Cynulliad Cenedlaethol Cymru

Thank you, Chair. What would you say the main challenges have been for Public Health Wales as an organisation throughout this outbreak? 

Thank you. Can I just check if it's okay to go ahead?

Yes, crack on.

Thank you very much. Well, obviously it's a public health emergency as we know, so, for us, it's mobilising at pace and scale as we've gone through the various phases, from identifying and seeing the pandemic starting to emerge, and preparing ourselves and supporting the NHS and partners to prepare for what was coming, and then rapidly scaling up as the case definition started to change, if you recall, with the different countries being added. We mobilised call centres, contact centres, across Cardiff, Swansea, Preswylfa; mobilised our surveillance teams; our advice around health protection and, very early on, began to mobilise our laboratories for testing capacity, which has been a big challenge and I'm sure that will come on. Obviously, moving into the current delay phase—being agile in providing advice very rapidly, and guidance to the Welsh Government; keeping part of the UK rhythm daily in understanding and contextualising that for Wales; and providing as open and transparent information as we can to our public, through our open-access dashboard, so that we can see the number of cases per day and, sadly, the number of deaths also. Most recently, it's the advice that we can provide, through the evidence that the team deliver every day, to say, 'Well, how best can Wales be positioned, going forward, as we go into the recovery phase?'

Okay. Jayne.

Thank you. So, how do you feel that you were able to respond to early cases in Wales? For example, in Aneurin Bevan University Health Board, they were ahead of the cases in Wales, ahead of cases in the UK, and they were ahead of testing than other parts of the UK. Do you feel that you were able to adapt to that situation as well, where places like Aneurin Bevan were really ahead on things?

I invite Quentin to answer that.

Quentin.

Thank you, Chair. So, to begin with, we started, at the end of January, seeing suspected cases, and we built a lot of our learning and expertise in responding, working with the health boards from that point, so that by the time we saw our first confirmed case on 27 February—I'm just checking; yes, that is the date, 27 February—we had already, if you like, established a rhythm, internal protocols, and arrangements agreed with the health boards.

The first confirmed case didn't in fact happen in Aneurin Bevan, but putting that to one side, it very quickly became evident by 6 March that Aneurin Bevan was where a lot of the cases were starting to emerge. We had regular dialogue with the director of public health. With each confirmed case, we would establish a case conference, and we would discuss that individual case in detail with senior clinical staff as well as the director of public health, and, at the same time, we would initiate contact tracing. When the numbers were quite small at that stage, in terms of the numbers of confirmed cases, we were able to keep that rhythm going.

Of course, then, things quickly began to take off, particularly in Aneurin Bevan. Aneurin Bevan approached us early in March to ask us for some assistance to understand the pattern of disease transmission at that time, which was a combination of some transmission within the hospital, but also, very significantly, early signs of transmission in the community.

Okay. Jayne.

Thank you, Chair. So, in fact, you were able to keep pace with that and learn from the experiences, then, in other health board areas?

So, we were, up to a point. Now, of course, as the cases started to take off, it became more challenging, and the challenge for us was that we were, first of all— . The health boards were expecting us to provide them with expert infectious diseases clinical advice. So, that was quite a significant commitment for the limited number of infectious diseases doctors that we had. We were having, literally, case-management discussions with each of the confirmed cases as they emerged. So, that became increasingly challenging. But also, in addition to that, we were undertaking contact tracing on all our confirmed cases, and we scaled up really rapidly. We mobilised a very significant proportion of our entire workforce, not just health protection, and took over almost a half of one of our floors in our main building in Capital Quarter 2, to run a contact-tracing centre. But by the middle of March and, just coincidentally, around the timing of the move from containment to delay, we were probably working close to our limits.

Okay, thank you. Can you just explain what Public Health Wales's role has been in developing and signing off UK-wide guidance—for example, we've seen the rapid review on PPE—and do you feel that there's been a strong Welsh voice in that process?

I'm happy to start, and then I think Dr Shankar, who's been a little bit closer to the discussions with Public Health England, may wish to add in a moment.

Generally speaking, this has been unprecedented in the amount of guidance that we've had to develop, often de novo, because this is a novel virus. This is not something that we all had good experience of. We work closely as four countries through a regular daily conference call led by Public Health England. We also engage through, at Welsh Government level, four-nation ministerial and officials' discussions. There was a lot to process in a very short time. You've touched on just a couple, but we were literally producing guidance overnight, and we, in turn, then had to take that guidance and adapt it for use within the Welsh health system where that was necessary.

So, in terms of our involvement, we were always invited, we tried to participate as much as we were able to. Often, the notice was very short, and I think, in fairness, one of the challenges for us has been the very short time intervals, sometimes, that we've had to process, turn around, convey out into the system and explain and help interpret throughout this pandemic. But maybe Dr Shankar might add something.

Okay. Dr Shankar.

Good morning. Bore da. Thank you very much for the opportunity to provide evidence to this committee. So, just continuing on from where Dr Sandifer left off, within the contribution of our colleagues in Public Health Wales to the UK guidance policy, one of our senior consultants, who has got particular expertise in infection prevention and control and the use of personal protective equipment, was a core member of the UK IPC cell that met at the time twice a week, which now meets once a week. As well as that consultant colleague of ours, another colleague, a nurse consultant, also contributed to that.

Within Public Health Wales, we have our internal incident management team meeting, where our infectious diseases consultants actually—[Inaudible.]—the issues on the ground, which were either relating to the quantity of PPE used or the type of PPE used. We collected the local Welsh positions, fed back into the UK cell, and we were able to influence some of the guidance that went in and that subsequently was published.

The challenge we also originally found was that, sometimes, the UK Government PPE policy position was a given one and there was a slightly different view from the royal colleges and, therefore, at some point in the future, there was a review of what happened and then subsequent reconciliation has happened.

So, I can confidently say, as to what Dr Sandifer said, that we had input into the UK guidance.

Okay. Jayne.

Thank you. Do you have any concerns about the current structure and the ways of working, or how could that have improved the management of the outbreak in Wales?

Who wants to take that?

[Inaudible.]—the strategic director throughout, accountable through our chief exec to the board. We first set up our enhanced incident management arrangements on 22 January, so quite early on in the process, and I've been chairing a gold strategic meeting for at least 11 weeks now. So, those structures have informed the way our organisation has worked.

But, in addition to that, what our organisation very quickly realised—before the end of January—was that this was something unprecedented, and substantially reorganised itself as an organisation to support the pandemic response. Of course, it wasn't then recognised as a pandemic, but, nevertheless. So, we effectively directed most of our resources as an organisation to the response. Subsequently, in a progressive and carefully balanced way, in discussion with Welsh Government officials, we began to suspend other parts of our core business so we could focus staff's attention on the pandemic response, and throughout, we've reviewed and subsequently amended, where necessary, the terms of reference, membership and working arrangements of our internal emergency response structures.

Okay. Tracey.

Just to reinforce what Quentin was saying, we have what we call a battle rhythm happening, so not only with our internal structures, but for a number of months now, daily engagements with the UK every morning, with the four nations, including the Republic of Ireland and constant engagement with Welsh Government and NHS colleagues. So, throughout the week and throughout the day, there are regular established meetings in order for us internally, but also as a system and a UK, to oversee the management of the incident.

Great. Jayne.

Do you think those structures are clear to the public?

I think that's a really good question, actually. Probably not. I think some are. So, I think on occasion, where there is guidance produced or where there are potential policy statements, a background as to how they've been developed with the partners involved, I'm sure. But I think that's a really important question. Certainly, for us, we can take that away and think about how we can make our structures more open and transparent. Interestingly, our board, similar to the committees, is having to adapt the way we do our business. So, we currently have board updates on a weekly basis and then the formal board meetings, and we are still trying to review how we can make that more open and transparent. But I think more transparency for many organisations perhaps would be helpful. I think the challenge is that we're dealing with it and running on an hour-by-hour basis, and having that challenge makes you think, so thank you. 

Thank you. Just finally from me, the chief medical officer last week said that one thing he'd flagged with colleagues in Public Health Wales is that bilateral relationships are useful, but there needs to be a more systematic approach to understanding what's happening across other countries. How are you progressing that? How are you keeping abreast of all the scientific evidence and the learning from other countries, and also making sure that Wales's experiences are fed into those as well?

I'll come in on that, because I've been leading some of that work within the organisation. So right from the very beginning, we've utilised our connections with the World Health Organization as members of the International Association of National Public Health Institutes and other international bodies, to seek to learn from other examples. Public Health Wales hosted a European webinar joined by 11 national public health institutes from across Europe, including Germany, Italy—at that time, Italy was at the height of the concerns in that country—but also France, which was probably running just a little bit ahead of us. So, that was one such meeting.

We've also joined webinars hosted by others—with South Korea and with China. We've also had bilateral discussions with countries such as Germany, and from those we've learned quite a lot. What has been really instructive is to understand where those countries started from. It's very easy to comment on what they've done, but sometimes, to understand where they came from is just as important. We probably haven't got time to go into that detail here, but we'd be very happy to share that, and I can assure you that we have applied, and we continue to apply, the lessons we are learning from our international colleagues. 

That would be really useful. Thank you, Chair. 

I'm very happy to. So, I think we've given you a bit of a flavour of early on in the pandemic, as things were progressing very quickly. We were fortunate in our labs in the University Hospital of Wales in Cardiff to commence testing relatively early for the UK—that's through our virology teams—and that has continued. We have worked very closely with our Welsh Government colleagues and also our UK colleagues in securing and procuring equipment and chemical reagents. As early as January, we saw what was potentially coming down the line, so we purchased equipment from South Korea as early as January and, only now, one has arrived and we're still waiting on another one.

So, the global supply chain challenge, all the way through developing a sampling and testing strategy has been at the heart of disruption and competition with other countries. Given it's a pandemic, obviously every country worldwide is trying to secure equipment and chemical reagents, and so we rapidly diversified our platforms. We've purchased another 10 that we're waiting to come in from South Korea and we're working closely with Scotland and England to facilitate some air freight in for all of the countries. So, it has been a real challenge. With the global supply chain, a number of companies based in certain countries have had to divert their supplies to those countries, which has disrupted the supply chain, including quite considerable amounts of reagents for us. So, whilst we've built on the capacity—and I'll say a little bit about that in a second—and we'll continue to do so in the next number of weeks, we hope that we'll have a considerable scale-up. 

We've worked very closely with the chief scientific adviser, Dr Rob Orford, right from the outset, in developing the testing plan for Wales, which the Welsh Government published, looking at the two different types of tests that are available: the antigen, which is the lab-based swab test that shows if someone has it; and then the antibody, as you know, if someone has had it. So, looking at how we procure those, how we distribute our testing, not just in Cardiff but rolling into Rhyl and Swansea so that we can create a more close-to-home testing strategy for other parts of Wales. 

We have been actively involved in evaluating some of the what we call point-of-care testing. At the moment, we're doing laboratory testing, but point-of-care testing are those rapid devices that we can put in emergency departments, critical care departments, et cetera. Unfortunately, at the moment, there isn't a point-of-care test for the antigen that is sufficiently sensitive for us to be able to confirm a diagnosis. So, we've been working very closely with our colleagues in England and the wider UK in testing some of those for antibodies, which is a small pin-prick test. We hope to be in a position to have procured and brought in a considerable number of those shortly, and that will be important as we go forward.

So, we have worked closely with them. I'm afraid I'm not familiar with the 9,000 number that you refer to. We have worked very closely on a daily basis looking at what our trajectory is going to be. We have a team that are chasing down air freight, that are chasing down managing directors of companies with equipment and chemical reagents, so we are on this. A month ago, we were at 1,000 tests per day, a fortnight ago we were at 1,800 tests per day, today we're at 2,350. We hope in the coming— 

If I can stop you there, that's capacity. 

It is, yes. 

It was 743 tests on Wednesday—or at least that's the last figure we have. 

Yes, in relation to demand. Yes. 

There's a difference between capacity and how many people are coming forward for testing. We can look at those two issues. 

On the 9,000, would you in Public Health Wales have been a part of setting those targets? Who would have guided Government to set those targets? It would have been based on some kind of evidence. Would you have been proposing that evidence?

Can you repeat when you said the 9,000 was set for?

On 21 March it was set for by the end of April. It was a gradual growth. I can give you the exact figures, if you like, of when we were supposed to have how many tests, but it was 9,000 by the end of the month. 

Okay. Well, we've worked very closely, as I say, all the way through this, with our Welsh Government partners. For a number of weeks, we were having daily testing meetings to look at the supply chain and what could be realised. We have worked closely around the trajectory and what's realisable, and, increasingly, over the last number of weeks, it has been very challenging, as I've said. However, we're picking up traction now and we're hoping in the next number of days, into next week, we'll have a significant increase, which the Minister will announce at that time.

Okay. Just to recap, we were on 800 tests a day, then—on 21 March. It was going to be 6,000 tests a day by 1 April, 8,000 by 7 April and 9,000 by the end of April, and it was 743 on Tuesday. So, would you have had a role in setting those targets? And it is important, because we're trying to measure what has happened to evidence given to Welsh Government, and what it has done with that evidence that it has been presented with. 

All I can say, to repeat the same point, is that we have worked very, very closely with them. The trajectories that we have managed through changes to the supply chain are happening on a daily basis. The Minister is announcing every time there's an increase in capacity and, as I say, we hope in the next number of days we'll be comparable with our friends in England and Scotland relative to our population, which will be a really important step for us. I'm not familiar with the trajectories, I'm afraid, that you were referring to. 

Okay. Perhaps Dr Shankar and Dr Sandifer can answer. Would you have been part of the team, or would it have been you who said, 'We need 9,000 tests by the end of April?', because I assume they wouldn't have said that they were going to deliver 9,000 tests by the end of April unless they thought they needed 9,000 tests by the end of April.  

Again, I'm not familiar with the 9,000 figure. We are working very closely around the trajectory, particularly as we move into recovery. You rightly say about demand or the utilisation. 

I'm going to have to stop you there, I think. It was 9,000. I'm just asking: would Public Health Wales have given advice to Welsh Government at that time that we needed 9,000? I'd like to assume that they didn't pluck 9,000 from the air. Somebody told them, 'We need 9,000 and we have the capacity to deliver 9,000'. Was it you? Was it Public Health Wales? 

Our focus on what our capacity is at any given time is what's realisable for what we can get from the supply chain. So, moving into recovery, absolutely, we need to be at that level. Lockdown has worked very well, actually, and you mentioned the demand, so the low uptake—

I'm afraid—. If you're unable to answer the question or you don't know, that's fine. I'm just trying to pin down one particular question. Was Public Health Wales a part of a group, or was it you yourselves who told the Welsh Government, 'We're going to need 9,000 tests a day and we can deliver 9,000 tests a day', or was it nothing to do with you? 

As I've said, I'm not familiar with the 9,000 trajectory. 

Okay. Is Dr Sandifer or Dr Shankar a part of that? Were they a part of it? 

Very briefly, what I would say is that I respect and understand that there is considerable focus on a number—a target, as you've called it—but from my point of view, from a professional point of view, I've always approached this as we need the right number of tests to achieve the strategic objectives that we have set for ourselves at that point in the pandemic—

Were 743 tests on Tuesday enough for where we are in the pandemic? 

I'm not sure I recognise—. The 743 are probably the number of tests that were carried out, I suspect. We have set a capacity at the moment, as has just been said, which is at 2,350 and growing. If we looked at the experience in other countries, very interestingly if you take South Korea, at the peak of their response, they conducted just over 20,000 tests per day for a 51 million population. So, pro rata that would be about 1,200 tests a day in Wales. Germany, at the peak of their response, conducted 125,000 tests a day for a population of 83 million, so that would be 4,600 tests per day. So, what I'm saying is that those countries, they didn't pursue a number, the test number—they pursued a strategy and they had then the capacity to deliver the testing associated with that, and that is the approach that I have always recommended. 

Okay. I've got a supplementary from Angela, then David, and then we'll come back to Rhun, all right? So, Angela first. 

Thank you very much, Chair. I'm sure that you don't need me telling you that one of the real drivers of this is about trust, and to say that there has been evasion over the questions or a lack of straight answers to the questions that Rhun has put forward would be an understatement. I am genuinely shocked that Public Health Wales is saying publicly and on the record that they were not aware of the Government's commitment, that the Government said very loudly, very clearly and in multiple media, that there was an ambition for 9,000 testing capacity by the end of April. And can I ask you again, because neither Dr Shankar or Mr Sandifer have actually answered the question directly? Did either of you know whether or not that 9,000 target existed? You are, after all, Public Health Wales.

Tracey Cooper then. 

Yes, and, look, apologies if you think we're avoiding the question; we're not intending to. Certainly, I'm not familiar with the 9,000 trajectory. That's my answer. We would be very keen to, and have been very keen to be maximising our available testing capacity throughout this pandemic. We've talked abut the numbers of demand and, if I may, Chair, in a minute, perhaps come back to that? What is absolutely key is making sure that we are scaling up for when we get into the recovery period. Because when we get into recovery we absolutely, as a system, with our partners—

We understand that. 

—need to be on top of it, and we need to have the testing capacity to support that— 

We understand that, but that's not answering the question that we've asked. 

I'm not familiar with the 9,000.

Well, I'm shocked. You are the chief executive of Public Health Wales and that is a major, major Government commitment. 

Okay. David Rees. 

On that particular point, you've talked about that you have trajectories that you were performing, and perhaps you can send us a copy of the trajectories you had had at that point in time, so we can see what your projections were and we can then perhaps work out as to what the Government might have used those for. So, I think that would be very helpful if you could give the committee a copy of those projections.

But also you talked about procurement. Now, clearly, at that point in time, there was a lot of talk about the loss of 5,000 tests a day from the Roche issue. Was Public Health Wales involved in that and has that been a major factor? Because it doesn't look like you had a plan B, effectively, to replace those 5,000.

Thank you.

Dr Cooper.

Yes, we have trajectories at any given time. What our trajectories are and what we believe we're able to deliver, given the supply chain, is a real challenge. And to give you an example, a week last Friday at a four o'clock meeting, by the time we'd got to quarter past four a global supplier of reagents for us withdrew what would have been 800 tests per day coming in the following week. Whatever we are setting as intended trajectories it is about whether or not they are realisable or not, and that is the challenge—the very, very real challenge that we're having on a daily basis. 

I think we understand that challenge and we understand it's very fluid. But if you can give us the copies of the documents you had at that point in time, we might be able to see whether those trajectories would have led into a 9,000 or not. So, whether you think there is a 9,000 or if you've heard of one is not the issue now; that's another matter. But if you have projections that could have demonstrated that that could have been reached, at that point in time, I think it's important for us to see those projections.

Of course, of course.

In relation to your second question, you referred to Roche as the pharmaceutical company. So, we had discussions with the company early on in the process to look at securing daily tests that the company then was involved, as a number of companies are, in a UK allocation, and we are now receiving an allocation from that company that equates to about 19 per cent of the overall allocation into the UK countries. So, given the size of Wales, actually we're managing to secure 900 tests a day as a result of that. 

Okay. Back to Rhun. 

Do you know why Welsh Government thought they were going to get 5,000 tests a day from Roche?

Well, we were in the discussions with Roche, and that was the understanding that we had through discussions and e-mail correspondence, and that was in advance of it then being, as I say, brought into the UK allocation, which has happened with a couple of companies. 

So, in a way, Welsh Government had done well do get discussions going early with Roche, they said they could deliver 5,000, then the UK Government stepped in and we lost that 5,000. 

Yes, and I think what the UK Government—. The allocation, at that time, was a full 5,000 for the UK. So, it's challenging for ourselves, challenging for the UK, but the allocation that we're getting now is more than we would on a relative population basis.

But less than we thought we were getting—

Yes, yes. 

—at one stage. And a lot of people will find that shocking and I'm glad that we've had that confirmed here this morning, that we were going to be getting 5,000 tests from Roche and that the UK Government or agency stepped in and that meant that we lost most of those.

Can we look forward now to the next stage of testing, which is clearly important? Now, on page 65 of your document that was shared last week, on looking ahead to the next phase, you identify 30,000 people as being the number of symptomatic members of the public that you may have to test in the next stage. Could you comment on that figure? It is a figure that you have identified as being an important one. I could quote from your report: 'Symptomatic general population testing will be essential to suppress transmission. If all symptomatic people are to be tested, this would generate a demand of approximately 30,000 tests a day.' Will we need 30,000 tests a day in order to deliver what you want, and are you confident that we can build the capacity to deliver that?

Who wants to take that one? Tracey?

After Quentin. Quentin?

I'll start—

Quentin.

—and then maybe others might want to come in.

So, you are referring to the draft document that came out last week, and we began work on that document at least three weeks ago, working with the chief medical officer's officials, and at that stage we were in the very early part of the lockdown period, which we're now coming to the end of. At that time we had no idea how the lockdown would work, what effect it would have, and we were drawing on, at that stage, UK scientific evidence of what might be the worst-case situation if the outbreak was unmitigated. It was a figure derived from our estimations based on that, but also, additionally, our expectations of normal background prevalence of upper respiratory disease and our expectations of the need for testing for healthcare workers, clinical diagnosis and so on.

But the fundamental point was that we drew that figure up on the basis of a worst-case scenario, quite early on in the lockdown period, when we had no real idea of how the lockdown period would work. That figure, by the way, is a worst case—it's at the upper part of a range. Over the last week, we have been revisiting those figures now with a better understanding of the effect of lockdown, and I think everyone recognises that the introduction of social distancing and the restrictions have led to a considerable improvement in the situation, with much less community transmission. So, we have revisited those numbers and we think those numbers now overstate what we believe now is the requirement.

We have submitted advice that suggests that the range is probably at the bottom end around 7,500, and that the top end—depending on the outcome of decisions on restrictions and the lifting of those, and depending on then what might happen to community transmission—the upper end is now certainly no more than about 17,000 to 19,000. We think, realistically—again, applying our best understanding of the experience of the lockdown—that it will be at the lower end of that range, so around about a 10,000 requirement seems to us a reasonable assumption as we move into the next phase.

Rhun.

Can I thank you for that? That's a really good explanation. You can forgive me for taking the 30,000 figure for what it was. I had a copy in front of me of a document that said 'Final version, 29 April', so I assumed it was up to date.

Now, can we get up to that 7,500 to 17,000? We thought we were going to get to 9,000 by the end of last week, and that didn’t happen in a month. Are you confident that now, given what we've learnt about supply chains, the machines that we need to do it and our capacity internally, including Cardiff University work that's been done there—there's some wonderful work going on—can we get to that point and can we get there very, very soon? Because I'm concerned about the talk about lifting restrictions and that kind of thing. Before we get to that point, we know that we have to be able to deliver that kind of capacity.

Okay, Dr Cooper—. Oh, go on then.

Very briefly, and then the chief exec will—. Sorry. Very briefly. I just want to re-emphasise that it is our professional advice and best estimation that we'll be at the lower end of that range rather than the upper end of that range, and I've just said that. So, on that basis, looking ahead at our expectation of the supplies that we are anticipating over the next couple of weeks or so, we believe that is achievable. The chief exec may wish to add a bit more to that.

Dr Cooper. 

Yes, if I may. Yes, we hope over the coming days into next week to have a considerable increase in capacity and the Minister for Health and Social Services will announce that at the time, and that will put us into comparable numbers of capacity with our colleagues in England and Scotland, relative to our population size—just slightly over, in fact. And then over, again, the coming weeks, we will continue to expand and I would like us to get to a minimum of 10,000. Similar to yourselves, we really want to be in a position where we've got that testing capacity and we've got the other elements that the Minister referred to in the test, track and trace approach. Testing is going to be key, as will be contact tracing, as will be surveillance.

Thank you very much indeed.

Okay. I've got some questions that are still on testing from David Rees. Briefly, because then we have to move on.

Okay. Thank you, Chair, I will be brief. You've talked about testing capacity, you have 2,300, and yet we've heard that only 700 plus were tested, and that's a third of the capacity. Now, before anyone says the demand isn't there, I can give you an example of a care home in my constituency who contacted me yesterday. They've had six deaths in the last month, five cases of COVID-19 confirmed, one still awaiting a test but in hospital, and five others awaiting tests in the home. When they asked for testing for their staff, which is now the guidance of Welsh Government, on Monday—so, it wasn't last week, it was Monday they asked, and they asked PHW—they were told by PHW, 'They're old cases; sorry, you can't be tested.' Now, is there a communication error, therefore, and therefore that's why the demand is not there because people are not being given the correct information as to who can be referred and how they get referred?

Okay. Dr Cooper.

Thank you. That's a really important area, around demand, and there's a number of elements to it and I'll come back to care homes in a second, if I may. So, at the moment, where sampling is taking place—so, there's obviously the testing in the labs and there's the sampling of the swabs—we have worked with partners to set up a number of sites, as you may know. So, health boards run what are smaller community testing units where people can go and drive through, including care home staff. We've also, in the last couple of weeks, established some of the mass testing centres. So, we run Cardiff City Stadium and health boards run ones now in Aneurin Bevan; in Swansea, which is just coming online; in Abercynon, which is coming online this week; in Carmarthen and in Llandudno. What's going to be really key is that we've been working with the military and, this week, there will be eight mobile testing units that are run by the military, one in each health board, with the exception of two in Powys. Their primary approach will be to be out and about, particularly in targeted care homes where we need to test both the residents and also the staff. 

That's the mobile testing, which I understand, because they're going to have to go into homes, but you have the standard ones, the ones that have been set up in the car parks or wherever. How are people being advised and referred to those so that your demand can increase to meet the capacity? Because if you're only hitting a third of your capacity, there are lots of people who could be tested, who perhaps need testing, but are not being tested.

Yes. So, just perhaps to sort of clarify our role: so, we have a call centre or a closed-setting centre, and we're in contact with just over 600 care homes across Wales at the moment. If we're contacted and we're concerned about someone possibly having coronavirus, we hand that over to the health board, so health boards are responsible for the swabbing and going out and doing the testing in care homes and also run the coronavirus testing units for care home staff to move into, and I think you're meeting with Aneurin Bevan and Betsi Cadwaladr, so it would be useful to ask them around that.

During this week, and into the following week, we are also supporting Welsh Government in setting up an online service for booking tests. I think that will make a really, really big difference, particularly to care home staff, many of whom may not be able to drive. So, at the moment, we're rolling out people being able to book a slot without unnecessary bureaucracy. So, they can go online, and, by the end of next week, we hope anywhere in Wales will be able to look at their nearest slot, be it a smaller testing unit or the larger mass-testing units, and book a slot for them to drive through. And then, the following week, we hope, we've got home testing on that, so, if I'm member of staff in a care home, I can go online, book a home-testing kit that will come to me within 24 hours, and then be collected from me so that we can do a rapid turnaround of testing.

Thanks. So, you say, in the future, you will have a website—which isn't yet up and running in Wales—which will allow you to book slots, and, beyond that, possible booking of home testing, but, for this week, and for the majority of next week, we're still in a situation where people need to be able to be referred and they're having difficulties in doing so. How are you making sure the communication is there so you can utilise the maximum capacity of your tests?

Yes, well it is—. The online is up and running. It's up and running for South Wales Police as we test it and then we'll be rolling it out. As I say, for us, every time we have a concern about a resident, we hand that over to the health board for the testing. There have been meetings this week, with the change in policy, with health board colleagues and Welsh Government to identify how health boards are able to ramp up with their sampling capacity to be out and about with care homes. Over the last fortnight, we've been working to support health boards with environmental health officers from local authorities, who have gone through an additional training package, so many EHOs across Wales are now going into care homes, providing advice and testing—

[Inaudible.]—is tight, and therefore I don't want to go on. The situation is, therefore, that you are saying to me that you pass it on to health boards, and it's the health boards who are now responsible for the referral.

For doing the testing, yes—the sampling.

Okay. Time is marching on and I'm looking for some fleetness of foot now, and, obviously, a prime candidate for fleetness of feet is young Angela, on data.

I've got some very straight questions; I'd like some very straight and short, direct answers. I was very shocked that one in nine deaths reported in Wales—i.e. 115 out of out of 997—were incorrectly reported by two health boards, including one under direct Welsh Government control. Why wasn't the computer system of reporting, which you introduced, mandatory, and did you think the guidance to health boards was sufficient to ensure consistent reporting? 'Yes' and 'no' answers would be great.

So, the—[Interruption.] Yes. So, the situation that you're describing I think relates to the Betsi Cadwaladr and subsequently the Hywel Dda health board areas. [Interruption.] Yes.

So, we worked with the health boards to design an electronic notification form for surveillance purposes. It didn't take away the statutory requirement that health boards retain for reporting deaths through the Office for National Statistics system. We put that in place as an additional tool to enable us to properly monitor in more rapid time deaths from COVID within Wales. So, we designed that with the input of NWIS, and with input from clinicians in Wales, under the auspices of the medical directors group—and I'm a medical director, and was party to those discussions. We did that as quickly as possible, we put that out, and Welsh Government gave a strong message that we expect health boards to use that tool to support our surveillance—

I'm sorry, Dr Sandifer, I'm really aware that time is against us. So, you used the word 'expect', so can I just clarify: you expected the health boards to use it, but it was not—? My question was: was it mandatory?

So, we aren't in a position to mandate to health boards. The—

Okay, thank you. That's all I wanted to know.

—chief exec of the Welsh Government has written more than once to health boards, setting out his very clear expectation that they should use that form. 

Okay. As I'm sure—

Okay. Dr Cooper. Sorry—

I'll press on, if I may, because I know that time's tight. As I'm sure you will know, there appears to be a blip in the ONS provisional figures on deaths in care homes in Wales. So, Aneurin Bevan, which has some of the highest overall figures of COVID-19, but has a lower amount of care home deaths registered than, for example, Cardiff and Vale or Cwm Taf—is that ringing any alarm bells for you? Have you just accepted it? Is anybody monitoring that kind of blip and looking at it?

So, of course the deaths from COVID in any setting, but particularly in closed settings, such as care homes, are a cause for concern. I do not know the detail of why there was that blip, as you've described it. As I say, the responsibility for reporting deaths statutorily sits with the health boards, and we have worked with them to try and make that as easy as possible, for our surveillance purposes, through the use of the e-form.

So, just to clarify, Public Health Wales have no oversight role, then, so that when you see a blip like that—because, of course, these are deaths in care homes, there is no mechanism within Public Health Wales that goes, 'That doesn't look as if it sits with other comparable health boards, so somebody ought to look at it in case there is another case of misreporting going on'. So, what you're saying is that Public Health Wales have no oversight role. 

Can I suggest Giri responds to that, if I may?

Okay. Giri.

Thank you. Over to you, Dr Shankar. 

Hi. Thank you very much. What we are saying is that there is a time delay between the two sources of reporting. So, what we report is timely, in real time, but not necessarily comprehensive reporting. The comprehensive mortality reporting comes from the ONS data and there is always a 14-day—a minimum of a 14-day—delay between the two sources. What we have is an oversight group now, through the chief statistician of Welsh Government, and there is a weekly meeting of that happening, and a link with the health boards, with named representatives of the health boards, who will come together to look at what data Public Health Wales receives through the electronic form, and what data ONS tell us, and then compare the two to see where we are. So, that work has commenced. It has only commenced in the last week or 10 days, and we will continue to work on it to make better understanding of mortality—[Inaudible.]

Thank you for that. That makes it a little bit clearer. Shielding letters—there's obviously been a real issue with shielding letters. What role have Public Health Wales—if you could be prompt on this—played in monitoring the successful delivery of shielding letters for people who need them?

Okay. Tracey. 

We haven't played a role in that. 

Right.

No, not at all.

No.

Okay, that's great. I don't want to fire a question that's not—inappropriately. Final question: how could the data on deaths and testing be better amalgamated and reported to include that care home detail? Because, of course, we're very well aware of the difference between the Public Health Wales system and the ONS system, that there is that time delay, and yet, in England, they seem to be able to report on a daily basis all of the deaths, whether they're in homes, hospices, hospitals or care homes. What can we do to get to that point, so that we know an accurate figure on a daily basis? 

Giri.

So, it will be really challenging to get it in real time. We have encouraged care homes to actually report to us as well, when they report to Care Inspectorate Wales and—[Inaudible.] What we can reliably report in real time is hospital deaths. There will inevitably be some delay in reporting care home deaths.

Okay, we've reached, some would say, the high point of the meeting, because it's Lynne Neagle's first appearance. Exit strategy—and you've only got a couple of minutes, Lynne, so apologies.

Thank you. Thank you, Chair. I wanted to ask about the exit strategy. The paper we were provided with yesterday by Public Health Wales has just one short paragraph on the exit strategy. It says that a plan has been submitted to Welsh Government to support the Welsh Government's plan. Can you tell us a bit more about this advice you've given the Welsh Government, and is this likely to be put into the public domain and supplied to the committee, please?

So, Public Health Wales has prepared advice at the request of and to the chief medical officer. It is Welsh Government that will decide what they wish to do with that advice and how they wish to make that publicly known, I would suggest. You—. So, I will leave it at that. That's the position from my point of view. 

Well, I mean, we've only got a paragraph off you on that, so are you able to give us any kind of insight into what you're suggesting to Welsh Government, because we are now talking about easing the lockdown, aren't we?

No, that's—. Sorry, and apologies, I had forgotten the reference to the exit strategy. The exit strategy is going to be made on a whole host of considerations. Clearly, Welsh Government itself will want to consider which restrictions and at what time they wish to ease those, and they will take into account a wider range of factors and considerations about the impacts of lockdown on broader health, on the health system, on the economy and so on. So, our advice is very limited to the public health protection aspects of that strategy. So, we're not advising necessarily on the strategy; the strategy is a conglomeration of a range of considerations.

But, very specifically on our advice, what we're saying is that there should be three parts to the approach we take, and that is to actively look for cases and then trace their contacts, that we should conduct enhanced surveillance—more surveillance than we have been doing—so we can monitor and assess the impact of any transmission of the virus across Wales, which will be important. As we ease our restrictions, we may see virus transmission take off again. And, of course, all of that requires an end-to-end approach to sampling and testing that is timely and able to meet the capacity requirements that we've discussed earlier. Those are the three essential elements.

From a professional point of view, what we want to do is to keep the R number down, as low as possible. It's only just below 1—it's too close for comfort, and we don't want viral transmission to take off. So, that's the advice that we have provided to Welsh Government.

How are you drawing on international good practice to inform the advice that you're giving? We've seen companies that have been really effective, haven't we—countries that have been really effective.

Yes. To return to a point I mentioned earlier, we've had direct conversations, for example, with South Korea and Germany, which are often presented as countries that have done very well. Now, those countries already had a heightened sense of awareness of the potential impacts of novel coronavirus, but for very different reasons—the SARS outbreak in east Asia in 2003, for example, in the case of South Korea. Both had already in place very large laboratory infrastructure that could be switched to coronavirus testing very, very quickly, and they were quick off the mark and able to access test kits ahead of other countries, and therefore managed to avoid a lot of the problems we've already referred to about competing global demand and supply chains. And, in the case of South Korea, but also in Germany, they either had on standby or could mobilise very quickly the necessary workforce to conduct the scale of contact tracing.

So, I think we are—. We've talked to both of those countries and I think they've confirmed in my mind, which is why we've set it out in our advice, that we need to have an ambitious, very large scale approach to the next stage, based on those elements of case finding and contact tracing, surveillance, and sampling and testing.

Okay, thank you. Chair, I'll leave it there, because I'm conscious that we're up against the clock.

Very wise indeed, Lynne. 

Thank you, Chair, and good morning, both. I'd  just like to ask you, really, if you could tell us a bit more about what you feel the financial pressures being faced by the sector are and what you think the main reasons are for this, and whether you feel you're getting appropriate support from the Welsh Government to deal with these pressures.

Who wants to kick off?

Mary?

Mary, go on.

Thank you. So, thanks very much for the question. As with everybody, there are enormous pressures on the sectors financially, but also, obviously, we're a sector that needs to keep running, keep caring for our most vulnerable citizens. The sector, as you know, was already in a vulnerable situation, with difficulties in recruiting and retaining staff, widely recognised as underfunded, and we've gone into this crisis in that situation. We've seen providers have to make extensive extra costs. Already, for both care homes and domiciliary care providers, the vast majority of their costings came to staff wages. We are obviously seeing the cover for people self-isolating, people shielding, but also where we've had cases, or suspected cases, in care homes, people have had to staff up in a way that allows them to be cared for in isolation, which is obviously an increased staffing cost. Then, in addition to that, we've got issues like IT moving things that don't need to be in-house, out of house, ensuring that residents can remain in contact with friends and family while there are no visitors in a care home. We've seen significant extra costs in terms of PPE, mostly because the usage has had to go up significantly but also because the cost of items themselves has increased. Also, there have been issues with food supplies, cleaning supplies, obviously. We are way above and beyond normal infection-control measures in terms of what people have to do—so, cleaning supplies in terms of staffing to do that and the supply itself.

So, there's a whole plethora of extra costs that are being applied and, you know, we were very pleased to see the extra £40 million from Welsh Government. But what we would have liked was a national distribution scheme, and the difficulties we've had are 22 variations on a theme, effectively. So, very little, if any, of that money so far has made it to the front line, and we are in discussion with local authorities and with health boards for the clients that they fund—you know, in some of our nursing homes over half of the residents are commissioned by health boards, and there's been a lack of clarity about whether the £40 million was supposed to cover that, or was it supposed to come from health boards? We heard this morning it will be down to health boards to fund their clients, and local authorities, out of the £40 million, to fund the social services clients. But in the meantime, this money isn't getting to the front line. People are having to talk to banks, talk about loans, talk about rearranging mortgages, and people have resorted to crowdfunding just to keep going and to reward staff for keeping going.

Okay. Mario, do you want to add anything to that?

I think that's a very comprehensive assessment, as you'd expect from Mary. I think I would just add that it's very important that we acknowledge the difference in Wales to the general tapestry, if you like, of care home services in England. A lot is made of the similarities. Well, the difference in Wales, of course, is that the overwhelming majority of our homes—and very fine homes they are—are small and medium enterprises, with very often one or two homes per family enterprise, if you like. They're often very, very important places where people don't have the transport—they're in those communities.

At this moment, so many of those people are really hurting. If you pay business rates, you get about £25,000 back. If you're not paying business rates, in my locality, you're getting a £10,000 loan. If you're a hairdresser, you close down, you furlough your staff, you wait until it's safe to come out. We should never forget this moment and the care homes in Wales—the domiciliary providers and their staff at the front line, dealing with people who are shedding huge amounts of this virus in some cases. I do hope that, when we come through this, one of the key things we learn is that we never look down on social care and social care workers again. I think it's so important now. The public need to have trust in what we're all doing. I think care homes are very safe places in normal times, but we were never commissioned to deal with this.

Of course, going back, as I started with the difference between England and Wales, we just don't have a significant private market in Wales outside very small local areas and a very small number of care homes. These are publicly funded residential homes for adults, and nursing homes, doing a great job, and without them, the issue that was referred to in the question about sustainability—. We put a very clear case to Government many weeks ago, and sustainability was one of the points. We got sidetracked to other issues, but, on that sustainability, I think, moving forward, when we've had all of the inquest over what may or may not have been done, we've got to have a national action plan to ensure that we keep as many of these services that we're going to need today and in the months and years ahead.

Great. Lynne.

Thank you. Mary, you referred to the difficulties with the £40 million and getting that to the front line. Is there anything that can be done now to accelerate that? I'm assuming that some authorities are doing better than others. Is there anything the Government could do to make sure that that gets to the front line really quickly now?

I think, as you say, some authorities are doing better than others, as you'd expect. What we've said is all providers have seen an increase in cost. What some authorities are looking at is a basic flat rate going to everybody to cover that and then looking at additional issues, which might be additional particular costings relating to a service, but also there are serious problems with regard to occupancy as well, which is potentially undermining services that, if they're not supported quickly, will have to exit the market. People are considering these decisions at the moment. I think we need action and clarity to get that money there as quickly as possible.

The more specific Welsh Government can be about the authority of local authorities to pay that money, the better it will be. The guidance that did come out said that authorities shouldn't wait until they've got the money from Welsh Government; they should pay on the basis of the guidance. But I've seen an e-mail, yesterday and today, from some local authorities saying that they are not prepared to do that until they've got confirmation they are getting money to cover those claims and got that actual money. So, we just need to cut through the bureaucracy on this and ensure that the money actually gets to those services before they take the decision that they can't carry on.

In terms of homes not being able to carry on, what is the scale of the problem that we're looking at here? Are you able to give us any idea of the numbers of homes that could be at breaking point?

It's obviously a moving crisis, but what we're seeing is more homes being hit by COVID-19, and what's potentially tipping people over is that reduction in occupancy and people's nervousness about taking new people in while they can't be sure whether or not they've got COVID-19 and whether doing so would put additional people at risk. So, I think we're talking—it depends how the outbreak proceeds—but we're potentially talking about a significant proportion of the sector, and this is obviously linked to the questions around testing as well, and how people can reassure themselves that taking new admissions is sufficiently safe that they are able and confident to do so.

Can I ask what morale is like, then, amongst the staff in the care homes? Because I've spoken to one care home in my constituency, and it seemed to me that the staff were really quite traumatised by what they had been dealing with. Do you feel that support is there for staff in this situation?

I think staff are doing as they always do, but particularly in this situation, they're doing an amazing job in terms of, you know, they realise that, for many care home residents, for most care home residents, they're the only people. They haven't got outside entertainment coming in, they haven't got visitors coming in. So people are going to enormous efforts to make their life as enjoyable as it can be in those circumstances, but they're then coming out of that and seeing the reality. We've seen staff lose residents they've developed a relationship with, we've seen them see themselves and other colleagues potentially contract COVID-19 as well. I think there is an enormous amount of trauma in the sector, and I think that's only going to increase. We have seen some local schemes provide greater support. Obviously, the larger organisations have the capacity to do that, but as Mario said before, over half our care homes in Wales are single, stand-alone organisations. We are having discussions, and as I say, some local schemes have been put in place to give people access to support services, but I think we're going to need that to be increased, and on an ongoing basis. 

Okay, Lynne. 

I've just got one final question, which is to ask you whether you've had any experience of care homes talking about concerns about do not attempt cardio-pulmonary resuscitation notices and approaches from local GPs, and whether that's an issue you're picking up at all. 

In terms of approaches from GPs, I think we've had contact from one or two members about that specifically. Obviously, in terms of care planning and end-of-life planning, it is a conversation that care homes are used to having with residents and families, and it's important that that's done in as sensitive a way as possible. What most people are trying to do is to continue to do that in a normal way while recognising the effects from outside. So, I think there have been a few isolated issues, but so far they do seem to have been relatively isolated.

Thank you very much. 

Okay, Angela.

I've just got a couple of questions on finances, and then I just want to ask a couple of other questions that I know don't fit in anywhere else on the agenda. Of course, as a committee we've been quite aware of the issue and the fragility of the care home sector, because we did a report on this only a few years ago, and it's more than unfortunate that nothing's been done to help underpin the sector since then. When we talk about the overall finances, I just wondered are there many homes—. Mary, I think your words were that there was a variation on themes when it came to, for example, how the local authorities were going to disperse the £40 million. Is there a variation on themes between local authorities in terms of continuing healthcare payments? Because I'm slightly worried, and I have had quite a lot of correspondence with some, especially in the light of the Supreme Court judgment that there should be more parity in terms of continuing care—of course, a lot of our care homes will do continuing care for patients—and what effect that's having on financial sustainability. 

If I could come in on that one specifically that you raised, it's a very, very important point. The First Minister said only last week on the television that the sector was fragile coming into this. Everybody knows that, and we've had the sector managed, effectively, by local government and health boards for virtually a generation. That's just a plain statement of fact. So we are where we are, and moving forward, when we talk about differences with CHC, it cannot be right that the difference between somebody in one part of Wales who is receiving funded CHC care through a local health board in a particular area could be as much as nearly £9,000 a year different to another part of Wales. This is why, really, from the inception of Care Forum Wales in 1993, it's not been about taking responsibility away from local government or health boards to a total degree, but there has to be some consistency.

What we're seeing at the moment, as you would expect, is that where those homes have a significant reduction in their income through loss of occupancy, and where they have a lot of people funded through CHC, if there is nothing, as Mary said, coming through yet from those CHC payments, you simply can't make it stack up. It's simply impossible. So, we have members losing £10,000, £12,000, £15,000 a week. I spoke with somebody yesterday and not only are half his staff self-isolating or ill or have left, he's got three quarters of his people funded through CHC. And he, just to put it in context, is receiving something like £5,000 to £6,000 a bed less than if he was in another part of Wales. Well, the figures—you can't make this work.

I think the big question, if I may be so blunt about this for the committee, moving forward in the months and even years ahead, is: what sort of a sector do we want? Where does that sector fit in with the NHS? Does it really underpin the NHS? Because what we're seeing is most people are being discharged from the NHS to care homes, where it's not reasonable for them to be receiving one-to-one care in their own homes. Obviously, we want people to go home, we don't want people in care homes, but there's never been more than about 4 per cent of the population. The over-85 population is supposedly going to increase by nearly 100 per cent in 20 years, and we've got 20,000 care home beds.

If I could just make one really important point here about occupancy, because this is the key to this issue. Knight Frank, and there are others, do an annual report on the care sector in the UK, and it's typically shown that, in Wales, occupancy has been just north of 90 per cent. So about 91, and I think last year it was even 92 per cent. Now, we've even got a fragile sector at that level. So what we need to watch now, and really the answer is what Mary was saying earlier, what we need to watch is that average occupancy percentage. And nationally we need to monitor that, because that will tell us the overall state of the sector, because people will get to the point—. This is going to go on, we're told, for 18 months or two years; we've got to make sure, if we want this provision to survive, that we have that national action plan. It is not about bailouts, it is about making sure that we've got the occupancy and the support that we need so that these vital services can continue in their communities, because if they're not going to continue, then we've really got to build more-or-less state nursing homes next to hospitals, or something, in the big cities. That's the only alternative. We're going to need this support. 

Okay. Mary. 

I just wanted to add a couple of things to that. Firstly, just to set the situation in normal times, as it were, we still have parts of Wales where a person's needs increase and they move from funded nursing care to continuing healthcare, and the fee that is paid for their care goes down because of the mismatch between health boards and local authorities. 

You referenced the Supreme Court judgment about funded nursing care. It took us over two years after that judgment to get a final settlement. So this is the sort of financial difficulty that nursing homes have gone into this crisis dealing with. We've had the £40 million announced, but we now understand as of this morning that that only relates to local authority-commissioned care. So CHC commissioned by health boards is down to health boards. And while that may be the right policy decision, we've now got to start having those conversations that we've already been having with 22 local authorities with seven health boards before money gets to the front line. 

Angela.

Yes. Thank you for that. In fact, Mary, I've spoken to a number of directors of social services in various authority regions, and I think almost without exception they've pretty much said to me that their share of that £40 million—very welcome, very needed, but it has already been spent in all the prep work that they've had to do so far.  So I can completely understand this issue.

I just wanted to touch on one other area, which was about, you talked about occupancy and the pressure to perhaps take people. Now, I've had quite a lot of care homes contact me, and they have two sides to that story: some who are saying that they've been under immense pressure to take patients in out of empty hospitals—i.e. hospitals with less pressure than we were expecting—without having confidence in the testing that has been undertaken on that patient, and I've also had people contact me with the converse, that they've had very sick patients or residents within their care homes and they can't get the hospitals to take them back in to look after them. So, I wonder if you could just give us a brief comment on those two scenarios, and also your view on some of the ideas that have been floated that some of our field hospitals might be used instead to look after care home residents who are COVID positive, in order to relieve pressure on small care homes that perhaps don't have a lot of distancing ability within them, and of course what consequential financial effect that will then have on that care home. 

Mary.

So, I think what you said is representative of what we're hearing as well in terms of both undue pressure from hospitals to take people without testing, and we know that just one test—actually, the scientific evidence is moving all the time, but it seems to suggest now that just one test is not sufficient to guarantee that someone is COVID-19 free. And equally, providers were told by health boards at the beginning of this crisis that sick residents would not be admitted to hospital. Particularly, residential homes without nurses are just not geared up to care for people in those situations. So, I think it's important to look at short-term solutions, which may include using field hospitals, community hospitals, et cetera, and we've got to be sure—. We've got to think about the other residents in the care home, but we've also got to think about that individual as well and where is the best place for them to be cared for.

But then, we've also got to be think about the sector we're going to need coming out of this. You know, Mario's reference to the demographic pressures we already knew about. What we also don't know is how many people who do recover from COVID-19 are going to need more care than they would have done previously. And so, we need a sector that's able to offer that as well, and unless we can guarantee payments that, over the crisis period, adjust for the low occupancy and reduced income that people have got—. We know of providers whose staffing costs per week are more than their current income. That's not sustainable, so we need to find a way to cover that, so that the sector is there to provide what's needed afterwards as well. 

Okay. Angela. 

My very last point, Dai, is just to pick up on that. You make an absolutely vital point about the fact that some of the people who are coming to your homes having had COVID will need more care afterwards. Could you just give us any indication of what effect that might have on your pay structure or the type of person a care home would have to employ? Does that mean you have to start, even if you're a non-nursing home, in order to look after somebody who has had COVID, would you have to then start looking at hiring a professional medical person, as well as your normal care team? 

I think the difficulty there is in terms of nurses, for example, actually we know there is a greater demand for nursing homes at the moment, or going into this crisis, but actually, the difficulty in recruiting nurses meant that some nursing homes were moving out of the nursing care market into residential. And in terms of the pay structure for staff, as Mario said, the vast majority of care in Wales is publicly funded. We see local authorities and health board commissioners using toolkits that assume that everybody is paid the legal minimum wage, or very marginally above, and we can't carry on like that. We've got to recognise the skills and training that are already needed, let alone the additional work we're going to have to look at in terms of rehabilitation for people recovering from COVID.

Thank you. 

Jayne, did you have a question or were you just randomly waving at me? 

I must have been randomly waving at you, Dai, sorry. Agreeing with—. Agreeing.

It's all appreciation, obviously, and taken; excellent. Moving on to testing, and we've got Rhun ap Iorwerth now.

If I could just come in. I'm going to ask Mary just to fill in some of the detail in a moment, which I think would be incredibly helpful, because she's in such close touch with so many members on a daily basis, and I think she'll forgive me if I suggest that she's quite expert in this area. But I'd like to just talk about some of the background to this so that everybody is very clear and it's a matter of public record. 

We could see, obviously, what was happening across in Europe early in the year, and we decided that what we needed to do was to look at some key things that social care needed to consider. We were somewhat surprised that we were not reached out to early enough in this, and that's also a matter of record already. We felt that the five nations, which we are fully part of, with our colleagues in England, Scotland and Northern Ireland should have been, along with Mary, involved right at the beginning to give that expertise. I think because there was this huge focus, and understandably, on the NHS, on people getting that planned and all of the issues around critical care—. We saw what was happening particularly in Italy and in Spain.

So, we came up with, right at the beginning, some very simple ideas and those were simply like writing to or asking the chief medical officer for, effectively, a form of words that we could say to relatives to reduce footfall. We were told very early on in this that if people were to succumb to COVID-19 in a care home, even in a residential home, they were not going to be admitted to hospital. This was early February, and so that started a whole issue around panic, because normally in these homes, particularly in residential homes, if somebody becomes very ill, unless it's a palliative case, which they're very often very skilled at dealing with, they would be referred to a hospital. So, the issue of PPE came up.

We were talking about helping the NHS before the virus was in the community in a large number. We could actually safely discharge people from the NHS hospitals into capacity that existed. And that's where this whole issue around testing started to come through. We could not understand, and this is why a lot of people closed their doors early, which is partly why we've got occupancy problems, because people were not confident that people were being properly and robustly checked, even without testing, in isolation before they were being transferred to care homes, and I think we can all see the results of that. You certainly don't need me to tell you that we've had many issues in care homes of people who have been admitted whether they're asymptomatic, whether they even had the virus. They have spread that virus in those settings and the results in some instances have been quite catastrophic.

One life lost should be considered a tragedy. And I think it's got to be on the record that there was not enough done early enough to look at the nearly half a million people in the UK, nearly 20,000 people in Wales, in our care homes—vulnerable people. And then, because of the policies that were being adopted, people were clearly being admitted, particularly to nursing homes.

I was astonished recently to note, I think it was a week ago, that about—I understand from the BBC report—that some 40 per cent of deaths in Cardiff had been in care homes in the Cardiff area. Now, that is not anything to do with poor care homes, poor infection control or the lack of PPE. And, quite frankly, it simply is not good enough where you've got a sector that is predominantly funded through health boards and local authorities for very vulnerable people with the public purse to turn around and say, 'Well, actually, if we've given you the PPE you have to pay for it in England', or 'Well, we'll sort testing out when we get round to it.' We should have been testing people or making sure that they stayed in the situ that they had, and I think this is so important. I'm going to hand over to Mary to talk about some of the—

Mary.

Thank you. In terms of testing, we've obviously seen progress in terms of the policy and the extension of who is eligible for testing, and that's very welcome.

I referred earlier to people's concerns about new admissions and, anecdotally, our understanding is that cases were introduced into care homes by early admissions where people were asymptomatic. And I think that's one of the things that is very different about this disease, compared to other diseases that perhaps people are used to dealing with, is that people can be carriers while being asymptomatic, and we know that there are asymptomatic staff and residents who are testing positive.

I think policy changes—as I say, we'd like them to go further, but they have moved in the right direction in terms of extending eligibility for testing. I think it's fair to say that some of the practice on the ground—and I heard Members refer to this in the earlier session—is not necessarily reflecting or keeping up with the national policy, and that is also causing confusion and stress. And some of the issues just around logistics in terms of the amount of time people have had to spend chasing tests that have been requested, chasing results for tests that have already been taken, and trying to ensure that tests happen has just been an increased burden on the sector that has been unnecessary.

Rhun.

Both answers are very useful, and I'm grateful for them. They raise many, many questions as well, and we'll perhaps look at a few of them. Could you see where the barriers were—either Mary or Mario—when you said that you were trying to get messages, sometimes very simple messages, through to Government? Could you see where the barriers were?

We've used our normal channels and, in the last six or seven weeks, we've had a great deal of involvement. If I can be quite frank with you, I think the issue was that the sector, particularly the care homes, were not given the urgent attention that they needed early enough. Outside of Wales, I think the Prime Minister even referred to that yesterday.

This should have been looked at in January and people should have been brought together to say, 'What are the particular issues?' And even with all of the difficulties, when the country that's locked down produces 90 per cent of the PPE, so we can’t get it out—even despite all of that, what things could we have done earlier? And the barriers seem to us to be that we started from this position on testing where there was not going to be any. We were told, quite categorically, unless they're showing symptoms, they're not going to be tested. So, people were being discharged from hospital to very-well-meaning people in the care sector in Wales, often with smaller homes, with people who had not been tested because they were not showing symptoms.

And it took until, I think, 10 April. You sent that letter to the First Minister highlighting those severe concerns about hospital discharge in particular—

No, it was certainly before. We actually started our communication on this back in February, and I remember it very well, because I was sitting on the tarmac at Dublin coming back from the rugby texting somebody just to check that I had the right name of the chief medical officer. So, that's where it started. The following day, Mary—because we've got clear timeline on this—. It's not about, 'We told you so'. This is about learning now, just as we started talking about sustainability, if we are going to sustain the capacity, we are going to have to go back and look at where does the sector need to be engaged. If we look at testing, we were calling for testing right back in February. We were following that up again in March. The letter to the First Minister came much later into this. We'd been having regular meetings.

But I think the bureaucratic process of where all of the health boards sit with local government, Public Health Wales, with Ministers or officials we were talking to—. We accept this was a global pandemic and we are all in new territory, but some of those simple opportunities were missed, and that has had a very significant repercussion for a lot of people and we've got to now decide—

Rhun.

Thank you for that. I should have been more careful in my use of words. What I meant to say was that you were still having to write to the First Minister as late as 10 April.

Two issues. Mary, you said that the guidelines now are better and most people would think they were—the guidelines published last weekend. You would still like to go further, you say. Does that mean full testing of all asymptomatic staff and residents in the care sector?

Yes. I mean, we recognise that there are capacity issues in terms of tests, but we would like to be in a place, because people being cared for in care homes are so vulnerable to this disease, we would like to be in a place where there were regular tests of both staff and residents. And we're seeing some evidence from overseas that that is what enables you to stop continuing outbreaks in care homes. 

And I've certainly seen some of that evidence too. You're not saying this because it sounds as if it's something that might work; you're saying this because you're seeing evidence that it does work in other countries or has worked. 

We're seeing evidence internationally that it does work and we're also seeing evidence in our own care homes that, where testing of asymptomatic people isn't done, that outbreak increases, but also where asymptomatic people are tested, they are proving positive in some cases.

There are other halfway houses that we could look at in terms of increasing testing from the position we have with the new guidelines. The threshold for testing everybody, the 50 residents threshold, seems a bit arbitrary. What are your thoughts on that? Because it seems to me that there are few residential homes with 50 in, say, rural parts of Wales, for example. Mario?

Yes, and a lot of the larger homes tend to be newer built and you can't generalise, but a lot of them, for example, you will be able to reduce down into isolation units far smaller than that, whereas particularly in smaller homes in more rural areas, you might have a 20 to 25-bed home where it's impossible to isolate people within that because of the structure of the building. 

Yes. Mario, did you want to comment on that threshold in particular and whether—[Inaudible.]?

I have absolutely no idea where the 50 came from, because the average care home in Wales is not 50 beds. You couldn't build a 50-bed home today and make it viable. You'd have to be at least north of 60 and probably in the 70s. But the truth is that, in Wales, most care homes are in the—. You'd expect them to be 30 or 40-beds. So, I have no idea why 50 beds, and I do think it is a bit arbitrary, but then, so many things about this changing guidance has been arbitrary and some of the things, it would appear to us, have been guidance changing almost with one eye to what was available, whether it's numbers of tests, whether it's the amount of PPE, rather than actually what should actually be put in place.

Rhun.

And the last one from me, again referring to what you said, Mary, but what we're seeing actually on the ground is rather different to what the guidelines are telling us should be happening. I've had another email this morning from a care home manager here in my constituency on Anglesey saying, 'We're not seeing what we're told we should be having'. What are your thoughts on that and how frustrating is that for you as a sector where even when you're seeing decent guidelines, they're not being put into practice?

It's extremely frustrating that we've had members yesterday being told by Public Health Wales and by health boards that, although the policy was now to test all residents and all staff where there were outbreaks, for example, actually, they couldn't facilitate that. Care homes where the outbreaks started before the policy change had been told, 'Well, you don't fall within that remit'. Care homes who have had a start of an outbreak have been told, 'Well, we need to gear up to do that'. I mean, it is happening in some places. One of our members reported back yesterday that they were very pleased to have the army arrive and do full testing of all residents and staff, but in too many cases, care homes are being rebuffed back by either Public Health Wales or health boards in terms of requesting the testing under the policy. Sometimes it's then happening, but there's an enormous amount of effort going into making that happen. And I suspect, firstly, care homes are dealing with an epidemic and haven't got time to put that effort in, but I suspect also there may be a bit of a case of who shouts the loudest, rather than it actually being available to all care providers in the way it should under the policy.

Diolch, Cadeirydd. On PPE, clearly you've already highlighted that you think you actually are getting to a situation where it's better—that's in your evidence given to us—and, Mary, you also mentioned this morning the cost of the PPE at the moment is one of the big burdens on all social care homes. Where are we at the moment? Are you getting sufficient supplies through the Welsh Government via local authorities? Is that compensating some of the costs you are facing as a sector, because we know they've increased in certain areas, so where are we at the moment?

So, I think we're not in a crisis situation, which I think we feared we were a couple of weeks ago. I think, you know, what happened with some of the PPE supplies is that things were delayed, so things that providers were expecting a couple of weeks ago are arriving now, effectively, and are already paid for. We are getting some supplies via Welsh Government and local authorities that can help supplement the supplies that providers are buying themselves. I think as—. You know, the problem with PPE is a lot of it is not reusable, and so we've got continuing concerns going forward about if something were to happen to break supply chains again, or simply just the escalating costs. We've been in contact with suppliers who are talking about 200 per cent increases in the costs of PPE going forward, and, obviously, that's another financial burden for providers. So, it's certainly something we can say: 'We're not in a crisis situation, but we need to keep our eye on it and we need to ensure those supply levels are kept up.'

Are you able to do a sort of national procurement type of approach? The NHS, for example, has an all-Wales national procurement approach, which gets bulk better, in one sense. Are you able to do that, or is it down to individual care homes to seek their own suppliers?

Individual.

Yes.

Individual.

Yes.

Therefore, it's more challenging for them to actually find, against some of the big demands elsewhere?

Absolutely.

Yes, absolutely.

That is the problem. And one of the things that we're not seeing coming through are gowns. I know that it's well documented today, the problems with gowns from Turkey, but, I mean, we are not seeing enough gowns for people, and if you have COVID-19 in your care home, you really do need to have the right masks and the right gowns. So, I would absolutely agree with what Mary said: it is certainly much better; people have worked very hard. We know the challenges, but we've got to accept that care homes in Wales supported by the public sector were never commissioned to cope with a global pandemic of this proportion—it is beyond anything. And you use so many of these every day; this is the problem. And you've got to take the view, because testing has been so shambolic—you've got to take the view that somebody might have it, so you're caring for somebody for maybe a week before actually using all of that PPE, when, within a couple of days, you could have found out that it was just a mild chest infection and that has been one of the issues.

Okay, David?

Yes, just one final thing on PPE. Where do we go now, because I've read your evidence, and you've actually indicated that one of the concerns you had back in February and March when you wrote earlier letters—? Did the sector prepare itself, because if it was just concern—you were obviously aware that this might be an issue? Was the sector getting ready itself at that time? I know the guidance has changed, I accept that. [Inaudible.]—clearly, the situation as to there was an awareness back in February and March.

Can I just say that we absolutely did everything? I mean, the efforts that people have made, going out to other businesses—tattoo artists that have closed, all those sorts of people—basically, trying to cobble together anything they could, because what very quickly happened was that major suppliers coming into the UK were effectively being commandeered by the NHS, so the suppliers, and my supplier is one of them—. I mean, I spend about £300,000 a year with one supplier; even some of his kit was actually being—it was getting into the UK and container loads were being effectively commandeered. So, what you had in a situation—. You couldn't get it from suppliers. People don't keep this sort of kit in the quantity that you need it, because it's something that you just wouldn't do. It's not barrier nursing of norovirus or the seasonal flu, this is something on a completely different scale.

David.

I'm aware of the time, Chair.

Okay. Jayne.

Thank you, Chair. Just going back a little bit on the supply, you sort of alluded to the fact that it has improved slightly, but do you think that you have enough understanding about whether that PPE is going through local authorities, or how do care homes know who to contact? Are there any problems? Do you find little hotspots around Wales, or where people are still having problems with that supply chain?

Mary.

So, I think the PPE that's coming through local authorities—the supply is quite unpredictable. I had one provider speak to me yesterday to say, 'Oh, it's brilliant, we've received—'. I think it was something like 6,000 gloves, whereas last time, in the last few weeks, we got a box of a 100. And so, it's great, but we didn't know if we were going to get that and we don't know what we're going to get through that route next week. So, you know, there does remain a lack of clarity there. Sorry, I think there was another part to your question.

Yes, just if you're able to map that, really, and find if there are hotspots, really, that you could work with local authorities, because I think it's really important that people know who to alert and if that is working.

I mean, I suppose our hotspots are based on members who are contacting us to say they've had problems, and, again—. The guidance on PPE was changed on Maundy Thursday. I think that's created some confusion in terms of—. There were some local authorities who were immediately sort of accepting of that new guidance; there were others where it took a week or so, and we were getting members contacting us saying the local authority was saying they're not supplying this because it's not the guidance, whereas, actually, we were saying, 'Well, no, no, no. This new guidance, issued on an all-UK basis by the four nations, was issued last week, and this is what they should be doing.' I mean, we got that guidance out to our members on the day it was issued, but the same communication channels, as I say, didn't seem to work all the way through through local authorities. 

Okay. Jayne. 

Thank you. We're having some reports about some homes who are confining residents to their bedrooms as precautionary measures for safety. Can you tell us a little bit more about that? Do you know how many homes are doing that, and what do you think could be put in place to make them feel more confident to relax those measures?

Testing. It's got to be testing, and regular testing. So, you can't just test people once and then assume that they're clear. I think—. We know if this disease spreads in a care home, its effects are absolutely devastating. So, what people are absolutely committed to doing is, if they've got a resident or a staff member who's symptomatic and they think there may be an outbreak, they want to preserve and cocoon those people who haven't yet contracted it to try and ensure that they don't. Regular and prompt testing, and speedy revelation of the results is what's going to help people in those circumstances.

Okay, Jayne? 

Yes. Thanks, Chair. 

Yes. Just to pick up on something that Mario said on difficulty in sourcing some PPE. We heard some of your members say over the past few weeks that they had been told by their regular suppliers that they weren't allowed to buy some equipment—that Public Health England had told some suppliers, 'Don't sell these bits of kit to Scotland and Wales.' How much of a problem did that cause for your members, for the care sector in Wales, and have you got to the bottom of what happened yet?

So, it caused problems, ultimately. Because of all the issues with the supply chain, a lot of PPE suppliers were only dealing with existing clients. If you happened to be an existing client of a firm that had things in stock that Public Health England were saying could only be sold to providers in England, then you weren't able to access those, but you also weren't able to access them from alternative suppliers in the way you normally would, because they were only dealing with existing clients. We haven't got a handle on the scale of that and I think it's probably one of the things for the review afterwards.

Were you surprised, Mario, that Public Health England were telling suppliers that they presumably knew would have been supplying to the whole of the UK, 'Only sell these things to England'?

I was astonished, and it also brought to my mind—as a personal view, this is not an official Care Forum position—that we need to consider moving forward if we're going to have another national emergency of this scale. We need a much clearer understanding of how the devolved administrations work together. Because the confusion, just to add to Mary's point—not just PPE, but the confusion on guidance and announcements on a Thursday that might be in London that people are listening to on their televisions—. Even the announcement about the £500, which was very much appreciated, that has caused all sorts of issues, as you can imagine. So, it is a major issue, and I think communication is something that we'll need to look at in the months and, indeed, years ahead.

Yes, okay.

Yes, thank you very much, Chair. Can I just ask one final quick question on PPE? Because of course we're having to go out now, we're buying it, it's being made, so we have a chance to influence the PPE that we have in care homes, and I just wondered if there'd been any feedback, or would you be interested in getting feedback, on what effect PPE is having on residents in care homes, given that many of them are extremely elderly. And I'm particularly thinking of people with dementia, people who are very hard of hearing who would find it very difficult to hear somebody from behind a mask, the anxious and frightened who might just see somebody coming in with lots of gear on and just not being able to cope with it. Maybe there are changes that we can make to PPE, making it transparent or whatever. I just wondered if there's been any work on that at all, or thought on that.

I'm not aware of any, but I think you make a very, very good point, particularly with regard to dementia. That is also one of the elements of this crisis that's been most challenging, because people will understand if they're going to be nursed in their own room, but people, obviously, with dementia, in very many cases, will be very ambulant and will be walking around, and of course you can't stop that.

I think the points you make about PPE moving forward are very, very important, because there are two things: (1) we've got to be sustainable; we cannot possibly go through this ever again where we're expecting kit from the far east to help us out, and to fly gowns in from wherever that don't even meet the standard. I mean, this is nonsensical.

I think that gives us an opportunity to actually look at design, because we've been driven in globalisation by price. We make this kit in places where working conditions—. I was told the other day, 'Why don't we make gloves?' And for anyone that's interested, I was buying packs of gloves in February at £14, I will be buying them next week at £60. Now, I used 1 million gloves a year before COVID—you can understand this is significant. I asked, 'Why are we not making gloves in the UK?', and I was told, supposedly by somebody that understood this, that, in fact, the environmental issues mean it's very difficult to make these things in Europe. So, it seems as though it's all right to pollute somewhere else.

I think the whole issue of PPE—and the first job of the state to keep the citizens safe is where we should focus our attention. And if we can do something special in Wales, I think you'll have the backing of the whole care sector.

Angela.

Yes, thank you, I'd just like to move on to deaths and how deaths are recorded in Wales and recorded in care homes. Could you just very quickly say, from a care home perspective, if somebody dies in your care, what is the process for registering that death? Because we talk about it, but I'd like to get on the record exactly what you have to do.

Mary.

Just to go back to the previous question, I just wanted to make two quick points. One is that some people are experimenting with design and putting things on masks that make them look less scary and that kind of thing. So, I think, again, that's something we can look at afterwards. I also think the confusion or changes to the guidance around PPE sometimes cause concern where other health professionals were coming into a care home or coming to see people receiving domiciliary care with one set of PPE, and then care workers were coming in with a different type, and people were made nervous by that as well. So, again, that's something we just need to think through.

In terms of recording deaths, obviously the first thing, if it's an unexpected death, is the verification and reporting to the coroner. But care homes are also— 

I think we've lost Mary.

We were going so well. 

I thought she was flying there, actually. 

Mario, can you pick that up, because I'm conscious—

I will, yes.

—we've got very little time left?

Yes. Mary was making the point about verification. So, obviously, you've got the verification, which now can be done by a competent person. Typically, in nursing homes, that would be a nurse. But, obviously, the certification hasn't changed, and obviously Dai is very well aware of that. 

I think, from the point of view of the recording, we have to, obviously, contact CIW with every death, and I think this is where some of the confusion has been, because, obviously, there's been the Office for National Statistics picking up information of deaths in relation to community deaths and obviously then you've had the verifiable hospital deaths—although not, as we know, every health board was quite as accurate as they might have been. 

So, what we now need to understand is how that translates. And I think, from a care forum perspective, we're very keen that we win over public trust about this, because care homes, as I said earlier, are very safe places in normal times. If we're not open and honest about how this has all occurred—and, clearly, so much of this has occurred by both community transmission, because of the nature of the disease, and some pretty, well, unusual policies, to basically save one issue in the NHS and actually decant that issue and that problem somewhere else. So, there are some very big questions to answer, I think.

In terms of certifying the death, it's CIW with every recommendation and, obviously, what goes on the certificate is key, and, for many people, they will have something on the certificate that may or may not be entirely accurate, because obviously we will not have had the testing to know. 

Angela.

And if somebody were to pass away today, how quickly do you have to tell CIW that that person has died?

Well, I would—. If it was somebody in my home, I would expect my managers to be dealing with that today—[Inaudible.] 

So, it would be: notify CIW today. 

I would—. They would notify that in the normal way. 

What I'm trying to drive at is how quickly we could try to get some up to date—. Because the ONS data is always so far out of date, and I was saddened by the CIW report that came out on 5 May, which basically said that deaths in care homes are 92 per cent higher this year than last year, 50 per cent higher than the year before. Obviously, it's not all—you know, there's going to be a mix, but I think what we're looking for is: how can we get real clarity as to the effect of COVID-19? How can we get those deaths reported very, very quickly so we know what our true figure is? And also, by reporting them very, very quickly, we can actually see and perhaps get more people to really understand the scale of the challenge that care homes are facing. 

Yes. May I say you make an excellent point there? I've got the figures in front of me from the report you referred to, and it's this thing about the underlying trend. It is so obvious, you would not need to know there was a global pandemic. We're seeing—. It is very, very worrying, and, of course, it leads back to that issue about sustainability in the future. If we don't on the one hand win the trust of the public about care homes and their safety and that they are well run—. Because care homes have been looking after infection control every winter: norovirus, often coming from hospitals—dealt with; it's not an issue. But this virus is so easily transmitted and the inability, particularly of those homes, possibly residential homes, where they wouldn't be used to working at this level—which is why we tried to get more awareness very early on; we wanted better training and so forth.

And, if we can improve that communication, the second point is we can plan. Because, if we can't plan for the future, then we simply won't have the capacity that Wales will need and then we'll have to have another debate about where we get that new capacity from. My argument would be, if it's literally £120,000 a bed for a new care home bed, and if you've got to build 70 beds to make it viable, clearly, you're not going to—if I may, Rhun, you're not going to have a new home in Pentrefoelas or Cerrigydrudion. We've got to make sure those valuable assets are protected, at least until we don't need them, and I think this is why the average occupancy is so important and why your point about deaths and accurate reporting is crucial to planning that is quick enough to stop us from actually falling over the edge, really.

Actually, I'll just make one other comment that hasn't really been made. When we talk about the drive for bigger, because bigger is more sustainable, we need to also sustain the small and the medium, because we're missing one bit of this—it's home.

Absolutely.

People have got to feel that they're in a home, not a hospital, not an institution, not some great big sort of monolithic place. And one of the great advantages of smaller homes is they tend to be highly, highly personal and much more like a home.

Well, can I just say, we at Care Forum Wales would endorse that 100 per cent? That is overwhelmingly our membership, and it's those small and medium enterprises that reach out to Care Forum Wales as a body that supports them. We've got members that have been there literally from day one, on 1 March 1993, and the day that those small homes across Wales are lost, in my view at care forum, will be a very, very sad day indeed. Because they are home and they do provide a level of care that you will not replicate in the future, because it won't be possible to do it. And, again, we argue: keep what we've got, at least until we decide that as a nation we don't need it.