Cynulliad Cenedlaethol Cymru

Good morning and welcome to the Health and Social Care Committee this morning. Thank you for attending on such a grim and wet day. This meeting will be bilingual, and there is simultaneous translation from Welsh to English available. Can I ask Members if there are any declarations of interest? No, I see there are none. If you find any as we go through, please declare them.

We are here today for our final evidence session to inform our inquiry into the future of general practice. And it's a great pleasure to have Cabinet Secretary Jeremy Miles with us today. Cabinet Secretary, would you like to formally introduce yourself and your colleagues?

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

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

Good morning. Paul Casey, deputy director for primary and community care. 

Well, thanks again for coming along. This has been a really important inquiry for us, and this session is absolutely fundamental to our work. We have several questions to ask you, and perhaps I'll kick off, looking at strategic vision and system transformation.

Now, reading your evidence paper, there's quite a lot around a major community-by-design information programme, which was interesting, and it's aimed at shifting care out of hospitals into community settings. That's great, that's the sort of thing I'm sure everybody would like to see. But could you, Cabinet Secretary, explain what the programme involves, what changes patients and clinicians can expect to see in general practice and wider primary care, and what would the timescales be for the delivery of that?

Thank you, Chair. So, the current system that we operate can best be summarised by the term 'hospital by default', effectively. So, we provide care in the most expensive and least convenient, from a patient part of view, part of our health system. So, the policy consensus has been for a long time—not just in Wales, but practically everywhere—that what we need to do is make sure that services are more readily available in primary care settings and in community settings as well. So, the direction of travel is obviously very clear. And we've had some success in that, obviously, over the years, but not the scale of success that I think everybody everywhere wants to see. And I don't limit myself to Wales; I think that's a general challenge. So, what this programme is designed to do is to turbocharge that policy commitment and to be programmatic and systematic about how we move more services out of secondary care into primary care and community settings. 

So, we had a recent summit, which was very successful. It was widely supported by the health board chief executives and the NHS more broadly. The programme is led clinically by the chief medical officer, and I think that's very important, because one of the things that we need to be able to do is speak with credibility and authority with other clinicians about the benefits of doing this. So, I think having it clinically led is actually a very important part of the approach. And so it's how we make those preventative services, population health services, proactive services more readily available in the community. So, I expect to see services such as phlebotomy, spirometry, minor skin surgery shifted out of hospitals and into communities. 

The mechanism, or one of the mechanisms, for doing part of this work is through what we're calling a 'CDSS', a collaborative directed supplementary service, which is a means by which health boards can and will be required to commission services of this sort from primary care clusters. So, that will be one of the mechanisms for delivering the outcomes, and we think that is beneficial from a patient point of view, but it's also beneficial from the point of view of the resilience of primary care services, because it provides longer term visibility about the resources that are made available to primary care, and it provides confidence that, as well as shifting funding, if I can describe it in that way, from secondary into primary—which is, I know, a thing the committee is interested in and something I'm interested in—it also means that activity. That's the critical thing: how we can get activity moving out of hospitals into primary care as well. So, that's essentially what it's about.

The board has been established. I expect it to meet for the first time before Christmas. We will not be seeing the results of this within weeks—it's obviously a significant piece of work—but I would expect to see progress within the next year. So, what I want to see is that the work starts immediately of moving at least the things that are most practically able to be moved out of hospitals pretty quickly.

Okay. So, you've given us an indication of the mechanism that is going to happen. How will general practice be supported? Because we've heard a lot from general practice how they're really up against it at the moment; in fact, they're struggling to retain things in the community setting and they're shovelling more stuff into secondary care. So, how will they be supported through this process of transition?

Well, the reason that's happening is because they're facing funding pressures in being able to deliver those services. So, what this mechanism will provide is a solution to both those challenges. So, my reflection as health Minister is that often you're faced with challenges where the strategy, or the direction of travel, the policy that you want to try and bring about, is pushing in one direction, and the funding pressures are pushing in the opposite direction. That's quite a common challenge for Ministers in all portfolios, frankly. This feels to me like one of those areas where, actually, those two things are pushing in the same direction, because what we want to see from a policy point of view is more of these services delivered locally to people. And also what we want to see is more funding being moved into primary care, because we know, given the point you've just made, that there are incredible pressures there. So, I think this is a golden opportunity, if you like, to align those, and we've got to make sure we deliver it.

So, there's a range of things happening at a local level, but also a national programme to drive this as well, engaging health boards and practitioners directly as well. And there'll be clear metrics, clear performance indicators, in the way that committees often press us to put in place, and we'll be publishing those as well. So, it'll be a transparent process as well, which I think is really important.

So, there will actually be more money going into that primary care to enable this transformation, and that's obviously coming from somewhere else—

It is coming from somewhere else, yes.

That's clear. That has to happen. We'll talk a bit more about finance later. But GP practices can be assured that this transformation will be funded.

Yes, absolutely. I mean, it won't happen if there's not sufficient resource to support it, so that will have to happen.

That's great. Thanks for that. I know prevention is also a central theme. We hear it in your evidence—there's a lot to talk about prevention, and virtually everybody we've talked to so far feels that prevention is fundamental. So, what steps is the Welsh Government taking to support general practice to deliver that preventative role, and how will this be embedded into future service models and funding arrangements? I suppose that's absolutely linked to what you were just saying.

Part of it is definitely linked to it, Chair. Health boards already commission preventative activity, obviously, from GP practices, so smoking cessation, vaccinations, blood pressure, those sorts of things. And the model that I've just described to you—that collaborative directed supplementary service model—is a means of commissioning at a cluster level, essentially, and that then provides the mechanism for more, as we call them, preventative bundles to be developed at a cluster level, based on population health management data that we have, so that we can move diabetes management, for example, into the community, and other chronic condition management, but also purely preventative activity. So, that part of it is what I've said to you now, but there are other things that we're doing in this space. We have an out-patient waiting list scheme, which is how we support GPs to be looking at patients who are on a waiting list, waiting for an out-patient appointment, just to make sure that that is still the best thing for that particular patient with their condition, and if it's not, that they're supported to have the care they need in a primary or community setting. We have a frailty directed supplementary service, which is specific, obviously, to patients with frailty. Again, that provides cluster-level support to patients in that space. And I think the common thread with these mechanisms, Chair, is that they deliver the outcome, but they also provide visibility to practices about the level of activity that can come over and the income, from their point of view, that will come with that, which I know from the evidence that you've received and I know independently in any event is often a challenge for practices.

Yes. Okay, thanks for that. One of the other key messages we've heard from so many angles through this inquiry is the challenge for primary care and GPs to get a strong voice, to get a voice into strategic direction, national policy creation and things like that. I wonder what steps you might be taking, or thinking of taking, to strengthen that, to put that right, because it's clearly an issue for a lot of people. And would you support the introduction of dedicated executive leadership roles at health board level to ensure that general practice is fully represented in all of that?

Well, when we started thinking through the transformation programme over the last few months, one of the challenges that health boards were saying to us we might encounter is the capacity at general practice level to engage with something like this. Bluntly, GP partners are feeling the pressure, obviously, as we all know, and so where do you find that extra headspace, really, to engage with something like this? And it's not a new priority, so people may feel, 'Well, we've been trying to do this for a while.' So, there are those practical things that you're trying to resolve as well. So, in the way that we've put together the governance of the transformation programme, those are things we're seeking to address by having clinical engagement, but also there's a set of negotiations, isn't there, an annual set of negotiations that will support some of this work, which happens in a different space, so trying to align that, really, in a way that makes it streamlined and mutually supporting, if you like, that whole set of activities.

But the point you're making about how do we make sure that the voice of GPs—but not, if I may say, only GPs, but primary care practitioners more broadly, that really is what I think we're talking about. How do we make sure that those voices are heard more loudly? So, we already have mechanisms for cluster-level leadership to feed into the health board planning cycle in their integrated medium-term plan planning cycle. There's a connection point there. We have regulations already, actually, which require every health board to appoint a voting member that is responsible for primary care, mental health and community services. So, that is already a requirement and all health boards are complying with it. It’s sometimes the medical director, but it varies across different health boards. And specifically, you will know, I think, that vice-chairs are particularly tasked with representing the voice of primary and community services in board deliberation. So, the regulations are in place, vice-chairs have a particular responsibility. So, bluntly speaking, if there isn't sufficient focus at a health board level in board discussions on primary and community care, the first port of call is to engage with vice-chairs and say, 'Well, what are you doing to make sure that the voice of primary is being heard more completely at that level?'

I think there's a shift, if I may say, Chair—and I don't think that this is an unfair point to make—that is required in how health boards think about where they prioritise their efforts. Perhaps understandably, a huge amount of focus goes on secondary care because we know what happens in hospitals, we know how critical it is that they function well and we understand the pressures that are very real. And often health board executives have more experience of a secondary care setting, bluntly. But really, in a rational system, you would say that since most people's experience of the NHS is, in fact, in the primary care space most of the time, that is where you should start your planning. So, it's about making that shift.

So, it sounds like there should be already the structures within the health boards to engage properly. But, clearly, from what we've heard today, that isn't working. So, would you rule out that dedicated executive leadership role, or would it be something you'd encourage health boards to perhaps think about putting in?

Well, the regulations require there to be somebody, a voting member of the board, in any event, who's responsible for primary care. I guess that one of the challenges, to be candid, is what we want to make sure is that what is represented at the planning levels in health boards is the voice of primary care, rather than specifically individual elements of primary care, and striking that balance, as you can understand, is challenging, isn't it?

I see that. So, they need to make sure that the systems that are in place are working better, if there's something wrong there. James, did you want to come in on that?

Yes, just really quickly on that point, we have heard from GPs and partners that they don't feel represented at health board level. I totally get the point that it does sit with someone, it can sit with a medical director at the board or, say, with an independent member, which is normally the vice-chair. If the GPs and partners don't feel like they're being represented properly by those people on the board, where can they go to say to Welsh Government, 'Well, we've got these concerns, the health board are simply not listening to us'? I hate the word 'institutionalised', but some of them have become institutionalised, they're listening to perhaps other executives in the health board, not the GPs. What sort of avenues can they go down to try and get their way through the treacle, so to speak?

Well, I wouldn't use the word 'institutionalised', but there is a set of behaviours, isn't there, which develop over time, which one would recognise. So, the transformation programme, really, is intended to make sure that, in order to deliver on the policy ambitions that we've got, the voices of primary care practitioners are heard more clearly. So, this is one of the things that we want to solve as part of that transformation programme. I do recognise the point that you've made. I think most GP partners would also say to you, 'I wouldn't know where I'd find the time to engage', as well. So, there are complex challenges here, which we're trying to resolve.

Okay, thank you. Joyce.

One of the biggest challenges that we're hearing about from our constituents is things moving in the opposite direction: GPs actually pushing people towards secondary care, mainly A&E, constantly. And there seems to be almost a tension between those two elements, where A&E are overwhelmed and unable to cope and feel that the GPs could have coped, and the GPs saying that they can't cope and pushing it. So, part of this has to be resolving that, if you're going to do the right thing.

I think so, yes. Clearly, people shouldn't be being directed to A&E unless they've got an emergency requirement. To be clear, GPs oughtn't to be doing that, if they are. However, there are challenges that GPs are often facing as well: the pressure of demand, how they manage access for patients, how you get, frankly, a better balance between meeting the needs of patients whose needs may not be urgent, but are complex and require a level of continuity of care—so, we're doing some things in that space—and, on the other hand, people who are coming in with an urgent need. So, getting that balance right for a GP practice can be challenging when demand is rising generally.

So, there are lots of things we're trying to do to support practices. So, we've got a quality improvement approach around continuity of care, which supports GP practices to identify those patients where, because they're managing more than one chronic condition, or because their needs are particularly complex or they're frail or whatever, they're a defined cohort, if you like, so they can provide increasingly more continuity for those patients. What we know is that even small amounts of gain in terms of continuity can make a really big difference, mainly for the patient, but also for the system. So, the prize of getting that right is important. And on the other hand, we're piloting urgent primary care centres, which are a means of dealing with the needs of urgent patients slightly differently. So, there are initiatives under way to try and resolve some of that.

Can I ask Lesley to come in?

Thank you, Chair. Good morning. I want to look at funding and contracts. So, it's really good to hear you saying that we need to get that activity from secondary care into primary care. At the moment, the money goes to secondary care, predominantly. It's completely transposed, really, the number of contacts in primary and secondary and the way the funding goes. So, it's really good to hear you saying that you want to align this and get more activity into primary care. But what we're hearing from GPs is that their funding pot has been dwindling over the years. And so how are they going to become sustainable, unless the money—? The money needs to go first, before—. You were talking about phlebotomy, dermatology, coming out of hospitals. So, how are you going to make sure that that happens, so that our GP practices are sustainable?

Okay. Well, firstly to say I do recognise that the proportion of spend on primary care has reduced over the last 15, 20 years, maybe, so I absolutely recognise that, and I also recognise the need, that that needs to be reversed. So, just to be to be clear, there's no debate, I think, about that in practice; the question is how you do that.

So, I would just say, though, two things, if I may, on the context for what you've just said. A reducing percentage is not the same as a reducing budget, and actually what, in practice, has happened, because of significant additional investment that we've made to the NHS overall, is most of that investment has gone into secondary care and therefore the percentages have changed in the way that we've just been discussing. And to be clear the reason for that is because much of the spend in the NHS is on staffing and the overwhelming body of staffing is in the secondary space. So, those are the dynamics at play. I think it's helpful to bear that in mind, because this is not a deliberate choice of any Government to reduce that percentage; it's the product of those features, if you like.

So, what can we do about it? There are a number of ways to address that: firstly, to have a clear path, if you like, to move that activity over, and for funding to follow. So, partly that's about your GMS funding, but it's also about that additional income stream that comes from the kind of commissioned approach I've just been talking about, those additional services commissioned at a cluster level, and there are other things as well. So, we provide support through lease payments, through business rates relief, through improvement grants. So, there's a range of different ways we are doing that.

One of the practical challenges that we will face is, unsurprisingly, it's not possible simply to turn off activity in secondary overnight and for it to appear the next morning in primary care, obviously. So, there's a transition arrangement that will need to be agreed and there's going to be an element of double funding for some time, which is an extra pressure on budgets, but it obviously is an issue. But I think the fundamental point is the funding will need to move from a secondary space into a primary space. That's the journey that needs to happen. The Chair was saying there will be choices that mean that that comes from somewhere else, and the truth is, it will come from somewhere else, but that's because the activity is moving.

So, just on that point, do you think health boards are ready to do that?

Well, I think they face a number of challenges. Many of them face very, very, very significant funding pressures, obviously. But what I think we've detected from the transformation board work so far is a recognition that this has to happen, and that we need to find a way to make this front and centre for every health board's concerns. The current model is simply not sustainable. It isn't sustainable, and the funding required to make a model such as we have today sustainable is not funding that is realistically available to any Government anywhere in the foreseeable future. It's also not delivering the best outcomes, so that's why we have to make the change and I think there's a realisation that we have reached that point, that it now needs to be front and centre.

I think that's really encouraging, because, certainly, from the GPs we've heard, they absolutely recognise it. I think, in my discussions with the health board, it's secondary care that perhaps are a bit more protective of their budget, don't recognise it at the level that GPs do. So, I'm sure GPs will be very pleased to hear you saying that.

The other thing is around the Carr-Hill formula, which I think is widely recognised as being outdated, and we heard from the BMA that there had been discussions at Welsh Government level with them about a possible review. Will there be a review, and, if so, within what timescale?

So, it is it is a live item in the discussions with GPs, just to confirm that, and so I think a review would be a useful thing for us to do. I should be clear: it obviously won't be a panacea, because, in any review, there are always people who gain and some people who lose out, and that isn't always straightforward. There are practices that have pockets of deprivation in communities that otherwise aren't especially deprived and will also face particular challenges in serving the needs of that population. So, it is actually quite complex, but it is one of the things we're discussing. It won't be an—. This kind of a review takes some time to undertake, so I can't give you details of it, because it's one of the items that we're discussing with GPs, but there will be extensive stakeholder consultation.

Good. I think the BMA themselves recognise that it wouldn't be a panacea, it would be a tool in a very large toolbox, but I think it's important stakeholders, obviously, are involved, and it's good what you're saying about consultation. We took some evidence around annual contracts, and I've also spoken to a GP practice in my own constituency who feel that, if they had a multi-year contract, it would be much more helpful. So, if they think, 'Oh, we need another advanced nurse practitioner or a physiotherapist,' they would be able to then employ that person, but, because it's on an annual contract, it's not easy to do. I appreciate Welsh Government's budget is not always multi-year, so it's very difficult to give health services multi-year, but also—. Again, it was actually somebody who gave us evidence, but they're from a practice in my constituency; they're concerned about how late the funding comes in in the financial year. So, I wonder if you could say a bit more about annual contracts and why that funding sometimes doesn't come in til month 10.

Okay. Well, I think there are a few things at play here. Obviously, Welsh Government's budgets are set generally on a year-by-year basis, and that is an important factor, but, obviously it's not the only factor, because we understand that there'll be an NHS in two or three years' time, so we need to provide on that basis. So, in a sense, that is important, but it's not the end of the story. My own view is that I think there are merits in agreeing multi-year deals if you can. They're very hard to agree, but they do provide the benefit of visibility, obviously. I think, where they've been attempted elsewhere, they haven't always succeeded, but I think the reasons for that are ones we could learn from, if I can put it like that. So, I think there has been evidence elsewhere in the past of those agreements being a little rigid and not able to respond to changing requirements, and then they've been challenging. If you can get a mechanism that provides visibility and some level of flexibility to be able to respond to different circumstances, then I think that will be a good thing to aim for, but they're quite—you know, they're not straightforward to negotiate.

Okay. What do you think about the BMA's suggestion about decoupling GP pay? They were quite firm about if you took GPs' pay from the annual contract negotiation process—. So, I was just wondering if you have any views on that and if any work's been done around the possibility of it being done.

Sorry, I should have addressed the second point in your first question. The point about late payment, I think, is linked to the fact that pay is part of a larger negotiation. I guess it depends on which way you think it's going to be sequenced, doesn't it, as to whether you think it's a good thing or a bad thing from a GP's point of view. I wouldn't expect to negotiate with GPs and say, 'This is the level of service we expect from you this year,' without giving some clarity on pay. I'm assuming the BMA think it would be the other way around, but I think there is a link between the two. We have a model that is an independent contractor model, largely, and inherent in that model, I'm afraid, is an element of negotiating around a contract. So, if we didn't have that arm's-length independent provider arrangement, then I suppose this might be something, but I think it's pretty inherent in that arrangement.

And then, just finally, you've talked quite a bit in your answers to the Chair's questions about the cluster-led innovations. I think we've picked up quite a lot of frustration around this. So, you get a really good scheme—you mentioned yourself reducing diabetes, smoking cessation—then suddenly that funding is stopped, or, again, it's a one-year pot of money and all that good work that's been done is then lost—well, not to the patients who've had it, but the intelligence and the data and the way of working are lost. So, what can we do, do you think, to support cluster-led practice? Because I think it's been really, really successful, certainly in my own constituency. So, what more can you do to help them ensure that any innovation that does come through is sustainable, is sustained and isn't lost?

Well, that's really what we're trying to achieve with the model that I was describing earlier. I think the most sustainable, resilient way of delivering that shift into primary and community services is through a commissioning model at a cluster level, which, obviously, addresses a larger footprint but also ought to be more resilient. If we can get that model right, then that does mean you've got multi-year funding, which would be for more than one year. And it does provide, and I think this is really important—. One of the things we're working through with that model at the moment is how we can have very clear criteria for understanding what service would go into it, is it working in the way that we hope it will, and if it isn't working how that comes out of it, so that we're identifying what the innovations are that work and that they then are baked in, if you like, into that model. That's what we're hoping to achieve with that.

Do you think there's some good sharing of best practice at a cluster level? 

Yes, I think there is. What you see in well-functioning clusters—I think they're each different, aren't they—but I think, in a well-functioning cluster model, you have the collaboratives driving activity represented at a cluster level and then that engaging properly with the health board. That's what we want to see and we do see that. It isn't true everywhere, I should say, but it is in the system. 

Okay. Thank you.

Thank you, Lesley. James, did you want to come in on that? 

Yes, just really quickly around protecting the funding that goes into these clusters, as well, because it, obviously, will be contracted out by the health boards via some contractual arrangement. A lot of them, especially the health board within my area, are under financial pressure, and I'm just interested, as we're asking them to take up more pressure from secondary care, in how we can make sure that that money is protected that goes into GPs, and that, actually, the health boards don't, in their budget deliberations, think, 'Well, I tell you what, we'll start cutting a bit of that money away to try and save money', because you're robbing Peter to pay Paul in one respect then. I want to know how the Welsh Government will make sure that that money is protected and is not being cut away by health boards to save the budget elsewhere.

Well, we already are able to do that and do do it. So, we have a mechanism for ring-fencing elements of primary care spend, so they are ring-fenced for that purpose. And there are also mechanisms that we have used already to direct health boards to commission services using that funding. So, the frailty—I think I'm right in saying—supplementary service is basically done on that basis. We've directed health boards that they need to commission using this framework and the funding follows it. So, there are protections in the system for that.

Okay. Thank you.

Can I bring Mabon in, please?

Diolch, Mabon. Could I invite John Griffiths in, please?

Diolch, Cadeirydd. Some questions on models of primary care practice, building on what you've already said, really, Cabinet Secretary. First of all, as far as GPs are concerned, do you view that independent contractor model as the model that we'll see in Wales as we move forward, predominantly?

I think, predominantly, yes. We will all have experience of this in our constituency roles, I'm sure. It's a model that is very good at being effective, being cost-effective, and encouraging innovation. GPs are always thinking of different ways of doing more and providing a range of services, despite the challenges that we've been discussing. So, I think that those are all good things that we want to encourage. So, I really want to make sure that the model is is accessible and effective from a patient point of view, but also attractive from the point of view of GPs. We've been talking about some of the challenges already, so I think that's really important.

I don't think that it's the only model. It's definitely not the only viable model. We see everywhere, in all parts of Wales, managed practices, where health boards are managing them, or federated practices where different practices are coming together. So, I definitely don't think it's the only model, but I think it is the predominant model and will continue to be, and we need to make sure that it continues to be attractive for that reason.

In terms of needing to ensure that it continues to be attractive, Cabinet Secretary, we've heard evidence around the financial pressures and workforce pressures that the independent contractor model faces, and you'll be very familiar with that, I'm sure, and some of the young doctors' views of what they see as the risk of becoming a partner within that model—too risky, basically. So, as it's your preferred model predominantly going forward, have you done much work on its sustainability to ensure that it can continue to be the predominant deliverer of these services in Wales?

Well, some of the things we talked about this morning are intended to improve the sustainability of it: so, more funding going through GMS, additional income coming through the commissioned supplementary services model, generally at a cluster level, but not, I think, always. But then there are a range of other elements of support that we already provide. We've talked a little bit about estates now, haven't we? So, I think, if you look at the tax returns for GPs, you'll see—. We've worked out the level of investment that we make in estates based on what indication that tells us about the level of spend that practices need to make. We try and calibrate our investments in that way, but also lease reimbursement, no—[Inaudible.]—costs, business rate support, the improvement grant that we were just talking about. We've got a piece of work under way already, which is around how we can—. We're reviewing how we can recast the regulations that support this work to make that level of funding more flexible, more useful from a GP perspective. So, there are always ways of trying to address some of those risks. The fundamental point is, in an independent contractor model, there is an element of risk that is inevitable and inherent. We need to make sure that the rewards of practice are also in balance with the risks. Obviously, that's the challenge.

Okay, thank you for that. You mentioned health board managed practices, Cabinet Secretary—obviously, they're part of the provision. Do you see those as, essentially, temporary solutions to problems with the independent contractor model, or do they have a more long-term and general role?

I think I'd describe it as a mixed economy, really. I don't think we should be saying, 'Oh, look, here is a problem that we're trying to solve', and if we haven't solved it through independent practice then that's a failure of the system. I don't think we're in that world anymore. I think, perhaps, in the past, we felt like that. But there are many advantages to managed practices. It's perhaps more easy to integrate some aspects into the broader offer of the NHS. We know that, with a particular approach, you can manage the same level of continuity of care as you can get in an independent model, and they provide excellent care; I've got ones in my own constituency. So, I don't think I would say it's a temporary element. Some will be, obviously. Some will be using it as a means of stabilising a practice and reintroducing it to an independent contractor model, but others will recognise, perhaps, the challenge in recruitment to particular geographic areas. So, I think it's part of a mixed economy, really.

James.

Just going back, Cabinet Secretary, to GP partners, I think the health boards and GPs said that's a model they prefer to use—that's where they want to stay. But what we've heard, and what I've heard from GPs and partners in my own constituency, is that I think some of the people coming through the system don't quite understand what becoming a partner really means, around the elements of you've then got to become an HR specialist, someone who manages the estates of the GP practice, an accountant, and sometimes they're not given support to be able to pick up those functions. I'm just interested how you bake that into training and support networks to try and encourage more GPs, as they go through training. If they do become a partner, they will be expected to do these other things, because it is running your own business, isn't it?

I think that's actually a very interesting point. I was a lawyer in a previous life, and we see, not just in Wales, in different parts of the UK, especially legal aid practices, where they're facing some of the same funding challenges, that people are less attracted to that model, frankly. So, I think it's not specific to health; I think it's a broader problem than that. I was talking to a dental practice in Cardiff recently about how they would go about making the changes that the new contract requires, and those are business changes and management changes as well as patient-facing changes, so they're quite complex challenges. But, Alex, can I ask you to give a bit of information on that?

Diolch. In terms of the support, whilst they're trainees, there are a number of conversations that take place in terms of the portfolio options, given it's quite attractive to have a range of different career paths now, which reflects, I suppose, the shift in the risk and reward balance of being just solely a partner. Lots of GP trainees take salaried roles, with a lower risk, to integrate them into the system, and part of the training model is to integrate them into various settings so that they have dedicated time in those independent arenas.

I think the other part for me is—. So, the British Medical Association have a training model to support their members, and they have conversations about what those options look like, and specifically on the kind of points you make on accountancy, HR support, in terms of that practical advice, (a) they provide some of that advice to their members, but also they advise them in terms of what they need to understand in terms of that risk that they're taking. But we're definitely seeing a shift in terms of fewer people wanting to take on full-time partnership very early in their careers, because of the range of options in terms of how the system works and operates. We're trying to make sure that we support those portfolio careers so that these are not, I suppose, siloed choices, in terms of people making a choice that we would have seen perhaps 40 years ago, where you were a GP partner for 40 years. That is a less attractive proposition now, so we need to support the various avenues that people want to pursue.

Could I come back quickly on that? But my view is: how could that be baked in? GP training is very medically focused. These things aren't put in. I know some GPs, I’ve got a couple of friends who are GPs, and they're not members of the BMA either, so they don't get that support. So, I just wonder, as you were previously the education Minister as well, how you can bake some of this stuff into the training model as a module that some people could potentially take, whether it's a short module or not, just as a brief overview of these services and how you would manage them so it's actually part of the initial training, so people, when they get into GP practice and they say, ‘Would you like to become a partner?’ they're already aware of some of the obligations and things they'd have to do when they get there.

Yes, I think it's an important point. I think there's also a role in the work that we do in identifying the support that practices need to have a direct conversation with practice managers as well—I'm speaking tomorrow at a conference with practice managers—because I think there's a slightly different perspective that comes from those conversations, actually. So, having that hands-on management experience in a practice will give you a different context for some of the choices that we need to make.

John.

In terms of oversight and sustainability of general practice contracts, I wonder if anything in particular is happening at the moment, Cabinet Secretary, particularly in light of concerns around remote management and the eHarley Street example?

Yes, well, we will all remember that situation. I think what the experience of that situation has illustrated—. And I've said, I think, in the Chamber that we've been doing a piece of work internally to look at whether, in light of that experience, there needs to be any change to the contract or change to the quite extensive guidance that goes with the contract. Do we need to do anything in that space to reform it? And I'm open to doing that if we do, by the way. I'm not at all precious. We need to make sure that the arrangements we have clearly enable health boards to manage practices in the right way.

So, there is a piece of work, I should say, which is a sort of lessons learnt piece of activity, which both the Aneurin Bevan health board and others are doing for us, and we will take that into account before reaching a final view. But I think a fair description of where we are is that the contract assurance framework, which is the accompanying arrangements around the contract, does provide quite a lot of intervention powers for health boards already. So, the question, really, is: can they be used more proactively, frankly? So, things around due diligence, but also compliance visits every—. Well, you can do them up to three times a year on the current contract, and they're being used in Aneurin Bevan health board now for that purpose. Escalation mechanisms, action plans, breach notices, no-notice inspections—there’s a range of things already that are available to health boards. We've taken some legal advice on some of this as well, because it's quite a technical area. The thrust of that, basically, is to say, 'Well, if the current mechanisms in the contract were used as purposefully as they can be, then the oversight questions can be addressed.' But when that lessons learnt work comes back, I've got an open mind, and if that suggests we should be making changes then we'll look at that, certainly.

Okay. Thank you for that. Dispensing practices—we heard concerns regarding their long-term sustainability, including the lack of a Wales-specific contract to support them. So, we'd be interested, I think, Cabinet Secretary, to hear from you as to what work Welsh Government is doing just to understand those particular concerns and issues, which I think are particularly relevant to rural practices.

Yes, they are. And just to recognise, there are parts of my constituency, and many of us will represent areas, where this is a particular issue, and I do recognise the challenge that is being described. So, there are particular challenges, particularly in rural areas, where the mechanism by which dispensing doctors are remunerated can be a challenge. As prescription intervals are extended, that means less activity and therefore less income in that sense, and I think it's true to say the payment has been frozen for quite some time as well. So, there are definitely challenges that I would recognise, and I do recognise that that can cause real pressures.

Again, as with the point that was made earlier in relation to Carr-Hill, this is one of the live items in discussions around GMS. We're looking at what options there might be for reform. Currently, it's tied, essentially, into an English model. Can we do things differently in a way that addresses some of these issues? Are there better alternatives that reflect the challenges that sometimes come with rurality, where populations are less dense? Can we do something in that space? So, just to give you the reassurance, that is actively under consideration at the moment, and I do recognise the challenge that you've been told about.

Okay. Diolch yn fawr. 

Just picking up on one of your earlier points, John, Cabinet Secretary, you talked about that there's a piece of work about lessons being learned. Have you got any time frames around when that might be fed back to us or available?

The piece of work is being done at the moment within the health board. That piece of work will go through its audit committee and then go to its board. Once it's passed through those governance procedures, then we'll receive a copy. Then we can take forward the further work that the Cabinet Secretary was talking about as to how we would go about in terms of whether there's any response that we need to make to the contracts or the assurance frameworks in order to respond to what that lessons learned exercise tells us.

Okay. Thanks for that clarity. Thank you, John. Can I move on and invite Joyce in, please?

There's just one final area, and, if you can't answer it now, we'll have it in writing. GPs did tell us that they take part in research programmes to deliver better care, and that they're now being squeezed with everything else that they're trying to achieve and that they would like to see some ease in that situation so that they can continue with their research. Just to say, if you haven't got an answer now, it would be useful for us to have it in writing, because it was an issue that came up. It didn't come up consistently. It came up with some of those aligned to that programme, I suppose.

But my question area is going to be the infrastructure and digital transformation. What, really, GPs want to know is whether there is a clear, up-to-date national strategy so that primary care estates in Wales will know if they're going to get any capital investment in infrastructure, particularly if you're trying to prioritise, which is pretty clear, that there should be support, care, close to home.

Yes. So, we have—. I'm just checking for the figures here. We invest about £140 million—. Sorry. We invest about £40 million a year into general practice estate premises, and our analysis suggests that premises costs make up just under 11 per cent of total practice expenses. So, those figures are broadly consistent with that level of demand in the system. So, that's the funding commitment that's already in place. There are two things happening in this space: firstly, the review of how we support practices with their estates generally, which is a task-and-finish project that I've just had some advice on recently. So, that's coming to a head now, which is very positive. And there are definitely opportunities there around how we can be more flexible, how we can address some of the points that Mabon was asking about in relation to MDT footprint and so on. So, there are good things in that review.

And then, separately, there's the integration and rebalancing capital fund programme, which is the system that we have for investing in new estates. Basically, that's worth about £70 million a year. I'm opening one in John's constituency tomorrow. There are about 38 of those projects, I think, across Wales. So, that is the programme for new estates. And in relation to investment in the current estate, we have published guidelines in this space, which talk about the criteria that we use in order to deploy the IRCF fund, which is available to all health boards, which tells them what they need to be able to describe in bids for that funding, in order to be able to get the support that they will want: so, moving away from single-partner GMS models, separating unscheduled and urgent primary care—a range of different criteria, which are public.

So, you said that the review is coming to a head and so when are you looking at a time frame where you can inform us about that review? People particularly want to know about some clarity on the minimum standards that are expected of them—and that, clearly, will be part of that review—so that they can then meet the service expectations that we're hoping they will be able to meet.

Yes. So, you're right, the minimum standards will be part of that review, and the review will be published in time for the guidance to be effective in advance of the next financial year. So, basically, in the next few weeks or the start of the new year is the time frame, practically.

Quite clearly, GP partners hold lease responsibilities and, in many cases, it's too onerous for them—so they're telling us. So, have you had any thoughts about transferring those responsibilities, for example, which has been suggested, to the health boards? That might help recruit, and reduce the barriers for those that might want to enter into a partnership but can't take on that load.

Yes, well, I don't, myself, think that is the solution. So, I think the solution is the one we've just talked about, which is having premises that are more bespoke for the kind of services that we need to have provided. And in particular, the suggestion that you've received that leases should be transferred to health boards is—. That has happened on a very, very small number of occasions for particular reasons, generally about developing a site for project delivery reasons, I guess. But there are some very complex accounting implications to that, and there are some complex operational implications to it as well, which mean that it's not a realistic alternative to the current arrangements. If you want detail on that, I'm going to have to turn to Alex, probably, because it is very granular. But, basically, we think the solution is to provide the support that we are in terms of lease payments, rather than transfer the lease obligations to health boards, which we don't think is a practical alternative.

Thank you. And on that, obviously, we have both a rent and a lease arrangement across the general practice estate, but, as the Cabinet Secretary describes, there is a reimbursement model in excess of £40 million to pay for that. The complexity around the leases is international financial reporting standard 16, which, essentially, would mean that if health boards took responsibility they would have to score the assets on their balance sheet. So, from a public sector accounting perspective, it's far more complicated than simply a transfer. Colleagues will be aware that Scotland had a model to purchase and buy out and lease back some of the general practice estate, but they encountered issues with the complexity because, actually, IFRS 16 came in about the time they were trying to make that progress, so it hindered their ambitions in that space.

Equally, we have a very mixed model in terms of the ownership, in that some of the new assets—. The example in Newport, being opened tomorrow, clearly that has general practice located in those new facilities. So, we have a range, depending on the length of contract that's being held. So, some of those assets are owned and are an asset to the general practice, and clearly some of those are leases. So, some are a benefit to the general practice and some are a liability, but, of course, any changes in that space would alter the risk and reward balance around the GMS contract—so that has implications in terms of the perspective of the BMA about representing their members—rather than just, I suppose, swapping the responsibility, because there are upsides as well as risk associated with the estate.

The other issue that's been raised to us was, whilst it's really welcome that the Welsh Government does invest in capital, there was a request for more transparency on how that's arrived at. And really that's it. I suppose some people want to know why they haven't had investment and what are the criteria against somebody who has. That's always the case with money.

Well, from an IRCF point of view, the points I was making earlier about the publication of those criteria around multidisciplinary working, environmental sustainability, equity of access, those are all—. That information is in the public domain already. So, there's a very clear set of criteria that health boards will need to meet in order to be able to access—they're often joint projects with local authorities, by the way—that those need to meet in order to be able to access the funding. So, that's available already.

Okay. I'm going to move on to digital data and technology. We've taken quite a bit of evidence in this space. I want to know about the governance structure to support a joined-up approach to that digital transformation across the NHS and to ensure that general practice is meaningfully involved in that decision making and procurement.

So, from a governance point of view, the new digital, data and technology board, which my colleague Sarah Murphy established, is the new governance model. Early indications are that it's very effective and it provides a unified model to resolve differences in priority, and the differing needs of different parts of the system, bluntly. It's a complex system, and not all parts of it will have the same kind of need, obviously. So, that is meant to do that, and it's representing at a senior level organisations throughout the NHS. I think that is a good way of discussing and resolving issues in a timely way. One of the challenges in a complex organisation like the NHS, including all the individual GP practices, is what you can deliver on a Wales-wide basis and what you can deliver locally, and there are different pros and cons to all of that, as you will appreciate.

But I think some of the points we've been discussing already do depend on an effective digital offer in primary. So, one of the things we've been really focused on in terms of eliminating that variation, really, is to have one single IT supplier across all practices. So, we took the decision to provide additional funding to that programme so that it could happen at—I think it's double the speed of it, actually, more or less. So, that's great. That means that by next May, rather than the year after, all GP practices will be on a common system, and it has much more functionality than some parts of the existing infrastructure, which will help us with those things that we want to do around access to records, the NHS app, and all those good things that we want to see.

Could I just bring James in a second before you go on? 

On digital, Cabinet Secretary, I'm just interested in what your perception has been around the willingness sometimes of GPs and people in primary care to move to more digital solutions, talking about AI and the way things—. Mabon and I were in an event last night with the cancer alliance, and actually, in Denmark, some of the stuff they've done there is around patient records all on a credit card, and they swipe into a GP practice and they've got everything right in front of them.

Sounds great.

Yes, it sounds lovely. But it's interesting, in some of the conversations that we've had with certain GPs, there is still that sort of reluctance about moving to AI to help with triaging, because of the elements of risk associated with that. I'm just wondering: is that something that you're experiencing as well, that, actually, on the digital journey, there is sometimes a bit of reluctance to go that way as well?

Well, I'm sure there is, obviously, but my own view is that that isn't the main challenge that we face. The main challenge we face is a very complex system, where different parts of it are used to doing, bluntly, their own thing. And that may be fine, by the way, in some cases, obviously, but, equally, there needs to be a more systematic, 'once for Wales' occasionally, approach. So, I think it's more how you align different parts of the system in a common direction, really. I think that's more of a challenge.

I think the point you make is an important point, in this sense. We already use AI, very successfully, in cancer and other conditions in all parts of the NHS, and it is very helpful for clinicians to be able to make better, faster decisions. The key, it seems to me, is that those innovations need to be clinically-led, because that's the bit that gets you the buy-in from clinicians, where you've got people saying, 'Well, actually, we've done this, and look at the great outcomes that we've been able to achieve.' So, that needs to be driven by a clinical voice, really. So, the transformation we've been talking about earlier, in the shift left, as Mabon called it, that's deliberately led by the chief medical officer, because an ability to speak authoritatively as a clinician is really important.

Because there are interesting things around booking GP—. With the NHS Wales app—which I know doesn't sit with you, it sits with Sarah Murphy—booking GP appointments on that, it's a simple thing to do, but, actually, I've seen some reluctance to doing that, because some GPs were saying, 'Oh, we could just be inundated by people who don't really need to see a GP.' But I—

Well, that's a fair point, though. So, just to be clear, there's a delicate balance to strike here. So, going to see a GP is not the same as ordering a pizza; you're going to see somebody with a complex set of skills and you're asking for a professional judgment. So, it can't simply be based on first-come, first-served; there needs to be an element of clinical triage.

And that's where AI has a place, isn't it?

Well, it has a role to play, but it won't ever be the entire answer. But we've worked hard—and, I think, successfully—over recent years in particular to strengthen clinical triage in terms of phone engagement. So, we're never going to get to a position where people can simply book for whatever they like to see a GP, because the GP may not be the best person for them to see. There will always be a need to balance that with the points that we were talking about earlier about redirecting people to other practitioners. So, it's quite a delicate balance. The area in which you can make more rapid progress, obviously, is where that triage is less important, so repeat appointments on a condition that is well established. So, on those sorts of things you would expect to be able to make faster progress than with the broader range of things you might want to see a GP for.

Can I bring Mabon in, briefly, as well, please?

Thank you. Can I hand back to you, Joyce? Sorry.

Yes. Data management and control are key in this space, because they are valuable bits of information in the wrong hands, and I am always raising that issue. But what I'm wanting to know now is: we want to move into this space, we've got Digital Health and Care Wales, and we've got GP practices, and we need to improve the collaboration between the two, so the job then of Government is to hold DHCW to account to deliver the contract. So, what are the systems in place to do that?

Well, as you will know from other discussions, DHCW is in escalation at the moment, so we have quite a complex architecture of engagement, or a comprehensive, rather, architecture of engagement with DHCW across a range of areas. But on the specific point, I touched briefly in my answer to your earlier question on the additional investment that we've made. It's just a bit over £2 million of additional funding, which has enabled DHCW to double the speed at which it's rolling out the unified IT system. I think GPs, to James's point earlier, do welcome that, I think, because it means that there's much more functionality, frankly, and on some of the demand challenges that practices are facing, which are common to lots of parts of Wales, we will be able to do more to support GPs when we have one common system. That'll be happening next year now, rather than well into the following year, which I think will help significantly.

Indeed. And the final player in this area is pharmacies. And, you know, we're asking again lots of pharmacies to become multidisciplinary teams. In order for them to do that, of course, they need access to some of the records from the GPs or hospital, if they're discharging. So, they want to know when they will have full read-and-write access to patient records for themselves and for their members of those multidisciplinary teams, and what, if any, implications that might have for the safety of patients and service integration, and also professional accountability.

Well, I think there are opportunities in this space. For the last three or so years, they've had the first part of that, which is the read access, and there's a non-digital mechanism by which comments and observations can be shared from pharmacies to GP practices, but that's not direct digital intervention, as you obviously know. So, that is the next stage, and that's what we want to be able to deliver. I absolutely recognise the points that you've just made. The mechanism we have now provides safeguards in terms of patient safety, obviously, but service integration in particular, I think, will be supported if we can have a read-write record for pharmacists and other members of that multidisciplinary offer for patients.

Okay.

Okay, thank you. James.

This is my set of questions, Cabinet Secretary, but I've been chipping in all the way along, so I feel like I haven't shut up today, but there we are. On one of the questions I have, I just want to go a bit 360 a second, back to where we almost began, with moving services out of secondary care into primary care. We just talked about pharmacies, but there is an element then of moving stuff out of primary care, isn't there, down to our pharmacies. I was talking to a pharmacist in my own constituency the other day about wanting to take on more to do with chest infections and all the rest of it, and I'm just interested in what work you're doing around that, because if GPs are going to take up more work from secondary care, what more work is the Welsh Government doing to move some of the work out of primary care into pharmacies, to try and relieve or sort of make more headspace for GPs to take up this work?

Yes. The common ailments scheme, I mentioned earlier. Paul gave me the number for the number of—.

It's about 50,000 appointments a month seen through the common ailments scheme [Correction: 'and pharmacy independent prescribing scheme'].

There we go. And we've extended common ailments now, in the last few months, to urinary tract infections as well as more throat interventions. And pharmacists, in my experience and I'm sure yours, are keen to do this because they recognise the benefit for the patient, but also the benefit for them as well. So, there's more to be done to promote that. Obviously, we promote that quite extensively anyway. There's been quite a good campaign running recently in this space. We already provide resources to practices to describe where services are available. So, web content in a standardised form and that sort of thing. So, there are those sorts of things.

Really, what we're talking about—I think Mabon mentioned this earlier—is that there's an element of generational shift here, isn't there? So, if you've been brought up in a health service where the GP is the first and last port of call, then there's always going to be a journey that you're going on, whereas for people who are maybe younger today, who are experiencing an NHS that is more differentiated in that way, it will be a more familiar option for them. So, I think there's more to be done to make this a kind of systematic set of arrangements.

I suppose one of the tensions—not tensions, but one of the things you're trying to navigate is that the offer locally will vary in different parts of Wales, won't it? So, in a rural part of Wales, there probably isn't a pharmacy that you can direct people to, so you've got a dispensing GP. In a city, you've got lots of options. So, it will look different in different parts of Wales.

It's just certain conditions as well, like weight-management services, for example. That could be moved into a pharmacy setting. So, different elements of health. And I think that would free up a lot more time for GPs to do some of the work that the working group that you're setting up is trying to do.

I'll move on now, Cabinet Secretary, to patient experience, really. I'm just interested in the impact of the unified contract and how that's going to make sure it actually serves people in deprived areas and those patients with complex needs. I just wonder what work the Welsh Government have done around that unified contract around those areas.

I think that what we want—. From an accessibility point of view, the contract already has provisions around improving equitable access. So, different kinds of ways of engaging practices: digital, obviously, non-digital as well. You'll be aware of the vast volume of people who have a vast number of contacts, both digital, phone and face-to-face and remote, which the NHS has, but also, as part of the negotiations that we have around GMS, there is a weighting in the formula for some of the particular challenges that practices serving deprived communities face. We had a conversation earlier in response to Lesley Griffiths about how we can do more in that space to rebalance the formula, but health boards commission additional activity through some practices serving particularly deprived communities. At the moment, that provides additional income. But, I do think that it does need to be reviewed. 

Okay. Lovely. Thank you. The Welsh Government's evidence paper said that the new project is aiming to strengthen continuity of care, and we all know that continuity of care does help the overall patient experience and the outcomes for that patient. So, I'm just interested in how this is going to be embedded now into everyday practice to make sure that we have got that continuity of care. And how does the GMS contract reflect that as well?

Okay. So, the mechanism that we're using to do it is currently focused, as I mentioned earlier, on the cohort of the most complex cases, so managing more than one chronic condition, maybe with frailty, maybe with mental health conditions as well. So, GP practices are being supported to identify those and to provide increasing levels of continuity of care for those patients. It's called relational continuity, where that relationship is one where you can expect increasingly to be with the same practitioner if you're in one of those cohorts. Clearly, this is not something that will be able to be done overnight. So, my expectation is that, through this quality improvement approach, we'll start to see benefits maybe a couple of years from now, probably, and the current plan is for there to be a review at year 3 to see what's working, what isn't, if there need to be any adjustments. I think that's at that point, because it'll take a while for that to embed.

My hope is that we see sufficient benefit in that, that it, over time, will be an increasing expectation for all of us, but I think we're quite some way from that at the moment. I should say, though, that some of the pressures we see in terms of the access pressures that GPs report are linked to the fact that we've moved away from continuity of care, so you have pressures coming in from all parts, where, previously, there would have been a relationship with one practitioner, which would have alleviated some of that. And I think, as I mentioned earlier, on the other side of it, you've got increasing numbers presenting with urgent primary care needs, where a customary GP practice setting may not be the best model for addressing that. So, it's a mix of the two things really.

I don't tend to disagree with you, Cabinet Secretary. I'll round the session off, Cadeirydd, now, because I think one thing we've heard in all the evidence from GPs, from patients, is that, actually, there's quite a negative perception of primary care at the minute, and of GPs. We hear it in our own constituencies. We all get e-mails, don't we, from constituents, and phone calls, saying, 'I can't get through to my GP', 'I've got to wait months for an appointment'? There's quite a negative narrative being pushed around, not just from patients, but the media, and sometimes political narrative as well around the role of general practice.

I'm just interested in what work the Welsh Government is doing, and we all have a responsibility on this as well, to really highlight the role and to offer a more balanced and informed public conversation about the role and the value that general practice has in our everyday healthcare system, and the invaluable work they do in actually saving a lot of people from going into secondary care as well. 

Well, I think GPs do an amazing job, and I think most people think that. So, most people's experience of the NHS is not the one that you're very fairly describing, but that is not most people's experience of the NHS. So, I've got a note here that tells me that, last year, GPs handled 29 million calls, 6.1 million digital requests, 18 million attendances, 12 million face-to-face appointments, 6 million remote, 223,000 home visits, in a population of 3.3 million. I mean, that's just an extraordinary level of activity.

So, you've rightly focused on the challenges today, absolutely correctly, but that is a system that is delivering a huge amount of capacity to meet the needs of people in Wales. There are things that we all need to make sure it does better—absolutely—but that is the reality on the ground for the vast majority of people, most of the time. So, I think it's a collective responsibility and it's inherent in the political process that you will focus on the things that we need to do better, understandably, but I think you are right to say that the tone of that discussion—not in the political space, but more broadly—sometimes does stray into a world where you think, 'Why on earth would I want to be a GP, given how things are characterised?', and that is not the experience of most GPs most of the time. They're doing a fantastic job in difficult circumstances, and most of our patients think that as well. But I'm looking forward to seeing how the committee deals with this in its report as part of the collective responsibility that we have, Chair. 

Well, that draws us to the end of our questions and thank you so much. Are there any concluding remarks that you might want to make, because we're at the end of this inquiry? 

I think the ones I've just made, as it happens, probably are the ones I wanted to conclude with, Chair. 

Yes, that's great. Well, thank you so much for taking the time and answering so thoroughly our questions. As always, there will be a transcript available for you to check over, and just thanks again for your input today.

Thank you very much. Diolch yn fawr.

Okay, Members, we'll move on to item 3, papers to note, and you'll see that there are a few today. Are you happy to receive those? You are. Okay. Thank you very much. 

So, that takes us on to item 4, a motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting. All happy to do so? Okay, thank you.