Cynulliad Cenedlaethol Cymru

Bore da. Croeso, pawb. Welcome to the Health and Social Care Committee this morning. As always, we operate bilingually. We are operating a virtual meeting this morning, so some Members are attending virtually as well. There are no apologies this morning. If there are any declarations of interest, please say now. No. In that case, I move to item 2.

Item 2 is our final oral session to inform our inquiry on supporting people with chronic conditions. I'd very much like to welcome the Minister for Health and Social Services, Eluned Morgan, being with us this morning. Perhaps I could ask officials to introduce themselves for the record.

I'm Dr Stuart Hackwell. I'm a senior medical officer for primary care and mental health in the Welsh Government, and I'm a practising GP in Barry.

Bore da. I'm Heather Payne. I'm a paediatrician by trade, and I work as a senior medical officer in the Welsh Government, offering professional advice on women, children, screening, and equality, diversity and inclusion.

Thank you, both, for being with us as well, and for your advance paper, Minister, before the session. So, Minister, throughout the evidence sessions, what we've understood is that there are more people than ever before living with a chronic condition and the projections are that's only going to increase. In one sense, that's a good thing because people are living longer, but there are, obviously, challenges that come with that. So, can I ask how you and the Government are—? What changes you're making to consider that change and that continued change in people living longer with chronic conditions?

Thanks very much, and thanks for your investigation into what I think is a really important issue for the future of healthcare in Wales. I think it's probably right to emphasise the fact that, actually, what we're talking about here is a success story. When Aneurin Bevan set up the NHS in 1948, people retired at 65 and men died at 66. That is not the case anymore. People live for a long time. That is testimony to the success of the NHS. But, with that, obviously, comes additional challenges. What we are looking at as a result of that is people living longer, but also living with more complex health conditions.

One of the things we did last year was I commissioned the chief scientific adviser for health to make some projections, 'What does this look like 10 years from now?', and it was a very, very sobering report because if you continue on the current trajectories in terms of things like diabetes, for example, then you are talking about tens of thousands of additional people on top of the about 7 per cent of the population currently living with diabetes. But, if you put on top of that the fact that one in two people are going to have cancer at some stage, all of these things start to build on top of each other. It means that what we need is to change the way we do medicine to make sure that there's an understanding that you have to treat the whole person. It's not treating one condition; it's about treating the whole person.

So, I think we do have one of the most effective healthcare systems in the world, but we do have to adapt and address that issue of multimorbidity. One of the ways we're doing that is we've got 'A Healthier Wales', which, as you know, is our strategic programme for health in Wales. We're doing a refresh of that at the moment, to take into account what the future looks like, taking into account that 10-year vision for what health in the future looks like, and how we're going to adapt our systems to look at that. And those chronic conditions and multiple conditions that people are suffering at the same time are, obviously, something that are going to be central to that refresh.

Chair, could I just ask a question there?

Yes.

Thanks, Cabinet Secretary, for the response. I just note in your response you talked about, rightfully, treating a whole person. But it's that phrase 'treating them', and I wonder if we've got the balance right at the moment between enabling people to support themselves and then the NHS being seen to treat people. And if we haven't got the balance right at the moment, what should that balance look like, and how do we get to that place?

Certainly, the capacity for us to deal with—. You think about the fact that we already have 2 million contacts in a population of 3 million every month. The trajectory to the future—. Unless we start getting people to take a bit more responsibility, then there will be difficulties in future, which is why we are already making adjustments and adaptations, using in particular digital technology. We've, obviously, got the NHS Wales app, but there are specific apps also that are being used to try and get people to support themselves. So, that's one way in which we are looking to do this. The key thing is to get all of these systems to speak to each other, but I think that getting people to support themselves is going to be absolutely crucial in future as well, you're quite right. 

You mentioned, Cabinet Secretary, in your answer to my first question that it's important to see and treat the whole person, and when I read various Welsh Government documents, I see 'person-centred care' scattered throughout documents—it's your vision. But when we've taken evidence throughout this inquiry, what we've heard from various bodies and individuals is that constant, 'We haven't got that person-centred care'. So, that is your vision, but that's not the experience that we've received as being the case when we take evidence. I wonder what the challenges are for you in reaching the vision that you want.

Well, I think there's—. If you look at person-centred care, it has to start in primary care, and GPs are generalists by their nature; they are people who understand the person and the need to look at the whole person. I think, when you get to secondary care, that's where it becomes difficult, because people are specialists. So, we just need to make sure that the specialists also undertake training and have an understanding of that generalist approach, and, obviously, there are steps being taken towards that.

I think, just in terms of the primary care model, though, one of the barriers, one of the challenges we have is that we can't rely entirely on GPs. Actually, we've got a much broader model than that now, where we are making sure that there is much broader support, so that people can go and perhaps see an allied health professional that may be able to help them with one of their chronic conditions. It doesn't have to be the GP. And there is a bit of work to do, I think, with the public, to make sure that they understand that the GP doesn't have to always be the first port of call. That is happening and I think people are starting to respond to that, but it's a journey that we have to take the public on.

Perhaps I'll ask it this way: the vision that you've got I think is the right vision, because that meets some of the issues that people are raising with us throughout our evidence, but is it a vision that's too difficult to reach? Or if we had this inquiry in five or 10 years, and we had the same group of people back, would they say to us, 'Well, everything's much better now'? 

No, we're definitely on a journey, and I think we're a long way down the journey already. I'll ask Stuart to come in now, as a practising GP, because this is their bread and butter. I think part of the challenge, as I say, is in secondary care, but there's a huge amount of training being done, for example, in our medical schools, to make sure that they have the training to make sure that they look at the whole person. On nursing, it's not just about nurses coming through in the future; it's about nurses who are in the system already being upskilled and up-trained to be able to look at the entire individual.

If Stuart is coming in, perhaps what I'd be interested in is how we address the challenges. How do we overcome the challenges? What realistic steps can be taken to ensure that we, as much as we possibly can, have person-centred care?

Person-centred care is not only a structural issue; it's also a philosophy as well, in terms of what patients want in terms of their care, what is important to them. That's what I would say is person-centred care. So, that's not just about how you would structure a service; it's also about how you train your health professionals to actually provide that care. So, a very simple example is someone who comes in with severe osteoarthritis of their knee. Now, the pathway would say, well, at that point you refer on to an orthopaedic surgeon and they have a new knee. Now, if that's not what's important to that patient, and actually what's important to them is to adjust their way of life so they don't need surgery, that is about patient-centred care, in the same way as you have discussions with patients around what treatments they want for any chronic disease. So, with diabetes, is insulin actually what they want to be on, because although that may be the right thing from a medical perspective, they may have lifestyle challenges where they do not want to consider that? So, you need to be able to adjust your plan and actually provide it in a different way.

For me, that's what holistic patient-centred care is. It's much more about a mindset that you're dealing with the whole patient. As a GP, that's what I do, and you're taking into account the psychological impact of that. And I think, when you're then moving into secondary care, we generally are—and I know Professor Atherton said we tend to have specialist care that deals with a single condition—making inroads. I think now, with certain conditions and certain clinics where you are having a much more holistic view of things, such as diabetic care and paediatric diabetic care, and also then moving into adult diabetic care, there's a lot more of a holistic view about the patient and how they deal with it, including psychological support and quick links into mental health services when they need it, especially in young diabetic care where you may have co-existing eating disorders. You often have a very quick referral pathway into those mental health services. So, again, it's all around finding out what is important to that patient and ensuring that you can provide that service.

If it's fair for me to ask, if you could provide two or three bullet points on what needs to change, what would they be?

I think patients being able to see the person that they want to see. I think patients are very good at identifying who they need to see, whether that be a GP or a physiotherapist. As the Cabinet Secretary said, I think you don't always need to see a GP, but, generally, a GP is behind the scenes overseeing all of that care. So, I think one is that patients see who they need to. I think, as we've already been doing, it's making sure that specialists have much more generalist skills as well so that they're able to see a wider picture. And if we take long COVID, for example, the clinics there, that had a very good way of actually—. We didn't necessarily just put it into one specialty; we designed clinics around providing all those aspects. So, it would be having much more integrated clinics as well.

Sure, sure. That's fine. I agree with you on your point about specialists being more general, taking a general approach as well, but it sounds a contradiction in itself, doesn't it, in one sense?

Well, it does, but if you think about hospital consultants back 20, 30 years ago, they were general consultants with a specialism, and we moved to being much more specialist, and now we are trying to move that back with dual training, with general internments.

I think that more Members may, perhaps, dig into that later, so thank you. Mabon, you wanted to come in on this point.

Could I—?

You go first, Stuart. 

There we are. Thank you, Stuart.

You'd better say the right thing here, Stuart, because you're in big trouble if you don't. [Laughter.] 

Your answer's got to start with, 'Well, I agree with what the Cabinet Secretary said.' [Laughter.] 

Yes. 

I do agree with what the Cabinet Secretary said. 

Good. [Laughter.] 

I'm not saying—. I don't think they're mutually exclusive terms. I think patients are generally very aligned about who they need to see and they don't always need to see a GP, and patients are very good at knowing that. So, even if we look at more traditional general practice from 10 years ago, we would have nurses providing a lot of chronic disease management, and patients knew that if—. And I would say that patients know that if they've got a problem with their diabetes or their chronic obstructive pulmonary disease or asthma, they go and see the nurse, because they have a vast amount of knowledge in terms of the management of that chronic disease. 

So, I don't think it's a contradiction. I think they are—. Patients do not always need to see a GP and I believe that patients know that to a large degree. As we've brought in new allied health professionals, such as physiotherapists, I think that is not so well known by patients. They're not used to being able to book directly in with a physiotherapist, for example, in their GP practice. So, I think those are the sorts of things where we need to—. And when we've moved services to pharmacy, and pharmacy first, and trying to redirect patients, those are the sorts of educations that we need to get to patients, that they can see those people.  

Sure. Do you feel you need to come in as well, Cabinet Secretary? 

Okay, thank you. Mark Drakeford. 

Your paper, Cabinet Secretary, makes it clear in the early stages the enormous pressures that are faced in the health service by people with chronic conditions, and on pages 15 and 16 you set out the precipitating background conditions that explain some of that: levels of smoking, alcohol use, lack of exercise. Tomorrow's chronic condition patients are already on the march, except of course they're not marching; they're sitting in their armchairs. [Laughter.] And you say on page 4 of your evidence that there's a particular need for health professionals 

'to sensitively and compassionately support individuals' lifestyle changes'.

And I looked to see whether I would find the word 'assertively' in there, alongside 'sensitively' and 'compassionately'—both of which I agree with, by the way. But do you think we have the balance right? Do we explain forcefully enough to people that, unless they take some of the steps that only they can take, they will end up in a position where their health in the future will be compromised?

And a second, just linked question: I didn't see—apologies if I just didn't spot it—any reference in the paper to expert patients. Now, at one time in the health service, we referred a lot to expert patients—people who would be educated to manage their own conditions, would understand them better than any professional could, and would be enabled to take charge, and, indeed, to take responsibility for some of the things that, otherwise, would become something that the health service is expected to sort out. So, do we have the balance right, do you think?

The balance is shifting. So, one of the things that I've been clear with my officials—. I choose about five things that I'm going to focus on when I become health Minister, because you can't do everything. One of them is a mission approach to tackling obesity. So, I do think this is probably one of the biggest threats confronting our nation at the moment: 60 per cent of the population are overweight or obese. This is a time bomb, it is waiting to happen. I've already held two round-tables with international experts, coming in to give us advice on, 'What are we doing about this, have we got it in the right place?' There is a balance. I've learnt already that politicians telling people about lifestyles is probably not a good idea, so we do have to do this in a different way. We've got to get the behavioural scientists in. So, Public Health Wales are doing a huge amount of work around this at the moment.

I think that we do have to perhaps be more assertive in the space of regulation. So, we'll be pushing forward with making sure that the environment is easier for people to make the right choices. It's really difficult for people who want to do the right things; we've got to make it easier for them. So, we are just about to go out to consultation on that food environment regulation. But there's a huge amount more work to do in this space, and I'm not going to apologise for that. We've got a lot of work to do. You're quite right: we've got to get people to understand the consequences of their lack of engagement with their own health. There are consequences to that, which, yes, we of course will have to pick up on as a society, but there's a lot they can do to avoid it. There's a big educational piece. Some of this goes into schools, and what we need to do in schools, but there's a much broader piece, I think, for society as a whole.

On your issue about expert patients, there are expert patients all over Wales already. There are people who are brilliant at using their apps and their technologies to monitor their COPD conditions. They already exist. How do we increase that number, as we get increasing numbers, of people to help themselves? I think digital technology, for me, is going to be absolutely key to unlocking some of that. But can I ask Heather to come in?

Yes, by all means. Cutting off the flow earlier on is tremendously important, and it's happening. We've already started it in maternity services. Pregnancy is not an illness, but it can lead to lots of risk factors. If mothers smoke during pregnancy—again, there's been a successful campaign, over the past few years, in actually making sure that carbon monoxide monitors are used—it's explained to mothers the likelihood of prematurity for their baby, low birth weight, the likelihood of intensive care. So, 100 years' worth of benefit for that child's life expectancy and future life. So, also, messages around breast feeding, which feeds into the obesity plan, which reduces the risk of obesity in childhood and later life. So, we've got pockets where the evidence is working.

And as the Cabinet Secretary explains, and I know you well know, it is remarkably difficult to explain to people what their future risks are in a way that doesn't feel oppressive or challenging or just something they're not ready for at that moment. Those are skills in terms of health promotion that, again, we've talked about being developed, as part of a comprehensive set of skills for compassionate and effective care.

We also see it in the bowel screening programme. We now use FIT, the faecal immunochemical test, to identify people at high risk of bowel cancer, who then go on to have a colonoscopy. We know that quite a substantial minority of people do not take up that offer of a colonoscopy. So, there's a lot of work going on, and whether we should use the late Dame Deborah James's approach, 'Check your poo.' You know, how are we communicating with the public, because they're not patients until they want to be—they're people—and, again, behavioural insights, but also working with and listening to what people feel is important to them.

It's all being channelled into this chronic care. The principle of voice, choice and control is a really important one, that people feel engaged and powerful in their own life and well-being. And just a message that a previous chief nursing officer used to use, which I think is one of the most useful, which is, 'Lead, follow or get out of the way', when you're offering healthcare. So, we use those very valuable principles.

Thank you, Heather. So, look, just one further point in this first group. If we want to persuade people to take the actions that only they can take in their own lives—and I think, Minister, you've already said this, really—doesn't Government have a responsibility to create the conditions in which people can do that? Now, it seems to me, we've done astonishingly well in smoking, but we've done it by being assertive in terms of the way that the law regulates people's behaviour. Haven't we been too slow in other areas to take a similarly assertive approach? Why don't we use the force of law to require firms to reduce sugar and salt levels in the highly processed foods that cause people dietary problems? Why haven't we regulated to prevent advertising close to schools, and other places, of things we know will do people harm? Haven't we, as a society, been too slow to use the collective power that we have, to create the conditions in which it is easier for people to do the things that only they can do?

I think we have, and where we have intervened—. And when I say 'we', I mean across the UK, so we've got to be really careful, because, obviously, some of these powers we have and some of them we don't. So, when the sugar tax was introduced, it made a huge, huge difference. It's massively reduced the amount of sugar that's in fizzy drinks, it's making a big difference, but that's just scratching the surface. There are huge amounts we need to do. We all know about super-processed foods now, and that is, again, something, I think, that needs assertive legislation.

I'm hoping that we'll be able to have an early conversation with a future Labour Government. One of the reasons why we haven't gone out to consultation, which was due to go out last week, on the regulation of the food environment, is because I wanted to hold it back, to see if we could include a reference to the Monster Energy drinks and others, because I didn't want to fall behind what a future Labour Government was going to introduce. That was in their manifesto. As soon as I saw it in, I thought, 'Right, let's not fall behind; let's see if we can put that into our consultation as well.' So, yes, there's more we can do, and that's an example of where we're going to be forging ahead anyway.

These round-tables have been really fascinating in terms of what other people have been able to do. So, for example, in relation to planning, where do you allow fast-food outlets to happen? We know that lots of big businesses will come and say, 'Hang on', and they'll chase after you. But there are examples around the country where they have done it, so let's go and learn from them. So, there's a place in Scotland where they've done it, so that's precisely the kind of example. It was really shocking to me. You'll be aware, Mark, from your constituency, when I was growing up in Ely, there was one chip shop on Grand Avenue. Today, every single shop is a fast food outlet. So, that is not making life easy for people to make choices, the right choices, in an environment like that. So, I think there's a lot more we can do around planning, working with local authorities. But we need to make sure that we've got the legal powers to do it if they're going to come after us in a legislative way. If we're going to get the big businesses saying 'You can't do that', I want to get belt and braces to make sure that we're doing it in the right way and we're all ready for it. So that’s precisely what these round-tables are set up to do. 

I won’t have a chance to ask about e-cigarettes, but Joyce might later, but saturation zones, as they're called in the alcohol field—. My constituency is full of e-cigarette outlets; nobody could argue there is a commercial need for another one, but it's very hard to stop without the powers to do it.

Yes.

So, here’s my second group of questions, which is about professional workers, and I think the committee, previous members of the committee, have heard contradictory evidence on this. They've heard lots of evidence. I'd say the predominant amount of evidence is about the need for generalists, people who can take a rounded view of the patient, a single person who has a sense of you as a whole person, rather than somebody who suffers from this and this and separately that and that. But the committee has also heard calls for more specialist nurses, more diabetic nurses, more asthma nurses. Where do you think the balance properly lies in chronic conditions management? And then a second, linked question to that. I see that the paper refers to work you've asked the royal colleges to do in this area: aren't the royal colleges the problem here, not the solution? Isn't the reason why we've had 20 years of ever-increasing speciality because those unelected, unaccountable, largely self-serving organisations that are the royal colleges have forced Ministers ever more down that path? Wouldn't we be better off getting our advice elsewhere?

Great. I'm going to bring Stuart in in a second, but one of the things that HEIW have done is to make sure that they're taking steps to make sure that registrars in medical specialities are dual accredited in general internal medicine in addition to their speciality. So, for example, new consultants in rheumatology are now dual accredited in rheumatology and general internal medicine. So, that is something that HEIW is starting to really push on.

We've also had the 'Shape of Training' review. So, you're quite right, the Academy for Medical Royal Colleges have revised their curricula, so they are in the process of doing that, to make sure they've got that emphasis on generalists, just trying to make sure that they cope with those comorbidities. I'm not quite so worried about primary care, because they're generalists anyway, but, certainly, when it comes to general practice nursing, there's post-registration training as well now, in particular those looking at comorbidity and multimorbidity. They can get these practices to make sure that they learn about hypertension, heart disease, diabetes, asthma, COPD management. So, all that happens post registration, because, obviously, you can train people who are coming in, but, actually, the vast majority of people are in the system already. So, training people who are in the system is also crucial.

Stuart, can I invite you to—?

Also the medical schools in Wales are taking a much more proactive structure to the curriculum, and making sure that there's much more generalism within the training. We have a lot more placements within primary care, for example, for our medical students, and that’s across all the medical schools, also placements within mental health to ensure that there's good a understanding of mental health issues.

Then, going to the GP element, we have an army of GPs that are expert generalists in their own right. Now, as we see increasing frailty and more complex frailty, then I think GPs are ready to step up to the mark in order to—are stepping up to the mark—help manage those things. So, if we look at, in Barry, for example, where I practise, there is Safe@Home, where GPs are helping to man that service to do assessments of frailty and provide that more complex generalist view on how to manage a patient in a multidisciplinary team. 

And back to your point around where the balance is around having specialist nurses, I think that comes back to my point earlier around ensuring that a GP is overseeing—or a generalist is overseeing— somebody's care in partnership with that person. And part of that is ensuring that you've then got—. Because you will still need expert opinion around how to manage different elements of their chronic disease, because chronic conditions—people have multiple chronic conditions. As a rule, at the moment, we're getting to see more multimorbidity. So, it's having that extra specialist input into those cares, but generally co-ordinated by a generalist. I would say that, even if you look at consultants, consultants are—. The clue is in the name—they are consultants. I as a GP consult with them about managing my patients. I would see that that's what the consultants are there for; it's for me to get more knowledge about how to manage their care in a more specialist manner.

Chair, I've probably run out of my time, but if, later on, there is a moment, I would have liked to have asked the Cabinet Secretary about what I think is one of the great successes of her time as health Minister, and that's contract reform in primary care, which is one of the great drivers for improvement in chronic conditions management, I think. So, if there's a chance later on, I will come back to it. 

There we are, you've almost asked the question there—if you can answer it in about 20 seconds, Minister. 

Yes, absolutely right. There are ways of changing people's behaviours. You can do it through contract management, and that's what we've done through the contract. We've done it not just in terms of access now, because that's made a huge difference, and the volume on things like the 8 a.m. bottleneck has gone down significantly. But it's much broader than that. Actually, within the contract, you say, 'There's an expectation to do this, that and the other, in terms of chronic management', and I think that has been hugely successful.

Stuart probably knows a lot more about this than I do, but what I do know is that, sometimes, you do need to incentivise people to do that chronic condition management, and that's what we've done through that contract reform. 

Thank you, Cabinet Secretary. Mabon, did you want to come in on this point, or a similar area?

Yes, very briefly, going back to a point raised by Mark Drakeford. We had a brief discussion before the start of this session. Minister, if I just read—or Cabinet Secretary, sorry—this one paragraph out:

'children living in poverty are more likely to experience tobacco exposure, asthma, hypertension, poor nutrition, untreated dental carries, mental health problems including future substance abuse'.

We know that people living in poverty are a two and a half times more likely to be diagnosed with type 2 diabetes. The cross-party group on cancer made it clear that people living in poverty were more likely to get cancer.

So, Mark Drakeford asked the question, 'Should we use the levers of Government to legislate more'? Should the Government not do more to tackle poverty and pull people and children out of poverty, as a tool to tackle chronic ill health?

Of course we should. What we know is, if you look at health, about 20 per cent of it can be managed through the NHS itself, but about 80 per cent of it is due to the conditions that people live and work in. So, obviously, there is a cross-Government approach to tackling inequality. We have done a huge amount in this space, and one of the things that is imminently going to be introduced is a health impact assessment across the whole of Government. So, whenever a new policy or piece of legislation will be introduced, it will be measured against what is the health impact of that. So, that is something that is unique. It's globally leading, and it's very much in line with the kind of future generations approach. I don't know, Heather, if you want to come in.  

Yes, thank you. It is so important. Our job as Welsh Government and professional advisers is not just to improve health, which is relatively easy for people who are in advantaged situations; the difficult bit is reducing inequality. For children, that's why we have Healthy Child Wales, which is a screening and surveillance programme that aims to contact every child. It focuses on the first 1,000 days, so that's actually conception to the age of two. There are fixed recommended contact points and, again, this is where the skill mix comes in. Those are done by midwives and health visitors and they use the evidence-based interventions and contacts in order to make sure that children's weight gain is appropriate, that they're feeding—that breastfeeding is supported—that their special senses, hearing and vision, and also that hips, cardiac problems, testicular descent, are all as they should be, and offer early intervention if they're not. And then looking at injury prevention in the six-month contact, looking at language development in the 15-month and 27-month contacts.

So, those are all put in place in order to make sure that any avoidable harm is avoided. That's also supported through social services with the Flying Start programme, which has been so important for children living in poverty. And, again, that's not just their health outcomes—it does promote vaccination, it promotes early social language contact, but it also helps with parenting skills and then identifies school readiness. Then that's going on to the second phase.

So, all of those programmes are incredibly important, multidisciplinary and absolutely focused on reducing inequality. So, we've got them.

Cancer screening—Public Health Wales does a lot of work to actually explore the sociodemographic disparities that still exist in screening uptake and looks for approaches to reduce those. So, we've got them in our sights and we are making progress, but, if anybody has actually cracked it in the UK, I've yet to see the evidence, but we are making progress.

Thank you. We've got about just over half an hour left and we've got four substantive subject blocks to cover, so if I could just ask Members to be pointed in your questions and we might just need slightly shorter answers. Sorry to have to ask that. In fact, we've got about eight minutes for each section block. Sam Rowlands.

Thanks, Mr Chairman. Just to touch on multiple chronic conditions and some of the challenges around those being managed or properly supported. And you mentioned previously, Cabinet Secretary, about the role that perhaps digital improvement projects or apps and those types of things could make to some people. I just wondered if you were able to expand on that a little bit—how some of that work will actually improve the care of people living with those multiple chronic conditions.

So, we've got a really comprehensive digital transformation programme. It's very ambitious. The key thing is that we need all of our systems to speak to each other, but we already have quite a lot in place. So, we have, for example, the Welsh clinical portal; we've got the Welsh nursing care record; we've got, as mentioned, the digital transformation programme. So, there are lots of things in place. But you're quite right, we've got, of course, the NHS app now, and the key thing with the app is that it's a core support system where we'll be able to bolt on a huge number of additional points that people will be able to use in order to manage their own conditions.

So, we also now have a system where all the GPs will be coming on to the same GP digital healthcare record system. But you're absolutely right, we do need to get people to take a bit more control in the management of their own conditions. But the other important point, of course, is that there's no point in just imposing a digital system on a workforce that doesn't know how to use it. So, actually, one of the key things that has taken a long time, when we were rolling out the Welsh nursing care record, for example—a huge amount of time was taken in training the nurses to get them to understand it, but also to get them to design it: what is it that they want; what is it that's going to be useful for them? So, all of that work has already been done. It has got to be something that is useful for the people on the front line, but key is also, obviously, that you need these systems to speak to each other.

Yes. Thanks. Obviously, the NHS in Wales isn't the only large organisation in the world having to regularly roll out digital improvements. I just wondered why, particularly, things seem to take so long on the digital front to deliver in health services, and all the lessons you think we could learn from other organisations or sectors as to how they are able to roll out things more rapidly, because I guess the risk is, by the time things are rolled out in our health services, it's way out of date already, and I just wonder have you, do you think, got, and have your officials got, a proper grip on this to ensure that things are delivered in a timely way.

We haven't got a good track record not just in Wales, but across the UK in terms of digital roll-out. I mean, they've literally wasted billions in England; we’re certainly not in the billions here in Wales. We're getting there; it takes a long time. I think there are lots of lessons we can learn. One of the things that I'm very clear with my officials about now is that, where possible, we should be buying things off the shelf—tried-and-tested systems. You couldn't do that when we started introducing some of these things 10 years ago; those programmes didn't exist, so we had to build our own. That's no longer the case, so it's an area that is absolutely key. If you look at 'A Healthier Wales', digital transformation is absolutely front and centre, and it is really important to me. I have monthly meetings with my digital team because I know this is an area that absolutely needs a lot of focus and a lot of attention. So, I breathe down their necks on a monthly basis.

As to Digital Health and Care Wales, we've probably asked them to do too much, and, obviously, we were very challenged financially last year, which meant that we had to cut back a little bit on what we were hoping to do. So, obviously, Digital Health and Care Wales were not able to deliver what we asked them to do, but there are priorities that we have focused on, and I think we have a very much clearer vision now about where we need to go. We've started work on a secondary care electronic health record, and we're working towards a business case for mental health, social care and community systems, so the kind of child of Welsh Community Care Information System. So, there's a lot of work being done on that moment as well.

Thank you. And I'd agree the focus on digital is massively important for the generations coming through now and for creating the efficiencies within the service that are needed, because part of the evidence that the committee has received has been not just specifically about digital, but lack of communication, whether it's between secondary and primary care, or whether it's between mental and physical health services, and it’s particularly impacting, as you’ll appreciate, people with multiple chronic conditions, with all sorts of specialists, or sometimes generalists, not communicating with each other in the way that they should. I'm just wondering what you think the opportunities are in terms of improving the systems not just digitally, but broader structural systems to ensure that communication takes place so that patients don't feel like they're being passed from pillar to post and having to repeat their stories time and time again.

Absolutely. So, as I say, we're in the process of developing a comprehensive digital care record, but I'm going to ask Stuart, if you don't mind, to come in on this.

Thank you. We already have quite a few digital solutions to aid communication between primary and secondary care, and also mental health services, if we count those within secondary care. We have the Welsh clinical communications gateway, which all GPs use to do digital referrals and which, as soon as I dictate or write that, is immediately received by the secondary care organisation as soon as I press 'send'. And that also offers a facility for consultants to then communicate back regarding that referral if there's any extra information they want or, actually, if I just want advice on how to care for that patient with that condition. So, sometimes, that will then stop a referral or, actually, mean that an out-patient referral isn’t necessary.

In terms of the immediate communication, then we've got Consultant Connect, which is an app on your phone. I've got it in my pocket, and that enables me to phone my local hospital that I'm referring to and to speak to consultants or specialist teams around either admissions or more urgent advice about certain specialities, and that can also include mental health services. We've got the Welsh clinical portal, which enables us to see investigations that have been done by hospital, as well as our own investigations. That gives us a better idea.

In most health boards now, the return letters are received digitally, so, as soon as they are written, you get them pretty quickly after that. And then, the discharge summaries are now electronic. I remember, when I was a house officer, we did them in triplicate, they were handwritten and, by the time you got the bottom piece, which you sent to the GP, you could barely read it. So, things are a lot better from a discharge perspective. The delays sometimes are in having the time to sit and do those things, but there are a lot of digital improvements in terms of dictation software, et cetera, to speed that up.

Thank you. That sounds pretty good, but the evidence we've received from people seems to be slightly different as to how that feels for them. So, I just wonder where that disconnect might be between what you're able to deliver as a healthcare professional versus what people feel like is happening in terms of that communication. I wonder also if it's, perhaps, different across Wales—so, some areas may be doing this much better than others, and how do we get that consistency across the country and across different services within health. Is that a fair reflection from my side that, actually, sometimes it feels different still for patients, and is that time constraints, like you described, Stuart, a moment ago? The opportunities are there, but we're not always able to grasp hold of them because of pressures elsewhere.

Just a very short answer, if that's all right.

We've got the all-Wales communication protocol, which I think Professor Atherton mentioned, which we've just sent out. We've revised it and we've sent it out for consultation at the moment. Some of that is around ensuring that there is timely communication and, where there is a problem, that there is a dialogue between the two problem areas to try and smooth out any issues. Part of that also recommends that patients are also sent copies of their letters and are addressed to the patient in layperson's terms so that they can understand their condition better, as well.

All right. Thanks, Chair.

Thank you. Mabon ap Gwynfor.

Thank you, Mabon. Joyce Watson.

Good morning. I want to talk about mental health, and I want to ask particularly what steps you're taking to improve mental health support for people with chronic conditions.

Thank you. In a lot of our quality statements, there are sections that address the issue of the need for that person-centred approach, and, obviously, mental health becomes an important part of that. We've done a huge amount of work in relation to mental health in Wales. We have a ring fence, unlike in England. I think the '111 press 2' system has made a huge difference to people, and, of course, we have the online cognitive behavioural therapy programme, which is available for everybody. So, there is a lot of support out there. We're back to, 'How much of this can you support yourself?' That is really important. The key thing with mental health, as we all know, is that you've got to get in there early so that it doesn't build. So, I think this '111 press 2' service is making a huge difference, and we know that about 80 per cent of people who use that service don't need to be referred on, they need that emergency care at that point in time. Stuart, you're the expert on mental health.

I think we touched upon it earlier in terms of having good, holistic care. I think that starts in primary care. Ensuring that patients' conditions are well treated, that they're able to talk about how it's affecting them. You're looking at how it doesn't just affect their health, but their wider social life, their work and ensuring that you're able to maintain some of those support structures for them. That comes from ensuring good back-to-work interviews, for example, if people can work and supporting them in that. As GPs, we do our best to do that. I think it's a key part of ensuring that, as part of equality statements, we are providing that psychological support for long-term condition management.

Some of the long-term conditions happen quite suddenly, like Parkinson's, stroke and other such conditions. If I use Parkinson's particularly, it is sudden and it is pretty traumatic, because the prognosis is what the prognosis is. It isn't a lifestyle choice that plays a part in that, for example. So, how are those people who have an immediate physical need, and without a doubt a mental health need, treated?

I know from the Parkinson's services I've worked in—. If we take Parkinson's as an example, what I think, in my experience of Parkinson's services in the areas I've worked in, is that they are very holistic services in any case. They have resources from psychologists, they have quite intensive support from Parkinson's nurses, for example, which look at that whole aspect and advise patients on how to manage their condition and help them come to terms with the degenerative condition and the general decline that's going to happen. You could use the Parkinson's model as a good model to look at other chronic conditions, especially in terms of stroke, in providing that holistic care. I know that in some services with strokes, again a debilitating neurological condition, they will have people who are looking at the psychological impact of that and working with some psychologists. It's part of where we want to be, and, again, we've got pockets of good practice and we are working to see how we can actually get that good practice wider.

But some of that good practice is down to need and, in some part, investment in having sufficient people to support those individuals in the right place at the right time. I know, Minister, that you're doing work in this space, so I particularly used that because I know it's a model that's out there and working quite well in some places, but failing in others.

I think one of the great things that we do is to use the third sector in this space as well. I think they do an incredible job in giving support, in particular that mental health support. When you think about cancer, a lot of people have cancer, and think about organisations like Maggie's—they are there to support people with that mental health support. So, it's not just about the NHS, actually, there are broader partners that we use in that space. If I can just ask Heather to mention children, I think that's important as well.

Yes, thank you. I think sometimes it's about the model we use. The medical model is great if you've got cancer or something that actually requires a medicine, but, actually, if we're going to use the right model—it's like having a knife and a fork, you use them for different things—we need to make sure that the social model is actually being brought into play. That's the holistic one. It's all in 'A Healthier Wales'—co-production, what does somebody need from their care. And that's about their own locus of control of their illness or condition and how it's affecting their own personal choices. And, again, that's fundamental to good compassionate care for every health professional that they come in contact with. And when people are outside their own sphere of expertise, then, again, we have the just-in-time support from experts, which Stuart has mentioned, available, maybe at the end of a telephone.

So, I think applying the right model is really important, and also using the third sector. We see this in children's care, so children with chronic conditions or disabilities. We know that, in children's services, it tends to be very multiprofessional and very holistic, and then we find that we have to pass them on to adult physicians and carers. And so we've developed a transition and handover passport for children and young people, which starts with, 'Who am I and what do I want from my care?' And it also includes the carers. So, again, it engages with the psychological needs and mental health needs, about locus of control, so that people can actually feel they are making the choices that are important to them. That is the starting point, so that we don't just go, 'Oh, an unhappy person, let's pass them on to the child and adolescent mental health services.' Again, it's making sure that we are using our resources effectively, and making sure that people are treated as whole human beings, and that they are responded to in a way that may include, again, social prescribing, engagement with the third sector. Of course, the school is tremendously important, and the support they get there.

Could I give you another example, or challenging example? It's when individuals, and particularly children, are neurodivergent, and also then experiencing a mental health crisis—not always a crisis, but sometimes a crisis. How adequate do you think the care is when it doesn't become, 'Well, it's your neurodivergence causing it, or it's your mental health'? Because I've heard many cases of where that is the case, and it's a pillar and post. It's not, 'You're this, it's that.' How well prepared are we to have individuals trained adequately, in your opinion, and what examples of good practice can you bring to the table where people have two very clear needs, but, very often, nobody wants to take responsibility?

We're just short of time. Did you have any further questions, Joyce?

Yes. You mentioned social prescribing, are we actually able to deliver it properly?

Just a brief answer, if possible.

Yes, briefly. It's person-centred planning, working between health and education, which is the Additional Learning Needs and Education Tribunal (Wales) Act 2018—the ALNET Act—that health has its bit to deliver, a whole-school approach to mental well-being, but also the person-centred planning for children with neurodivergence or any other additional learning needs in school. Again, it's health doing what it can in order to use the same approach. What is important to the child or young person, and what is an effective intervention?

So, person-centred care planning as training in a multidisciplinary way has been very effective. Our DECLOs—designated education clinical lead officers—in each health board area, again, are overseeing the actual implementation of that. Undoubtedly, there is a massive challenge in capacity of CAMHS services, but, again, we're trying to do the fence at the top of the cliff, as well as the ambulance at the bottom, with the measures that we've mentioned.

With social prescribing, again, there are examples where it is going extremely well. We do need to rely on and engage with the third sector, voluntary organisations, through RPBs. It is happening well in some areas, such as frailty, where there are the safe-at-home exercises, but there's plenty of work for everybody in that space, I would say. I don't know if you want to add anything else.

Which is why we've got this framework, because one of the key issues for me is that there are these pockets where it's working brilliantly, but one of the concerns, I think, was how do you make sure that there's a quality standard around it? How can GPs have the confidence that, when they’re referring people who are quite vulnerable at times to a service, that actually the support is going to be there for them? So, that's why that that framework has been set. All of that work has been done now, but some of this is about you know what happens locally. You can't impose a system on it from above. It's about what's available locally.

And are you satisfied that there's enough cross-over between those people working in, say, physical health and those working in mental health, so that they both do meet?

I'm sorry, Joyce—we're really out of time for the question. Is there a brief response to Joyce's last question, Cabinet Secretary? 

Yes, I think that that cross-over does happen. It probably, again, is different in different parts of Wales, but there does need to be that cross-over. It’s absolutely essential. It's GPs who generally do that. It's that whole-person approach that is absolutely central to our vision.

And just a very quick question, which demands a very short answer, do you think that those living with severe mental health should have an annual physical health check?

I think we've got to be driven by the evidence on that, so I'd need to look at advice on how frequently they need that kind of thing. I wouldn't want to sign up to that without further evidence that it would be exactly what has worked elsewhere, for example. But I'm more than happy to have a look at that. It's basically done on—. We're trying to work in clusters as well at the moment in relation to that.

John Griffiths. 

Health inequalities, Cabinet Secretary: we know that there are major issues from one community to another in Wales in terms of life expectancy and healthy life expectancy, and chronic conditions—multiple chronic conditions—are more prevalent in our more disadvantaged communities. So, what is Welsh Government doing to address this inequality?

Thanks very much. Well, obviously what we have is a situation where we've got to get into the preventative space, so, as I've said, I've got this obesity mission that I'm trying to push on. You've already heard the fact that, actually, a huge amount of work and success has been achieved through reductions in smoking levels. We're very disappointed, obviously, about the Tobacco and Vapes Bill, so I'm really hoping that that will come back through Parliament.

But the key thing, as far as I'm concerned, is that broader piece that is very much a cross-Government approach. So, making sure that we give children the best start in life, which Heather has touched upon, with Flying Start. We've launched our approach to early childhood play, learning and care in Wales, to make sure that children have stimulated learning. We've got a real, very concerted effort to tackle educational inequalities: help in relation to cost of school uniforms, free school meals, free breakfast. All of those things we hope will help to address those issues in relation to inequality.

We know that work is the best route out of poverty, so making sure that young people have a guarantee and support to get a job is absolutely crucial. Quality housing: there's some incredible work that has been done in relation to quality housing and we've got, obviously, the Welsh housing quality standard, which means that people in Wales who are renting homes don't have the kind of issues that you see across the border. We've got income maximisation. We've got a huge programme to tell people to claim what they deserve, what they are entitled to, and the fact is we've helped over 36,000 people claim over £10 million that they were entitled to. So, there's a huge number of things. You know about the discretionary assistance fund—£38 million to help people who are really struggling to fight to pay for those essential issues, with the £5 million Fuel Bank Foundation—we all know the cost of energy has gone through the roof—support for that. There is so much support going on from the Welsh Government, particularly at this time when there's a cost-of-living crisis. But I'm going to just get political here: I think that what we need is a much more concerted effort from the UK Government as well. We know that, actually, the tools to address some of this issue are held at the UK Government level, which is why we need a Labour Government. There we are, I've said it.

Thank you, Cabinet Secretary. In terms of that cross-Welsh Government approach, are you able to tell committee what impact you think the Welsh Government's commitment to health in all policies has had? Is it possible for you to give us a flavour of that?

This was something that fell out of the Public Health (Wales) Act 2017. We're going to have these health impact assessments. They haven't actually started yet. They've been out to consultation, they are about to be introduced, and, obviously, that then will become mainstream. I'm hoping that what that does is to get people into a mindset—a bit like the Well-being of Future Generations (Wales) Act 2015—to say, 'Have we considered health in relation to this?' And when we talk about health, it's got to be not just physical health, but obviously mental health, and I am hoping that that will make a difference. The World Health Organization has a real interest in monitoring what difference this will make as well.

Could I ask you about being proactive, Cabinet Secretary—health services and others being proactive and reaching out to communities and groups where health inequalities are a very real issue? We know that we had a pioneering doctor, Julian Tudor Hart, in Wales, showing the importance of these sorts of approaches and just what can be achieved. Are we in that space very strongly now in Wales, with that proactive outreach into communities and groups that really need that service?

I think we definitely are. I think we learned a hell of a lot during the pandemic about how to reach out to those communities that were perhaps not coming forward for vaccination. We've been able to learn a lot from that: how do you do that outreach, how do you gain confidence within those communities, who do you use to speak to those communities. All of that learning from the vaccination programme is now being mainstreamed into different programmes, including, for example, the screening programmes, taking screening out into our communities, making sure that they're embedded with those hard-to-reach communities. There are specific programmes to tackle some areas. For example, there's been a lung health check rolled out in the Rhondda. They've gone through the GP records and said, 'Right, who are the people who've said they're smokers? Let's target those people, let's invite them for a lung health check'—really proactive. We've gone into a lot of behavioural analysis into what works, what gets people to turn up, how do you write the letters to invite people. A huge amount of work and learning has gone on. So, I am confident that we're getting now to a place where that outreach to those hard-to-reach communities has definitely improved.

I certainly know that, during the pandemic, for example, Muslim Doctors Cymru did some very good outreach work in mosques around the vaccination programme, and have now carried on that work in mosques and other places to bring services to communities, so I do think that's very important, Cabinet Secretary.

But could I just ask you, finally—? You mentioned data. How systematic is it in terms of collecting data to help services target those most in need? We heard, for example, that children's physio services in a part of Wales were looking at where referrals were relatively few, and having done that mapping, they then worked with schools in those areas to make sure that children were accessing those services to a greater extent. But we always wonder whether good practice happens right across Wales, so how systematic is it in terms of collecting and using data in that way?

I'm going to ask Heather, if you don't mind, to address this.

It's tremendously important to demonstrate effectiveness, and we rely a lot on national audits, which we buy in from the Healthcare Quality Improvement Partnership, which runs those kinds of audits and clinical outcome review programmes—so, quantitative and qualitative information coming to us. And, again, we feed that into what we now have in the clinical networks. We also have a huge amount of professional intelligence coming through via our lead for allied health professionals in the Welsh Government, who links with all the allied health professional leads in health boards. So, we have numerous sources of evidence and data coming through and, therefore, different levels at which those kinds of solutions can be found, because, again, the principle is no unwarranted variation—that's a fundamental of 'A Healthier Wales'. That is the continuous process of listening, hearing and fixing issues as they occur. That is happening at various levels, locally and strategically, but also in terms of actual comparable outcomes. And the advantage of us being in with the HQIP national audits is that we understand how we're doing not just across Wales but across the UK as well.

Diolch yn fawr.

Thank you, John. Sam Rowlands.

Thank you. Just briefly, Chair. You touched on preventative work previously as well, and you described it as a fence at the top the cliff as well as the ambulance at the bottom. I'm just wondering about the capacity within primary care for people to engage in that prevention work and how you think that is working. And also whether the 'make every contact count' initiative could be strengthened so that preventative work can be even better.

We know that GPs are under incredible strain at the moment. They see 1.5 million people a month—I think that's the figure. It is quite remarkable. And they get about eight minutes, on average, per patient. This is an intensity that you can't imagine. So, I think you're right, we've got to be really careful that we don't pile on too much. But, obviously, the GP is one part of a team, and there is a whole-team approach that you can use for some of this, making every contact count. We are very keen to move the focus away from an illness service to a wellness and a prevention service. But already, GPs are doing a huge amount. There are things like the enhanced service for adults with type 2 diabetes. Again, you heard earlier that there are nurses who are absolute experts in this, and they don't have to see the GP. Actually, the nurses are better than the GP because they do have that specialist approach. I think, if you look at things like the cervical screening, vaccination, child health checks, learning difficulty checks, all of those things are already happening at the GP level. Stuart, I don't know, have they got any capacity to do any more?

Prevention is a key part of the general medical services contract in any case. We have cervical screening carried out by GPs, vaccination, child health checks, opportunistic health checks when you're seeing patients. We have a supplementary service around diabetes care to give enhanced diabetes care for patients. Diabetes is a leading cause of other chronic health conditions, and a risk factor to controlling that is prevention—providing medication prevention of either primary or secondary events, checking blood pressure. So, it's part and parcel of a GP's day-to-day work, and is within the contract. And, yes, I think that the pressures the Cabinet Secretary’s already mentioned can cause problems with that.

If we look at the other primary care contractors, such as dentistry, there's the Designed to Smile initiative, which was looking at improving tooth brushing in children and making sure that we reduce the incidence of tooth decay. That was targeted very much at our more deprived communities. In optometry, we're trying to encourage people to get eye checks and have a set of checks around their eye health as well. And then more and more stuff is being done by pharmacy in terms of checking blood pressure, case finding for blood pressure.

Outside of what we do, I suppose the rise of Apple watches has seen a few people come in with atrial fibrillation, which we've then dealt with in primary care to prevent strokes and other cardiovascular conditions. So, it is being done, and it is an integral part of the job.

Thanks. Thanks, Chair.

Thank you. In terms of outcomes of prevention work, is data being collected?

It's often difficult to quantify prevention work, isn't it? It's very easy to count people who have had strokes. It's very difficult to count people who haven't had a stroke because of the intervention put in, other than from population health data and the incidence over time. So, whatever data we have from initiatives and interventions we are putting in now we're not going to see for some time.

I suppose it's data on the outcomes and seeing more positive outcomes.

You could see that, for example, during COVID—how many people were in hospital and how many people died before vaccination was rolled out. Once the vaccination programme was rolled out, you had a massive decline in the number of people who went into hospital or who died as a result of COVID. So, there is a direct relationship, but collecting that data—. We know there's a relationship. We know, for example, that that drop in the number of people smoking will make a huge difference, but it is quite difficult to prove that link.

I suppose the question is how do you measure the impact of preventative care, where you're actively progressing an area to make better outcomes and you've got to measure that in some way. 

It's possible to have a kind of grapeshot approach to these things, but that's where, with the screening and vaccination programmes, uptake is a proxy for better outcomes, because we don't introduce universal asymptomatic screening or vaccination programmes unless there is already evidence that they make a difference. Therefore, the uptake is the proxy for the outcome. 

Just on that uptake being the proxy for better outcomes, we've seen measles vaccinations drop, and we've seen a correlation. We've seen the same with whooping cough, which is doing the rounds now, again. And, again, we've seen it with the vaccination of young people in schools, with the HPV vaccine. So, there are all of those things. Vaccination, I think, sometimes, is overlooked in terms of prevention.

Vaccination is a miraculous intervention. It is so effective. And that's where, again, we need to be thinking, in terms of prevention, about behavioural approaches, using COM-B models: capability, opportunity and motivation gives you behaviour. And teachable moments. When there is an outbreak of measles, whooping cough, then people go, 'Oh, this is awful, what if this happens to me?' That's the teachable moment, and that's when Public Health Wales put on additional vaccine offers. So, again, it's that dynamic response to things that are happening for interventions that we absolutely know are effective.

One of the things that I've been trying to promote as well—. We have people on waiting lists. They're looking for something from us there. That's an opportunity for us to have a conversation with them about, 'This is a relationship here, so we can offer you this, but, actually, what are you going to do? Are you going to, perhaps, lose a bit of weight before you have the operation so you have better outcomes? Are you going to get fit before the operation, so you get better outcomes?' I think all of those things are also opportunities.

Cabinet Secretary and officials, can I thank you for being with us today? We have run over a little bit, so I'm sorry for that, Cabinet Secretary, but I appreciate your time this morning. Diolch yn fawr iawn. 

Diolch yn fawr. 

I move to item 3. We have just one letter to note—a letter from the Llywydd in connection to the legislative competence and human rights considerations in the Health and Social Care (Wales) Bill. If Members are happy to note that one letter. Thank you. Diolch yn fawr. 

We move to item 4. In accordance with Standing Order 17.42, I propose that the committee resolves to exclude the public from the remainder of today's meeting, if Members are content. Yes. Thank you. In that case, we move to private session.