Cynulliad Cenedlaethol Cymru

Good morning. Welcome to the Health and Social Care Committee meeting this morning. I'm Peter Fox, Chair. Can I welcome Members to the meeting this morning? We have apologies from Lesley Griffiths. We have three Members in the Senedd and two colleagues who will be coming in online today. The meeting is bilingual and there is simultaneous translation from Welsh to English for anybody who needs it. Can I ask Members, are there any declarations of interest that anybody would like to make? No. Okay, fine. If you find one as we go through, please just mention it at that time.

We are going to continue our inquiry into the future of general practice in Wales. I'm really pleased to welcome this morning our panel: Professor Adrian Edwards, professor of general practice and co-director of the division of population medicine at Cardiff University—welcome; Dr Neil James, Deep End Cymru chair and GP partner in the Gwent valleys; Joanna Watts-Jane, Deep End Cymru deputy chair and business manager at Hirwaun surgery; and Dr Jonny Currie, Deep End Cymru policy lead and GP partner at Ringland surgery in Newport, and consultant in public health with Cardiff and Vale health board. Welcome to you all. Thank you.

Professor Edwards, you have kindly offered to give us a presentation, which may help us shape some of our questioning as we go through the morning. So, perhaps I can hand over to you at this point before we move into our formal questions.

Thank you very much. Bore da, bawb. Good morning, everyone. Apologies for my voice—I hope it will hold out. I'll see how we go. I'll just offer a presentation, hopefully to give us a few starter points to lead into discussion.

Just to confirm my interests, I was a GP partner for 25 years, and it was a practice that then resigned its general medical services contract a few years ago. So, I've been there and done that, and you know the experiences from your constituencies about how that affects everybody. I was then a salaried GP for five years and actually retired from practice earlier this year, but still working at Cardiff University. And just to make the point, this is not a party political presentation. The points that I refer to go way back over many years of politics. All colours and stripes of Governments have been in charge. It's just where we are in the NHS.

Much of this material I actually presented at the UK COVID inquiry a few months ago. Just to start us all off, as we know, at least 70 per cent of healthcare encounters in the NHS are in primary care. And by the way, we did more than 70 per cent of all the COVID-19 vaccinations. There is evidence that investing in primary care services is cost-effective at the societal level. Each £1 that's invested leads to £14 delivered in productivity across the working community. It's remarkable. These are not our figures. These are from the NHS Confederation.

Let's have a look at where we are in terms of provision of general practitioners. Per 100,000 population, let's compare with some reasonable comparator countries. Australia: 121 full-time equivalent GPs per 100,000 people, and that figure is rising. There's an arrow behind those pictures on the side of the screen. So, 121 and rising in Australia; 74 per 100,000 in New Zealand and rising; 103 per 100,000 in Canada, and actually decreasing a little; and the UK, 45 per 100,000 and decreasing.

Where does that put us within the UK league table? Actually, Scotland is pretty good, right up there, followed by Northern Ireland, then Wales, then England. But actually, those figures were 2023 and 2024—sorry, there are some figures behind those screens. The latest figures that I've been able to get from HEIW show that Wales is actually right down at the bottom now. We've fallen behind England in terms of the provision of general practitioners per 100,000 of population. And what we all know is that patient experience is declining. We know it from our switchboards and you know it from your mailbags. We're not going to contest that point today. 

And the inverse care law, which we do hope to talk about in discussion later—let's just remind ourselves exactly what it says. It's from Julian Tudor Hart who was, of course, a GP in Glyncorrwg, and he wrote this over 50 years ago, that the availability of good medical care tends to vary inversely with the need for it in the population served. And the further point that he made, which is a party-political one, is that the inverse care law operates more completely where medical care is most exposed to market forces and less so where such exposure is reduced. 

Let's just quickly look at the workforce. These figures are actually from NHS England Digital. It's actually easier to get figures about what's going on in England than Wales, but I think the situation is very much the same. I'll show you a graph from Wales in a second. In these figures from England, the top line of the coloured area of the graph shows that the number of workforce GPs has stayed largely the same over 10 years, but the proportions of different types of GP have changed a bit. The dark blue columns at the bottom there are the GP partners, and you'll see that declining every year for 10 years, and to some extent being replaced by salaried GPs and also trainees at the top. But the overall numbers are the same, and we note, obviously, that various Governments at various times have committed themselves to increasing numbers, but it hasn't happened. These are the figures in Wales, which show very much the same thing: a top line of a declining number of partners to some extent being replaced by salaried GPs and others. 

It's not all about GPs, of course; other staff are changing in the service. The number of nurses is the top line. That's been largely flat, actually, but other staff are coming in to the primary care team, and that's a good thing. They can range from healthcare assistants through to highly qualified pharmacists and so on. So, there's a wide variety within that group, but it is increasing over the years. 

What do we know about workload? This is now testing my eyesight, probably as much as anyone else's. The figure is the number of patients per full-time GP, and it's going up from somewhere around about 1,600 at the start of that graph to close to 2,000 by the end of the graph. So, the number of patients per GP is rising. And the number of appointments provided in general practice is rising year on year. There's a dip there in 2020 with the pandemic, which was then largely replaced with COVID vaccination and other activities, and the dark blue blocks are the total number of regular consultations, which are rising year on year.

What we also have is the inverse workload law. In the affluent areas of Wales, the average number of patients per GP is 2,100, and in deprived areas, it's 2,400. And by the way, those practices get 7 per cent less income to provide those services. When we look at what's actually happening with those patients, the doctor has got more patients to start with in a deprived area, and then those patients are actually presenting more often as well. This is a graph that shows the deprivation quintile. The top dark line is the poorest quintile in our population, and the bottom line is the most affluent. You'll see at a glance that people in the deprived population are presenting about twice as much as people in the affluent areas of our communities.

As to what's happening across our Welsh health board areas in terms of provision of GPs to meet this demand, we've got the seven health board areas here, and the yellow line across the middle is an average. So, you'll see that the fifth one across, Cwm Taf, is below average for GP provision, and we all know that that is an area of high deprivation, if not the highest, and Powys has the highest number of GPs provided per population, although there are some differences about Powys because it doesn't have a hospital. So, there are differences about the ways that healthcare is provided. But, nevertheless, definitely for Cwm Taf, the area with the greatest need has the fewest doctors.

Just a few background points about workload in general. The number of people living with disability is increasing substantially. There are some figures there: it's increased by over a sixth from 1990 to 2016 with the ageing population. Between 2003 and 2016, the number of people with a single long-term condition rose by 4 per cent per year, and the number of people with multimorbidity rose by 8 per cent per year. The number of over-65s is forecast to rise by over two-thirds in the next 10 years, and the number of over-85s is forecast to rise by 55 per cent by 12 years' time.

A study from several years back showed that, within the 10-minute consultation, a GP was dealing with 2.3 problems for each patient showing up, and that was 10 years ago. So, what's it doing now? Many of you will know a luminary from public health circles, Professor Sir Muir Gray, and he had a saying one time: he said that the GP morning surgery is one of the wonders of modern medicine. I agree with him. If we look at what goes on, the complexity and scale of what's going on, it really is astonishing.

At the start, my slides said that I'm the director of the Health and Care Research Wales Evidence Centre as well. We did a study for the Welsh Government last year, looking at the prevalence of several conditions—what's forecast over the next 10 years—so that they can start to forecast and build that into provision in relation to need in NHS Wales. Perhaps unsurprisingly, all these chronic conditions—cancer, cardiovascular, dementia, mental health, multimorbidity—are all forecast to rise over the next 10 years.

We would all like to think that prevention was better than cure, wouldn't we? What have we been doing in the NHS over all these years? This graph goes right back to the start of the NHS, and it shows the number of doctors, the number of GPs, the number of consultants. GPs is the bottom—it has largely flatlined ever since 1947. The line in the middle is the number of other doctors, therefore mostly consultants. So, what have we been doing? We've been putting our resource into hospitals, trying to do cure and not doing prevention.

Budget is very important. Again, figures are slightly easier to come by for England, but I think they're largely showing a similar pattern for Wales. But in England, the proportion of NHS budget spent on general practice fell from around 11 per cent 20 years ago, now to 8.4 per cent. And the figure I was able to find was that Wales was 7.6 per cent. I believe it was discussed in this session with colleagues from the British Medical Association and the Royal College of General Practitioners a couple of weeks ago. I saw a figure quoted in the transcript of 6.2 per cent in Wales for primary care. I don't know where they got that figure from, but that's what was presented here.

There has been a real-terms increase in spend across the NHS, but it has disproportionately not gone to primary care. So, primary care has risen by 14 per cent over these last 10 years, but in other areas of the NHS, their real-terms spend has increased by 17 per cent to 45 per cent. So, someone's getting a huge slice of the cake. Remember, resourcing primary care is cost-effective at societal level.

So what should we do? There are discussions about redistributing within primary care—the Carr-Hill. I'm actually not going to dwell on that. You discussed it last time with those colleagues. But I'll just make the point that it is a zero-sum game. If you help someone, you're taking away from someone else. So, I don't think that's really a big part of the solution.

We do need to make moves to get back at least to 11 per cent of the NHS budget. But actually, I think that's a minimum, because of those massively rising workloads that are forecast. What we need to do alongside is a transparent assessment of what budget we need in relation to workforce, workload and population need. That needs to be a regular process, at least annually, and the likes of Public Health Wales and ourselves in academia could be a vehicle to do that.

The workforce: we definitely need to expand and sustain the primary care workforce across the disciplines, and it needs to expand fast enough to meet those challenges of increasing workload. One possible tool for that in general practice could be the academic fellows scheme. So, colleagues may know about that very much, but just in case: it's been going for 20-plus years, funded by Welsh Government, and motivated GPs, usually early, sometimes mid-career, come into our department in the university and they do a two-year post of teaching and research and a postgraduate diploma, and they work in practices in the deprived areas of south-east Wales, and there's a parallel scheme in Swansea and north Wales. And it's a great recruiting sergeant: 70 per cent of those graduates from that scheme work in those practices in deprived areas. But it's only producing five GPs per year. So, proof of concept, yes; scale, no. It could be really useful.

Other ways to enhance capacity: there are reimbursement schemes that directly reimburse practices when they appoint or give existing staff extra hours. There's one called the additional roles reimbursement scheme in England, which reimburses 17 other roles, but not doctors, but does give them full reimbursement for those roles. We have one in Wales called the additional capacity scheme. It started during COVID and is still going on, but it gives 50 per cent reimbursement. I think that could be a vehicle if it was scaled up. It could allow practices to recruit staff, to provide services, and maybe the reimbursement could be differential according to levels of deprivation, so that, yes, all practices need help, including in affluent areas, but the deprived areas need more help.

We also need to be looking at student and training place numbers. In other countries, they have quotas. They say 40 per cent of all training doctor places should be in primary care, like Canada. Should we be looking at that in Wales or the UK more widely? When we do all this training, we need to ensure that the supervision capacity is there for GPs, because at the moment, it's falling on the GP partners, and we saw that graph, the number of GP partners is trickling away, and it won't be there in another five or 10 years to actually do the job.

Last couple of points. The urgency. So, in 2023, 10 per cent of the GP workforce aged under 40 left the workforce. We're haemorrhaging. We've got to do something about it immediately. On the other hand, there is strong interest in training. There are three times more applicants for each place, so let's use it.

Those are the points that I started with. I won't dwell.

No, well, thank you so much. That was excellent in laying some context, and we will be reflecting on many of those points during our questions this morning, but I think there were some very powerful messages there as well, which are food for thought and will no doubt help us in our deliberations. So, thank you once again for that.

We've got, obviously, as you can imagine, several questions we'd like to go through. Please feel free to come in on each question, but don't feel you have to if you feel it's been answered well enough. We'll probably get enough time then to get through everything. So, perhaps I'll kick off, and some of these points we would have touched on, Adrian, through the presentation, possibly, but this will give us an opportunity to perhaps explore a little deeper.

So, I'd like to start with funding and the inverse care law. I wonder could you provide examples of how underinvestment in general practice has impacted patient outcomes, particularly in areas of high deprivation. I'm not sure who would like to start on that. Yes, please, Jonny.

Thank you, Chair. I just want to say 'thank you' for the invitation this morning. I want to give a big credit to all the work of Deep End in the last few years, which we know has been supported by Welsh Government; it’s meant a lot.

We came here a number of weeks ago, colleagues, remember, to present to you, and mentioned the analysis that we published last year—supported by Cardiff University, obviously—and I think the easy answer, in all fairness, is that we don't know, because we can't see the data. So, we don't know what impacts we're seeing and having when it comes to equity of general practice, the NHS and the community. But what we do know, building on what Professor Edwards just shared, is for every 10 per cent increase in practices' populations with patients in the poorest areas—. So, my practice in Ringland, you mentioned before, has got 65 per cent of our patients from the poorest 20 per cent areas across Wales. Julian Tudor Hart's practice, I think, was still sitting at about 80 per cent the last time I checked. Most practices are about zero or one; it's very skewed. For every 10 per cent increase in patients in the poorest areas, your practice income, on average, goes down by 1 per cent. It doesn't sound a lot, but when you start to add this up with maybe 5 per cent, maybe 10 per cent less income, given that we know your average GP practice in Wales is differentially less funded than your average practice in England, which you might want to come on to this morning, we're looking at tens of thousands less money coming in to general practice in Deep End areas, despite the fact that Professor Edwards talked about the demand, the need, the premature mortality, the morbidity.

And this doesn't just affect us as GPs and doesn't just affect our patients; we know that there are huge pressures in hospital and a huge focus on waiting lists, which is necessary since the pandemic. But if we look to forecast everything that Professor Edwards has talked about in terms of where do we get to by 2040, where do we get to by the mid 2030s, all those people with all those chronic diseases and ageing populations are going to hugely affect emergency hospital services, which we know are already stretched to the limit. So, this has to be the time to do something.

Yes. Neil.

Thanks, Jonny. Thank you for inviting us, once again. Just to maybe add a little bit of context to that, I work in the Rhymney valley, in a highly deprived practice. And we have tried to produce evidence—and Professor Edwards's talk talked about hard facts and evidence—but qualitatively, up in the Valleys or in the inner cities, working in practice is very challenged. And what we have seen is practices collapsing, going to the wall, in many of these areas. And you asked about what the effect is on patient care. If a practice collapses and hands a contract back, you lose all the goodwill in that practice. It's very hard to pull that practice back from that situation. You will probably know that local health boards try different models. They are usually unsuccessful. They have to bring in other providers like eHarley Street, you might have heard of, with a different business model, which again hasn't worked.

So, once you've lost the practice, you've lost goodwill, but more importantly, it's disastrous for patient health. Because in deprived areas, in Deep End, continuity is important; it's far more important than access. And we have been emphasising, for too long, access over continuity. For people with multiple chronic problems, continuity is vital, and when a practice goes to the wall and hands a contract back, you lose all that continuity. It doesn't take a rocket scientist to understand the effect that that will have on patient health. You don't even need the data, though we need to provide the data as evidence.

I have been seeing this in Rhymney, at the top end of the Rhymney valley, for 20 years. We knew the issues 20 years ago. And if you actually go back, even to the advent of the NHS, inverse care has always affected us. I mean, I'm from Senghenydd in the Valleys, and having lived and worked in the Valleys—I spent some time outside the Valleys as well—I've seen societal disintegration, and the effect that has on patient health has been profound. So, patient care has—. We have endeavoured to provide good patient care, but it's a beleaguered environment.

Thank you, Neil. Joanna, would you like to—?

Yes. I'd just like to say 'thank you' for having us this morning. The other thing that I think we need to bear in mind is that we have the option, in primary care, of doing enhanced services. So, we get an option to do an enhanced service to provide, say, ADHD monitoring or frailty monitoring. What we need to think about in the more deprived areas, when we're struggling for staff, is actually whether or not we can provide that service to our patients. If we can't provide that service, then our patients don't get it. So, if you've got a practice that's really robust with workflow, they have enough capacity to take on some of these wonderful projects, like the frailty project, which is amazing for the older patients. It's looking at them holistically, which is what we want. We want prevention; we don't want cure particularly. But, actually, what we have to work out is: do I have enough capacity to do that without taking that away from my daily capacity? So, there is an impact then on your patients as to whether they're getting the same standard of care as another practice that can provide that service.

Yes. Thank you for that. Adrian, anything? 

Just to add one stat for you on that concept that Neil's describing, because you said, 'How do we know it's particularly affecting people in deprived areas?' So, in the Deep End practices that we're talking about, in this poorest quintile, 10 per cent of the practices closed or merged in the last three years, compared to 2.8 per cent elsewhere. So, it really is targeting these areas. 

Yes. There's clearly a huge amount of pressure in those practices and I can understand how challenging it seems to be. So, clearly, I was going to touch on the Carr-Hill formula, but clearly the Carr-Hill formula isn't helping. It's not addressing this, it's not recognising this. Anything you want to share about the Carr-Hill formula? Yes, Jonny.

Again, to rehearse what we said a number of weeks and months ago, Wales doesn't have a technical committee that is able to robustly produce advice and evidence to feed into that when it comes to health service planning and funding. There are welcome messages we've heard across the UK, including in Wales in recent weeks, around what road map we might see ahead of us in terms of funding finally coming to general practice. If we were to go along the lines of, from where we are just now, with about 7 per cent of NHS Wales funding going into general practice, to 11 per cent, I think you have to question how you do that stably and respectfully, because we don't want to destabilise any other parts of the health ecosystem.

But in parallel to that, I think we have to consider equity, and Scotland has, in previous years, produced its own funding formula for general practice. It may not be perfect, but at least they've tried. There seem to be signals from across the border in England, which we don't need to copy necessarily, obviously, that there is going to be a revision of Carr-Hill undertaken by the National Institute for Health and Care Research. It's still at an early point, and we don't know what's going to happen, but it looks as though into next year there may be announcements that would suddenly skew funding, fresh funding, going in to Deep End practices across the border in England. It would be hopeful that we could be in a position in Wales, with all of that happening around the rest of the UK, that there is precedence, there's evidence, there's data, there's clearly a lot of will, and, I think, we just have to be careful around the framing.

It is a challenging environment to practice a Deep End practice, but it's very inspiring too. I think we just have to be careful to say, 'We really want to inspire the next generation.' We really want to look at, as Professor Edwards talks about, anyone that comes in to train with us, works with us in a stable practice that is committed to continuity of care, that is committed to continuous improvement. At the moment in Wales, we still don't have that training infrastructure that can really encourage people.

So, whilst we recognise that the current system isn't addressing certainly that area of inverse care, we know it looks like other countries are doing some further work on seeing how they can address things. So, for Wales, what would a fair needs-based funding model in general practice look like? We recognise the problems. Because it's got to recognise the differences, the challenges that you have in Deep End areas, compared with other areas as well. So, it's got to have some sort of flexibility, hasn't it? Have you given any thought to what a needs-based model might look like, if it were to work?

I don't have insight into the detail of the Car-Hill formula, but the Car-Hill formula seems to favour age over deprivation. So, if you want a needs-based formula, it needs to favour deprivation as much, equally, or perhaps greater than age. So, at the moment, practices with high elderly populations benefit from the Carr-Hill formula, even though those elderly populations may be in very affluent areas. And it doesn't take account of the fact that younger deprived communities can outstrip the demand of elderly populations in affluent areas. So, it needs to recognise deprivation.

Also, we are no longer naive. For the last generation, there's been an element of systemic naivety. It's not malign intent, but we haven't understood the issues properly, and that's influenced the way funding has gone. There have also been perverse drivers in the system. So, there have been elements of funding that have actually, because the data haven't been there and haven't been understood—. It's driven health inequality. So, we have the opportunity to be smart now, because we have better data, though it's not perfect, as Professor Edwards said.

Yes. Just to be super blunt, as you say: how should the formula be adjusted? Yes, lots of fine tuning, but as Neil says, it's favouring age over deprivation. In the deprived areas, people are dying before they get old enough to score in the system. That's what needs to be fixed.

Yes, I get that. Any further points before I bring in—. James has a question. James, would you like to come in? You're muted at the moment. You're still muted, James.

Am I back?

Yes, you're back now.

Great. Lovely. Because you touched on funding, Chair, I think it would be remiss of me not to ask: during the presentation that Professor Edwards gave about restoring the funding from 8 per cent to 11 per cent, at a minimum—. I'm just interested if any work has been done on where that money could come from. Obviously, there's no more extra funding in the system, within the budgets that the Welsh Government has got. So, I'm just interested in whether any work has been done by Professor Edwards or others on where they think that additional money could come from within the current NHS funding structure that we currently have. Thank you, Chair.

Thank you, James. Adrian.

I haven't—. I'm not actually aware, but I think that it's as described by Jonny just now: it needs to be done incrementally because, essentially, it is going to be coming out of hospital-based services. And yes, clearly, they are stretched, but what they have had is that redistribution, over 75 years, of the NHS—that all of this money has been put into treatment services and not enough into prevention. So, we need to understand it and shift that culture so that, gradually, without destabilising hospital services, we're actually putting money where it will save money.

I think we'll come on to prevention in some detail a little later, but I can absolutely see that point. You've had to be very innovative in Deep End practices, I'm sure, to try and counter the inverse situation. Have you got any examples of things that you've been doing that have helped mitigate the effects of inverse law?

Well, speaking from my experience as a GP of 22 years in Rhymney, we have followed a merger process. So, we have actually had to merge on a number of occasions to maintain viability and sustainability. We've reached a point of sustainability, I think, and part of that is by offering multiple services—all the services that we can. But the other thing is being a training practice. Adrian touched a little bit on this. Training practice status is a marker of excellence, and it enables practices to train young GPs or other health professionals. That, in itself, leads to a higher likelihood of those professionals staying in the practice and staying in the area. So, for example, in my partnership, four of our partners are ex-trainees of ours.

So, training practice status is very important, I think, and it's one of the key—. At the moment, with the funding situation as it is, it's one of the key indicators of stability. It enables continuity by enabling you to maintain your clinical staff. Aspiring to training is an important thing. The problem is, in Deep End areas, there's a paucity of training practices, because people are so busy at the coalface, they don't actually sometimes have the capacity to actually engage in other activities and to invest in other aspects of practice. That's a problem. So, developing training practice, I would say, is a key issue in trying to increase the flow of doctors and clinical staff into Deep End areas.

Thanks. Adrian.

Thank you. Just to illustrate that point, as you say, the distribution of training practices is an issue. It was mentioned earlier about the practices that had been taken over by a private provider from health board management in the Gwent area. So, in Pontypool, for example, that's exactly where the problem is. It's no longer a training practice town. All three practices are not training, and then they end up with those problems, because they haven't got that pool of people to be able to draw upon, even though people would like to do a great job in these areas. That's what it actually looks like in real life—the whole medical service in Pontypool falls over, and then has to have urgent attention to resuscitate.

If I could answer the question—you asked what's also being done in Deep End areas. An example is the academic fellow scheme. I mentioned what happens with the doctors who go there as the fellows. They get some extra training, they work in those areas, they get exposed to the way of working and they very often like it and they want to stay. But what I didn't say was what the practices do with that allocation of resource. So, what actually happens is that the academic fellow goes and works there for two days a week, and that frees up the GP partners to do some other work, which is the development that Joanna was talking about that we haven't otherwise had the time to do. What can we do about getting this enhanced service up and running to do with ADHD, frailty, or whatever it is? And that enables those practices to get their head above water and do it. That's an example of targeting resource into a Deep End area and helping them to get further on.

Jonny. Thank you.

I just wanted to echo those thoughts. So, I joined Ringland in 2021. At the time, I was working two days a week as a GP there, salaried. The model we had with the staffing base, bearing in mind what Neil has cogently shared, was a GP and a locum, with a population of 9,000 patients, climbing up and down. It wasn't safe, it wasn't dignified, and there's been a lot of blood and sweat and tears over the years, really. But we've had an academic fellow twice. We had one for six months in 2022, I think, or 2023. You need a lot of time to consider, even when you back for that member of staff, because it's a multidisciplinary team. So, you need to engage the admin team, the management team. We've had a lot of issues there, but we've come a long way. And I do think that that time to breathe, that time to just be able to stay still for a period, the time to be able to look at your data and go, 'Where are we trying to go?'—. General practices don't always have the facility to look at their own data. And I think, going back to the point we made before around what innovations have we seen, it's difficult to know, because so many practices across the whole system, whether Deep End or not, are firefighting to keep the doors open and the lights on.

Deep End is obviously differentially impacted by that, but bearing in mind what Professor Edwards said at the beginning, we're innovating every single day, to be honest, with what we do. But Deep End, I think, has been the final time that—. General practice is a lonely business. You're seeing people in your room most of the day. Bearing in mind the graphs and the stats that you've seen, it used to be that you'd be able to have a break for tea or coffee, maybe at 10.00 a.m. or 11.00 a.m. Back in the day, the kind of cliché was always that a GP goes off for golf in the afternoon. Whether that's true or not, I don't know. But those days are numbered and long since gone. We don't have time to build relationships with our teams, never mind with the local services, never mind with that lack of any interface and relationship with hospital consultants, which has made it very adversarial. But doctors don't always have the training and the background from an undergraduate point onwards to really consider inequalities and to really consider population health. We consider what is it that you do that you have to do everywhere, but maybe a little bit more of in a Deep End practice or Deep End context. So, we train these people up, we don't have enough money going to general practice, and then we scratch our heads with, ‘Well, what did we do 10, 20 years into that doctor's career to get them to go to a Deep End area?’

This isn't about robbing Peter to pay Paul, but rurality has its challenges, considerable challenges that are very different contextually to Deep End areas, but they have incentive schemes. They have golden hellos and golden handshakes to get people to go there. Rural practices get dispensing pharmacies, understandably, because otherwise, where are you going to go to to get your medicine and your prescriptions? And that dispensing fee that the practice gets supplements their income, so it's another added drop in.

But I just wanted to finish by saying, without Deep End as a network—which I think we're so proud of being able to have in Wales, finally, thanks to the funding from Welsh Government at the moment—I think we haven't been able to really prove it, because it's very difficult to measure these things, but I suspect a number of colleagues might not be still doing the same job they're doing now without that camaraderie and that intervention to address that loneliness and isolation, because it has made a huge impact for me personally, and it seems to be the case for a number of others too.

Thank you. I'm going to move us on to the next section, but thank you for that insight. That was really, really helpful. Can I bring in John Griffiths, please?

Diolch, Cadeirydd. I'd like to start by thanking all our witnesses for coming in today, because these health inequalities, inequalities in good health, inequalities in healthy life expectancy and life expectancy itself, between different communities in Wales are very stark, and we need to do an awful lot of work in very many different ways and different areas of Government policy and activity if we're going to make major inroads into lessening those inequalities. And we certainly need lived experience, as we always say, and ideas around that, and I think today is very, very useful.

I'd like to ask some questions about strategic representation, really. Obviously, primary care, general practice, is not being heard, or at least its concerns are not being acted upon to the extent that they should be, in the light of the presentation that Adrian has given us and other evidence that we've heard. So, in terms of where the decisions are made, and the strategic decisions are made, how can we strengthen that voice of general practice in the health boards in Welsh Government at a Wales national level? I just wonder if any of our witnesses would like to make any specific comments as to how that might be achieved.

Thanks, John. Who would like to start on that? Neil.

Yes, in my experience of being with Deep End, bearing in mind I've been a GP siloed in my practice for 20 years, in interacting with various organisations within Government and outside Government, it's clear that there is a lack of a GP voice throughout all levels. So, we need, I think, to be strengthening that voice, looking to have primary care people in important areas of influence within all levels of government and the NHS infrastructure.

But actually more important is having those representatives to be well versed in matters of health inequality. Because if you think about it, in Wales over 50 per cent of our households are said to be deprived. It's a huge proportion of the population. So, when you have a voice of primary care, that voice of primary care needs also to be a voice of health inequality. The problem is that, in a democracy, you depend upon votes and a collective voice to have influence. And Deep End practices haven't had a collective voice for the very reasons that we've talked about—people are hard at it at the coalface. People from Deep End practices are under-represented in all bodies that make decisions. Hence, we've had inverse care for a long, long time. We need to be moving in the other direction.

Part of the answer to that also is to help enable primary care representatives from Deep End practices to move into roles of influence and leadership because, at the moment, they are largely hard at it and under-represented. So, we need to think of a means of going to those areas and developing leadership from within those areas to influence NHS policy.

Thank you. A sound point. Would anybody else like to contribute to that? Adrian.

Yes. Thank you, Peter. If I could maybe just offer a perspective. As you say, we find this problem of lack of influence. There seems to be a lack—. I'm not sure if it's about representation; that's what I'm really coming to. I guess, from my experience of being in the Aneurin Bevan University Health Board for many, many years, the assistant medical directors who led for primary care were extremely in tune with our needs and difficulties. So, it seems to me like there's an issue that those people who are meant to be in a position of influence within a health board are not managing to influence decisions. It probably very much overlaps with that graph I showed about the investment into consultants and other doctors, and not into general practice. It's the same issue, I think. It's a culture. How could that culture be changed? That's the question we need to grapple with.

So, I'm wondering if, in the health boards, general practice is seen as something else, something other. Sure, it's contracted out, isn't it? It's somebody else's job. And I'm just wondering if that's some part of the issue. As we've said a couple of times, health boards have increasingly had to manage practices lately because of the closures and mergers. I don't know whether that is getting enough attention in health boards. Maybe there is an opportunity right now to be looking at different models of provision of care. I'm probably going out on a limb here from my colleagues—I actually think there could be more to be said for salaried models in the culture, in the ecosystem of primary care, not to the exclusion of the contracted partner model, but I think there could be more in the way of salaried provision. There appears to be a workforce right now that is gasping for jobs. Let's employ them in practices managed by health boards. Maybe that would move the needle a bit so that health boards felt it was more of their issue. Definitely not to the exclusion of the partner model, but I wonder if we need to do more of that right now, and that could help with changing this culture about leadership and influence.

John. 

Thanks for that. One thing that we know is that the Welsh Government is recognising the particular issues of Deep End practices and providing some funding, which is very welcome. Is that in itself useful in terms of the issues that Neil raised—that it's not just about the GP voice, as it were, but the voice of practices that are in these areas that have the worst health inequalities? Are the developments around Deep End itself very significant in terms of getting that voice to the table? 

Can I—?

Yes, please, Joanna. 

Hi, John. I would say 'absolutely'. This funding that we kindly receive from the Welsh Government allows us the time to be backfilled in our practices. That's tremendously important. I happen to be sitting in this role purely and simply because my GPs did not have the headspace to attend the first ever Deep End meeting, so I was sent along. And I'm very grateful for that, because I'm able to bring a voice from the practice management side of things, but also from the wider practice teams as well. So, yes, it's incredibly important. It gives us, as areas of deprivation, a voice. It gives us a chance to sit with each other and talk about our problems and understand that we are not alone—that when we talk to our colleagues about how terrible our days are or how awful the things that we see are in our practices, we do not sit alone. We are able to talk to each other, we're able to look at collective problems that we all need to address.

We've got an event coming up in December now, where we'll talk about the world of digital and artificial intelligence. And, actually, as areas of deprivation, we don't have the headspace to sit and look at those things. So, as a collective, we are able to do some of that, I suppose, donkey work, for want of a better description. So, I don't think I speak alone, though, when I say that, for us, Deep End is absolutely critical. And also, as a collective now, we do have a voice, and we are starting to knock doors, we are starting to be heard, and that, I think, has been really, really, really important for all of the practices that engage. Interestingly, we've only recently had engagement from one of the managed practices in Gwent, because, actually, those managed practices, categorically do not have the headspace. But also they don't have the buy-in because there's nobody there that takes the ownership for the practice, because it's a managed practice, it's a health board-managed practice. I will disclose now that I used to manage a health board-managed practice, so I kind of know the ins and outs of them. But there isn't that interest, because, as GMS contractors, we are all independent contractors.

Jonny.

Senedd Member Griffiths will be aware, as our constituency Senedd Member, that lived experience is something that some of us do try to build in, and I just wanted to respond by saying this isn't just about GPs. Deep End, with the resources we've had available in the time, has wanted to be participatory in how we arrive at the message that we think needs attention brought to it, the goals we want to achieve, but also what we want to be advocating for, both locally, regionally and also at a national level, obviously. We are multidisciplinary. We have had great engagement from colleagues that aren't just nurses. Obviously, Jo is a practice manager, which sets us distinctly to other Deep End networks across the UK, at times, but we've had fantastic engagement from local nurses, health boards, primary care nurses.

I think we need to continue doing what we're doing, but we just have so many assets in Wales. We have a fantastic public health agency that is armed with data and that's got fantastic resources of people who want to tackle inequalities. We've had a devolved Parliament in Wales that wants to tackle inequalities for a long period of time. I think debates around the models of care and the models of funding are long and complex ones. But we're not getting through nationally. It seems to be that there's been a stalemate for a long time when it comes to contract negotiation at a national level, which is why, funding or not—we hope it would be there to remain for the long term—we know that, at Deep End, we really want to continue to share our reflections and experiences at a national level, and we'd be most pleased and privileged to be able to continue to come to the Welsh Government, to be giving information, to be supplementing what the professions are saying, at the GP committee, the BMA, because we each have different messages, I think, that we need to convey, really.

Thank you. John.

Thanks very much for that and, yes, I know Jonny's practice very well in Ringland in Newport East, and I'm very grateful for the work that's done there. If I could just ask one further question, Chair, to Adrian, really. It's about the need that we always come across as a committee for quality data, quality evidence, Wales-specific facts in trying to shape policy and do the work that we're tasked with. So, Adrian, in addition to your presentation and other things that you've said, would you like to bring anything to the committee's attention now as to how the Welsh Government and NHS Wales can strengthen that link between academic research and front-line general practice so that we can be confident that we get a more evidence-based design for these vital front-line services?

Thanks very much indeed. So, there are maybe two areas to cover off there. One I alluded to in my presentation was that it is, in my experience of trying to collate data from across the UK for the UK COVID inquiry, much harder to find relevant figures from Wales, and also Scotland and Northern Ireland. Actually, England does this better in terms of not just collecting the data, I think, but also making them available in presentable formats that are actually digestible for us, like those graphs that we showed. It's just easier to get figures. I actually genuinely believe the phenomena are the same, of the workforce and the workload in Wales, Scotland and England, but the figures are much more easily available in England. And I don't think that's just technical; I think it's cultural. So, whether we can, again, develop that culture to more transparency and availability of data, I think that's a discussion in itself.

And then there's the actual academic role for developing general practice. So, yes, general practice has come a long way in the last 25 to 30 years in terms of its standing in the medical profession. In medical schools, the departments of general practice very often now are parts of bigger groups influencing public health and population medicine approaches. I think we can do more, and we definitely need to do more. Research in general practice and on general practice are not quite the same thing. There's quite a bit of research going on in general practice. You might be looking for patients with diabetes or patients with asthma. Actually, what we need to do is more research on general practice, which is the way we're working. So, that's about funding UK-wide National Institute for Health and Care Research and so on, as well as Health and Care Research Wales, putting money into research on general practice so that we can strengthen the evidence base. So, there is a need for that as well as what we've already been doing.

Thank you, John. Can I invite Joyce in, please?

I'm going to talk about workforce—you've all already talked about workforce—and the barriers. You've mentioned lots of those barriers already. We need to understand the relationship, really, between recruitment in all areas of Wales. So, some are deprived, some are rural, and each has its own challenge. I looked at the Powys—because I cover it—model, where recruitment was higher. But within those areas, there was a statement about them being perhaps more affluent, but nonetheless, if you dig deep into a rural area, you'll find high levels of deprivation within that. So, I just wanted to draw that to your attention if it's not already there, and I'm sure it is. So, what are the barriers? Or do you have anything more to add about those barriers than you've already stated?

I can answer that initially, if I may. Deep End doesn't seek to be an exclusive organisation. Currently, we define it as the top 100 practices of deprivation, by the deprivation index, to have some sort of identity, but the intention isn't for it to be an exclusive organisation, and we recognise that all—well, not all practices—very many practices have populations of deprivation within them. I think the evidence, though, is unarguable that, in Deep End practices, it's just the extent of that deprivation. I mean, in my practice, it is, as somebody once said, wall-to-wall deprivation—over 90 per cent of the population are deprived. That has a massive effect on the practice, and proportionally much more so than a practice that may have 30 per cent of its population deprived. There are pockets of deprivation in many practices, but it’s just the extent of it, and what that entails.

In terms of recruitment, one of the things I’d like to mention is that we talked about training practice, and currently, there is an idea that there is a glut of doctors, and suddenly, for some reason, there’s all these doctors waiting to be employed, looking for jobs. And it makes a headline. Actually, if you dig down into it, one of the problems is that, particularly in areas of deprivation, those practices don’t have the financial capacity to be able to take on more doctors, who are an expensive resource, even though those practices need those additional doctors. So, we have to dig under the headlines sometimes and understand what is actually going on. That has partly answered your question, I know.

We have recently recruited. We sit on the edge of the Brecons; it’s a lovely little practice. But, actually, our issue is around travel. You’ll understand this if you cover Powys. We recruited, we had to dig deep to match financially some of the inner-city practices, and the GP stayed with us for four weeks before he realised the commute was too much.

But it’s not just about that. The commute was too much, and then, actually, when he got into work, there is a lot of work in our practice. There’s a lot of deprivation, so the consultations are longer. They’re more complex. You can’t necessarily see a patient—. It’s very rare—. I think the doctors will always say, 'It’s quite nice when they get a chest infection', because it’s a chest infection and it's done. But most consultations have multiple issues in them. What that meant was that he was staying later and later and later, and then, with his commute on top, it became untenable.  

So, it is really difficult. I think we also need to be aware of the financial constraints that we face. Like Neil said, doctors are an expensive commodity, a necessary one, but it’s working that out. Actually, it’s making sure you get the right doctor who is happy to stay and work with the patients. It’s not always straightforward.

Having said that, and moving on, on the same theme, how can we support those newly qualified GPs that you've both mentioned—I'm assuming they were newly qualified, maybe they weren't—into sustainable employment, particularly in the areas that you're talking about, the underserved areas? Jonny.

Thank you, Joyce. Our experience obviously draws on work in programmes across the UK. There have been thoughts for some time around how we could replicate a programme, I believe it’s in Sheffield, in the north-west of England. Because, what keeps you in a job? Having a good team. That team being stable. We keep coming back to data. I think one of the challenges nationally is there’s not disaggregated data on training places by deprivation quintile, even down to deprivation quintile by health board. I believe we asked HEIW for that a couple of years back. We didn’t get it. Anyway, moving on. But it's that role modelling and mentoring, and, I suppose, kind of teasing out some of the things and the disentangling that we have been able to in Deep End, largely for colleagues that have come through the professional training and have been GPs for some years.

Sheffield has a programme that’s funded to take those newly qualified GPs out of work—I believe it’s once a week—for a chunk of time, recognising that, perhaps at an undergraduate level in medical school, talking about doctors, for instance, but also at postgraduate level and GP training, there are things that we probably don’t get sight of, or access to, in terms of, 'Right, what are some of the issues that come up in those multiproblem consultations?' It’s debt, it’s housing issues, it’s safeguarding issues. It’s supporting people through personal independence payment applications that we know are challenging and complex for a number of reasons. It's also many more things. It's giving the newly qualified GPs those skills and training sessions, but also the chance to develop the camaraderie amongst their peer group, which will have lifelong consequences for those doctors.

That's a big resource, and that needs a lot of careful thinking through. And I think that would be, whilst it's not something we've put a lot of thought into in Deep End in recent times, bearing in mind that we have said we feel we need a Deep End training programme, building on what has happened across the water in Ireland very successfully, and has been done in a few cases across the UK, bearing in mind that that is where it needs to start—. It needs to start before medical school, to be honest, really, about how we select people and how we role-model people in medical school too.

But if you were to have that programme to keep people, because it's the retention where people drop off—. You know, the number of people who are still fleeing to Australia and sunny climates is massive. A number of people are going, 'I can't imagine being a partner at the moment really, I'm not even sure I want to be salaried—I'm going to locum', but if they just had a few things that would just keep them on board along the way, and that inspiration as well, the experience in that part of England seems to be very promising.

I just want to support and add to some of those points, very much so. Fundamentally, it's about the strength of the primary care system that encourages and enables people to stay in that system. The stronger your primary healthcare system, the stronger your whole healthcare system is. But it's not strong at the moment. There was reference to that last meeting with BMA and RCGP colleagues, where they kept on talking about a quantum, didn't they? I thought, 'That's an interesting word in this context', but what they're talking about is the whole amount of funding to primary care. As Neil says, it just isn't enough to enable practices at the moment to take on those doctors without taking a financial hit. We need to increase that envelope—that might be the other word that we're more used to using—going to primary care, so that practices can take on the staff, so that they can be stronger environments that people want to work in, and we'd address some of this problem of people drifting off.

As you said, we've got this problem of recruitment, but also retention, and by the way in the middle we've got this issue of resilience, and that's where we're falling down as well, and various things can be done. Jonny was talking about some of the professional development activities, and indeed released time to do other activities and so on, and peer support. We should definitely at this point mention the work that the royal college does in supporting doctors in their first five years of their career—very much so. So, there are a number of things that are being done. Just one brief signpost, perhaps, from my own perspective: in the Health and Care Research Wales Evidence Centre, we've also reviewed the evidence about what can be done for recruitment and retention in general practice, health visiting, ambulance staff, worldwide evidence and what can we learn about that to take forward in what we do in these sorts of ways.

Neil, do you want to have the last word and I'll move us on?

Only to add to what Professor Edwards and Jonny said. A small issue, but it's also a big issue, to add to that conversation is estates. Primary care estates are incredibly variable. I know that's not an easy solution because it involves capital investment, but estates make a big difference. The quality of the estate, the premises, makes a big difference on the working environment. I know there aren't many terraced houses out there that also serve as GP surgeries anymore, but still, many of them are dated and not particularly aesthetically nice places or professional places to work, to add to that.

That's a really good point to finish on. Can I invite Mabon to come in, please?

Professor Edwards touched on this earlier. Our understanding of general practice has come on in leaps and bounds over the last 25 years, and I think that, for a long time, a lot of our activity was quite hidden. I think that one of the things that's helped with that has been digitalisation, because up until we had an electronic patient record, we couldn't actually be accounting for what was done activity wise, we couldn't be looking at any outcomes very easily. And obviously, over the years, we've managed to demonstrate that, whilst the NHS, including general practice at times, can be reactive, and of course preventative activity or what general practice does is a contractual question, general practice has a lot of variation, it has lots of examples of innovation, but predominantly, particularly under the funding envelope, what is done largely is demonstrating continuing activity and achievement of contractual obligations and expectations. 

We've touched on the lack of data in general practice across the UK; it's not just a Welsh problem. But one of the distinctions—and this applies to Scotland, actually, as well as applying to Wales—given that we got rid of the quality outcomes framework years ago, is the lack of granular, detailed, local practice-level data on activity and outcomes. You can see this—Professor Edwards touched on it—from year to year. Quality and outcomes framework data is published in England, and there is a huge, very sophisticated analysis of that that I would really encourage colleagues to go and read. It's done by the Health Equity Evidence Centre, with Queen Mary University of London, where they've looked at patient satisfaction, they've looked at workforce statistics, they've looked at funding, they've looked at QOF outcomes, they've looked at vaccination, the list goes on. It's all socially patterned, which doesn't surprise us.

But I think until we can address the contractual side of things, to what extent general practice—. Despite the fact that we've realised, with the evidence and data that we have, over the last 10, 20 years, that general practice has a huge impact on public health. It has a huge role in prevention. Obviously, that goes to seeing people and trying to coach them and do the motivational interviewing bit around their health behaviours, but with people diagnosing conditions, managing those conditions, the medical bit, which is obviously key, probably accounts for something around 20 per cent of the entire life expectancy gap that we have between the deprived and least-deprived areas in Wales, but I don't think we always carry that narrative or message into how we plan and fund and deliver and hold services to account.

Sorry, I'd just like to say something about some of the fantastic projects that have been launched over various years that are piloted, and we have a wonderful pilot that lasts for 12 or 18 months, just long enough for us to embed it, and then the funding is pulled. And that's really challenging, we find. You have to get patients to buy into a service. They won't just accept it straight off. So, once they get used to that brilliant service, then it disappears, or the expectation is that the GMS contractor will take on the financial burden, but we can't necessarily afford to take that financial burden. So, I think there needs to be some way of looking at these really brilliant projects and working out how we make those provided for our patients rather than something that we have to find the funding for in order to provide.

A few years ago, I worked in the Blaenau Gwent valleys, and we had a wonderful audiology service that was home-based, and it had been running for about 12 months. And they came and presented to our cluster this fantastic service. And then at the end of the presentation, they said, 'So, we haven't got any funding for next year; it stops in a couple of weeks' time, and we would really like to know whether the cluster can pick up the funding for this.' And we don't have that kind of flexibility within our systems to be able to do that. And particularly now, cluster funding is going to become more challenging, because of the framework that we'll all have to go to in order for it to be able to be spent. That was—. Everyone sat there going, 'Gosh, this is amazing'. It was brilliant; it was fantastic for our patients, and then, poof, it all went.

We also had, while I was in Aneurin Bevan, a link worker, if you will, between the hospitals and the practices. So, they did discharge liaison from a practice end. So, the patient would be discharged out into the community. We would then contact them, depending on which area of the hospital they'd come out from, and we would ask them whether they were coping at home: were they managing their pain? Did they have anyone to do their shopping? And then we could signpost them to the relevant front doors of information, advice and assistance and things like that. But, again, that was short-term funded, and then there was the expectation that the practices would start picking up the funding for that. Does that help? 

Thank you. Just to briefly add, mirroring Jo's comments there, my practice has a link worker. They are seconded from Newport City Council, very kindly, at two half-days a week—a community connector. We've had lots of discussions in Deep End that general practice, NHS, has had a rich, long history of a plethora of stop-start, pilot-funded, grant-funded, initially successful and then hard-stop roles. I believe, off the top of my head, because I don't think we've mentioned it this morning, that we need to talk about austerity. The NHS is a single service that was richly funded in Wales, like the rest of the UK, and I think the NHS has started to try to think, 'Well, we need to address the social bit too, so, how do we bring in that support?' But I believe, when I last checked, Newport City Council had something around four full-time community connectors for the city population, which is clearly not enough.

But, borrowing on examples from the rest of the UK, which have been done very well internationally, around community health workers, we know that the more these roles are practice-based, a core part of the practice team, so that they have that relationship and trust, they've got the same access to data and the same record, that are there sustainably—. The patients we see, as we try to support them with their acute needs, but also their long-term conditions, their housing situation impacts that, what income they have to keep going from day to day obviously impacts that, the food and the environment around them they have to get healthy food and all the rest of it clearly impacts those conditions too. So, whilst all general practices clearly need ancillary and support services that doesn't just sit in the NHS, it has to sit outside too, one of the things we clearly have arrived at knowing that we need is to make sure we have that multidisciplinary support—bearing in mind Welsh Government, I believe, a couple of years back published a very promising framework for social prescribing, but we've yet to see the data on what the breakdown of those link workers is by deprivation by area. We need the support around our practices to deliver those outcomes.

Mabon, I’m just conscious we’ve got 10 minutes left.

Fine.

Thank you. If I could just add a comment, I think you asked what should be done for prevention, and I just want to revisit the conversation we had earlier on about this trade-off between access and continuity, and in the context of resources as well. So, the economist will tell you, 'Good, fast and cheap—pick two', won't they? So, what have we got here? We've got cheap. Actually, we've got reduced resources into primary care. So, therefore we've got a trade-off now between access, which is the quick, and the continuity, which is the good. And continuity is not just nice for doctors and patients—it is, very much so—but it's actually good. It saves lives. There's research evidence about it saving lives. But also it's where the prevention goes on; that’s the key point here. In that long-term relationship with people dealing with their multimorbidity and the complexity of it all, interfacing also with the social care factors, that's where we actually instigate prevention, which will, ultimately, be cost-effective for society. So, what we need is that big-picture view of not always focusing on access. Okay, it's important, we’ve got to work out how to deliver the essentials, but we need to ensure there's enough investment resource going into continuity, which is quality and prevention. So, we've got to keep that view, I think, really front and central. Thank you.

Please carry on.

I don't want to put Adrian on the spot, but how do you think we could deal with the redistribution, if you like, in a rising tide?

That's a very good way of describing it. So, I think actually what it comes down to is, when there is new resource, that needs to be targeted to these areas of challenge. We can't be taking away from those who are currently using resource, but if we actually have some money—and it might even be, for example, around investment, let's call it that—in managing waiting lists, now, the immediate understanding is, 'Oh right. Waiting lists. Well, that clearly means that we need more people doing things in hospitals.' Now, I'm aware, from discussions with the strategic programme for primary care, that they feel that that conversation is developing and it's not only about chucking money at hospitals to deal with waiting lists—actually, some of that money, when committed, needs to be spent in primary care on the prevention. But maybe, actually, we need to really swing it even more considerably; perhaps, as well as waiting lists, there'll be numerous other examples. If we're talking about, say, a shift from a focus on access to continuity, then we will need resource to do that. When we're developing new areas of resource commitment, let's put it into these areas of prevention, rather than patching up the existing underperforming system.

Mabon, do you want one final question?

Dispensing practice is primarily used in rural areas. From my experience, which was a few years ago, the downside with a dispensing practice is it doesn't have the pharmacist element. So, at the moment, when you ring a GP surgery, you will be care navigated. If you have something that can be dealt with by a pharmacist or a pharmacy, you will be directed to them. Unless dispensing practice has changed dramatically, there isn't that element, so, actually, what you're going to end up doing is pushing that element of work into the GP practice.

I don't think—. Perhaps I speak for myself here. I don't think we would find it particularly helpful to absorb a pharmacy into our practice. We have a pharmacy on our site, but it's not managed by us. I think pharmacies are a whole other bag of worms that I wouldn't really want to dip my toe into, if I'm completely honest, because we all know that they have had more than their fair share of problems with recruitment and retention. So, for me, I don't actually see that it would be helpful to have a pharmacy coming into general practice per se, but I may have completely misunderstood your question.

Diolch.

To me, there seems an inequity about dispensing practice, because it's a means of generating income in a practice, but why should one practice have that availability and another practice not meet the requirements, just by geographical quirk? I guess that's an issue of Deep End as well, that lots of practices have—. They're independent businesses, they have opportunities to make money in other—. They may own their own building, they may rent out rooms to pharmacists or to homeopathists or whatever. As much as that's the prerogative of the business, it does seem difficult, because, if you're in Rhymney, for example, where I am, those are not options for us. There's no additional business development that we can look at, so we rely solely on the contract. So, I don't know about dispensing practice. We applied once and we got knocked back in our patch. It always seemed to me rather inequitable the way things have been worked out.

I think we've just about—. Well, we're smack on 11 o'clock, and we've exhausted our time, even though we had a few more areas we would have liked to have covered. But thank you so much for your input today—invaluable and great to have an insight into the Deep End practices, as well. Some fantastic work and it's challenging for you, we recognise.

So, thank you for your evidence. There will be a transcript available for you to check anything you said. Can I just thank you once again for taking the time to come in today?

Thank you for having us.

Diolch yn fawr.

Diolch yn fawr.

Members, we will be taking a short break now for 10 minutes.

Welcome back to the Health and Social Care Committee, for our next evidence session, with Digital Health and Care Wales. Welcome to you all. Perhaps I could ask you to introduce yourselves. Can I start with you, Sam? 

Yes. Thank you. I'm Sam Hall, and I'm director for primary, community and mental health digital services at DHCW.

Hi. I'm Dr Sayma Ahmed. I'm a GP partner and I'm an associate medical director for primary care for DHCW. I'm also the cluster collaborative lead for Cardiff south-east, as well as a local medical committee member, GP trainer and honorary clinical tutor for Cardiff University.

Thank you.

Nice to see you. My name is Rhidian Hurle. It's my thirtieth year in the NHS in Wales. I'm still doing clinical practice. I'm a consultant urologist once a week. I have been a medical director for 10 years in digital, and I'm here as the medical director of Digital Health and Care Wales. I also hold the position of the chief clinical information officer for Wales, reporting to line management in the Welsh Government.

Thank you so much. What a breadth of experience we have, so thank you for coming along. We have several questions. We'll try and get through them, and we've got an allotted—what have we got—an hour and a quarter. About an hour and a quarter is what we've got, and we'll try to get through everything as best we can. Don't feel that you need to answer every question, but if you want to come in and out, please yourself, and I'll invite you to do so.

Perhaps I can kick off, then, with strategic leadership and accountability. I wondered how effectively DHCW is supporting the digital transformation of general practice in Wales. Is there sufficient strategic leadership and accountability to deliver those sustained improvements that we need? Who would like to kick off? Sam.

I'll kick off. So, there's a real focus, and I'm sure everyone's heard, in recent years, the whole 'Let's shift left, move more into primary care'. So, that strategic position is well thought through. We can see things moving more into the primary care space. That doesn't always come with the funding required to do that. So, from a strategic point of view it's really good, it's well planned out. We know that there needs to be much more linkage between primary and community and mental health in those spaces, so that we can give that holistic out-of-hospital support that people need. But that needs to come with the funding to be able to deliver it. I think that we have got some very good relationships built up from a Digital Health and Care Wales position with GPC Wales, with the general practitioners. They support us through a digital board, where we can talk about the strains and the challenges, but also what innovation could be made. So, we've got very clear support through that channel.

We also work very closely with Welsh Government policy colleagues. We've got a very very good relationship in that primary care space, and I feel that the closer that digital can work with policy—. We can deliver on policy but, actually, what we should really be doing is influencing policy for the the benefit of our patients. So, building that relationship and really nurturing it to deliver in the future is something that we're really keen to do, but we do have that working relationship already.

And then, the other arm where we have very much more strategic direction is through the strategic programme for primary care, which sits within NHS Wales Performance and Improvement—that part of the NHS. That programme is charged with looking at how primary care is going to be in the future, what it is, what it needs to do, what it needs to harness, what it needs to do now to prepare for the future. I think we all know that we have challenges now, but they're going to be nothing like the challenges we have in the future. We've got an ageing population in Wales, we have people that live longer, which is fantastic, but they live longer with the challenges of old age. And much of that responsibility falls in primary care to support. So, what is it that we need to do in that space, in that strategic space now, to prepare for the future? What is it we need to be changing now? What legislation needs to change? What funding needs to be put in place, so that we can prepare for what's coming in what's potentially only, maybe, a decade's time, when we start to really see that position?

I'll just come in there, if I could. The strategy, the delivery of policy objectives and the use of data to empower the service to understand where quality improvement could be achieved, where harm is being caused, to mitigate the risks of harm, and empower the individual to hold their data in a way that enables them to self-manage often chronic diseases, and also gives them the ability to navigate what is quite a complex health system, whether it be community pharmacy, whether it be primary care, dental, optometry and, of course, the most costly element of healthcare being secondary care—. The strategic policy of the data has to be the way forward that we improve the population health. And until the delivery of the data-sharing agreement across all those sectors is delivered, we won't have aggregated data that we can understand what is happening, where it's happening and how we can improve. 

Thanks for that. Sayma, would you like to add anything?

I think Mr Hurle's covered all the points that I'd like to cover, but I think, just on the data piece, as a GP partner, we're the data controllers. As a GP, I can see the benefit of being able to share that data and work with our other collaborative colleagues. I think we really need to look at how we can move that forward.

I'll just come back in on this, because I think this is a key policy objective, and the benefits are tremendous, if they can be achieved. Wales has a real opportunity to lead across Europe in this. What we would be looking for is Digital Health and Care Wales to become a data controller, through some directional statutory legislation, to provide our primary care community with the air cover, because they're independent. I think you may have heard from the Information Commissioner's Office, and the risks of—. Data controllership is, basically, the person who owns the data. Data processing is the person who is told what to do with the data. As a data processor, you have to ask the controller X, Y and Z. If we're going to deliver preventative medicine, to shift that left, we need to be able to identify cohorts within the population that would benefit from intervention earlier in their pathway. At the moment what happens is we wait for them to appear in secondary care. Now, without that data controllership, without that data being aggregated in the centre, we're missing an opportunity.

Okay. Thank you for that. I'll move on. Digital—. Sorry. Yes, Joyce.

On data control, data control is absolutely key for lots of reasons—the reasons that you've outlined, but also the knowledge within it and how it can be used or abused, whichever way you'd like to look at it. You've obviously made those views known, I would imagine. How far along the line are you of, hopefully, being successful in having that data control? 

We are in a position to influence and advise. It is policy and Government who are in a position to deliver on this. 

Okay. So, not far, then.

Not far.

Thank you.

Okay. Thank you. Thank you, Joyce. I'll move on to my second question. Digital Health and Care Wales is currently under level 3 escalation due to concerns about delivery of major national programmes, including those affecting primary care. Can you outline what impact this enhanced monitoring is having on your work to digitally transform general practice, and how is it influencing priorities, timelines or engagement with stakeholders?

I can pick that one up. We take being in special measures really seriously. We have taken that to heart. We've put a lot more controls in around—. We were specifically called out around, as you mentioned, major programmes, and we've got a number of those, including the NHS Wales app—it's a major programme—and the one that my team are running, which is the migration of GP systems. So, we have put very much more rigour around our own management within DHCW, within our own programme. I suppose that the best way to say it is 'our transparency'. We've been really clear about where we are on programmes and really honest about that. So, with being in those measures, and being on that level 3 kind of scrutiny, there are more meetings, obviously, more papers being written, and I'm sure it gives our Government colleagues some comfort in the fact that they are there and they can challenge us on those things, and that's absolutely your job to do that, but obviously it does then take us away from actually delivering on occasion. So, we spend a lot of time preparing information for those meetings, where we probably would rather be hands-on with digital people, a lot of us—my medical colleagues as well. But I am digital through and through. I've done digital delivery for 30-odd years, in local government before health. We want to keep delivering, keep doing.

There's a lot of governance and a lot of bureaucracy around how you do that currently. There are changes currently being made in that space, in the digital and data space, to look at that governance model, and hopefully that will give us a new way forward in health. But when it comes to our major programmes that are really linked to primary care—so, the NHS Wales app—that comes out of its programme wrapper. It has been a big programme. At the end of this financial year it won't be a programme anymore. It will become a tool that we use, a product that we develop. I'm really pleased that, actually, where that will land, where that will live, going forward, will be in our space. It will live in primary, community and mental health so that we can help really drive that impact for patients. And we should stop—. We get the ability then, the opportunity, to stop looking at the app as a programme and a thing in and of itself and start realising it as a part of how you deliver a really good service for patients. And so, I'm really excited about the opportunities we've got with the app and that we've got some really good things we can do to make people's lives better and to support our colleagues in primary care.

But then, alongside that, we've got the big migration, which is a programme we report on all of the time—the migration to one single system in Wales for general practice. That's a huge deal. That's a really big deal for our GPs. There's a lot of upheaval that goes with changing a system. There are a lot of things that, for want of a better way of putting it, you need to unplug and plug back in, and they all have to work. And then there's the training of the people on the ground. So, we understand that there's scrutiny around that, and there are lots of people watching how well that goes. But that is on track to deliver. It's on track to deliver in May next year, which is going to be eight months ahead of the original schedule. So, I honestly believe, even if we weren't in the special measures condition, we would still have done that. We would still have tried to deliver as fast and as well as we can. But having that extra scrutiny on it, obviously, has brought that out.

Can I just make some points? There's a big difference between what Digital Health and Care Wales does for primary care and what it does for secondary care. So, for secondary care, we provide the software, some of the major software products, but we don't provide any of the hardware or the connectivity—so, no computers, no Wi-Fi. In primary care, we provide the infrastructure, the hardware, the printer service, the connectivity, but, of course, the software is a commercial product. 

My reflection on enhanced monitoring is it's to be welcomed, because it's supportive. It brings out the complexity of the relationship between the NHS bodies and those key stakeholders, which are commercial partners. No-one particularly likes to go into special measures. One needs to find a path to get out and to de-escalate. But it really has brought transparency about the complexity that Digital Health and Care Wales has to deal with.

Thank you for that. I've been in that same situation myself in a different life. It is hard at the time, but it generally drives improvement and that's what we all need. Sayma. 

Could I just add around the complexity? Being a GP, I've got 8,500 patients. Yes, it's around the system, but actually what DHCW do is that understanding of the people on the ground. I think it's really important that we have that one-to-one relationship from the surgery point of view. We're not talking about just the clinicians; we're talking about the non-clinical team and the business as a whole. Software, hardware—any of these changes impact the whole business and not just the consulting in the consulting room, which is huge in itself, but that wider impact, which, in turn, will also affect the consulting.

I've got my foot in both camps. I am a six-session GP partner on one side of the week, and I work for DHCW on the other side of the week. I think when you're in the clinical camp as a clinician, it can appear that this is the software and that's it, but actually being able to be in DHCW, what I've seen is there are lots of things that are out of our hands when we are dealing with another supplier. Our previous supplier that we were dealing with, that was a crisis situation that we were in. I was brought in as that clinician to bring in that clinical opinion, because that's also vital.

I feel that DHCW are continuously looking at how can we involve the clinicians to better understand what's on the ground. But the primary care teams are also on the ground, so there are lots of little bits that often get missed if we're just looking at the bigger picture, but little bits are just as important, I feel.

Thank you. Sam, you may have already touched on this a bit, but how are you aligning your digital strategy with the broader primary care policy agenda, including that shift towards prevention and community-based care? 

I'm quite lucky that my directorate—. We're only three years old, but we've designed it based on that. We have community, primary care and mental health working very closely together. There are strategic programmes set up in the mental health and primary care space. We also have a large project called Connecting Care, which is looking at systems for community health, systems with our local government partners for social care, and also a mental health system as well.

That probably is the furthest back where we are in Wales, actually, digitally, with digital systems for mental health. A lot of that work is still done on paper. Bringing those things together under one roof absolutely makes sense, because there will be economies and efficiencies that can be made. You also start by looking for things that work well together, which is always a problem with digital. Digital can solve everything; I believe that. Why wouldn't I believe that? It can deliver that if you have things that work well together. That's part of what we can do under the Connecting Care programme.

It also has two other really important elements as part of that overarching programme. One of them is to look at what those patient pathways look like digitally. Where are the patient's interactions digitally? Where do they need to come into services and get information from services? Where does the clinical support around them work, too? It's a little bit like what does that tube map look like for digital for each of those patients in different scenarios, whether it's looked-after children in our local government area, or if it's someone with substance abuse issues. What does that pathway look like for them? Where are they expected to interact digitally? How do we make that smooth for them? That's another really important bit.

The fifth element is something that, again, is really hinged on the data, and that's a proper integrated care record, so that people are able to see the information they need to see at the time they need to see it to support the person in front of them. We can't explain how absolutely vital that is. If you are a social care worker and you're out in the field, you need to know that the person that you're dealing with has just come out of hospital because something bad has happened. You need that information in front of you.

One of the things that we find when we're talking to people with that lived experience is that one of their biggest criticisms—they've got a couple of criticisms, but this is the biggest one—is they're always having to relive and retell their story all the time, because the person they talk to doesn't have the information in front of them. And that can be really unsettling, it's really jarring, it doesn't make the service smooth, so that can be really, really painful for people. And add into that things like dementia, caring, you just make that more and more. The people that need to help you need to have the information in front of them, so that integrated care record could literally revolutionise how care is delivered for people. So, I'm really keen, from our point of view, that we get that really well. I'm quite passionate about that.

Perhaps to simplify it to a soundbite: collect, store and share. Collect everything from every care event, store it centrally, securely, in a way that gives the public the reassurance that their information is being held as safely as possible, and then share it with healthcare professionals and patients, wherever the patient presents, regardless of the healthcare context. To do that, we need some changes, which you've highlighted.

There are some good examples quite close to us. Legislation is being introduced in Ireland mandating that if you are providing care, you will share the information that you collect, so that it goes. We would hope, wouldn't we, that health boards and health providers across Wales, many regulated by Health Inspectorate Wales, would share the data. That is not the case, and it would be very useful if a policy position was established that mandated the sharing of all data, wherever it's collected, for the benefit of the patient.

That's very helpful input. Yes, go on. 

It's that sharing of the data that is critical. There are two aspects, obviously: who's got control is the key to everything, for people to feel that their data is being used in the right way, and then the sharing comes out of who's controlling it, obviously. But this mandatory sharing has to have caveats in terms of who you're sharing that data with, and that's the bit I'm interested in.

I think you've hit the nail on the head, and that's a conversation that needs to be had with the public. The data, I believe, should be within the NHS; beyond the NHS is a completely different subject. I know people are concerned about commercial leverage of data and how that is used. There's a big difference between personal, identifiable information and aggregated data that allows population understanding.

To give you an example, there are real benefits from us understanding the impact of a change in a diabetic drug, with one in six patients being diabetic. There's a cost improvement exercise that could release benefits, but there's also a patient improvement exercise. The ability to enrol patients into trials—there's very good evidence that patients do better in trials. How do we enable people who have certain disease characteristics to access those trials? If we do it within the NHS family—I believe the public still believe that the NHS blue badge, the brand, is trusted—I think there's a conversation, hand in hand with policy leads, with the general population, around how can your information help you as an individual, your family, your village, your valley, your region, your nation, to provide better care for everyone. 

Thank you, Rhidian. Is there anything you want to add, Sayma?

From the question that you asked at the beginning about the preventative piece, that's going to be the answer. Because if we can predict, we can prevent, and that, around the data, will give us those answers.

Can I just come back in? It is absolutely around that, and there are two other things. One is—onto your point specifically—if you asked people whether they thought their data was shared with the people that are helping them already, they would think that it was. I think that is something that is really important. They're quite shocked when we say, 'Well, I don't have that'. And we put clinicians in difficult positions when they say, 'I haven't seen that; I don't have that information'. That's a terrible position to put a clinician in.

The other thing is something that we'd really like to do, and we talked about that, and Sayma and Rhidian have mentioned it—the ability to prevent and to predict is massive. So, access to some of this data, and to use it to be able to do that. We're getting—. It feels maybe a little bit like science fiction, but we're getting to a position of being able to really understand what the future health could look like for people, and to be able to almost design their healthcare for them.

We're looking at something inside DHCW at the moment that we're calling as a bit of a badge 'cohorting as a service'. What that means is for someone to be able to say, 'We need to find the population that would benefit from this vaccine or from this screening service. How do we find those people in the population that we can help sooner and quicker? How do we do that?' We're doing that at the moment with synthetic data, with fake data, to be able to prove that it can work, but, actually, the real power is when that's real data, because the data is a person. That's a real person that could be helped. We're really passionate about being able to do something really powerful around that, because, quite frankly, the technology isn't the problem, and I think that's really key now. It's not going to be the technology that holds us back.

Can you share how you're evaluating? What metrics are you using to measure the impact of digital transformation on patient outcomes and practice efficiency? 

That's a very challenging question. Patient-reported outcome measures, the PROMs programme, and PREMs, which is patient expectations, is in its infancy across NHS Wales. There have been some programmes that have had some pump-priming from the Welsh Government. There is some variation across different specialties, across different health boards, and there requires an alignment that everyone who goes through a particular process has the opportunity to return their opinion and outcome.

I think it was Mark Drakeford who said, 'What matters to the patient is what we should be talking about' when he was health Secretary, when we talked about prudent healthcare. That's not quite—. Well, it hasn't been delivered yet. The ambition remains that in every consultation we should empower the patient to make an informed choice of what they want.

Thanks. Would anybody like to add anything further, or I'll move us on? Yes, Sayma.

I don't think we have many, as Mr Hurle mentioned, but I think in terms of the data that we do have, we've got the activity data, and just from 2024, what we will see is the data that we didn't have before we had digital and text messages. In 2024, we had 6 million text messages sent back and forth between surgeries and patients, and 5 million digital requests. That's from the 12 million face-to-face appointments, and even the 27 million calls to and from general practice in 2024. So, I think it's just highlighting how much digital is being used. And just to quote that that's general practice. Of that number, you could say, comparably, secondary care are only at about 10 per cent. So, the numbers are huge in general practice.

Thanks. I'm going to move us on, because we've got quite a lot to cover. Can I bring John Griffiths in, please?

Diolch, Cadeirydd. Thank you very much to our witnesses for coming in to give evidence this morning. I have some questions on stakeholder engagement and co-production. Firstly, how are you working with the health boards, general practitioners and other stakeholders so that the digital infrastructure that supports joined-up care across our health service in Wales is co-designed in that way?

My team, the primary care team, we work out with general practice all the time. We're out every day, pretty much, in practices. We're there primarily to support them and to help them. We offer training, but also, if things break, we fix it. We're there all the time. But through that engagement, we've learnt a lot around how general practice works. For want of a better term, we know where the real pain points are. We speak from witnessing that and seeing that when we talk with our general practice colleagues. So, there are always structures set up. We have engagement groups, and we have service boards and panels set up, and they’re the real, almost the structure of getting something done, but, actually, behind that is a lot of on-the-ground engagement that happens in general practice. And so, when we’re now looking at the opportunities that general practice has to really consume new technology that is now available—and AI might be a buzzword at the moment, but it's real and it’s here now; it’s not in the future for us, there are things now—we can see, within general practice, where some of these things can be consumed, and could be employed to really support efficiency gains, and to really support the patient in some way. We’re embedded. We work very, very closely with general practice. We have very good relationships with our general practice colleagues and, generally, we can solve problems between us.

I think what everyone would say—my team included, as well—is that there isn’t enough money to invest in the way we would want to, to deliver the things that we know would make a big difference, because that isn’t in our budget to do that. We have a very, very tight budget to deliver the systems and the hardware, and the support that sits around it, because we can’t have a GP without access to a GP system or a laptop. So, that’s where most of the money goes, on that day-to-day stuff. There’s very little left over to then exploit those new technologies. And that’s really sad. And it’s really sad because, out of—. I work across a range, in that primary care and community and mental health space, but, in primary care specifically—and I’m not just saying this because I’ve got a GP sitting next to me—they have huge ambitions on how they want to improve the care they give their patients. They are probably the most open to change and improvement of all the clinicians I work with, because they see it every day, and they can see the amount of workload that’s going up and the demands on their service. They’re already going out and looking for things, and the problem with that is—. It’s great on the one hand that they’re doing that; on the other, it’s going to create an inequity across Wales that we don’t want. You’re going to have practices who have technically savvy, really capable people, and maybe some extra funding, and some money somewhere, that can go out and can buy these great things, and can employ them, and then you have others who are really struggling, and they have lots and lots of patients, and they just don’t have the capacity to do that. So, you’ll create an inequity, and we need to find a way to solve that.

And then, one of the worse things that I get is a GP or practice manager coming back to me to say, 'We bought this tool, it was really great. We had a brilliant new deal. We had a one-year deal for this tool. It was great. We’ve embedded it in our workflow. I don’t know how we can live without it, but I can’t afford it next year and it’s going to have to go'. So, we have to find a way to solve some of that, to bring that equity, because everybody, whichever practice you’re in in Wales, should have the same level of service, and you should expect to walk through that door and get the same level of service.

Jonny mentioned the word 'stakeholders'. Stakeholder management is leveraged through contract negotiations—so, who holds the contract. With some of the national programmes, you'll see that contracts are held locally, not centrally. Therefore, the ability to influence the delivery pathway is often tricky. 

On stakeholder management with our GP colleagues, I declare an interest here—my late father was a rural GP, so I grew up in a rural practice. My wife is recently retired, and I've felt, over the dining room table, the pressure of primary care all my life—one of the reasons probably why I'm a surgeon and not a GP. The relationship with the GPC Wales has been key to some of the excellent advances that we've made. So, in 2015, through negotiation with them, we provided access for the GP summary record to all secondary care clinicians and healthcare professionals, including pharmacy. This was a real breakthrough that was never really celebrated. You'll hear NHS England talking about the summary care record being available and making a lot of noise about that, but the ability for secondary care clinicians to see the problem list in the accident and emergency department, for pharmacists to see the medication in a legible format, digitally enabled, has revolutionised some of the care delivery and made it safer. The ambition, obviously, has to be to share that with the patient, and that record could be shared with the patient if the legislation and the air cover was delivered. So, I think, in primary care, that relationship is strong.

In terms of stakeholders, secondary care is a different playing field—seven different health boards at various different stages of digital maturity. That is potentially more difficult for us, because everyone has different objectives, and there is a trend to go it alone rather than, perhaps, focus on regionalisation and the powers that come from having single systems that do things.

And you mentioned major programmes. We're seeing this in the radiology programme. We're seeing that in the laboratory information management system programme—the re-procurement of that. Those programmes did not start with the organisation responsible for digital. They've ended up with the organisation responsible for digital because we are the people who have the domain knowledge and expertise within our workforce to make it happen. And there are lessons to be learned about digital programmes starting at a local level, rather than with the organisation that has been established to deliver.

May I just elaborate on the stakeholder engagement? Not only do we discuss with the GPC, but the LMCs and other groups like the Deep End group as well. We recently took on a project around the demand in capacity where we thought about how we include practices from rural, urban, different areas of deprivation. So, we are thinking about it, because one doesn't fit all, as we know for general practice, so we need to think about all of those areas and how we bring them in. So, I feel that we are engaging very well with our different groups. Outside of GMS, there are our pharmacy colleagues, our dental colleagues, our optometry colleagues, and that's a work in progress, as well, that we're trying to engage with. Whether that's RCGP or CPW, we're trying to bring them in, because we're all trying to work closer together, whether that be via clusters or actually in our day jobs. So, it's how we can improve those and create those efficiencies.

Thank you. John.

Thank you. If we move on to patients and the public, is there good engagement with the patients and the public in terms of digital services and digital tools, and is their experience of using those factored into possible improvement?

I was just thinking that one of the biggest digital doorways into health currently is the NHS Wales app. That has a really clear feedback loop, so people can tell us about their experience of using that tool to access services. Of course, within that, within the app itself, being able to do things like reorder your prescription is a big boon for patients. When it comes to using digital to access other services, then it's really mixed. I think the feedback we get when we talk to patients is, 'There are lots of doorways into health and it's not always easy to find the information that I need, and I don't know that I'm always going to the right place, and I don't always know that I'm asking the right people.' That's something that patients shouldn't have to do. That's a burden on the patient that digital should be able to take away. So, there shouldn't be a wrong door. There shouldn't be a wrong way into health. And it doesn't matter who you ask for help, we should be able to direct you in the right way, and digital can help to do some of that. So, I would say it was mixed. I think the feedback we're getting on the tools—. In DHCW, from a patient-facing point of view, we have the app and the dental access portal, which allows people to register for an NHS dentist. They're the two main primary public-facing applications, and generally I'd say it was fairly positive, but both of them are, in boring digital speak, if you looked at those products, in the growth phase. They're not mature products and they're not at the level of what we hope for, which is saturation, which is everyone using them. So, they're currently in the growth phase, which means they still need development. There's still lots to do on them. We still need to make their reach better. We need to open them up more to other people, other patients and other members of the public, use them more to deliver more services. But those things are only tools; they don't deliver healthcare. They just enable people to get to the right place and to get the information they need; they don't deliver care themselves. So, we need to make sure that we're using them in the right way to enhance that.

I'll just add that, with the NHS, during certain developments, as well, we did engage with Llais and members of the public around the interface and what it looks like. So, there was quite good engagement with patients and the public around the NHS app from the early stages to what we're seeing right now, as well. 

And in terms of access, obviously, we took the original code and made it bilingual, and we've introduced Welsh identity verification management for people who didn't have what are perceived as common forms of identity so that they can onboard. And we're acutely aware—in fact, we've given evidence, haven't we, on British Sign Language—of people with accessibility needs. So, that's part of that NHS programme.

Yes. Thanks for that. John.

Yes, if I could, Chair, ask just one last question. The Dispensing Doctors Association raised concerns that they have limited access to digital investment and support. So, we'd be interested as a committee in what steps you are taking to ensure that those dispensing GP practices, and particularly those in rural areas, are included in digital transformation and the initiatives that go around that.

Who'd like to start? Sayma.

I wouldn't be able to comment too much, actually. I understand that it's a legislation issue, but I'll hand over to—

I think the comment there was on funding. Digital Health and Care Wales don't fund. We're funded from central Government to deliver, often through direction—for example our remit letter, et cetera. So, if something comes through in the remit letter, obviously we scope out what it would take, and that comes with a resource, and then there's a decision to be made about prioritisation with the stakeholders.

Okay. Anything further? Anything further, John? Do you want to come back on anything?

No, I think that's fine. Thank you, Chair. Diolch yn fawr. 

Thank you very much. I'm conscious of the way that time is moving on so fast, because this is quite interesting. Can I ask colleagues to be succinct and, perhaps, witnesses as well? Thanks very much. Can I move on, then, to Mabon, please?

Okay. Sam. 

Thank you. So, the reason that GPs are migrating to another system is that we had two systems until recently and, with one of the systems, the company, first of all, pulled out of the market in Wales and Northern Ireland. They really needed a bigger market share to continue to work, and they didn't get it. So, they stopped trading, and then, actually, the company went into administration. So, that's why we have the current programme to move everyone to one system, which was EMIS—everyone calls it EMIS, but it's now the Optum system. So, the impact is huge, actually, on a practice, because many of them will have been using the other system for decades. So, there's a big shift. There's a lot of on-the-ground work, and my team are out with those practices. The whole process from end to end can take about 20 weeks—so, that's training upfront, that's moving the data, that's all the data checking, that's then plugging everything back in, making sure it works, training, and then, once the data's moved, making sure the data's arrived in a sensible way. So, it's quite a big undertaking, and so we've worked with health boards and with practices to spread that load around Wales a little bit, because it's over 100 practices. There are a lot of practices moving, close to 200 actually, and so we spread it around so that we weren't putting so much pressure on any one bit of Wales at any time. So, we've managed it through that. One of the things that is really good about the fact that we're going to move to one system, from a digital point of view, is that we were actually having to do everything twice. We were having to duplicate our work with one system and another system. Now we can actually work with the one system provider to really get the most out of what they're working on.

Also, they have some really good strategic partnerships, which will make interoperability with systems we'd like to use even better. So we—it's a horrible term—really want to exploit that relationship with our new single partner in Wales. We think it's actually good for them. We think they should be really proud of the fact that they have got to badge a whole country: they support all the GPs in Wales. That's a big thing and it should be seen as a big thing, and we're leveraging that throughout our conversations with them. In fact, last week, we had a strategic workshop with them to look at how we could potentially use some AI tools within their system. We are very much working very closely with them, but I wouldn't want to—and I'm sure Sayma can comment on this—underestimate what it takes to switch systems in Wales.

Just to follow on from that, I remember when we first had the discussions. We really can't underestimate it, because we were having discussions that if this isn't done properly and smoothly then we're talking about sustainability of practices. We know the practice numbers have hugely fallen in the last few years, and this, if not done correctly, would completely drown practices. The 20 weeks is definitely still tight for practices. It's a huge undertaking, because, again, it's not just clinical staff, it's our non-clinical staff, it's from the booking of appointments, taking those phone calls, all the way over to prescriptions, to seeing what their past medical history was, their drugs, and all of those things.

The other part of the question was the time given. There were practices that had chosen to migrate in the first place, before the In Practice Systems Limited issue came about. The practices that didn't want to—and now we're calling them the forced migrations, unfortunately for them—are getting more resource and more time to be able to migrate in a more comfortable manner, because it is a huge undertaking for them.

To be brief, just a couple of things. One is that, when you're dependent on a commercial partner, you have no leverage when they drop out of the market. Who has the data is something that we should be always cognisant of when we're dealing with commercial partners, because data migration is one of the trickiest things to do when you're migrating from one supplier to another. The unintended benefit of this, bizarrely, is that you can train GPs in Wales to use one system and they can move anywhere, whereas previously, when you had two systems, particularly the locum workforce would often say, 'Are you at "that" practice or you at "that" practice—I only work in the practices that have that software'. So, there might be an unintended consequence, and it's a benefit.

I think we can have a general conversation about that as opposed to being primary care. I've highlighted where the contracts are held, who does the negotiating and the specification when one goes to market. To use an analogy, most people like vanilla ice cream, but when you give your kids a choice in front of the counter, they want the sparkles and the flake and everything. Most of care can be delivered with a vanilla product. Starting with delivering a vanilla product everywhere and then looking for the need to enhance it is a much better way of doing it than everyone having their choice at a local level.

Where the programme starts is a key to that contract delivery. How does the taxpayer hold the supplier to account to deliver? That is a key part of commercial understanding. In a digital world, we are surrounded by people selling snake oil and there's a lot of money sloshing around for digital. We have to use taxpayers' money wisely to get the benefit, and I think, through contract negotiating, generally, public services are better off with a collective purchasing power.

To give you an example of that, we work with colleagues across the four nations understanding our Microsoft relationships, because that's one of the biggest spends, one of our biggest dependencies. Working together in partnership with all stakeholders is a much better position to start the process, with a better chance of delivery. So, that would be the lesson that I would reiterate. For 10 years I've seen programmes have to be saved at the last minute. Some of those have failed, some of them have come to fruition. Those lessons are documented.

I can answer the first bit. For the SNOMED rollout in GP practice, that was completed in August this year, so that's happened, so that's good. But as for the—.

In terms of workload, we had some training. It has been pretty smooth, if I'm completely honest. In terms of benefits, it means that lots of third-party software can click on. For example, I've got a blood pressure machine in my waiting room that saves from nurse appointments, but it also means that patients can come in at any time to get their blood pressure checked. It's not only a machine that takes your blood pressure, it takes your height, weight, BMI, smoking and alcohol history, all of the information that we really need from our patient population. They can turn up, put their arm in the machine, press a few buttons, and that electronically goes into their system. There's no manual coding that is required, and it's actually SNOMED-coded as well. We've got a text messaging system, for example, in that. Then, because it's SNOMED-coded, anything that we're putting in that text message and that's being saved will also code, which means overall we will be improving our coding through different systems.

In terms of the manual input for coding, I think that probably remains the same. There is definitely a push that we do need to continuously improve coding, but I think I just want to highlight that when you're in a busy consultation—I do 32 patients in a morning; the BMA contract advises 25 patients a day—coding can sometimes slip down the bottom of my list when I'm trying to manage through my 10-minute appointments to see as many patients as possible, because, frankly, at the moment, that demand is far exceeding that supply and capacity that we have.

As a digital and data doctor in DHCW, I can absolutely see the value in coding. That's not the issue; it's that time, and 10 minutes to see that patient, walk in the door, take off their coat, examine them, put the information in, safety net, give them that management plan and everything else that we need to do. I'd love to say, ‘Yes, let's have 15 to 20 minutes’, but it means fewer of my patients would be seen, which means fewer appointments. It's just not possible.

The pressure is there. The policy position is through the Welsh health circular. We are SNOMED enabling first, and when we have commercial relationships, it's about SNOMED data. In secondary care legacy systems, there are mapping exercises to take previous codes into SNOMED. We need to get all the data in the centre coded properly in the same codes, so that we can get the true value. So, we are absolutely—. In fact, we're front and centre nationally on this as well, because members of our staff in DHCW actually chaired the SNOMED forum, so we're very proactive there.

There are areas that I feel that we can improve as well, like the structured data coming through from secondary care into primary care. If those could come through as structured data, it could be coded automatically on the system, so you're not having to have an admin staff to manually code things through. So, you've got those standards and you've got that efficiency.

I think one would start with the GMS contract as to whether or not there's—. And you'll have heard from previous colleagues who have been here about negotiations relating to that. There is definitely a place for ambient voice technology, the ability to code as you speak, and that requires—. Obviously, there's a cost associated with that, there's a regulation that's required with that, and that is work to be done, I think.

In terms of secondary care, secondary care is way behind primary care in terms of coding. Committees in this building will have seen evidence relating to poor quality and compliance with coding, and that is being raised at a senior executive management level across the NHS.

Electronic prescribing has been rolled out to around a third of general practice at the moment, and slightly more pharmacies. We have taken a decision, actually, to slow that process of rolling out EPS so that we can focus very much more on moving everyone to the new GP system. There are some very good reasons for that. One is that the old system doesn't support electronic prescribing, so until we can get all of our GPs and our GP practices onto the new system, they can't consume electronic prescribing, so that is a real driver for us. What we've actually done is accelerated that move so that we can then, effectively, accelerate electronic prescribing. As I mentioned before, we should have completed the move to the new system in May next year. Electronic prescribing was then going to be rolled out, and I think it was going to go up to around about summer 2027. Because of the way we have moved things around to move to the new system, we're now looking at bringing that in to have full roll-out for electronic prescribing across all areas by November 2026, so about an eight or so month—. 

Could I take us onto a bit more on data sharing, perhaps, with Joyce?

I'm really keen to know about how that sharing is going to work between the NHS Wales systems to ensure that seamless data sharing, because that is what we are all after, and the interoperability between each part of the NHS, so that we get to where we are trying to get to.

You need to collect the data from everywhere in a structured format, you need to store it centrally and you need the communication systems and the security around making it available. The ambition of the architecture review previously commissioned by the Welsh Government was the delivery of the clinical data space within the national data repository—think of it as a Welsh health data space. If you can collect all the information and put it in the centre with cyber security, with all the things that we mentioned earlier, in a structured format, then you can have messaging fabric with systems that are built within the NHS or procured by the NHS along those patient pathways so that data flows.

What are the challenges? Because we've also got cross-border compatibility that will have to happen between the systems of the NHS and other nations. I think of Powys as a really good example, and there will be areas in the north, too.

I have personal experience with this. I used to spend some time working in Hereford and, yes, I've felt the pain, although that, admittedly, was in the last century. We've done some work in an Offa's Dyke programme to work out the configurability and the interoperability. Again, this is based on coding. If you comply to international systemized nomenclature of medicine coding, and you call a full blood count, a blood test, a full blood count by that coding, then you can communicate with partners who also use that coding.

Interestingly, some of the work we've done on the borders is—. There are four, essentially, regions that border onto us. They can't communicate with each other because they haven't got their coding sorted. So, it comes across our border and up and down our border. We also have commercial relationships with centres of excellence across the UK—if you think of north Wales, the Christie, if you think of St Mark's in London. We enabled—DHCW enabled—negotiation with what was NHS digital the ability to safely and securely exchange patient information using electronic systems such as e-mail. That might sound a bit archaic, but that has revolutionised the ability to transfer information safely and securely, so that when someone has something done somewhere else, that information can be brought back to NHS Wales.

Yes, because all too often we hear stories about somebody moving out, even just of their health board, and all their information being lost, not acted on, and huge delays, and you alluded to that yourself early on. So, it leads me quite nicely, then, onto the integrated care record. How is that coming along?

We're in the discovery phase for that. When you talk about an integrated care record, it sounds—. We all know it's absolutely critical to get it right. One of the things that you mentioned was that people have to trust who's seeing their data. So, the very complex piece of that, again, is not the technology to do it; the complex bit is understanding who can access what and where and under what circumstances. So, there will be no reason, potentially, for someone to see all of everything, because they may not have a need to do that. So, part of the work that we're doing is understanding who needs to see what and to what layer of access to that information they need. For some people, they may just need a very shallow view. They might need to know what the last incident this person had, the last piece of information. Others may need to know deep information. So, part of the work we're doing is to draw up what that model needs to look like, because, without that, we can't design a system to deliver it, but we also can't give confidence that we're treating the data in the way that it needs to be treated.

So, first, as Rhidian spoke about, having all of that data in the national data repository is really important, because then what we can do is create, effectively, a view onto it, so you can only see the bit that you need to see. And if you're coming to this class of person doing this type of job, then you can only see this kind of data. Getting that right and getting that model right is a critical part, and we're working through that now. We're doing some work with one of the health boards specifically.

I'd just add that role-based access is really what we're thinking about there, but also the ability to audit access. So, in secondary care, we use the national intelligent integrated audit solution—think of it as spyware. So, at any point in time, in my Caldicott guardian role, I can identify who's looked at the record. I believe, ultimately, we should be providing that data to the citizen so that they can challenge the system: who's looked at my record, why have they looked at it?

In primary care, to access that summary record, we have a different consent model relating to the patient directly. So, it is absolutely centre to what we do, that we maintain the trust and the relationship that we have with the patient and where their data is, and how it is used.

I think that's your biggest challenge. And then—

Just to remind you, we've got a quarter of an hour left, and I want to try and get through all the questions. There's about another four left.

We'll try one-word answers, shall we?

I just want to know about the development of the digital skills that will be needed to transform and address the variation that exists currently amongst GPs and other practitioners, and the role that Health Education and Improvement Wales could play, or is playing.

We work very closely with HEIW, especially in the strategic programme—we both sit on the digital and data board. There are work streams that look specifically at that. They have a challenge. One of the challenges, currently, is: how do we upskill the workforce that we currently have, so that they can consume and take advantage of the new things that are coming online? Then, also, how do we prepare for the workforce for the future, whose lives are going to be predominantly digital? They are going to need to be much more digitally savvy.

Also, there's the fact that the workforce's work will change quite significantly, and we're already finding that, with new GPs that come into the service, they are understanding that they need really to be able to grasp the data and the complexity around that. That is higher now than their expectation was. So, what is the full suite of skills that a GP will need to take them into the future? As I'm sure Sayma will say, it's not just the GPs; it's the whole team, because they all use the systems. I think that we forget—we've got 369 GP practices, but there are 11,000 staff—they are not all GPs. So, we're working with HEIW to look at what that will look like. What does it need to look like? What can we do now, but what more needs to be done in the future to prepare people?

Can I just put in also that Digital Health and Care Wales provides a data protection officer service for primary care, which is an important part of understanding what they need to do to protect their data? We also have a cyber security personal training programme and an information governance compliance training programme, because we know that our workforce are the weakest link for those bad actors that are out there. So, we take that very seriously.

Okay. Thank you. Is there anything that you want to add, Sayma?

I just want to add that, within NHS primary care, GMS, specifically, are the most digitally advanced. So, I think, from a workforce point of view, we are in a very good position compared to the rest of the NHS. I would say that, personally, it's about the new innovations that we will need, moving forward, to be more sustainable, or sustainable at all. That may create some difficulties, but I think that those training programmes are there. We work very closely, as Sam said, with HEIW to try and look at how we can improve that, moving forward.

Thank you very much. Thank you, Joyce. I will bring in James now, for the last couple of questions. James.

Thank you very much, Cadeirydd, and thank you very much for your evidence today. I'd like to talk about equity, access and innovation. So, first of all, I'm very clear that I think the NHS app needs to do more. So, I'm just interested: is there a plan to make appointment booking for GPs universally available across all GP practices in Wales? I think that this could make a really huge difference in how people are accessing healthcare. I can't see you in the room, so someone will have to go first.

I think that there is a functionality within the app where you can book a GP appointment. The reason that you'll find that many GP practices aren't necessarily turning on the full functionality, or the full suite, of that area is because, at the moment, the appointment booking system doesn't offer any triage or care navigation. So, what that means is that you may be trying to get an appointment, and when you're calling at 8 o'clock in the morning, or at 12 o'clock in the afternoon, or at 3 o'clock in the afternoon, about your eye problem, my receptionist can care navigate that patient to the most appropriate care provider. So, that would be your optician. If it's a dental issue, it would be dentist. You'd be surprised at how many patients call up after having a road traffic accident saying, 'I don't want to wait eight hours in A&E, but I've just had a car accident', or 'I've just fallen down the stairs', or 'I've got acute chest pain', which needs urgent hospital advice. There are lots of patients actually who could access Choose Pharmacy for their health needs as well. So, at the moment, the app, unfortunately, doesn't offer care navigation. The next step that it doesn't offer is triage. So, those are things that we need to look at to develop within the app. If we can get those pieces in, I'm sure that it would be used more widely. I think if we look at just opening up appointments, what we don't want to do is see patients that could be seen elsewhere more appropriately and then not be able to manage our demand that we need to be able to manage anyway.

Can I come back in there, if that's okay? I think I'd probably lead on to perhaps another point. Don't you think that AI could help in that space, though, with regard to triaging and signposting people the right way? So, as long as you have a system in place where, when you're booking an appointment, you've got to put your symptoms in exactly as you think, AI could step in there and actually put the flags in on where they think you should and shouldn't go for the appropriate level of treatment. If someone's fallen down the stairs, they could go to a minor injuries unit rather than sitting in an A&E department, if they're not that bad.

I'll be brief here. Babylon app, if you're familiar with the triaging service that was introduced as a mechanism to remove patients from the primary care model, was a highly leveraged company that was going to save general practice and was promoted by health Ministers from Westminster. That company went into administration in 2023, and the reason it went into administration is because it is not safe. So, there's work to be done.

I don't dispute it isn't safe, but something has to be done, doesn't it? We can't carry on as we are. That's the point, I think, that we're all trying to make on digital, isn't it? If we go around 'safe', we'll have people moaning forever and a day that there's pressure in the system. But you have to find a way, through digital solutions, to try and make it safe, don't you, and make it work. And I'm sure that's the word of DCHW.

[Inaudible.]—has highlighted the fact that if you can provide a navigation system through the NHS app, incorporating 111 symptom sorter, common ailment systems that are available in the community, you can move patients to where they can be seen appropriately. And that will create space within primary care for them to use their expertise to see the patients that they, and only they, can deal with. The frustration is palpable across the whole service—I get that. Collectively, we could do more, and that is through policy and healthcare in secondary care and community care. It is a wicked problem. AI is being proposed as the solution to a lot of things. There's some maturity that needs to come in this area.

I don't know if any other colleagues want to comment on what I've asked so far.

One of the things we are looking at—

No. Sorry, I can't see.

Sorry. One of the things we are looking at is that care navigation piece. I completely agree with Sayma and Rhidian. Triage would be brilliant, but there's a lot of work to be done on that still. There are systems out there that can do that. They're very expensive, actually. Some of our GPs use them. That may allow them to open up appointments. But care navigation, I think, and getting that embedded in the app will really help. That's just making people able to self-direct themselves where they really need to go, to free up that capacity, so that the appointments that are then available are used for the people that most need them. That's definitely something we are already looking at, but we'll be looking at it much more closely in the very near future.

Just briefly, to come back, and to give a positive slant on it, there are the acute issues of medicine, and then there's the chronic disease and the screening. The app and making appointments available for cervical screening or breast screening are manageable. That should be promoted everywhere, and equity of access should be available. But, for the acute access, there needs to be some form of triage and, at the moment, that's human.

Back to you, James.

I'm going to move on slightly. I'm just interested in how you're balancing the national digital roll-out compared with the need for those locally driven solutions, because I'm sure you probably get health boards coming to Digital Health and Care Wales wanting their own solution to a problem, but then you've got the national priorities as well. I'm just wondering how you balance that within the current model of the health system that we have here in Wales, with individual health boards wanting something compared with what the Minister is telling you to roll out.

I can talk about primary care, and then I'll hand over to Rhidian on the wider piece. So, in the primary care space, it isn't generally the health boards that come up with a suggestion of something. It's very much driven at the GP level and the practice level. They will invariably find something that they want to buy and then embed that into their system, which is where some of the inequity potentially comes from across Wales. 

Then, for our teams in Digital Health and Care Wales to be able to support that, it's almost impossible because we don't know those systems—we didn't purchase them, we don't have the relationship with the supplier to be able to leverage that. We help where we can, but when it's a system that we haven't bought and rolled out, or is not on some kind of framework that we understand, it's very difficult for us to really get involved. I think that is an added pressure. We should be taking the pressure away from the practices in that, and the only way to do that is to have national investment, good structures and guidance and economies of scale for procurement to get better deals for things. So, from primary care, it won't be local health board initiatives that cause us some headaches. Actually, it's, really, more headaches for the general practitioners who are trying to deal with things on their own.

Can I just add to that, sorry, very quickly? Around AI, new software, new technology, I think that we need some sort of baseline equity across Wales, which you don't have, and hopefully the NHS app could offer that. Then what we need to be able to do is to flex digital, whether that's allowing the NHS app to bolt on those extra bits—. Because our populations aren't the same: our rural populations are going to have completely different needs to our urban, our areas of deprivation. So, we need that bit of flexibility, which is why practices are going out to do their own bits in between—only if they can afford to. So, that's where the inequity then comes in. We really need to look at that, and the only way we can look at that is that funding piece, but also the frameworks, the assurance, the governance, the data sharing, the indemnity. I'm just conscious of time, but those are my key words around what we need to be thinking about nationally.

Yes, to get to the nub of the point: governance, visible, transparent governance, with direction that is adhered to. And the statutory functions, the directions that were provided to DHCW in 2021, lack some of that functionality to enable us to do what you may believe we are currently, or you may think we're empowered to do. Our statutory functions don't allow us to do that.

Do you want one last question, James?

My final point here is about equity of access. There's no person to promote digital more than me. I think it's great, but obviously I represent probably one of the most rural of constituencies—maybe Mabon would like to argue against that—in Brecon and Radnorshire. But there are a lot of people who are digitally excluded, aren't there? A lot of the elderly population aren't up with digital. Actually, a lot of people don't have Wi-Fi or mobile phone signal. So, I'm just wondering what you're doing to make sure that we don't—and I push the digital, so I'm a devil's advocate against myself now—actually leave people behind, because we do need to make sure, if we are moving this way, that it's available to everybody, not just those people who can use it and access it.

I'll just come in on what DHCW can do and what they can't do. So, if you take the example of an appointment letter being sent to a patient digitally, DHCW can enable that to happen. We don't make a decision about whether the health board fully implement it or whether they switch the paper off or how they communicate with their patients. We don't deliver healthcare; we support and facilitate it.

From the digital point of view, I work in one of the most deprived areas in Wales, and digital can create efficiencies that would then create capacity. So, if we're creating those digital efficiencies, it means that, those patients that perhaps don't have the digital access, we're able to meet their needs in the ways that they need to be met.

And there's good evidence from Australia on the ability to use community services to provide hubs where people who don't have access, whether that be because they can't afford it or don't know how to use it, can use the social support within those communities and actually have remote consultations, for example, from their libraries or other facilities that are provided. So, community hubs are a way forward that can support those patients.

That's me done, Cadeirydd, thank you.

Thank you, James, and that brings us perfectly to time. Sorry I had to keep people on a little bit, but it was important. We had lots of questions to get through.

Can I thank you so much for giving your time? Very valuable time, I know, so we do appreciate you coming in. There will be a transcript for you to check over if you wish, and just, once again, thank you for contributing to this, what we think is a very important inquiry.

Thank you.

Thank you.

Thank you.

Members, we'll move on to item 4, and that's papers to note. There are two papers to note. Are you happy to receive those and note those? Okay, I see you are, so we will note those.

And now, under Standing Order 17.42, can I resolve to exclude the public from the remainder of this meeting? Are you happy to do that? Yes, you are. Thank you very much.