well. So,
that’s for people with complex needs who would previously
have been sent well out of county or beyond.
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[146]
Dai Lloyd: Okay.
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|
[147] Dawn Bowden: Sorry, just a final point on that—you mentioned
earlier the arrangement for moving towards pooled budgets by 2018
for residential care. Is that likely to be extended? Because
I’m conscious that some of the pressures or concerns coming
from colleagues in local
government, is the apparent imbalance in terms of funding in local
government as opposed to health, and whether the implementation of
pooled budgets across the integration programme would assist with
that.
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[148] Rebecca
Evans: This is a first step in terms of joint commissioning.
Then we would consider, or we are looking to increase that then
onto people of the autistic spectrum. Albert’s going to
provide us with some more information.
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[149] Mr
Heaney: Absolutely, the regional partnership boards are
statutory. Within that statutory, the Minister has asked the
regional partnership boards to look at pooling budgets across a
number of areas. But the Minister has actually, in law, prescribed
that there are certain areas that must be pooled. At the moment, we
have the integrated family support service, which is an integrated
pooled budget, and by 2018, then, in relation to care homes. But
there’s nothing at this moment in time, given the legislation
and given the intent by Ministers, to stop and prevent those
regional partnership boards. I know a number of them—because
it is a new approach, it has created a culture change. We’re
seeing not just health, local authority, social services and the
third sector working together, but we’re seeing other
partners come in to begin to look at things very differently from
how they have worked previously. I think your question leads to the
opportunity to doing more things together as we go forward, but it
is bearing in mind that we also have been supporting the capacity
to do that through the delivering transformation grant, and that
will now transfer into the RSG in the next financial year under the
draft proposals.
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[150]
Dai Lloyd: Ocê. Mae amser yn carlamu ymlaen ac
rwy’n benderfynol o gael cwestiynau dwys ar iechyd meddwl a
CAMHS. Fe wnawn ni ddechrau efo iechyd meddwl yn gyntaf. Caroline
ac wedyn Angela. Felly, Caroline Jones.
|
Dai Lloyd: Okay. Time is moving on and
I want to have quite detailed questions on mental health and CAMHS.
We’ll start mental health first, from Caroline and then
Angela. So, Caroline Jones.
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|
[151]
Caroline Jones: Diolch, Chair. Can you please clarify the
total amount of NHS funding to be ring-fenced for mental health in
2017-18, and the proportion of health funding this represents?
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|
[152]
Vaughan Gething:
The ring fence for 2017-18 should be
£620 million plus, representing a bit over 10 per cent of
total health board allocation. But as from previous conversations,
the ring fence is not the maximum or the minimum—it is a
minimum, it is a protected sum. We know that more gets spent on
mental health services than simply the ring-fenced
amount.
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|
[153]
Caroline Jones:
Okay.
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|
[154]
Dai Lloyd: Angela.
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|
[155]
Angela Burns: Thank you. The question I wanted to ask you about
mental health, Cabinet Secretary, is: where is the money that is
going to help the young people who do not fall inside
CAMHS—and I don’t want to talk about CAMHS because
that’s going to be spoken about later? You talk about funding
to have an extra £0.3 million to work with young people
between 14 and 25, but there are an awful lot of younger children
like that who do not fit the CAMHS criteria, and find it almost
impossible to access decent mental health services, ranging from
looked-after, adopted children, children with complex needs
that—. There is still this view that if a child is in a
wheelchair and a child had a mental health condition, one precludes
the other and they don’t fit into this bracket or that
bracket. I’d like to understand where money is coming from,
or in what department those children will be able to access those
kinds of services, so that I can have a good examination of the
funding element there.
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[156]
Vaughan Gething:
Well, since we introduced to mental
health Measure, you’ve seen a significant expansion in local
primary care mental health services, and these are for children and
young people too. We’ve invested specific sums in that for
children and young people too. I would not find it acceptable for
any part of the health service to prioritise physical healthcare
needs above mental health care needs, or to simply say that they
will only deal with, for the person in front of them, and only
prioritise one need over the other. You have to see that person has
a whole, in the way that they access support and treatment.
It’s difficult to unpick it from CAMHS, because part of our
challenge is that, for CAMHS to work more effectively, we need to
get people out of the CAMHS stream who are inappropriate referrals,
which means that there do need to be other places for them to be
seen and supported. If you look at what we’re investing in, I
think that, over the next year or two, you’ll see that
happening—an improvement in CAMHS and that improvement in the
local primary mental health care services for children and young
people who do need some support that is not in the specialist CAMHS
area.
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[157]
Angela Burns: A lot of those children actually need quite a lot of
support that isn’t in the specialist CAMHS area. So, to put
my question slightly differently: are you content that there is
enough money in the system to support children who are under 14
years of age to access additional mental health
services?
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[158] Vaughan Gething: Yes, I think we should be confident that there is
enough money to support those children. The challenge will be
making sure that money is well used and it gets to people who need
it. Within that, we recognise that there is a challenge of
improvement for us to deliver upon. Going back to all those earlier
conversations about how much money there is, and what we will and
won’t deliver, this is absolutely an area of priority for the
Government where we see that improvement is required and
we’ve invested significant sums of money to do so, and
we’re doing something that isn’t replicated in every
other part of the NHS family across the UK in making this level of
commitment. The challenge exists for us to make best use of the
system that we have, the integrated services that we have, to make
it a real integrated service and not one that we talk about in
theory and doesn’t get delivered in practice. That’s
why we see a range of different workstreams taking place, and
it’s why Together for Children and Young People is not just
looking at the CAMHS services as well.
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|
[159] It’s a
really important area, but it will remain a commitment for the
Government and it will remain a ministerial commitment and a
commitment for the service, because we do know that, until we get
to that improved position, Members will have their postbags filled
with these certain challenges and problems, and I expect they will
continue until we reach they genuinely improved and sustained
position.
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|
[160]
Angela Burns: I totally appreciate what you’re saying, but it
is the one area where children and young people fall between the
educational stool and the medical model, and I still don’t
see that safety net coming in. But I appreciate your comment on
it.
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|
[161]
Vaughan Gething:
We’re improving a range of services
with education for children and young people in the education
sphere. That’s part of the point about the greater buy-in
across the different parts of not just Government, but actually
services on the ground as well. So, I recognise the level of
challenge there, but it is about making sure those people
don’t fall through cracks between services, and that we do
have appropriate services outside CAMHS where that isn’t
appropriate. I’m sure that there’ll be a continued
focus in this committee and your partner committee, the Children,
Young People and Education Committee, to make sure that the
Government understands that this is a continuing priority for
Members. That’s not something to avoid.
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[162]
Dai Lloyd: Diolch yn fawr am hynny. Rydym ni’n symud
ymlaen i CAMHS nawr, a Lynne Neagle fydd yn gofyn y cwestiynau.
|
Dai Lloyd: Thank you very much for
that. We now move on to CAMHS and Lynne Neagle’s
questions.
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|
[163]
Lynne Neagle: Thanks, Chair. The additional funding that was
announced last year for CAMHS was made recurrent. When you came to
the children’s committee, you were reluctant to give a
timescale for meeting the CAMHS waiting times targets, but you must
have made some sort of assessment of what that money is going to
buy. Are you able to say a bit more about when you expect those
waiting times to be met? We know also that the waiting times are
worse in some areas than in others. How is that money actually
going to be allocated to deliver the maximum improvement in
specialist CAMHS waiting times?
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[164]
Vaughan Gething:
We expect each health board area to be
compliant within the course of the next calendar year for the new
28-day and 26-week targets. We expect most to be compliant at the
start of the next financial year. So, from April onwards, we expect
to have seen—over the next two quarters of this year, this
financial year, sorry, as opposed to calendar year—we expect
to have seen continued improvements. We expect by the end of the
next calendar year to see each health board in balance and
delivering against those deadlines. That’s why the investment
going in was important. It’s always important to make sure
it’s recurrent and that the new staff who will come on board
will be delivering against those demanding but necessary targets,
because too many people are on the waiting lists. It’s a
challenge to get people out if they don’t need to be there,
but too many people who do need that support wait too long, as
well. That’s why we’ve made the investment and I fully
expect that there’ll be questions on whether that expectation
about the timescale for improvement is going to be met in this
committee and in the children’s committee, too.
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[165]
Lynne Neagle: Can I just follow up on what Angela said? We know
that GPs are still making inappropriate referrals to CAMHS, which
is log-jamming the whole system. But, to some extent, they should
be providing that sort of service locally. So, to what extent are
you actually monitoring specific delivery on children’s
provision by primary care under the Measure?
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[166]
Vaughan Gething:
Do you want to come in on this one,
Andrew? It’s important to recognise that is something that
we’re taking account of—where are those referrals
coming from?—because it’s a different picture across
the country and locally as well. So, that sort of intelligence has
to be there. But it’s also why, if you like, from a
leadership point of view, I’ve made very clear my expectation
for the vice-chairs, that they need to be on top of this, that
I’ll come back to it in each meeting that we have, and that
they need to understand locally where those different pressures
exist and how they’re going to be managed within the
system.
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[167]
Dr Goodall: We know, for example, that between April 2015 and
June 2016 around 2,200 young people came through the primary care
gateway, and were referred in at that stage. Obviously, we can try
to give a more updated position at that stage, but we are looking
at aspects of the system as well. In particular, we’ve had a
concern about where children are getting referred out of area,
because that’s been a historical concern and
problem.
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13:00
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[168] In fact, over
these last 12 months in particular, we have seen reductions in
those numbers of children being placed in those kinds of areas. So,
actually, the numbers over the last two months or so have actually
been some of the lowest that we’ve seen at this stage.
Traditionally, around 25 to 30 a year are going out, but
that’s been much reduced at the moment—probably below
six patients at the moment. I think we just need to look at the
system, but certainly we do have some monitoring information around
the primary care activity that’s going on as well.
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[169] Lynne
Neagle: Would you be willing to share that with the
committee?
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|
[170] Dr
Goodall: I’m very happy to give the update to
September.
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[171]
Dai Lloyd: Ocê. Mae’r amser yn prysur dod i ben
felly rwy’n mynd i neidio ymlaen a jest cael un adran arall i
orffen, gyda’ch caniatâd. Rydym ni’n mynd i
sôn am gynlluniau cyfalaf ac mae Rhun yn mynd i ofyn cwestiwn
37.
|
Dai Lloyd: Okay. Time is quickly coming
to an end, so I’m going to jump forward and we’re just
going to have one other section before closing, with your consent.
We will talk about capital schemes and Rhun is going to ask
question 37.
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[172]
Rhun ap Iorwerth:
Yn syml iawn, a oes yna ddigon o
gyllid cyfalaf ar gael er mwyn cyflawni, os liciwch chi, dyheadau
byrddau iechyd a chi fel Llywodraeth?
|
Rhun ap Iorwerth: Quite simply, is
there sufficient capital funding available in order to achieve the
aspirations of health boards and you as Government?
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|
[173] Vaughan
Gething: Well, we can always make use of more capital, so
let’s be upfront about that. But in terms of the service
transformation that we wish to see, then capital is an important
lever for us, both for the secondary and tertiary care estates, the
hospital sector. Importantly, I want to see more focus on what we
can do to help transform primary care as well, and the way in which
we work with different partners in local government and housing, as
partners in doing some of that. So, I think the capital will be an
important lever, but I wouldn’t just want—. The
question is, if you don’t mind me saying, a little loaded, on
whether there is enough capital, but it’s always about how
it’s used, whether the plans are there that are underpinned
by evidence about how they will transform services so that people
really do have the best setting to deliver care, as well as the
right number of staff to deliver that care as well. It isn’t
just a capital question; it is about the whole system and about
planning and understanding what the whole system could and should
deliver.
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[174] Rhun ap
Iorwerth: A lot of capital spending can be seen in an
invest-to-save kind of way. If there are capital projects that
would be desirable and that aren’t deliverable now, have you
made an assessment of the savings, if you like, that you’re
not able to make in the longer term?
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[175] Vaughan
Gething: Some of this goes back to the project-based nature of
some of this as well. With each bid you get coming in,
understanding will that deliver the sort of savings we want in
terms of revenue and outcome terms as well, and then if
there’s slippage in there, you know, that isn’t being
delivered at that point. We can provide you with an update on more
of how we see the capital picture moving forward and I can come
back and have another session on capital if you like, given
we’re only talking about it at the end. We can identify
challenges in projects not going ahead and what it then means in
terms of running with a different sort of system, but to try and
take a whole-system approach, we need to look at each of those
different areas that aren’t happening, or aren’t
happening at the pace we want to see, and at the same time
we’ll be looking forward to those things we think will
happen, whether it’s a new centre in Flint, Blaenau
Ffestiniog, or whether it’s a new primary care estate in
Mountain Ash that we’re looking to deliver. With the health
board and partners as well, there’s lots and lots you can
look at that should remodel that in a positive way. This is
actually really exciting for professionals as well, because when we
talk about some of the challenges of delivering primary care in our
GP estate as well, it’s one of the big issues the royal
college raise and the BMA raise as well. So, we could actually move
people into a new estate, a new setting, where they don’t
have financial liabilities coming with them, where the ownership is
in a different place so it’s not something for them to worry
about and it’s a better setting for them to deliver care,
and, as I said, where we design in a multidisciplinary team to
deliver that whole service. So, there are real opportunities for
improvement as well. Anyone who’s dealt with capital schemes
across a large organisation knows that at some point there’ll
be slippage. So, part of our challenge is, when that happens, do we
understand at an early enough point in the year that’s not
going to take place, and do something else in the queue that can
replace it and make use of that money within the year to deliver a
different one across the system.
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[176] Rhun ap
Iorwerth: Finally, can you point to elements of this budget in
terms of capital spend where you believe that the result will be
transformation in the kind of NHS that we have? Rather than just
improvements here—any capital spend leads to an improvement
in delivery of healthcare in whatever way it might be—but in
search of transformation and a better, new kind of NHS, can you
point to where the capital spend that you have in mind is going to
make that difference?
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[177] Vaughan
Gething: Well, I think the capital spend in the intermediate
care fund will do that as well. That really is about transforming
the way we deliver services—why we deliver them, who we
deliver them with. You’ll definitely see a whole range of
products. If you had another half hour, the Minister could talk to
you about each of those that are already delivering, and we expect
that to happen more in the future. I guess the other obvious one is
the SCCC. We delivered that commitment to a huge investment to
transform the service and it’s part of a whole
picture—it isn’t just that one
decision—it’s part of a whole picture in Gwent and
across south Wales, where that capital investment should transform
the whole nature of how the system works in driving some of those
services out into the community and changing the way that the Royal
Gwent and Nevill Hall work, but also then changing the way the SCCC
works and fundamentally changing the way primary care works as
well. So that isn’t just one capital investment simply for
one part of the system; it is supposed to be, and designed to be,
transformational for the whole system.
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|
[178]
Dai Lloyd: Diolch ac mae’r anrhydedd o ofyn y
cwestiwn olaf yn disgyn i Jayne Bryant. Cwestiwn 39.
|
Dai Lloyd: Thank you, and the privilege
of asking the last question falls to Jayne Bryant. Question 39.
|
|
[179] Jayne
Bryant: I was thinking that I was too slow here.
|
|
[180]
Dai Lloyd: Efallai nid y cwestiwn olaf, Julie.
|
Dai Lloyd: Perhaps it’s not the
last question, Julie.
|
|
[181] Jayne
Bryant: I just wanted to mention—. You mentioned about
the money for the new neonatal unit at the Royal Gwent Hospital,
which I am really pleased about, and the SCCC as well. But just
wanting to move on, do you think that there’s sufficient
future capacity within neonatal care services?
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|
[182]
Vaughan Gething: Yes, we’re planning for it. We’re
planning for it, both in terms of the—. The investment in the
Royal Gwent is a medium-term investment, if you like, because we
recognise that there will be change, particularly with the SCCC now
being confirmed for the future. We’re planning for an
expansion in neonatal capacity in Cardiff as well, and that’s
based on our best understanding of both staff numbers, but also the
numbers that will need neonatal care and the ability to meet
standards of care and outcomes for people as well.
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|
[183] So, we’re
planning for it, and I think that you’ll find in our cancer
programme, that we’re aiming to deliver that increased
capacity as well. I know that you visited the unit in the Royal
Gwent, and hopefully you’ll see, on a future visit, the
additional space and capacity that that’s going to create for
people in the here and now, as well as in the future. This is part
of the challenge in how we make sure that the system that we have
now continues to deliver appropriate care as best as possible, as
well as a transformational change to what we see in the future as
well.
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|
[184]
Dai Lloyd: Diolch yn fawr. A sôn am anrhydeddau,
Julie Morgan.
|
Dai Lloyd: Thank you very much, and
talking about privileges, here’s Julie Morgan.
|
|
[185] Julie
Morgan: Just quickly on the capital spend, I’m very
pleased about the Velindre development, and I would certainly say
that that was linking to a transformation of the way cancer
services are delivered in a way beyond the capital building. But my
actual question was: since we have Brexit on the horizon, have you
considered at all in terms of your financial planning for the
health service what implications there will be for the health
service due to Brexit?
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|
[186] Vaughan
Gething: I don’t think there’s any measured
assessment of Brexit being a positive for the health service. But
it’s one of those great unknowns and challenges, particularly
if it interrupts our ability to make workforce decisions—not
just about recruitment, but about the ability to understand
qualifications across the piece. There’s lots and lots of
facets to this. But the uncertainty was highlighted by
today’s decision on article 50 as well. So, we can’t
know when Brexit will be a reality or what form it will be. And
that makes it incredibly difficult to plan, and not just for
Government. I guess the public will say, ‘Who cares about a
man in a suit who’s a politician?’ but when it comes
down to planning the service that they receive and take part in
locally, I think people will be very interested at that point in
why they can’t or whether they can get the service that they
expect to receive, now and in the future. So, this is one of the
big challenges for not just this Government, but for every tier of
government right across the UK, and understanding in amongst the
fog of uncertainty about where we are going and what the ultimate
end-point that the UK Government wishes to reach is, and what the
impact will be, and not just for every public service, but also in
our private sector as well, and the jobs that we all rely upon
here. Health is involved in the work within Government, about
trying to plan for what Brexit does and doesn’t mean, but I
can’t give you clarity where we don’t have that at a UK
level at this point in time. What I can say is that it’s
something that is very much in the minds of everyone who leads and
runs the health service.
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[187] Dr
Goodall: Minister, just in respect of workforce rules, it could
be a very strong area, but there are other aspects around the
research field and how many work in that community, about
regulation around medicines which operate through a European
prospective, and procurement rules, for example. So, as the
Minister said, we are working those things through centrally, but
it will be on some of the headline issues, perhaps on workforce,
that we need to understand.
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[188] Julie
Morgan: And so you’re not really doing anything in any
detail at the moment.
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[189] Vaughan Gething:
The challenge is that we can’t do much in significant detail
now because we don’t know. We don’t know enough to make
that sort of level of detailed plans. We were talking about shared
services in procurement, which have generated significant savings
that you can see. If you look at shared services just over the last
12 months, they can say how much they’ve generated in terms
of savings for the health service by the procurement route
they’re taking. But actually the procurement rules will
probably change. But they may possibly not because that depends on
our deal with Europe about our trading relationship in the future.
Because actually, as you know, one model is that, potentially,
we’ll have entirely different procurement rules, or it could
be that we’ll still effectually stick to the same procurement
rules as part of the deal of having continuing access to that
market. So, it really makes it incredibly difficult to properly
plan in detail about what that could mean, but we have to try and
understand what different scenarios might mean. I couldn’t
give details now because we don’t have them, and that is
because they don’t exist. You know, no-one here could
say with certainty what the Government of the UK wants to
achieve, and the effect it will have on the devolved nations, on
our public services and all the very different multifaceted aspects
of running a highly complex healthcare system in this part of the
world, let alone anywhere else.
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[190]
Dai Lloyd: Rhun, a oeddet ti eisiau dweud
rhywbeth?
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Dai Lloyd: Rhun, did you want to say
something?
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[191]
Rhun ap Iorwerth:
I was just going to ask: you are
investigating what steps you might have to take in the face of a
whole set of different scenarios. I accept entirely that we
don’t know which scenario it’s going to be.
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[192]
Vaughan Gething:
Broad scenario planning, of course, takes
place across Government on a range of different things, and of
course we’re having conversations with different parts of
Government, and the First Minister and the Cabinet Secretary for
Economy and Infrastructure are leading on Brexit. But I’m
just being honest about the fact that I can’t give you
detailed certainty because we don’t have it ourselves. If and
when we get to a better level of certainty, then we can do more
work and have a much better level of preparation. But when
there’s a vote in Parliament—
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[193]
Rhun ap Iorwerth:
I think you’ve got a fair bit of
time.
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[194]
Vaughan Gething:
We’ve got a fair bit of time before
we get to the endpoint, but the challenge will be, ultimately, to
change lots of our systems in these areas, and actually it does
take time to do that. So, the less time we have, the less prepared
we can be, and the more risk there is for all of us that will be
driven into the system, and that’s not a comfortable place to
be. I won’t pretend I’m happy about it, but
that’s the challenge we have being in Government and actually
having responsibility for delivering the system.
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[195]
Dai Lloyd: Diolch yn fawr iawn i chi, Weinidog. Mae’r
amser, ac mae’r sesiwn yma, wedi dod i ben. Diolch yn fawr
iawn i Ysgrifennydd y Cabinet a’r Gweinidog, a hefyd y
swyddogion, am eu tystiolaeth ysgrifenedig ac ar lafar.
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Dai Lloyd: Thank you very much,
Minister. Our time and this session have come to an end. Thank you
to the Cabinet Secretary and the Minister, and also the officials,
for their evidence, both written and oral.
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[196]
A allaf i gyhoeddi, fel buasech chi
wedi deall, nid ydym ni wedi gallu gofyn pob cwestiwn yr oedd angen
eu gofyn y bore yma? Gyda’ch caniatâd, mi wnawn ni
ysgrifennu llythyr atoch chi efo’r cwestiynau ni wnaethon ni
lwyddo i’w gofyn y bore yma. Hefyd, fe fyddwn ni’n
danfon trawsgrifiad o’r cyfarfod yma i chi ei
wirio.
|
I’d like to announce, as you may have
understood, that we’ve not been able to ask every question
that we wanted to this morning. With your permission, we will write
a letter to you with the questions that we didn’t reach this
morning. We’ll also send you a transcript of this meeting to
check for accuracy.
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[197]
Felly, gyda hynny o eiriau, a allaf i
ddiolch i chi unwaith eto a datgan bod y sesiwn yma ar ben? Diolch
yn fawr iawn i chi.
|
So, with that, could I thank you again and say
that this session is now closed? Thank you.
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[198]
Vaughan Gething:
Thank you very much. Take
care.
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13:12
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Cynnig o dan Reol Sefydlog 17.42 i Benderfynu Gwahardd y
Cyhoedd o Weddill y Cyfarfod
Motion under Standing Order 17.42 to Resolve to Exclude the
Public from the Remainder of 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).
|
that the committee
resolves to exclude the public from the remainder of the meeting in
accordance with Standing Order 17.42(vi).
|
