Cynulliad Cenedlaethol Cymru

Good morning. Thank you very much for the opportunity to come and give evidence today. We have provided some written evidence to the committee, and the committee will see in there that there have really been six areas of concern for us that have come through from our members. And you asked for the headlines, so I'll just briefly explain what those six areas are: firstly, personal protective equipment, which has been an issue for our members, and that has been regarding the supply, the guidance around what equipment should be worn, and then the communications across both health boards and into social care.

Secondly, testing for health and social care workers—a number of our members are experiencing difficulties in obtaining a test, and, again, some difficulties in terms of communication as to which staff in which sector should be presenting for testing and then how to go about both booking and actually having that test.

Thirdly, arrangements for student nurses—this group of students, particularly in the second and third year, have been given opportunities to join the NHS in the fight against the virus, undertaking some paid work, and we've had a number of issues in ensuring the smooth implementation of those arrangements for nursing students.

Fourthly, risk assessment and guidance on staff deployment, particularly for black and Asian and ethnic minority staff in a changing landscape, as evidence has come in during the course of the last few weeks demonstrating that that group of staff seems to have a particularly severe reaction to contracting the virus.

Fifthly, levels of safe and effective patient care, working to ensure that both the legislation—the Nurse Staffing Levels (Wales) Act 2016—continues to apply, where appropriate, and then just looking at, if the pandemic was to reach a particularly difficult point for NHS Wales, what safe and effective care would look like in that context.

And then, lastly, communication and partnership working with the Welsh Government. When we started out on this journey some months ago now, we were asking, on a daily basis, for information, which was not always forthcoming. I believe that that has changed in the last few weeks and we are now being briefed regularly by the Minister and his officials in terms of both personal protective equipment and testing. And we have regained some of our good partnership working that we've always enjoyed to do well here in Wales.

So, those are the six key areas, and I'd be happy to delve into those slightly more for committee members as they require.

Thank you. We've also submitted some written evidence, which you will see. The first thing I want to say is, really, credit to all the professional staff in the NHS in Wales for the work that they've done, and indeed to the people in Welsh Government, who've been actually quite supportive.

A lot of issues—and I wouldn’t disagree with anything that Helen has just said—are due to perhaps sub-optimal management, rather than negligence of people. So, I'd highlight a few others, if I may.

The first one is technology. We are dependent today on technology, and there were some glitches in rolling that out. I think the feeling is that it could have been easier for health staff to work remotely when they were self-isolating than it has been had we had more access to technology. And this is now being rolled out.

Also with technology, we've had the introduction of remote consulting. This has worked pretty well, and GPs across Wales have been embracing this, and I think it's well-received by patients. We've also just, in this meeting, highlighted one of the issues with that, and that's that the broadband infrastructure in the country is somewhat deficient and is not fully able to support this.

Moving on to the organisational issues. I think, centrally, like Helen said, once we'd got together with Welsh Government officials and senior NHS officials, they've been responsive and receptive to suggestions that we've made. I think where there have been issues, that's in the health boards across Wales, which have had, I think, different competencies in terms of implementation of the measures that need to be taken for management of the COVID effectively.

There have been inconsistent messages across the country. We've had members in one part of a health board saying, 'Well, we're being told to do this', and in another area being told to do something differently. So, a more consistent and better distributed message. Also with messaging, we've had—. I get lots and lots of e-mails—they're almost too much to keep up with. We have been moving to a single daily e-mail from our health board, bringing together all the information from other sources, and that's been an important measure, I think—the information to GPs.

And then, finally, I'd talk about clusters. Clusters are groups of GP practices in localities in Wales, and we've been brought together. And that's been a positive thing—that it's forced the development of clusters. Some of them haven't had the maturity to do this as effectively as others, and there have been teething troubles, but, in general, that has worked reasonably well, particularly in the establishment of COVID centres. But, again, the support of those centres from the health boards in many areas has been deficient, and people have been left very much to get on with it on their own, feeling that they haven't had the help and support.

I'll happily expand on any of those points later, and we've got other things to raise, but that's my summary. Thank you.

Helen.

Thank you. So, obviously, some of that the Government itself will need to respond to, but from our perspective, we do have well-established partnership forum mechanisms, particularly in the NHS. We have the Welsh partnership forum; it has a business committee and a number of other sub-committees. I genuinely believe that what happened when this pandemic first hit was a lack of understanding about what structures were already there and how to dovetail in emergency planning quickly into those partnership structures, because all the advice that there is out there says that when you have a situation like this you actually need to do more partnership working rather than less. So, I believe there is a lesson to learn there to be able to follow that in a more succinct and quick manner if—and hopefully never—we're in a position like this again. But similarly, things like answering letters, et cetera, has been slow and clunky and letters have only been sent because we haven't been able to get the information to seek those assurances for our members. 

I do believe that that has got significantly better, but it's taken us a bit of time. So, there is learning in that in that organisations like the RCN, we represent large sections of the workforce. We can be very helpful; we can help with messaging; we can help with allaying fears; with pushing forward positions about particularly around what type of guidance should be being followed, which was a really big issue at the beginning. So, I do believe that the Government needs to look at that as it analyses its response to this pandemic and put in place mechanisms to make sure that, early on, they consider how best to communicate with trade unions and professional bodies. 

And one key point made to me was that the communication in this context isn't just a nice-to-have; poor communication or ineffective communication can have a direct impact on the effectiveness of the response to a pandemic. Would you agree with that?

I would agree with that. I think we do a very good job in Wales of understanding how to work in partnership and it's a shame that we didn't embrace that very quickly on, because things like staff—. The guidance issue is a good one to explain. So, we had a change in guidance at several points. Some of that was about personal protective equipment and then we had a bit of change about guidance around self-isolating, et cetera. So, we're dealing with members who are contacting us asking us to help them to clarify that, asking what to do if something doesn't apply, et cetera. So, if we don't understand that, we're actually causing more of a problem because we're having to send members back to their employers or other areas and thus increase their anxiety in this situation when we could have easily have dealt with those issues, signposted them well, and allayed their fears that we'd been involved with the employers, that we'd been assured around risk assessment, around adequate supply and provision. So, getting it right is really important, and I believe we could do that better. 

I think Dr Saul wants to add to that. Thank you, Helen.

Yes, thank you. I'd like to support that. I mean, issues to do with what PPE to wear was difficult at the start, but the other thing that GPs were faced with were many people coming to us asking for guidance about how they should be isolating, whether they should go to work, and really, we didn't have clear guidance to give them. I mean, I'm sure that you may wish to talk about the shielding letters later on—

That is definitely coming later.

—but that also was poor messaging that caused a lot of anxiety in patients and a lot of work for health professionals. 

And I think you've alluded to it, but I'll ask the question in the same direct way as I asked it to Helen Whyley: did that lack of communication, or weaknesses in communication, mixed messaging, have a direct impact, at least early on, perhaps still now, on the effectiveness of the management of the pandemic in Wales? Dr Saul or Dr Morgan.

Rob, do you want to take that one—Rob Morgan?

Yes, no problems. In terms of the communication that we've sent to you in our written evidence, I think we have had very good communication lines, and meetings are regularly set up to have those conversations.

I think at the initial start of the pandemic, things weren't as well organised in terms of those communication lines as they are now, and perhaps it needed a little bit more work on our part to seek that information for clarification of what was being said publicly, or what might be coming out publicly subsequently. Unlike the Royal College of Nursing, we're a membership organisation that tries to respond to our members who are actually on the front line, and the quicker we can get that information out to people, the more effective their care is in seeing patients.

I think you can turn it on its head, though. It's not just how quickly you can get information to your members, it's how—. Certainly in the RCN's case, I think what they felt was that it was difficult to get the intelligence from the front line back into Government. Is that fair?

From our point of view, I think that that would certainly be the case. Mair and Peter, in their meetings, are taking information that is from the front line, and I can understand Helen's point, then that, if that information isn't feeding up, it's very difficult for the Government to respond in a way that is effective for that element of the workforce.

Okay. Thank you. I'll leave it there, Chair. Thank you.

Diolch, Cadeirydd. Can I go back to the RCN point? Helen highlighted the issue—or both groups highlighted the issue—of the advice on PPE changing during this process to date. Helen, can you confirm as to whether you actually had any input into the discussions that led to the change in guidelines, or were you simply informed, 'The guidelines have changed and here they are', and do you have any instructions or advice as to what that means for staff?

Helen?

Thank you. The guidance that's been used across the UK was co-ordinated and led by Public Health England, though as a UK organisation, the Royal College of Nursing has expertise in our HQ function around infection and prevention, and thus, that level of the UK RCN expertise was informed and consulted with, et cetera, for all of the original personal protective equipment guidance, including the development of the four tables that show what equipment you should wear in which setting when the virus is circulating in the community as it is now.

So, we saw that from a UK level, and we were involved in that. I believe there was a large number of consultation responses to the guidance and obviously, Public Health England then took a view about which to add into their guidance. The only area where that's different for the Royal College of Nursing is the further guidance that came out from Public Health England relating to what to do in the event of shortages of personal protective equipment. As a royal college, again on a UK level, we were shared that guidance, but we were very clear that we did not support the content in it, and that we felt that it had been driven by the lack of supply, rather than the health and safety of the individual worker. And again, on a UK level, we raised our concerns about that with both the Health and Safety Executive as well as Public Health England.

Obviously, because we have this UK approach to the guidance, then what happened here in Wales was that the chief nursing officer and the chief medical officer shared with me an alert letter that they had sent out to the NHS following the publication of that guidance by Public Health England. But in that letter, they also stated that they did not believe that we were at a point in Wales where our supplies were of such an insufficiency that staff would not have the appropriate equipment set out in the four tables. And obviously, that's something that we have been seeking assurance on and to get assurance on on a weekly basis now from the Welsh Government in our technical personal protective equipment briefing, which we are also then privy to to see the supply and any problems in the supply chain to be experienced or to be expected to be experienced here in Wales.

Okay, but just to confirm, that last bit of the guidance didn't actually apply to Wales, because you had reassurances that there were sufficient stocks and didn't need to have that guidance in Wales at this point in time.

We did, and we were grateful for those. I think that's also part of the turning point of where the communications got a lot better and we moved into doing that technical briefing, so that we were aware, and could support, as best as we could, problems that might be being experienced in the service. 

You've both, actually, in your evidence, highlighted at the beginning of this pandemic, shall we say, the lack of PPE or the confusion on PPE that existed. Do you feel that you're in a better position now—and we will look back—but are you in a better position now, as we're moving forward, to ensure that your members can actually receive sufficient PPE to address the needs of the patients they're dealing with?

Dr Morgan.

I would like to say that I do think we're in a better position now, and I think we as GPs feel a little bit more reassured by the fact that we do have reassurances of supply chains and that PPE isn't likely to run out. You were just saying that we will look back and, I think, those early days were quite scary for us on the front line, and particularly at the point where it was clear that this condition—when it was being contact traced from returners from Italy—was likely to hit the community quite quickly, and even as far back as January, GPs were starting to think, 'Well, I'm going to need some sort of protection', and were sourcing their own material at that time because, obviously, PPE hadn't been sent out.

I think, if you're okay, I could just talk about those initial stages, unless you want to talk about where we are now?

No, it's important to understand where those stages took us and so, it is important to understand was there a lack of awareness within Government to address the community settings rather than the hospital settings? 

I don't think—. I wouldn't say that that was the case, because at that moment in time, people were starting to be admitted into hospital, and those patients had significant illnesses, and it was important that the front-line staff who were treating those patients, particularly in intensive care, were as protected as much as possible.

However, what's become clear as time's gone on is that there's a number of patients, probably in the community, who've had the illness but may not be evidencing it as much as those people who've subsequently been admitted. And so, at that early stage, it would have probably been beneficial for GPs to have as much personal equipment ready, because that was always going to happen. You know, in the early stages, there were some discrepancies between what the World Health Organization was suggesting and what Public Health England was suggesting, and over time, that guidance has changed depending on supply chains and what setting you might be in. I think we're all very clear now and that the guidance that Helen's referred to has been signed up to by the Academy of Medical Royal Colleges.

In the initial stages, once it became clear that general practices were going to need supplies of PPE, I think it would be fair to say that some practices received a token amount of PPE—certainly not enough to deal with what was probably happening at the time, which was community spread, and practices were having to consider whether the PPE they had was sufficient—sufficient both in terms of quality and amount; certainly it wasn't in amount. And so, that led to lots of GPs buying stuff from industrial organisations, relying on donations from local industry; people making visors; a donation of sanitising equipment. And, certainly, in terms of the guidance, GPs found that some of the equipment they had in terms of goggles weren't fit for purpose. I think that has most definitely improved, and I would say that we are in a different place now to where we were right at the beginning, but—

Can I ask then, in that case, we are moving over to the next stage, and clearly, there's an anticipation that community transmission is going to be something that we need to ensure that we suppress if we ease the lockdown. But, do you think the committee teams, the GPs and the community nursing and the district nursing and practice nurses have sufficient PPE to handle that type of situation to ensure that there is a reduction in community spread?

It'd be difficult for me to comment on the community nurses, and perhaps Helen will add some input into that, but at the moment, I think, as GPs, we're always seeking reassurance that there is that PPE there. It's important that that supply line is continuous. What we're also concerned about is that, should things remain at the current level, once lockdown measures are reduced, the amount of community transmission will go up, and we need supplies already in our practice to start dealing with that. It does make us feel uncomfortable, if you read WHO guidance that's translated into the English guidance that we're adopting, that when supplies go down we're reusing equipment or using it for sessions that perhaps are a bit longer than we'd ordinarily like to. So, it is important that we do have that equipment and the assurance that there is a supply coming.

Helen.

Thank you. I think the position in terms of social care and care homes is one that is worth our consideration. I would agree with the availability of personal protective equipment across the NHS and its services, because we can see that on our technical briefings now each week. But for us—and you'll see in the survey results that we attached in our written evidence—we do have a number of our members in social care explaining difficulties in accessing personal protective equipment.

Now, that's a lot more difficult to communicate because, obviously, that care is commissioned through local authorities, but they all have relationships in some form or other with their local health boards. So, we have been working and talking to local health boards about how they can best assist care homes to make sure that they have sufficient supplies. But I think that's an area where we really do need to learn, because you can see quite clearly from the data coming through on people passing away in care homes that the pandemic has hit care homes.

So, I think we still continue to seek assurance and triangulate that information with our members and in how our members contact us, to make sure that nurses working in care homes and social care are receiving adequate personal protective equipment. We are seeing good relationships being built, and we're hearing that, as I'm speaking to chief executives as I go around Wales, et cetera, they are working with that sector, where clearly they're part of the commissioning process.

But, again, I think that has come as a bit of a second wave almost, of, 'We need to do this and we hadn't really planned well enough for it', and the data seems to suggest that and back that up, especially if you look at both residents who have sadly passed away and also the testing data that's come out from the Government.

Community nursing is a very complex picture because it's a number of different things. So, community nursing could be your traditional district nursing service or specialist nurses that deal with heart failure, through to nurses doing rapid response and frailty work. The majority of those, again, are NHS services. So, when we have our technical briefings, we do explore that the supply of personal protective equipment is going out to all areas of the service and not only to the acute in-patient type settings. And we do receive those assurances, I'm pleased to report. 

Okay. David. 

Okay. On testing, you've both—. Well, the RCN on the issue of testing has highlighted deep concerns regarding testing. Are you seeing any improvement? We are being told that the test capacity is increasing to 5,000 but we heard that only 1,000 yesterday were tested. So, there's a gap between capacity and actual testing. How are your staff, nursing teams and staff within the GP practices accessing testing?

Who wants to kick off there? Helen?

Helen first.

I'm happy to cover that. Again, hopefully helpful for the committee is some written information on this. Again, the experience is across a spectrum. So, there are a number of members reporting that they know how to get a test, they get the test quickly and they get the response—positive or negative—within a couple of days. So, that's to be celebrated and rolled our further and elsewhere.

We've seen a lot of our members involved in actually doing the testing, setting up testing centres on really short notice, making sure that patients can get through the tests, and have them done as quickly and as dignified as possible with what is quite an invasive test.

The other end of the spectrum is, again, in the social care and the care home sector, where they don't how to get the test. They're then sometimes told that they can't have one because they don't fit into the five original categories that the Welsh Government prioritised for in terms of testing, and sometimes, they're also told that they don't need to have one because there's no requirement to test people working in that sector.

I think the data shows that we've still got some work to do, although that is improving, to make sure that we get the message out about who can have the test and who can't. Because we're doing it for several reasons, aren't we? We're doing it because we want to try and make sure the workforce can stay at work, where it wants to be, and then, if they're negative, they can return. But we're also doing it because it helps us to understand what the profile of the virus looks like as well. So, that is very important.

We have seen an increase, but the increases are quite small, still, so we still need to do more work in this area and, particularly, we need to get much slicker about how we test staff who are working in social care settings.

It's okay, or has Helen not finished?

Yes.

I'd echo what Helen said. This is a completely new process; it's been set up rapidly and it's developing, and I think the testing process has improved in terms of accessibility and time taken to get results back. From what we're getting back from our members, I think experiences are different still across Wales, and in terms of arranging tests, although it's become more streamlined, if you look back to March, I know that some of my colleagues have e-mailed and tweeted members on the committee already about difficulties they had, and particularly if they're working freelance. But those difficulties seem to have been erased now and people seem to be able to access tests very well. I think that's because the system's become a little bit more refined. It's actually become more expansive in the range of symptoms that you have that might have originally been rejected when the process first started up. But now, we know so much more about this disease, that if you lose your sense of taste and smell, you've possibly got COVID, and it may be worth testing you if you're on the front line. So, our understanding of the disease has meant that the range of conditions that we're testing for are greater now than the original temperature and dry cough.

I think we're still getting some feedback from members that test results coming back quicker and more expediently would help them decide when they can get back to work, and perhaps advice that, when members have a negative test, 'You can now go back to work', may need to be refined. Because, speaking from a practice that's been significantly hit with the number of doctors having the condition, we know for a fact that those doctors have had COVID but their tests were negative, and that does raise some concerns in workers, really, that they might be told, 'You can go back to work',  but it's clearly not the case when they're laid up in bed and can hardly move.

I think, from our point of view, going forward, it would be useful, perhaps, as GPs, if we could, if it was clinically appropriate, order tests rather than go through a completely separate testing procedure, and that could apply particularly in any hot hubs that are developing. But also, again, in terms of patient management, it would be really useful for us to have, perhaps, those test results just streamlined into our clinical systems so that we can manage patients better when we're having contact with them rather than relying on them telling us, or having to go into the clinical portal and try and work out, 'Is this this patient?'

Do you think, therefore, that the testing approach should be one where, with the lessons learnt, we should be looking at GPs actually referring for tests, therefore they get the results back in?

I think the testing process has improved, and it's likely to be expanded. If patients are unwell in the sectors that agreed to be tested, they will come forward. But if patients don't think of coming forward, you might not reach that capacity. I don't think we're saying that for every patient we see we should be organising a testing process, because I think it does lie separate, outside general practice, because of the range of people who are going to access it. But one or two patients who you might see, perhaps in a hot hub, may benefit from the test, just for clinical benefit.

Okay. Time is of the essence, and I'm looking at the shielding queen next—Lynne. Shielding.

Thank you, Chair—yes, I've got the scars on my back from shielding issues. I wanted to ask for your perspective on the way that the whole shielding system has been handled. The Royal College of General Practitioners has referred to it in your paper. Can you just tell us what you think the problems have been and what could have been, maybe, done differently to prevent those problems, please?

Who wants to kick off? Peter.

Thanks very much. So, shielding is a really difficult area because we're trying to define a group of people who are all different and to put them into categories, and if you're in the wrong category, you're told to shield. But, in actual fact, in an ideal world, we would look at everybody and make a whole assessment of them and say, 'You need to shield,' or, 'You're less at risk.' But we can't do that, and we have to accept that a group of categories was set up and we had to work with that.

The first issue was that these letters were—. There were delays in sending them out, patients were unsure, they were coming to GPs, and we didn't have the information to start with. That was the first issue.

The second issue was that it was made conditional to get a range of services on having a shielding letter. So, if you got a shielding letter, then Tesco, Asda or whoever would deliver your groceries and you could get other services. If you didn't have one, then you didn't get that, and people were therefore coming to us asking to be put on the shielding list because they needed those services, not because they were medically at risk. So, it would have been better to try and separate the access to services from the medical advice.

The third one, and I come back to my first point, is that there were a group of people who, although they didn't fit into an exact shielding category, had several other things. So, you might have somebody who'd got, for example, type 2 diabetes, who'd got asthma, but it wasn't terrible asthma, who'd got ischaemic heart disease and was 70 years old. Now, each of those would not result in them getting a shielding letter, but put them together and you've got an individual who is probably at fairly high risk.

And then there was the serious problem, and I think that was when you were involved with the advanced care planning and the 'do not attempt CPR' issues, where there was this mix-up. The good practice that we put out in guidance to our members and to the profession was that patients who are at high risk should have advanced care planning done with them. That means that a clinician, a doctor or one of the nurses, would have a 'what if' discussion—'If you become ill with this condition, how do you want to be treated? Do you want to stay at home? Do you want to go to hospital? What sort of level of care do you want?'—and explain to them what it meant, that, 'If you stayed at home, it wouldn't mean you wouldn't get any care. If you went to hospital, it would mean potentially being isolated from family and friends'; empowering patients to make their own decisions. But it was unclear at the first that these were the discussions that people were having, and some practices were under the mistaken belief that they needed to send out letters, which perhaps could have been more sensitively expressed, talking about resuscitation and do not resuscitate, which was inappropriate and it was because of mixed communications.

And then the final point I'd make is that there were issues about letters going to the wrong address, and that caused a lot of confusion with patients. We wonder if better use could have been made of the shared patient record, where the GPs have the most up-to-date details about patient addresses. There are a few other issues, but I think those are the key ones that I'd like to raise. Thank you.

Lynne.

If I can pick up first on the DNACPR issue, and, to give you an example, I had an older constituent, living alone, who was basically just rung up and asked to sign a DNACPR, and she was terribly distressed over it, understandably. Now that was, as far as I can see locally, a relatively isolated case, but it's worrying that it's happening at all, and I'd just like to try and pinpoint how that confusion happened, because she was told afterwards, 'Oh, I'm very sorry, but we were just following the guidance.' Was that your guidance? Was it Welsh Government guidance? How did that confusion happen, that calls like that could happen to very vulnerable people living on their own?

Yes, it wasn't our guidance. Our guidance came out after that, and it was that practices should have a conversation with people about what sort of care they wanted. If DNACPR came up, you could discuss that, but we shouldn't be ringing up saying, 'Do you want to be resuscitated?' It was in response to some guidance from—I think it was Welsh Government—that was talking about things like if a patient's got COVID, CPR is going to be very impractical in a community setting. It was also guidance that certain patients would be unlikely to benefit from admission to hospital. It was advised that certain groups of patients do very badly in intensive care units, so people with long-term chronic conditions, very elderly people, have very low survival rates, and this was put out to GPs, together with the resuscitation guidance. I think probably some practices put one and one together and made three, and it was really part of the information muddle that was going on at the beginning of this whole process. Had information been clearer, more thoughtful and, yes, if practices—some practices—had engaged, had thought about it a bit more, then this probably wouldn't have happened.

One other thing I would say is that we had some discussions with the Commissioner for Older People in Wales following this to see what lessons we could learn, and she had not been aware of or not been involved in any discussions about how discussions about advanced care planning should be held with vulnerable groups, many of whom are in the group that she has responsibility for. So, I think it's something that, for the future, we need to engage with commissioners like the older person's commissioner, like the Children’s Commissioner for Wales, if things are affecting groups of people that they have responsibility for.

Thank you. Just on the shielding, I recognise that there have been a lot of problems, but I also recognise that it was a hugely challenging exercise given the numbers of people involved. You said that you thought it would have been better not to link services to shielding, and that is the crux of the matter, really: that's why so many people felt that they had to get on the list, because they were frightened about how they would get their supplies. There are still people now, people who are disabled, with sight problems, and they can't get online shopping slots even though they might have shopped online for years. Have you got any suggestions about how that could have been handled better then, other than, obviously, we can say that the two shouldn't have been linked? What could we have done differently to make sure that the people who really needed those online services could actually get them?

I think it's probably more of a responsibility for local councils and social services, and for people proactively to say, 'Look, in a crisis, how would you cope?' It might be an external crisis like a pandemic or it might be a personal crisis, and they can then access services through the council, through a council list. But, yes, I went to visit a care home yesterday and they said that they'd had problems getting deliveries because they weren't on a list—

Yes, absolutely.

—because they were a care home. But all the residents clearly were, or most of the residents would be on a list. So, that was another issue that was brought up.

Okay.

Yes. Okay. Thank you.

We need some agility. Angela.

Just really quickly, my understanding—good morning, good morning—is that most of the information for the shielding list came from GPs, from the GP database, but I've been approached by a significant number of patients who live in north Wales in particular who have had major treatment in places like Liverpool Heart and Chest Hospital and other hospitals such as that, and they've been put on a shielding list in England, but they were never put on a shielding list in Wales. So, they've been having calls from 'shielding England' saying, 'Do you need any help? What can we do?' and they're going, 'But we live in Wales.' And there's been a real hole, and more and more people are now beginning to contact me about it because, of course, they're saying, 'We need to go on the shielding list in England.' Do you have any views on that? 

Yes, because some of this shielding list was built up from hospital records, so if they haven't been in a Welsh hospital, the shielding list wouldn't get information from that source. It's down to coding on GP systems, and I think that we could be better at coding sometimes. GPs are basically hands-on clinicians who want to do stuff for people; we are less good maybe at putting codes on computers. We often rely on administrative staff to do that, and they have to be trained. So, I think one of the messages is better coding on GP systems.

Data.

Okay. Angela, moving on to care delivery issues that haven't been covered yet and cognisant of time, as you always are. 

Right. I've boiled myself down to two questions. The first is: could you just give me a view on how we can deal with some of the non-COVID harms that are beginning to happen to people because of the pandemic, i.e. people are not going to hospital for heart treatment, for strokes, they're leaving it too late, perhaps, to contact their GPs? Do you have any views on that, and how do you think we might be able to rectify that situation, because it appears to be a growing issue? Our accident and emergency department attendances have just fallen away, for example.

Who wants to kick off there? Rob.

Yes, thanks very much. Obviously, the A&E attendances are reflected in what we're seeing in terms of the patients who might be attending otherwise for either the onset of chronic conditions or more significant conditions. I think when we speak to patients who are phoning us up daily, now, they're afraid—they're afraid of coming to us. They're afraid of coming into the general practice, they're certainly afraid of going into hospital, and there's another element, particularly perhaps in the elderly population who are contacting us, that they don't want to burden us because we're busy as a health service. I think it's important that those messages are got out and are repeated again and again. RCGP, at a UK level and in Wales, the chairs, have been very active from the start in media and social media saying that general practice is open, but I think there's a cohort of patients who aren't coming for their own reasons. 

There is a slight positive to all this in as much as patients might be managing minor illnesses with self-care without resorting to a pharmacy or a GP, and those behaviours might be something that people will be able to take forward. For the more chronic—

Actually, Rob, can I just interrupt there, because you neatly lead me on to question two—and sorry, Dai, I actually have three questions—which is, what are the positives that we can see out of this in terms of, perhaps, people's different way of using the health services, about the technology that's supporting people to access healthcare, et cetera? 

From a general practice point of view, not only GPs but patients, our day-to-day working has altered completely and I cannot see us going backwards. The positives are that general practice has embraced the technology, and patients have as well. I have conversations on the phone, on the video, with elderly patients and I'm managing their cases without the need for face-to-face. We still have to remember there's a cohort of patients who are going to need face-to-face, and it's important that we don't forget those—either non tech-savvy, or perhaps elderly patients who are more used to a conventional form of consulting. So I think the positives are that we've developed rapidly technology that we definitely need to keep, going forward. We need to expand it, and things like electronic prescribing, to try to just streamline the technology services even further and release a little bit of burden on our local pharmacists. I'm sure you're going to speak to them, but they're getting hammered at the moment. 

Yes.

So, video consulting, telephone consulting and infrastructure support for that in terms of ensuring that patients have got good broadband access are very much things we'd like to take forward. We would like to take forward the capacity to have remote working, and I'd just like to say that the NHS Wales Informatics Service have been incredible rolling this out. Having been someone who's had to work remotely from home, they were very supportive when I had problems. So, that infrastructure has to be there going forward. 

I think, if I can just add about going forward, again, working with Government, we need to give the right messages to patients and saying, 'As from tomorrow, general practice is open', will create more harm, I think, to both the well-being of GPs, the structure of what we can currently offer and patients, because we will be overwhelmed. We're busy enough at the moment, so I think we do need to look to progressive opening with the same messages coming from Government as from local health boards, as from general practices, and trying to take account of local variations in current infection rates, or R rates, and what different practices can offer at different times. So, I think we've got to have a progressive approach, but, certainly, keep all the good bits that we've done and perhaps re-examine the bits that we've done previously and think, 'Do we need to do that at the moment?'

Okay. Lynne has got a question and then I'll come back to you, Angela. 

My question was on mental health, so I don't know if there's time for you to even answer that, but I would be interested to know whether you've got any concerns about people accessing GP services for mental health and their rights under the Mental Health (Wales) Measure 2010 in this pandemic. If you can't answer that now, maybe we could have a note about it.

No problem. I think it is a problem and that is a group that we need to give special consideration to. My consultations at the moment, I'm speaking to patients with mental health problems. So, patients can access us, but it's very difficult then to tap them into the subsequent services that ordinarily we would tap them into. So, it is a problem, and it needs to be one of those groups that we need to look at as equally quickly as these other groups that are developing chronic or life-threatening diseases.

Okay. Angela, briefly, and then we have Jayne to wrap up. 

Just finally, obviously a number of GP practices straddle the border and many provide services on both sides of the English/Welsh border. What impact are your members seeing in terms of the differing lockdown rules between England and Wales, and any lack of clarity? 

In terms of what I've had feedback from, I'm probably going to devolve that to Peter because he's got probably first-hand experience—

He's waving furiously, so—.

—where he is. 

Yes. So, my practice is in Wales, but I'm on the Welsh border and a lot of my patients will work in England and vice versa. So, I think 'confusion' is about the only word I can use in that—that people don't know what they should be doing. I think it's probably the English advice that's confusing enough on its own, but combined with, 'I'm going to work in Wales—does that mean I have to obey the Welsh rules, or I'm picking up the children from England; can I still do that?' You know, it's just—. It's confusing to have—. I can't say anything more than that because I haven't got an answer, sorry. 

No. Thank you. 

Time is beating us, but obviously we've reached the high point of any meeting now, which means Jayne is asking questions about workforce.

Oh, the pressure. Good morning. I just wanted to ask you about the recently returned staff and the recently retired staff to the professions, and how you feel that has been working out. 

Shall I go first? Sorry. 

Helen. 

There we are, I'm not on mute now. Thank you. We have seen a really large number of nurses who had either recently retired or retired for some time come back into the system. We've had a bit of a mixed response from our members on how well that has been processed. So, those that have identified that they have got acute skills have been quickly redeployed into acute environments,  but those that have identified that their skillset might be more to support the 111 system, et cetera, many of those have not received any contact back from the Welsh Government on their offer to step up and do other things. So, it is a bit of a mixed bag. It's been super to see so many people so keen to want to come back and help the NHS, but the process of actually translating them into posts, I believe, has been too slow. It could be that, actually, the workforce we thought we needed, when we were hearing the early learning from places like Italy, has actually not manifested itself, and we've seen that with student nurses, where there was to be the potential for them to get onto the register early, but we've seen that we haven't required that workforce. Thinking about if we do have a second wave, we do need to get this process to be slicker so that we can quickly move those people from an expression into a post. Those that have been through the process have been very, very complimentary about the support they've had and the training that they've had in order for them to go and do clinical work. 

Okay, and from the— 

Can I just ask—? Sorry, can I just ask, on that point, do you think there's a regional variation within that? Or do you think that it's just generally across Wales? Do you think that perhaps the—

I haven't got the data to quantify that in a substantive way. The input that we've had back from members has been more about the 'I said I couldn't do acute clinical care but I could do something else' and that group of volunteers has not been contacted—a number of them have not. But, the other group, a number of them have and, of course, that's been a very positive experience for them. 

Thanks. 

Okay. What's the GP point of view? 

Yes, so we've had—. A fair number of GPs have volunteered to come back into the profession. We've set up a programme from HIW to reorient them but, in actual fact, I think hardly anyone has actually come through it and gone back to work, I think because, as Helen referred to earlier, what our expectations were at the beginning of this pandemic have not been realised and the shortage of staff has been less critical. In fact, what we've seen in general practice is that fewer GPs have been taking holidays. There's not anywhere to go, really, and there has been, actually, less use of locums, so locums have provided a pool of additional staff. My colleagues in the out-of-hours—. I do some out-of-hours work. It's been a lot easier to find doctors to do shifts. And the other thing that we've seen is some of our trainee GPs, who've got acute medical skills or acute anaesthetic skills, have been seconded to use them in the relevant departments in hospitals. So, yes. So, it's been pretty reasonable, the staffing so far. But one thing we have to think about is coming out of this and making sure we've got good numbers of appropriately trained staff to deal with the bulge that's to come, I think.  

I think that was going to be my next question, about how you see the skills and how to encourage more retired and returning staff to take us forward into the next phase of test, track and trace. Do you have any more comments on that, or anything you'd like to add? 

I think the only thing I'd say about that is it's been gratifying to see the number of health professionals, both doctors and nurses and others, who have been willing to come back, and we need to continue to engage with them to develop the service over the next year. 

Okay. Finally, from me, just from your papers, you mention stress and you've mentioned today around stress of GPs, and obviously with nurses as well, and the risk of burnout. Do you think there's sufficient support in place to help people cope with the stress, with going through it? Because we know that in certain areas of Wales this has been very pressurised for three months, in particular, and the burnout that can arise from that, and obviously, when people do return to services as well, the stress on professions then. 

So, yes, I think that there are lots of resources available. I've published a list for our GP trainees and it ranged from Health for Health Professionals through a whole range of other, both face to—sorry, online digital sources to telephone sources. So, there's lots of stuff there. The problem is getting people to access it, knowing that they need to access it, and I think one of the messages is that health professionals—anybody dealing with this crisis—need to have time to think about themselves and reflect. And it's only after that reflection that you can maybe think, 'Yes, perhaps I do need some help. Perhaps I should go and speak to one of these resources.' The problem is staying on the hamster's wheel in the cage, going round and round and round, not coming off it—it's giving people time to come off for a little while that's critical, I think.

Okay, and finally Helen, from the nursing point of view.

Thank you. So, we have a number of ways of working in the partnership working in the NHS in Wales, which leads to us having quite a lot of resource about wellness for staff. We were pleased to see the announcement that the health professionals counselling line is to be extended. We would like to see it extended to all health workers—that's an ongoing discussion with the Government—but pleased to see it extended to nurses and other people working on the front line.

Again, as part of my discussions, as I've gone around the NHS, I've been speaking with chief execs and nurse directors and others about this. I'm pleased to report that in many—in fact, in all—health boards resources are well presented on the intranet and the website. I think I would echo the message there as well about helping staff to understand how to access them and when to access them would be good.

We've also worked in partnership to put forward some guidance. It's things like not working too many long shifts. So, many nurses work a 12-hour day. Now, clearly, doing that for more than two or three at most is very stressful and very tiring, so we've worked with the employers and the Welsh Government, who also put forward some best-practice guidance for the NHS to consider as it deploys its staff.

Again, I think this is quite difficult in care homes, and you will have seen reported in the press where many care staff have been volunteering to sleep and stay at work in order to continue to provide care. So, I do think this is something where we need to make sure that we are also considering the welfare of that part of the workforce, because it's a lot easier to do these things in a well-established machinery, as is present in the NHS.

Good morning. Thank you very much indeed for coming along today. I just want to set the scene and ask you about the overall response to the outbreak from the community pharmacies and RPS and CPW. I'm particularly interested to try and understand what your members are saying, how they're feeling today, how they felt the initial response to the outbreak happened and how easy or difficult communication streams have been between themselves and GPs, themselves and Welsh Government. Over to you.

Who wants to kick off? Elen?

Diolch yn fawr. So, just to start with, we are extremely proud of the commitment of pharmacy professionals across all sectors in maintaining the delivery of care and the supply of medicines during the pandemic. The profession has certainly risen to the challenge of the increasing workloads and developed innovative approaches to service design that have quickly been implemented to ensure continuation of care for patients. We've seen great collaboration among pharmacy teams and with other healthcare professionals.

So, to touch on your point on how the profession is feeling, first of all, I think quite mixed. There have been huge challenges, and I think pharmacy teams have really worked together and come together to ensure that work continues in the right way for patients. 

There have been some dips in morale at times, I would say, some of that resulting from maybe a lack of recognition of pharmacy teams, particularly in their NHS key worker status. I do understand that that isn't intentional from Welsh Government, but we have heard from our community pharmacists and primary care members about difficulties associated with the lack of recognition as NHS key workers and that they've not been able to routinely benefit from some of the positive initiatives, such as priority access for NHS front-line staff to supermarkets and free public transport. I think some of that comes from not having NHS ID cards and that wider recognition of always being a part of the NHS family.

We're pleased that colleagues in social care have had ID cards introduced from Welsh Government. We would really welcome the opportunity to work with Welsh Government and yourselves to find a similar approach for community pharmacy teams, but also a long-term solution to this for the public and other professional groups to understand that community pharmacy, primary care pharmacy, work in the same way as GP practices and dental colleagues and we are a part of key workers and the NHS family.

Judy.

There we go. I was waiting to be unmuted. So, to echo what Elen has said, yes, there were some initial issues in relation to key worker status, accessing schools as well for those kind of pharmacists and all of their teams—to access any childcare did cause some concerns, at least initially. We also had, I suppose—it was an unprecedented increase in our workload, particularly in the first few weeks. We saw massive increases in terms of prescription volume, and part of that was driven by patients' desire to have enough medication in their house just in case they needed to self-isolate at any point, so, suddenly, everybody was bringing everything forward, but also because there was a push to suddenly move patients to having three months' worth of prescriptions—so, not single prescriptions of 84 days, but actually three separate prescriptions or batch prescriptions, which meant that pharmacies had to change how they worked almost overnight. So, we weren't—. That's not something that has been universally embraced across Wales previously in terms of repeat dispensing and batch dispensing, so we suddenly had to manage how were we going to handle that workload, how we were going to shift and look after those prescriptions in the future.

But pharmacies stepped up to the challenge. Pharmacy teams came in very early, stayed very late, worked sometimes seven days a week to make sure that they cleared the backlogs, and, on top of that kind of workload in terms of prescriptions, what we did see was a significant increase in the number of phone calls as well to pharmacies. So, GP practices were suddenly working behind more of a closed door kind of approach. Patients felt that the only people that they could suddenly access was pharmacies, either in person or by phone, so we were getting a huge number of queries. Where patients would have otherwise popped into their GP practice, they were now phoning us, which caused significant increases.

Yes, thank you. And I'm so glad, actually, Judy, that you've made that point, because, of course, my initial question was marginally barbed, in that I've had quite a lot of traffic into my inbox from pharmacists, and I would say that they're incredibly proud of the work that they've done, and we are very grateful for the work that the pharmacies have done, but they're also pretty fed up, and they do feel that they're at the end of the food chain, that they've been the neglected front line—and I'm quoting words that have been given to me—and that there is a sense that, actually, GPs have been empowered because of this crisis, allowed to take that one step back, and, suddenly, all that stuff has fallen on there. So, I wondered if perhaps you might expand on that little bit more, but also talk about how the different sizes of pharmacies have coped, because we've got everybody ranging from the big Boots all the way down to a very small pharmacy, and the pressures in that must be extraordinary. And I know people who are volunteering for pharmacies at the moment and going out and doing deliveries and things like that. So, almost everybody I know who is volunteering under all these volunteering schemes has ended up working in a pharmacy. So, that tells me, if nothing else, that's where the pressure is in the system, so perhaps you could just expand on it all a little bit more for us.

Judy to kick off, then we'll have some others.

Yes, sure. So, yes. So, yes, a lot of the pressure, obviously, came to us. We've obviously had the additional pressure of social distancing. So, as you said, quite a significant number of our premises are relatively small, which has meant that, actually, quite a lot of pharmacies have had to move to almost a 'one in, one out' policy, which has added to the burden in some ways, because you've then got a queue to manage as well outside—and a queue of patients of, I suppose, varying backgrounds, with varying needs as to what they feel. So, you've also got mixed into that queue obviously people with palliative care prescriptions or people with daily supervision prescriptions as well in there, which can cause significant tensions at different points.

But, on the whole, pharmacies have coped. We were very appreciative of the Welsh Government's support that allowed us to be flexible in our working hours. So, relatively quickly and early on, we were allowed to close for up to four hours a day and to be working behind closed doors—so, closed to the general public but still actually working—which allowed us to actually manage our workflows better, because the volume of prescriptions that we were getting from GP practices were—you know, significant, massive bundles coming down, which was causing additional pressures in terms of the admin perspective of how we handled those. So, giving us that flexibility of how we worked has been significant. And we have been inundated with people offering help to volunteer, which has been great. There's been a real outpouring of support to pharmacies, which has been really useful, but also, obviously, that comes with its own difficulties in terms of managing volunteers and making sure that that's all appropriate, and that the correct people are volunteering and that they haven't maybe got any ulterior motives.

Any other comments from—well, either Suzanne Scott-Thomas or Mark? Suzanne.

Yes, thank you. I think the whole profession of pharmacy—just to put a sort of different aspect to this—has stepped up to the mark, and access to medicines and the continuing supply of medicines has been our No. 1 priority for patients, and that goes across into the hospital and primary care GP sectors as well. But there is, again, a general—. These roles are not recognised across the whole sector, really, and, although RPS is continually striving to raise the profile of pharmacy, it sometimes takes a crisis like COVID for it to come to the fore. But there's still a lot of roles that are unseen and go on behind the scenes—so, the managing of critical care medicines to patients on ventilators has been extremely challenging for pharmacy, at a time of increased demand and decreased supply. And I think that has not been recognised in the planning of expanding the number of ventilator beds. You can put as many ventilators as you can but we potentially did not have the medicines to manage that, and that was not recognised early enough.

Pharmacists have been instrumental in ensuring patients have access to the medicines that are only available via clinical trials within our hospitals, and they have very much been on the front foot in supporting that, and I'm assured that we now have a huge number of patients in Wales that are registering for those trials, which is really good because that's informing our future evidence.

They've stepped up and created pharmacies from nothing into all these field hospitals that have appeared, ensuring that we have not just medicines but oxygen. Pharmacists are instrumental in ensuring oxygen supplies are secured and the quality control is there where oxygen infrastructure is expanded across hospital sites. And, lastly, you may be aware that, on social media, there's quite a lot of pharmacy pictures where we are stepping up and making medicines in ready-to-use syringes or whatever—saving hundreds of hours of nursing time in that critical care arena at a time when they're finding it difficult, with wearing PPE. Again, it's probably a lot of things that go on behind the scenes that the public and other healthcare professionals, actually, never see. I just thought it was worth mentioning.

Angela.

Yes, thank you. I'm going to leave it there, because I actually have a whole series of questions I want to ask you about business continuity, but I think we'll leave that to the end, because—

Yes, okay.

But I would like to say: I never knew about the oxygen. I had no idea that you were responsible for oxygen delivery. So, thank you for that.

Jayne Bryant.

Just as you've mentioned about the pharmacists being on the front line, how have you found, or have your members found, the access to PPE and testing if they've needed it?

Who wants to kick off? Mark, you haven't said anything yet.

Right. Well, just to put my position in context, I'm a contractor, I have five pharmacies in the Valleys, and I have to say, being a pharmacist for 35 years, the demand on our services has been unprecedented during the COVID crisis. We've had to adapt and change. We are used to that as a profession, it happens to us all the time, but when you have to adapt your systems within 24/48 hours, that takes some doing. So, therefore, there was a lag period where—you know, it took us quite a while to get that into a position where we could work it properly. 

To your question, we received supplies very early on, I have to say, from the health board, which was really good. But, as the time has gone on, there have been issues with regard to getting hold of PPE. I think the smaller contractors have probably struggled more than the larger contractors in getting hold of extra supplies. I think we're now in a position where the health boards are in a better position and I know supply is a lot easier. But I think the guidance that's come out has been quite confusing, because initially it was only for one-to-one consultations, for cleaning your pharmacy, but staff were more comfortable when they felt they had some protection when they were wearing masks, or—. I purchased guards for them, things like that. So, I would say it's a mixed bag with PPE with regard to pharmacy.

Okay. Any other issues? Judy.

Yes. So, I suppose to support where Mark was coming from, one of the things we found was that actually PPE was causing us some additional workforce issues. So, our staff didn't always feel protected. So, regardless of what the guidance said—that you only needed it in certain situations—we had reports from our contractors across Wales that their staff teams didn't want to come to work unless they felt protected, and whether they needed it, I suppose, is a separate kind of discussion. So, that, in the interim position, meant that contractors were put under additional pressure and additional cost pressures to actually purchase PPE for their teams. And, as Mark said, some of the contractors really struggled to get hold of any, and larger ones found it easier. 

To answer your question in relation to testing, pharmacists were included very early on in terms of access to testing from health boards. We were really pleased that we were included in the primary care list for all health boards relatively quickly—some quicker than others, but all within the first week or so. That was extended out to additional staff members following on, and we're now at the position where household members who have got the symptoms themselves can also access testing. So, we haven't had massive issues in accessing testing. We are getting anecdotal reports, though, of how long the test results are taking to come back, particularly from contractors in north Wales.

Okay. Elen or Suzanne? Elen.

I think, going forward, assurances will be needed about the plans for ongoing supply of PPE, and clear guidance for its use across all pharmacy teams during the transitionary phase that will accompany any lifting of lockdown restrictions.

Okay. Jayne, back to you.

Thank you, Chair. That's very helpful. I know that you've mentioned already this morning about some of the practical difficulties around social distancing that some pharmacies have had, and I do know of pharmacies that have had to change their whole configuration, really, to put in some protection in their pharmacies, where they're able to. Are you able to support those smaller pharmacies that aren't able to have that same reconfiguration? And what sort of pressures do they feel coming forward, or do they think that the system's working with that one-in-one-out situation?

Who wants to take that on? Suzanne, then, first, and then Mark.

I understand, as you say, there are varying sizes of pharmacies, and each have put in their own system that works the best for them, their staff and their patients. I think we're under no illusion that this is a quick fix, and social distancing is going to be with us for a significant time.

I think, going forward, what we probably need to look at is how we can do things more digitally, where we could support patients in their own homes through remote access consultations, through web-based access for access to that pharmaceutical advice, but also in terms of the whole process of managing repeat prescriptions so that we can avoid the footfall into the community pharmacy. It's only where essential, then, that you can prioritise the patients you actually need to see face to face, and are accessing your pharmacy. So, I think there's a whole review, an urgent review, needed of how we manage prescriptions and how we can access the digital world and remote—. I am aware that Welsh Government have initiated plans for the Attend Anywhere software to be installed into community pharmacy and is being piloted. So, that's excellent, and we've got to make good use of that.

In the Royal Pharmaceutical Society, we are doing some work to underpin how you take forward how you safely do remote consultations, et cetera, building on what GPs are doing already. That's got to be the way forward. So, it's how we reduce that footfall, how we use digital better, and how we can support the ordering processes for medicines.

Mark.

A couple of points with regard to the layouts of pharmacies and things like that. Obviously, there are different ways of keeping the 2m distance. Some people have used barriers; some people have used screens, depending on the size of your non-professional area, the retail area. It depends on how many people you can have in the pharmacy at any one time who are 2m apart. If there are issues with regard to queuing outside, then, obviously, pharmacies have got lines on the pavement, telling people where the 2m lines are.

The other thing is it all depends on how proactive your staff are in that, when we are aware that there are a lot of people queuing outside, we tend to send somebody, who's protected, out to check exactly what these people require. So, if they're waiting for repeat prescriptions or whatever services they require, if we can deal with them outside of the shop, outside of the pharmacy, then, obviously, that is something. We're very, very conscious of how we can adapt our service provision to the conditions that they're in at the moment.

Okay. Jayne.

Can I just ask another question about the well-being of pharmacists as well, and staff in pharmacies? Because you've mentioned that there's been an increase in the number of phone calls, and we know how much pressure there has been on pharmacists and pharmacy staff. Do you think there's enough support available for those pharmacists? And just thinking about the issues around burnout that could happen easily now, and, obviously, going into the future, I just wonder if you think there's enough support available and that pharmacists and their staff will be accessing them.

Who wants to take that? Judy.

So I suppose—. Obviously, the Welsh Government announced the support in terms of the helpline and things like that that was available, and that was confirmed that that was available to pharmacy teams. We, ourselves, and RPS had contact with several different companies offering apps and things to, on each occasion, confirm whether the pharmacists are available, and they are available to pharmacists and their teams. So, we've developed a whole series of information and support that pharmacists can access.

But, yes, you're right, the significant workload pressures that were continuing and were seen in the first few weeks were unsustainable at that level. Luckily, it did start to decrease, but that did have a knock-on effect when we were already suffering with staff being off because of self-isolating or shielding in whatever way, plus an increase in workload has caused some of these knock-on effects. So, it's about how we adapt to start to incorporate some of the volunteers as well into how we can work to use them to try and relieve some pressure. But it has caused some issues.

Okay, Elen and then Mark.

Diolch. Just to share with you that, at the end of last year, RPS conducted a survey around well-being, and even before this pandemic, it showed that around 80 per cent of pharmacists were already at risk of burnout due to the significant volume of work that they're dealing with. We are really pleased, as Judy said, that health professional support has been extended to all front-line workers, including pharmacy teams, and also Health Education Improvement Wales have got a portal for well-being resources, as have we, and we share resources with them. But we would like to see this kind of well-being support that's been introduced during the pandemic extended after this period, because pharmacists and their teams are certainly dealing with volume and pressures throughout the year. It's been heightened during the pandemic, but we would like assurances that this is something that would remain.

That may well appear in some recommendations, you never know. Mark.

A couple of points: I think what it has highlighted is that there's not enough resilience in the service at the moment to cope with this sort of demand on a regular basis, and I think that contractors have—. For instance, if I use my own example, I've had to employ some temporary staff and obviously, I've incurred an expense there. My overtime bill for March and April was in the region of £24,000, and I've done that without any thought of whether I'm going to be remunerated in the future. I'm assuming that we are going to get some help when our submission goes in, but that was a necessary—recruitment was required because of the volume of work that we had to take on at that time, plus, to COVID the loss of staff that were either testing positive or people within their families were testing positive.

To give you another example, I employ in the region of 55 people, and in the five-week period from just before the start of lockdown and further on, I had 17 members of staff at any one time—certainly, staff not available; they weren't all off together, fortunately, but that's the way it panned out. So, it gives you an idea of how we've had to cope. I've managed to recruit people who had been in pharmacy before, so there was experience. I lost quite a few delivery drivers, because they were of an older persuasion, so I've had to bring other people in to sort that out. But that's the way we've managed to cope with the system, but what we've done is based on a lot of trust that we will have help in the future. 

Suzanne Scott-Thomas.

Thank you. I think one of the things that has also been recognised is the increasing demand, I suppose—the shift of patients from accessing A&E. We've seen, I think from the figures that are there, about a 30 per cent decrease in people attending A&E. Some of that actually is good. It's patients perhaps having more self-care or accessing community pharmacy in the right way, so it's the prudent healthcare bit; it's seeing the right person at the right time, and there's something there about not moving back to the increased footfall in our A&Es. But it's how we recognise that, and how we support our community pharmacy colleagues to deal with that appropriately now and in the future, because there is still the reluctance of people to attend A&E, and some of that is for the wrong reason, but some of it is absolutely where we want health to be going, and then community pharmacy have to be seen as part of that pathway and have the resources and the referral pathways to escalate up where they need to. So I think there's something there as well. 

Good. Jayne, are you done?

I'm done. Thank you, Chair. 

Excellent, because we need to move on. Shielding letters have caused some aggravation. Well, Lynne leads for shielding—Lynne.

Thank you, Chair. Yes, I'd just like to ask, please, first of all, to what extent you've been involved in handling shielding issues, and how they've impacted on your service.

Who wants to kick off? Judy.

We had a very early conversation with the chief pharmaceutical officer back before the start of lockdown in terms of how we could support patients who were shielding. So, there was a move of funding from a particular service into supporting arrangements to support patients who were shielding or self-isolating, who had no other forms of obtaining their medication. And we've made sure that pharmacies are aware of that need to do so, so pharmacies have, as Mark was saying, increased the volume of deliveries that they've been doing. They've also been using volunteers to help those.

Obviously, the Welsh Government announced their delivery scheme as well, which has provided an app that actually lists the shielded patients that every pharmacy has so that you can access that information from your pharmacy perspective to actually support those patients. There was a delay, I suppose, because the letters in relation to shielding went out at the end of March, and we didn't get the details in terms of our shielded patients until relatively recently. So, in the interim, patients had to self-identify themselves, which the majority, I believe, have done. It's just making sure that there are no patients who've fallen through the cracks. There are always issues in terms of supporting patients in terms of delivery of services. Sometimes, they can't necessarily be always as flexible as patients may wish them to be, but pharmacies have put in place arrangements to make sure that they can provide that service, and we've confirmed with the pharmacies that don't have a delivery service that they have got those arrangements in place. 

Lynne.

So, in the early weeks, before you had the data, were you getting a lot of issues with people coming in and asking you about shielding? Did that increase your volume of work?

It increased the volume of phone calls significantly, and there was always that mixture, as well, of patients who ask to be on the shielding list as well, so it's asking patients whether they should be on that list as well. But it all added to the volume of phone calls that pharmacies were getting, so it did add to our workload in that respect.

Can I just ask one final question? Do you know why it was, then, that you didn't get the data on the shielded until relatively recently?

It was to do with the delivery scheme that was being launched. It was part of the app that they were working up. I suppose we went from not having that information to having that service and all of that scheme in place, which, although it felt like there was a delay in getting it, actually it's still relatively quick in terms of how long these things usually take to roll out and be available. But yes, that did obviously cause some delays and some concerns in the interim.

Thank you.

Mark, and then Suzanne.

Over 650 pharmacies in our network advertise a delivery service, so therefore, there's always been the issue of those patients having a delivery. So, I think even though we didn't know that they were shielded, they were being looked after by their local pharmacy. Probably, over the last month or so, my delivery service has doubled in size. So there are an awful lot more deliveries going on, and obviously it is non-contractual, but it is a service that, as I said, most pharmacies provide, and we're more than happy to do that in this circumstance. These people are vulnerable, they need to be looked after. That's our job. That's our mission statement, I would imagine, really, when you think about it, with a pharmacy. So they've been looked after. The delivery service has been put in place, and I have to say that Andrew and the rest of his team have done a good job of that, but as I said, I don't think there's a lot to worry about. I don't think there are many people slipping through the net. 

Okay. Thank you. 

Suzanne Scott-Thomas. 

Just to add, I think, in terms of going forward again, we need some sustainability around the delivery service. The service that is coming through Welsh Government, which is excellent at the moment, is based on volunteers. We are also delivering—. I'm aware of delivering across Wales from hospitals as well, where patients still get medicines that are hospital only or managed by consultants, et cetera. That has initiated a delivery service, too. These are very dependent, in some circumstances, on volunteers and people who have been redeployed. So, as we go forward and people go back to work and go back to their normal employment, there is a risk that the availability of volunteers in this system could decrease and then we would be unable to keep up that demand. So it's just something that we need to be aware of, that if this is going to go across a number of months and possibly into the winter where people are still in the shielded category and reluctant to come out, that is something we need to consider.

Thank you. 

Okay, we need to move on. Care delivery issues, David Rees. 

Thank you, Chair. You've already mentioned this morning quite a lot of changes that have been put in place as a consequence of COVID within the pharmaceutical sector and the pharmacies and how they operate, and I suppose you've just highlighted one aspect of how deliveries have been changing and increasing. How many of these do you think are here to stay and, if they are here to stay—before Angela gets in with her business continuity question—what impact will this have on business continuity? Because you've talked about delivery services and extra delivery services; that's going to be a huge impact upon funding. Sorry, Angela. 

Who wants to kick off? Elen, you haven't said anything for a while.

I think there have been a lot of innovative approaches to care, both in the community and elsewhere, one of which is the service for medication at the end of life, which I think has been a fantastic service that has taken contributions from pharmacists working right across Wales to ensure that the most vulnerable patients at the end of life are getting access to the critical medicines that they need. It's really good to see the pace of change that this has happened at and the huge team approach to this that has been supported by Government, but incorporating all pharmacy teams and other healthcare professionals, the army and all kinds of groups coming together to ensure that medicines get to the people who need them as quickly as possible. So I think certainly changes like that we would really advocate keeping. It would be great to see the pace of change being enabled long term.

The question of the pace of change will be an interesting one, because you won't have the army, for example, to help you in the future. 

Yes, and understanding that, obviously, there will be different approaches going forward, but I think a lot of the bureaucracy around some of the services has definitely been streamlined, but ensuring strict governance is still there. It's still vital that medicines reach people safely, they know how to use them and they get that pharmaceutical care and support through every stage. So, although these things have been implemented and developed quickly, governance and the important information from pharmacists to patients is still critical. 

Okay. 

Suzanne Scott-Thomas. 

Yes, I think there has been some relaxation of legislation to enable pharmacists to make professional decisions for patients for their best care. For instance, they are now able to provide controlled drugs as an emergency supply. We would like to see more of that going forward, putting the decision making back into the professionals' hands. You know, shortages of medicines, et cetera, where pharmacists can make decisions without going back to the GP. I think that is something that we need to recognise.

I think there has been, as Elen has said, a huge move towards more collaborative working, which has always been here in Wales; I have to say that we do have very good partnership working across pharmacy. Those foundations were really built on in COVID, and it was really excellent to see how people came together and worked for the common cause and put the patient at the centre. So, I think we can build more on that and, hopefully, that will enable good decisions to be made quickly and we can get on and develop pharmacy that's fit for the future.

Okay. David. 

Has there been any challenge in sourcing medicines in that case, to be able to deliver those, because you've had an increase in access and an increase in ability? Has there been any challenge in sourcing those medicines? 

Suzanne and then Mark. 

So, just to share, my day job is the chief pharmacist of a health board, so I see it from all angles, I suppose. There has been a huge increase in demand for particular critical care medicines, for those used in intensive care, and that has been a day-to-day challenge at the local health board, at a national level where we have pharmacists working on a national level as part of the national procurement team, and actually across the UK because medicine supply is global. We don't make our own in the UK; we are dependent on the global infrastructure, so where there is high demand, and there has been high demand across the world, you are in a very competitive market to secure the necessary medicines. 

There's been a huge amount of work ongoing to make sure Wales has their allocation of medicines, and that we use those wherever the need is. And there's been very good collaborative working across health boards to ensure that where the need is, we will move medicines. Again, we've worked with the army and worked with Welsh health courier services and procurement services to ensure that that has been done. We had numerous examples when we were at some peaks where that was done.

But I'm also aware that the supply chain within community pharmacy was put under considerable strain when the demand came on for three-month supplies. We've got examples, I'm sure Mark will tell you, of prescriptions for a lot longer as well, and that really then destabilises the supply chain. It is not set up to provide that length of treatment to patients and we need a better way of managing that, and the best people to manage it are pharmacists. 

Okay. Mark. 

To put it in context, we've had issues with—. It tends to fluctuate: it's one drug, one month; it's another drug, another month, but there have been issues with shortages for a number of years. They were compounded. As Suzanne said, we import the majority of our drugs and a lot of them are imported from China and India. So, when COVID hit China, we had issues with quite a few drugs. Then, India decided that it wasn't going to allow any export of drugs, mostly generics, so they have caused an issue. So, there have been some problems with the supply of certain medications, and that does cause issues with availability and also the price of drugs. 

Just to give you a potted history—I'm sure you understand—the drug tariff sets the prices. So, the drug price is set at, let's use an example of £10, and it's a supply and demand situation. You can't get hold of a drug that you're normally paying £8, £6 for. It goes up to £12, £14, £16 and we are being remunerated at £10, on the understanding that by the end of the month there will be a price set at a realistic level for the purchasing value that you've had to do. So, there's awful of trust involved in it and that's how the system works. So, over these last few months, there have been particular drugs that have been very difficult to get hold of, but we tend to manage.

What I would say, going forward, is that we need to look at things such as generic substitution, so the ability that a pharmacist is allowed, if it is a branded drug to be prescribed, that we can give a generic equivalent, and I think, on special occasions, there could be something like therapeutic substitution, but obviously that's much more difficult to decide on. But I think, going forward, these are things that we probably need to look at. 

Okay. Elen. 

[Inaudible.]—Mark's point there, I think there are certain things, challenges, for community pharmacy, in particular, that this has shone a spotlight on that we need to address, and simple things like having the ability to change small things in a prescription. So, if you have a 20 mg tablet in stock but it says 40 mg on the script, in order to give to two 20 mg tablets you would have to get that signed by the doctor or the prescriber, a lot of to-ing and fro-ing of prescriptions, sometimes with patients having to go from one place to another.

We need to really empower pharmacists and enable them to be able to make these small changes to prescriptions. That does require legislative change from UK Government, but we would really value the support of Welsh Government and this committee in order to get that through.

Good, sounds like another recommendation. David. 

Well, that's very interesting, because obviously we often talk about shortages of PPE and other aspects, but we have never, I think, really talked about shortages of medicines in that aspect and how we actually move it forward, and particularly the ability to modify a prescription to allow you, as a pharmacist, to actually use your stock effectively, rather than say to somebody, 'I can't do this, I have to have a specific type of tablet.'

Yes, absolutely. 

It's an interesting point. And other services are complex. Substance misuse services is another big issue. Are you seeing challenges in actually complex services, such as substance misuse services and your work involved in that area? Because that's another impact upon you. 

Judy, then Mark.  

In terms of substance misuse, a lot of those patients have had their medication regime changed. So, if they've been daily patients, a lot of them have been moved to a couple of times a week and things like that. So, that has caused impacts on pharmacy. We've found that has caused some issues in terms of throughput for pharmacies, but also in dealing with some of these patients who are sometimes quite chaotic as well. There were a couple of incidences early on where some patients didn't self-isolate who should have been self-isolating, which was causing concerns for those pharmacies where patients were turning up in pharmacies who shouldn't have been and were refusing to take advice. But that, unfortunately, comes with the territory with some of these particular types of patients. There has been relatively good communication across Wales in terms of what these patients require and things, but that does obviously have an impact in terms of pharmacy footfall and service delivery as well. Because, obviously, a supervised service we would usually do in a consultation room face to face, but that's had to be managed in a completely different way because of the fact that our consultation rooms don't necessarily, well, don't usually allow for a 2m social distancing gap easily.

Okay. David. 

Yes, I'm aware of the time, Chair, and I think I'll let Angela ask her questions on business continuity.

There we are, because we've reached the final slot and so business continuity, Angela, and closing remarks, team, in the next few minutes. Angela.

Yes. Thank you. Sorry, just checking you can hear me. Quite a number of pharmacies have written to me to raise financial concerns, obviously, going forward, and they range from having to try to renegotiate with health boards a different payment regime because, often, it's a quarter in arrears, which, of course, is because they're having to buy in so much more and deal with so many more customers than usual—it's really put a pressure on some pharmacies.

And, of course, the other thing that's happened is that pharmacies have lost the add-on business—all the shampoos and the toothbrushes and the kids' stuff and all the rest of it, and, of course, that's having a detrimental impact. So, I just wonder if you can give us an overview on your views on the finances and the business viability of community pharmacies going forward. Mark, perhaps.

Right. Mark.

First and foremost, I'd like to put on record that I'd like to thank Andrew Evans and his team—how innovative they were with this before the start of the crisis. We had some emergency board meetings—[Inaudible.]—in order to work things through to see where we thought the pinch points were going to be, and, ultimately, this led to Andrew sanctioning an advance on our normal payments of one month's fees, one month's payment. So, that has allayed some of the cash-flow problems, probably now for the next two or three months.

Now, obviously, that money has to be paid back, and we've agreed a pay-back system over a number of months. Obviously, the way your wonderful finance works within the Government it has to be within that financial year, so that advance will have to be paid back within this financial year, but we've worked out a process of doing that, and that has solved some of the initial problems. And, as I say, we are very, very grateful for that. That's not the same as in other countries I have to hasten to add. The one very close to us—they gave their contractors 37.5 per cent of their advance, whereas Andrew gave us 100 per cent of our advance. So, that was a big help.

Going forward, we have, as we've explained, incurred some extra expense that was out of the ordinary and, obviously, we are expecting—we are in a negotiating situation with Andrew and his team to get these sorted out so that, hopefully, any extra expense that's been incurred will be paid back to us. So, we're—. There's a lot of trust involved, as you can imagine, from a lot of the contractors who are not close to the negotiations. Then, obviously, they've really just jumped over the edge of the cliff and done what they've had to do for their patients, which is what we do—that's the way we work. So, I think that, going forward, I'm confident that we can get this sorted out and the problems will be sorted.

The one issue that possibly is not within Andrew's remit, because of the way that we are remunerated via the drug tariff—and that's controlled by the Westminster Government—is the fact that a lot of drugs have gone up seriously in price. My purchasing's gone up somewhere in the region of 50 per cent from one month to the next because the value of drugs I've had to purchase has been more expensive. But, as I say, I'm confident that these things will wash their way through the system and get—[Inaudible.]—a financial position that is comfortable for both sides.  

Is that universal across Wales, because it's certainly not the story that I get in from some of the people who write to me? Could you just make a comment on the non-drug sales aspect?

Judy.

Yes. So, in terms of, I suppose, contractors across Wales who are not as close—who are not actually, obviously, on the board—may not have been aware fully of some of the conversations that have been going on between ourselves and Welsh Government. So, there was an announcement last week in relation to the services payments. So, that information has now gone to contractors; that went out last week. Obviously, we are still in discussions in relation to the additional costs that we've incurred and what position we may get to in relation to that. I suppose, as per all things, whilst the negotiation is ongoing, we communicate to our contractors that we're having discussions but we obviously can't give them the details or any definite assurances in terms of what financial position we will be in.

We have, in this last week, been having the discussions with Welsh Government in relation to what fees will be paid for prescription items as of 1 April. So, obviously, we're part way into May now and there has been a delay, because we were still in very detailed conversations in relation to our contract going forward for a three-year period when COVID-19 hit. So, those negotiations obviously have been put on hold whilst we focused on the pandemic, which then meant that we've now needed to go back to actually agree some of the actual detail. But that detail will be going out to our contractors relatively shortly and then, obviously, we'll be in negotiations in terms of any additional settlement to support us from our additional costs that we've incurred. 

Okay. And finally, Angela.

Can I just clarify that bit then about the full repayment, because people have written to me and said that they've had to negotiate with their individual health boards? But what you're saying is that, actually, it was pan-Wales and—

So, yes. So, our contact discussions are across the whole of Wales—

No, sorry, I know that yours are. I beg your pardon, I—

Yes. So, contractors—. Contractors shouldn't have had to do any negotiations locally in terms of—. The majority of these are all discussed nationally in terms of our enhanced services and those kinds of things. So, it may be due to the—. Because of focusing on the pandemic, maybe our communication in terms of finances haven't been potentially as upfront as they needed to be.

Thank you.

Mark, any addition to that?

Not really. If there are any local pilots or any services like that that are not nationally commissioned, then they would have to discuss those with their local health board, but I have to say that's very small fry compared to the main aspect of the contract. 

Okay. Angela, finally. 

That's it, thank you.

Okay. Fantastic, Angela. Amazing—amazing. That's a gold Blue Peter badge, although you're probably not old enough to remember that concept, but anyway. [Laughter.]

Yes—

Angela. 

Yes, Chair, thank you. I noted the contents of the letter from Public Health Wales. I have to say that it's still asks more questions than it answers, and I do have real concern as to the communicative relationship between Public Health Wales and the Welsh Government.

Okay. Any other comments? Those are noted, Angela. I think we could pursue those with the Minister when he's next in front of this committee, and we should pursue them, obviously, as well with Public Health Wales. Everybody in agreement with that?

Yes.