Cynulliad Cenedlaethol Cymru

Good morning, and welcome to the Health and Social Care Committee meeting this morning. It's good to see you all. We have a long day ahead of us. Just to note that the meeting is bilingual and there is simultaneous interpretation from Welsh to English available. There are no apologies this morning. We have four of us in the room, and Lesley Griffiths and John Griffiths online. Welcome to everyone. Are there any declarations anybody would like to declare at this point? No. If you find an interest as we move through the agenda, can you state it when we might get there?

Today we are completing our evidence sessions on ophthalmology services in Wales, and our first session is evidence session 8. We have a witness today from the NHS Wales Shared Services Partnership. Welcome to Rebecca John. Would you like to introduce yourself more formally?

Thank you. Bore da. Good morning. My name is Rebecca John. I'm here in my capacity as national clinical lead for Wales general ophthalmic services. It's a role that I hold with two of my colleagues, Mike George and Tim Morgan, who sadly couldn't be with us today. We are all practising optometrists, and, between us, we've got a huge array of clinical experience in optometry, but also leadership experience in optometry. You'll be very familiar by now that Wales general ophthalmic services are the primary eye care NHS services within Wales, delivered both within high-street optometry practices, but also within a patient's own home as well. It is a national role, so we are employed by NHS Wales Shared Services Partnership. I guess a key part of our role is acting as the bridge, if you like, between Welsh Government policy and delivery of NHS primary eye care services. We do this by working really closely with a vast array of stakeholders and obviously with health boards themselves. Another key part of our role is in the evaluation and continued development of NHS primary eye care services.

Thank you so much for that introduction. We're so pleased to have you with us, because your knowledge will be invaluable to this important piece of work, which has become a much bigger piece of work than perhaps we originally thought, so thank you very much.

We have quite a lot of questions. We'll try to get through, certainly, as many as we can, but perhaps if we don't quite finish, if there are some final questions we need to put, perhaps we could put them to you in writing. We'll see how we get on. Hopefully we'll be okay.

You partly answered, perhaps, my first question, and that was really about the role of the shared services partnership in ensuring ophthalmic care in Wales is delivered efficiently and by qualified professionals. Do you want to add anything further to that?

First of all, I think it's important to highlight that the shared services partnership plays a huge role in the delivery of primary eye care services. When I'm speaking here today, I'm here to represent the clinical role that they play, rather than any of the other aspects that NWSSP gets involved in with the delivery of eye care services.

It has been a new role with a new contract. The national clinical lead was a new role that came with that contract and was positioned in NWSSP. There's a lot of work that has gone on in embedding us as the role, and the role has developed and matured, certainly over the last three years.

When we started, the role was all about implementation of the new contract, and I guess we're in a position where we're still introducing new aspects of the contracts, but at the same time we're moving into business as usual around the aspects of evaluation, monitoring and ongoing development.

Thank you for that. Could you share how the partnership collaborates with the Eye Care Wales Committee? Who provides the oversight of the committee's work?

The new legislative directions allowed for the Eye Care Wales Committee to be set up. It's chaired by a member of one of the health boards and has representation of all of the health boards on that committee. It also has representation from key stakeholders—you've got Wales Vision Forum, Optometry Wales, Health Education and Improvement Wales and such. We sit on that committee as national clinical lead. The committee has got three subgroups. They are made up of the clinical subgroup, the health board subgroup and the IT, digital and data subgroup. It is probably pertinent to note that Rhianon Reynolds, clinical lead for ophthalmology in Wales, also sits on the Eye Care Wales Committee, as we have a place on the clinical implementation network. So, the structures between ophthalmology and optometry in that respect interlink, but the governance structures are slightly different.

Thank you. How do you work with the health boards and the NHS Wales Executive to ensure accountability in the provision of eye care services? Are there some big challenges related to the overlapping roles or co-ordination of such? 

The Eye Care Wales Committee obviously plays a key role in the oversight of Wales general ophthalmic services. And like I say, the clinical lead for ophthalmology sits on that group and the health boards sit on that group. We have a really good relationship with the health boards as well; we sit on the health board sub-group and we regularly meet with the chair of that sub-group as well, as the national clinical lead. Sorry, can you repeat the—?

It was really about if there were any challenges relating to the overlapping roles or co-ordination with the partnership working with the health boards and the Wales executive.

From a national clinical lead perspective, we think we work with the health boards very well. I guess it would be for the health boards to give their opinion on how they feel they work with the NWSSP, the other way round. Similarly, we have a really good relationship with the clinical lead for ophthalmology. There is the potential that, because of the different governance structures, they're not completely intertwined, but that said, we sit on their committee, they sit on our committee, and we have very good interpersonal working relationships as well. 

So you understand each other's positions quite well.

Yes, exactly.

Thank you for that. Just a final one from me before we move on. How does the partnership ensure effective auditing and review of eye care programmes? What gaps and inconsistencies have you identified in service delivery?

It is a massive question that we could probably discuss for the remainder of the day, so I will try and make my answer more succinct.

With the evaluation of services, you've got the Eye Care Wales Committee, which oversees the delivery of services. We are really fortunate that the contract introduced clinical services and it also introduced different aspects as well, and one of those was the quality in optometry. As part of the quality in optometry package, there are three service insights that are performed by the national clinical lead each year.

These service insights are mandatory for contractors to take part in, and they can cover all aspects of eye care delivery. They can cover the delivery of wider Welsh Government policy within primary care NHS optometry. For example, last year, we looked at the impact of environmental Welsh Government policy on primary eye care optometry.

We can also look specifically at the services being delivered, so we did a deeper dive into the smoking cessation practice of optometrists, because that was a new part; the prevention agenda is a huge new part of the optometry contract, so we took a deeper dive into how optometrists are approaching that. It is a new part of their practice.

We know, in Wales, not everybody is eligible for NHS eye care, so we know what we know about our NHS patients, but there is obviously a cohort of the population in Wales who don't access NHS eye care services. So, the insights give us an opportunity to review that as well. 

We have the service insights and the content of those is agreed by NHS Wales and Welsh Government. We also have a massive amount of data that is reported across all five of the WGOS levels. That data is reported to health boards on a monthly basis, because at the end of the day, they're their services, they deliver their services, it is their data.

It was one of the things that we really took a lot of thought over in the design of the new pathways, particularly the WGOS 4 pathway. That's a pathway that will be most instrumental in moving patients out of secondary care into primary care, and in stopping patients going from primary care to secondary care. In doing this, we are not only looking at moving clinical care, but we have to move everything else that goes with that. So, the governance that exists in secondary care for our patients in Wales, we need to make sure that the equivalent governance exists in primary care.

We are familiar with waiting lists in secondary care. We don't just want to shift waiting lists from secondary care to primary care, but to ensure that we are not doing that, we need to collect the data to capture waiting lists, to understand capacity and resource, and how patients' needs are being met. We collect a huge amount of data, it's reported to health boards, and then we have oversight, as national clinical lead, from a national level. We can see what's going on. We have the advantage of being able to look at activity across different health boards, and if something is working very well in one health board, and maybe another health board isn't quite there, we can explore why.

One last bit. That data also then gives us the opportunity to identify areas where, maybe, more research is needed, because data gives part of a story, it doesn't give the whole story. So, we might identify an area where we think we need a deeper dive, which is maybe a research project, and we might do that, we might collaborate with academics to do that.

Then, the final part, which is really important to highlight, is that we collect, routinely, patient-reported experience measures across WGOS 1, 2 and 3, and we will introduce that into WGOS 4 and 5 as soon as we can. Again, it's tempting, isn't it, to look at the data, to look at the waiting lists, and for it all to be very quantitative and dry. Actually, what we are trying to do is to improve services for patients, and in doing that, make sure that the experience they have in accessing our services is as good as it can be. So, we are trying to bring the patient voice, the patient representative, into what we do as well.

Thank you for that. That was really important, comprehensive coverage to give us those assurances, so thank you for that. Can I move on to Lesley now, please?

Thank you, Chair. Good morning. I want to look at workforce planning, which is obviously incredibly important for any organisation, but within the health service it is vital. So, could you just say a bit about your role in supporting health boards and other partners in relation to workforce planning? 

Yes. So, as part of the WGOS quality package, contractors need to report on their workforce on a monthly basis. The organisation that leads on workforce planning is Health Education and Improvement Wales, and I know that they have already been and given evidence, so I would probably look to their input. They are the experts on workforce, so I would look to their input for more information.

That said, we work with HEIW very closely. We discuss the workforce needs. Each health board has got an optometric advisor as well. They work very closely with HEIW on the provision of educational places and workforce planning. So, we are collecting workforce data and that workforce data will be used intelligently to plan what training is needed for the profession and where that training is directed. The training in Betsi Cadwaladr might be very different to the training that is required within Cardiff and the Vale, depending on what qualifications exist there already. So, we work with the optometric advisors within the health boards in supporting that, we work with HEIW in supporting that, but, as national clinical lead, we don't lead on that.

No, you are quite right. We did, obviously, take evidence from HEIW. Do you focus on any particular initiatives that they have to address the shortages across Wales? For instance, in Betsi, they said there was a shortage of consultant ophthalmologists; down in Hywel Dda, there was a shortage right across the board; and Swansea bay had its own particular difficulties. Do you work with them on the initiatives that they have, to try and address those gaps?

Because we only cover primary care, within a primary care capacity, we work with HEIW, but it would be beyond our scope and remit to work on secondary care workforce issues. 

Okay. We also had a discussion around international recruitment, which I think we all accept is essential for our health service here in Wales. Again, do you do any assessment about how dependent we are on international recruitment?

Again, it's not an area that, as national clinical lead, we would get involved in. From a primary eye-care workforce perspective, I think that's a very different picture to the secondary care workforce perspective. We like to think that optometry in Wales—. No, it's not 'we like to think', it's a fact that optometry in Wales is strides ahead of optometry in our other home nations. What the clinical services optometrists are able to provide is strides ahead, and I think that other home nations look at us with some envy, actually. Optometry in Wales is a really attractive offer, and we're really proud of that as a profession. We hope that secondary care can offer that as well at some point.

Just on that point, it's interesting to hear you say that, because one of the things we discussed with them was the fact that Wales is an attractive place to live and work, as you say, so if we can attract people to come and train in Wales, particularly from NHS England, then hopefully they would choose to stay, if that training had been an enjoyable experience. So, again, do you look at each health board and see what they need and then try and align it with encouraging placements and attracting placements over here, particularly from NHS England? 

Sorry, I feel like I'm shirking responsibility to Health Education and Improvement Wales, but that's the role of HEIW, and I wouldn't want to comment on something that they take the lead on.

Okay. Do you have any discussions with NHS England in relation to that, to attracting people over here?

Not around workforce. We wouldn't, as national clinical lead, around workforce.

Okay. On another area, I've been looking in my papers and I can't find the table that we had in front of us when we were taking evidence from HEIW, but if I remember rightly, Swansea bay UHB had zero glaucoma monitoring. That was what they told us, that they basically didn't do anything, and they needed to attract people there to enable them to do that. I wonder if you support health boards in relation to that.

Yes. So, the scoping of what qualifications people have and what they can do is, again, exactly what Health Education and Improvement Wales do. They've done lots of work. They work really closely with the optometric advisors in—. The optometric advisors know their patch. They know their practitioners on a very local level. They're in a position that they can go and have conversations with their local practitioners and literally say, 'Is this something that would interest you? What are the barriers?'

Something that is fantastic in the way that their profession has been supported is not only the amount of funding that Welsh Government is putting into upskilling the workforce in Wales, but also now the fact that there is an amount of money there to cover the cost of an optometrist being out of practice. Because the cost of training for optometry is not only the monetary value of the course, but obviously if you take a person out of practice, that costs the practice. So, there are now resources available to support practices. We've got teach and treat centres, which will help with the clinical placements that are required as well. So, it's such a multifactorial process that it's not as easy as saying, 'Do you want to do that qualification? Yes, I'd love to.' But I think that so much work and resources are being put into enabling practitioners to take up the qualifications, and we're seeing that. I looked at the HEIW figures on the amount of training placements that they've got this year, and year on year on year, we're just getting more and more qualified practitioners—advancedly qualified practitioners—in Wales.

Thank you.

Thank you, Lesley. James.

Diolch, Gadeirydd, and bore da, Rebecca. It's good to see you today. I'd like to talk about facilities, if that's okay. What we're seeing is a growing demand for these services across Wales. The numbers are going up, the waiting lists are going up, and I'm just interested: do you think that we have the facilities across Wales to meet that demand that's coming through the system at the minute?

With facilities, again, I'm going to bring it back to primary care, because the picture between primary care and secondary care is very different. With primary care, we have around 900 optometrists; it's a bigger workforce than we have in secondary care and we've got more physical locations for optometry practices. I think that the new contract is a once-in-a-lifetime change that we will see within primary care optometry, and primary care optometry is responding to the demands made of it. We are seeing, month on month—. Particularly when you look at WGOS 4, for example, month on month, we're seeing those figures increasing.

I think the difficulty, with regard to facilities, is that we can do everything that we can do in primary care, we've got the capacity in primary care, and like I said, that's something that we'll continue to monitor. But with regard to waiting times and referrals, the facilities have to be there in secondary care as well. It has to be a whole-system approach. Again, I know that Rhianon spoke at length on facilities in secondary care, and that would be for her to comment on, not me, but I acknowledge that it needs to be the whole system. A massive amount of resources in primary care needs to be supported. Secondary care needs to be supported as well.

Does the shared services partnership help with upgrading services within health boards to meet the demands as well, within the secondary care elements, and perhaps in primary care as well? 

Can you clarify?

So, are you putting any investment, or expertise and knowledge, into health boards to help them upgrade those facilities, to make sure that they're fit for purpose, to meet the demand? 

As in, secondary care facilities? 

Yes. Or primary care. Whichever one you want to—.

So, with primary care facilities we probably wouldn't need to, because the facilities are there, and it would be, again, out of our scope to comment on what secondary care needs.

Okay. Of course, with the people who are coming in, a lot of them are visually impaired as well, which means that it's more difficult to access some services, so I'm just wondering what the shared services partnership does, working with health boards, to make these facilities more accessible to people.

Most of these places, if they are in secondary care as well, tend to be at the back end of hospitals, and you have got to find your way through a hospital to get to the care to start with. With all due respect to most hospitals, they're not the most accessible places, actually, for people who are visually impaired. So, I'm just interested: how does the shared services partnership work with health boards, who do run those hospitals, to make sure that they are as accessible as possible for people getting those services?

So, again, from a secondary care perspective, that wouldn't be our role. From a primary care perspective, we work really closely with the Wales vision forum, and with the Wales Council of the Blind as well. So, they sit on our Eye Care Wales Committee. We sit on the patient advisory group, which is chaired by Owen Williams from Wales Council of the Blind, and we'll support our primary care practitioners in making sure that they meet the accessibility standards that they need to meet.

WGOS 3 is our low-vision service in Wales, and we have 200 practitioners that provide that, meeting the needs of people with vision impairment. So, it's something that we're very aware of, and we definitely currently encourage practices—and we'd like to further encourage practices—in making sure that they meet the needs of people with a vision impairment to access those services.

That's positive to hear, because we need to make sure that people who are visually impaired get as much as access as possible, because it's a service that they're using.

I just want to move on, if that's okay, to the variation across Wales in terms of facilities. Obviously, some areas have good very good facilities; other health boards haven't. What role does the Welsh shared services partnership have in actually making sure there's that equitable access of technology, equipment and facilities right the way across Wales, so one person in one health board isn't getting less of a service than somebody in another health board area?

So, with regard to primary eye care services, we have got set equipment lists that you need to have to provide the different levels of WGOS. So, if you reference our clinical manuals for WGOS 1 and 2, there is a set equipment list. For WGOS 3, which is our low-vision service, the equipment needed to provide that low-vision service is actually funded by the Welsh Government. So, when people do the qualification, they then get given a low-vision trial kit, as we call it, which comes with an array of low-vision aids for the patient to trial. But it also comes with specialist testing charts, because when we test the eyes of people with a vision impairment, we use different charts than we do with people with our general ophthalmic services—WGOS 1. 

Again, with WGOS 4, if you reference our clinical manuals, we have got a set equipment list that practitioners have to have to provide those services. And when practices, contractors, come on board to deliver the services, we have optometric advisers in NWSSP as well, and there's actually a check that is done against, 'This is the equipment that we say you have to have, and do you have that equipment?' So, you can be assured, if you go for WGOS 3 in practice A or practice B, it is the same level of equipment that is being used.

Is there a—? It's my last question, sorry.

No, it's fine.

Obviously, the Welsh NHS is using a lot more of independent contractors now to do a lot of ophthalmology—I can't ever get the word out, so I won't say it—work across the country. So, I'm just interested: do you see a disparity between NHS-provided equipment compared to independent contractor-provided equipment? 

So, again, secondary care, I couldn't comment on.

No, that's fair.

From a primary care perspective, we cover NHS optometry and not private optometry, so it would be outside our scope to go and have a look at the equipment that is being offered in private primary care optometry. That said—

'That said', I'd love to know.

—I'm not sure that we have any optometry practices in Wales that only offer private optometry and do not offer NHS services, and, to offer NHS services, they have to have the level of equipment that is outlined in our clinical manuals that they need.

Lovely. Diolch yn fawr. Thank you, Cadeirydd.

Thank you. Rebecca, perhaps—[Interruption.] Oh, yes.

[Inaudible.] So, in terms of outsourcing, if you like, or working in partnership with the private sector, and you said they have to meet this checklist, is there an inspection and a record of that?

Yes.

So, we'd have an idea, or you'd have an idea, of how frequently those services are being used and where they're being referred to?

In primary care optometry, we don't outsource services. So, in secondary care optometry, they would maybe outsource the cataract surgeries to a private company. The equivalent doesn't happen in primary care. So, in primary care, we deliver NHS services, and optometrists who deliver NHS services also deliver private services, because—and this is where we're different to secondary care—not all of the patients that we see in primary care are eligible for NHS services, whereas when you get to secondary care, all of the patients that you see in secondary care are eligible for NHS services. So, the outsourcing issue isn't an issue in primary care, because it's a slightly different set-up, and we probably use the words 'private' and 'NHS optometry' to mean something slightly different, because all optometrists do both, because we have to, because not all patients in Wales are eligible for NHS primary eye care optometry.

Thank you. Rebecca, we've talked several times, and you don't touch on the secondary side. Can I be clear: does the partnership support secondary care?

No. We are primary.

You don't. I think it was important to clarify that.

With regard to optometry and ophthalmology, it is primary eye care, not secondary. 

That is really helpful, because we might be chasing something that you cannot respond to. Mabon, would you like to come in?

So, yes, in digital, NWSSP has a role to play. We have one of the sub-groups from the Eye Care Wales Committee—it’s called IT digital and data. That is potentially slightly misleading. The digital agenda for optometry and ophthalmology sits with Digital Health and Care Wales. Again, I am aware that it has formed a huge part of the conversations that have been had in this inquiry. So, that work has been led by DHCW. It is not something that we get as the national clinical lead—that we have a massive role to play; DHCW are leading on that. We are acutely aware of the need for a digital solution, and I think everyone is keenly awaiting an electronic patient record and electronic referral system for our patients, because that will make patient care safer, more efficient, more streamlined. It will also free up resources. You will have heard that optometrists' time is being spent on submitting data sets and writing referral letters, and that is time, with a digital solution, that could be spent seeing patients. That is, obviously, what we want our optometrists to be doing. A vast amount of resource has been put into the digital solution, and we are all keenly awaiting the result of that.

'The Digital Workforce Team provide world-class electronic workforce and learning solutions to NHS Wales and the wider Welsh public sector'.

I would suggest that that is probably a question to be asked of the directors within NWSSP. It is probably outside the remit of my clinical role to comment on that. 

I don't think there is anyone who is going to sit here and say that things would not be better if we already had Open Eyes, if that was already up and running. There are so many advantages that patients would gain, that the system would gain, if that was up and running, and we really wish it was. It would be fantastic for the service. When you look at waiting times, when you look at the numbers of patients going through, particularly for WGOS 4, which stops patients going into secondary care but is also around the discharge of patients to primary care, in doing that, it demands a huge exchange of clinical information and complex clinical information, complex images. If that was in place—. I think month on month, we see that numbers of patients seen in WGOS 4 are increasing. I think it's really admirable that nobody has sat back and said, 'We haven't got a digital solution, therefore we are not doing it yet'. Progress has been made despite not having a digital solution. Some health boards are using alternative digital solutions at the moment. I think, for us, if Open Eyes was in place, if the digital solution was in place, it would just be a catalyst for more and more patients being discharged from secondary care to primary care.

Absolutely, and I think, again, when you sit in the committees and the meetings that we have, there is no doubt that we need the digital solution. Nobody is saying that we don't need it. That's made very clear in every eye care meeting that you will ever go to—the digital need is always raised. That's a piece of work being progressed by DHCW at the moment. It's not even at a point where putting pressure on health boards would be beneficial, because it's not with health boards at the moment—it's with DHCW, so it needs to progress there. Everybody wants it. Primary care optometry wants it, secondary care ophthalmology wants it, health board management wants it. Everybody is recognising the importance, and no-one will deny the frustration in the system that we don't have it.

Can I bring James in briefly on that?

Just really quickly on this point, as the clinical lead for this area, I'm a little bit surprised, perhaps, that you don't know some of the timelines for when digital note and Open Eyes will come to fruition from Digital Health and Care Wales. So, I'm just interested—. Perhaps I've misunderstood that. Do you as clinical leads have any indication of when these programmes are going to come on-stream, like the single note, which I think should be here anyway by now? Do you have any indication of when they're coming, or is it just a case of putting your finger in the air and hope for the best?

At the moment, we don't know. At the moment, we don't have any power to say—. It wouldn't be us directing DHCW, to say, 'You have to deliver this now'. I think that would be the Welsh Government.

But, as clinical leads, though, who need this on the ground, if you're not asking for it—

We—

Yes, I know you said the Welsh Government should be asking for it, but, you know—

And we do ask for it. Like I say, it is made very clear that it is a need.

And how seriously do you think that that is taken by the Welsh Government? 

Like I say, a huge amount of resource—. It's a really tricky one, because a huge amount of resource is being put into this. I've been in a leadership role for the NHS for a long time, and it's been talked about for a really long time.

Well, I've been here four years, and I have heard it since the day I got here. 

I can only imagine that if it was easy to do, it would be done already, because work is going on. So, yes, we need it for services. That's made very clear. Like I say, that's made very clear at every eye care meeting you go to, by every person around the table, and it is a frustration. Investment has been put into it, work is going into it, and I think, if it was an easy solution, it would have been delivered already.

Mabon, please.

Yes.

So, with regards to blockage, I probably don't know, to be honest. So, in my mind, it's a complex system. It's beyond my grasp of IT systems to understand why it's not here. Like I say, I feel that, if it was an easy solution, it would be here. So, in my mind, there must be technical issues, maybe, that prevent it from being implemented.

Aren't these the questions you should be asking in those committees—you know, asking DHCW why isn't this happening? What is the blockage? What's stopping you from doing this?

And we do, but, again, I think it's probably a question that Welsh Government needs to ask of DHCW, and probably the ask of this committee would be—. Everybody who's sat here has highlighted the importance; people are asking questions. At the same time, we can't only do that, we have to progress with the other aspects of our work; we have to think of other solutions. If we just spent all of our time talking about IT, we wouldn't have done all of the work that we've done already. So, I think it is a question that is—. NCL will absolutely support the need for IT solutions, but it needs a higher-up influence, probably.

Yes, I think we get the message that you really would like it in place. There are clearly issues beyond many of us. We're all trying to understand why it isn't in place, and I think that's where we'll be challenging further, perhaps in the next session. James, did you want to add a point on that?

Yes. Just one last point on this, if I may. Do you think, sometimes, there's a reluctance from health boards around having a Wales-wide solution to a problem? Because, in other areas where Digital Health and Care Wales have tried bringing in a more national basis, some of the health boards think, 'Well, actually, we'd like to run that system internally within our own health board systems, and have our system running it, and we'll procure it' and don't want it run nationally. You might not be able to answer that question, but do you think that, sometimes, that can be a little bit of a blocker to some of these things coming through? 

With regards to IT across the eye care pathway, it would be my view that health boards are not the blockage at all. I think health boards—. Again, they can speak on behalf of themselves. My view is, my interpretation is, that they're as keen as all of the other stakeholders.

It's quite nice to hear that. Thank you.

Thank you. I'll bring in Joyce. We're running on, but we've got just a few more questions. Joyce.

Thank you. I want to particularly look at risk management. I understand the nuance between ophthalmology and optometry, which is always getting confused here. But I want to particularly ask you about patient harm and how you address patient harm, should it happen, and there are many reasons for that.

So, within primary care optometry, we use the same reporting mechanism as they do in ophthalmology. So, we have the Datix reporting system. It's the same system, so it has the same difficulties as when they use it in ophthalmology. Again, I know Rhianon touched upon those. What I will say is it's a really nice thing to see that one of our health boards has actually recognised that the Datix system was difficult for optometrists to use, as not all of the questions were really designed for primary care optometry and didn't always allow the capture of the information in the timely, efficient manner that would have been preferred. So, one of the health boards has actually redesigned the Datix form for use in primary care optometry so that the data collected is more pertinent, and it's a more succinct form, which will, hopefully, encourage increased reporting when patient harm is identified.

Okay. That's good news for one health board, but there are quite a few health boards. So, in terms of your committees that you sit on, would that be highlighted as an example of best practice and easily accessible so that the others could come on board?

Yes, absolutely. So, we've got the Eye Care Wales Committee, and one of the sub-groups of that committee is the clinical sub-group. The clinical sub-group is chaired by ourselves as national clinical lead, and each of the optometric advisers for each of the seven health boards sit on that group. So, exactly that will happen. The health board that has—. And this was quite recently actually, so it's due for discussion at our next meeting. The health board that has developed that form can discuss, can show, and we can encourage other health boards to take the lead and to learn from that. The clinical sub-group is a really good forum, actually, for the sharing of best practice between health boards, and also offers the opportunity for addressing difficulties and challenges that other health boards experience.

Does that sub-group cover all the aspects of your work? Is it common to share that best practice, but, more importantly, to initiate the change in the other areas perhaps more quickly, by learning from others?

Yes, exactly. There's a lot of learning that happens. That sub-group feeds up to the Eye Care Wales Committee as well, so we'll often develop service developments from a clinical perspective. A recent example would be a change in our Welsh general ophthalmic services 3 pathway with regards to certification of vision impairment. Since the new contract, optometrists have been able to certify vision impairment in people with bilateral atrophic age-related macular degeneration. That was one of the massive impacts of the contract reform. That process was reviewed, was discussed, and we knew that not all of the patients that needed to access certification were accessing certification in a timely manner. So, as a clinical sub-group, we developed a proposal that optometrists would be able to certify all conditions within certain criteria. So, we developed that proposal, and that went up to the Eye Care Wales Committee, and at that point that gets signed off. That change is actually due to be implemented on 11 June. So, yes, the clinical sub-group is instrumental in the continued development and evaluation of services.

Yes, because that inability, if you like, to do work that helps to improve, or to offer services that help to improve, the eye care for patients would really fall under a form of harm by delay.

Yes.

That's why I said there were a couple of aspects to harm. And of course, if you can't act quickly, and in eye care it's critical in some cases to act really quickly, you don't get a second chance, in some cases. So, I want to—. Most of these questions are for ophthalmology, so I'm trying to rework them for you. Do you have a risk register within your profession?

The health boards will hold a risk register. So, in our role we have national oversight, but it would be for each of the health boards to hold their own risk register. I know that they have quality assurance meetings that optometry are part of within each health board as well. 

Yes. And on that risk register, again, looking at risks on both sides, to the patient but also those delivering, those risks could be, perhaps—we've talked at length, so I'm not going to start off again—not having digital, but also access to other items that could be invested in to deliver, perhaps, faster, more efficient, more effective care. So, it would identify equipment as well. 

Yes. So, at a national level, when you look at the committees that we have, each of the committees will have a risk register as well, which has exactly that, aspects that may impact on the delivery of WGOS.

Okay.

Thank you, Joyce. We've got a few questions left. If we nudge over the hour, are you okay for a couple of minutes?

Yes.

Great. Thank you. John, can I bring you in, please?

Diolch, Cadeirydd. Bore da, Rebecca. Rebecca, I wonder if you can help us with the NHS Wales Shared Services Partnership work on the development of regional care models for ophthalmology, including pooling resources and establishing regional hubs. Is that something that you can help the committee with, or is that, again, outside your remit?

I'm sorry, that would be outside our remit. 

Yes, so there's not much that you could say about that, really. No.

No.

No. Okay. Rebecca, in answering my colleague Joyce Watson's questions, you've touched on sharing best practice and the work of the clinical sub-group. I wonder if you could help us with a particular example of good practice that might be shared that you've heard about. We heard from Nik Sheen, head of optometry at Health Education and Improvement Wales, on the need for better integration and recruitment of hospital optometrists, including pay alignment. And while optometrists are supporting ophthalmologists at the Aneurin Bevan University Health Board, this isn't happening at other health boards. Could you help us at all with why that particular best practice doesn't seem to be shared and implemented across Wales?

There are lots of advantages to having optometry within secondary care. It helps with communication between the professions, it helps to build trust and a relationship between primary care and secondary care professions, and I think that the set-up with having optometry within Aneurin Bevan health board is recognised as being a good model. Optometry also exists in Cwm Taf Morgannwg health board as well in a secondary care setting, and in Cardiff and Vale health board as well. I'm doing a quick—. In fact, we do have optometrists working in secondary care across the majority of the health boards in Wales. So, it is recognised as good practice. Potentially, it's something that could be built on further, but that's optometrists sitting within a secondary care setting, so, again, it would be for secondary care to progress that. 

Okay. Rebecca, just a final question from me: in addition to what you've already said this morning, are there any suggestions you have for improving the operation of eye care services and the implementation of new initiatives as we move forward?

I think it's a really—. They're all good questions, obviously, but it's a really pertinent question. We've touched on IT, obviously; no-one's going to argue with that. For me, I think the key is we've got the contract, it's a once-in-a-generation change that is going to happen within optometry and primary care, and it's around a recognition that once that contract is fully implemented—because it's not fully implemented yet; we're still working on signed orders, for example, for optometrists within primary care—there are still populations in Wales that we know we're not meeting the needs of; we have hard-to-reach populations, we have children and adults with additional learning needs who cannot, in many cases, access primary care optometry or secondary care optometry, so we know that there's more to be done.

I think my ask would be that once the contract is deemed—by whoever deems it—to be fully implemented, that's not viewed as the end of eye care transformation; that's viewed as the beginning of eye care transformation, and that the drive that we've seen—. We've seen drive from Welsh Government policy makers, we've seen drive from health boards, we've seen drive from all of the stakeholders that we work with—the optometry profession and third sector organisations. It's been actually really remarkable, I think, to evidence such a seismic change.

I've been involved in healthcare management leadership roles for a long time, and just to change one pathway takes a lot. We've completely rewritten the page and changed everything. There's been behaviour change from optometrists, ophthalmologists, health board managers, whole organisation behaviour change has been demanded. There's been behaviour change asked of patients as well, because they're being asked to go to their optometrist instead of seeing the consultant that they're used to seeing.

To try and be more succinct in my answer, contract reform in optometry is the beginning, not the end, and we need to continue with the drive, both from policy makers and from people responsible for implementing and delivering services, to continue to improve care for the population of Wales. We'll never be finished. We need to always evaluate our services and always make them better, and listen to our patients, and keep them at the centre of everything we do.

Thank you, Rebecca, for that closing point. Can I thank you for all of the evidence you've given? That's quite a task, on your own, with so many questions. Thank you for all you've contributed. There will be a transcript available after the meeting for you to go through, and if you wanted to correct anything or we've misinterpreted something, please do. Can I thank you once again for taking the time to give evidence today?

Thank you very much. Thank you for having me—us—as clinical lead, it's appreciated.

Members, we'll have a short break for 10 minutes. If you can be back here for a quarter to for the next session. Thank you.

Good morning, everyone. Welcome back to our second and final evidence session today on ophthalmology, a really important piece of work, an inquiry we've been conducting for some time. We're really pleased that the Cabinet Secretary and supporting officials are with us today. Could I ask you, Cabinet Secretary, to introduce yourself and colleagues? 

I'm Jeremy Miles, Cabinet Secretary for Health and Social Care. 

Bore da. I'm Alex Slade, director of primary care, mental health and early years. 

Bore da. I'm David O'Sullivan, chief optometric adviser for the Welsh Government. 

Great. Thank you so much for making some time for us today. We have about an hour and a half. We have quite a lot to go through, as you can imagine, and this, as I said, will be our last evidence session on ophthalmology, so it's quite a key one for us.

Cabinet Secretary, I'll perhaps start, and colleagues will be coming in afterward. Looking at ophthalmology waits and patient care, given the serious consequences of delayed ophthalmology treatment that we've heard several times, which include avoidable sight loss, why does there appear to be a lack of urgency in implementing effective solutions to reduce the long waiting times for these services? I just wondered how you would respond to the frustration felt by both patients and clinicians about the current state of ophthalmology care. 

Diolch. I'm not sure I'd recognise a lack of urgency. I think that there are, obviously, challenges in the system that I'm sure we'll come on and discuss in more detail during the course of the time we have together.

I'm really clear Wales is not just the first, but I think the only UK nation that has in place a risk-stratified set of eye health measures that allows us to be very granular, very transparent about performance in the system overall, and, most importantly, enables us to identify where we need to focus our efforts and where we need to improve performance overall.

The committee is able to have the level of scrutiny that I'm sure we will see today by virtue of the fact that we publish very granular data that enables us and others to maintain a close handle on progress. But there clearly is work to do, I absolutely recognise that, and we'll be happy to elaborate on that.

I chair, personally, eye care summits that are crucial, I think, because what they allow is an opportunity for clinicians in different parts of Wales and health board management to look at some of the challenges, to identify where there are potential blockages, and obviously there will be, and so to identify those, to track the progress, to share that best practice and, crucially from my point of view—and we're moving the summits on to this kind of footing, really—what actions are people committing to taking, when will they be done, and a follow-up process after that. I think it's really important to have that strong link.

I think we've been very focused on changing the way that we deliver eye care in Wales, so linking up primary and secondary in a much more integrated way that's starting to bear fruit. That clear reformed pathway, I think, is the answer to a number of the challenges that you've heard about in evidence, obviously.

Just lastly, if I may say, we have increased the value of the contract by about £30 million, and that's recurrent. Before that, it was roughly worth about £40-odd million, so it's a huge increase. That is funding all of the work I've just touched on briefly, which is capacity in primary care, capacity in community settings, upskilling optometrists in particular, creating that capacity in secondary care so we can bring those numbers down. 

I used the word 'urgency' only because it was reflecting the frustration through the evidence sessions. For us, we recognise that a long wait for people with eye conditions might mean that it radically changes their lives, because there's often no comeback from this situation. That's why we're pushing really hard to understand why this might be perceived as not being the priority it ought to be. I don't know if you want to reflect further on that.

There'll be plenty of opportunity for me to highlight just how much of a priority it is, Chair. It's why we publish the data in the way that we do, because actually, it's not just about the numbers of people waiting for treatment, waiting for surgery, it's the numbers waiting within that time frame that is critical for their eye care, getting the follow-up in the same way, within the relevant time frame. We publish all of that, because then we can focus our efforts on the areas that we most need to improve.

Thank you. Whilst the longest waiting times are reducing, which is positive, significant delays do still persist right across Wales, with some areas still experiencing waits of well over two years. More concerning is that only around half of the patients requiring the most urgent eye care are being treated within clinical prioritisation targets. What are the main barriers, as you see it, preventing more consistent, timely treatment for those high-risk patients?

That figure that you referred to there, that 50 per cent, that is the one that I'm most concerned about and I'm sure the committee will be as well, and the evidence you'll have heard, I think, will reflect that. If you look at the longest waits, though, Chair, if I may say, those have reduced from about 8,800 a couple of years ago down to 1,200 now. That's 1,200 too many, obviously, but that is a very significant reduction. We've seen about an 80 per cent drop in those long waits over the course of the last six months, since October of last year. So, I think, to give a fair assessment, that is very good progress, but I absolutely recognise the point about that 50 per cent figure that's getting treated within that crucial window.

I guess what I would say to you is that there are three things that the system needs to be focused on and is focused on. Firstly, it's getting to grips with the backlog, which is the figures that I've just talked to you about. Unless that happens, the system, like any healthcare system facing a backlog, is running to stand still, isn't it, because the demand and the supply of service is out of kilter. So, it's absolutely critical that we get those figures back into balance, so that we can then tackle that priority with the urgency that we are and that we need to.

The second thing is the level of variation across Wales in relation to performance, and you'll have had evidence about that, and the work that we are doing about standardising pathways, clinical implementation network, driving through the strategy, so the expectation in all parts of Wales is the same, making sure the skills levels of optometrists in different parts of Wales are at the level that we need them to be—that's critical as well.

And then thirdly, that transformation of the pathway, so that we can see more people in primary care, more people in community, freeing up the capacity in secondary, so that we can get that 50 per cent figure up to where it should be, which is nearer 95 per cent. So, all of those things are pushing in that direction, if I can use that phrase. But I do share the frustration, which you've heard as a committee, about the speed. We clearly need to be doing that more quickly than we are. Some of the changes are still comparatively recent, but we do need to make sure that the pace increases in terms of implementing some of those aspects.

Thank you. I think, Joyce, you wanted to come in.

Thank you for everything that you've said, and I'm sure that everybody's focused on that 50 per cent, but there's another aspect, isn't there, to people waiting for ophthalmology, and that's the risk for falls for elderly or anybody who can't see obstacles that might be in their way.

It would be interesting to look at the orthopaedic waiting times and see if there are any links between those people whose eyesight was failing who now find themselves with a broken whatever. Because the point I'm trying to get at is the economy being affected by people who are not having treatment in a timely way, which adversely affects their life, and also the cost to healthcare, but also those people who could be in work and can't work, because they literally cannot see or they can't drive to work—all those sorts of things. So, it's much wider is what I'm trying to say than purely being visually impaired. That's the point I'm trying to make, and the knock-on effect is significant. But that 50 per cent really, really worries me, because, as Peter said, not as forcibly perhaps as I will, you don't get a second chance at this. 

No. Well, that's why we publish the data in the way that we do. If I may just respond, Chair, to that. So, there are two aspects to what you said, which I think are important. I absolutely agree that there are potential health consequences beyond eyesight loss, which can have other health consequences. But also, it's really important that we can make sure that people who are otherwise healthy and, as you say, are in work and so on, can get access to the treatment they need in a very convenient way. So, at the moment, we are looking at about an extra 3,000 appointments a month in a primary or community care setting, which would otherwise have been in a hospital setting. Our target is to reduce, is to shift, if you like, the appointments—about 30,000 appointments—out of secondary into primary, because, frankly, that's just more convenient for people as well. 

So, clearly, Cabinet Secretary, you recognise that patients are at increased risk or are already experiencing irreversible sight loss while waiting for treatment. I think we all accept that. If that's the case, would you agree then that faster implementation of the clinical strategy for ophthalmology is essential, so we can stop that?

Yes, there's no doubt about that. I've been very clear in all sorts of contexts that one of the critical reasons for reducing waiting times is because for many people, depending on their condition, the longer you're waiting the more likely you are to be deteriorating and that means harm. So, there's no doubt about that. NHS Wales Performance and Improvement, which is the new iteration of the NHS executive, is working with health boards to identify rapidly what their improvement needs are. We've got very well-established GIRFT guidelines—Getting It Right First Time—which has a set of standards that we are mandating health boards to implement. There are some services that are more fragile than we want them to be. So, all of that work is happening at a health board level with support from NHS performance and improvement. As I say, the answer to it is to ensure integrated pathways, so that we free up capacity in secondary care, so that people go to a hospital setting, absolutely, only when they need to do that, but when they do, they can get there quickly.

Yes, thank you. Mabon, would you like to come in?

Alex, what's the target for the 30,000 shift? I think it's—.

The 30,000? We're on target for the 30,000 at the moment. We're running slightly higher than that, at 36,000 each year. There's a real appetite from the optometry sector in terms of involvement in the pathways. I would say we are clear in terms of WGOS levels 1, 2 and 3; and 4 and 5 is where we're investing most of our energy, to make sure that we're hitting the levels that were expected for those more complicated clinical pathways, which is where we'll see the real benefit for patients not going into hospitals. But we're on trajectory at the moment, so, in terms of a full-year cycle, we're hitting those levels.

Full-year cycle. Diolch.

So, what do you think is causing the disconnect between the strategic vision and current outcomes? Is it due to insufficient funding—it's not prioritisation, you've said that; it's important to you, it's a priority for you—or are there other systemic challenges we've got to get to grips with? 

Well, I think it's a slightly more variable picture than that, Chair, if I may say. I absolutely take the point about the target we've been talking about, the 50 per cent target, so I'm not disputing that at all, but I've just outlined to you what I would describe as a very clear link between a national strategy and improved outcomes on the ground, which is an 80 per cent reduction in the longest waits over the course of the last six months. So, I think there is good evidence of a strong link between national direction and health board level performance in relation to that, but I accept it's a variable picture elsewhere.

Look, we've got the national strategy, we've got the clinical implementation network, which is driving that strategy with health boards on the ground. I've been clear to you about the approach that I'm taking in those ministerial summits, which is being very action focused, if I can put it like that. I think, if you look at what's happened over the course of the last year with the clinical implementation network, there's been, I think, pretty good progress. They've developed new guidelines for the sector, new discharge protocols, follow-up arrangements, self-management guidelines, KPIs for us to measure performance against. All of those, I admit, are in the inputs side of the ledger, but it's a year since many of these interventions have been put in place, and I think that does show a real seriousness of intent on the ground.

In the planning guidance that I issued at the end of last year, there were very, very specific expectations of health boards, which we will expect them to deliver this year, and we will publish performance against that, and some of that's around improving treat-in-turn rates, theatre optimisation, direct referrals in cataract. All of those things that we know, when they can be implemented on the ground, will make a difference, and we expect those to be put in place during the course of this year.

So, we've got all the ingredients in place, we just need to give it time, and then we're going to see remarkable changes, or significant changes.

Yes, but I don't want you to just take my word on that. We've just heard about the progress against the number of appointments that we're moving, which is tangible, and there are 3,000 people a month being seen in the primary care setting who otherwise would be waiting to go to hospital. So, we are seeing evidence of that at the moment.

Good. Finally, from me, I just wondered if you can make a commitment at all today to publish detailed data on ophthalmology waiting times, so that patients can actually see the specific waits that are there for the various specialities.

Well, we publish a lot of it anyway, but I am looking at making a statement in the autumn about what more we can do in terms of transparency. You'll have heard me say in other settings that, over the course of this year, the NHS app will develop a functionality where people will know how long they've got left to wait for their own treatment, but that's a slightly separate point, I admit.

That would be very welcome. Can I pass on to John, please?

Diolch, Cadeirydd, and bore da, Cabinet Secretary, and your officials. A few questions from me on patient harm. We heard from RNIB Cymru that they have concerns about the under-reporting of patient harm and system inefficiencies in ophthalmology services. I just wonder if that's something that you recognise, and, if so, what steps might you take to ensure that all our health boards consistently apply the Royal College of Ophthalmologists' guidelines and definition of harm, such as sight loss? 

We've got a duty of quality and a duty of candour, haven't we? So, it is important that all parts of the system are transparent. We've talked about that a little bit already, but, in the context of harm, certainly, both potential harm and actual harm, and both as a consequence of delivery of services and non-delivery of services, or delayed delivery of services. So, all of that, as a principle, is absolutely clear and must be delivered.

The reporting of patient harm is something that we include as part of our accountability meetings with health boards. So, they are reported to us and then we are able to test, challenge and provide the support that health boards need in relation to that. Critically, we will want to see, and my officials will want to see, evidence alongside of that data of lessons being learned and corrective steps being taken. The data is only useful if it leads to better outcomes, isn't it? So, it's about using that data to change things for the better.

The clinical implementation network is working at the moment on turning our national vision into that health board level strategy, and one of the things it will deliver as part of that is a consistent approach to the reporting of harm in the way that you were asking about in your question. I think it is fair to say that, as of today, there is likely to be under-reporting. I think it is getting better, and it is getting better partly because of the steps I've just mentioned. 

Okay. It's interesting that you say that there's likely to be under-reporting at the current time, Cabinet Secretary, because that's something that I think as a committee we wanted to probe a little on, but it's useful to hear that. I don't know if you would be able to provide this information this morning, Cabinet Secretary, or maybe write to the committee, but we're also interested in how many patient harm incidents relating to ophthalmology services have been reported to Welsh Government by health boards over the past year.

I don't have the figures over the past year, Chair, but over the last two and a half years, roughly speaking, it's around 70 nationally reportable incidents. I may ask David to say a bit more about this, but I would say, maybe to pre-empt a further question, I would also expect that that is under-reporting as well, but that's where we are. David, do you want to say a bit more about that? 

Yes, sure. I think we recognise that there has been that level of under-reporting, but it is improving, I think that's fair to say. The figures that we've got this morning from June 2021 through to September 2023, there were a total of 15 incidents reported, and from September 2023 to the present there's a total of 61. So, we see that improvement in the numbers in the reporting. Yes, we recognise that will still be under-reported, but there is a significant improvement in those figures.

Yes, I think, Cabinet Secretary, you correctly anticipated what might be the the committee's view in terms of those figures and under-reporting. But yes, okay. Could I raise a specific case with you? And that's the situation at Cardiff and Vale University Health Board, where we heard safety concerns regarding age-related macular degeneration services, which led to a request for a review by the Royal College of Ophthalmologists back in October of last year. I wonder if this morning, Cabinet Secretary, you are in a position to provide an update on when the findings of that review are expected, and how Welsh Government is supporting that particular health board to address those issues identified.

That incident is captured in the figures we've just been talking about. It's one of those incidents, I believe. My understanding from the health board is that the report hasn't yet been provided, so we aren't in a position to interrogate the findings and to respond to the findings, or the health board isn't. But my expectation would be, Chair, that when that report has been provided to the health board, we will see it, we will expect the health board to put in place arrangements to respond to the recommendations and develop an action plan, and we will obviously work with the health board in relation to that. 

Yes, okay.

So, is there anything further you could say just about the timescale for that, Cabinet Secretary, at this stage? 

Looking to my officials, I don't think there is today, but we would be happy to keep the committee updated if we find out the time frame for that. 

Okay.

That would be very welcome. Thank you, John. Can I move to Mabon, please?

Thank you, Cabinet Secretary. Can I move on to Joyce, please?

Cabinet Secretary, I'm going to look now at facilities and equipment. The first area I'd like to explore is the facilities within hospitals or hospital-type settings, and their safety and accessibility for visually impaired individuals. We've had evidence that that is not always the case.

In terms of the estate, which is used for eye treatments of all sorts, I know you have heard evidence, including from NHS performance improvement, previously the executive, about the Exeter model, and so on. Where we are at the moment is—. We've, obviously, provided capital funding for estate development, for kit, for reconfiguration over a number of years. What we are doing at the moment, actually, is to look at how we can deliver services differently. One of the key ways in which we can improve access and improve speed of access as well is by delivering services increasingly at a regional level, rather than solely at a health board level. So, you can see evidence of this working already in the south-west. We are seeing it as well now in the south-east. Increasingly, that's how I expect more and more services to be delivered, and what that means, in practice, is that when we're looking at the needs from an estates point of view, and from a kit point of view, a technology point of view, an equipment point of view, it isn't actually sufficient to apply the lens of what is required in this particular hospital setting or even in this particular health board setting. So, for example—and this is an in-principle example, really—if you look at the south-west, Swansea bay health board may have a particular configuration of assets and Hywel Dda will have a different configuration. If we're looking at delivering that regionally across those two health boards, which we are, then we need to make sure that the mix of assets across the two health boards, across the sites in both health boards, deliver what we need. So, at the moment, the clinical implementation network is working to understand what the current picture is, as part of that regional change, and then, when we have that, we'll be able to implement and make the investments that we need to.

I'm quite aware of it, because there's a consultation with Hywel Dda at the moment, and ophthalmology is part of that consultation. We've also heard that some of the equipment that is being used is outdated, it breaks down, it's causing delays. I know that the Welsh Government's invested in that. How's that investment, and the upgrade, to replace those critical bits of equipment—and I refer you to the 50 per cent urgent cases, perhaps—progressing?

Well, there's a range of investments, which I'm sure we can write to the committee about, if you like, in terms of capital investment, and for particular items of equipment or facilities, if you like. In the time I've been in post, I think two of the most exciting investments, if I can put it in those terms, was visiting Cwm Taf Morgannwg, where they've procured—I can't remember how many—several of what are called the SurgiCube, which is a sort of small operating theatre, which is more like a very large dental chair than a conventional operating theatre. I think it's the first time that they've been deployed in Wales. There's definitely scope for more of them to be deployed, and they are really focused on eye surgery. They can also be used for, I understand, other small sites, like hand surgery, I gather, and I've seen them work. And they are significantly less expensive than kitting out a new theatre, and they enable there to be a faster turnaround of the list. So, that's a very good example of productive capital investment in this specialty.

I was able to go and visit the simulation suite at Cardiff University, which is being used to train ophthalmologists. When I was talking to some of the students there who were telling me, specifically, that they were drawn to coming to study in Cardiff because of the simulation suite that was there, which was—. I saw it being used, and I'm not a clinician, but it looked incredibly impressive. So, you know, there is significant capital investment already. Clearly, there is need for more. That's true of all specialties right across the NHS, in all parts of the UK. But the strategy is, as I've just described, regionalisation, clinical implementation network identifying the current mix, and then we'll know what more is needed.

Finally from me, some of the health boards have told us that the funding that the health boards rely on is often ad hoc, that they're isolated business cases, and it's not, quite frankly—in their words, not mine—a comprehensive way to go forward. Now, you've given examples, of course, where you're trying to tackle that and meet modern healthcare demands. So, in terms of progressing that, from what they've described, to what you're hoping for, how do you see the trajectory and the outcomes being—I won't say 'completed', because, for everything you replace, there'll be something better coming behind—improved?

Well, the first thing to say is there's absolutely no world in which I'm going to be moving away from business cases in order to justify the expenditure of public money. That absolutely is a pretty minimal requirement, so there's no prospect of that changing.

I think there are two things, really. So, on the regionalisation, which I've just talked to you about, we've already made funding decisions that will drive that set of outcomes. So, for example, in the funding that we introduced into the system over the last few months, which has driven down the longest waits, in the south-east that was conditional on cataract intervention happening on a regional basis across the three health boards, and that is what happened as a result. So, I think that's a very positive example of health boards able to work together, and the funding being absolutely conditional on that being the way of working, which is what's happened, and thousands more people have been seen as a result. We just want to see more of that. So, that is positive.

The second thing that I've said—and I've said this in other contexts to health board colleagues as well—is that I'm not prepared for us to continue to invest capital at a health board level for services that are better delivered at a regional level. That is not a reasonable expectation for us as a Government. We have to move the investment strategy to drive the outcomes that we want to see. And if, as in this case, but there are definitely others across other specialties, the way of delivering the service in a way that is better for patients, better for value for money, more sustainable, is all the things that we all want to see, where the answer to that is regional, that is where the capital will be invested.

Thank you.

Okay. James, would you like to come in on that?

Yes. Cabinet Secretary, with the maintenance backlog across the NHS, it does impact delivery of service, doesn't it? You mentioned a lot about capital there. A lot of these ophthalmology—I can't say the word; I couldn't say it earlier either—specialist eye care services are delivered in a number of older, especially in secondary care, hospitals, where sometimes the places where they need to be treated are perhaps not fit for purpose. I'm just interested in that maintenance backlog. How much is left in the capital that the Welsh Government identified that needs to be spent to bring all those services up to where they need to be so there are not unnecessary delays due to, say, an estate being perhaps not where it should be?

Well, not related specifically to ophthalmology, but if you look at the entire NHS Wales estate and the backlog, I think—I haven't got the figures in front of me—

It was £793 million in 2023-24.

Sorry?

It was £793 million in 2023-24.

No, I think it's more than that; it's probably closer to £1 billion, probably.

It's gone up now, has it?

Yes, to be frank about it. So, clearly that is many, many, many years away from being able to be addressed because of the constraints that we're operating under. The capital budget this year will be the highest for many, many years, and yet it clearly won't meet the need, as described in that way.

What I would say to you, though, is—. I just gave an example about the intervention at CTM. That suite is operating in a hospital, and it is the most cutting-edge technology. So, it is possible to use that capital budget in a way that absolutely can make a difference. There are examples in Cardiff as well—the Vanguard technology in Cardiff is another good example of this.

I get the regionalisation, and I can understand where you prioritise your money. How far off are we from getting a standardised model of expectation across all regions? I mean, is there a lot of disparity between regions as you see it, and you need to have more focus in certain areas, because clearly we don't want a postcode lottery of where people can get good eye care?

No, of course we don't. So, there are a few things in that question, Chair. So, in effect, north Wales is its own region because of the scale of the geography. So, in a way, this operates as a regional health board in any event. In the south-west, health boards have already created a regional board, effectively, to deliver services jointly, and I'm just talking a little bit about ophthalmology, but orthopaedics as well and other specialties. And a few weeks ago—a couple of months ago, at this point—I directed the establishment of a regional board in the south-east for the three health boards to work together. I knew that there was pre-existing good work happening there in relation to cataract anyway. So, the effect of that, obviously, is that the clinical practice and the pathways for the relevant specialty within that region moves from being two or three separate ones into one consistent one, and sometimes one common one. So, in the case of cataract in the south-east, that was effectively operating as one combined waiting list. So, you have to make sure the clinical activity is aligned, and the same thing in the other part.

So, then you're left with, potentially, three hopefully very slightly different approaches, and, again, what we want to see is an elimination of all variation that isn't helpful. But that is a gradual process and we're building towards that.

Great. Thanks for that. I'll take the next section, just to look a little bit more at integration of primary care optometry services. I just wondered what measurable improvements in patient outcomes and waiting times have been observed since the implementation of the Welsh general ophthalmic services. What evidence is there that supports the shift? Is it actually improving patient outcomes?

Some of those interventions are based on legislative change that is comparatively recent. Some of it was the tail end of 2023, and some of it is probably a little over a year old at this point. So, when you ask about what the outcomes are, that's the time frame that in practice we're talking about. So, in a sense, it's the earlier stages of the evidence of the impact that we will see in the system. But, as Alex was saying earlier, the two pathways that will make the biggest difference to that shift are pathways 4 and 5. Being able to deliver those pathways depends on two things: firstly, having optometrists with the right higher skill set in each of the health board areas, each of the cluster areas, really, on the one hand, and then secondly, obviously, identifying patients who have the right risk profile, so at the low or medium end of the risk profile, who are able to be seen and then managed in a community setting. So, those are the building blocks, if you like, of how this is being taken forward.

Each health board starts from a different place, because of the configuration of individuals, but each health board has an agreed transition plan that reflects both their starting point and ending up in a consistent place. The committee might have heard evidence of this. The legislation directed health boards to establish a joint committee that is tasked with ensuring that each health board is delivering pathways 4 and 5 in a primary care setting, so pushing all health boards towards that consistent offer. What that has meant in practice—you asked me for outcomes—is, as we were talking about a little bit earlier, 3,000 extra appointments a month so far, or probably a little above that, where otherwise people who would have been seen in hospitals are now being seen by optometrists on the high street or in the community, which is very positive. If you look at Hywel Dda—and some members of the committee will have more information about this from their own experience—Hywel Dda has quite a mature optometry service in this way. Ninety-three percent of all patients are being managed independently in primary or community settings. That's an incredible level of success. So, that's the prize. If we can deliver that across all health boards, that will be fantastic. So, that's actually pathway 5.

If you look at pathway 4—so, things around glaucoma, medical retina—the first quarter of this year saw about 1,200 appointments in a community setting. That's the first three months of this year. And we're almost at the same level of the first three months in April of this year. So, you can see how quickly the pace is picking up. So, roughly about 1,200 appointments in April itself, which was the equivalent of the first three months of the year. So, again, in pathway 4, a real speeding up of that shift, which is good news.

Yes. Well, that's reassuring that there are measurable improvements and they're being monitored. That's really crucial. Just based on current data, is NHS Wales on track to achieve the target of shifting 30,000 appointments into primary care?

Yes.

It is. Good. Right. So, how does the cost per appointment in primary care compare to the previous cost in secondary care? Have we got some indication of that?

Well, the way we account for the cost of treatment in the NHS in Wales isn't tariff based, so there isn't a price per intervention in that way that I think the question assumes. However, there is clear research, which isn't specific to Wales, that tells us that providing the kind of service we're talking about in a primary or community setting is probably cost neutral, in terms of the individual intervention, to what happens in a hospital setting. That's our rough understanding. However, actually, Chair, I would strongly make the case that the case for this isn't actually about the unit cost to the NHS of delivering that particular intervention. It's actually about freeing up capacity in a secondary setting to get the more serious cases seen by consultants when they need to be—so, making sure that optometrists are upskilled and are working to the top level of their skill so that we can move more and more people into optometry settings, then freeing up the ophthalmology capacity for those who we can't move into that setting. So, it's really more about—. There's a value-for-money argument in there, obviously, as well, but actually it's about making sure that people can be seen more quickly, and we think it's cost-neutral from a cost point of view. 

Okay. It's an interesting side of things, the whole finance, the whole tariff argument as well, but that's for a different arena, perhaps. 

So, given that advanced WGOS services, certainly 3 and 5, are not mandatory for all optometry practices, how are you ensuring, through the health boards, consistent access to these services across all of the regions? And I wonder what steps are being taken to ensure equitable access to enhanced eye care services for patients in rural and underserved areas in particular. 

So, the directions in the legislation, as I was touching on briefly earlier, require health boards, and they have, to establish an oversight body, an eye care committee is what it is called, which is tasked with making sure that these pathways are delivered at a health board level. So, that committee was established a little over a year ago at this point. It’s required to report on progress against the objectives in a year, so it will be coming to us very shortly, and then every three years after that. So, when we see the outcome of that report, we’ll be able to assess the points you are asking about. Equality of access and parity and all of those important points will come out of that review.

Yes, because one of the bits of evidence we had was that there's a real issue, really, to try to get the optometrists into some of those—. Certainly in western areas, it's a real struggle. We're seeing optometrist levels, I think, at about 1.7 per 100,000 people here, as opposed to a target of three. 

Well, that’s ophthalmologists.

Ophthalmologists. Sorry, I do get mixed up. 

So, I recognise that figure, more or less, and there is work under way in relation specifically to ophthalmology recruitment, but I think that the picture is different for optometrists. There is obviously a variation in skill levels, because people choose to be trained to a higher skill level or don't, but the strategy I've just been talking about does get to grips with that and identifies where the skill levels are. Actually, the picture for optometry upskilling—if you haven't had the data from evidence, we can provide it to you—is really quite remarkable. So, in some health board areas, there's a twelvefold increase in the higher skilled optometrists in either glaucoma or independent prescribing or the various requirements. So, I think that that picture is actually quite different on an optometry basis. 

Okay. Thanks for the clarity on that. A final bit from me, and then I'll hand over to Lesley. I just wonder what plans are in place to sustain or increase the capacity of primary care optometry to manage the growing workload. 

So, that's the point I was touching on, Chair. The aim is to make sure that we have two higher trained optometrists in each cluster area. That is the basic—. That's where we're working towards. We've made good progress, I think, in medical retina and in glaucoma—. No, actually, medical retina and independent prescribing, and we need to make sure that the same progress is coming through in glaucoma. But we can provide you with the details of the level of upskilling, if you like.

Okay. That's helpful. Thank you, Cabinet Secretary. Can I move on to Lesley, please?

Thanks very much, Chair. I want to look at workforce planning, because effective workforce planning is very important in any organisation, but I think in the NHS it's absolutely vital. You just mentioned to Peter, in his penultimate question to you, the low ratios of consultant ophthalmologists right across Wales, and I'm certainly very aware of it in my own area in Betsi, and the fact that the Royal College of Ophthalmologists says that we should have three per 100,000. We took evidence from HEIW around this, but I was just wondering what your thoughts are around why we have a shortage of consultant ophthalmologists, whether it is attractive training positions, or whether it's more budgetary, but I'd be grateful for your view on that. 

My understanding of the most recent figures is that we have the equivalent of 1.9 per 100,000, and that needs to be closer to three, so that obviously is a challenge. I think, though, if you look at the trend of recruitment into ophthalmology, over the last five years, I think we’ve seen about a 16 per cent increase, so the trend is positive, but obviously it needs to continue, and increase in pace, obviously.

So, I think one of the challenges here is how, at a UK level, ophthalmologists are trained. The application for a place on ophthalmology training programmes is operated currently at a UK-wide level, so, people who want to apply apply at a UK level, then they are ranked, effectively, I think, based on how they perform, and that ranking then determines the choice they have about where they want to go and train. So, sometimes people end up being trained in areas that are not areas of their first choice, and that applies to us in Wales—for some people, obviously; for some people, it is their first choice; it’s a mix. And there appears to be what I probably would describe as a geographic imbalance, if I can put it like that. So, there is quite an over-representation, perhaps, of quite a cohort in the south-east of England that end up having allocations in other parts of the UK. And we have some experience in Wales—and it may be shared in other parts of the UK, I don't know—of people who come here to do their training placements, for whom, a certain number of them—which will be true definitely in all parts of the UK—it is not their first choice, and therefore they will either leave at the end of their training programme or, in some cases, during their training programme, which is actually very bad news, because then that training capacity is lost for the balance of that year. So, there is a challenge there, and we have to rectify that.

So, we've recently—. HEIW may have said this to you. They've recently appointed a head of a school of ophthalmology, and that person is tasked with a wide range of things in relation to the workforce, as you can imagine, but specifically, in this context, developing a specific recruitment programme, which would operate at a Wales level rather than at a UK level, and we think that will mean people who are more likely to make the choice of wanting to practise in Wales applying through that programme, and therefore retention will be improved, which will help us in relation to that.

Sorry, it's quite long-winded, but it's quite a complex—.

That's okay, that's fine. So, you're not unhappy with the offer that HEIW are doing, but you don't think it's budgetary. Is that what you're saying?

Well, to be fair, there are budgetary pressures in terms of recruitment generally, so I would not make the argument that there are no budgetary pressures. We have maintained our budgetary commitment this year as against last year, and you will recall that last year's was an increase—I think quite a significant increase—on the year before. So, that's where we are from a budget point of view.

I think the recruitment of this head of school will make a difference. It'll give a particular focus to what is a particular challenge. So, I think, in a way, that has been the challenge and we now have a solution in place for it.

I think one of the things HEIW told us—and this will go for every specialty—is you need, obviously, the doctors at the junior level or mid level to want to do ophthalmology, to see it as an attractive proposition. So, I think it is very important that they've put this head of school in now to make sure that the offer is comparable across the UK, but also to try and encourage people to come here. Have you set them a target? Have you set NHS Wales a target? You said it was 1.9 at the moment per 100,000. Have you set a target for when you want to see three per 100,000 in place?

What I can say is ‘not yet’. There's a new person who's been appointed. I want to get their assessment of where we are and how quickly we can change—move the dial on it, if I can use that language. But I'm absolutely open to doing that, based on that information.

Just one tiny point to follow up on: I do think, in terms of recruitment, one of the things we hear a lot about is, well, actually, if there was more innovation in the system, that would attract more practitioners. I do actually think that, in this area of practice, there is a good story of innovation in Wales, perhaps compared to other parts of the UK, about the change that we've just been discussing today, and I think that will attract people as that beds down, because they can see changes in the system being beneficial to overall performance.

I certainly think that's the case for optometry; I'm not so sure the evidence we've heard is that's the case for ophthalmology or the clinical side of things. But I think in primary care that's certainly the case.

You mention that there's a variety of roles. Again, some of the evidence we've heard was around vitreoretinal surgery and the fact that we had been relying very much on England for these clinicians, so they were looking again at capacity in Wales. Having looked into it myself, I certainly think there is very comprehensive training on offer for vitreoretinal surgeons. Would you agree with that? Do you think the capacity is being built?

Yes, absolutely, the training is there, but we are also aware, as you said, of people being referred for treatment over the border. So, what we are expecting is, as part of the clinical implementation network, for us to understand what more we can do to enhance the training available in Wales as part of that piece of work.

Do you think more mentoring is a way forward?

Possibly. On the point I was making earlier about the training placements for ophthalmologists more generally, the educational supervision and mentoring in that way is a very valuable commodity, isn't it? It's a very valuable resource, and so making sure we are able to make use of it, to deploy it, if I can put it like that, in a way that is likely to mean that people who are training end up staying, making sure those relationships work, is really important. If people are prepared to make that time available to provide that supervision, that leadership, then it's particularly challenging if people then leave training placements midway through a year, isn't it? That's just such a huge loss.

Just picking up on that point, again, we heard from HEIW that it was a barrier for training, finding particularly consultants who are prepared to give the time, because, obviously, they're then taken out of the clinical setting to provide that training. The current workforce planning is a projected 6.4 per cent increase in demand for ophthalmic services by 2030, which is significant. Do you think, within that, there will be some specialties in which we will not reach that 6.4 per cent? I go back to what I was saying—as you know, I worked in ophthalmology 40 years ago, when a surgeon did everything, but now one will only do glaucoma surgery, one will only do vitreoretinal surgery. Do you think that is a concern that we have all these specialties and we're trying to fill in the gaps in the workforce?

I'll bring in David, if I may, on some of the subspecialty points that you're making there.

Thank you. I think this is the reason that we're making the whole-pathway changes for eye care. I hear what you said about it not being attractive for ophthalmology but it is for optometry. I probably disagree there, because we're looking at this as a whole pathway. The subspecialties that we are talking about—glaucoma, medical retina—that is where we are improving the workforce in optometry particularly.

Actually, in that movement between ophthalmology and optometry, that divide is being broken down. So, it's becoming a more attractive place for us in terms of that training and that mix between ophthalmology and optometry. There's no reason why ophthalmology training can't be integrated with optometry training and vice versa.

Yes, ophthalmology is divided into a lot of subspecialties, but that integration of the whole pathway will make a huge difference, and moving into that regional area. I think there's a lot of work to be done in terms of the workforce. But breaking that down, that barrier, and making it a whole pathway, an integrated pathway, is hugely important to the work we're doing in Wales.

Thank you. Dr Andrew Pyott said that if there was one thing he would do to improve ophthalmic services it would be to have dedicated nursing teams. For me, that absolutely follows. If you've got clinicians doing ophthalmology as a specialty, why would you not have nurses? I don't think, from what we heard from HEIW, that they are moving in that way to make sure there's an improvement in nursing and non-medical workforce structures. So, I don't think co-ordination is good. Do you, as a Cabinet Secretary, agree with Dr Pyott? Would you say that that needs to be looked at across the health boards? Do your officials monitor that? How is progress reported to you via your officials? 

We know that it's the multidisciplinary working that actually enables us to deliver this pathway increasingly, isn't it? So, we need to make sure that is right. Clearly, the main responsibility for delivering on that is at a health board level. We absolutely make sure that HEIW should be providing the support that they need to do that. I'm interested in what you've just said in your question. For me, the piece of work that needs to inform that is the clinical strategy work, which the network are developing, about workforce needs. Having HEIW and that piece of work aligned closely will be critical to making sure that we are able to get the range of nursing and non-medical workforce in the right place, as you were saying.

Thank you.

Thank you. Can I move on to James, please?

Thank you. We've talked a bit about regional collaboration already, Cabinet Secretary. You've mentioned some good examples of where regional collaboration has worked. I wonder if you could go into that a bit further and perhaps where it's working well and areas where it needs further development in certain parts of Wales and what the Welsh Government thinks those areas are.

The biggest reduction we've seen is in the south-east, I think. I think we saw about an 88 per cent reduction in the longest waits over the last few months in the south-east, and that's been driven largely by regional working. What that has meant is the alignment of clinical practice, which is critical, obviously, pathway management, and then that common waiting list. So, that's a good example of joint working. There's more that can be done, for sure, but I think there's good evidence of regional working there. We heard earlier questions about individual business cases and so on.

Where there are areas such as this that can be better delivered at a regional level, then the funding needs to go in at a regional level. Health boards then will agree how that is allocated for the individual components that they each bring to the table, if I can put it like that. That's how we allocated the funding most recently for the last few months, and it's shored up that model, if I can put it in those terms. So I think that's positive. It's a national strategy for delivery at a regional level—that's how I would describe it. Cataract is a good example but there'll be others we can build on.

It's working well in the in the south-east, but there are other areas of Wales, as well. How do you make sure that the individual personalities in health boards don't get in the way, sometimes, of regional working? Because what we've heard from some clinical leaders is that, because each health board works independently, sometimes it can be a barrier to the regional working. I'm just wondering is there is any way in which the Welsh Government can—. I won't say 'force' people to work on a regional basis, but where you know it delivers to actually say to health boards, 'Well, come on, it's about time you did this', because it's about patients not personalities, sometimes.

Just to say the only reason I highlighted south-east Wales is because you asked me to identify where there is good practice. There is nobody in the south-west waiting for more than two years and the the drop in Betsi was 33 per cent, so there's good progress right across Wales. But I was highlighting that as one example; I absolutely recognise that there's good practice working right across Wales.

To your point, though, about clinicians wanting to work more regionally, my reflection is that if you talk to anybody about regional working, sometimes clinicians will say, 'Well, health boards make it difficult for us' and sometimes health boards say, 'It's quite hard to get clinicians to work together across health board boundaries'. Maybe that's a bit inevitable in a complex organism like the NHS, but I gave a speech recently where I was challenging the NHS, frankly, to be an organisation that was ready to grasp the nettle and point the finger.

At the end of the day, if there are specific proposals that clinicians want to make around regional clinical working where they think health boards are an obstacle to that, I would like to be told about that, because that would not be a good outcome. I would be a little bit surprised if there was much of that. I think it's a more complex picture than that. At the end of the day, what we need to see, increasingly in these areas—cataract, but others as well—is that alignment of clinical practice, that elimination of variation that doesn't have a good basis. That's quite challenging. These are highly skilled, professional practitioners with a lot of experience and so making that clinical alignment can sometimes be challenging, but that is really what we want to be able to see to move away from that variability.

There is sometimes a differential between the clinicians and what the health boards want to do. Some clinicians did say to us that perhaps if some areas wouldn't collaborate, they would like to see a centrally funded system, perhaps like the Velindre cancer service or the Welsh ambulance service. Is that something that, if health boards wouldn't start collaborating, would be in your thought process, moving to some sort of centrally funded model? 

No. They are collaborating. There is nothing particular to ophthalmology that suggests that there should be a national intervention. It's challenging; there are lots of specialties that are challenging. But what I'm describing to you is a way in which the Government is using its powers of intervention to fund at a regional level and really good evidence of that working on the ground in all parts of Wales. So, I don't think there is a case for doing that. But that national direction for regional delivery, I think, strikes the balance that works best.

Mabon. 

On that, we had someone from Hywel Dda in a couple of sessions ago, who was trying to explain the difficulty around regional working, and part of the difficulty is around the governance of each different health board and the legal structures that each health board has, which means that they collide, they clash, basically, and they can't work together because of those different structures. Is there anything the Government can do to overcome those obstacles in order to ease co-operation and get them working together?

Firstly, I think that is a factor that is easy to describe but I'm not sure is particularly the reason that there are problems. I actually think it's more of a cultural question and a historic question. And I'm not being critical; these are quite understandable on one level. I'm not suggesting it's irrational, but it is the challenge that we have to overcome. It's not surprising that clinicians think, 'Well, this is the cohort of people that I'm responsible for'. It's not at all surprising. It's a very human and very professional way of approaching a challenge, so it is understandable.

The task is—and we have evidence of success, so this is not a counsel of despair by any means, we see evidence of it working—resetting the boundary for clinicians and health boards to say, 'Well, actually, it's this combined pool of people that we are here to serve' in this particular specialty. And that's then what gets you into a place where clinicians, creatively looking at the pathways, think, 'Well, actually, we can align on that. You're doing it there. Oh, there's good evidence of that working. We'll try it here'. So, that's the shift that you want to bring about, and it is happening, but it needs to be faster, frankly.

On the second point of your question, what we can do is what we have done, which is direct the establishment of a regional board in both the south-west and the south-east. Betsi is different—it's its own region. So, the board then has a collective responsibility for the entire local population of the combined region. We've seen that already starting to work in the south-west. The board's been in place for probably—I can't remember how long—coming up to a year, possibly, at this point. Last summer it was established, I think. And the new board now in the south-east is about to meet, I think, for the first time, and I'm confident that we'll see the same thing happening there.

Do you mind if I just come back? Just to counter a little bit on that, and I'm sure you'll be able to push back, you mentioned, earlier, Vanguard. Well, Vanguard was a good example of co-operating. Some of the people involved in that felt that they were actually penalised, because they didn't get the credit, or they didn't get the funding or they didn't get the allowances that they deserved, because they helped other health boards out, but it meant that they might not have reached their own targets.

Well, that should not have been the case. There are two elements to it. I recognise a bit of the point there, but I'll just elaborate. On Vanguard specifically, but it's not the only example by any means, the activity delivered by it will have been funded from two sources, effectively. Part of it will be the core allocation that Cardiff, in that case, will have been given, and it will be required to deliver its core allocation using that funding. Its own patients ought to have been met largely through its core allocation. But there will have been some patients in Cardiff for which the core allocation wasn't sufficient, obviously, and there'll have been patients in other health boards who will have been treated through Vanguard by additional funding, and the additional funding was conditional on the resources and facilities being available on a regional basis.

So, you would expect there to be a bias, if I can put it like that, in the use of a particular resource, in this particular case, towards the health board's own patients, because they were funded through their core allocation to deliver that. But there will have been a requirement, which was met, for that facility also to be available to other health boards with the additional funding we provided. What is absolutely not part of the picture, if I can say it like that, is that additional funding is used to deliver core functions. I'm not making a point about Cardiff, I'm making a point generally. I've said, for the year ahead, that if there is evidence in the system of additional funding being used to deliver core functions, that funding will be clawed back.

On the point of Vanguard, it's a great service, and that sort of informal regional working as well across regions. As you know, where I represent in Powys, for example, that can access a lot of different services and a lot of different regions, actually, for work. What sorts of elements are you aware of of informal regional working between the south-west and south-east? Does it go back and fore? If Vanguard has got a bit of capacity, will that go and pick up somewhere else? It's that more Wales-wide regional working to get waiting lists down and people seen.

I wouldn't describe it as informal, because it is obviously all formalised, but I understand the point you're making about being slightly less systematic. So, there are two things that we are doing. You mentioned Powys particularly. So, in establishing the board in the south-west, and in establishing the board in the south-east, and in order to achieve parity with Betsi's board as well, we've required—they were happy to do it, obviously—a Powys health board representative to be in attendance at those board meetings, recognising Powys's particular relationship to other health boards in Wales. So, we're trying to formalise some of that relationship in that way. And there are already examples. There are some specialties that aren't delivered by health boards at all because they're tertiary or other particular specialties where people, as a routine, have to travel between health boards. So, there is some of that happening already.

Okay. And just one final general question, if I can, about the NHS executive, if that's all right. In the past, it did say it does lack the tools to support transformation of services. I'm just wondering: do you still think that is the case—that it does lack the tools—or do you think, actually, the NHS executive is helping deliver the transformation of—I can't say the word—specialist eye care services across Wales? 

Well, the tools that are required by the NHS executive, which is now called NHS performance and improvement, to support the NHS, are twofold—one is budget and the second is capacity and capability. So, those are the tools that we're talking about. I recognise, and I have for some time, that we need to, with two years of experience of the NHS executive—. And it does fantastic work; it's a really important resource, both for Ministers and the NHS, in a wide range of ways, both clinical but also improvement functions as well, and the driver for performance particularly. It does need, with the benefit of those two years, to be refocused. That's partly why I've chosen to rename it. It's not just about renaming it, but it's to give the system a very clear understanding of what it is there to do. 

It doesn't have executive powers in the sense of being able to direct. Those powers are with Ministers. So, I felt that created a bit of confusion in the system, to be blunt, in a way that is unhelpful for everybody, including the executive. So, we will be publishing a fresh role for it, but I can tell you what it is because it's very straightforward: one is to support the NHS to improve the way it delivers services, and the other is to support Ministers in holding the NHS to account. So, where I want to get to is that the NHS performance and improvement team is the first port of call for any health board thinking, 'I've got a challenge here that I want to improve this service, who do I go to?' It's the people at NHS performance and improvement. That's the culture I want to establish.

There are some changes that will go with that. So, we will be doing a zero-based review of its funding to make sure that it's perfectly aligned with national priorities, and we will appoint a managing director into the performance and improvement team to make sure that we streamline and focus all the incredible resource and expertise that we have there on those key priorities. 

We'll have had discussions in other contexts about the cancer programme. So, we have two strands of work within the executive historically dealing with cancer improvement. That needs to be combined, aligned and focused. So, that will be one of the outcomes, but there'll be others as well. And secondly, as I set out in my response to the ministerial advisory group report, we will be appointing a national clinical lead with particular responsibility for NHS Wales performance and improvement, who will be one of the deputy chief medical officers. 

Just a 'yes' or 'no' question: so, there'll be no legislative changes to the NHS executive to give it more directional powers in this term of the Senedd?

No.

No. Thank you.

Joyce, you wanted to come in on something that was said?

Just a final question really, because of time, and thank you, Chair. We've talked about delivering regional services, which we know will be better for people, and that's fine, because we're sitting here telling people that. How are you helping those delivering the services to send that message to the individuals who may have to travel?

Well, our experience to date is that people are—. We're talking within regions, so often the travel times aren't huge. In your part of the world, in the west, distances are obviously slightly longer, or at least can be. Our experience to date is that, where people know that this means they will get faster access to the care that they need, they're prepared to make the journey. So, in cataract in particular, what we want to get to is a position where people's attendance for the surgery is much, much briefer than it is now. So, people will feel much better about having to travel further to get care earlier, and for that to be a less intrusive experience for them anyway. So, it's painting that fuller picture, I think.

The truth is a lot of this operates on the basis of experience of the system differently delivered, and people's shared understanding of what that means. There is some evidence of positive word of mouth as well about some of the developments that we've seen, where people are saying, ‘Well, actually, my neighbour's been invited to come for surgery’ and there's a positive, benign effect that goes with that. When I met—. I've been to Nevill Hall to see where some of this is delivered in the south-east, and my experience of talking to the staff there was that they were very excited about it because they could see the benefits of operating in this way. And that is—. We want to get staff feeling that sense of buzz, don't we, about the positive changes in the system.

Thank you.

Okay. Cabinet Secretary, one final question from me. We've got a bit of time, so I thank everybody for getting through the questions as we have. We aspire to get as many people into primary care as possible, and I just really want to get a flavour of how you feel—. If we can achieve that and get as many in the primary sector as possible, will that leave enough capacity in the secondary care sector? 

To hit our targets? Yes.

It will.

If we succeed to the fullest extent of our ability, the pathways are rolled out in every health board consistently, we are able to continue making sure that optometrists are upskilled to the level they need to be, we've got the two in each cluster that we want to have there, we're able to make the changes in ophthalmology that we've been talking about, and the regionalisation of the service works in the way that we've described today, then I think we'll be able to hit those targets. 

Well, thank you, that's reassuring. I think James wants to come in.

I just wanted to mention—I think it'd be wrong if we didn't—the digital side of ophthalmology, and actually making sure we roll out a lot of the schemes that are in train, especially around single patient note as well. Do you know, Cabinet Secretary, when those things are going to come online? Because everybody we've spoken to from a clinical side of things has said, ‘We need this to happen’, and, Open Eyes and the rest of it, ‘We need these things to happen. It will improve the system.’ I know Mabon asked a question earlier about what are the blockers to enabling this to happen at pace, and, in fairness to the lady who came to see us, she couldn't give us an answer. As I said, you're the Cabinet Secretary with responsibility for the department. I'm just interested: do you have any idea when these are going to come online and how quick they're going to be? 

Yes, by March next year.

By March next year. There we are. Well, we'll hold to that, Cabinet Secretary.

You're welcome to.

Thank you so much for taking all the questions. Is there anything you want to close with? 

I think it's been a very full discussion, Chair, so I don't have anything particular to add. 

Great. Thank you so much. As you're aware, there is obviously a transcript, which will be available to you all after. Can I just thank you once again for taking the time for such an important debate—I'm sure, clearly, you agree—and an important piece of work that we now can bring to a head? So, thanks very much. 

Thank you.

Colleagues, can I now move under Standing Order 17.42 to exclude the public for item 5 of today's meeting? Thank you.

Good afternoon and welcome back to the Health and Social Care Committee, and this afternoon we're starting off—. We're taking some evidence on the Employment Rights Bill, or the legislative consent memorandum associated with the Bill. And I'm really pleased that we have the Minister for Children and Social Care with us. Dawn, can I ask you to introduce yourselves? 

Yes, by all means. So, I'm Dawn Bowden. I'm the Minister for Children and Social Care, and to my right—

Laurie Haward. I'm head of social care workforce policy. 

Prynhawn da. My name's Stephen Layne and I'm deputy director for fair work. 

Great. Welcome, and thank you for making some time for us today. We have about half an hour, I think, so we've got a few questions to get through. We'll try to get through them all if we can, and I'll kick off. It's a general theme, really. I wonder if you can talk us through the reasons why the Government supports this Bill, particularly the amended provisions around fair pay agreements and the powers to establish a social care negotiating body. In your view, why should the Senedd support the proposals and give consent?

Okay, and I think those are very fair questions to start with. So, I think our starting point as a Welsh Government is that we actually fully support the introduction of the Employment Rights Bill. It's a very wide-ranging Bill, covering a lot of employment rights around flexible working, zero-hours contracts, statutory sick pay—I could go on. I think what we've seen is several years of the rolling back of employment rights, and this is the opportunity to see a new piece of legislation that is moving forward on employment rights. Fair pay agreements for social care is just one aspect of the Bill.

It is the Bill in its entirety that we support, but, specifically for the LCM, on the social care workforce, I think it's primarily because as a Welsh Government we've been striving to promote fair work in the social care workforce for many years, but what we have not had are the legislative levers on enforcement around the non-devolved elements of employment law. So, by being part of this legislation, that enables us to continue to do the work that we're doing here in Wales on the social care workforce in the devolved setting, but have the security of employment legislation that is underpinned by enforcement action.

Okay, thank you, Minister. Why are you content then for the UK Parliament to legislate for Wales? We recognise we need these tools. Why aren't we introducing it ourselves—the legislation ourselves?

There are a number of things around that, aren't there? In some respects, we have to be pragmatic about what is achievable, certainly in the time remaining in this Senedd term. But, more importantly, as I was just saying, although the Bill does have regard to devolved matters in that it will impact on social care, it is primarily a Bill that is making provision related to reserved matters, i.e. employment law. So, it is on that basis that we felt that the UK Bill offers the most coherent approach to what we are seeking to do in this area anyway, and underpinning that with legally enforceable rights. By presenting the LCM and hopefully getting the support of the Senedd, it will really enable us to make those provisions quickly and align and co-ordinate right the way across the UK.

Okay, thank you. Mabon.

Can I just check? What role did you or your officials play in developing the LCM and wording around that?

We've had ongoing discussions with the UK Government. Very early on, when the UK Government came into power, I had early meetings with the Minister, Stephen Kinnock, who is the Minister for adult social care in England. He had explained to us that they had proposals around adult social care, and what they were going to do in that area with the fair pay agreement. So, it was from those very early discussions that we then said, 'Well, really we need to have those provisions applicable in Wales as well.' The Scottish Government were making similar representations, that we didn't want to see social care workers and their pay and conditions diverging across the UK. You know only well that we've got a very long border with England. We have lots of cross-border working, and we wanted to ensure that there was consistency around the pay and conditions of our social care workers.

So, we started those discussions with the Minister very early on, and then my officials picked up the cudgel and started the ongoing discussions with UK Government officials, so that we got to a point where the UK Government agreed that both Wales and Scotland could be part of the fair pay agreement element of a wider UK Bill.

Okay. Can I draw your attention to clause 151, which states that the Secretary of State is provided with the power to make consequential provisions in relation to the Bill, which includes a Henry VIII power, and enables the Secretary of State to amend, repeal or revoke legislation that includes an Act or Measure of this Senedd. Do you think that's right?

That is the provision in the Bill, and that's what the consent aspects mean, as far as I understand. Now, you will appreciate I'm not a lawyer—I mean, Stephen may be able to give his views on that—but we were very well aware of what being part of this Bill would mean, and what agreeing to consent would mean. I think it's also worth me saying to the committee that we made it very clear to the UK Government that we didn't think this was a necessary provision, and we continue to have that conversation with them, that we don't think that it was necessary for them to have consent over this particular area, which is devolved. They did not agree with us. There was a lot of discussion between Welsh Government lawyers and UK Government lawyers to try to persuade them of our view, and, unfortunately, we could not persuade the UK Government of that view. So, I had to make a decision, in the end, along with my colleagues the Minister for Culture, Skills and Social Partnership, and the Counsel General, about what the greater benefit to the social care workforce would be.

Don't you think this undermines completely this Senedd and the Welsh Government, that you're allowing the Secretary of State in Westminster to overrule, essentially, decisions made by this Senedd?

No, not in this context, Mabon, because this context is really about underpinning legally enforceable conditions that we don't currently have the right to do ourselves, and we wouldn't have, if we didn't join this legislation. So, there is a recognition that this is quite a novel piece of legislation in that it will apply in an area of devolved competence. But the overriding concern that I have and, I think, more importantly, our stakeholders and our trade unions and employer representatives in social care, is that social care workers in Wales should not be disadvantaged by not being part of this legislation.

With regard to social care, the purpose of this Bill is to allow a body for Wales that would develop and agree fair pay agreements, right? 

Sure.

So, you can't do that yourself? 

We can, but they're not legally enforceable. That's the difference. What having a Wales negotiating body within the context of this legislation would enable us to do would be to legally enforce any agreements that are made within that body.

Now you will be aware, for instance—I'll give you an example of that—that, unlike in England, we have had, in Wales, the real living wage in social care for the last three years. Now, the real living wage is not an enforceable condition. The national minimum wage is, but the real living wage is a voluntary condition, and it's a voluntary agreement that we have, but we can't enforce that. Now, if we get to a point where we have a legally enforceable condition, as it would be under the fair pay agreement, underpinned with a competence that we don't currently have, because it's a reserved matter, we think that that is a huge benefit to the social care workforce.

So, it can be done in Wales, albeit it's not enforceable, but it can be done.

It is not enforceable.

But the note I have here notes that the power of the Welsh Minister to establish this new body can't be exercised without consent from the Secretary of State. Do you think that's acceptable?

It is what it is, Mabon. I mean, we don't agree that this should be the way that it is done. I've said that, and I can only repeat that. But I think you have to come to a position, at some point, about what is the greater good, and we believe that the greater good is to involve the social care workforce in Wales as part of this legislation so that we have legally enforceable rights in Wales. We don't believe it would be right to have those legally enforceable rights in Scotland and England and not have them in Wales.

Okay. So, just to confirm, then: the Welsh Government's own principles on UK legislation in devolved areas, your own document states that delegated powers, including Henry VIII powers in UK Bills in devolved areas, should be conferred on the Welsh Ministers alone. So, you're happy to ignore that, put that aside, and let the UK Government make decisions on behalf of Wales in areas that are devolved to Wales?

I am absolutely not saying that we have ignored that, Mabon; I think I've explained very, very clearly the very lengthy and detailed conversations that we have had at ministerial and official level to try to overcome this, and we have not, at this stage, been able to do that. But I still believe, and so do our trade union partners and our stakeholders believe, that the greater good here is that we will have legally enforceable employment rights in social care in Wales that we otherwise would not have. And we do not believe in the United Kingdom that we should have colleagues in Scotland and England finding themselves in a better position than they are in Wales.

Nurses in Scotland are being paid more than in Wales already. 

Come on in now then, James. And, Stephen, did you want to come in?

So, if that's a position you've come to and you're not happy with it, you could also try and amend the Bill in the House of Lords, couldn't you, if you really wanted to. So, you as a Government could instruct Welsh Labour peers up in the House of Lords to put amendments forward that are favourable towards—. So, it's something you could do, if you're not happy. Even though the UK Government don't agree with you, you could use mechanisms to do so.

Yes. There are potentially other options down the way. We are still in the early stages of this Bill. There are other options. I'll ask Stephen to say a little bit more about this in a moment, but there are other options. We also have written to the UK Government about a potential carve-out in the future, which I'll ask Stephen to explain, because, again, you'll take my point that I'm not a lawyer, and I kind of understand what carve-outs mean, but, Stephen, perhaps you could say a bit more about that.

Yes, sure. I just think it's worth picking up the points that both Mabon and James have made. We've made our objection to the kind of consent requirement. We've made that forcefully. We've made that point forcefully with the UK Government on several occasions, and that's been made at an official level, but also at a ministerial level. And we continue to make the point. So, as the Minister has just said, in recent days, we've sent a letter from Minister Sargeant to Minister Madders, who is the Minister who's piloting the Bill at the moment through Parliament, seeking a Schedule 7B carve-out. So, effectively, what that would enable is for the Senedd to remove the consent requirement at a later date. So, we're, obviously, awaiting a response to that letter, but we don't believe the consent requirement is necessary. We would wish that it wasn't there. We've made that point forcefully. But I think it's also worth emphasising that there isn't, at the moment, anywhere in the UK, a pre-existing law on sectoral agreements in social care. So, we are breaking new ground with this Bill and, effectively, it will establish a new legal framework that will allow sectoral agreements to be enforced. And that's very much new. So, there's an element here where we are just breaking new ground. But the point about the consent requirement, we absolutely agree, and we've made that point forcefully with the UK Government.

I'm going to move us on, because we've got very limited—. We're almost halfway through the session.

But it's—

I know, but there are some very important points. So, I think we've got the position. I think there's some concern around it. I think, at some point, we'd like to know why the UK Government is so adamant on their position, but I'm sure we could use the whole half an hour up talking on this one bit. Unless it's very short, James—.

My point is very short. If you don't get the carve-out, is it an option the Welsh Government would look at to put amendments through the House of Lords?

Well, I think that we would be open to any options that would deliver what we want to be delivered. The option of carve-out is about something for a future Senedd to look at. It is not something that we could do in this term of the Senedd to develop our own legislation. We just would not have the time. But a future Government may decide to develop legislation in this area, and then there would be the option of a carve-out if we can get agreement on that. But I think we've got to deal with what we've got in front of us right now.

Okay. Thank you for that. Thank you for the probing on that. Joyce.

What we've got in front of us, as you've just said, is groundbreaking, and it's legislation that allows enforcement of fair pay. So, to that end, can I ask you, Minister, what engagement you've had with the social care sector and the trade unions thus far on the proposals? What have their reactions been, particularly the care providers, the local authorities and the relevant stakeholders and trade unions in Wales?

Well, we are fortunate in Wales in that we already have well-established social partnership arrangements both with our trade unions and with employer representatives. So, we've got initiatives like the social care fair work forum, and the social care workforce partnership. That vehicle has enabled us to have regular updates with our stakeholders on progress, and the positive feedback that we've had from them has been one of the main factors in why we've decided to take the route that we have in terms of presenting this as an LCM, and seeking to be included in the legislation. It was very much the view of our stakeholders and our trade unions that we should do that. So, we have had very detailed conversations—as detailed as they can be, given the amount of information that we have got at this stage. But, as I say, our existing partnership arrangements really do put us in a strong position for engagement on this once we are in a position to fully proceed.

We understand the UK Government has set up working groups. You have already got, I believe, working groups with the sector and the representatives, including trade union providers. Are you going to agree a process before consultation on this Bill, and are you committing to consulting widely on the design of this fair pay agreement and its process?

The first thing I would say is we have not made formal progress on the work of setting up a negotiating body or setting up working groups here in Wales, because we think the right process here is to get the agreement of the Senedd first. So, once we have the agreement of the Senedd to proceed in the way that we are proposing to proceed, then we will look to proceed with the work around setting up the negotiating body and setting up working groups in the way that you've described. In England, they are already progressing with that work, but, as I say, that is because they are starting from a different position to us. They don't have any kind of mechanisms in place at all in England for anything like the kind of partnership arrangements that we have in Wales, so we are in a better place. But once we have got the approval of the Senedd, we will then be looking, through our existing partnership arrangements, as to how we can develop a negotiating body and any working groups that we will need to test out all of the things that are contained within the legislation and how we can best implement that here.

Have you got a timeline?

We haven't got a timeline yet because we've got to wait until the legislation has Royal Assent, and we don't know yet when that will be. We were expecting that we might have made progress, or that the UK Government would have made some more progress on this, before the summer recess, but, unfortunately, it's been delayed, so we are not likely—I think, Stephen, I'm right in saying this—to get any progress before summer.

Yes. The current timetable is that the Committee Stage in the Lords is taking much longer than initially anticipated, so some extra days have been added. Committee Stage in the Lords now will run through until 23 June. Initially, it was going to end on 10 June, so that's been extended. That will then, obviously, impact upon Report Stage, so it's unlikely that this Bill will clear all its stages before the summer recess. Latest thinking would indicate that it will achieve Royal Assent sometime in the early autumn. I think that is the plan, the timeline.

Okay.Thank you.

Thanks. James.

Sorry—

Oh, sorry. Did you want to—?

No, that's fine. Just to add that the officials are also on the UK Government working groups as well. So, we're with them in part of the discussions that they're having around this work, moving forward.

Thank you.

Thank you. James.

I have a question on the fair pay element, Minister. As you know, I have always been an advocate for paying our social care staff more. I think they are undervalued for the work that they do. This Bill is going to increase wages, and I am just interested in how the Government intends to fund that wage increase. Obviously, it is going to put a lot of pressure on local authorities, self-funders, independent small providers as well. I am just interested in whether the UK Government has made any sort of noise, from the Treasury or from Minister Kinnock, around whether the UK Government is going to send any more money down the M4, because they are bringing this Bill in, which is going to put a pressure on the Welsh Government.

Sure.

You would expect that there will be something coming through—I won't say through Barnett, because it is not really a Barnett-able thing, but whether that money is going to come down the line to the Welsh Government to pay for these rises.

Funding is absolutely a key element of this, and that is very much at the forefront of the discussions that we are having with the UK Government. Actually, stakeholders in England are having the same discussions with the UK Government, as are colleagues in Scotland. So, the UK Government is well aware that we need to have some clarity around the funding, but as this is a piece of UK legislation, we would very much be expecting the UK Government to be providing financial support for its implementation.

The issue that I think we have been able to negotiate in Wales that isn't applicable in England, of course, is that this agreement will also apply to children's social care as well as adult social care, and so that, again, features very much in the discussions that we're having with the UK Government, because it is the UK Government that have agreed that we can do this, that we can include children's social care. It's because we don't separate them in Wales. In England, they sit under separate departments, and so on. So, I can't give you an answer to that yet in terms of how much money the UK Government will be providing for this, but we fully expect and anticipate that this is a new piece of legislation that is about improving pay, and so we would be expecting the UK Government to fund that.

If they don't fund that, obviously the Welsh Government would probably—I'd hope—have done some impact assessments on what this will do to the sector. So, I'm just interested from your side of things—obviously, the Welsh Treasury has probably looked at this—how much additional money do you think this is going to cost? If the UK Government decide that they're not going to fund it, like they weren't going to fund the national insurance rises, how much extra money is this going to cost the Welsh Treasury every year, because that's obviously going to mean cuts in other areas, isn't it? As the ex-First Minister said, there's no more money to throw around. 

Absolutely, and it's a fair point, but we haven't done the assessments yet. That will be done. We've looked at the UK Government's impact assessments for the Bill, but we need to do more work on this specifically in Wales to see what the impact of that is. We understand the importance of testing and the potential implications, and we are committed to evaluating that before we lay any regulations. So, this is an ever-moving feast at the moment, but we just haven't got there yet. We're still in the relatively early stages. As I've said, we do believe that, through the existing relationships that we've got with our social partners, with our employers as well, there's a large amount of agreement here that we need to pursue this, for all the reasons that we've identified, and they will be very much part of our discussion around the impact assessment in this area. 

Thank you, Minister. We've got a couple of further sections to go, are you okay to give us another five minutes?

Yes. As I was a few minutes late, I think it's only fair. 

Thank you so much. Can I hand over to John, then, please?

The UK Government's impact assessment highlights that it would likely lead to higher costs for providers and then also through to local authorities. It also notes that smaller businesses are likely to be more exposed to those associated costs and consequences, which would possibly include lower profitability and potentially leaving the market. We know that the majority of providers in Wales are small businesses, so I think as a committee we'd be interested in what the Welsh Government's response is to these concerns and possible consequences, and how Welsh Government might support providers to mitigate that potential market instability.

The starting point, I think, in all of this is that there's also a cost to not doing this, to not improving employment rights and pay in this sector. We know, over the years, how difficult it has been to recruit and retain people within the sector. We've done a huge amount of work in this area already, but we still know that it is an enormous challenge to keep people in the sector and to recruit them in the first place, despite a number of initiatives right the way across Wales.

But we do accept, of course, that this also does present some challenges to employers. I've said in response to James that we are carefully going to be considering all of those potential impacts, but it is also important to highlight that providers that you talk about, particularly some of these small third- and private-sector providers, will have a seat at the negotiating table, and so they will be part of reaching the agreements that we will seek to secure with the social care workforce.

That same impact assessment also highlights that increased costs to providers are likely to result in increased prices for those who pay for their own care—the self-funders—and it then goes on to say that this may increase unmet need and reliance on unpaid carers. So, again, are these possibilities that you have at the forefront of your mind, and how would you protect self-funders and unpaid carers?

I think that is why the discussions with the UK Government around the funding of this legislation are going to be so important. We do understand the importance of how changes are going to impact on different parts of the sector, and that includes self-funders and unpaid carers, of course. So, as part of our ongoing engagement, the formal consultation that we'll be involved in, and all the subsequent analysis that we're going to be undertaking, we're going to have to carefully consider all the specific impacts on all of these groups. We give an absolute undertaking that we will be doing that, and as I say, that's why it's so important that we get early clarification from the UK Government about the budget and about funding for this, so that we can plan effectively and ensure that the proposals are both fair and sustainable going forward.

Of course, Minister, there is a difference between Wales and England, in that the fair pay agreement in Wales will include children's services. The additional cost for Wales with that inclusion of children's services is going to be significant. Have you made an assessment of what those additional costs are likely to be?

That will be part of our ongoing assessment—again, similar to the question I responded to from James Evans. In England, this is only applying to adult social care; in Wales, it will include adult and children's social care. But I think the important thing to say in relation to that is that children's services generally have higher vacancy rates, and there are better terms and conditions generally in adult social care than there are in children's social care, and that potentially could exacerbate the problem if we don't address the entirety of the children and adult social care. So, that was why it was a priority for us to include children's social care in that, recognising that what that may mean is that in future budgets, we might have to identify additional funding to cover the costs of children's social care. 

Just one further question from me, Cadeirydd. I just wonder, Minister, whether there are any other anticipated challenges or concerns that you've identified in relation to the social care negotiating body and fair pay agreements and how they work in Wales. Is there anything else that we haven't mentioned up to this point? 

I think we know what the risks and the challenges are. As I said in response to questions from Mabon earlier on, we are not happy about the consent arrangements, but we believe the bigger picture here is that the overall social care sector in Wales will be better served by this arrangement than they currently are, but it also does present a potential for a divergence of agreements across the three nations, and this is why we started off saying that we wanted to have a UK negotiating body, but the UK Government didn't want that—for obvious reasons, actually.

They didn't want that because what they didn't want to get involved in was policy area in devolved nations. So, their only interest is in the reserved matters, which is the employment-related matters, the employment law-related matters. So, that will be something that we are now talking to the UK Government around in the GB working group that's been established. On the GB working group, we have representatives from Wales, Scotland and England talking through how we can ensure that we don't have those divergences that we don't want to see and that wouldn't be beneficial in either Scotland, Wales or England either, actually. So, that work will be ongoing to, hopefully, prevent those unintended consequences.

Could you bear with us to take a couple more questions from Lesley Griffiths, and then we'll be closing?

Yes, indeed.

You just mentioned that the UK Government didn't want to get involved in policy and, obviously, we've got very ambitious plans for the social care sector here in Wales. So, could you tell us a bit about how you think this Bill will align with your vision and priorities for the sector and also give us an update on the latest wider developments in terms of actions focused on improving the sustainability of our social care workforce?

Thank you, Lesley. Yes, absolutely, and that is one of the key reasons why the Welsh Government is supporting the Bill, because it does align with our policies, it does align with what we're specifically trying to do and have been trying to do over a number of years now in relation to fair work and improving pay, terms and conditions.

Again, as I was saying in response to Mabon earlier, we have been able to do that to a large extent with things like the introduction of the real living wage, and we're trying to do it through the social partnership forum with the third sector, looking at introducing some kind of commonality around procedures, grievance, discipline, maybe trade union recognition and so on. But none of that is underpinned legally because the employment rights elements all sit with the UK Government. So, it will put on a legal footing the kind of things that we've been trying to do not on an illegal footing but on an informal footing in Wales. I think that that is absolutely clear. 

From our point of view, strengthening the social care workforce remains an absolute priority. I've talked to the committee about this several times and I've been questioned on this several times about what are we doing to support the social care workforce, to improve the pay, terms and conditions of the social care workforce, to ensure that we can recruit and retain. We see this as absolutely a vehicle that will enable us to do that.

Can you explain how you're going to be monitoring the effectiveness of the regulations? Obviously, they will need to be monitored in making sure that they do exactly what you just said and improve that stability, particularly in the social care sector.

Absolutely. We will be proposing to ensure that there is robust monitoring and evaluation undertaken and that will be done as part of the discussions for the establishment of the negotiating bodies once it's developed. 

Is there anything else you want to add that you feel we haven't asked you about?

I think just to reiterate that our starting point here is the value that we place on the social care workforce. This is now providing us with an opportunity to do something that has been the ambition of the Welsh Government for a long time. I do understand the constitutional concerns, I absolutely do, but I think my overriding concern is to ensure that we have a fair pay agreement for social care workers in Wales in the same way that they will in England and Scotland.