Cynulliad Cenedlaethol Cymru

Good morning, everybody. These questions relate to concerns that have been raised about the development of a new cancer centre, a new Velindre cancer centre. I think I'm safe in saying that I'm speaking for all of us on this committee in saying that we would very much like to see the delivery as quickly as possible of the strongest possible new cancer services for Cardiff and the much, much wider region. I think it's also important to say that our interest here is not in local planning concerns. We are very aware of local planning concerns around habitat protection and the use of local land for various purposes. That is not our interest; our interest here is in asking questions to make sure that the correct clinical decisions are taken into consideration when moving towards delivering the new cancer centre. So, I think it's important to have that as background. 

So, Minister, there are very serious concerns about the clinical model being chosen, namely having a new standalone cancer centre to replace the current standalone cancer centre, and suggestions that perhaps it would be better placed next to our main hospital, the University Hospital of Wales. There are concerns about the management of acutely unwell cancer patients through the standalone model. We've seen figures suggesting—. It was claimed that maybe around 30 patients had to be transferred by ambulance, perhaps, to the University Hospital of Wales in 2019 when freedom of information responses suggest it's well over 100. That's the basis of the concern. Given those concerns, should you have intervened earlier to make sure that the basic questions were being asked to get us the right clinical model delivered?

Minister.

Thank you for the question. I've written to the Chair of the committee setting out the position on Velindre—I don't know if that has been circulated to committee members—because I'm in a position where I am still a potential decision maker. As you know, as you'll be familiar, with any proposed or potential service changes that can come to Welsh Ministers, it's important we don't prejudge matters. I will receive advice having had an outline business case, and I expect to receive the final version of the outline business case in the foreseeable future. And you'll know that, as with all proposed service changes, Welsh Ministers can't comment on what's been proposed—it could be referred in to me. So, Welsh Ministers have to ensure that we don't comment on proposals for service change in case a referral is made. The clinical model would be fully considered within the advice that I receive about the outline business case.

It is worth noting that the chief medical officer has asked the trust to seek independent advice on its proposed clinical model, and to re-engage with the clinical community about the regional model that they are proposing. Velindre has appointed the Nuffield Trust to provide it with independent clinical advice, and that will, I understand, consider the concerns raised and practice across the UK.

Beyond that, I can't really say much more. But as I say, Chair, I don't know if you've had a chance to look at the letter yourself, or to share it with committee, but I have put that in writing, to set out the position that Welsh Ministers will need to follow. And I appreciate your opening, that you're not looking to get yourself involved in the planning process, but in terms of planning, of course, that could potentially be called in for a different Welsh Minister to make a decision on. And of course, because Velindre is in Cardiff North, that's why the Deputy Minister isn't here for this particular item.

Thank you for that, Minister. Yes, we are aware of your letter, obviously, and Members are aware of the letter, and the constraints necessarily. But obviously, we also have a scrutiny role as this committee, and so we are trying to address this situation, fully acknowledging the constraints that you and others are under. Rhun.

Absolutely, I read the letter last night, and I appreciate you sending that letter to us. I think it's important that some of the questions are still put this morning, whether or not you feel you're able to answer them, and maybe there are some questions that I think you should answer. For example: can you confirm whether looking at those issues around the management of acutely unwell cancer patients was a part of the remit that you've put forward in asking, 'This is what I would like delivered', and how you proposed that that assessment would be made of, whatever answer was suggested to you, would be able to fulfil your requirements as a Government and as a Minister for the management of unwell cancer patients?

Dr Atherton. You're muted, sir.

Thank you for that. Sorry, Chair. Just to add to what the Minister has said really, in terms of the clinical engagement process, clearly there was a—. When the concerns around the clinical model resurfaced earlier this year, I've had significant discussions, of course, with the medical director of Velindre, Jaz Abraham, and with the clinical lead up there, Tom Crosby. And we talked about the kind of process of clinical engagement that has been undertaken. And of course, up to 2018, there was a huge process of clinical engagement. I think perhaps, with the benefit of hindsight, having made the decision by the health boards to go ahead with the construction of the new Velindre cancer centre back in 2018, perhaps that clinical engagement should have continued, and that's perhaps allowed—that perhaps didn't happen as much as it needed to.

The thing I would say is that the new Velindre cancer centre, of course, provides the non-acute services. And it is part of the system for improving cancer services across south-east Wales, not the totality. And so it's right to say that there will be questions about how acutely unwell patients—and there will be a number of those; there are currently—will be managed. And that's about how we construct the proper pathways, so that patients are transferred when needed. The two main examples are spinal cord compression and neutropenic sepsis. And people do run into problems with those and need to be transferred, and that happens currently in Velindre and elsewhere.

When I spoke with the medical director and the clinical lead, we did recognise that we need to bring in some external support, some external lens, to help us to make sure, because cancer services move on and have moved on since 2018. And so, making sure that the current proposals continue to be fit is really quite important, and that's why the Nuffield Trust have been brought in, really.

The only other thing I would add is we have looked of course in Wales at how cancer services are provided elsewhere, not just in the UK, but internationally, and although, in the UK, many cancer services are co-located with the acute hospitals—Clatterbridge is the most recent redevelopment, up on the Wirral—there are still issues around transfer of patients between the cancer part of the site and the non-cancer site. Slightly broader across Europe, there are a number of facilities where cancer facilities are standalone and where patient pathways are used to manage those acutely unwell patients.

The final thing, of course, is that there is a sense of urgency here. We know in Wales that our cancer outcomes are not what we want them to be or what we need them to be and so there is a balance to be struck, I suppose, between the timeliness of any decisions and getting the ideal solution, as opposed to getting—[Inaudible.]—for the next four or five years.

Okay. Rhun, you're muted.

I had been muted. We're making decisions here for decades to come. It's important to get the decisions right, and, as I say, we want this to be delivered quickly. You said there was a huge process of clinical engagement. The Dr Barrett report I've seen referred to as being a robust process pointing to the benefits of a standalone model, but I've seen an e-mail from Dr Barrett herself saying that her work was nothing of the sort.

I was sent a written answer from the Minister on 12 August, saying that an option appraisal was undertaken on the new hospital's location. I wonder if the Minister stands by that. And was a clinical assessment carried out? Because that's what we're talking about here: getting the right clinical solution.

Well, as you've heard from the chief medical officer, there has been clinical engagement up to 2018; the chief medical officer has indicated that they should undertake and get a further independent review—that's coming from Nuffield, and I don't really think there's anything more to add. We'll have that and that will be considered as part of the advice that I get when the outline business case is provided to me. So, we'll of course consider the different options available and the model that is being proposed.

But, given the significant amounts of money that will be invested in this and the potential for delays that nobody wants, wouldn't it make more sense for you as a Government to have your own assessment carried out now, alongside, perhaps, the Nuffield assessment that has been commissioned, of course, by the Velindre University NHS Trust itself, so that we are in a position for you as a Government to say that the right clinical model has been chosen?

Well, that's what happens during the business-case process and the interrogation of that, including the clinical model. And the Government isn't the developer here. You've heard the chief medical officer outline the role that he plays in terms of the clinical leadership and engagement; the Government have to make the choices.

And, as I said in my letter, and in the opening, there is a real limit to what I can say this morning and my role in the process. So, I don't think I can intervene and set out a different range of questions part way through when we're waiting for the clinical model and the review that is already in train—the independent review that's going to be taken on the clinical model—and that will, of course, play a part in the decision-making process and the interrogation of that. And ultimately, I will be asked to make choices about this, including the potential for a formal call-in, but, if the business case is approved, then the Government still have to agree to move forward with the finance around that as well.

So, I've got a distinct role to play in decision making, and that's why I really can't go beyond what I've already said. I'm trying to be as helpful as possible without getting myself into a position where I create problems for this. And I appreciate what you're saying, that you're not looking to create challenges to get in the way of the right choice being made, but I have got to be careful about what I say and how, and ultimately I could well be the ultimate decision maker on the project going ahead.

Diolch.

Okay. Andrew R.T., you've got some questions. We can't see you, which is a blow to your fan base, but do you want to ask some questions?

Yes. My apologies—we're having problems with the video this morning. But if I could just direct this to Dr Frank Atherton, the chief medical officer, because I appreciate the position the Minister finds himself in, and I fully understand why he's limited in what he can say. But just to clarify that the chief medical officer does recognise that there were flaws in the medical engagement and consultation and preparation of the case so far around the Velindre development, and those flaws, as he sees them, will be reviewed by the Nuffield review that is currently being commissioned by the Velindre NHS trust. Is that correct? 

Exactly what I was saying. I was saying that there was extensive clinical engagement. Talking to Tom Crosby, in particular, he spent a huge amount of time travelling around all the health boards, talking with all interested parties from a clinical perspective, up to the decision by the health boards in 2018 to proceed with the development of the new Velindre cancer centre. Of course, since then, time has moved on, and, with the benefit of hindsight, I think it would have been better if that clinical engagement perhaps had continued. It probably paused because a decision had been made; it was assumed that everybody was comfortable. With the benefit of hindsight, I think it might have been better to continue to run some of that. And there is, now, clearly, a need to go back and to reassure clinicians, to have those discussions with clinicians. And my understanding, from Tom and from Jaz Abraham, the medical director of Velindre, is that that's a process they're embarked on, as well as bringing in the Nuffield to try to look alongside them to make sure that the advice is current and up to date and that the plans that were agreed in 2018 are still as valid as they were then. 

And you reckon—

You reckon, Andrew. 

—the 57 cancer specialists, oncologists et cetera that have made their views public around their disquiet over the proposal are valid, and that the Nuffield review will need to take those views on board when compiling their report.

Well, of course they're valid; we have to listen to our clinicians. As ever, the clinical opinion is not uniform and there are divided opinions. There are many cancer clinicians who believe that the model as agreed in 2018 is the correct one, but the issue of the management of acutely unwell cancer patients who need to move from the elective stream into acute stream needs to be managed, and people are looking for reassurance around that. So, that's the process that we now need to put in place. 

Okay, Andrew—moving on. 

Thank you. If I can move on to the Minister, now, on the legislative consent memorandum in relation to— 

Sorry, Andrew, we can have Julie Morgan back in at this stage, because we've moved on from Velindre now; this is on the LCM. So, Andrew R.T. 

Okay. I presume Julie's joined us. I just want to ask a couple of questions on the legislative consent memorandum. Could the Minister confirm whether he's received a reply from Lord Bethell, and, if so, could he update the committee on the contents, and share that information with the committee?

Yes, I'm happy to do so. I had a response to my letter of 28 August on 14 September from Lord Bethell. I think it was a constructive response, albeit it doesn't provide all of the answers that we were looking for. The response emphasises the importance of a UK-wide approach and recognises that we have started the legislative consent process; we're not yet in a position to recommend agreement. There's a recognition, I think, not just within the UK Government, but in all four Governments in the UK, about the benefits to patients to have a proper registry of implanted medical devices and our ability, then, to take earlier action to avoid harm for patients. And we're all aware of the significant harm that has been caused, and the recent focus that comes from mesh surgery and the life-changing outcomes that some people have been left with. 

Lord Bethell agreed to table an amendment to the Bill that would require the relevant UK Secretary of State to consult Welsh Ministers and other devolved administrations when making regulations. Now that's a step forward, and he indicated that they want to implement an operational model to serve the best interests of patients across the UK and to take particular consideration of devolved administrations. Now that is a step forward. However, given that the Bill does cross a range of devolved responsibilities, I am still looking for something that goes beyond consulting before, nevertheless, deciding. We have a range of areas where UK Ministers can only act with the agreement of Ministers in devolved national Governments, and that's the sort of indication that I'm looking for. If that came in and we were clear that the way in which UK Government responsibilities would be implemented would not cut across devolved Government responsibilities, then I'd be much more comfortable, because the point and the purpose of the Bill is, as I say, one that there is broad support on.

So, it's progress, but not quite there yet, and I do want to recognise that I think the response is a constructive one. There are meetings that I've asked for with Lord Bethell on other matters, and I'm hoping that if we can't find, through our officials, who are engaging with each other between the Governments—if we can't find an agreed way forward, then I'd hope we'd be able to resolve the matter with a brief ministerial engagement.

Okay. Andrew.

Could I just ask about the financial implications that the Royal College of Nursing have raised? And have you any concerns around the financial implications of the Bill, and, in particular, plans for its implementation?

Well, part of that is because it's an enabling Bill, so it wouldn't necessarily have all of the detail through it. In terms of the financial implications, the cost estimates have been done by the UK Department of Health and Social Care, and they cover the whole system. And they're hypothetical, because the shape of the system isn't agreed yet; we don't have clarity on all of that, and you wouldn't expect that, because, as I say, it's an enabling Bill. So, I wouldn't want that to be seen as a direct criticism of the UK Government and the way they're framing the legislative vehicle at this point in time.

It's also worth reflecting that, whilst there will be costs of implementing a new system, we expect there will be significant benefits, not only in terms of harm reduction, but in terms of direct costs for that, whether that's by corrective procedures, or, indeed, litigation costs. So, I don't think it's quite as straight forward, as I say, at this point in time.

I think we would have been able to have a more rounded approach if there had been some earlier engagement between the UK department and devolved Governments, and we could have then had some more engagement around the proposal and draft regulations. But I think we're going to be able to make progress in a constructive way. And, as I say, this isn't a matter where I think that the four Governments of the UK are pointing in wildly different directions. It's about making sure we get it right, and understanding that, within that, there is some urgency to act, because, as I say, all of us recognise the harm that has been done that we're trying to avoid for the future.

Thank you.

Okay. Are you done, Andrew?

Yes, thank you.

Moving on now to local coronavirus restrictions—we may have heard a bit about this over the last couple of days. David Rees has got some questions.

Diolch, Cadeirydd. Minister, I appreciate very much the statements you've made in the Chamber in relation to the introduction of local restrictions, as we're now in a position where over half our local authorities either are currently in local restrictions or will shortly be in local restrictions as a consequence of the COVID-19 situation.

Before I ask some other questions, how—? Carmarthenshire is the only one that's actually got a section of the county borough in local restrictions. How far down will you go to have viable local restrictions, because the county boroughs that are left are far more diverse in their urbanisation than the ones you've currently placed in restrictions?

Well, we're continuing to take an approach that works with local authorities and the local health services and local partners. So, the police have been part of our conversations in each of the decisions that we've made. I think it's important that we have that joined-up approach, because, as well as understanding what we think the right answer is in public health terms, we need to understand what that means in terms of policing terms for any restrictions that we are imposing upon the population.

I think it's really important to recognise here that, underneath the broader point, lots of people have a much bigger appetite for more significant impositions on the public. And they are impositions, and it's a real and significant decision to make. So, we need to understand what that means in terms of the policing impact, but also the impacts upon the way that people can go about their business and act within the law.

I wouldn't set out a template that says that there is a limit beyond which we would or wouldn't go, because it really does depend on the information that we have. The coronavirus control plan sets out a range of markers and indicators in the data where our concern raises to the point we would take action unless there's an explanation why not. So, the typical marker is about 50 per 100,000, but we've acted ahead of that if we can see the trend's going in different areas, as indeed in Neath Port Talbot—we acted before we got to 50, but I'm afraid if we don't get there later today, then we're likely to get there within the rest of this week.

So, we're learning not just from the first six months, but we're also learning from the last few weeks as well, and that includes the point about local restrictions, because the example that I've given before is about both Caerphilly and indeed RCT before we got to Carmarthenshire. We did look seriously at whether we were really talking about a couple of towns within the Caerphilly county borough, but actually the evidence was that there were a range of clusters that weren't explained and that weren't linked back to others, where we couldn't control the spread of the infection across the county borough and it had spread so far within the county borough in terms of—the phrase that is used about coronavirus—it had 'reseeded' to the extent that it didn't make sense not to take action across the whole county borough. And we looked very seriously at Rhondda Cynon Taf, about whether we could isolate part of the Rhondda in terms of the actions that we were taking, but again, the evidence was there for community transmission in other parts of RCT, so it didn't make sense to try to take that approach.

In Carmarthenshire, we did have an instance where eight out of 10 infections in Carmarthenshire were within Llanelli town, so it was very, very local and distinct as well, because people broadly understand what Llanelli is and we can use the ward boundaries covering the town. I think we've indicated that if you took Llanelli out of the Carmarthenshire case numbers, then the rate would be around about 18 per 100,000, so not at the point where we'd contemplate taking action. That doesn't mean that everyone in the rest of Carmarthenshire can do as they please. It means people in the rest of Carmarthenshire continue to behave in a manner that reduces their contacts and reduces the opportunity for coronavirus to spread. And you heard in your last meeting, I think, from Rob Orford, about the reality that you are more likely to get coronavirus from your close family and friends, you're more likely to give coronavirus to your close family and friends, and indoor contact is the biggest method and environment in which transmission takes place.

So, as we move for the sake of argument to Gwynedd, well, Bangor is quite a long way from Tywyn and so we may want to look at, 'Well, what is happening in different parts of each of those authorities?' and we have that conversation as part of our regular consideration, so we may find other local lockdowns—other local restrictions, rather—that don't include the whole county borough, but that will depend on the intelligence and information we have at the time.

Okay. David.

Did I see Dr Atherton's hand raised up then?

Dr Atherton.

Thank you. Just really to add, I think it's worth reflecting on the fact, Chair, that as the pandemic evolves, our response needs to continue to evolve. So, it seems like only yesterday, but when I think back over the last three or four months, we've had a series of interventions that we've needed to put in. Initially, of course, we had problems with food processing places in Anglesey, in Wrexham, in Merthyr Tydfil and we responded to those with outbreak control teams and incident management teams and that managed that situation.

We've now moved to a different position where we are seeing far more infections seeded into the broader community, and that's why we need to take action at a local authority level usually, but in some cases, of course, at a town level, as we've just been reflecting. The sorts of things that we need to look at—I don't think we have a single formula that the panel should be using, but there are indicators that the Minister has referred to—the rate of new cases per 100,000 population over a seven-day period is a really important indicator, as is the percentage of tests that are being done that are positive. If that goes above 5 per cent, we get quite worried. And we also need to look at the number of cases that are not related to those clusters and those outbreaks that we saw in Anglesey, Wrexham and other places. So, those three things give us a clue as to what's going on, but they're only part of the picture and it really is important that we put local context to that.

So, what's evolved over the last few weeks, really, is that we now have, as the numbers escalate, as the situation escalates in certain areas, in local authority areas, incident management teams are created and they provide the local context not just in terms of the numbers, but in terms of what's going on. They can get a far better feel for how transmission is happening: 'Is it contained to pubs?', 'Is it contained to food processing plants?', 'Is it more widely spread in the community?' With that qualitative information together with the quantitative numbers, we can tailor local decision making, and it's not just—. It shouldn't be—and we've learned this from looking across the border at England—it cannot be just Government imposing restrictions onto local areas; it has to be done in consultation with our health boards, with our local authorities, and that's why incident management teams, which work across all of those partners, are so important.

Great. David.

Yes, okay. I appreciate those answers and I'll take Neath Port Talbot, my own area, as an example. I do understand the trend because, on Friday, I think it was 25 per 100,000, then it went up to 37, then 41.2 and then 48.1, so I understand the tendency and how quickly it rises to those figures. On that basis—because this time last week, we would not have been considering that through local restrictions—on that basis, are you looking at whether that speed can actually hit the areas you have not yet put local restrictions on, and therefore put local restrictions across the whole of Wales, rather than just simply those authorities that are already demonstrating those high numbers, to ensure that no-one gets to those high numbers and no-one gets to that trend?

Well, this is a difficult but necessary balance. There is an appetite in some parts of Wales to have much more significant and nationwide restrictions, but as I say, these are impositions. We are restricting the way in which people can live their lives by the law and, so, what I wouldn't want to do is to take an approach that says that we will do that and do that readily, when the evidence at present, I don't think, has been made out where the balance tips into saying, 'You need to impose those restrictions and intrusions into how people live their lives.' And it's really about asking people to look again at how they follow the rules to keep each other safe.

We've got relatively low rates in Ceredigion, Pembrokeshire, rural Carmarthenshire, Anglesey and Gwynedd. And for us to say that even though the evidence isn't there, we're prepared to take action that would affect day-to-day life and businesses, I think we've got to be really careful about that. The message for those parts of Wales—and indeed the whole country, including Monmouthshire and Powys on the eastern side of Wales—is that we're prepared to do the right thing, and that includes imposing restrictions, if that's going to help to keep people safe. Whereas we have seen through the summer—and indeed in the here and now—that it's possible for people to carry on following the rules and avoid a significant increase in transmission of coronavirus; it doesn't mean that we need to take legal action to enforce that.

The local restrictions are not a one-way escalator to more and more intervention, and more and more imposition. If you look at Caerphilly and Newport, they've had a real fall from where they were in terms of infection rates, and that's good news, so it shows that where there is concerted action, as there has been in Caerphilly, and very high agreement with the measures in the way people have chosen to go about their business, it's possible to see coronavirus rates fall.

So, yes, we always consider the balance of what to do on an individual local authority basis, within that local authority, and indeed across wider areas, including the whole country. But I don't think we're at the point where now, we need to take further significant measures across the whole of Wales, but the clear message for every single part of Wales is that it's up to us to do all of our parts to help keep Wales safe.

Okay—[Inaudible.]—

Thank you, Chair. I left the question with the behaviour of RCT. Is there anything we are learning from people's behaviour to ensure that we can get the communications right? Because the examples of Caerphilly and Newport are showing that it can be done, but what are we doing to ensure that, across the county borough councils that you're now going to be placing restrictions on, we get that communication better?

Well, I think there's been very strong leadership across RCT, actually: very clear messages from Andrew Morgan, the leader of the council, and his team and very clear messages from the health board as well. What we've found, though, is that the breakdown in behaviour about social distancing and indoor contact had got to a stage where it took quite a lot to recover it and to rediscover that sort of collective discipline. Now, even with that breakdown, the majority of people were still following the rules and were doing the right thing, but it does come back to this point that a minority of behaviour can actually cause a really big challenge and problem.

It's also the fact, as we've seen, that disease transmission doesn't just stay within young adults. It's also worth noting that the sort of behaviour that we're talking about isn't just confined to people in their 20s; there have been plenty of older adults who've engaged in behaviour that is problematic and likely to lead to coronavirus transmission taking place at a larger level. Now, we are seeing some signs that perhaps we're reaching a plateau in RCT. It's still at a high rate, but the next week will tell us whether we have managed to turn a corner, because as we set out with each of the control measures we've introduced, with those restrictions, we still expect it to be two to three weeks before we start to see the benefit of those measures. And that will then tell us about whether we need to be in a position to do more or not.

I think, though, from an RCT perspective, there's been clear local leadership and very engaged partnership working. The state and the extent of the spread when we took the measures is being played out and there's a challenge about bringing people back. You'll have seen the obvious example of people who were very proudly—well, perhaps 'proudly' is the wrong word, but being very upfront about the fact that they saw nothing wrong in what they were doing, and that's an example of the risk-taking behaviour that we need to see rowed back.

And I actually think that that is partly because over the summer, when we suppressed coronavirus so successfully, we saw a real fall-off in hospital admissions and in deaths. We still have very low death numbers, but actually, if you look at the death numbers over the weeks that we're going through now, they're low but you can start to see an increasing trend already in hospitalisation rates, including in Cwm Taf Morgannwg. And so we can see that harm is being caused to a more material extent than it was in the middle of August, and we're acting ahead of the sort of harm that we saw in the first wave. Because that's the problem for us: if we don't act now and learn from the first six months of experience, we could end up seeing something like that or worse during the autumn and the winter.

So, I'm not too downhearted and pessimistic about where we are in RCT or other parts where local restrictions are in place, but we do need to follow the evidence. And as the chief medical officer outlined and as is in our coronavirus control plan, it's partly driven by the stats and the data, but it's also driven by the softer, local intelligence we have as well.

Okay. David.

I don't think that there's any criticism of leadership; I think Andrew Morgan has been at the forefront of the whole process and leading from the front. I think that's been exceptional. But I suppose the question is people's behaviour and understanding. And perhaps, to an extent, the fact that we do have low numbers of people in hospitals and we do have low numbers of deaths, but, unfortunately, some people, though, still do not see this as a serious situation. So, it is about getting that message across to the people.

And you just mentioned that, you know, it's the expectation of about two to three weeks—for all those that have gone into local restrictions, it is now, therefore, an expectation of two to three weeks before you even have an opportunity to see the position of decline. What criteria will you be using to look at that decline to see whether restrictions can be eased?

So, I think there is more scepticism now. We've seen that, unfortunately, for all the benefits social media can bring, it's also a platform for conspiracy theories to take hold and to be shared widely. We saw a councillor in Blaenau Gwent, for example, sharing the utterly absurd set of conspiracy theories; we see former figures, who've been in the public eye, sharing conspiracy theories as well. And that's really difficult when you have sources of disinformation being promoted by what appear to be, for a number of people, reliable sources—that's really challenging. We hadn't seen that, to the same extent, at the start, because if you recall, when we went into what was a proper national lockdown on 23 March, we'd seen the rising tide of not just infection rates but deaths in other parts of the world, and in particular in mainland Europe. And so, actually, I think the public, at that point, was thirsting for action to be taken and they were ahead of where politicians wanted to be in taking away liberties. Now, we saw the significant harm caused, we've seen more complacency, and I'm afraid that there are apparently respectable commentators who are fanning the flames of ignorance, which is dangerous and has real consequences. So, that's one of the factors that we didn't have when we were in February and March, I'm afraid.

The thing about where we are now, and the prospects for moving out—. In every new set of local restrictions, we'll consider them after two weeks—that's what we said in our coronavirus control plan—and end within at least seven days. We're trying to set a regular pattern to have that formal touch point on a Thursday, for the seven-day review, to consider the picture individually and collectively. And that will partly be driven by the data, which has fallen in the positivity rate, the number of new cases per 100 tests carried out, and we've seen a jump, for example, in some of our north Wales authorities on positivity rates, as well as overall infection rates. So, the infection rates, positivity rates and, indeed, the information we're getting at that point about the sort of lag effect of hospital admissions—they're all really important for us, but we'll have to marry that up with the local intelligence about whether we're seeing a change in the number of cases that are coming through and whether, actually, we've got a controlled picture, with our test, trace, protect service, of where those clusters are taking place. If we can rediscover that sort of control, we can successfully have very smart, very local restrictions in place for those people to self-isolate, and then we can take other measures with the rest of the community. It's what we did successfully with Kepak in Merthyr, with Rowan Foods in Wrexham, and with 2 Sisters in Anglesey, and I would like us to get back to that position where we can have that TTP-led approach on self-isolation and release community measures. But it's a combination of factors, as I've said, and as we describe in our coronavirus control plan.

More on TTP in a minute. Dr Goodall wanted to come in.

Just, really, to build on the Minister's comments on the broader population tracking measures and where we are. You know, our experience back in March, April, May showed us that we would see a lag into the system when the NHS pressure would be more visible; and it is just to say that, over the course of the last two to three weeks, I'm afraid that we have been actually seeing a conversion of those positive case numbers, particularly in areas with that higher prevalence, into numbers of hospital admissions and patients in hospital, including into critical care. Even over the last week, we've seen a significant increase in the number of patients in our hospital beds. So, that has actually gone up by around 60 per cent just in seven days. We're now up at 550 patients in our NHS beds who have got COVID-related reasons for being in those beds. And also we've seen a 90 per cent increase in the number of COVID-related patients in critical care—that's gone up from 16 to 34. It now also means, for the first time, that we are starting to use the expansion plans for critical care across Wales in some of these areas so that patients are having to be cared for outside of the normal levels of beds that are available.

And if I could just conclude that picture, as we look across Wales, there is a disproportionate level of those admissions in the areas that are under local restrictions, and at the moment there is a higher proportion of hospital patients in Cwm Taf Morgannwg beds than other areas of Wales. So, the change happens very quickly, Chair.

Okay. We have to move on, David, all right?

Diolch, Cadeirydd.

Moving on to Rhun ap Iorwerth and testing and TTP. Rhun.

Diolch. The problems with the testing regime have been pretty well publicised over the past few weeks. Is the main problem that the bulk of Wales's testing regime is beyond your control, Minister, because of overdependence on lighthouse labs? I get the attraction, you don't have to pay for it, it's, in principle, meant to be there, but it's not, it's let people down over the past few weeks. You tell me in letters, 'It's not my responsibility.' Well, you opted to go with it. Is that a frustration of yours, is that something that you recognise is an issue—you don't have control?

Minister.

Well, I would always prefer it to be the case that I had direct control within the Government and the national health service in Wales over all parts of the testing system. The UK Government decided to introduce a testing programme that they funded and resourced and made available to every country in the UK. Now, there is a choice for devolved Governments about whether you do it nationally, or who wants to take part, as the Northern Ireland Executive did, as the SNP in the Scottish Government did, at an earlier point than we did. Actually, in terms of where we are now compared to where we were, there were questions asked by Adam Price about whether or not we were going to have what he referred to as a mega lab in conjunction with the UK Government's when they were developing the facility in Glasgow that is a lighthouse lab.

So, we're in a position where we have that as our programme, and the challenge about where we are is that there's the ideal world of what I'd prefer, and there is actually making the very best of what we have available, and we're not in a position to dynamite the system and start again. I'm actually looking for a return to the level of service that lighthouse labs were providing, because five to six weeks ago, we wouldn't have had this conversation about the deterioration in performance. Five to six weeks ago, we were expecting the lighthouse lab in Newport to be functioning by now. There's been a delay, we're now expecting that to come on stream in October, and that will make a difference. Even over the last three weeks, the position of lighthouse labs has seen some improvement. The sooner that happens the better, and at the same time, we are flushing through more of our NHS Wales tests. We are doing, between NHS Wales lab tests and lighthouse lab tests, just under 70,000 tests a week over the last two weeks, so there's been a significant increase in tests that have been carried out, despite the well-advertised challenges, and that's the position that we're in, and that's what we need to work with.

So, we do now have a better position in terms of relationships between the Governments on how some of those resources are deployed. So, if there are challenges and there is constrained capacity, there'll be a decision for the Welsh system to make about how the overall total of lighthouse labs is deployed, and we're looking to have further mobile resources to deal with the outbreaks and the hotspots that we have in large parts of Wales. So, we are in a better position. Just to give you an example, from Monday compared to where're expected to be, I think, by the and of tomorrow, but Jo-Anne Daniels can confirm this—we're going to see an over 40 per cent increase in testing capacity available in north Wales, and that is because we're responding rapidly to the changing picture, and the great majority of those new tests will be done through Public Health Wales labs. So, we're using our capacity, together with the lighthouse lab programme as well.

I think we should put this in context. Sorry, I was scrambling through my drawer there, looking for this notepad of mine from March, which I found here, and you said 70,000 a week—did you say—between the Welsh capacity and the lighthouse capacity. Seventy thousand. My notes here from the Government statement on 21 March said capacity would be up to 6,000 a day on 1 April, 8,000 by 7 April, 9,000 by the end of April, and here we are in—well, it's October tomorrow, and we're still at that level. Given that we were told right from the outset, before the national lockdown on 24 March, that it was all about test, test, test—you know, test, isolate, identify where the cases are, identify where the clusters are.

We know in hospitals we need to be regularly doing asymptomatic testing of staff, for example. The Royal Glamorgan Hospital, which I brought up with you yesterday—the staff want to be tested, because there's a worrying level of hospital transmission there. We're at the same point as we were six months ago. I just don't get why you're so calm about that, given that we need to be building up that capacity at a much, much quicker rate, surely.

Well, I'm happy to re-cover old ground as you've raised it. Those were the expectations we had of our ability to increase our testing capacity here in Public Health Wales. We then found that, despite there being purchase orders made some time in advance, we had well-advertised challenges in a range of medical equipment actually arriving in the country, and we then had some challenges in the equipment then being validated and ready for use. So, for all the plans that any Government or any part of the health service makes, there are times where reality means that doesn't happen, and we weren't in control of the import of all of the equipment required. We also have ourselves in a position where the time at which tests can be done—so, whether a lab can operate more than, if you like, a normal working-day period, the ability to have surge capacity and also the ability to work 24/7—. It's something we set out in the £32 million plan that I've previously announced, which will increase lab capacity and sustainability, we think, to make sure it's robust, so that we'll have a better service going through the winter. If you go back to where we have been and where we are now, the ability to have 70,000 tests essentially being delivered each week in Wales means we are in a position to have a much broader and deeper range of testing available across Wales. And that means—

Yes, but if I could just interrupt—

That means we're in a better position to understand the spread of infection and how we help people to safeguard themselves and their community.

If I could just interrupt there, I sympathise—you know that I sympathise with the loss of thousand of those tests that you hoped you were going to be able to deliver in April, goodness me, and some of the actions of the UK Government in relation to that. I get that problems have arisen. Some of those problems—the import of machines and that kind of thing—are beyond your control. But in terms of the aspiration, you knew in April that you needed to be delivering 9,000 tests per day, and here you are going into October, with the winter period upon us, and you seem happy that that is the level that we're at now, and the aspiration hasn't seemed to change. To me, the evidence has become stronger, that we need to be testing more.

With respect, I think that's a mischaracterisation of where we are and where I am in terms of what we're able to do. That's our current regular capacity to test, and actually we've seen a small dip in the last two days, but, actually, in most of the days last week, we were undertaking 10,000 to 11,000 tests a day. We actually expect that, from the information that we've been provided, and the commitments that have been given to us for the lighthouse lab programme, when we get to the start of October—I think Jo-Anne Daniels has got the figures—we should have about 18,000 tests a day available to Wales from the lighthouse lab programme. With the capacity we have within Wales, with the investment that I've already announced, with the people that we need, with the technical resources we need to undertake more of those tests, we'll then have that capacity available as well, so we will have a much more significant capacity available through the autumn and the winter.

And that is important, to have flexible capacity because, as we've seen—and I've just given an example in north Wales—we're able to deploy more of our own tests from the Public Health Wales labs into areas of higher prevalence. We have a range of mobile testing units that are available to go into hotspots as well, as the way health boards can organise to have community testing facilities as well. Those are all things that we provide within the Welsh system in addition to what we're getting from the lighthouse lab programme. So, we have more tests available, we have more tests on their way and we have, importantly, greater flexibility on its way in the way that those testing resources are provided.

So, if you look at the number of tests we're providing, compared to comparable countries, we're testing at a relatively high level. We expect to be able to do more, and it's the rapid turnaround and the rapid access to those tests where they're needed that will be really important. I think that the idea that we should have a regular asymptomatic testing programme with NHS staff isn't entirely borne out by the scientific evidence and advice, but we'll look at where we need to do that. And because there's an outbreak in the Royal Glamorgan Hospital, that's why we are already testing staff within that hospital, as we did, indeed, within the Maelor. So, we're again being guided by the evidence whilst we build up our resources to enable us to do so. 

So, staff at the Royal Glam are being tested regularly—

Yes.

—when asymptomatic.

We're testing the staff cohort at the Royal Glamorgan because we know there's an outbreak. And, as we learned from the Wrexham Maelor incident, there are the staff on the wards that have been closed and affected, but actually, because of the way in which those sites operate, we are looking to test the staff population. And that is being done in conjunction with staff and trade union representatives, exactly as happened in Wrexham. So the learning from that incident is being transferred to Cwm Taf Morgannwg and the current position that the Royal Glamorgan finds itself in. 

Moving to tracing, what do you think are the additional elements of investment that need to go into tracing over the winter period, and how do you propose to deliver that?

Well, I think—and, again, Jo-Anne Daniels may correct me if I'm wrong—we've moved from 700 initially, and I think we're now approaching 1,300. I think we're going to get up to about 1,800 over the winter. Jo-Anne can come in and correct me if I'm wrong on the figures. So, we are seeing more people come in. And, again, we are in the very fortunate position of having not just a public service approach, which some may prefer from an ideological point of view, but actually it's demonstrated it's been a robust and effective way to deliver the system. And the partnership working that we've undertaken over many years between health and local government I think has really helped us to make progress through the pandemic together. So, these are staff employed within local authorities, staff who know their local communities.

It also means there's mutual aid between different parts of Wales. So, in recent times, there's been mutual aid provided to some authorities in the south, but previously those authorities in the south provided mutual aid to Anglesey and Wrexham, when they had those significant incidents that I have mentioned before. The system is robust and it's more flexible, and it does mean that councils are making choices about their staff who have already been trained and are now effectively surge capacity. So, it's a robust system, and actually I think everyone across Wales should take some real pride in what we're doing with our contact-tracing service. It is materially better than it is in England, where they are contacting about 82 per cent of new cases. We're getting to 94 per cent of new cases, in last week's figures on that last week. So it's a highly effective service, and I'm genuinely proud of the work that our staff are doing.  

Jo-Anne Daniels, you received a lavish introduction from the Minister, there. Do you want to add something?

Thank you. Just to reiterate what the Minister said, the staffing projections look like they're going to be hitting 1,800 in October, amongst our contact-tracing teams. We think that gives us the capacity to trace about 11,000 new positive cases and, obviously, their contacts each week. But we're in very, very regular dialogue with colleagues in local government. We meet with them on a weekly basis to assess their capacity, and if we need to increase that capacity further, then obviously we can look to do that. 

Just to add on the testing figures, we published our weekly testing figures this morning—they were published at 09:30. So, in the last seven days for which we published data, there were 75,000 tests undertaken in Wales. So, an increase again on the previous week. So, our capacity to test is increasing week by week, and responding in particular to some of the surges and outbreaks that we're seeing. 

Thank you. Rhun. 

Your suggestion there that more funding might be made available—just to confirm, that would be for the direct employment of tracing individuals and teams within local authorities, yes?

If that's what's needed, yes. 

Okay. The tracing app, finally. Questions have been raised about the effectiveness of the app. In many ways, you'd expect any new system to be questioned, but it is important that we get this right. You had the opportunity to pursue a Welsh-only app, as Scotland and Northern Ireland have done. In fact, a company from my constituency had prepared it for you. What evidence do you have to show that you made the right decision in not opting for the home-grown system that had been developed?

Well, there were some challenges in the way that the app store recognises individual apps; that was the technical part. But actually the app that's available in Scotland and Northern Ireland does proximity—it's a proximity device; we actually have more functionality in the NHS COVID-19 app that is available in Wales and England. So, it's got some extra functionality to it, which I think is important and helpful. And it's also the case that if we're making choices about the functionality between apps and the reality about how people live their lives, the fact that we have a long porous border with England is a material consideration for us.

I think the Scottish Government are looking to have both apps available potentially in Scotland—that's a matter for them. But I think we have got an app that is functional and it's accurate. You'll recall that we didn't have the same challenges that colleagues in England had for a few days, where not all of the tests were being reflected in the way that you could enter those into the app itself. I think it's a real credit to NWIS, which I know have come in for some criticism from time to time, but their work throughout the pandemic I think has really put us in good shape, and on the app in particular, their ability to make sure that those tests can be linked into our system and the way the app works that allows that to happen for the data to be entered, I think, is a real advantage.

As to whether these are the right choices, we'll have the opportunity to have some hindsight about where we are, as opposed to the very recent introduction of the app and other choices that have been made. So, I think we need to wait for the judgment of the coming months, but, at this point in time, I think there are good reasons to think we've made the right choice. And when I say 'we', of course, it's me—it was ultimately my decision about opting in to have an app that is being developed in a way that works with the Welsh system, not just the issues about language, but actually about how it properly integrates with our healthcare system here in Wales.

I don't think it is available in Welsh on Android, actually, as far as I can see, just out of interest. It is on my Apple phone, but we tried to get it in Welsh on an Android and couldn't—making that point. Thank you, Minister. Thank you, Chair. 

Universities questions—and after that we'll take a short planned break. Lynne Neagle.

Thank you, Chair. Minister, can I ask you what additional preparations have been put in place to reflect the start of term, and how that is being integrated with Public Health Wales work on testing?

Well, I've had a number of conversations with the education Minister and with the First Minister about plans for the return of university students. Each university institution have their own plans in place for a blended learning approach, where they should have some contact time and other remote learning, and also about the way that each university has set out their plans for how they want students to behave on and off campus.

There's also been direct engagement, not just with university institutions, but also with the student movement as well, so the National Union of Students Wales and also the local student union leaders have been engaged within that. So, from the start, the education Minister had an approach that took on board the different sides, so both the learner representatives as well as people with responsibility for delivery. I think that has had paid dividends. So, we've had an opportunity to understand that there is a plan for what happens if there's an outbreak, about how people should behave and what that means.

It's trying to treat students in the same way as the rest of the population. I think there's a real danger that we could collapse into saying that students are somehow to blame for what is happening across the country, when actually there's very good evidence that student behaviour is much like other young people who are not students, and that it isn't just young adults who have some responsibility for the way that we all conduct ourselves. As I say, unfortunately there are plenty of people who are not being entirely responsible and are much older than the traditional undergraduate student.

We have got, as I said earlier in response to the testing questions, the ability to provide mobile testing units around the country, and Jo-Anne Daniels might want to tell you a bit a more about the walking centres that we're looking to develop. That's, again, part of the partnership with the UK Government, but I think it might be helpful to explain what we're trying to do in the siting of those and the availability to both the university population and the town as well. 

Jo-Anne Daniels.

Thank you. So, the first local test site, as they're known, was opened in Pontypridd, the campus there, on Friday last week, and people have started to access tests. We've now got plans in place for these local testing sites to be opened in Cardiff, Swansea, Aberystwyth and Bangor. We're also looking at arrangements for Wrexham. These are designed for high-population areas where perhaps there's limited access to cars, so people can't necessarily go to drive-throughs. They're not exclusively for students, they are for the population generally, but obviously we think it makes a lot of sense to look at how we can co-locate these sites with university campuses or areas where students live in high density in order to make sure that the student population has quick and easy access to testing sites when they need them. So, they'll be rolled out in the next few weeks. But, as the Minister said, in the meantime, all health boards have available to them mobile testing units that they can deploy to university sites and university towns as and when they need to respond to the issues that they face. 

Excellent. Thank you. Lynne Neagle.

Thank you. I do very much welcome the engagement with NUS and also the commitment not to treat students as if they're somehow at fault, because clearly that's a very poor message to send out. So, can I ask, then, about universities in rural areas and low-population areas, particularly Aberystwyth and Bangor? Ceredigion has had practically no cases of COVID in recent months. What assessment have you made of the impact in towns like that?

Aberystwyth and Bangor are, if you like, medium-sized towns with a very high student population; about 4 in 10 of the residents in both those places are students. So, it's a really big part of how the whole town functions socially and economically. So, obviously, we do need to think, in those areas in particular, thinking about the local health service, about what might happen if we do see outbreaks. That's part of the point about why the universities need to have robust plans, but also why local authorities and health services need to be aware of the plans they have.

If you think about it this way, the fact that lots of students live in a halls of residence means that they're in a relatively unique set of accommodation, but each halls of residence is different. As a student, I went to Aberystwyth and I stayed in Pantycelyn for one of my years there. Now, that's very different to different halls of residence within the same university. So, an outbreak potentially centred on Pantycelyn would be very different to the student village or to the Rosser halls of residence.

So, you've got very different contexts all around, so it's important not to treat students as a block, and the plans that universities have have to take account of that, and that's the assurance that we've been provided with. So, you should expect to see varying responses depending on what happens within each of those local contexts, just as you'd expect the response to Cardiff and Carmarthenshire to be different in terms of the reality of their local populations. 

If we do see a situation where students are asked to self-isolate—we've all seen the scenes in England last week with parents arriving with mercy packages of food, et cetera—what assurances can you offer that students, if that happens in Wales, will be well supported not just in terms of their physical needs but also in terms of their mental health needs?

The guidance we've given to the university sector has been that they need to have in place, as part of their plans, how they will support students who need to self-isolate. That's not just about food and drink, it is about the broader student welfare support. And there's a challenge here, I think, because again that will vary from one institution to another, in that some institutions will have a student union that has an independent student welfare service that is well developed. Smaller student unions with less resource won't have that. But, each university will have a form of student welfare service, and it's important that they understand the very real health and well-being impact that could take place if students are required to self-isolate.

That's why the message about self-isolation is important in itself. It's not about, if you like, a collective punishment for students, it's actually about measures to keep those students themselves safe and to help them to manage the risks that they face as well as their friends within the wider student population. So, it really is about saying that this is the right thing to do for those individual students, as well as for the student community they live in, as well as for the town or the city that they're living and studying in. So, it's really important that the message is an open and an honest one about why people are being asked to do something, and the support that is essential for those people to cope with the period of self-isolation and to hopefully come out of it safe and well.

Okay, Lynne?

Thank you.

Okay, we'll take a short break there now for 10 minutes. It's 10:55 now, we'll reconvene at 11:05. Thank you—

Chair, can I just ask one question on TTP before we go?

Go on then.

The reason I'm asking for—I was searching my social media for this, because I've had concerns raised by constituents. The app side of things: the concerns are that there are many businesses still not displaying the QR code for them to use the app, and there are concerns about why they're downloading an app if they can't actually get that information in so that people can understand where they are. Will the Welsh Government look at this agenda to ensure that businesses are displaying the QR code, so that people who have the app are able to actually use it properly?

Okay, so, briefly, we are encouraging businesses to display the QR code so that the check-in function can work. That's one of the additional functions that other apps in the UK don't have, and that diary function is really helpful for contact tracers. We haven't made it mandatory, but it would help the business itself to understand who's coming through it and, in any event, even without that, the proximity function still is there. The function to understand the local prevalence in your area is still there, there are nudges and reminders about symptoms and whether you should get a test, and it would allow you to input your test results as well. So, even if you visit a business that doesn't have the QR code, the app is still of value, and it's important to remember that the app is a support, not a replacement for contact tracing. It isn't just highly effective in terms of how many people we get to, but it's also a genuinely rapid service as well. We're really proud of that. We're publishing data on how quickly we get to people as well, and those figures, I think, are a real credit as well. The app definitely supports the work of the contact tracing service, but we'll need to take a review at some point about how many businesses are displaying the QR function. There are always options for us to change requirements, but at this point, I don't think that the bar has been met to try to require businesses to display that QR function, and actually, in many ways, pressure from customers is often the most effective way of getting businesses to change the way they operate.

Diolch, Gadeirydd.

Okay, as aforementioned, we'll have the planned break now. We'll make it back at 11:10 then. Diolch yn fawr.

Diolch, Gadeirydd. Minister, we've obviously been looking very carefully at the impact COVID-19 has had on normal services within the health board, and over the summer we did see some return to those services, but I think you highlighted the fact that there's going to be quite a large backlog. Do you have the numbers we are seeing regarding the waiting lists and the increase in those waiting lists as a consequence of COVID-19?

Yes, we're counting those. I'll ask Andrew Goodall to come in to give you some of the operational detail, but we know that, from our management information, we have seen a significant increase in the waiting list size. The total waiting list size in Wales had increased by just over 9 per cent at the end of August compared to March 2020, with a significant increase in the number of people waiting over 36 weeks. It's a common challenge that we face together with other healthcare systems in the UK, and I know that Dr Goodall can also tell you more about challenges in other parts of the UK as well, where they're tracking a similar problem. What we haven't done, though, is we haven't tried to set unrealistic targets and expectations on activity because our staff need to have a break with the winter that we have ahead of us. But I think in terms of giving you some of the detail it's probably best if Dr Goodall comes in to provide you with that.

Dr Goodall. 

Yes, we have obviously been tracking, through our management information, the pressures on the service, and they do translate into concerns. You'll recall, not least on previous evidence, describing some of the drops in activity that we had seen, not least with the very specific measures that were taking place on a national basis across Wales beforehand, and our message to say that there was a real ongoing focus on essential services.

Perhaps to just quickly run through some of those for Members: firstly, on the emergency side, I at least would like to report that we have seen a return to normal levels of emergency activity across Wales. One of our original worries was seeing such a significant drop that there was latent demand, and that members of the Welsh population were not accessing care and treatment that they required. Our emergency admission numbers, our A&E attendances and, indeed, our 999 calls have actually returned over the last two months or so to normal levels, which means the system is as busy as it normally is. In fact, on some occasions, it's actually running higher than our normal levels. So it does raise questions about how we are organising our services around that.

On the elective side, which relates mainly to our planned treatments and also to our out-patient sessions, whilst, on the one hand, certainly for out-patients, there has been a transformation around the way in which we discharge those responsibilities, including the opportunity to facilitate a much higher level of remote consultations, whether they are video-conferencing or just calls that are taking place with patients, obviously there are patients who simply need to come in for operations and, as the Minister said, we have seen the overall total waiting list in Wales actually increase between March and August on our management information. It had actually not deteriorated as much as we thought, probably reflecting the fact that there were lower levels of referral that were happening in the system, certainly between March and June. Our numbers of patients waiting over 36 weeks, in terms of the longer waiting times, have deteriorated over these recent weeks and months. So, despite some reversion to more normal levels of activity, we now, on the provisional figures for the end of August, are seeing over 140,000 patients who are over 36 weeks. So that is a material change. And the disappointing thing, Chair, is that that is in a context where we had been seeing improvements in our waiting times in the NHS in Wales over recent years. We'd been able to make genuine progress on those and support things.

We have an outstanding responsibility for any of our patients who require care and treatment to be supported, to understand their status within the system, but obviously there is also a need at this stage to ensure that we can focus on those patients who will be of urgency and of clinical priority. And the levels of activity at the moment that we're seeing for out-patients and elective work have dropped probably to about 50 per cent of the normal levels. So they have increased from where we were in March and April, but it has been much harder to find a way of reverting those levels of activity. And just to give you a simple example, if you think of a theatre environment taking place with staff wearing full PPE, inevitably there is a knock-on effect in terms of the cleaning approach that takes place in between patients and in terms of the PPE being put on by individual members of staff within the clinical teams. There are delays that are reducing the number of patients that are being seen because we are trying to have as safe an environment as possible.

What I would like to see retained, however, is that there has still been evidence and examples of significant change in the way in which we support patients through our system. And whilst patients are on waiting lists, it should never remove that we avoid different opportunities for them to be seen and accommodated. So, there are genuine examples of the transformation of services that allow patients to not have to be seen physically in hospital environments, particularly in the arena of out-patients, and we need to both retain that and continue with it. We need to allow patients to move into alternative settings for treatments, perhaps, rather than revert to some of the traditions of wanting to see particular members of the clinical team, because we have much more flexibility within our multi-disciplinary teams, and there are also examples of practice, including the need to both prioritise and be really clear on patients' individual circumstances.

My final comment, Chair, is that what I would like to continue our focus on—and we've been very explicit with this, with the system—is an ongoing focus on ensuring that there is access to essential services, even whilst we try to ensure that patients need to come in for planned care, but a real focus on harm, so that we are able to ensure that we work our way through harm that will be created if there is a problem about our response to COVID-19, which we're trying to anticipate, but of course harm that can happen to patients if they're unable to access treatment as well. And that has been embedded within the NHS operating frameworks that I've been issuing out into the NHS in Wales, not just this last occasion, in the last month, but actually during the course of the pandemic response.

Thank you for that answer; it was quite detailed and deals with, perhaps, some of the later questions I would have had. But you also highlighted, I think, in your answer, the rise in the demand for A&E services, and I'm seeing the same issues, and I'm also seeing the same troubles with ambulance handovers as a consequence of this, and full A&Es. So I think we're going back to the situation where there were difficulties before the pandemic, and we are seeing it now with the pandemic included. So, that's a serious challenge that I think the health boards will have to address and I'm not sure how you're going to get over that one, to be honest. 

But I want to also look at the electives, for example. I know that Royal Glamorgan today, because you talked about it earlier, have now cancelled some electives as a consequence of the impact of coronavirus in the hospital. Are you looking at the COVID-lite approach? I know it's going to be impossible—because I think the fact that you've got it in Royal Glamorgan has just demonstrated it's nigh-on impossible—to ensure that a hospital will be COVID-free, but are you looking at a COVID-lite approach so that you can get some of these electives undertaken as easily as possible and as quickly as possible whilst everything else is going on, to ensure that some of those cases—you talked about priority—are dealt with and people don't wait five to six years for an operation, which could mean in that period of time their quality of life has deteriorated, and it may be, to some extent, that the operation will no longer be actually beneficial to them?

First of all, just to touch on your point about normal pressures—and, of course, the Minister launched a winter protection plan for the NHS and the care system just a few weeks or so ago that set out our expectations, but also the key areas that we need to focus our attention on. But I think you're absolutely right to say that we are seeing normal levels of activity and normal pressures, irrespective of our need to have to focus on a COVID-19 response, and also, of course, other mechanisms, for example, to ensure that what we don't have are further outbreaks, for example, in respect of flu—so, the opportunity to expand on programmes like vaccination. 

I think, on the emergency side, we have to recognise that we are in a different position than in March and April. To some extent, of course, the fact that patients were choosing not to enter in through the front doors of hospitals helped with some of the flexibility in the response of the NHS itself, but if we're seeing those normal levels of activity then we still have a responsibility to make sure that the environments are as safe as possible. So, there are examples, and Cardiff has been leading the way for us on this about a scheme that we want to roll out nationally about contact and phone first. And some of the initial feedback from Cardiff, just over these recent few weeks where they've been implementing that mechanism, is, whilst perhaps some of the activity levels haven't reduced, what they have been able to do is to better organise the environment of receiving patients because appointments are booked in advance. Therefore, we don't have the congestion that perhaps would be as visible in some of our other areas in Wales. That isn't just what Cardiff is doing—we have an expectation that other parts of Wales will pick that up.

But, on the elective side, the fundamental test for us is that we need to ensure that we have a safe environment—an environment that can protect staff and patients. We have to ensure that we're able to discharge any of our treatments and operations that need to take place in that kind of environment. So, as I reflected earlier, it will be a slower throughput through those areas, not least because of some of the measures that we are taking to ensure that safety, and your reflections on how we can designate areas as COVID-free or green zones—as we've articulated, that is a mechanism that we have put in place in all of the health boards and across sites so that there can be some designation. It does allow us to ensure that those protective measures are in place more significantly, and that there can be more confidence about the way in which we are operating with those patients. But it will still depend on some of the underlying levels of community transmission, and we need to be clear about those risks as patients will be admitted, of course, or attend hospitals for their own treatment and care. And I think you're right—the Royal Glamorgan example demonstrates that there is still a need to take the right actions where there is a need to protect the populations in that way. 

We have been working with colleagues across Wales, and whilst that includes health boards and medical directors, chief operating officers, it also means that we're trying to keep a close focus with the cancer network, also using advice from the Royal College of Surgeons, and also learning from some of the practices that are in place across the UK and some of the things that we're doing in Wales. But even just yesterday, I was chairing the NHS executive board and one of the clear areas that we were focusing on was how do we continue to ensure that we carry on with as much activity as possible, as safely as possible, in a COVID-19 context. We will continue to develop those plans, which are underpinned by the winter protection plan. 

Okay. I'm assuming that's going to be part of the quarter 3, quarter 4 plans being produced.

Indeed. It is.

I look forward to seeing those, because I think they're crucial. Because one of the concerns I had over the early stage of the pandemic was the lack of people coming forward, as you said, with these conditions. We saw the drop in cancer referrals, for example, dramatically going down to about 25 per cent of normal expectations. But they need to be reassured that if they come forward and there is a condition, they will be seen and, if they need surgery, they will receive that surgery. For example, I've got a constituent who came forward who had breast cancer, was referred by a GP, delayed for a few weeks before they got an appointment, chased the appointment up after a month and was told there was an eight-week waiting list for urgent referral. Now, people need to have confidence that that's not going to be the case—that, if there's an urgent referral, it is urgent and eight weeks is not deemed urgent. And I think they need reassurances that services are going to be there, irrespective of the COVID-19 increases.

Yes, I share the concerns that you described about the way in which there was potential harm if patients and the population were unable to access the care and treatment. And, in fact, that was one of our very strong public messages—to make sure that people were aware that they should, if they have concerns, not least about their symptoms, be looking to access the system and services. Now, we were, of course, responding in March, April, May to very extraordinary pressures that we had not been through before. and we have needed to make sure that the NHS can adapt. But our focus at the moment remains on those essential services, and remains, as I said, on committing to try to maintain activity as much as can safely be done within a COVID-19 environment at this stage.

Just in respect of giving you some reassurance about where our activity is at the moment, the cancer referrals had dropped, as you reported yourself, but we have seen a recovery of cancer referrals into our system in Wales over these recent months. So, the current level of cancel referral is pretty much back to normal levels. In fact, there are some signs that some of those are in excess of the number of normal level of cancer referrals we would see.

I think we have seen a return to levels of cancer activity that feel more appropriate to what our system should achieve, but I don't think we've quite recovered yet to the levels of activity that we would have been seeing pre COVID. But there are a much higher number of patients being treated on cancer pathways, for example, than were as we were seeing the pressures emerging in March, April and May. But we absolutely need to keep a focus on this.

And also an important part of this has been the reinstatement of some of the screening services that we oversee in Wales on a national basis. Those have been deliberately reintroduced during the summer months on the breast screening side, on the cervical screening side, et cetera, just to ensure we have the normal population screening mechanisms in place, again to support people through the access that they require.

But if people have a concern and a worry, then they should be looking to access their services, and we obviously need to continue to be flexible in the solutions that we're putting in place to make sure patients can receive that.

Can I ask, therefore: are all the screening services back up and running—bowel cancer screening as well and all those other screening services? Are they up to the levels you expect them to be now?

So, they were staggered in their return through the summer, as we worked through. So, we had started, for example, with cervical screening services in July and breast screening services in August. They have been moving their way towards getting back to some of the more normal levels of activity, but, again, from a screening perspective, there is an impact on some of the environment, because we need to make sure that those screening services can also operate in a safe environment. So, in the same way that other services have had some limitations on it, as we are processing patients and ensuring it's safe for both the staff and for the patients themselves, there is some impact on that. But we're also learning about how to adapt to that and put in changes as well. But it was an important decision, as part of demonstrating our wish to maintain services, that we're able to restore those national screening services.

Okay—

Okay, we need to move on.

I know. The regional partnership boards obviously were a key factor in 'A Healthier Wales'. Can you just give us an update as to how they are working in relation to COVID-19 in particular?

Regional partnership boards have been an important part of the response, and, actually, we've built on the way that those relationships brought health and local government together. And, as I say, in terms of our decision making about local restrictions, we've deliberately involved and engaged local government and the police, together with the health service, and there's a contrast with the way some of those choices have been made in England.

There's been a specific role. We've put more money into both planning for winter, as we would normally do, but also in terms of the discharge process. Because some of the challenges in discharge are again about how we support people effectively, because we know that harm can still be caused if someone is in a hospital bed when they no longer need to be. But it's been more complicated. So, we've used regional partnership boards as a vehicle to see more of that happen. The continued way in which that drawing together of people through regional partnership boards and through the integrated care fund, and, indeed, the way that the transformation fund is drawing together on those rates, I think is really important. If you want to know more about discharge, then I think Albert Heaney may be able to provide some more examples of how that's worked in practice and the role that regional partnership boards have to play in the pandemic, but, more broadly, in delivering the vision of 'A Healthier Wales'.

Albert, the floor is yours.

Thank you. Thank you, Chair. Thank you, Minister. I think two main comments to make: one is that the regional partnership board approach worked well, because it had partners talking together, working together, and reacting to the immediacy of the crisis. So, some of the things that we would have had to build were in place and enabled them to respond quickly. The second point—as the Minister referenced, we continue to invest, through ICF, around community services and discharge services. And the work of the regional partnership boards was, really, refocused. So, they focused on loss of provision, around step down, to enable that there would be safe discharges—really important, especially for our care homes, not to cross-contaminate, and you will have well rehearsed some of those debates at your committee. And then they used other things, and we met, the Deputy Minister and I, with the regional partnership board chairs a week ago and went through things in some detail, but there are other areas, such as the community connectors. They were used to play a leading role in communities to help people who were isolated access the services and support that they needed, and examples such as that were around shopping, prescriptions and those types of important provision in services. Thank you, Chair.

Thank you, Mr Heaney. Are you done, David?

A final question from me. We've very much talked about the physical side of things. We've just, in a sense, touched on the well-being side of issues, and mental health and mental well-being is critical. Two points: are you satisfied that there is sufficient support in place to support the mental well-being of health workers? You mentioned the pressures they're under already, and they are extremely overworked. So, are you satisfied that everything is being done to make sure that their mental well-being is taken care of? And are you also satisfied that their mental health agenda generally is also on the list that you're considering? Because there are going to be definitely impacts upon people's mental health as a consequence of some of the issues in COVID and ensuring isolation, self-restrictions and everything else we've been facing up to.

[Inaudible.]—meant the future of mental health and well-being in the country is heightened, not decreased, in terms of where it is on my radar of concerns. Because we know that, within the population, from people who have been in hospital, whether they've been in intensive care or not, but people in intensive care often have a difficult challenge in recovering from the impact on their general mental health and well-being—we know that delirium for people in intensive care is a real issue for many people. We also know that, even when you haven't been in hospital—the people who've got, if you like, long COVID, there are significant impacts for them as well. So, within the population, we know we're going to have more concerns in mental health and well-being, including for those people who haven't been physically unwell with COVID, but with the impact of the range of control measures we've had to take. As I say, the restrictions are not risk free and they're not consequence free, and there are potential harms that can be caused from that.

It's also the case that I am especially concerned about our staff in both health and social care, and I have made this point with NHS leaders as well, on the health side, as well as that it's a concern that's raised in our conversation with local government leaders. Some of the things that our staff have had to do to keep us well, including caring for people at the end of their life, will have an impact on them, and that impact will be, I think—. It's part of the difficulty about getting ready and being prepared for this winter. We know that, in the next Senedd term, whoever is in Government, we can expect that we will see some of the consequences of what people have done and are going to do through this winter, because we often see—there's a fairly well-evidenced trail—that it's often a few years later that events can come back to have an impact.

So, we're going to need to do more not just now to support our staff, but in the future, and the point about training and bringing staff in will be more important. The Health for Health Professionals Wales service is now available across the country. We've also got an employee assistance programme that Social Care Wales will lead on, because, as I say, it isn't just an issue for our health service; it's very much an issue for our social care sector as well.

Okay. Thank you, Chair.

Okay. We do need some agility now, because the agenda is slipping a bit, and at such times I naturally turn to a couple of dependables on the committee to spring things forward a bit, and Jayne Bryant is going to ask about flu and other matters. Jayne.

Thank you, Chair. Good morning. The winter protection plan states that there's a need to be prepared more than ever before to provide flu vaccinations, and the plan wants to see a 75 per cent vaccination rate amongst the most vulnerable, as well as health and social workers. Can you achieve this, and how will the take-up rate be monitored?

Well, of course it's possible to achieve it. The challenge is whether we're going to be able to persuade enough people to get the flu jab this year. I think, in many ways, the reality of the position we're in will mean that more people will be queuing to get their flu jab if they're entitled to one. We will do what we often do—what we always do—in terms of running a campaign for the take-up of the jab. We'll still be running the nasal-spray vaccine for young children as well. We'll still have the flu vaccine delivered largely through primary care, and so general practice and community pharmacy will be the main vehicles to deliver it.

I think, this year, we want to make a real effort to get our staff to get the jab, because it's not just about protecting them, it's about protecting the vulnerable groups of people they will work with. We have made some progress in the last few years on a greater take-up from our staff in health and social care, but there's more that we want to do.

I think the message this year is even clearer, and the chief medical officer is very clear about the need and the benefit from getting more people to take up the flu jab. It's why we have procured across the UK more flu vaccine this year than ever before. That should then mean that we can get a high level of protection for the most at-risk groups, and then understand whether we are going to be able to deliver more vaccine for over-65s and then, potentially, over-50s.  

Okay. Jayne.

Are there any plans for any targeted campaigns? As you said, NHS staff and people with—. Well, for NHS staff directly and then NHS staff who have direct contact with patients, last year's figures are just under 60 per cent, but there are also those people who are younger than 65 in a clinical risk group, and I notice that those figures are around 44 per cent. Do you think they'll want to come, because of, obviously, the dangers that people are aware of this year, or do you think, perhaps, targeting certain people would be something that would help?

Yes, so, our communications campaign is looking to target different groups. The challenge then is—. I think it'll be helpful, in terms of the take-up, the position that we're currently in. There's much more national messaging about the importance of the flu vaccine campaign this year than in previous years. We often get an occasional story, and we often get a photo story in regional press as well. But, after that, we don't get the same sort of sustained attention that the flu vaccine campaign has already had this year and the heightened level of concern and the heightened awareness of the harm that flu causes. In an average flu season, 8,000 to 10,000 people lose their lives across the UK because of the flu—it's a factor in those deaths. We've seen much greater harm and mortality, but also if people are susceptible to harm from flu, they're susceptible to harm from COVID. So, I do think that the situation we're in will see more people wanting to come forward.

The pressure that our delivery services will face is, actually, a better problem to have than the challenge of wanting people to come forward who are not. There'll be people of my age who are in a risk category who are used to getting their flu jab every year. There are others who know they're in that category and haven't, for a variety of reasons. I think, this year, we'll see more of those people coming forward. 

Is there any support available for general practitioners' surgeries and pharmacies, which will probably see an increase in the amount of patients coming forward to take up the vaccine? I'm just thinking about a surgery that I'm aware of that is looking to put up some marquees, really, to try to get more people in and out because they don't have an outdoor space to vaccinate people.

Actually, I've been really encouraged by the way that general practice and community pharmacy have thought of innovative ways to deliver more of the vaccinations. They all recognise that it isn't just that there's a financial return for delivering the vaccine itself, but, actually, that there is a return in terms of protecting the population they serve. So, I'm genuinely encouraged by the can-do approach we're seeing from general practice and community pharmacy. They all know that the delivery of the flu vaccine campaign is a potential forerunner to what we may need to do in terms of delivering a potential COVID vaccine as well, if and when that becomes available.

Now, there are some different challenges in the way that COVID vaccines may need to be stored and delivered, but, actually, to have a significant attempt to vaccinate large parts of the population and to undertake vaccinations in workplaces, as we have done in the past with social care and the health service, I think that will be even more important as we roll forward, as well, access to the general public.

So, I haven't seen a particular request for additional support from the Government, but what we're doing is we're looking to support and highlight innovative and successful ways that general practice and community pharmacy are already planning for and delivering themselves.

Jayne.

Thank you, Minister. You've touched on a potential vaccination for COVID-19 and the challenges that that might bring. Have you had any discussions with Public Health Wales on how to deal with any potentially competing vaccination plans?

Yes. Public Health Wales are part of the organisations that we've drawn together, with people from the chief medical officer's department, within the Government, and a wider group of partners from health boards, primary care, the NHS Wales Informatics Service and others, to consider how we could deliver not just an enhanced and increased density of the flu vaccine this year, but also to plan for the potential of a COVID vaccination programme as well. So, that is already under consideration, and I think that the board have already met seven or eight times this year, so it's under active consideration. As I say, the flu vaccination campaign this year is one that will be a forerunner for it, and it all depends on if and when a COVID vaccine becomes available and the type of vaccine it might be, because some of the ones under consideration have particular storage requirements, as I said, and we also need to understand the level of protection it may give. We're used to many vaccines providing, essentially, lifetime immunity; that may not be the case with the COVID vaccine. It may be much more like a seasonal flu vaccine where we're going to need to undertake a vaccination programme on a regular basis, as opposed to a single shot of protection for life. But we will have to learn more about that as we go through. This is a new condition, a new disease, and we will have to continue to learn from it.

Jayne.

Thank you, Minister, and I'll just move on to a couple of other issues now, one around shielding. I'll be asking you a question later this afternoon on shielding, but I understand at the moment there are no plans to reintroduce shielding in the local areas where there are restrictions. Do you have any thoughts about those people who were on the shielding list initially, and those people who, as the days and weeks and months go on, we know could be more at risk from COVID?

I'll say something, and I'm sure the chief medical officer will want to say something as well. The shielding approach came with real benefits for people, but also there were downsides to it as well. We know that there was loneliness and isolation for some people, which was difficult to cope with, despite the broad support that we had in place—the formal organised support and, indeed, the community support that people had as well. We know that people are anxious and worried about their enhanced risk to COVID.

But we also know that a medicalised list approach has limitations. We have learned, from the first six months of the pandemic here in the UK and in Wales, that the risk factors for significant harm aren't all covered by medical conditions. If you look like me, you're at a higher risk to people who don't look like me, typically. If you look like me and I were an extra three or four stone, I'd be at an increased risk again. And, again, if you look like me and you're three or four stone heavier and you're not very well off, then we know that has an impact too. So, a socioeconomic position, where ethnicity and challenges about your weight, they may not appear in a medical list. But, actually, those are all significant risk factors and, so, actually, we need to think through, with advice from the chief medical officer, how we have an approach to protecting our most at-risk citizens and how we have more nuanced advice about the risks that they'll need to manage themselves and the support we'll be able to give them. But I think Frank may want to say something about the conversations the chief medical officers' departments are having with each other across all four nations.

Okay. Dr Atherton, briefly, if you could.

Yes, thank you. Just very briefly on flu, we are expecting increased demand this year. Interestingly, in the southern hemisphere, it's been a very flu-lite season, because the things that protect us against coronavirus protect against flu. We have, as the Minister says, acquired extra vaccine, and we've increased the eligibility in Wales to the over-50 years and older, if we have enough vaccine, but also to household context of the shielded group and to people with learning disabilities. So, a lot going on in that area.

But in terms of the shielded group, you know, it's actually quite difficult to quantify the benefit. We do believe there have been benefits; there were some early indications that there was a reduction in mortality. We do believe that it was the right thing to do at that time, but, as the Minister says, there have been harms as well. We're not in the same position now, and we hope not to get back to the same position that we had in March and April where we need to advise all of those 130,000 people who are in the shielded group to go back into shielding. That would be unfortunate because of the harms that would accrue. We know, within that group, people had different levels of risk. So, for example, children—we had a lot of discussion with the Royal College of Paediatrics and Child Health, and we know that the benefits for children shielding were actually relatively low. So, we're going through the process of having a conversation between them and their clinicians to decide whether they should remain on the shielded list.

We think it's important to retain that shielding list, so we are keeping that current and keeping it up to date in case we do need to do anything further with that, and, as the Minister says, if we do need to advise people to shield again, we probably need a more nuanced and more personalised approach, and there's a piece of work being done through Oxford University, which Professor Julia Hippisley-Cox is leading, and that will help to provide a personalised approach. That may not be available until November or so, but we're looking at that as chief medical officers. So, I think shielding may well be an important tool in our box, continuing going forward, but it may be very, very different.

The really important thing is that those things that we've repeatedly said to keep people safe and healthy are particularly important for the people who have been in the shielded group. So, as we go into local areas of health protection, it's really important that people in those groups remember maintaining social distance, using other people to do their shopping, accessing those supermarket slots that are still available and working with pharmacies so they can get medicines delivered. Those kinds of options are still available to people, but probably on a more personalised basis, rather than a blanket approach.

Okay. Jayne.

Thank you. Finally from me, Chair, how have you seen the advice about three-layered face coverings? Do you feel it's been followed and do you think the messaging has been clear enough for people? Often you can see people who are wearing perhaps still just a scarf. How have you seen that going?

Well, I think the Welsh Government advice has been very clear, and we state it on a regular basis in a range of different media. Actually, you've seen face coverings become much more widely available. Virtually every pharmacy, every sort of retail outlet appears to have face coverings available.

My bigger concern isn't the availability of face coverings or Welsh Government advice, it's actually about whether they're being worn and disposed of in a way that helps to manage risk as they're intended to. So, these are the points about when you see people with them under their chin or under their nose and they're taking them on and taking them off, as there's a risk they're potentially shedding the virus, and in particular the large numbers of face coverings that you see—the disposable ones—that have not been disposed of correctly; they're lying around on the floor. It's not just the well-worn and understood challenges of litter, but, actually, if someone has COVID and they've used that face covering and discarded it, then it's a biohazard. So, actually, it really is more that people are responsible not just in following the rules on when to wear them and understanding that there are some people who have good reasons not to wear face coverings—so, they need understanding from the wider population—but if you're taking it on and taking it off, you think about how you're doing that, where you're doing that. Wear it correctly and, please, dispose of it correctly.

Jayne.

Thank you, Chair.

Great. Moving onto matters of social care now. Lynne Neagle.

Thank you, Chair. Can I ask about testing in care homes, please? The Welsh Local Government Association has said that there should be weekly testing for staff and residents in all care homes, and that that should happen with immediate effect. What's your response to that?

Well, that isn't currently supported by the evidence. What we are doing is we carried on with our regular programme of testing for staff within our care homes, and so we're continuing with that. Where we have positive results, we're following those up to check that they're not false positives, and, if they are true positives, we're then undertaking further understanding of whether we need to undertake more testing within that care home environment. Jo-Anne Daniels can help me to fill in more of the detail of the policy, but we'll be guided by the evidence.

There's always a challenge in that the conversation around testing can often feel like the more testing we do and the more we spread it out, the safer people will be, and yet, actually, we need to use testing in a way that helps us to understand the proper value that we get from that test. So, if we test a large asymptomatic population, we may not get the benefit that we think we'll get, and in doing that, we may find that we don't have tests for people who are at much greater risk. And that's the challenge in potentially burning up the testing resources we have, even with the significant increases in the testing resource we expect to have. So it's really important we have an evidence-led approach that means we're getting the proper benefit from testing that we expect to, and that of course includes the surveillance around care homes themselves, where we know we've got a vulnerable population.

Okay. Lynne. 

We've also heard that there have been delays with test turnaround for results. What are you doing to address that so that care homes are getting the results in a timely way?

I'm well aware of the fact that there are real concerns and unhappiness within the residential care sector about delays in turnaround, and that is part of the challenge we still have with lighthouse labs. So, the national care home testing programme is one where the tests are delivered through lighthouse labs, and we're still seeing delays. I understand the very real dilemma, if you're running a care home and you've sent away your results and you're due to undertake your next set of tests but you haven't had all the previous results back, so it's not providing the assurance and the surveillance capability that we'd want it to. And that is definitely part of the conversation there. I think it really would be helpful if Jo-Anne Daniels could set out the conversations that she and her team have had directly with lighthouse labs about this, because I know it's a real concern, not just in Wales, but in England too, where they've got, in some ways, a more significant problem. 

Jo-Anne Daniels. 

Thank you, Minister. The policy remains as set out previously, that all care home staff should be tested on a fortnightly cycle, other than in areas where it's been agreed that, because of heightened risks, we should move to weekly testing. So a number of local authority and health board areas are now reverting to weekly testing, in line with the enhanced protection measures that have been taking place across Wales. We've also been in discussion with Public Health Wales as part of the overall review of testing capacity to look at how many additional tests from our care homes Public Health Wales can support. We've had a number of conversations with colleagues in the Department of Health and Social Care. The issues affecting care homes in Wales are affecting care homes across the UK in terms of the turnaround times. It's not something specific to us. And I know that they are also very concerned about it. And I think we are seeing some improvements, but not fast enough, and it's still not where we would want it to be.

It's worth bearing in mind—and I'm sure colleagues know this—that turnaround times for care home tests are generally longer than those through the normal drive-through, in-person process, because care homes often, for very good reasons, batch their tests up. So they'll test over a number of days before returning the samples to the lab. That's to accommodate different shift patterns amongst staff within the organisation. So we'll never see turnaround times in care homes at quite the level that we expect to see for symptomatic individuals undertaking tests in our walk-in and drive-in centres, but we do expect them to be significantly better than they are now. And, as I say, there have been some slight improvements in the last week or so that we need to now build on. 

Excellent answer. Lynne. 

Thank you. Is there any update on the rapid review of support for care homes that has been commissioned, and also the action plan that is due to be published?

I'll respond to that. Good morning, everybody. Yes, the independent rapid review. I commissioned Professor John Bolton, who is an independent consultant in adult social care, to undertake a rapid review of care homes' operational experience between July and September this year. And that is imminently due for publication. Professor Bolton did a wide range of interviews with local authorities, health boards, Care Inspectorate Wales, the Commissioner for Older People in Wales, the Children's Commissioner for Wales, Public Health Wales and Social Care Wales. He also held interviews with 15 care home owners and with general practitioners and environmental health officers. So he had a wide range of consultation and, as I said, we are imminently expecting his report to be published.

All the regions have planned regional care home action plans, and they will take into account Professor Bolton's recommendations. So, progress is going along well in that area. Of course, the rapid review that John Bolton has done for us is only part of the overall care homes action plan, which sets out the high-level action under particular themes, such as infection prevention and control, PPE, general and clinical support for care homes, the well-being of people who live in care homes and, of course, the well-being of the care workers and financial sustainability. So, the overall care action plan is looking at all those areas.

Okay. Lynne. 

Did Albert want to come in briefly?

Yes, please. 

Yes, come on in. 

Thank you. I'll be very, very succinct. It's just really adding to the Minister's comments around the rapid review. The rapid review, obviously, was an extensive piece of work. The report really highlights that health and social care staff across the board actually work diligently and professionally to try and reduce the impact of the virus into care homes. It found that there were some challenges of co-ordination and understanding of the nature of the virus in the early days, but once these were resolved and worked through, the sector has really worked to reduce risk. It also shows that there's now a good working relationship that's been established between these providers and care, and those advising them as well. So, a healthier picture adding to some of the actions, and the actions, as the Minister just outlined to committee, have been embedded into the seven area plans that sit under the winter protection plan. Thank you, Chair.  

Okay. Thank you, Albert. Lynne. 

Thank you. I wanted to ask about visiting in care homes, because what we saw in the first phase of the pandemic was a huge increase in the numbers of excess deaths of people living with dementia from dementia, not COVID. Andrew, you've acknowledged the particular harms that have arisen from people with dementia being cut off from their families in this committee before now. I heard the answers you gave yesterday in the Senedd, Minister, but I'm really looking for more from the Government on this now, really. A blanket ban, I think, will lead to many more excess deaths of people living with dementia. The older persons' commissioner has called for the Government to be smarter on this, to look at testing, looking at designated visitors. We can't go into this winter just accepting that it's going to be like the spring for people living with dementia in care homes. What are you going to do about it? 

Okay. Minister.

I think the reality is that we have issued guidance to this sector. The Deputy Minister issued a statement, I think last week, setting out where we are, and the older persons' commissioner produced guidance as well. We are, of course, concerned about the reality that people living with dementia gain real benefit from having contacts with familiar loved ones, and that interrupting that has a real impact on those people. That has to be balanced against the very real challenge of coronavirus circulating within the community. It can be very difficult to have safe in-person visits, particularly indoors. So, it's a balance of judgments that need to be made, and they're made by local authorities and providers. So, it is very much a choice that local authorities need to make, understanding their own local risk. 

We set out the way to help to guide them to do that, and that has always included the reality that there are certain circumstances in which visits should go ahead, even if the circumstances are such that there is a rise in community transmissions. So, we've never encouraged a total blanket ban, even at the height of the pandemic, but I understand that lots of people are anxious and nervous about this as well. As ever, there isn't a straightforward answer that says there is one single straightforward answer, but it's about the guidance where people have to make those choices, to have a broad policy position within that local authority area, but to understand you still need to take decisions on the basis of the individual circumstances of the person who's in your care.

Okay. Can I just ask one final question on this then? Do you recognise that local authorities and care homes are perhaps not doing that balancing that you've referred to in the way that we would like? Because as far as I'm aware, no care homes in Torfaen allowed indoor visits, even in the summer. Do we need to be doing more to ensure that everyone doesn't just look at the physical health risks, and not balance? And there is a really real risk that people with dementia will just die without contact with their loved ones—we saw that in the first phase.

Yes, we definitely recognise that risk, Lynne. So we're not sanguine at all about blanket bans, particularly where the local circumstances don't justify it. And I'm sure the Deputy Minister can give you some more detail on the position that we're setting out and the guidance we have issued.

Thank you. I think you are making a very important point and I want to emphasise how closely we are working with local authorities, for example, to try to get them to look at this in the round. We do not support blanket bans, but we do understand how people are very nervous in these circumstances and we want each case to be looked at individually.

In the department, Albert Heaney meets with the directors of social services every single week, and this week, he has had a conversation with them all about how they can enable people—particularly people with mental health problems—to have contact with their relatives. And as a result of those conversations, I think we have seen some developments. For example, one local authority is encouraging outdoor visits to still continue to take place. Because of course, a lot of these visits can take place safely outside. And I think we do need to reinforce that with the providers, who've got the ultimate responsibility, and with the local authorities. So, Albert has had quite a successful development in terms of encouraging them.

But I think it's essential that we do absolutely keep in touch with all those providers. And I personally have kept very close touch with Care Forum Wales, for example—I meet the chair of that every single week. You mentioned the older persons' commissioner. I am very well aware of her views, and of the statement that she issued earlier this week, and I meet with her every week. So we are very well aware of those questions that you're asking, and I think we have made some progress. I don't know if Albert would like to say a bit more about his working with the directors of social services.

Mr Heaney—you've been mentioned in glowing terms.

Thank you, Chair, thank you, Ministers. Just to add to what the Minister has said, I've had a number of conversations with local authorities and directors of social services. I have to say that directors of social services are very keen, wherever possible, for visits to continue, and indeed a number of authorities have now put arrangements in place that outdoor visits will continue to take place. What I've actively encouraged is a much more dynamic risk assessment for individuals, in individual homes, so that we really take account of the important needs that people have, in terms of contact, in seeing their loved ones. Thank you.

Diolch, Albert. Lynne, are you done there?

Yes, thank you.

Moving on to Jayne Bryant.

Thank you, Chair. The provisions of the emergency Coronavirus Act 2020 that was brought into force included temporarily modifying local authorities' care and support duties. You would have heard the older people's commissioner calling for the powers to be revoked and rights reinstated. And we heard also from the Welsh Local Government Association last week though that they wanted to see the modifications remain in place as a safety net. When do you have plans to review the powers that are in place?

Thank you. Yes, I know that the older persons' commissioner—and I know that there has been unease about the Coronavirus Act provisions relating to social care. I know a number of the stakeholders have also expressed their concerns, including the older persons' commissioner, as you mentioned, so—. And you also referred to the views of the WLGA. So, I've asked my officials to have a rapid engagement exercise to find out what stakeholders' views are, and that will inform the decision we'll make about the suspension or retention of these provisions.

So, that engagement will start early October for four weeks—a very short, rapid engagement—and then the evidence that comes forward will inform our decision in early November. And, of course, I can't in any way prejudge the outcome of that process, but I can reassure you—I can reassure the Members here—that work is already in place to secure and prioritise the necessary legislative time that might be required. So, I would therefore expect the necessary secondary legislation to be made in November or early December and to come into force within days of being made, unless Members of the Senedd choose to seek a debate on that legislation. So, there is a timetable there, but obviously I can't prejudge the outcome of the consultation process. But I'm very happy to keep the committee updated on that progress.

Thank you, Deputy Minister. Jayne.

Yes, that's really helpful. We've heard from the WLGA as well that the demand on social care services, particularly children's services, is increasing, and it's likely to do so in the months ahead. What preparations are in place to meet the increasing demands?

Well, I'd like to reiterate the intense, very close contact that the Government has had with the social services all the way through the pandemic. Along with the weekly calls and meetings with the directors of social services, the heads of children's services in each local authority have also met with Welsh Government officials on a weekly basis, and I've also met with the children's commissioner on a weekly basis to have an independent view of how things are going with children's services. So, we have kept in very close touch with what's happening with children's services. And, obviously, I feel that, on the whole, they have coped well.

There was an effort to recruit more social workers at the beginning of the pandemic, because we thought they may be needed. About 1,000 former social workers were contacted and there are currently 73 individuals on the temporary register, and Social Care Wales are having discussions about the demand for the temporary register.

I think it's been very important that we've judged and taken the temperature locally and are trying to jointly develop any solutions to any problems that might arise. And, as I said, I do feel that local authorities have managed the issues that have come up with the pandemic well, and children's services have remained stable. 

We are aware of additional pressures in the system and we're aware that, with children going back to school, and when there's more contact with professionals, there may be other issues that do arise. But we have worked closely to co-produce with local authorities—and, of course, very importantly, with the third sector as well—a recovery framework, and this sets out some guiding principles for recovery planning, and local authorities can follow it when they're making their own arrangements. The principles behind it are looking at the well-being of the workforce—because I think, during the session today, we've all talked about the well-being of the workforce and I think we all know that that is one of the key issues that we need to deal with—and then, of course, the reintroduction of person-to-person contact; placement capacity, which is something that we are very interested in and concerned about developing; and then, of course, engagement with the judiciary. So, that's all part of our recovery planning for children.

So, as I say, I think that local authorities' reporting back to us has been generally fairly positive.

Okay. Jayne.

Thank you. Just moving on to the issue of unpaid carers, I know that, over the summer, you were looking at doing some work to look to how to best support unpaid carers. Can you update us on that work, and what further action do you intend to take to support those carers?

Well, we obviously recognise that unpaid carers are often unheard voices, and we know that many of them have been under huge strain during this pandemic, and many of them have been in the position where, in fact, they've had a lot more strain than they would normally have, because they've often felt unable to have the, possibly, professional carers in to help, because they've been so worried about the infection. So, we do know that unpaid carers have been under a huge strain during this time, and so we have worked to try to see what we can do to progress things. So, we convened a dedicated task and finish group to consider the evidence, and we've also got the ministerial advisory group for carers, and that's one of the key mechanisms that we use to determine what are the issues that affect carers, because there are strong representatives of carers in that group. 

So, in October, we're planning to launch our public consultation for the new national plan for carers, which I did announce last November. That will give carers, young carers, the third sector, local authorities and many others the opportunity to tell us how we can focus and prioritise help and support for carers, and then we'll have the final plan in March 2021. So, we have been working to establish what are those key issues with carers, and we are very aware of the strain that unpaid carers have been under during this period in particular. 

Thank you. I think, as you've mentioned, many of those community support services that were relied heavily upon by carers came to an end during the restrictions, and obviously for those places that are now facing further local restrictions it can feel like a very lonely place and a worrying time for those people who are looking after their loved ones. Are there ways to prioritise resuming and further developing carer support services during this time? Because I think the real worry is that a huge burden will be put on many carers, and, when they're trying to do their very, very best, not having any respite, which happened to a lot of people during that time, puts such a huge strain on them.  

Yes, thank you, Jayne. I think we do want to make a point, really, of thanking all those unpaid carers for their selfless hard work to protect the people that they care for. I know many face-to-face services were halted during the lockdown in order to protect people's health, and we know that that was absolutely necessary. But a wide range of services did continue and they did continue online and they did continue on the telephone. The carers organisations did go to great lengths to ensure that support did continue, and these did include local authority funded young carers services—they did continue, but they continued online. We do expect local authorities and other bodies to ensure services are restarted, where they were temporarily halted, and mechanisms are put in place to ensure that the health and well-being and the support needs of carers are addressed. So, we do hope that more services will open up with support for carers, but certainly the online stuff and the telephone help has continued. 

Thank you. Just moving on to some issues around financial pressures, you've touched on it earlier, Deputy Minister, around the rapid review, but how do you see the funding model for social care perhaps needing to change, as the pandemic goes on? There are obviously pots of additional funds being provided on an ad hoc basis. It does worry me, and I'm sure you and others, about the fragility of the funds for social care—do you have any comments on that?

Well, we've wanted to respond to the needs of social care in as swift and proportionate a way as we can, and I would say it hasn't been ad hoc; it's been responding to the need as quickly as we can. So, right at the beginning of the pandemic, we allocated £40 million for adult social care provision, and we did that initially for a two-month period, which was then extended to three months. Following that, we've come up with a further allocation of £22.7 million and, again, that's for a three-month period. And I think we’re aware that the impact of COVID-19 is going to be with us in social care for some time, so we've looked to continue this support for an even longer period. So, the Minister for Housing and Local Government did announce, very recently, a £264 million package to support local government with the costs of COVID, and that's for the remainder of the financial year, which includes funding for social care for the same period.

So, I do think that we have responded to the circumstances as we've gone along and have made sure that local government has had the funding there ready to use, because I think it's absolutely undeniable that the care home sector, for example, has been in need of extra funds in order to provide the services that they do, and also to deal with the problems of voids in care homes, which, again, is a big issue. So, that funding can be used by the local authorities to cover the voids that there are in care homes, and also to cover the additional expenses that operating a care home in a pandemic inevitably brings. 

Thank you, Chair.

Okay, we're right out of time, so I'll call a halt there, I think.