The proceedings are
reported in the language in which they were spoken in the
committee. In addition, a transcription of the simultaneous
interpretation is included. Where contributors have supplied
corrections to their evidence, these are noted in the
transcript.
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Dechreuodd y cyfarfod am 09:45.
The meeting began at 09:45.
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Cyflwyniad,
Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
Introductions, Apologies, Substitutions and Declarations of
Interest
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[1]
Dai Lloyd: Bore da i chi gyd a chroeso i gyfarfod
diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma
yng Nghynulliad Cenedlaethol Cymru. O dan eitem 1, felly, a allaf i
estyn croeso i’m cyd-Aelodau? Mae pawb yma felly nid oes
unrhyw ymddiheuriadau. A allaf i bellach egluro bod y cyfarfod yma
yn naturiol ddwyieithog? Gellir defnyddio clustffonau i glywed
cyfieithu ar y pryd o’r Gymraeg i’r Saesneg ar sianel
1, neu i glywed cyflwyniadau yn yr iaith wreiddiol yn well ar
sianel 2. A allaf i bellach atgoffa Aelodau i naill ai ddiffodd eu
ffonau symudol ac unrhyw gyfarpar electronig arall, neu eu rhoi ar
y dewis tawel, achos mae’n tueddu i amharu ar y system
ddarlledu? A hefyd a allaf i hysbysu pobl y dylid dilyn
cyfarwyddiadau’r tywyswyr os bydd larwm tân yn
canu?
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Dai Lloyd: Good morning to you all and
welcome to the latest meeting of the Health, Social Care and Sport
Committee here at the National Assembly for Wales. Under item 1
I’d like to welcome my fellow Members. Everyone is here so
there are no apologies. Can I explain that obviously this meeting
is bilingual? You can use headphones to hear simultaneous
translation from Welsh to English on channel 1, or amplification in
the original language on channel 2. I’d like to remind
Members either to switch off their mobiles and any other electronic
equipment or to switch them onto silent, because they can interfere
with the broadcast system. I would like to inform people that they
should follow the ushers if there is a fire alarm.
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Craffu ar Gyllideb
Llywodraeth Cymru 2017-18—Sesiwn Graffu Ariannol Canol
Blwyddyn—Ysgrifennydd y Cabinet dros Iechyd, Llesiant a
Chwaraeon a’r Gweinidog Iechyd y Cyhoedd a Gwasanaethau
Cymdeithasol
Scrutiny of the Welsh Government Budget
2017-18—In-Year Financial Scrutiny—Cabinet Secretary
for Health, Well-being and Sport and the Minister for Social
Services and Public Health
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[2]
Dai Lloyd: Symud ymlaen nawr i eitem 2 a chraffu ar
gyllideb Llywodraeth Cymru 2017-18—gwaith craffu ariannol yn
ystod y flwyddyn. Mae hyn yn fater sy’n arloesol i bwyllgorau
yn y Cynulliad hwn y tro hwn. Felly, i fynd ynglŷn
â’r craffu yma, rydw i’n falch iawn o groesawu
Vaughan Gething, Ysgrifennydd y Cabinet dros Iechyd, Llesiant a
Chwaraeon; a hefyd Rebecca Evans, Gweinidog Iechyd y Cyhoedd a
Gwasanaethau Cymdeithasol; Andrew Goodall, cyfarwyddwr cyffredinol
iechyd; Alan Brace, cyfarwyddwr cyllid iechyd; a hefyd Albert
Heaney, cyfarwyddwr gwasanaethau cymdeithasol ac integreiddio.
Croeso i chi gyd. Rydym ni’n diolch am eich tystiolaeth
ysgrifenedig ymlaen llaw ac, yn ôl ein harfer, fe awn
ni’n syth i mewn i gwestiynau. Felly, mae’r cwestiynau
cyntaf o dan ofal Caroline Jones.
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Dai
Lloyd: Moving on to item 2, scrutiny of the Welsh
Government budget for 2017-18. It is in-year financial scrutiny.
This is an innovative approach for committees in this Assembly. So,
regarding this scrutiny work, I am pleased to welcome Vaughan
Gething, the Cabinet Secretary for Health, Well-being and Sport;
Rebecca Evans, the Minister for Social Services and Public Health;
Andrew Goodall, director general for health; Alan Brace, finance
director for health; and also Albert Heaney, director for social
services and integration. So, welcome to you all. We thank you for
your written evidence and, as usual, we’ll go straight into
questioning. So, the first questions are from Caroline Jones.
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[3]
Caroline Jones: Diolch, Chair. Good morning, everyone.
I’d like to base my questions on the outcomes from the
additional £240 million NHS investment. I’d like to say
in my first question that there still seem to be mixed messages
about how the additional funding for local health boards in 2017-18
will be used. Will it be used for levering service change or will
it just go into meeting funding gaps and overspends? Regarding the
overspends, if this happens constantly, is the baseline right to
begin with? That’s my first question.
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[4]
The Cabinet Secretary for Health, Well-being and Sport (Vaughan
Gething): Thank you. I think there’s more than one
question in the first question—
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[5]
Caroline Jones: Sorry about that. [Laughter.]
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[6]
Vaughan Gething: —but I’ll try and work through
them because obviously these are big issues for the future of the
service. It’s worth reminding ourselves, when we think about
the budget that we’re talking about and the additional money,
that this is based on the work that we had done previously by
Nuffield Health and the Health Foundation. They told us that we
needed about £200 million extra on a regular, annual basis to
keep the wheels turning in the health service. They didn’t
say that was £200 million for significant service
transformation or improvement. So, that’s money to keep the
service going, and that’s on the basis that we continue to
have year-on-year efficiencies made within the service, as the
health service has done for a period of years.
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[7]
It was also on the basis that there would be continuing pay
restraint, which I’m sure we’ll talk about later on,
but that’s a real risk, as we’ve seen, in terms of the
goodwill of staff and the ability to deliver pay restraint.
I’m sure I’m not the only person here who would like to
see pay restraint end for staff in the health and public service,
but that’s a choice to be made at a UK budgeting level, to
allow us to do that. But there are those big risk factors. Also,
let’s not forget, because we’re talking about health
and social care, it pointed out that actually inflation in social
care, which they hadn’t addressed, was running at over 4 per
cent, and that’s a really big challenge for us too.
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[8]
So, when you talk about the £240 million, that there’s
lots and lots of money in there to go out and say there’s
extra money to deliver service reform, the point I’d make
about that also, which is a bit different to the money, is that
lots of service reform we could and should deliver is not about
saying, ‘You must have more money to deliver service
change’, because sometimes you can deliver service change,
improvement and efficiency, whether it’s from a technical or
allocative end—looking at Alan here, who’ll no doubt
tell me later on whether I’ve got this right—. You can
do some of that by changing the way in which you run the service
and the culture.
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[9]
That’s why the prudent healthcare movement still really
matters, because that’s a way of driving more efficiencies
through our service and genuine reform, and at the same time not
surrendering our values as well. So, that’s still about how
we use the large sum of money we have, as well as the additional
sums of money we have. So, service change: the drivers for that are
partly about the health service inflation that is still there. And
the £240 million that we’re putting in—a bit more
than that, actually, which I’ll explain
shortly—doesn’t mean that the NHS is awash with money.
There are still very real choices to be made, even in those health
boards that have met the financial duty. I’ve already made
the point about service change not being necessarily reliant always
on money, and often it isn’t the money that makes service
change difficult, as all of us in this room know. It’s us, as
politicians, it’s the public, and it’s clinicians, who
all need to buy into what service change looks like and the case
for change not just being about money. The drivers for it
aren’t just money; they’re also about demographic
change, the demand that we know is coming to the service, and
they’re also about the need to change services on a quality
basis as well. If we don’t change some of our services and
wait for them to be broken, we’re actually saying that
we’re prepared to wait for people to suffer real clinical
harm before we change the way in which services are run. Those are
real and serious issues that I know the parliamentary review will
look at in a number of different areas as well. So, that’s
part of it.
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[10]
On the point you make about health board overspend, we’ve
been upfront from some time out about those boards we were worried
about, and whether they’d meet their financial duty or
overspend. We then confirmed—I think in the last scrutiny
session—that we didn’t think the four health boards
would meet their duty, and they haven’t. We’ve been
upfront, and it won’t be a surprise about the integrated
medium-term plan statements as well, about those—all the ones
that we’ve approved and those that we haven’t. So, I
think we’ve been pretty transparent and upfront, and
we’ve made a choice about what to do with this because we
could have simply said that everything is balanced and no health
board has overspent. We could have effectively hidden the
overspends that exist in health boards. We made a choice to
highlight and be upfront about those boards that are not living
within their means, and the balance of money that we are retaining
to cover the health service overall, and to be really clear about
those boards that we do not think are managing their finances in a
way that is sustainable, and where there is still a need to change.
That is partly about the way in which they manage their finances,
and not just about broader service reform.
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[11]
The £240 million we’ve got, you will have seen the
additions that have been made, both in the way we’ve used
that—. Some of that money’s gone into inflationary
pressures within the hospice service, but also primary care;
£20 million has come in from the agreement we did with Plaid
Cymru in the previous budget, going into mental health; and we put
additional money into two health boards who can go on and do more
on performance as a result. They’re in a position where they
can do that. So, we’re allocating money to try and get gain
where gain is possible, but not forgetting that the overwhelming
case here is about how we use the budget overall to deliver the
service change that we know is inevitable and necessary, not just
because of money, not just because of the demand that will go into
services, but also because there is a very real quality case to be
made about improving services for the public.
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[12]
Caroline Jones: But are the targets set for the health
boards realistic to achieve to begin with?
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[13]
Vaughan Gething: Yes, and I don’t think it’s
about changing the baseline. There will always be a question and a
conference to have at various points about how we allocate money on
a formula basis and how we understand what need exists, balancing
the needs, say, of rural healthcare, as opposed to delivering
healthcare for significant areas of deprivation, and there are
different arguments to be made. There will be no formula that keeps
everyone happy because of the competing demands that exist, but in
the work that we had done by both Nuffield and the Health
Foundation, it did show that we are potentially in a position where
our service is sustainable, and they did not think that was a case
for colleagues in England. The risks of that are that if we
don’t see investment continuing to be made in public
services, then that will give us a different answer. So, these next
four or five years are really important for what sort of health
service we will have, both in terms of the reform that we think is
a necessary thing to want to achieve in any event, but also where
the money really does drive us in a different direction. Because
whilst the health service isn’t awash with money, compared to
other parts of public service, we have done relatively well within
this part of Government. There is extra resource, in real terms,
going into the health service that is not going into other parts of
public services. So, there is an even greater responsibility to
deliver on a quality-led and demand-led reform that must take
place, because other parts of public service are suffering in very
real terms.
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[14]
Caroline Jones: Okay. Thank you. Also, the figures are
slightly unclear because, in the submission, there’s
£110 million identified to meet inflationary costs. So, can
we please have clarity about what is in this £110 million and
what, of the £240 million increase, actually remains for the
development of services?
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[15]
Vaughan Gething: I tried to point out that, actually, you
know—
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[16]
Caroline Jones: I know you said that it’s £200
million to keep it turning, anyway.
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[17]
Vaughan Gething: —the point about what is and
isn’t development of services, but the broad stuff about pay
and inflationary pressures goes between primary care and secondary
care. We made particular announcements, for example, like the
£20 million going into primary care
for inflationary pressures and £90 million going into the
rest of the service. With the rest of the money, we’ve held
back around £95 million to try and manage those pressures
across the service because we know that there are four boards that
are overspending, and there’s still an expectation and a real
drive to see an improvement in the first two months of this year,
actually, in the expected position in the run rate to where they
are now. That’s partly about the steps that we’ve taken
proactively about the way in which boards manage their money.
It’s about the direction and the conversations I have with
chairs. It’s also about the interaction that Andrew Goodall
and Alan Brace have with chief execs and finance directors as well.
So, we’ve seen a narrowing in the expected gap, but that
£95 million is being retained centrally to try and manage
those pressures, and, as I said, there’s £15 million
being released to Cwm Taf and to Aneurin Bevan to actually make
more progress on improving performance and achievement. So,
that’s where the £240 million is used and is allocated,
and, of course, I mentioned earlier the £20 million of
additional money that we agreed to go into the mental health ring
fence in our budget agreed with Plaid Cymru.
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[18]
Caroline Jones:
So, is the Welsh Government therefore
satisfied with how well service transformation is being achieved in
health and social care in terms of both the extent and pace of
change? Is it delivering the change that is intended to drive the
NHS forward?
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[19]
Vaughan Gething:
Well, the short answer is
‘no’, because how could I ever be satisfied with the
pace and the delivery of change? There’s so much more to do.
That’s partly because the NHS has always had to reform and
change through its history, but it’s also because of where we
started the series of questions about the very real drivers about
demand—not just age, but public health as well—and the
very real drivers over finances that will make choices, and we need
to get ahead of those choices, but also the quality case for change
and improvement as well. So, I said when I was appointed to this
role that I wanted to see scale and pace in the way in which we
deliver service reform and improvement, and it’s the right
challenge to give the service and the right expectation to set. The
difficulty always is whether we’re able to do that. So, there
are good ideas that appear to deliver service transformation in one
part of the service, but we still need to be more demanding in our
expectation that they get delivered on a wider basis. Actually,
that’s within health boards, not just across and between
health boards as well.
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[20]
For example, I was having conversations
yesterday about improvements made in the way in which we deliver
eye care in the west part of the Abertawe Bro Morgannwg health
board, but, actually, they haven’t been able to do that as
successfully in the eastern part of the same health board.
That’s something about the nature of a really complex
organisation that doesn’t just spend lots of money;
it’s got so many different facets and organisations between
secondary care and local and primary care that, actually,
there’s an understanding that delivering change is difficult.
You can’t just click your fingers and say,
‘There’s a ministerial lever to pull and everything
will change’. Actually, if we don’t have clarity in our
expectations for change and reform that is based on quality, and
understanding and anticipating the changes in demand that we know
are coming through, at the point that there are real efficiency
gains to be made that don’t compromise our ethos, but should
lead to a better use of the capacity that we have, then we’re
setting the wrong expectation.
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[21]
So, I wouldn’t tell anyone that I
am satisfied with the pace of change or the scale of change. We
know there is more to do, and, actually, I think the parliamentary
review that Members in this room will be well aware of, and the
contact group we’ll have more conversations about as well, is
an important step forward in us trying to understand what the case
for change is. So, not just, ‘Listen to the
Government’, but an independent group saying,
‘Here’s the case for change. What does it look like?
What do we think you need to do in the next five to 10
years?’ and then the detail of some of those answers that
we’ll get challenged over, and not just challenges to the
Government, but every politician in the room and beyond about: what
do we really want? To answer this question of: how much money do we
have, is it enough and, in any event, how do we make the best use
of it? Because those demand drivers, and that quality case for
change, aren’t going to go away.
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[22]
Caroline Jones:
So, could you give me one example of
change that you think will be a good change and give me that
example of where you will be satisfied with that change?
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[23]
Vaughan Gething:
Well, I’ve already said in public
before that we’re looking at ways in which to change the way
we deliver eye care. We’ve already had some change, for
example, in the way in which we provide services in primary
care—that’s high-street optometrists, and the way they
can do things that, previously, people would have been sent off to
a hospital for. The way in which we have nurse injectors, and the
way that, when wet age-related macular degeneration first started
to be treated, actually you had to go into a theatre to do it. Now
you can have nurses trained and, actually, mobile orthoptists
trained to do that as well. That’s a significant change and
it means that it’s more accessible and less expensive. But,
actually, that’s a service change that was expensive. It was
an innovation that was expensive to deliver but really high value
to the individual, and the ongoing work that I’ve already
talked about in previous times, on changing our
referral-to-treatment times, and the way in which we’re
looking at those measures, that could be really important in having
a more clinically smart and useful way to have targets that make
sense and drive the right clinical behaviour in that area.
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10:00
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[24]
That’s work that has to be done by the service, including
clinicians, managers. It means there’s IT that needs to
change to help deliver that. It also means that we need to listen
to the voice of the third sector and the patients in delivering
that change as well. I think that, over the next year, we’ll
see more work done on that, which I think will be a really
important quality improvement, which should also mean we use our
resources better as well.
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[25]
Caroline Jones: Thank you. Diolch, Chair.
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[26]
Dai Lloyd: Did you want a supplementary here, Angela?
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[27]
Angela Burns: No, I’m fine, thank you.
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[28]
Dai Lloyd: Full answers; you’re satisfied. Excellent.
Moving on—Jayne.
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[29]
Jayne Bryant: Thank you, Chair. Good morning. There are lots
of different individual funding streams on top of the core
allocation, such as the intermediate care fund, primary care money,
services for older people. With this in mind, do you think this
helps to drive the change that we need?
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[30]
Vaughan Gething:
Yes. It’s a funny thing about
delivering change in the service, because you would have thought
that, with an enormous budget of nearly £7 billion, you talk
about the way in which the great majority of that money is used
rather than the more marginal elements of money, which are,
frankly—. The money that we’ve put into the integrated
care fund is a large sum of money. Let’s not pretend that the
£50 million plus £10 million capital is a small sum of
money, but, actually, when taken in with the whole budget, actually
it’s a smaller sum. I know Rebecca will talk about this, but
those smaller sums of money make a really big difference in
delivering change, and, in some ways, it’s frustrating to
think that, actually, the way in which you ask people to spend
£10 million, for the sake of argument, can make a really big
difference to improving performance, or the way that they work with
other partners, rather than thinking about how you deploy your
nearly £1 billion of a budget if you’re one of our
larger health boards. But that’s the honest
reality.
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[31]
The drivers for change that we have are
clinical. Delivering clinical change in behaviour is the biggest
thing that we can do, and that’s also the most important
thing in terms of persuading the public that there’s a real
case for change on a quality basis too. Because, as much as I like
myself, I do accept, reluctantly, that the public are more likely
to be persuaded by someone in the service rather than a politician
in a smart suit saying there’s a really big important case
for change here. It’s important to understand that, and,
actually, people in the service taking more ownership of the case
for change. How those small sums of money get used is actually
quite important in terms of delivering some of that change and
changing behaviour, because, otherwise we have really big, blunt
instruments.
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[32]
You can threaten to dismiss people, which
happens on a regular basis in the English system. Sir Bruce Keogh
pointed out in his leaving speech to the NHS Confed that the
average tenancy of a chief exec in an NHS trust in England is 2.5
years, and I don’t think that’s healthy. So, that, in
itself, is like your ultimate weapon, as it were, but it’s a
really blunt instrument, and that doesn’t persuade lots of
people in the service to do things differently. We can change the
law, as we have done, and that’s an important driver for
change, but that isn’t a quick driver for change either. The
work that Rebecca’s leading on delivering the Social Services
and Well-being (Wales) Act 2014 and the partnerships, that takes
time, but, actually, getting that right, with the change in culture
and money that comes alongside it, gives a better prospect for
seeing change delivered. If you look at—. I’ll stop,
because Rebecca will want to talk to you about examples of how we
think, for example, the integrated care fund really has delivered
change, but it’s important to recognise that that sort of
money makes a difference, but we still need to be more demanding
about the main sum of money that goes into health and care services
and the change we expect to see delivered with that in the main
stream, and not just, if you like, the specific elements of funding
we provide as well.
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[33]
Dai Lloyd: Minister.
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[34]
The Minister for Social Services and Public Health (Rebecca
Evans): Good morning, Chair and
committee. Yes, I think the intermediate care fund, or the
rebranded now as integrated care fund is, as Vaughan was saying,
not just about the amount of money that we put in. Actually,
it’s about the structures that we put in around it, to ensure
that the money is spent in a truly integrated way. So, our regional
partnership boards have been up and running for over a year now,
and I am pleased with the progress that they’re making. They
had a statutory obligation to provide us with population needs
assessments. They’ve all done that. They’re available
now on the Welsh Government’s website for people to look at.
But we’ve also gone a step further and asked Social Care
Wales to use those plans—to use those assessments, I should
say—to provide us with a Wales-wide assessment of need as
well. This is the first time that we’ll have this kind of
understanding of what the needs are locally, and specifically,
really, for those groups of people for whom we’ve asked the
regional partnership boards to focus on as a priority—so,
older people with complex needs and long-term conditions, including
dementia, people with learning disabilities, children with complex
needs due to disability or illness and now for the first time this
year as well, carers.
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[35]
So, the next step for the regional
partnership boards will be to use the assessments that
they’ve carried out to develop plans to meet those needs that
they’ve identified. This is the first time that we’ve
ever really seen health and social care working together in such an
integrated way, but also alongside housing and the third sector,
and involving service users themselves, and carers, and so on. So,
although the sum of money is £60 million, actually it is
really driving change in the way that services are delivered, and
we’re seeing health and social services now coming together
to integrate beyond, so, using their core funding beyond the ICF
moneys as well. And, from April of next year, of course, we have
the requirement that regional partnership boards—so, health
and social care—jointly commission placements for adult
social care as well. That’s going to really transform the way
in which we commission those places. At the moment, it’s done
22 times by 22 local authorities but, in future, jointly seven
times on that regional partnership board basis, and I think that
that will make a big change in the commissioning arrangements that
we have. So, we’ll be commissioning for quality rather than
commissioning on price. We’ve got work starting just this
week, actually, looking at the future of fee levels in Wales as
well, and I’m happy to update the committee in due course
when that comes to some kind of conclusion.
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[36]
Dai Lloyd: On this point, Lynne.
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[37]
Lynne Neagle: It was just on what Rebecca had said, really, about
the various strands of this work, which includes children with
complex needs and disabilities. As you know, I was very concerned
about what happened with the family fund in Wales. I wondered
whether you could say a bit more about how you see that strand
actually working to deliver for families with disabled
children.
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[38]
Rebecca Evans: The population needs assessments that the regional
partnership boards have completed look strongly at the needs of
children and their families as well. So, there’s a statutory
duty now on local authorities to plan to meet those needs that
they’ve identified, and I think that is really strong in
terms of giving that statutory footing on which needs are
identified as well.
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[39]
Beyond that, of course, you’ll be
aware of the additional funding that we’ve announced for
children on the edge of care and children in care—the
additional £8 million of funding through the consequential
funding announced recently. We know that, often, children in care
also have disabilities or are also disabled and have multiple
needs, so I can happily talk further about what we would expect to
see from that additional money as well. I don’t know if
Albert wanted to add anything.
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[40]
Dai Lloyd: It’s a budget scrutiny session but, yes,
Albert.
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[41]
Mr Heaney: I think the only thing I’d add—thank you,
Minister, and thank you, committee—is also that, out of the
£20 million consequential funding that’s been announced
recently, there is £3 million for carers and respite. And
it’s really important for, certainly, families and children
with disabilities and complex needs that the family structure
around respite gives them that support as well.
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[42]
Dai Lloyd: Okay. Jayne.
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[43]
Jayne Bryant: Thank you, Chair. You touched on the importance of
integration, and, following on from that, there is a significant
range of bodies charged with spending these moneys—LHBs,
clusters and, as you’ve said, the regional partnership
boards. How can you be assured that this allows the bodies to
really plan coherently and deliver the major improvement in service
change that’s needed?
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[44]
Vaughan Gething:
As ever, it’s not straightforward.
We expect health boards to plan jointly with health board partners
to engage in the third sector, but we set up clusters, for example,
because we recognise that, actually, the cluster group and the
cluster level of that population size is the right sort of size to
plan for that population, to understand the local health needs of
the population that those practices and partners are serving, and
then to decide what they think will make a big difference to
improving their healthcare outcomes and delivering against their
needs. So, I don’t wish to pretend there is a
one-size-fits-all approach, but we do know, actually, that
improving our planning function within health boards centrally is
part of what we need to do.
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[45]
We were just talking earlier about the
fact that four of our boards that have not met their financial duty
are in a heightened status of escalation. That demonstrates
there’s still more work we need to do about planning and
delivering our whole system. And it’s part of what the
Organisation for Economic Co-operation and Development
said—they didn’t disagree with the structure in which
we deliver this in general terms, but there were some questions
about being clear about the governance within that. So, actually,
it’s a challenge of moving into a position where you
don’t just talk about Powys, Aneurin Bevan and Cwm Taf as
well-run, well-performing health boards, but, actually, you have
more health boards in that category as well. So, this next year to
18 months will be really important in doing that at a health board
level, and then understanding how we join up local planning
in cluster levels, and, actually, some local authorities have moved
themselves to plan on the same basis. So, you can actually see
neighbourhood planning taking place in local authorities on the
same footprint as our primary care clusters, to try and aid some of
that service integration and understand the needs of those larger
community groups. So, there’s something about understanding
local health board and then cross-regional planning as well.
That’s why health boards have grouped themselves
together—west Wales, ABM, and Hywel Dda having joint planning
meetings. In south-east Wales, Cwm Taf, Aneurin Bevan, and Cardiff
and the Vale are having joint planning meetings now as well,
because they understand that patient flows across their health
board areas are not neatly defined by health board boundaries as
well.
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[46]
And, so, there are the different tiers of planning, and
there’s no pretence that there will be a simple and easy way
and one way to plan a service, one way to deliver it, and everyone
can buy into that. It is about understanding the complexity, about
how we make it as easy as possible, and the clarity in expectation
and accountability for delivering against outcomes. But, within
that, you have to have space for innovation, because, otherwise,
you choke all that off, and that, in itself, isn’t good for
health outcomes, or, indeed, understanding how to appropriately
meet healthcare needs.
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[47]
Dai Lloyd: Andrew.
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[48]
Dr Goodall: And, Chair, just to comment that I think
it’s important to really try and bring everything back to the
three-year plans, so the integrated medium-term plans, although, of
course, we’ve got direct monitoring in place to make sure
that these very symbolic areas can have an impact—areas like
clusters, for example. We do introduce planning guidance. We are
very clear, and, actually, a lot of our contact that we have, in
terms of the conversations that take place with the NHS, are very
much looking at the broader spends and making sure that all of
these tie back to the strategic plans of the individual
organisations. And that’s why there’s such a lot of
focus around approval or non-approval of these plans and the
monitoring arrangements that we’ve put in place.
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[49]
Dai Lloyd: Okay. Moving on, Jayne.
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[50]
Jayne Bryant: Thank you. Just looking at the money invested
to help with winter pressures this year, what is your assessment of
how effective that’s been?
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[51]
Vaughan Gething: I think we can be broadly satisfied with
where we got, both in unscheduled care, we didn’t see
a—. We didn’t see our system collapse in the winter.
That might sound like a low bar of achievement, but, actually, we
had real worries coming into the winter, as in every winter, about
the ability of the system to deal with the rising nature of demand,
not the numbers, but the numbers of very old, very sick people who
come into our hospitals and then move around our health and care
system. But that doesn’t mean to say that our staff and our
services weren’t extremely busy. I went into a number of
A&E units, but also into primary care as well through the
winter, and there’s very real pressure that our staff feel.
So, let’s not try and be glib about the fact that the system
was okay because the numbers weren’t as bad as we thought
they might be. That isn’t, I think, a particularly helpful
way to look at it from an unscheduled care point of view.
There’s still more to do in understanding not just how we use
the money, but how we understand what our system could and should
do to improve unscheduled care throughout the year as well. And
we’ve seen some improvements in that—the numbers of
people going into hospital as unplanned emergency admissions. In
chronic care conditions, our management of those conditions has
improved, and that’s really significant, because those people
often end up staying for longer as well if they do get
admitted.
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|
[52]
But it isn’t just about the unscheduled care part of the
winter planning, and the money to go in. We also wanted to make
sure that we didn’t see a significant dip in elective care as
well, in planned care. And, in most health boards, we saw them meet
the plans that they delivered, to continue to deliver an
improvement. That’s why we ended the last financial year in a
better position on planned care than the year before—real
gains made in referral-to-treatment time, real gains made in
reducing the backlog we have in longer waiters, with bumps in
different parts of the service. The one board where we took money
back was ABM, because they’d signed up to a plan and
hadn’t delivered it. So, we took money back. I think
that’s really important, in terms of the discipline we need
to have in the system, because, if, otherwise, we say,
‘Here’s money that goes out to health boards for a
purpose on the basis of plans they’ve submitted to deliver
improvement’, and we then say, ‘Try your best, but
don’t worry, you can keep the money even if you don’t
do it’, well, that’s a really poor message, and we
won’t deliver the sort of discipline and approach that we
need within our whole system.
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[53]
I think that’s important in terms of behaviour as well at a
senior leadership level. They need to understand that, when you
sign up to something and you then get money on the basis of that,
you’re then expected to deliver against that as well. And if
we don’t have that clawback operating within the system, then
I think that means that, otherwise, we compromise our ability to
deliver improvement that all of us would want to see.
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[54]
Dai Lloyd: Okay. Rhun’s got a question on this
point.
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|
[55]
Rhun ap Iorwerth: Just to pick up on that, I would argue
that orthopaedic elective surgery, for example, did collapse,
certainly in the western region of Betsi Cadwaladr over the winter,
with wards closed for elective surgery between December and
April/May. How do you see that in the context of the budget that
you laid for them, which helped them perhaps to deal with the
patients who came in because it was winter, but helped nothing at
all when it came to elective surgery?
|
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10:15
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[56]
Vaughan Gething: No, ‘helped nothing at all’, I
don’t think that’s a fair reflection on what actually
happened, because, if you look at elective activity that continued
through the winter, elective activity did continue. There’s
something also about commissioning that activity as well to allow
you—because, in every winter, you plan to reduce areas of
elective activity because you know you’ll have more capacity
taken up by unscheduled care, by those admissions that come in.
That’s not a surprise; it’s not a secret that that
happens. The challenge we have in terms of north Wales, and
you’ll have seen that they’ve had an orthopaedic plan
delivered to their board, because they recognise that the way in
which they currently use their resources isn’t optimal. They
recognise they don’t deliver the sort of efficiencies they
need to against the demand they have coming in. I know we’ve
run through this in the Chamber before, but, actually, Betsi
Cadwaladr health board now perform significantly more orthopaedic
procedures than they did five years ago. The challenge is that
demand has run ahead of that significantly. In some areas, in
particular long waiters, we’ve seen those rise to a level
that, clearly, isn’t acceptable. So, they have to plan to be
able to deliver both the day-case activity—the stuff that we
wouldn’t have done 10 years ago—but also to understand
how they deal with those long waiters as well. What the balance is
in those areas where they commission activity on a regular basis,
for example in Gobowen—people go there regularly for certain
forms of their surgery. We need to understand what we will continue
to commission on a regular basis outside of NHS Wales, and what we
then do to be more effective and efficient with the resources we
have within the service as well. And, for north Wales, that’s
an issue for—. And, for Powys, for example, as well, where
they commission different forms of activity. There’s got to
be some honesty in the understanding about how you plan to manage
winter in an honest way that reflects the reality that there will
be more unscheduled care pressure coming in, and at the same time
making sure that we don’t see a complete stop in elective
activity so that no-one gets to have those procedures
undertaken.
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[57]
Dai Lloyd: Okay. Minister, briefly, because we’ve got
to move on.
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[58]
Rebecca Evans: Yes, I just wanted to say something quickly
about delayed transfers of care because, although they are a
feature year-round, actually, they are a particular feature during
the winter months. But delayed transfers of care in the first four
months of this year we actually managed to keep under 400 for the
first four months, and that’s unprecedented. Delayed
transfers of care at the moment are 12 per cent down on the same
time last year. Actually, in the year to date, they’re 21 per
cent down on the equivalent period last year. I do think
that’s a significant achievement when we do see increasing
demand due to an ageing population. I’m sure that we can
attribute this to the work of the integrated care fund, which puts
a lot of work into preventing people from going into hospital in
the first place, but then also facilitating a quick release from
hospital as well.
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[59]
Dai Lloyd: Grêt. A’r cwestiynau nesaf o dan law Angela Burns.
|
Dai Lloyd: Great. The next questions
are from Angela Burns.
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|
[60]
Angela Burns: Thank you. Good morning. The questions
I’d like to pose actually pick up slightly on
Caroline’s about the IMTPs and the budget deficits and so on,
but can I first of all clarify the three-year rolling forecast,
which was introduced in 2014, which is obviously a really sensible
methodology going forward for any large organisation of this kind
of scale and complexity? Of course, in theory, that enables a
health board to continually push its deficit forward and forward
and forward and forward. So, when you say that you’re judging
them on a three-year, rolling forecast, at what point might you
turn around and say, ‘You’ve now got to catch up with
that particular deficit’, or is the intention that it gives
them that flexibility to constantly flex for the rolling three
years their particular financial situation?
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[61]
Vaughan Gething: Well, it allows flexibility, but
you’ll have seen in the settlements that are made whether
people have met their duty or not. The flexibility comes from the
point you make an assessment: ‘Have you met your duty over
these three years, “yes” or “no”?’
And we know that there are boards that have not. Again, we’ve
been completely upfront about that. When the Wales Audit Office
published their report, we issued a statement on the same day,
confirming that that’s the position. Again, in the previous
committee, I indicated that I didn’t expect those boards to
meet the duty. So, the flexibility—you see that flexibility
in those health boards that have managed it successfully. So,
it’s understanding are there any additional pressures that
are unique to those organisations, or is it really about how we
improve what those organisations do in planning and delivering
their services, and what do they need to do with partners,
including other health boards, other statutory partners, and
partners outside the statutory sector, to understand how they
deliver that service in a way that is financially sustainable and
sustainable from a service point of view as well. We’ve had
some work done already on the four boards in a heightened status of
escalation.
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|
[62]
So, we’ve had a governance review
to look at the way in which they run and deliver their
organisations and I’m looking forward to receiving those
reports over the summer. Obviously, we’ll update Members on
the messages of those, because I think it is really important to
understand, three years in, where are we, what are the positions of
those boards that we don’t think are—in fact, the Wales
Audit Office have confirmed are not—living within the more
flexible duty that’s been provided, and, then, how do we
ensure that, both within this year and the next year, we see a real
improvement in those organisations as well rather than simply
saying, ‘These organisations haven’t lived within their
means’, and then just move on? That would be the wrong
response, because, ultimately, there are huge amounts of money that
are spent. As I said earlier, that money, the additional money
going into health, comes at a real cost to other public services as
well.
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|
[63]
Angela Burns: But this is the point that I’m trying to drive
at, because what I’m interested to try and understand is,
particularly when you look at Betsi Cadwaladr University and Hywel
Dda health board, they have a consistent shortfall, so, what I am
wondering is: does there actually need to be some fundamental
recalibration of their baseline because there is an inherent
backlog from way before? What is it about those two health boards
in particular that gives them a—? Is there anything about
those two health boards in particular that gives them a unique set
of problems? I know, when I’ve talked to those health boards
in the past, there is a lot of argument over rurality and the
difficulty of providing healthcare in a very rural area. And, of
course, you can argue that Powys is a very rural health area, but
it doesn’t have expensive hospitals up and down the length
and breadth of Powys.
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|
[64]
So, Betsi and Hywel Dda do have that
geography that plays against them. Rurality can be counted as a
form of deprivation, but I’m not sure if there’s any
weighting. I just wondered if you’d give us some
clarification of whether there is any weighting, when you’re
giving out money to health boards, for rurality. My understanding
at present is that perhaps there is not. Just back to that comment
that rurality is a form of deprivation—and I understand why
you would give more weighting to areas of high deprivation, but it
cuts the other way as well. Because this rump of overspend is
consistent and I think, in any organisation, when you see that
permanently set there, you’ve got to question that basic
principle behind it and see if there needs to be that
recalibration.
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|
[65]
Vaughan Gething:
I’ll make some brief comments and
ask either Andrew or Alan to come and talk about the zero-based
budget exercise that we’re having done in Hywel Dda. Again,
we’ve had discussions—. I know that Plaid Cymru are
particularly interested in this as well; it came from conversations
that we’ve had. But we think that won’t just be useful
for understanding what Hywel Dda’s real base costs are, but
also there’ll be real value for other health boards as well
to look at some of the methodology that’s gone into that.
But, also, to comment about the formula, because, actually, this
has been a long-running concern, we’re using what we think is
the best, up-to-date formula that we have. We’ve got Townsend
about how we understand the additional shares, but, actually, it is
very easy to say, ‘We are special and we are
different’, and every health board has a version of this,
every health board has a version of ‘treat me fairly’.
If you talk to Cardiff and Vale, they’ve got population
growth that other health boards don’t have to the same
extent.
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|
[66]
Angela Burns: Yes, absolutely; I recognise that.
|
|
[67]
Vaughan Gething:
So, it’s about matching and
understanding what the different levels of need are and, actually,
I think we should all have a healthy dose of scepticism about
health boards that don’t currently live within their means,
about what the real scale of that is. Does it really account for a
real answer? If it does, does it explain everything about the
overspend that they currently have? And, actually, Betsi Cadwaladr,
the chief executive there says that he thinks that, really, they
have enough money within their system. It’s about how
effectively and efficiently they get to use it. But I do think that
it will be useful to talk not just about the formula, but also the
zero-based exercise, because I think that will be really useful to
actually flesh out what we really think—not just what we
think, but an independent view on what the additional costs are of
running that system in that part of Wales and what else that tells
us about the opportunities for improvement within that in any
event.
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|
[68]
Angela Burns: Before you come in, can I just say that I totally
accept that point and that’s why I asked the question?
Because, sometimes, you can have, in an institution, a legacy
problem that you don’t actually have the margin to deal with
and get out of the way. And you know that, once you’ve dealt
with that legacy problem, you can move forward and it’s going
to be a much clearer passage, going forward. But if you’ve
never had enough of that fat to deal with those legacy problems
then it’s very hard, and that’s why I wonder if we
need—. You know, is there—. Because it’s always
these two that have this major problem consistently—if
there’s either a recalibration of a baseline or that
pump-priming to get rid of or enable the management of that
legacy problem so you then can move forward. Because I accept your
point that on a revenue basis, year in, year out, there should be
enough fat within health boards to run their organisations, but
you’re still not going to run it at a profit if you’ve
always set out in the deficit, because you’ll just keep that
going. I mean, that’s just—
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|
[69]
Dai Lloyd: Okay, and before you answer, sorry, Lynne’s
got a point as well.
|
|
[70]
Lynne Neagle: It’s a very interesting discussion, isn’t
it, and I certainly welcome what you’ve said about having a
healthy dose of scepticism towards health boards that consistently
overspend, and I’m in the opposite position, because Gwent
consistently—in fact, there’s a small surplus? And
under the Townsend formula, which has never been properly fully
implemented, Gwent would have got a great deal more money, so the
counter-argument is that Gwent isn’t getting enough money to
recognise that deprivation. So, I’d be grateful if you could
respond to that point in your answer, really, and whether there is
actually any intention to go further with the proper implementation
of anything approaching resembling Townsend.
|
|
[71]
Vaughan Gething:
Well, when we allocate new money, we do
it on a Townsend-share basis, so the new sums are going along that
Townsend-share basis. None of this is easy, as this debate between
different Members encapsulates, and why would we expect it to be
any different? There is a real argument about how we allocate
resources across the country and the relative level of need, and
understanding what that need is. The zero-based exercise in Hywel
Dda, I think, will be helpful for us to understand what that looks
like, but equally it reinforces the points about reforming our
service. Because, actually, if you currently run the model
you’ve currently got and you know you can’t live within
your means for that, you should actually ask yourself, ‘Well,
is that the right model of care to be providing?’ Some of
that is about needing to pay over the odds to get staff in to keep
models of care going, and that in itself is difficult, and some of
that is also whether it’s the right model even if
you’ve got the staff there anyway. All those different
questions need to be run and to be asked properly, sceptically, to
understand how we then get to a position where we have the right
resource going into organisations that are committed to actually
using that money in a different way to deliver the service that we
always want to see in every single part of Wales. But I do think
it’ll be really important to understand what we get for that.
What do we think is the real cost for rural healthcare
systems—do we need to reflect that in the way we provide the
budget? And then does that explain the whole part of the
gap?
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|
[72]
But, actually, we’ve already made
some provision to recognise the current reality of where health
boards are. You’ll remember that last year I announced that
we would be holding back a sum to try and understand where Hywel
Dda and Betsi were to provide some of that support. And
that’s part of the recognition that, actually, we’re
not just saying, ‘Get on with it—it’s your
problem’, but, actually, there’s got to be something
real about what is a real basis for moving forward and saying,
‘What is the sum of money that’s required here?’
and what we then expect health boards to do and to deliver, and to
reflect and remember that the two health boards that live within
their means, that are large health boards with secondary care
provision, actually cover a significant chunk of the most deprived
parts of Wales. So, there is something about understanding how
those health boards have been successful. And that’s part of
our challenging the system, about making sure that we transfer that
successful leadership and understanding across our whole
system.
|
|
[73]
Dai Lloyd: The science, Alan? [Laughter.]
|
|
[74]
Mr Brace: I think generally when we’re looking at
resources, I think we’re looking at models of service and
then how people are staffing those models and what that looks like
on the financial side. And I probably would separate out Betsi from
Hywel Dda when we look at that analysis, because under all of the
funding formulas that we’ve used in Wales, north Wales has
always been the best funded area within Wales, and that remains
true under the current funding formula. If you look at the last
seven years, in the first four years out of seven, Betsi Cadwaladr
broke even; it’s only in the last three years that
they’ve hit difficulties. So, there is something in
understanding now around what changes they need to make in their
service models—can they appropriately staff it and can they
do that within their available resources? And that’s the work
that we’re doing with them.
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|
[75]
I think Hywel Dda is different. I think
they’ve consistently not delivered a break-even position over
the last seven years, and that’s why we’ve commissioned
a review. At the moment, the review is looking at the population
and the demographics, it’s looking at rurality and
remoteness, it’s looking at the scale issues, about trying to
run perhaps smaller hospital facilities over a broader geographic
patch, but it’s also looking at efficiency opportunities as
well—even within that configuration, are there known, agreed
and measurable efficiency opportunities that the organisation could
still go at? I guess when we get that report, it’ll then give
us a picture about what may need to be done on the resource side,
but also what the organisation will need to do to drive greater
efficiency and productivity within the model they’ve
got until any changes could be made to that model.
|
|
10:30
|
|
[76]
Dai Lloyd: Okay. And Julie—sorry, Julie’s got a
question.
|
|
[77]
Julie Morgan: I welcome the way that you’re approaching this,
and you mentioned Cardiff and the Vale, and you mentioned the fact
about the increased population. I think there has been a
long-standing issue about issues related to a big city—a
capital city and the most deprived wards in Wales and the
night-time economy and all those sorts of issues. There’s
been a long-standing issue related to that from people in the LHB.
I just wondered whether you were taking that sort of issue into
account when you were trying to look at what is needed, related to
the models of care.
|
|
[78]
Vaughan Gething:
Yes, and it’s part of what we
expect the health board to be able to try and anticipate and
manage. So, not just to say, ‘We think we’ve got
population growth other health board areas don’t have,
therefore that requires more money’—so what does that
mean in practical terms? So, rather than just a bid for some more
money, actually there should be an understanding or an attempt to
understand what they think that is doing to their drivers for
healthcare and how they anticipate managing that with their
partners, as well as the conversation they have both with us as a
Government but also with health board partners too, because this
neatly again encapsulates the ‘Treat Me Fairly’
conversation.
|
|
[79]
Gwent has significant areas of
deprivation, as does Cwm Taf. Cardiff and Vale actually does as
well—with my constituency hat on, I represent some of those
areas—but it also has significant areas of affluence as well.
Now, put all that in the mix, and you can get those versions in
every other health board—it’s what makes them different
and unique and special. But, ultimately, there is a block of money
that we have to allocate to the health service, and we will never
get to a position where everyone is completely happy.
|
|
[80]
The Townsend share is being used to
allocate for the additional sums of money that go into the service.
If we wanted to undo everything, we think we’d probably have
too much flux within our system. But new money going in goes on a
Townsend-share basis. So, those sums of money that are going into
health boards now are going on a Townsend-share basis—the
additional sums of money we’re investing year on
year.
|
|
[81]
But I expect each health board to look
critically at what it is doing and why, and this goes back into the
population needs analysis and understanding as well, and how they
plan to meet those. If there is a case about the different services
they run, then there needs to be a conversation across the service,
not just a bid into Government for more money. Because, as all of
you know, as we’re doing budget scrutiny, the NHS are doing
better than other parts of public services with money coming in,
but it comes at a very real cost and it does not mean that that
financial pressure disappears in other organisations. So,
it’s a point we take seriously in the conversation with
Cardiff and Vale, but we’ll need to see some more granularity
on what that really means and how we then understand. Actually, the
governance review I think will help to flesh some of this out as
well. So, as I say, I think those reviews will be important not
just for organisations in a heightened state of escalation, but
across our system as well, even those relatively well-performing
health boards at the moment. Equally, I think there’ll be
interesting learning across the system from the exercise in Hywel
Dda about the zero-based budgeting exercise as well, to understand
how you can assess the differing needs in that population and what
that really means to expenditure and where you should start from.
In all of this, though—the unavoidable part of this is that
austerity is not ending any time soon. These challenges will get
more acute, not easier.
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|
[82]
Dai Lloyd: Indeed, and we’ve been discussing Townsend here
since 1999. Lynne and I will remember that—we were both
considerably younger in those
days—[Laughter.]—but the issues remain. Angela,
do you want to mop up your section?
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|
[83]
Angela Burns: Yes, may I just have a couple more questions,
Chair?
|
|
[84]
Dai Lloyd: Yes.
|
|
[85]
Angela Burns: Thank you. You’ve already mentioned that
you’ve clawed back money from ABM for winter pressures that
they didn’t spend, and you’ve clawed back money from
Betsi Cadwaladr. Will you be asking the health boards that are
currently in deficit, and which you’ve been supporting, to
pay back that money as well? Is that your intention, or are you
not—?
|
|
[86]
Vaughan Gething:
Earlier on, I tried to get some clarity
about not pretending that health boards have lived within their
means or have performed better than they have done. So, again, the
money went in to organisations to deliver a certain outcome that
they’d planned for and they said they could do. When they
didn’t, the money came back in. We’ll cover off the
money so people can pay their bills, but it was showing their
year-end position about how far away they are from actually
achieving break even or not. So, effectively, it goes into their
overspend and, like I said, if you don’t do that, then I just
think you lose the financial discipline that is really important to
actually have as part of our system, and that we do see takes place
in other health board areas.
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|
[87]
So, this is about improving not just
financial management from the health board’s point of view,
but actually the broader point about achievement and reform
and how they drive better efficiency into their whole system. So,
there are important questions here, but, yes, the money gets clawed
back centrally but we effectively have to cover that off in any
event, but it means that you’re not artificially
demonstrating a better level of financial performance within that
health board.
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[88]
Angela Burns: Could you just give a quick comment, then, on
whether you believe—particularly for Betsi and Hywel
Dda—that, given their financial situation, they have had
enough money, or they have enough money, within their yearly
running cost to be able to effect some of the very
important—particularly that you talked about
earlier—quality changes and delivery changes that you want to
see and you’re charging the health service with delivering?
If they haven’t got money and they’re constantly in
debt, I just wonder how they’re going to be able to make
those changes that they need to make.
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[89]
Vaughan Gething: Some of that goes back into what the
drivers for reform are and how you deliver it. I don’t want
to get too philosophical but, actually, there are some things where
you understand that you need to change the way you run a service
because you will actually save money but you can also deliver
better outcomes—that doesn’t necessarily cost you extra
money. In some parts of service reform, you may need to spend money
upfront, for example on capital spend, but that doesn’t cover
against their revenue costs—but you then deliver revenue
savings, the way you change the way in which you run the
service.
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[90]
I’ll give an example that I’ve used before about ways
in which we think we can deliver more
efficiencies—outpatients. It’s not just my
view—it’s pretty much across the service—that
outpatients isn’t an effective use of clinicians’ time
and financial resources in the way it’s currently run and
delivered. The challenge isn’t all the clinicians saying,
‘Well, this is outrageous. It’s a waste of time and
money’—because, actually, a lot of clinicians within
the service are part of the challenge and the behavioural change
that is required to make sure that people aren’t needlessly
sent back into the outpatients’ system for a follow-up that
doesn’t need to be made. So, actually, there’s
efficiency there to be delivered that will make better use of
clinicians’ time, better use of your and my and every other
patient’s time. If we don’t need to go to an
outpatients’ appointment—for the time it’ll take
us to get there, to park or to get public transport there, to then
have that five minutes of time with a clinician, when actually, you
need not have attended in the first place—. So, that’s
really important because that’s real money being spent in a
way that isn’t effective.
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[91]
It should not be a significant additional cost to deliver some of
that greater efficiency. That’s a good example where
‘efficiency’ isn’t a dirty word that sounds like
it’s privatisation, but, actually, it’s really
important. It should mean you have more capacity to use that
precious public resource to deliver a better service in a better
way. It goes back to the eye care example as well. We’ve
changed eye care already and there are greater changes to come, but
that does mean that you are more likely to see a consultant, if you
need to see a consultant, because of the change we’ve
introduced about delivering parts of that service within primary
care on a high-street basis as well. Our challenge is how we
deliver more of that and at greater scale and at greater pace. So,
we come back to these themes, and that shouldn’t surprise
people. I think we’ll keep on coming back to those themes
through the next year and more, and we’ll wait to see what
the parliamentary review tells us again as well. I expect
there’ll be a real challenge about not just the level of
resource we have, but actually how we use that resource being
perhaps the most important question in delivering the reform that
is necessary.
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[92]
Dai Lloyd: Okay, Angela?
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[93]
Angela Burns: I was going to ask you, Cabinet Secretary, and
also perhaps Mr Brace as well—you both mentioned the word
‘efficiencies’ quite a lot of times—how would you
define ‘efficiencies’? Many would argue that the
easy-to-have fruit has already been taken. I just wondered if you
could give us some feeling of it. I do take your outpatients point.
StatsWales are very clear: April 2016-April 2017, the outpatients
appointments have dropped by 10,000 appointments. And if you
replicate that throughout the whole of the rest of the year,
that’s a significant number of outpatient appointments
saved—although it would be interesting to see what effect
that has back down the line within GP surgeries. If you could just
give a little bit more of an indication of the kind of efficiency
savings that you think that the NHS still has to offer.
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[94]
Vaughan Gething: I’ll make one brief comment then
I’ll pass you to Alan, who I’m sure will want to give a
technical analysis. The one point that I would make is that when
people say all of the low-hanging fruit is gone, I am healthily
sceptical about that again as well. Outpatients
reform—you’re saying 10,000 fewer—well, actually
there’s more to go as well. These are areas where clinicians
have signed up to, on a national level, saying there are things
that we could do in the way we run and drive behaviour into the
system. It isn’t about the public demand coming in,
it’s a demand that is generated by healthcare professionals
in the system and the way it’s used. I don’t mean to be
unkindly critical—I’m saying that cultural and
behavioural change is really important to what gets done.
Sometimes, that cultural change is more difficult, but actually to
say all the low-hanging fruit is gone, I have real scepticism about
that.
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[95]
Angela Burns: So do I. Don’t worry, we’re on the
same page.
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[96]
Vaughan Gething: But actually, the more difficult stuff is
often in the more valuable areas, not just in terms of saving money
but in terms of delivering real value.
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[97]
Dai Lloyd: Alan—fruit, hanging low or otherwise.
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[98]
Mr Brace: You should never ask a finance director if
there’s low-hanging fruit. But I think, if I just take it at
a summary level—what we’re trying to achieve across all
of the health boards—and then, if needed, perhaps give some
examples. So, I think there’s two types of efficiency that
we’ve got an opportunity to go at within Wales. One is the
technical efficiency, which is: without changing anything, can you
get more for the same input? Can you cut your inputs and maintain
your outputs? So, the normal sort of stuff you’d see in any
sector. The bigger prize, I think, is what is in the allocative
efficiency, allocative value. So, that’s in an integrated
system: could we move money? I guess the Cabinet Secretary gave
examples about where you could move money out of traditional
hospital provision into more primary care provision, and that is
allocatively effective, can drive better outcomes, but can use
resource better. We probably concentrated too much on the technical
efficiency. If you look at the work of the Health Foundation, the
long-running trend across healthcare systems is that 1 per cent to
1.5 per cent is probably routinely available within the technical
efficiency. If you look across Wales, that’s variable. Some
people have driven greater efficiency than others.
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[99]
So, what we’ve done is, chaired by Andrew, we’ve got a
national efficiency and productivity group, and that’s
achieved a number of things. There is a national framework of
efficiency and productivity measurement now that all boards are
using as part of their plans. The challenge within there for boards
is to share and make sure that everybody is getting to a consistent
level, so that we’re not seeing this variability. The medical
directors within this group are looking at clinical variation:
where have we got variation in clinical practice that we can
improve? The nurse directors are taking a lead on how we roster our
nursing staff better using e-rostering tools. Through the national
informatics service we’re looking at the efficiencies that
ICT could give us, and then lastly we’ve got a lot of work
going in the traditional areas of medicines and procurement, but,
again, just making sure everybody is stretching themselves in a
consistent way. On the allocative side there’s lots of work
going on within individual boards. In Aneurin Bevan they’ve
just moved—they almost will save £1 million by shifting
the pattern of service from high-cost intervention around medicines
into much more pulmonary rehabilitation and smoking cessation. So,
for a £0.25 million investment, they will save £1
million just by redistributing money.
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[100] We’ve also
signed an all-Wales agreement with the International Consortium for
Health Outcomes Measurement—ICHOM—which is an
international movement to try and measure outcomes that matter to
people as well as the more sort of technical, clinical outcomes,
and put that together and then have a look at how international
systems are doing. So, all boards at the moment are measuring lung
cancer, where we know we’ve got opportunities to improve our
outcomes, and they’re probably either going to do one
different set and share or they’re all going to do heart
failure and measure that. Then we’ll be matching
resources—financial and workforce resources—alongside
that, again with an expectation to drive up allocative efficiency,
but more importantly effectiveness, and drive better outcomes for
the money that we invest. So, I guess that’s a snapshot. Are
there opportunities? Absolutely. I think there’s always this
argument. Just by way of an anecdote, when cost improvement
programmes first came into the health service, they were set at 0.3
per cent and everybody said the end of the world was nigh. Then,
when it went to 1 per cent, everybody said there would be savage
cuts because we could never get here. So, we have, over the years,
always said that these are really difficult things, and yet
we’ve always achieved and we seem to be capable because
health services adapt and change. So, there will always be
opportunities, I think.
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[101] Dai
Lloyd: Okay. We need some more agility now, team, because time
is pressing on. Angela, you’ve—.
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[102] Angela
Burns: I’ve just got one more question, which I
won’t ask now. But if there’s time at the end, I would
like to ask about agency fees.
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[103] Dai
Lloyd: Excellent. Rhun.
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[104] Rhun ap
Iorwerth: Thank you. I think you’ll find most of my
questions have been asked but there are a few issues that I’d
like to explore. I’m interested in investing to save and the
capacity of the NHS in Wales to invest to save. It’s about,
as you say, efficiency of inputs balancing with effectiveness of
output. If you look at the additional funding, the £240
million, £110 million of it for inflation—. If we look,
perhaps, at similar overspends to what we have now, maybe £85
million going on that, and £20 million for mental health
services after the budget deal, there’s not much left, is
there, for that investment to save and to increase and improve
outputs. Is that a fair assessment?
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10:45
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[105] Vaughan
Gething: It’s part of the challenge we have in our system
about the inability of the health boards to live within their
means. It means that where you could use money to try and transform
services, the ability to do so is being denuded by the inability to
live within means. That’s a very real frustration. No point
pretending that, as Government Ministers, we don’t feel
that.
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[106] Rhun ap
Iorwerth: That’s fair enough. So, in reality, is the
additional funding, really, just going to—at best, and being
realistic—allow you to maintain the balance between the
efficiency savings, the input and the output? It’s hard to
see where you can steadily or dramatically, even, improve outputs,
seeing that there isn’t much space for investment.
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[107] Vaughan
Gething: Well, we need to think about outputs and outcomes,
because we can deliver lots of outputs without changing outcomes
too much. I think it goes back to, if you like, where we started
this session and thinking about the money we have to keep the
wheels turning, but what ‘keeping the wheels turning’
means, and the space that allows you—and should allow
you—to still transform and change a service, because we are
asking the service to do both those things. We want the service to
keep going and to deliver acceptable levels of performance, and I
know that, in this room, and in the Chamber, you will all ask me
why we’re not doing better on a whole range of measures, and
that’s the natural part of scrutiny that is there, but
it’s also about how we change the systems underneath those.
If you think about the example you gave earlier on concerns about
orthopaedic performance in north Wales, well, actually, as well as
saying, ‘Look, we can find some money to try and make sure
that your performance doesn’t slip further’, actually
you’ve got to change the way that system works if you
fundamentally want to do something different. It’s the same
on the bubble we have on diagnostics in south-east Wales. We need
to be able to change the way that system works and whether
that’s investing in resource—whether it’s staff
resource or others—. Actually, if we don’t change the
way in which our systems are run and that part of reform that
isn’t always about big service change and moving things
around between hospitals—actually there’s an awful lot
of service reform that is entirely necessary that needs to take
place, but to do that you have to keep the wheels turning as well,
because otherwise, you’re essentially looking at what the
health service will no longer do. Austerity means that we can
ultimately end up getting there. I think that you’ll see that
in parts of England, actually, where they’re having to have
that really difficult conversation. So, these are high stakes that
we are playing for. But, again, I think the review that we’re
having will help us to flesh out some of those choices as well.
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[108] Rhun ap
Iorwerth: Who or what is driving innovation Wales-wide? Because
I can see that every health board should be looking at ways to
innovate within their own health board areas, but we also need to
be looking at ways of innovating nationally. Where do we look in
budget lines to see the investment that is being made on improving
the Welsh NHS and sharing best practice and so on?
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[109] Vaughan
Gething: Well, I don’t think you’d see a budget
line that says ‘innovation and improvement’ because,
actually—. And I will tell you that I am driving innovation
and improvement, but the reality is that the biggest drivers for
innovation and improvement are our staff, because they’re the
ones who come up with the ideas about improvement. The challenge
over, say, for example, the referral-to-treatment example I gave in
eye care—well, actually, it wasn’t that I said,
‘I’ve got a great idea; let’s change this’.
It actually comes from staff, and it comes from people saying,
‘We think there’s a better way to do this’, and
the third sector also saying, ‘We think the way you currently
run your system doesn’t provide the best outcomes for
patients and it doesn’t drive the right sort of clinical
behaviours.’ So, how do we do that? It’s about, if you
like, systems innovation, as well as, if you like, service
innovation then as well, and we see that in a whole range of the
things that we do. Every health board has their own awards for
staff, which I think is a really important way not just of saying
‘thank you’ but of recognising innovation. In the NHS
awards that we have, the NHS Wales Awards, we look at innovation
that has already taken place. And actually, what’s really
important is those awards are now very clearly run on the basis of
promoting prudent healthcare examples of how we drive a set of
values to deliver greater efficiency. Our challenge then still
remains: how do we get those examples of what looks like good
practice and deliver them on a broader and deeper basis with real
pace and scale? You’ll have seen this within your own health
board in the use of telemedicine. There are really good examples of
telemedicine across the service. The frustration is that, actually,
we’re pretty certain that we could have a much wider spread.
That requires investment in IT systems and infrastructure, but that
would provide much greater efficiency in the way that staff and
patients have their time used and the outcomes that we then deliver
for people.
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[110] Rhun ap
Iorwerth: Okay.
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[111]
Dai Lloyd: Hapus?
|
Dai
Lloyd: Happy?
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[112] Rhun ap
Iorwerth: Yes, for now, thank you.
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[113] Dai
Lloyd: Keep them keen. Turning to social care—Dawn is the
queen of social care.
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[114] Dawn
Bowden: I wish. Thank you, Chair. Some stuff around cost
pressures: obviously the different allocations, and the imbalance
in the allocations between local government and the NHS, are well
known—we understand the particular pressures in local
government—but is there the potential for that to lead to
difficulties in progressing and speeding up the process of
integration, because of that budget imbalance?
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[115] Rebecca
Evans: Vaughan and I are always very keen to take a
whole-system approach and to look at health and social care as
equal partners. Actually, that was one of the parts of the
parliamentary review, and one of our requests was that health and
social care are considered and treated as equal partners, because
we know that when there’s pressure in one part of the system,
actually it leads on to pressure in another, back and forth and so
on.
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[116] So, we’ve
always seen them as equal partners, but we’ve also
highlighted social care as a sector of national strategic
importance, and that’s driving a lot of the change that
we’re delivering, especially through the additional
investment that we’re putting into the sector as well. I
think that the intermediate care fund of £60 million this
year is absolutely crucial in terms of starting to drive that
change, and it’s been warmly welcomed by all of the partners
who use that fund. But, also, we’ve given a commitment in our
manifesto to retain the integrated care fund for the lifetime of
this Assembly, so I think that gives those partners involved in
those regional partnership boards the confidence that they need to
plan for further change over the coming years.
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[117] Dawn
Bowden: Can you just explain a little bit more about how shared
budgeting—is there shared budgeting around health and social
care? How is that working? Is that something that we ought to be
looking at if we’re not already doing it?
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[118] Rebecca
Evans: The intermediate care fund in itself is a shared budget
for health and social care, but they are also able to bring in
other partners such as housing, the third sector and so on. The
regional partnership boards will decide how to draw down that money
and how to spend it locally. We know that it is driving change
elsewhere, so health and social care are teaming up to pool budgets
in other areas as a result of seeing, actually, the way in which it
is delivering change. It has to be change on the front line. But
also we have the pooled budget requirement now, which I spoke of
earlier, as of April next year, for adult social care. As I
described, this is going to be a big change in the way in which we
commission adult social care placements, and that is joint
commissioning.
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[119] Dawn
Bowden: Is that not meeting with any resistance—everybody
seems to be quite happy with that arrangement?
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[120] Rebecca
Evans: On the whole, health and social care are very keen to
work collaboratively and integrate where they can. I think
it’s fair to say that some local authorities would prefer to
integrate directly with health on a local authority footprint
rather than the regional partnership footprint with regard to
pooled budgets for April 2018. However, the legislation has been
really clear, and we’ve been very clear as Government, that
we will be requiring pooled budgets on a regional partnership board
basis—so, the health board footprint.
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[121] Dawn
Bowden: Okay—sorry, Albert was going to say
something.
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[122] Mr
Heaney: Just to come in to support all of that, as the Minister
describes, one of the really important aspects of a regional pooled
budget is the ability around care homes to come
together—strategic commissioning. Some of the market analysis
that the Minister’s had done shows us the opportunities for
both local government and health, working together with the third
sector and the independent sector, to really deliver that change
agenda, working with the quality that’s required and the
resources in the right place at the right time. So, it’s at
scale—moving away from, sometimes, an individual boundary,
which is important to local government, but the opportunity that
exists in terms of the scale.
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[123] Dawn
Bowden: Do you see a role, then, for the Welsh Government to be
driving that strategic change, or is that something that you see
very much happening at a local level? Obviously, the delivery is at
a local level, but what is Government’s role in terms of
driving that strategic change?
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[124] Rebecca
Evans: We are driving that strategic change through legislation
and through the requirements that we have in the legislation.
However, we’re also keen to support that change as well, and
support health and social care to work more closely together.
We’ve done that through our regional partnership board
training days, for example. We had one specifically on pooled
budgets. So, we realise that this is a difficult, complex task, and
we are there to provide as much support and guidance as we can to
local authorities and health in terms of delivering this.
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[125]
Dawn Bowden: Okay, that’s fine. I’ve just got two more
quick questions, Chair, if I may. You’ve alluded already to
the additional funding, Minister, but, on the additional £25
million in particular for social care, what were the particular
outcomes you were looking for as a result of that?
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[126]
Rebecca Evans: The additional £25 million that was announced
in the budget is very much in the same kind of field as the money
that Vaughan was talking about earlier, in terms of keeping the
system going. We heard very clearly the messages from the
workforce, from providers, from local authorities about the quite
severe pressure in the social care system, which is why that
£25 million was provided to local authorities to help them to
meet those pressures. That £25 million went through the
revenue support grant, so it’s for local authorities to
determine on a local basis how they use that money to meet that
need.
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[127]
However, we have been much more
prescriptive in terms of some of the other additional funding that
we provided to local authorities. The £20 million of funding
that we announced as a result of the consequential funding that we
received—£9 million of that joins the £10 million
I announced earlier this year, which was to help local authorities
meet the pressures of the national living wage. That, in this first
year, is provided through grant funding, so we’ve been clear
with local authorities about the outcomes that we expect to
receive. We see it very much as a tripartite agreement between
ourselves providing funding, also local authorities commissioning
for quality, and providers themselves investing in their businesses
and their staff.
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[128]
Dawn Bowden: So, is it still a bit early to see whether all of
that is panning out in the way that you wanted it to at the
moment?
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[129]
Rebecca Evans: Well, it’s very early at the moment. We provide
the money in two halves. So, the first half has gone out to local
authorities with regard to that £10 million, and then
we’ll be requiring them to report to us on various measures
to demonstrate that they are helping to meet the pressures of the
national living wage before we can free up the second part of that.
So, we’d expect to see improved quality and sustainability in
the workforce, reduced staff turnover, improved conditions for
staff, and so on. But then, alongside that money as well,
we’ve put £8 million into improving outcomes for
children in care and reducing the number of children in care, and,
again, this is part of grant funding, so we’re being very
specific as to what we wish to see. We wish to see expanded,
integrated family support services for families and for children in
care, or for families. This will prevent children coming into care
and increase the capacity that we do have for those children who
are currently in care. Also, we will be expanding the Reflect
project, which started out in Newport and is being expanded to the
whole of Gwent now. That’s to help mothers who have multiple
births taken into care, which is obviously extremely distressing
for the mums involved, and then increasing the number of children
that we have in care. So, this is a really exciting project that
this funding has allowed us to expand across the whole of Wales as
well.
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[130]
We’ll also be providing funding to
ensure that children, or young people leaving care, are now able to
be supported by workers up to the age of 25 rather than 18. So,
that’s helping in their transition into adult life, and,
again, hoping to improve the outcomes for those young people.
Again, we’ll be seeking to ensure that local authorities
reinvest those savings into prevention.
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[131]
Just to complete the £20 million,
the final part of that was the £3 million for a national
approach to respite for carers as well. Again, we’re looking
at what we might be asking local authorities to deliver there. We
haven’t set out those parameters yet.
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[132]
Dai Lloyd: I think young Lynne has got a question on this
point.
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[133]
Lynne Neagle: Has any of that money for children in care gone into
enabling local authorities to provide adequate support for kinship
carers?
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[134]
Rebecca Evans: This funding hasn’t actually gone out to local
authorities yet, because we are still working out the parameters of
what we will be asking, but it will be very much in the field of
what I have described to you. We can certainly look at the
pressures on kinship carers. I know we’ve had a discussion
about this outside.
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[135]
Lynne Neagle: Because they’re not gettingthe same
amount of money as non-family foster carers.
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11:00
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[136]
Rebecca Evans: That’s right. We can certainly look at this. I
think Albert also wants to come in.
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[137]
Mr Heaney: Just to add to the Minister’s comments, the
ministerial advisory group that’s currently being chaired by
David Melding is actually looking at these issues. So, that’s
being currently looked at in terms of kinship care, special
guardianship and issues of that nature.
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[138]
Dai Lloyd: Okay. Dawn.
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[139]
Dawn Bowden: Just one final question, Chair, around domiciliary
and the care home sector. Certainly when we were taking evidence on
the winter preparedness sessions, there were some concerns being
expressed about the resilience of both those sectors, and I really
wanted to get your views on whether you’re satisfied with the
resilience of both the domiciliary care and the care home sectors,
and, if not, is that primarily a financial issue, or are there some
sort of structural issues as well around those sectors?
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[140]
Rebecca Evans: I’ve been very clear that I do understand the
fragility of the social care sector as a whole, so, domiciliary
care and also the care home sector as well. I think the answers lie
in a number of areas. Funding is an important part of it, and I
described the additional funding that we are providing. I should
have also mentioned the fact that we are allowing local authorities
to access further funding by increasing the cap on domiciliary care
from £60 to £70 this year. That should ensure that
local authorities are able to claim about £4 million there,
as well, which also will help with the pressures, and we’ve
also provided local authorities with an additional £4
million—more than £4 million—to meet the
pressures, as a result of the furthering of the capital limit to
£30,000 as well. That was a manifesto commitment and we
thought it only right to provide that additional funding to local
authorities. So, funding is part of it, and I think that Welsh
Government is playing its part there.
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[141]
Also, there’s a role for
commissioning, and we’re trying to change the way that care
is commissioned so that we commission for quality, and we’re
doing that through a number of ways. I described the adult social
care placement pooled budgets from next year, but we’ve also
had the opportunity to develop, with the sector and with local
authorities, a commissioning concordat as well. So, that’s a
tripartite agreement, again, about commissioning for quality and
investing in staff, investing in business, and I was able to launch
that in partnership with the Homecare Association very recently as
well.
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[142]
The third part of it is regulation, and
we have the Regulation and Inspection of Social Care (Wales) Act
2016 to drive up standards in the sector. We’re consulting on
the second phase at the moment, which is about what standards we
require from the people responsible for businesses, but also the
kind of quality standards of the care home itself—so, the
environments in the care homes—so that people can have a good
understanding of what should be expected there. And we’re
also consulting on the issue of zero-hours contracts as well,
because we know of the link that these have with the quality of
care that people receive, particularly in domiciliary care, where
there can be a high turnover of staff and so on.
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[143]
So, there’s a role for funding,
commissioning and regulation, and phase 3 will be our final phase,
then, in terms of delivering the regulation and inspection of
social care Act, and that will be looking at market stability: what
information we will require from providers in order to give Welsh
Government, actually, a better oversight of the market, and we will
understand where we have pressures in the system. We will have a
duty, then, to inform local authorities if we think that there are
businesses that are weak and that could cause a problem locally.
So, I think that will give us much better market oversight. I think
that covers most of it.
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[144]
Dai Lloyd: Okay. Before we move on, in terms of budgetary
scrutiny and the living wage situation regarding social care
support workers, it’s a very laudable aim, but how did you
arrive at the £19 million figure? It seems to me that it
could ideally be a lot higher than that, so I was just intrigued as
regards how the £19 million came about.
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[145]
Mr Heaney: We had a number of round-table events. The Minister
asked us to meet with all the partners in the sector, which we went
through. The original knowledge and analytical services projections
were between £14 million and £22 million, and then it
was from a series of conversations. Part of the solution was
investing money, which Welsh Government has done, but part of the
solution is also looking to the sector in terms of how it can
contribute to aid staff development, pooling, sharing, perhaps,
back-office services as well. So, it was a wider conversation on
the pathway to sustainability.
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[146] Dai
Lloyd: A lot of it, though, is the actual contracts on the
ground, so that if you’re putting downward pressure on care
support workers to deliver services in 15 minutes as opposed to 30
minutes because of financial considerations, how is that built into
your £19 million deliberation?
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[147] Mr
Heaney: In terms of the 15-minute visits, in the passing of the
Regulation and Inspection of Social Care (Wales) Act 2016 it was
quite explicit, and it comes from Lindsay Whittle, Assembly Member,
in terms of one of the amended motions that came through very
successfully, and put the terms and conditions into what can be
done and what can’t be done so that the foundation is placed
to ensure that the care provided is sustainable.
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[148] In terms of the
financial packages, we work together with section 151 officers
across the Welsh Local Government Association and the chief
executive of the Welsh Local Government Association. So, in terms
of the funding amount that’s gone in to meet that particular
need, that is a substantial investment. I think it covers what we
will be doing, as the Minister explained earlier on, namely having
very detailed monitoring returns that will come back to us so that
we can monitor and make sure that that goes into the front line,
because, in a sector that has around about a 30 per cent turnover,
then we are investing a tremendous amount in terms of new staff
recruitment and trying to get retention, and this is a way to
create what we believe is that enhanced sustainability and
continuity of care.
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[149] Dai
Lloyd: All that’s accepted, but there is still a very
tight financial situation with regard to the living wage, and
that’s why we’re losing staff. They’ve been
trained, and then they just can’t carry on. So, I presume the
£19 million was based on numbers of care support workers, the
hours worked. There’s a mathematical equation; it
wasn’t just plucked out of somewhere just after a
meeting.
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[150] Mr
Heaney: It wasn’t just plucked out of somewhere.
It’s from the—. I mentioned the knowledge and
analytical services as well that assisted us in the statistical
analysis of the figures that were acquired.
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[151] Dai
Lloyd: Okay, thank you.
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[152] Rebecca
Evans: Can I just make a quick point on the delineation between
care time and travel time? We’ve been clear in our letter to
local authorities that accompanies that extra £19 million for
the national living wage that, actually, this money might be used
to ensure that social care providers do delineate. But, actually,
this would be a precursor to some of the work that we’re
consulting on at the moment as part of phase 2 of the regulation
and inspection of social care Act, which relates to delineation of
care time and travel time. So, we will be requiring providers to be
very clear in terms of their workforce—what time they would
be expecting them to travel, and so on. We know at the moment that
the workforce tell us that, actually, they feel pressured to move
between jobs because they’re not always paid necessarily,
even though they should be, for time between, for travel, and so
on. So, this will be explicit in the law.
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[153] Dai
Lloyd: That’s why it’s an important point. Anyway,
time is going on. Budgetary issues as regards
prevention—Julie.
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[154] Julie
Morgan: I wanted to go back to the issue of prevention. I think
you do say in your paper that it’s difficult to identify all
the ways that the money is actually spent on prevention. Do you
feel it’s possible to see the money that’s going into
prevention and the outcomes? Is there any way of measuring
that?
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[155]
Rebecca Evans: Last year, the previous Minister for Health and
Social Services published the national outcomes framework for
public health, and that’s a really important document for
Welsh Government but also for our partners in the health boards and
in local authorities, and so on. It has a series of 43 overarching
outcomes, and I’d be happy to send a copy of that document to
the committee to have a look at after today’s meeting. But it
does look right through the whole span of life, from years of life
and years of health, so life expectancy at birth but also healthy
life years expectancy at birth, mental well-being amongst children,
mental well-being amongst adults, and also a fair chance for health
as well. So, measuring that gap in terms of life expectancy at
birth between the most affluent people and the poorest people as
well.
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[156]
It moves on then to look at living
conditions that support and contribute to health, both now and for
the future—things such as the gap in employment rates for
those people with long-term health conditions, and so on. And it
then moves on to look at resilient, empowered communities—so,
people who volunteer, the number of people who feel
lonely—and to look at the natural and built environments,
which support health and well-being, by looking at the quality of
the air that we breathe and the quality of housing, because we know
all of these things come together to have a preventative
impact.
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[157] It looks at ways of living that improve health. So,
we’re measuring in our public health outcomes framework
adolescents who smoke, for example, adolescents who drink
alcohol, adults who drink above the guidelines, smoking in
pregnancy, breastfeeding at 10 days, which I know is something that
you have a particular interest in as well. And, then, finally,
health throughout the life course, so healthy ageing, for example,
life satisfaction amongst older people, older people of a healthy
weight, hip fractures amongst older people. That’s just an
overview of some of those 43 aspects that we’re measuring in
terms of getting a good understanding of how these preventative
measures can be demonstrated through outcomes.
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[158] Julie
Morgan: So, how do you actually measure those?
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[159] Vaughan
Gething: Can I just make one brief point about measuring
improvement and prevention? You know we started the inverse care
law work a couple of years ago, with pilots in Aneurin Bevan and
Cwm Taf, and maybe it would be useful to give the committee an
update on that. I think we’ve got some figures that we can
share on what we think we’ve actually done with those people.
So, it’s that point about, in the middle of your life,
it’s still possible to make significant improvement in your
own health outcomes, and I think that’s been quite a
successful example. It’s been rolled out in the Abertawe Bro
Morgannwg health board area, but we’ll send a note to
committee, because I think would be genuinely useful to share with
you.
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[160] Dai
Lloyd: Thank you.
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[161] Rebecca
Evans: The outcomes document will let you know how we access
these data as well. So, they’re things like Office for
National Statistics data, national surveys, research in
universities and so on. So, it’s a robust set of data.
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[162] Dai
Lloyd: Okay. Julie.
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[163] Julie
Morgan: Right. To carry on with the different groups that we
want to reach in terms of prevention. Obviously, one of the key
things is physical activity as prevention. How do you feel that
that is being addressed, and do you feel that Sport Wales is
achieving the goal of reaching the hard-to-reach groups that
don’t naturally physically exercise?
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[164] Rebecca
Evans: Well, this is one of the key questions that we’ve
asked the panel who are undertaking the review of Sport Wales to
look at. We’ve asked them to explore whether the current
vision, aspirations and strategic intent of Sport Wales actually
meet the Welsh Government’s aspirations and priorities and
objectives. And we’ve been really clear in that piece of work
that, actually, our priorities are about getting Wales active, and
particularly reaching those communities who don’t often
partake in physical acitivity and so on as well. And I’ve
been clear with them in the remit letter that that’s where we
expect them to be undertaking a lot of their work and a lot of
their effort. We should be having the review formally submitted to
Welsh Government in the next, I would say, week or so, and there
will be an opportunity then to have a discussion on it as well. So,
we’ll have a clearer idea as to what the findings are of that
review panel, and that will—
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[165] Julie
Morgan: And that will particularly look at reaching these
different groups.
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[166] Rebecca
Evans: Yes, that very specific question.
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[167] Dai
Lloyd: Okay. Julie.
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[168] Julie
Morgan: Thank you very much. And, then, my final question is
about the financial impact of legislation and the costings of
bringing in legislation. For example, the figure of £198,400
was submitted to this committee for the implementation of the
Public Health (Wales) Bill. Now, what does that figure cover?
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[169] Rebecca
Evans: The regulatory impact assessment described in detail
what we would expect the costs to be as a result of the public
health Bill. But we’ve been quite cautious in the way in
which we’ve looked at those costs as well. So, whenever
we’ve had to estimate, we’ve estimated at the upper end
of the scale. So, it could actually be that the costs of
implementing the Bill, or the Act, as it will be next week,
actually, might be lower than we—
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[170] Julie
Morgan: You’ve covered for unanticipated costs.
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[171] Rebecca
Evans: Where we have anticipated costs, we’ve gone to the
upper end as to what those anticipated costs might be. So, it might
be that they will be less. And, so, the kinds of things that
we’ve anticipated the costs for would be staff time for Welsh
Government officials in terms of dealing with the huge range of
regulations that will now sit underneath it, and the guidance,
producing signage and the development of the registers, which were
part of the Bill as well. So, there’ll be that work, but we
have costed all of that into the regulatory impact assessment. And
we’ve also been really keen, where possible, to give local
authorities the chance to lower their costs as well in the Bill,
for example, by having joint training days for parts of the Bill
that actually have a lot of synergy, such as the part on intimate
piercings, for example, and the part on special procedures. So,
there will be opportunities for local authorities to keep the cost
as low as possible as well.
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[172] Julie
Morgan: Okay. Thank you.
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11:15
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[173] Dai
Lloyd: Okay. The final section: a quick trot through
capital investment with Lynne.
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[174] Lynne
Neagle: Is there enough capital money there to enable health
boards to meet their planned aspiration, including major
projects?
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[175] Vaughan
Gething: Well, the two biggest major projects we have are the
Velindre Transforming Cancer centre and the Specialist and Critical
Care Centre. Those projects are proceeding. Our challenge is that,
across Government, even with some loosening in capital, there are
real challenges around the whole capital programme. It
wouldn’t be right to say, ‘We have lots of money to
throw around.’ So, there’s still real tight control on
the capital programme, and I am a bit concerned about our ability
to re-engineer parts of our system because we actually think that
investing in primary care could and should be a really useful way
to actually get services to work together and to provide revenue
savings. Also, we think that the Specialist and Critical Care
Centre, for example, will not just deliver better care; we actually
think it should deliver some revenue savings as well. That’s
really important in the way we use capital. So, there are always
going to be concerns about the way in which the programme is
managed. I mean, historically, as a Government, we have actually
come to the end and realised we’ve got a small underspend at
the end of the year. That’s not unusual for most
organisations, not even in the private sector. But, actually,
there’s an even bigger need to make sure that in our capital
programme we deliver on time and in budget, because otherwise,
we’ll potentially compromise other parts of the programme.
But those two major projects are going ahead. Obviously, the
Velindre one is a different model with a new Welsh mutual
investment model.
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[176] Lynne
Neagle: And, clearly, being able to have enough capital money
is important for service transformation, isn’t it?
You’ve alluded to that. Are you saying, then, that you are
confident that you have just about got enough money in the system
to achieve those transformations?
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[177] Vaughan
Gething: We could always do more if we had more, but the money
that we will use will have to be used in a way that transforms
services. The previous health Minister, who is now in a different
role in Government, who has an interest in money, was really clear
in the parameters he set, which I’ve continued with, that the
use of capital has to be able to deliver revenue savings and
actually deliver service transformation as well. Those are still
important tests. The architecture we have, with an investment board
that looks over these decisions, means there are real tests there
as well. It’s why some of our decisions take time to get
through, to be clear that the evidence really is there, and that
they’ll deliver against the parameters they’re set. I
would always like more to be able to spend on capital because I
think that we could spend lots of money very usefully in primary
care, but there are real limits to what we do have available
to us as a Government, let alone within the health and care
field.
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[178] Lynne
Neagle: And you referred to the Velindre model, which is a
mutual model. Can you tell us what the current state of play is
with that, and whether there’s any potential to take that
model and use it elsewhere?
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[179] Vaughan
Gething: Well, interestingly, Velindre is one of the first big
projects to use that model. I was at the launch day for that with
people who are interested in participating, with both Mark
Drakeford and Kirsty Williams, because the other area that
we’re looking at to use it as finance is education. I know
we’ve got a range of our school buildings that we want to
transform as well, but it’s actually finding capital to do
that. So, we’re looking at those two areas first, as big
areas where it could be used, and we also learn lots more from it.
But, at the moment, it’s proceeding.
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[180] We’ve met
with people at Velindre as well. People are interested in actually
designing the scheme as well. So, at this point, I’m as
confident, I think, as I could and should be that the model should
work; that ONS aren’t going to be—. Part of the issue
about having the model ready was to make sure that we didn’t
get into a position where ONS reclassified the money. Because
that’s what happened in Scotland: they had a different model
of investment and, after they’d actually spent money, ONS
reclassified the money and I know that the Scottish Government had
to find about £0.5 billion of capital moneys within their own
real moneys on the budget. So, that was a real risk and one I had
to redesign our own model on, so it’s slightly different to
what we initially wanted it to be, but we think, from the
conversations we’ve had, that we should be able to do that in
that way and not have all of that money on book, and, at the same
time, not be paying out the sort of moneys we would have done if
we’d have gone down the traditional PFI route as well. So,
it’s definitely a better option, but it does come with a
revenue cost attached to it. But, otherwise, we just choke off
completely our ability to deliver those larger capital
projects.
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[181] Lynne
Neagle: And just finally, your paper talks about an active
programme of disposal of surplus land across NHS Wales, and joint
working with other agencies. Can you tell us about the governance
arrangements that are in place to take forward that work? Also,
what assurances can you offer that any money that’s then
brought back into the system is being used to deliver service
improvements?
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[182] Vaughan
Gething: Well, perhaps I’ll ask Andrew and Alan to
comment, but I think there’s an important distinction to draw
between our approach here in Wales. We want to see reinvestment
made in partnerships, for example. You’ll be aware that the
previous housing Minister was looking at the ability to have
surplus public land and housing having an early call on whether
that land could be used to deliver against our affordable housing
targets. But also, the reviews being done in England on the
disposal of land in the NHS estate didn’t necessarily
guarantee to deliver resources back into the public purse as well.
So, that isn’t the approach that we’re taking here. I
think there’s a proper distinction to draw. I don’t
know if Andrew or Alan want to give you some more detail.
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[183] Mr Brace:
On the governance side, I think all disposals of land and property
have got to be approved by Welsh Ministers under the Act. So, to
some extent, the boards need our approval, and part of that
requirement as well is that everything over £0.5 million, in
terms of reinvestment, has also got to be approved by us. As the
Cabinet Secretary said, we’ve got a fairly rigid set of
investment criteria we would use and, therefore, apply to any sort
of income that we would receive from disposals, and how that was
going to be reapplied back into the service.
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[184]
Lynne Neagle: And does it always stay within the NHS? It
doesn’t go into any other broader capital pot in Welsh
Government.
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[185]
Mr Brace: I think all of these things get factored at a
Government level in terms of available capital and support or not,
but generally the NHS would remain within the NHS.
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[186]
Lynne Neagle: Thank you.
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[187]
Dai Lloyd: Okay. Angela, your question about agencies, squeeze
it in.
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[188]
Angela Burns: Thank you. We all know that we spend an awful lot of
money within the NHS on agency staff. I just wondered if you could
explain to me a little bit about that process. Because my
understanding, which is entirely incomplete, but from talking to
particularly nurses and the nursing profession at large, is that a
lot of our trained nurses will go and also work sometimes either on
bank or for an agency and for another trust, because they’re
unable to work within their own trust and get appropriate overtime
rates. I wondered if there had been a body of work undertaken that
actually examined this to say whether or not it would be cheaper in
the long run for the NHS to say to a nurse, ‘I’d rather
you stayed here on the ward and in the hospital that you know and
we pay you appropriate overtime,’ rather than, in order for
that person to earn extra money, them having to go off to the trust
next door and we end up paying agency fees or they have to go
through bank, where they actually earn less money. I just wanted to
try and understand that whole situation a little bit
more.
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[189]
Vaughan Gething:
I’ll ask Andrew to come in, but I
can just start by saying, ‘Yes, that is actively in our
minds.’ There’s work ongoing and I expect to receive
formal advice in the near future.
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[190]
Dr Goodall: I would distinguish our focus on bank as opposed to
agency, because of course bank is a local issue for management.
However, we do feel that a system that has been more based around
the individual health board boundaries—there is an
opportunity for both regional and Welsh banks to be in place, which
I think will address the issue that you’re raising about
consistency of the framework. But, yes, we’re doing some
particular work with the NHS in Wales. We’ve been looking to
put more controls in place, we’ve been looking at different
and more innovative models of service, we’ve been actually
learning from the English and Scottish systems’ experiences,
and there’ll be some ministerial advice coming up for a
refreshed policy in Wales.
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[191]
And, absolutely, what we want to focus on
is the extent to which we can rely on our own employees and give an
environment for our own nurses to work within our own services. And
I hope that will be underpinned by broader issues about recruitment
that would give people support as well. So, the ‘Train. Work.
Live.’ campaign is obviously looking to attract more nurses
in, our expansion of nurse commissioning numbers also gives some
kind of confidence, and the retention of the nurse bursary also
gives people the opportunity to feel that they’re going to be
looked after in the Welsh context at this stage. And, we’re
hoping that, as part of the advice to the Minister, there will be
some further clarification on this Welsh bank approach, which I
think will be quite innovative.
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[192]
Angela Burns: Will the Welsh bank approach be looking at the rates
that a nurse would be paid and whether or not that rate is
comparable to what he or she would have earned in their full-time
job for someone, because I think that’s quite an anomaly,
isn’t it?
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[193]
Dr Goodall: Indeed, the advice going up will be to remove the
reliance on agency, although there are some more substantive
service issues for using agency on a longer term basis, and it will
introduce a more consistent framework across Wales so that people
don’t pick and choose between individual health boards and
individual services. So, that is the underlying intent.
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[194]
Angela Burns: And just a final question on agency: the agency costs
that we see within the NHS, which are huge, are they mainly for
nursing or general medical staff or are there also substantial
amounts of that for staff elsewhere within the NHS organisation? Do
you have that breakdown?
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[195] Dr Goodall: Just
to continue the response, it’s a mixed picture, but the
predominant pressures are around medical and nursing agency
use, and, in broader terms, there is some peripheral use of other
members of staff. Our general approach is to see whether we can
shift all of those, but, obviously, in terms of bringing resources
back into use and also our focus on the quality of care
that’s provided, the focus for us is really around medical
and nursing. There are different reasons, so, you can have a
short-term issue and a concern about quality on a particular ward,
and people making those sorts of judgments. I think there are
different ways of supporting that in terms of the local operational
management approach. I think there are more tricky issues when
you’re looking at, perhaps, the fragility of some services
that have been reliant on locums over a longer time, so I look at
areas, for example, about the support that underpinned maternity
services in Betsi Cadwaladr, which required some longer term
locums, or indeed around Withybush hospital with some of the locum
arrangements. However, having said that, positively—and I
think, again, this is, hopefully, with a more assertive Welsh offer
that’s in place—we’ve actually seen staff
who’ve come in initially as locums, perhaps on a slightly
enhanced rate, wishing to be remaining locally within substantive
roles. I think there’s been success there with both Betsi
Cadwaladr, and, actually, more recently, in Hywel Dda, where people
have converted to become NHS employees.
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[196] Angela
Burns: Thank you.
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[197]
Dai Lloyd: Ocê. Diolch yn fawr. A dyna ddiwedd y sesiwn, felly diolch yn fawr
iawn i Ysgrifennydd y Cabinet ac i’r Gweinidog a hefyd eich
swyddogion am eich presenoldeb y bore yma. Mi fyddwch chi yn derbyn
trawsgrifiad o’r cyfarfod yma i gadarnhau ei fod e’n
ffeithiol gywir. Ond, gyda chymaint â hynny o eiriau, diolch
yn fawr iawn i chi am eich presenoldeb. Diolch yn fawr.
|
Dai
Lloyd: Okay. Thank you very much. And that bring the session to
a close, so thank you very much to the Cabinet Secretary and the
Minister and your officials for your attendance this morning. You
will receive a transcript of this meeting so that you can check it
for factual accuracy. But, with those few words of thanks, thank
you again for your attendance.
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11:26
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Papurau i’w
Nodi
Papers to Note
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[198]
Dai Lloyd: Rydym ni’n symud ymlaen i eitem 3, papurau
i’w nodi. Mi fydd Aelodau wedi gweld y papurau i’w
nodi. Unrhyw bwynt i’w godi? Nac oes.
|
Dai
Lloyd: We move on now to item 3, papers to note. Members will
have already seen these papers to note. Any points to raise?
No.
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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
|
|
Cynnig:
|
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).
|
|
Cynigiwyd y cynnig.
Motion
moved.
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[199]
Dai Lloyd: Rydym yn symud i eitem 4, cynnig o dan Reol
Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod
a mynd mewn i sesiwn breifat fyr. Pawb yn cytuno? Diolch yn
fawr.
|
Dai
Lloyd: Therefore we move to item 4, motion under Standing Order
17.42 to resolve to exclude the public from the remainder of the
meeting and to go into private session. Everyone agreed? Thank you
very much.
|
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Derbyniwyd y cynnig.
Motion
agreed.
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Daeth rhan gyhoeddus y cyfarfod i ben am
11:27.
The public part of the meeting ended at 11:27.
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