Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd

Health, Social Care and Sport Committee - Fifth Senedd

15/11/2017

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Caroline Jones
Dai Lloyd Cadeirydd y Pwyllgor
Committee Chair
Dawn Bowden
Lynne Neagle
Rhun ap Iorwerth
Suzy Davies Yn dirprwyo ar ran Angela Burns
Substitute for Angela Burns

Y rhai eraill a oedd yn bresennol

Others in Attendance

Alan Brace Cyfarwyddwr Cyllid, Llywodraeth Cymru
Director of Finance, Welsh Government
Huw Irranca-Davies Y Gweinidog Gofal Cymdeithasol a Phlant
Minister for Children and Social Care
Simon Dean Dirprwy Brif Weithredwr, GIG Cymru
Deputy Chief Executive, NHS Wales
Vaughan Gething Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol
Cabinet Secretary for Health and Social Services

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Amy Clifton Ymchwilydd
Researcher
Sian Giddins Dirprwy Glerc
Deputy Clerk
Sian Thomas Clerc
Clerk
Stephen Boyce Ymchwilydd
Researcher

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle y mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:33.

The meeting began at 09:33.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Croeso a bore da i chi i gyd i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Cynulliad. A gaf i estyn croeso i'm cyd-Aelodau, gan ddatgan ein bod wedi derbyn ymddiheuriadau oddi wrth Angela Burns, ac mae Suzy Davies yma yn dirprwyo yn ei lle? Felly, croeso, Suzy. Rydym ni hefyd wedi derbyn ymddiheuriadau ar ran Julie Morgan a Jane Bryant, ac rydym wedi clywed ein bod ni'n mynd i gael Joyce Watson a David Rees fel dirprwyon.

A gaf i bellach egluro i bawb fod y cyfarfod yma yn ddwyieithog? Gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. Fe allaf bellach gyhoeddi ac atgoffa pobl i naill ai ddiffodd eu ffonau symudol ac unrhyw gyfarpar electronig arall, neu eu rhoi ar y dewis tawel, a hefyd hysbysu pobl y dylid dilyn cyfarwyddiadau'r tywyswyr os bydd larwm tân yn canu.

A hefyd, yn yr adeilad ac yn yr oriel gyhoeddus, mi fydd pwyllgor iechyd Senedd KwaZulu-Natal yn ymddangos i wrando ar ein trafodaethau y bore yma. Felly, yn naturiol, fe gânt groeso pan fyddan nhw'n ymddangos. Rwy'n eu gweld nhw i fyny yn fanna ar hyn o bryd. Felly, gyda chymaint â hynny o ragymadrodd, fe wnawn ni symud ymlaen i eitem 2.

Welcome and good morning to you all to the latest meeting of the Health, Social Care and Sport Committee here at the Assembly. Can I welcome my fellow Members? We have received apologies from Angela Burns, and Suzy Davies will be substituting for her. So, welcome, Suzy. We have also received apologies from Julie Morgan and Jane Bryant, and we have heard that we will be having Joyce Watson and David Rees as substitutes for them.

Can I please explain to everyone that this meeting is bilingual? Headphones can be used for simultaneous translation from Welsh to English on channel 1, or for amplification on channel 2. Can I also ask you please to turn off your mobile phones and any other electronic equipment, or put them onto silent mode, and can I also let you know that in the event of a fire alarm, please follow directions from the ushers?

Also, in this building and in the public gallery, we will have the health committee from the KwaZulu-Natal Parliament—they'll be here today listening to our discussions. So, naturally, we will be welcoming them when they arrive. I can see them up there at the moment. So, with that much of an introduction, can we move on to item 2, please?

2. Craffu ar Gyllideb Ddrafft Llywodraeth Cymru ar gyfer 2018-19—sesiwn dystiolaeth 1—Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol a’r Gweinidog Gofal Cymdeithasol a Phlant
2. Scrutiny of the Welsh Government Draft Budget 2018-19—evidence session 1—Cabinet Secretary for Health and Social Services and the Minister for Children and Social Care

Prif bwrpas y cyfarfod y bore yma yw craffu ar gyllideb ddrafft Llywodraeth Cymru ar gyfer 2018-19, a'r sesiwn dystiolaeth gydag Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol, Vaughan Gething, a hefyd y Gweinidog Gofal Cymdeithasol a Phlant, Huw Irranca-Davies, sy'n newydd i'r swydd. Llongyfarchiadau ar eich dyrchafiad a chroeso i'r pwyllgor yma, Huw. Yn ogystal, mae gyda ni Simon Dean, dirprwy brif weithredwr gwasanaeth iechyd gwladol Cymru, a hefyd Alan Brace, cyfarwyddwr cyllid.

Felly, yn ôl ein trefn, rŷm ni wedi derbyn y papurau ar y gyllideb ymlaen llaw. Mae'r Aelodau wedi eu darllen mewn cryn fanylder ac mae yna gwestiynau yn deillio o'r rheini. Felly, fel sy'n draddodiadol, awn ni'n syth i mewn i'r cwestiynau ac mae'r cwestiynau cyntaf o dan law Rhun ap Iorwerth. Rhun. 

The main purpose of the meeting today is to scrutinise the Welsh Government draft budget 2018-19, and the evidence session with the Cabinet Secretary for Health and Social Services, Vaughan Gething, and also the Minister for Children and Social Care, Huw Irranca-Davies, who is new in post. Congratulations to you for your promotion and welcome to this committee, Huw. Also, we have Simon Dean, deputy chief executive of NHS Wales, and also Alan Brace, director of finance. 

So, as would be normal practice, we have of course received the papers on the budget in advance. Members have looked at those in great detail and we do have questions arising from those papers. So, if we can go straight into questions then please, and the first one is from Rhun ap Iorwerth. Rhun.

09:35

Diolch yn fawr iawn, Gadeirydd. Bore da i chi. Mi hoffwn i ddechrau efo ychydig gwestiynau ynglŷn â chynaliadwyedd cyffredinol y gwasanaeth iechyd wrth symud ymlaen. Rwy'n meddwl eich bod chi'n dweud, Ysgrifennydd Cabinet, mai eich bwriad chi, drwy fuddsoddiad ychwanegol yn y gwasanaeth iechyd, ydy helpu i gynllunio ar gyfer cynaliadwyedd canolig a hirdymor a chynorthwyo'r busnes o ddiwygio'r gwasanaeth. Ond mewn difrif, beth sydd gennym ni, yn ôl yr Ysgrifennydd cyllid, Mark Drakeford, ydy setliad sydd ddim yn hael iawn ond sy'n caniatáu i'r NHS barhau i wneud y gwaith mae o yn ei wneud—hynny ydy, cadw'r olwynion i droi. Sut ydych chi'ch sgwario eich uchelgais efo'r gwirionedd?

Thank you very much, Chair. A very good morning to you. I'd like to start with a few questions on the general sustainability of the NHS as we move forward. I think you've said, Cabinet Secretary, that your plan, through additional investment in the health service, is to plan for the medium and long-term sustainability of the NHS and support service reform. But in reality, what we have, according to the finance Secretary, Mark Drakeford, is a settlement that isn't particularly generous but allows the NHS to continue to do the work that it's currently doing. So, it's keeping the wheels turning. So, how do you square your ambition with the reality?

Thank you for the question. Sorry, I should say, Chair, we have two other Government officials in the room with us. We have Irfon Rees, the deputy director of public health. We also have Alistair Davey from social services as well, should the need arise. 

Turning to your question, Rhun, this is part of our central challenge, is it not? For keeping the wheels turning, the NHS requires a commitment in itself. It also requires, as the Health Foundation set out, the ability to have a sustainable health service to be able to deliver and manage reform. We're not talking about new and increased ability to do significantly different things. That's our challenge: how we continue to reform our service so we can continue to do what we can.

If you think about the drivers for that reform and change, they're obvious and we know them. We know that we have an ageing population. That's a cause for celebration but it's a cause for challenge in health and social care. We know that we have a population where we have continuing public health challenges. So, we keep people alive for longer but, actually, we have more people being unwell and living an unhealthy life for a longer period of time. We also have the demand that comes from people's expectation as well. In the face of that and in the face of austerity and the challenge we have within the health budget—which is the big winner in terms of Welsh Government, when it comes to how we've divided up the cake—we know that other parts of public funding have a direct impact on health outcomes, because most are determinants of health and, looking at the good doctor in the centre there, people know that the key determinants of health are not actually all about the health service. So, that's part of our challenge, how we honestly manage that, and there are trade-offs that are unavoidable.

To keep the service sustainable, we need to be able to reform our services in the way we go about delivering them, and that's why we have the money to allow us to do that. It's based on evidence—we have Nuffield, we have the Health Foundation, but also it's about that longer-term transformation as well. That's why we've got a planning framework that is still maturing, because we want people to look at three-year plans rolling forward and having a long-term plan within that as well. That's perhaps a phrase that people in politics may not wish to hear very much after the way it's previously been used. We also, of course, have the parliamentary review of health and care, and that's a recognition that health and care go together—they're systems that rely on each other and affect each other.

When we think about the ability to change, the ability to do things differently, some of these questions are difficult and everyone, as a local or regional Member, knows that. Because even with evidence for change, there is always a powerful case that is made locally to maintain the status quo. Every politician in every party knows that. Part of the difficulty and the challenge of being in Government is that you have to make difficult choices from time to time. From our service point of view, though, this settlement is about giving the service the resources that objectively we've been told it should need to be able to keep the wheels turning and to allow it to be sustainable while we continue on that path of reform. I don't think there's anything inconsistent with that in saying that, actually, we won't be able to do new and significantly different things on the settlement that we have got. That's the honesty in the conversation.

I agree with you up to a point that we will not have new money to do significantly different things, but we need to find a way of doing significantly different things without that additional money. That's the whole point of the parliamentary review, to seek new ways of working that will allow us to do more—if not for less then for the same funding. 

09:40

But that's my point: doing different things to keep the wheels turning, rather than doing different things to do entirely different things.

But in order to get to that point, we need the investment in change, and evidence that we have taken in this committee in recent weeks has pointed to this budget being enough to keep on going, but not including the funds needed to drive change.

Well, I guess that comes back to whether you think that change is only about money and is only about investing more money to change services. 

If I could just stop you there—investing the money in making the change, not putting additional money into the delivery of the services that we already deliver.

Well, if you think about the ways in which we use money already, we're investing in changing the way we deliver our services. I'm sure we'll have questions for Huw later on about pooled budgets and shared and different ways of working and the integrated care fund. There's the way in which we're incentivising different ways of working as well. There's the value and efficiency board, which is about changing the way services are delivered, and that's been a key part of the work with organisations in targeted intervention—being clear about the way in which they need to change the way that they work to be able to deliver a service that is sustainable, and that's the honest part of our challenge. I don't think there's a real misunderstanding between us about that. It's really about: can we do that in enough time or will change overtake us?

Because, the NHS will look different in five to 10 years' time, partly because it should do, because there are things we would want to change, and partly because it has to, because of demographic change, because of the realities of money—that, actually, we can't run some of the models of care we currently have because we don't have the money to sustain them. Things like the variable pay bill for agency and locum fees mean that, actually, we couldn't sustain some of those models even if we wanted to, and it's some honesty about the different drivers for that change that we face. So, we will either choose to change our NHS, because we will have had a conversation within the service with our staff taking a lead, having a conversation with the public, and we'll make some choices—a range of which will be difficult—or change will happen to the NHS because we won't already have got ahead of that curve, and we'll find that the system is at the point of being knocked over, and that is no way to run the service. So, it's easy to say objectively; it gets much more difficult when you're faced with the reality of a choice. You and other Members will ask me why I can't do something different, but that's the joy of being in this position.

Could you point us to the specific areas of the budget where you think the money should come from to drive transitional change? I mean, investing to save, if you like—give it whatever title you need—but somehow we need to be changing the Welsh NHS, and that's going to mean a targeted investment in driving that change.

Well, I think capital is a useful way to look at service transformation. Think about the big choice that we made that I know one of your members was particularly keen on and spent several elections campaigning for. The Grange university hospital isn't about adding something on top of the healthcare system in Gwent; it is part of the south Wales programme, and it is part of transforming services, in primary as well as in secondary care, in that part of Wales. So, it does mean change in other hospitals that exist within the system, and that's always been well understood by the people planning the service. I'm not sure everyone who's argued for the new hospital to be built has understood that's what it really means, but that is exactly what it means, and that is about transforming the way that our services are delivered. So, that capital use is part of that. And the pipeline of products that I've indicated we have in primary care—that is about transforming the way that our health service works. The part where most people go, one in which they have the first interaction with the health service to have their conditions managed—that matters as well. The money we put into Choose Pharmacy—that is absolutely about transformational change, about moving people away from one part of the system into a different part. And, actually, it isn't just about the common ailments scheme, it is about having a platform and having trust between professionals and the public, and using a network of trusted healthcare professionals that exists within easy reach of most communities. There is a range of different areas you can look at, without going into areas that Huw will want to talk about later, where we are definitely directing money to deliver change, as opposed to, 'Let's keep everything the way it is right now', because that's a recipe for failure.

We're just hearing a different story from people telling us that there isn't enough money to drive that change, and all they have is the money to keep their services just about going. I mean, prevention—

You can understand why people say that. You can understand why people make those bids for more money in different parts of the system.

And I can understand why you're saying what you're saying, because—

But, then, that's part of the honesty in the conversation, isn't it? And it's about—. You understand why people make bids for more money. You understand why there's a set sum of money that the Welsh Government has to allocate, and it's our job to then make the best use of that money, and a lot of that is about behaviour change, and that comes back to the planning of a system as well—the culture that we have. And that's why if you look at those health boards and trusts that are successful—. And a number of those have done that: think about Powys five or six years ago—it was not in the position it is now; think about the ambulance just three to four years ago in a significantly different position; Cwm Taf eight years ago was in a very different position to how it is now. Some people talk about some of these health boards and trusts as if it was always inevitable they'd be the good ones, and they've actually had to go through a difficult journey to get where they are now, but they have delivered more of that change. The challenge for the rest of our system is to understand how they have got there and to do more of it, and not look for reasons outside of our system.

09:45

And prevention is another area of it, where you tell us, and we agree, that we need to shift towards prevention. That's a big part, obviously, of taking the pressures off the NHS in years to come. Health boards tell us in evidence that they need transitional funding, for example, to enable them to make the shift towards a more preventative strategy. What are your thoughts on that?

Well, look, we've been clear about where we want to be and there's the first point about understanding that lots of what the health and care service does already is preventative; it isn't just an illness treatment service. The obvious parts: things like immunisation; the obvious parts about the way in which, for example, it was World Diabetes Day yesterday. Lots of the care that we provide around diabetes is actually about primary prevention. It's one of the big priorities of the implementation group, so people can manage their risks of acquiring diabetes, and then the condition management side of it is about how you make sure that it doesn't get worse and more expensive, both in the human costs for the individual and the family, but also for the service and the money that we pay. We reckon that about 10 per cent of NHS Wales's costs go into diabetes and its complications. So, an awful lot already goes in, but when we then think about putting all the shift money into prevention, this comes down to part of our big system challenges, because we're looking at how to move into a more preventative system. That's why the parliamentary review will help us in some of that, but it's also why the planning system matters, because a lot of it is about how we shift into being a more preventative service and working with other people to do so.

If we can't get some of the health boards and targeted interventions into a different position, it will compromise our ability to have some money to help with that transformation. I wanted to be able to have a central transformation fund to help incentivise greater change. We haven't been able to achieve that within this year because of the scale of the financial challenge that we have facing us, and that's a real disappointment for me. I've been upfront and honest with the Welsh NHS Confederation about that and public audiences as well: if we get those health boards that are running deficits at present to improve their position, it will allow us to have more space to have more money to put into that, to drive system change, to drive more prevention.

But, I can't pretend to you that I can magic up different answers or have money that doesn't exist; it is still about the consistency of the message from the Government, from the leadership here—Alan, Simon and others—but it's also about the system leadership from people who are running and leading trusts and health boards. There's an understanding of that, there's no disagreement about where we want to go: the challenge is how far and how quickly we can go.

How much of health board funding should be going on preventative?

I'm not going to get into giving artificial figures on sums of money or percentages, because the problem is—and I've said this before—if you think about areas where there's a significant amount of preventative activity—general practice: lots of preventative activity, lots of treating illness; think about the health provision of midwives: lots and lots of preventative activity, and some of that is actually about treating the person as well—I don't think it would be helpful to try and say, 'Sixty per cent of health visitors' time is preventative', and then artificially allocate that to preventative spend. I don't think that's an helpful way to look at the system. It has to be about: what do we expect from our whole system? What do we want the drivers to be? And are we investing in those choices to allow us to do that without saying, 'I'm investing in a preventative choice here and a non-preventative choice there'? Because I actually think that's not the way in which you run, plan and manage a hugely complex system. I appreciate that's frustrating for people who want me to put a figure on it, but I'm not trying to—[Interruption.] I'm saying why I can't and why I won't, rather than just giving you something to allow me to get through a question, saying 'Here, I'll give you a figure.'

No, I mean, you can give or not give a figure, I think it's just over 5 per cent according to your figures in England, and we know that in Wales there's no indicative percentage or bar that you would like health boards to reach in terms of preventative spend, and I was just going to go on and ask, you know, within the budgets that they have now, would you like to push them towards increasing the share of their spend that they put into preventative work?

No, the drivers are about how we want to deliver more care, closer to home; more care that is delivered around patient experience and patient outcomes, recognising that the more we can invest in local healthcare, the more likely we are to keep people in their own homes for longer; the more likely we are to prevent ill health as well. The way in which we work with other partners, it isn't about money as well. Even though sport is no longer part of this portfolio, there's still a direct relationship that we have to have on our public health outcome and keeping people well and healthy with community sport, and with social prescribing and physical activity more generally. So, I still think that it would be artificial to say that I have a percentage figure or a monetary figure, that I have a target that I require or ask people to meet, as opposed to the service transformation that we started talking about that needs to take place. Some of that is about hospital-based care. A large chunk of it is actually about how we move more care out of hospital systems into the community, and those parts of our hospital system that need to change in the way they work to be more effective.

09:50

How does a real terms cut in Public Health Wales funding help with preventative—

[Inaudible]—is Public Health Wales the only part of our preventative spend, and it isn't. And this comes back to our honest challenge. This is the first year we've had to make cuts in a range of health budgets, and that underscores the financial challenge of austerity delivering in its seventh year. And I won't look you or anyone else in the eye and say this will get easier. I think it will get tougher, because I don't expect the UK budget, when it turns up, to deliver more money in significant sums for us. And in all of these areas, you could make an honest criticism about saying, 'Wouldn't it have helped to have more over here?' And the challenge is that you can't simply do that. So, when I cut the health and social care research budget, which is a decision that I made, I signed off on that, and you can say, 'Well, actually, investing in research is preventative. You're thinking about new ways of helping people and preventing ill health.' That's true, but I have to do something about making sure we can balance the books overall.

And we're coming back to the initial point: you're giving £200 million extra just to keep the wheels turning, and there's no additional money towards that preventative agenda, which surely, if we're heading into a transformational period for the NHS, turning the NHS into something that is more sustainable, we cannot let go of that preventative, that transformational funding aspect and just keep on throwing money at the keeping-the-wheels-turning aspect. 

But I hope we're getting back to the central disagreement that we do have, Rhun, and that's about whether or not we are making a real difference in trying to transform the services we have or not. I think we are. I'd like us to be able to go quicker. There are barriers in the way of doing that, but when you think about the money that we have, it's much easier to say you need to take more money out of another part of the system and put it into preventative spend. If you want to go through what hospitals spend on keeping people well and treating ill health and say which parts they don't need to do, I can tell you that isn't easy for health service managers, let alone politicians. And when you think about what is preventative, think about, again, the primary care programmes that have started in Gwent, and in Cwm Taf, and are rolling into AMBU—that is a way of preventing ill health. That's actually about understanding people and how they manage conditions, and people who are at risk of them. And that living well, living longer approach is showing returns now. So, that isn't about spending large sums of money, but about how we deploy the current resources we have in a different way and using different staff. And that's why healthcare support work is a really key aspect in non-medicalisation—

But the fear we have, of course, is that we're going to be in the same place in three years' time because of the lack of transformational—. Or the evidence that we're hearing that there's nothing here that allows room for transformation. That just means we're in the same position in three years' time. I'll leave it there. 

The biggest risk to three years' time is austerity, with respect. 

Diolch am hynny. Cyn i ni symud ymlaen i'r adran nesaf o gwestiynu, rwy'n credu ei bod hi'n briodol i ni gyfarch pwyllgor iechyd Senedd KwaZulu-Natal o Dde Affrica sydd yn yr oriel gyhoeddus. Felly, cyfarchion o bwyllgor iechyd Cynulliad Cenedlaethol Cymru a'r Senedd i Bwyllgor Iechyd KwaZulu-Natal o Dde Affrica. Croeso i chi gyd. Ac fe fyddaf i fel Cadeirydd yn eich cyfarfod chi yn nes ymlaen ar ôl diwedd y pwyllgor yma y bore yma. Gyda hynny o ragymadrodd, symudwn ymlaen i'r ardal nesaf o gwestiynu sydd ynglŷn â'r adnoddau sydd ar gael ar gyfer gwasanaethau cymdeithasol, ac mae Lynne Neagle yn gofyn y cwestiynau hynny.

Thank you. Before we move on to the next section of questions, could we please welcome the health committee from the KwaZulu-Natal Assembly from South Africa, who are in the public gallery? A very warm welcome from the National Assembly for Wales's health committee to the KwaZulu-Natal health committee. Welcome to you all. I, as Chair, will be meeting with you later on today after this meeting comes to an end. With that much of an introduction then, can we move on to the next area of questions regarding the resources for social services? Lynne Neagle has these questions.

Thank you, Chair. Can I ask, first of all, about the extra £42 million for social care in 2018-19, which increases to £73 million in 2019-20? How much of that is new money, and how does it take account of the £30 million of social care grants, and the £27 million independent living fund money, which has been transferred into the revenue support grant?

Lynne, thank you very much for that question. And I'm happy to confirm that the £42 million for social services doesn't include the £30 million of social care grants, and the £27 million for the independent living grant, which was transferred to the local government RSG. So, I can give you some reassurance on whether those two amounts—and it's understandable why you raised them—are included. They're not included within that amount. So, a categoric reassurance to you on that. 

09:55

Okay, thank you. When we had the Welsh Local Government Association and the Association of Directors of Social Services Cymru in to give evidence, they were talking to us about a perfect storm that they feel they face, really, of huge demographic change and also the major pressures on their budgets, which is a picture that I very much recognise from my own local authority. What assessment have you made of the impact on NHS services of the pressure on social services in Wales?

I think those pressures are undoubtedly there. We can't escape that fact, and neither can we escape the fact—and there is a reality about this—about the context that we're in. When we look ahead to 2019-20, we know that the budget we have will be 7 per cent lower in terms of Welsh resource grant by 2019-20. That cannot but have an impact, not only in terms of the funding but, as Vaughan has just said—as the Cabinet Secretary has just said—in the way we think about the way we actually deliver services. It's going to be £1 billion lower in real terms than we had in 2010-11, with the increasing pressures at the same time. So, we've got to be a lot cleverer. The capital budget is going to be down 10 per cent. So, 7 per cent in terms of the Welsh resource grant, 10 per cent down in terms of the capital budget. Those pressures are undoubtedly there. So, that does mean, Lynne, that we do have to think very differently about how we actually deliver—not only health and social care, but, actually, the combination of them and how we look after people's health and well-being needs collectively. We're still waiting, as you're probably aware as well, to see how the UK Government is going to deal with the further £3.5 billion of cuts in 2019-20 as well. So, there's the context that we're in.

That doesn't mean that we should be entirely pessimistic. To touch back on Rhun's question as well, some of the ways we need to actually think about cutting this now need to be about how we use the existing resource there, anticipating this context that we are in—we have to be frank about it—and deal with this in a very different way. It is worth saying, however, Lynne, that, even in that challenging context, even in that, we often hear within the press and the media and outside of here, 'Well, we're being cut to the bone, cut to the bone', and across the UK there are deep pressures on, but it is worth pointing out significantly that the spend on social care in Wales, albeit with our massive challenges that we have, is 33 per cent higher than that in England. It's 33 per cent higher than that in England. We have, I would suggest as well, some significant challenges around that as well in terms of the complex challenges for our population and our ageing population, but across the whole age spectrum as well. But we are spending £142 per person more in social care then we are in England. What we now need to do is actually make sure that we spend that very wisely, and part of that, by the way, is to do with transformational change within health and within social care. It means working in that horribly used phrase—overused phrase now—of co-production, but basically working and collaborating with people on the ground, using the resources that are there, not only with local government but also within the third sector. How do we look at how the third sector can contribute to these aims as well, in order to provide the sort of health and social care that we need?

But you are right: the challenges are great. Welsh local government realise and will repeatedly say the challenges are great. We don't disagree with them on that, but what we do say is that we've got to work together to resolve these issues. There's no use throwing our hands up in despair. And there is a note of optimism in this. I'm sure we'll get on to some of the ways that we're working, including how we use the ITC funds and so on. There are some real innovations out there at the moment. What we need to do is use those to drive forward further change, so that we have that transformation, but not in a way that requires unrealistically saying, 'We've suddenly found a magic new amount of money', short of the Chancellor of the Exchequer turning round next week and throwing it at us.

Okay. So, mindful of these pressures in local government and also of the fact that so much of this money just goes out into the RSG for local government, what steps is the Welsh Government going to take to monitor the extent to which local government is spending that money on social care?

The monitoring is crucial, and this is in partnership with local government, but we have to make sure that it is developing genuine outcomes. Part of the review process that we're currently engaged in will be to look at not only the outcomes, but also the value for money on the interventions that we do. There are some that I'm happy to go through with you—some of the practical illustrations of some of the quite exciting initiatives on the ground at the moment—but we do need to make sure that we learn from them in the process of—[Inaudible.]—in order that the finite amount of money that we have is then delivered towards the best outcomes; both the best outcomes for the individual on that person-centred approach, but also the best outcomes for value for money. So, that monitoring is ongoing, Lynne, and part of that review process is to look at value for money as well as outcomes.

10:00

Can I say, on the monitoring of money, there's a choice to be made, as ever? We either tell local government what to spend—and we regularly get bids to say, 'You must tell local government to spend this money' because, broadly, people, the lobbyists, don't trust local government—or we trust local government to understand their local communities and to make these choices. That's difficult, because, as politicians, when we get asked questions we would always want to have control over that. But there is an honest difficulty, and this is about whether we trust local government, and the monitoring returns will show us how much has been spent and they have to account for themselves anyway. It's then, obviously, about whether that's enough to deliver and to transform our services.

Okay. The Cabinet Secretary for finance and local government has said that, prior to the final budget settlement, further evidence will be considered on the financial impact of increasing the capital limit for charging for residential care to make a decision on further increasing the limit. What assessment have you made of the likelihood of that happening now?

Well, we are committed, as you know, to implementing, before the end of this Assembly, our pledge within 'Taking Wales Forward' to increase to £50,000 the capital threshold used for residential care. We've already moved some way towards that by increasing the limit from £24,000 to £30,000, and we're encouraged by the response that we've seen from that. This is part of a staged implementation, because we want to learn as we go forward, rather than do it in one big fell swoop. The first increase that we did, from £24,000 to £30,000, was supported by an addition of £4.5 million recurrently in the local government settlement to enable those local authorities to support residents benefiting from the new limit, but we're now looking at the data and what has come back from that. So, we're currently collating, we're looking at, the second quarterly data in order to look at the increase that would take place next year. So, this is very much a learn by the information that's coming in, decide what the impact is, what the budgetary impact is, but also what the outcomes are, and how many people have benefited from it as well. This is going to give us a better, more balanced, mid-term analysis of where we are and the effects of the increase introduced to date. Also, going forward, it'll help us decide what the forward announcement will be for the capital limit. We're hoping to make that announcement quite shortly, when we've analysed that data, and to bring forward funding to support implementation in the local government settlement for 2018-19, to be published, we hope, next month. So, we're doing a thorough analysis. We took the approach from the word 'go' at this that we wouldn't rush at this. It is a firm commitment of this Government to do. We think it's achievable. We think it's deliverable. We can see the benefits delivering. I have to say, as well, it is immensely popular as a commitment as well. So, people are expecting us to deliver on this. But we do want to make sure that we do it in the right way. So, this mid-year, more balanced approach, to look at the analysis and see how we take it forward for the next part of the budget, will be a crucial one. But we are confident we will be taking this commitment forward.

Diolch yn fawr, Lynne. Mae'r cwestiynau nesaf mewn adran wahanol ac yn sôn am y pwysau ariannol yn y maes iechyd. Mae'r cwestiynau yma o dan ofal Suzy Davies.

Thank you, Lynne. The next questions are in a different section and on the financial pressures in the health sector. These questions will come from Suzy Davies.

Diolch, Cadeirydd. Before I move on, I just wonder if I can take you back very quickly to Lynne's point about monitoring. Of the extra money that was given towards social care specifically during the previous year, which included some of the Barnettised money from the £2 billion coming from the UK Government, I understood from your predecessor, Huw, that conditions were placed on the money that went to the local authorities, which meant that, when bids were made to them, they had to prove that there was a social care outcome.

It wasn't a case of being told what to spend it on, but they had to prove a social care outcome, which was important when the money was given in the first place to meet demand for social care. Now, monitoring is one thing, but, on the basis of monitoring, what do you expect to be able to do in local government if the monitoring reveals that, actually, the money hasn't gone to social care outcomes?

Yes, absolutely. My predecessor was absolutely correct in that, and part of the innovation, part of the flexibility with the funding out there—rather than prescribing, 'This is exactly how you will spend it', a top-down Welsh Government-led one, the innovation through the funding with this, and the flexibility, is to see exactly what the outcomes are. And I mentioned previously that it is both the outcomes in terms of social care, social services, and the outcomes for the individuals within that, and it's also then the value for money to make sure that we learn from what does work. We recognise, I have to say, that, sometimes, when you take an approach that's based on flexible options, delivered in co-production on the ground, there are going to be some that work better than others, some that don't work as well. That's why the analysis has to actually say, 'Have the outcomes been delivered?'

10:05

Can I just leap in here? How easy is it going to be to follow the money when it's outcome based rather than input based?

I think it can, and the assessment that we're doing internally is very much focused on the outcomes rather than the input. The inputs are easy—

The inputs are easy to measure, but the outcomes—. For example, the Powys example that Vaughan referred to earlier on—there's £700,000 that's gone into that, but with the flexibility for them to determine how they actually move people more rapidly back into a home-based scenario. We can look at the numbers of people who are actually benefiting from this now and whether they are being sustained at home, rather than reliant on, once again, coming forward into the rescue service aspect of the national health service, but actually being supported better at home. We'll be able to actually monitor and assess whether that is successful. If it is, it provides something of a template, but, again, not a predetermined model that says, 'You must do this everywhere'. But, we'll know, for example, whether that, in a predominantly rural situation, for that money, has been (1) value for money and has actually delivered the outcomes for those individuals on the ground. Now, this is a more difficult form of monitoring, I appreciate, because it's not a tick box.

This is what I'm coming to. Six months down the line, when I'm asking you to prove that the outcome was dependent on the additional money, I want you to be in a position to answer.

Can I just move on now, please, to the financial pressures in health? You mentioned earlier, Cabinet Secretary, that choices have to be made and there have to be trade-offs, and, actually, you referred to evidence and cited the Health Foundation, in particular. I wonder if you can give us just a few examples of the trade-offs that need to be made and how you think that will meet the Health Foundation's report's indication, shall we say, that £700 million of efficiency savings need to be found in this year's budget cycle.

Well, some of those are headline budget trade-offs, aren't they? So, the investment we're making in the NHS comes at a cost to everyone else. So, it means there is less money to spend, so you come to the position where you can't, on the one hand, argue, on our current budget settlement, for a significant additional cash injection into the health service and for a significant additional cash injection into local government. You just can't do it—

—so, that's part of the budget trade-off at that large, Government level.

Then, within the health service, it is about how much more efficient we can and can't be. The health service makes efficiency gains, and the Health Foundation said they'd need to continue doing that, finding different ways to work. There are opportunities, for example, in looking at the way in which on our drugs bill—I'm thinking about biosimulars, the way there are savings to be made there. In procurement terms, we regularly deliver extra savings when you think about the whole value of that, and not just about the financial part, but the value in wider-than-health-service terms as well. So, the trade-offs exist throughout the whole system, and, actually, they exist at every single point in time. The challenge now is that they're more acute and more pressing, and we think about the gap that the Health Foundation identified—some of that would be on the back of additional investment from the Government. Some of that comes from efficiency continuing to be made—continued efficiency gains, which NHS Wales has actually managed to deliver—

Can you give us an indication of what—? I know it's difficult to give specific examples, but can you think of one thing where you can say, 'Yes, that's where an efficiency has been made'? You mentioned drugs earlier. There's a potential for you in prescribing—

Yes, biosimulars. But, even if you think about something going into the environmental field, when you think about using heat and power within the health service, if you look at the Gwent health board and the way in which they have actually invested in different ways to run their estates, so they're actually investing, they've got a more environmental and efficient way, and it's actually saving money as well. I know they've got a joint venture with their partners to look at how they use some of their waste material as well. So, they're investing in different ways of working in the way that they use their whole estate, the way in which they use their staff resources and the way in which they organise all of their models of care.

Now, the other part that I think is really difficult, though, is staff, because what the Health Foundation also said was (a) you need to have continuing growth in budget in line with the growth of the economy, and that's a challenge—and that is really a challenge that starts at UK level—but the challenge for our staff in continued pay restraint is a real strain for people across the service who have not had a real-terms pay rise for a number of years, and they're getting more and more unhappy. It's affected morale and the willingness of NHS staff to continue to have their pay suppressed to meet the bottom line is not something we should rely on for evermore. That’s a real risk for all of us, and it doesn’t matter what part of the UK you’re in. So, the pay cap issue, and the statements the Government have made, and what will happen in the new year—because they’ve delayed the timescale on both evidence going in—. But then whether that’s going to be funded or not will make a really big difference to our ability to keep going. For me, that’s a really big risk factor.

10:10

Have you looked at some of your more generous policy areas to see whether some money can be saved there? Obviously, I’m thinking of universal free prescriptions, which I accept is a popular policy for some, but there’s scope for saving there, for example—for asking those who can pay to pay something.

Well, that gets us back into our regular arguments about whether there is a real financial saving to be made, and we have a straightforward disagreement on that. There's the cost and the reality. I’ll give you a real example. My wife is Irish. In the Irish system, the state system does not provide everything, so almost everyone who can afford it has a form of healthcare insurance. It doesn’t necessarily cover everything. If Dai were a GP in Ireland, people pay to see him for an appointment, and it’s more than €50, the going rate, to have your appointment. Then, you pay a much more realistic fee for your medication, and that means—and I know this from my own family—that people choose not to go to see the doctor, and, even if they have gone, they’re making choices about which prescription medication to actually go and acquire. That is a really difficult place to be, and that ends up affecting the choices that GPs make about what they’ll prescribe, because they think about the financial reality of the person in front of them. 

I would hope that GPs are prescribing the cheapest, most generic drug anyway, aren’t they?

But they’re actually then choosing whether they’ll prescribe a drug full stop, not on the basis of the health need of the person, but they’re thinking of the financial means of that person as well. It’s not just that, but, actually, there is a real cost in running a means test. The evidence we had at the time was that a means test did not deliver real money for the service, so you’re effectively running a means test that would pay for itself but not deliver a real amount of money back into the service, so—.

If we could have a means test that didn’t alter prescribing decisions, that didn’t mean that people were fearful of having their medication, that meant that people were prescribing the right drug for the right person, and it would deliver real money, we could have a different debate. But that isn’t where we are. So, it’s not an area that I’m interested in re-examining because I think there are very practical reasons not to do so. I appreciate there’s a difference of opinion between us on that, but that’s part of the reality.

I’ll try to move it on a bit. Okay. It’s not an area you’re prepared to consider. An area you really do have to consider is whether the four health boards that are in deficit at the moment can realistically get back into the black in a three-year cycle. Is that realistic?

It is realistic, but it’s a real challenge, and looking at each of those health boards and thinking about their collective impact on the system and individually what they’re able to do—. I had a very difficult and not enjoyable meeting with health board chairs at the start of the year when we saw their plans come in, and the plans across the whole service were just unacceptable. They would have taken all of the money and more that was available. So, we had to have a difficult conversation and say, ‘You can’t do this, and these plans aren’t going to be accepted. You need to go back and be realistic, both individually, but also you need to talk to each other so you’re not presenting plans that individually might make sense to you, but actually make no sense when it comes to being able to run the whole system’. Some of those health boards have managed to do better than others, and if I’m thinking about the four health boards in targeted intervention, the one that’s probably made the most progress is Cardiff and Vale. We think they will live within their controlled total. They won’t break even this year, but we think they’ll live within their controlled total, and they might do better.

I have more concerns about Abertawe Bro Morgannwg. If you’d asked me this question six months ago I’d have been more concerned than I am now. I think they’ve made real progress and there’s credit to the leadership in ABM for the progress they have made. I think we do now, with more confidence, expect them to live within their controlled total, and that’s important.

Hywel Dda is a challenge still. They’ve got real challenges and pressures. We think that, actually, the steps that we’ve taken on helping every health board to reduce the cost of agency and locums will help Hywel Dda and Betsi Cadwaladr in particular. But there is more for them to do.

The one that I am most concerned about is still Betsi Cadwaladr, though. The £50 million figure is not one that I recognise, and I don’t think that it was helpful to put that into the public domain as a worst-case scenario. But I am concerned about where they will get—. They are the health board that give me the most financial concern at this point, given what we thought for them at the outset. They’re also the best funded per head health board in the country, so it's about their ability to manage within the systems they currently have and their ability to change so they're not putting money into parts of their service that could change. That's again going back to the circle of  questions and conversations we were having with Rhun earlier on. So, there is a different picture between the four of those. Two of them I'm positive about their ability to live within their control totals. The third—Hywel Dda—I've got some concern about, and the fourth—Betsi—is my greatest area of concern. That's being perfectly honest, as I think I should be. 

10:15

Can I just ask you about that, because time is against us on this one? I just want to finish off, if that's okay. Obviously, Betsi Cadwaladr has been in special measures for a while. I think it would be helpful if the group could understand just one specific instance of where the intervention has actually really moved things on. So, that's the first question, and then I want to combine two other questions. One is: are you planning to keep anything back in this year's budget to meet shortfalls, should there be any in the year coming? There was about £95 million held back last year to help balance the budget. And, you know, if these health boards can't manage to meet your expectations, what are the consequences for them? 

In Betsi, we think they're making real progress in their out-of-hours service. We'll have—

Is that down to the special measures intervention? 

That was one of the areas for going into special measures. They've also significantly improved their conversation with their public, and in particular around their maternity services, but they have other areas where we know there is more progress to be made. This isn't a secret. This comes from the previous public reports from the regulators. We're expecting to have another one published and, of course, I'll have to take seriously what they say both about areas if they think there is progress made, and areas where they don't think there is enough progress being made.  

And what will you do if not enough progress is made? 

Well, that depends on the nature of the challenge and it depends on our ability to support the health board in doing so. The financial pressures were not a reason for the health board going into special measures, but my concern is that the inability to control their finances potentially will affect the organisation and its ability to focus on the areas of improvement that were required when it went into special measures. This is the point about having a rounded view of the whole organisation and seeing where it's made progress and where it hasn't, and what we then need to do either in terms of the clarity of our expectations, which I think are very clear, but also then the ability to support the health board to make further progress. So, if we have other people around there, sometimes there's a cost to doing that as well. So, it's an issue that occupies a great deal of my time, and it will continue to do so, as it should do.

I'm sure it does. Will you set a time frame on it? 

Well, I'll know more when I get the regulator's report, then I can be more upfront with you. I just don't want to set any hostages to fortune, because I think I need to be not circumspect, but I just think I need to be responsible about this. 

Okay, thank you. Can I ask this last one on capital? This is just a quick question, actually. Obviously, we've had evidence here that the scale of funds needed for maintenance, let alone innovation, in terms of capital spend is already pretty squeaky. What evidence did you take to make sure that the capital line in the MEG at the moment will be enough to meet just the current needs, let alone anything innovative?  

There's pressure on the capital budget as there is everywhere else. So, I can't and I won't say, 'Everything is fine, don't worry about it', because that's the reality of the choices that we're having to make, and we've spent lots of our capital in the transformational project around the Grange University Hospital. We've got a different model in building a new Velindre that's not just about building a new hospital, but is about transforming cancer services. And I recognise there's a pressure in the newer developments that we'd make and in actually restocking some of our equipment. So, for example, I managed to bring forward some of the money on imaging equipment to come into this year's budget, where I think we can make useful decisions. And there are honest challenges about how we manage and maintain the whole NHS estate. These are big choices and difficult choices for us to make, but, as with everything, there is a balance.

So, I'm not particularly surprised that people are raising concerns about maintenance—in every significant public estate there will always be concerns about maintenance—and as long as our capital budget continues to be attacked, then that will be the unfortunate reality of choices and balance we have to make. I'd like to give you a more upbeat picture, but I think I'm better off being honest with you now rather than saying one thing to get through today and be positive and then just giving an entirely different message in a few weeks' time. 

Symud ymlaen nawr i atal ac ymyrraeth gynnar yn y maes gofal cymdeithasol, ac mae Caroline Jones yn mynd i ofyn y cwestiynau. 

Moving on now to prevention and early intervention in social care, with questions from Caroline Jones. 

Diolch, Cadeirydd. Good morning. Given the constraints on social services budgets and pressures on non-statutory services provided by local authorities, many of which have a preventative function, how do you see the agenda on social care being taken forward, given that when local authorities have been asked to make cuts, they've made cuts from everywhere that they can visibly see possible? So, when you're asking for further cuts, it becomes more difficult year on year really, and my concern is that, once you're giving to one area, you're taking from another, and we've seen that with the provision of toilets, which have a knock-on effect for people who are disabled. Then, that also leads to people not being able to go out, for example to do their shopping. So, maybe they have to engage the employment of a carer. So, we are not really gaining; we are taking a step back. And, also, we ask people to take responsibility. We now have the highest level of child obesity, for example. So, we're asking people to take responsibility for their lives and, in doing so, we're taking away recreational facilities. We're taking away children's playing fields, because we're now building more and more. So, how can we work to overcome all of this?

10:20

Well, Caroline, it is the right question. I know everything seems to come back and start from the context we're in, but it is a real challenging context and it doesn't simply affect Welsh Government, or even one department. It permeates all the way down into local government, but also into third sector organisations who provide such an important part of the fabric of social care as well. So, this does make it more challenging, but, again, this is why I think it really does require a very different way of thinking and doing in response to this. And this doesn't mean necessarily saying, 'This must be cut in order to deliver that.' It does mean focusing on the outcomes we want for a better quality of life for people, for people living healthy, longer lives closer to their homes or in their homes, and being part of their community as active individuals. Now—

But we're not helping people, are we? If we're cutting, for example, the provision of toilets, we are enabling people to become more lonely, more isolated. That has a knock-on effect—mental health issues, and so on.

You are so right in the fact that part of the Social Services and Well-being (Wales) Act 2014 actually put in there a statutory requirement that those local authorities, social services, local partners should work across the piece to make sure that there is a requirement to actually deal with prevention. So, rather than people getting ill, getting isolated, all the issues that we are increasingly well aware of now with social isolation, which comes from very practical measures, such as the inability to go out and to be a part of the community because there may not be toilet facilities, there may not be good local transport to get to it—. It's wider than pure health and social care spending, but that's why we require, that's why we have that now statutory requirement on local authorities, on social services to actually deal with preventative measures. There is, by the way, also the aspect of how the regional partnership boards tie into this, and they are actually developing, as you're aware, population needs assessments within their areas so that they can identify very much what it is that their local populations require, then to produce a plan, and those plans are being developed as we speak there. And then they can use aspects—. Part of this is not finding huge new bundles of money at the end of the rainbow, but it's using things such as the integrated care fund to say, 'Well, how do we make those interventions?'

I mentioned Powys previously. The one I referred to there was an example as part of the Safe and Healthy Home and Home Safely service. Thirty-five individual patients with an unsafe home environment have been able to actually return home, stay at hospital and return faster, within three days, from hopsital—115 people receiving treatment and medication within their homes, 39 people benefiting from the 24/7 call-out. These are part of it, but it is also the wider issues that you rightly refer to there, with local authorities thinking cleverly, 'How do we make the well-being of our constituents, our citizens within our area, properly looked after in everything that we do?' And this is the cross-cutting agenda. This is the joined-up thinking we have to do. So, it's not simply health or social care. It's actually the wider issues of well-being, and there is a statutory requirement now for them to work on the ground to bring forward these proposals on how they look after people better. But it isn't easy—you're absolutely right. It sometimes looks, for people on the ground, I think, that the club that's being cut there or the toilet that's being closed there seems to run contrary. This is not without its challenges within the difficult financial climate that we're in.

10:25

But children and people in Brombil in Port Talbot were devastated that the playing field was taken away to have a school built on it. This playing field was used constantly in the evenings. The floodlights were there and children were engaging in activity and so were young people. So, was there nowhere else that we could have looked at so as not to devastate the lives of these young people? I'm sorry to land you in this, Huw, but it is importnat—children's natural wont is to play during their play time. Also, in the evenings, the cars were lined up and down the road where they were all engaged and it was wonderful to see, and then suddenly this huge school has taken away the whole of the area.

Caroline, your point is very accurate in that every Assembly Member here will recognise the picture that you're portraying of the way in which individual well-being and health and issues around preventative measures can be affected by very individual items on the floor. I think this is why it's incumbent on all of us—. None of us are leaders of local authorities and none of us run the local services, but I think we all do have a role to step up to the mark and work with them, I have to say, and not bully and not browbeat or whatever, because they are working under difficult circumstances, I have to say, financially as well. We need to try and work with them to say, 'Look, we have to approach this with a different way of working. What is the joined-up way across all your departments, whether it's housing, transport or whether it's children and youth servcies—all of these matters—in that you properly look after the adequate services for children, for adults and preventative well-being measures right across the piece?'

I can look, for example, in my own area. In fact, the previous committee I served on went for a visit up into the upper end of the Llynfi valley, which you'll know well and Suzy will know well. We looked there at the development of the Spirit of Llynfi Woodland. There you have a joined-up approach. It's based on the 2020 model; it's a recognition that there is a 20-year age difference in mortality from the Blaencaerau at the top of my constituency to Porthcawl and Ogmore-on-sea.

Chair, you will see this as well in terms of your surgeries and the people you deal with. We have to deal with that. But in this climate, how do we do that? So, the Spirit of the Llynfi Woodland is based on, not just creating a woodland with Natural Resources Wales, but on the GP clusters in the area working in a preventative way with schools, with local knitters and sewers groups and with walkers and striders groups to say, 'This is where we are going to refer people to'. It's way away from the 1980s model of the Oasis leisure centre and of GP referral to exercise on prescription for six weeks and then you fall off the edge. This is, 'Let's embed people in getting out there and get the mental and physical well-being benefits that flow from that'. But it's a joined-up approach and it's cross-cutting across services. Transport are involved, schools are involved and the local GPs are involved. The third sector are intimately involved. My wife is a member of the woodlands group that helps to drive this initiative as well. Sorry, I should have declared that before I started.

But every time—and you were right—we all look as individual Assembly Members at the instance of something that's cut, I think it's incumbent upon all of us to say that we need to work with our local authorities and say, 'Right, how are we cleverly going to deliver the outcomes that we want for all of our constituents? How are we going to deal with that 20-year mortality difference? How are we going to keep people looked-after better and closer to their homes?' Whilst, at the same time, we do have quite a traumatic financial settlement at the moment that they are having to live with.

Right, okay, much as I'd like to spend the time waxing lyrical about the charms of the upper Llynfi valley, this is a budget scrutiny situation, and, Suzy, you had a supplementary, hopefully on something financial.

Yes, it is absolutely on something financial. Apart from repeating the point that all of those outcomes will need to be evidenced by input at some point, I asked your predecessor, when we were talking about pooled budgets, whether the Social Services and Well-being (Wales) Act 2014 restricted pooling to just local authorities and the NHS. She said that she would come back to me to explain whether the Well-being of Future Generations (Wales) Act 2015 allowed pooling from other sources as well. I don't know whether that information has come back to you, but that would be several streams of money that we could follow.

10:30

It certainly goes in line with our approach, not just with the regional partnerships but with that idea of pooling, to make these clever interventions.

So that housing associations could pitch in—anyone.

Yes, indeed. So, it's an interesting line of thought, and I'll happily come back to you and write to you on that matter.

Yes. Could you, Huw, please elaborate on the new preventative integrated care fund being established? It's been suggested by WLGA and ADSS that the double running of some services may allow the savings to be reinvested back into the system. Can you tell me more about what you think about that and how that will evolve, really?

I've heard that same call for some sort of double running, in effect bringing additional money into it. I think both the Cabinet Secretary and I have been fairly clear that there is money already going into the system through the rebranded integrated care fund, formerly the intermediate care fund. That money is going in. It is helping to drive what I think is transformational change, and there are really good examples on the ground.

The idea of double running would, in essence, say we need to find some additional pot of money, again, to do this. I don't think there's something we have in our back pocket to do it. I think we are very, very keen, as part of the integrated care fund, to use that as the vehicle now for delivering the requirements of the well-being and social care Act, including the requirement to provide preventative services. We don't see the need for this double running of services. We think there's sufficient good practice now going on.

Going back to the point that Suzy raised earlier on, we're evaluating that. We're trying to see what the outcomes are, and then roll that out. Despite the challenges, I'm quite optimistic, actually, that this is being taken on, and taken on well by partners on the ground and by local authorities. We probably need to give it—sorry, in a very colloquial term—more welly now as we—[Laughter.] Chair, you're nodding. This is very much a Penclawdd and Swansea—

It's worth also pointing out, Suzy, in answer to your question, that this isn't just to do with integration and pooling of budgets. It is also to do with—and we have to emphasise this—this idea of co-production. It's not us telling local authorities, or you telling local authorities, or pointing fingers; it's actually saying, 'How do we deal with these issues? How do we deliver the outcomes together? Is there some funding that we have through the ICF that can help drive this change and lever this change? Well, in that case, we'll incentivise it.' But, ultimately, it's got to be a change in the way of thinking and doing on the ground, and it is to do with breaking down silos.

Good. Excellent. Some agility is required now on the part of questioners in terms of timing.

Well, I'm fully confident in your ability to respond on your feet, Members. So, NHS workforce—go on, Rhun.

And one cheeky one before that, again sticking on prevention. Just a word of explanation might be enough. The Sport Wales programme costs real-terms reduction of 23 per cent—can you explain that and how reducing funding into sport and physical activity fits into the preventative strategy?

I think this is part of the challenge of having to make budget choices, Rhun. I'd like to be able to tell you we're investing more money in sport as a Government, in the Sport Wales budget, but I can't do that, because we've just gone through a range of budget trade-offs in local authorities, recognising the impact on the field of health and health outcomes. So, if I could tell you there are consequence-free choices to make in a time of austerity, you'd either think I was a magician or a liar. So, that's why we're not doing it, because I am not magic, but nor do I want to look you in the face and lie to you.

I was hoping there'd be an innocent explanation, but it's a cut in funding, so that's fair enough. Onto NHS workforce pressures, we know that nursing is a particular area of shortage. ABMU told us that they have had 300 nursing vacancies over the past few years. Could you tell us about the tough choices that you've had to make on funding for training nurses—we need more of them, we're not able to have them—and how those challenges will be problematic when it comes to implementing safe nurse staffing levels?

We recognise this is a significant area of challenge. That's why, in the last three years, we've invested more and more in nurse training—22 per cent—then last year a 10 per cent increase in training places, and this year a 13 per cent increase in training places. Also we recognise the need for more midwives. That's why, last year, I announced we are going to train more than 40 per cent—an increase in midwifery training places. So, we are investing in the future as well as looking to recruit in the here and now. So, it isn't just one or the other. Actually, ABM have significantly improved their position from where they were a few years ago. They've still got challenges, as every health board does. Hywel Dda have done much better on nurse recruitment. That should help them in managing their budgetary position, so they won't need to fill those places through agencies—as many of them.

This is a UK-wide challenge. Actually, it is one of those areas where Brexit is actively making it more difficult, because it is reducing the supply of nurses coming in from Europe at a time when we already have challenges keeping people in the nursing profession and bringing them back. That isn't just an opinion from me; you've seen evidence from the Nursing and Midwifery Council on the number of registrations, recruitment figures—. So, this was already a very competitive marketplace to recruit nurses. It is now even more competitive and it really does highlight the success that we need to see from the ‘Train. Work. Live.’ campaign for nurses, and it highlights why we are investing more in nurse training.

The reason why, of course, we're investing is because we recognise we need to do it, but also we know, with the nurse staffing Act, that we've given people plenty of time to be in place for that and that will mean there are choices to be made. It's also why we're also investing, for example, in new ways to roll out the Act, but also the money that came from the budget agreement we reached on having more district nurses trained as well, to think about the different ways we look at the nursing workforce. Often the picture comes into our mind of nurses on a hospital ward as opposed to those nurses who work in the community, work in general practices and go out to people's homes. So, it is the whole picture that we're interested in.

10:35

Problems in recruiting, perhaps including because of Brexit, mean that training becomes more important. The bursary is an important part of what can attract a young man or woman to want to go into nurse training. Can you explain what budgetary decisions have been made on keeping the firm foundations of the bursary programme? 

Well, it's an area that obviously distinguishes us from England. We've made a choice to keep the bursary and in England they made a choice differently. And not just the choice to keep the bursary—in terms of the return, we expect people to take up the offer of work within the health service after they've completed their nurse training. So, we're guaranteeing a job for two years at the end of that training, and part of the reason is the understanding of who the nurse undergraduate group of people are. The average age is in their late twenties; men or women—mostly women, but men or women—who by that point are likely to have responsibilities and attachments to an area. Most people train as locally as possible because they want to work as locally as possible. So, maintaining the bursary isn't just about a values choice. It's also, I think, a very practical choice to make. But in investing that money into the bursary, that means there's money we can't spend somewhere else and then it goes back into where we started this—about the choices we make about what to invest in and what not to. 

One area of pressure on funding—and this is relevant for nursing and for doctors—is the significant amount of money being spent on locum and premium rate agency staff. What calculations have you made, in planning your budgets, on what could be saved over the medium term, through reviewing the spend on premium agency staff or locum staff, and how is that playing in, in any way, to your budgetary plans?

Well, the value and efficiency group that I previously mentioned was chaired by the chief exec of NHS and director general now, who is unfortunately not with us today—that group, in a conversation with the service, said they thought savings could be made on agency and locum fees, and I've agreed to do so. So, I have made a decision, which I've previously announced, and from this month onwards, we expect there to be real savings. We'll know more as we go forward, at the end of each quarter, about how much we're going to save and what that will then mean in planning for the year ahead.

I said earlier that we recognise the increase in agency and locum costs across the service. It's a problem across the UK. Our challenge—we're looking to meet it in a way where I think there's been some success already. It's also about changing our models of care so we don't have to support them with agency and locum fees. It's also where we're investing in training the future workforce. So, all of these things are linked to each other.

Of course, as we look at the future, we've got a new organisation being created—Health Education and Improvement Wales. We'll have, hopefully, an even more joined up and intelligent approach to training numbers, but that won't get away from the choices that need to be made. The £95 million that I invested in training the future workforce across not just nurses but a range of healthcare professionals—again, that was at the top end of what the NHS asked for. I understood, and they understood, that in doing that it would mean that there'd be other things that they'd have to find different ways of doing. But, we're investing in the future of the workforce, because otherwise, we know there's a bigger bill to pay on agency and locum fees.

10:40

Could you see us moving towards a position, certainly advocated by one political party represented around this table, of cutting the private-sector profit out of agency and locum staffing, i.e. doing it internally?

I think it's rather difficult for the NHS to say, 'We're going to run our own agency'. We run bank arrangements to try to help staff to move around in the nursing world, and we're looking at the potential for an all-Wales bank, which is interesting, and looking at how we can be smarter about rostering arrangements as well, which should make it not just about saving money, but actually about helping to improve people's work-life balance, understanding what they can and can't do and how they can opt in and out of rosters. So, e-rostering is actually really important, from an experience point of view for the service staff as well as in saving money.

I would hesitate before committing the health service or the Government to run an agency. I think the idea that we would set up a business, whether it was not for profit or not, to run that—I think that would cut across what we're trying to do on the way in which we want to make better use of our staff. I think that our ability to do so, and that of the staff to do so—I think it would be the wrong way to direct the resources within the service.

I understand some of the argument behind doing so, but, actually, our focus is on reducing locum and agency costs through the measures we've already announced, investing in our workforce and actually bringing people back into the workforce and helping to keep them there. I'm thinking about the arrangements to allow us to do so.

Also, one thing we need to to do, clearly, is train more doctors here in Wales. I think we need to train more in Cardiff and more in Swansea, and there is now development funding through this budget for developing medical training at Bangor. Could you update us on work that has been done since that budget on developing full undergraduate medical training in Bangor, including, hopefully, a centre for rural medical training?

There are active conversations with not just the current medical schools but other universities—plural—about how we could achieve this. Actually, I think there's potential to think about rural training in mid Wales—I'm thinking about Aberystwyth—and the ability to have links there as well. That's about how the programmes run in Cardiff and Swansea as well, and how you give people opportunities to have a longer placement in rural healthcare, because lots of people want to do that.

We actually know from the updated round of 'Train. Work. Live.' and the GP training and recruitment campaign that one of the figures there made a choice to come back to Wales because she wants to practise rural healthcare. She actually came back from New Zealand—this was someone who went away and came back, and she brought her husband from England as well. So, actually, we've gained an extra pair of hands here as well.

So, we are actively thinking about all of those things, including the north Wales question, and understanding what will be the best fit to take that forward. We want to be as ambitious as possible. We also have to work within the reality of what we can do, because I recognise that it's not just where people undertake their undergraduate training but where they have their postgraduate training that makes a real difference when people make their choices, as well as, then, how people feel they will be valued and trusted within that healthcare system. Obviously, the First Minister indicated yesterday that I expect, over the coming days, to be able to give a definitive update on the GP training programme. From the 91 per cent figure that we previously had we've made a bit more progress, so that's positive for us.

So, all of these things matter—all of them—in understanding how and where we get our doctors from within Wales, as well as the continuing need that we face to bring in doctors from outside Wales to want to come to train, work and live here as well.

Rŷm ni'n troi nawr at wariant ar iechyd meddwl—Caroline Jones.

We move on now, then, to spend on mental health—Caroline Jones.

Diolch, Gadeirydd. How confident are you that sufficient resources are available to meet the continuing pressures that health boards have highlighted on child and adolescent mental health services, mental health services and community health teams?

We've invested more money, again. Thinking about the last budget, we invested £20 million that went into the mental health ring fence. We've announced in the two-year budget deal—which the Assembly, I hope, will approve—an extra £40 million over two years, again, into the mental health ring fence. So, this is, as I've said on a number of occasions, the largest area of programme expenditure within the health service. It's made significant progress over the last few years, and it is a continuing area of focus. The challenge is not just about the resource going in but, of course, how that resource is used. I know the investment we've made in CAMHS has seen some improvement. There is more to do to get that to a more stable position from a performance point of view, but that is us committing more resources into the picture. So, I'm as confident as I can be without giving you a misleading impression that I can guarantee that all will be well, because there are challenges that each of us face and we know the health service faces, but we are committing more real-terms money.

Again, I think Wales has a good story to tell here, and not just about our conversation and continuing to make it more real so that people can recognise mental health as a health condition and the stigma around it to reduce, but also looking at England, where I think the commendable conversation that has taken place by the current and the previous Prime Minister on mental health is really positive—they talk about it. But they need to then commit the resources, and if you talk to colleagues in the English system, they'll say that the resources haven't matched the rhetoric yet. In Wales, real money has gone in. We should be proud of that and recognise that I can't give you categoric assurances about what that means because I can't tell you about the demand coming into the system.

What I can tell you is, and this is the point about transformation again, we continue to look at how we transform services in local healthcare as well. We continue to look at, for example, the social prescribing. That is, at least in part, because we think it does improve, and will improve, people's mental health and physical health as well. So, all of those low and intermediate levels matter every bit as much as the acute level in understanding the whole picture on treating and valuing the resource that needs to go into mental health to deliver better outcomes.

10:45

I understand the further investment of £20 million, but health boards in 2015-16 overspent by £54 million on this service. Therefore, the ring-fenced allocation was lower than what was spent by £54 million in that area. So, therefore, are we really giving additional money? Or is there even more money needed? I know every little bit helps, so to speak, but if you've overspent by £54 million and then you've had an investment of £20 million, how can we be sure, in the next year, that we're still not needing that further investment for services that already need improving upon?

I wouldn't say that the £20 million is 'Every little bit helps,' but also I think it's—. I don't think it's correct to say that they've overspent. It's actually that health boards—

It's actually that health boards are spending money than is the ring fence on mental health services, and that is a good thing. It is a good thing that health boards, in planning and running their services, are choosing to spend more than is in the ring fence on mental health services. That's a really positive place to be. Some of this will get into those areas where we think, 'This is mental health spending,' and other areas where we think, 'Actually, this will have an impact on people's mental health, but does it count within the ring fence?' And I'm not precious about those other areas, and I'm not looking for health boards to reduce that spending outside the ring fence on mental health services. We've got significant society-wide challenges in mental health—what's recognised about dementia, for example, which is a huge societal-wide challenge. We need to invest more; that goes across health and social care again. But I just don't think the £54 million over and above the ring fence is an overspend; that is a positive reflection from health boards about them choosing to spend more money in this area because they recognise the value of it. If you think about where we were five and 10 years ago, that's a really positive step forward.

Yes. I see it as a positive step, but what I'm saying is: do we need more investment yet again to keep level with the pressures and the needs of society—the increasing needs for mental health services?

Well, this goes back to the choices that everyone has to make. We've made a choice to prioritise this service. We're spending, we're putting more money into the ring fence—that's absolutely clear. We are not saying to health boards, 'That means you need to reduce the money you're spending outside the ring fence'—far from it. That is absolutely not the message of the Government. When it comes to demands that we face, well, that's part of our overall challenge and it's not just for the health service. Work makes a huge difference; that's why in 'Prosperity for All' you're seeing that mental health is a cross-Government priority. Mental health in the workplace is hugely important, from keeping people in work to getting them back into the workplace, and there's something about our relationship with employers that actually have financial support as well from the public purse. So, that's part of that new relationship we want to develop as well. So, it goes across a whole range of different fields, but different factors matter, and it is a truth that at times of economic stress and difficulty you're more likely to have people having mental health problems. So, actually, some of these demands are absolutely not within the gift of the health service, but we always have to try and manage the pressures that come through our front door.

10:50

Yes, okay. How is the NHS budget promoting reconfiguration and to what extent are health boards reconfiguring mental health services towards prevention and recovery?

Well, that's part of what I was saying about the low and intermediate need as well, and when you think about social prescribing as an area that is a key choice for us; it's a manifesto commitment; it's now in 'Prosperity for All' as well, so we will have a national social prescribing pilot, we think there'll be lots of learning there about improving and dealing with low and moderate mental health challenges, but also about prevention in the first place—primary prevention too. Not only that, but you see Valleys Steps as a good example in south Wales, which already existed; a good example, our well-being bond, appears to be making a difference. And in north Wales—I was in north Wales, in Flint, a few weeks ago and they're having a whole north Wales approach on social prescribing, and I'm really interested to see what—. Betsi's a health board that often takes a lot of flak, but actually, in this area, they're taking a lead approach within Wales, and I think there'll be lots that we can learn from their approach, and that isn't just the health board approach: they were launching their approach with local authorities; with the third sector; with individuals; with healthcare professionals. So there's a real recognition of more that we can do. Some of that, again, like I said, that partnership between the health service, the citizen and other actors as well. So that's partly about social prescribing, it's also about the money we invest with the third sector, it's also about how we equip citizens to be more resilient themselves as well. So, all of those areas of activity don't neatly fit within budget holes, but it's part of our policy approach, as well as our financial choices, to invest more in this area. 

And we need to increase Welsh language mental health provision. So, to what extent has the budget allocation taken this into account, given that the Welsh language ability within certain areas of the mental health workforce is as low as 1.9 per cent? 

Well, it's about making 'More than just words' real. So, our approach on 'More than just words', about making sure it's not a tokenistic or a non-existent choice, and this goes back into some of the questions about workforce, actually, and the future workforce and keeping people from Welsh-speaking areas and making sure that they either stay in Wales or that we bring them back to Wales. Because I know that lots of people, understandably, will choose to undertake training outside Wales, particularly doctors. There's an understanding why people want to go to a university outside Wales and not to live their whole life in one town or village, and I wouldn't try to discourage them from doing that: we need to be better at encouraging them to come back, as well as developing our current workforce. I've been in north Wales and I've met doctors from within the European Union and from outside the European Union who have come to Wales and then made a choice to learn Welsh because they recognise it's part of the care need, and it's also part of being part of the local community they've chosen to live in as well. This is, I think, as much about how health boards are expected to provide those opportunities or encourage staff to take them up, and it's also part of the whole care team as well, to make sure that a member of the care team is able to provide that because it is not—. I think it's important to restate this over and over again: this isn't just a preference. Welsh language provision is a real care need in health and social care for a number of people, and if we see it in those terms, that will help to drive, I think, the choices we'll make when investing in our staff that we have now, as well as our future staff as well.

Symud ymlaen, ac mae Dawn wedi bod yn amyneddgar iawn, felly Dawn Bowden.

Moving on, then, please, Dawn has been very patient, so we can move onto her questions now. 

Our prisons, I want to talk about, and understanding that the health boards have to commission the services for their prison population. But the health boards themselves in evidence to us said that they felt that funding for prison healthcare wasn't responsive to the changes in prison populations. So, I'm just wondering whether you're confident that the current mechanism for funding healthcare in prisons is responsive enough and is adequate to cover people on the secure estate, because following on from the questions from Caroline, the particular challenges in prisons are issues around mental health and drug abuse. So, just to hear your view on that, really.

Yes, I think this is a really difficult issue because we received a recurrent transfer in for prisoner healthcare, but it hasn't gone up. It's a bit over £2.5 million from the UK Government. We don't receive an annual uplift to take account of the changing needs of the prisoner population. We all know that lots of people who go into prison have a range of healthcare challenges with them already—physical and mental health and, in particular, substance misuse—and that is often an expensive issue to deal with. There are significant mental health challenges for lots of the prisoner population as well. With the new prison that is being created in north Wales, HMP Berwyn, there is a real challenge about making sure we get a proper location for that as well. The challenge will be that, if we get a transfer in on the same recurrent basis that looks at the need of the current prisoner population, we don't know how many more prisoners will be there in the future, because the story of prisons in the UK is that we continue to put more people into prison. So, actually, as much as I would disagree with David Lidington on a whole range of things, I've been encouraged by what he said about wanting to take a different approach to prisons, to crime, punishment and rehabilitation, and to public safety. The challenge will be whether that is made real, because that requires the UK Government to invest in other services like probation, for example. If we continue to see a growth in the number and the needs of the prison population, then I am honestly concerned about our ability to match the need that is there adequately, and I think it's a potential area of transferring responsibility that doesn't match need. I'd say honestly that the UK Government have some form on this.

10:55

Obviously, there is a crossover here between what is the UK responsibility and what is the Welsh Government's responsibility in the provision of healthcare. So, what discussions have taken place between Welsh Government and UK Government around this area—or are there discussions? Is it something that we should be looking to seek devolution of, accepting that prisons are a justice issue, a UK matter, but health provision is a devolved matter?

We provide healthcare for the prisoner population in Wales. There are conversations between Governments, there are conversations between the NHS and the Ministry of Justice in the running of prisons in this area. My concern is that those conversations don't lead to a realistic recognition of the healthcare need that is then matched by resource. We have a flat cash recurrent sum of money coming in, and I don't think that the needs of the prisoner population are operating on a flat cash basis.

It's just a point of clarification, really. I don't know about all the prisons in Wales, but my understanding for HMP Berwyn is that they actually employ their own medical staff and, therefore—. Obviously, for emergency things where prisoners might need to go outside, that would be Betsi Cadwaladr that would provide the service, but I thought, actually, that they provided their own. Have I misunderstood that? Is there a difference in the provision across Wales?

At present, yes, because in south Wales we've had a recurrent transfer, and that's a flat cash one. The future of healthcare provision in Berwyn will be that the expectation is that the health service in Wales will provide all of that service, and that there will be a transfer to recognise that. The problem is that if the transfer works on the same basis as in south Wales, if we get a flat cash transfer that recurs, actually that doesn't match need. To be fair, it isn't as though Wales is deliberately being done down on that basis. It's not as though the UK Government is putting lots of extra money into prisoner healthcare in England. This comes back to our central choices that all of us are being forced to make given the way that public expenditure is being managed. So, for me, it still goes back to austerity and to direct choices and direct consequences.

I was just checking if there were differences, that was all. Thank you, Chair.

Thank you, Chair. Just on substance misuse, which we've also just touched on, there are two substance misuse programmes that have seen substantial changes in this year's budget, but you have increased the ring-fenced allocation to local authorities around substance misuse. Are you confident that there are now sufficient resources to address what, again, is an increasing demand? Presumably, this also feeds in to the prison population stuff as well. Are you confident that the changes with those two programmes, but the general increase in allocation around substance misuse, is going to meet the demand?

I'm confident we've made the best possible choice that takes account of our current demand, and that goes back to the difficult budget choices. I agreed and I made the choice to end the funding of Operation Tarian and to indicate that the fund will come to an end for the school liaison programme with the police. I would have liked to have been able to continue those partnership arrangements, but the reality is that I could make a choice to do that and not to put more money into the front-line service when I know there are real pressures there. So, that's what we've done. Actually, the way in which that operates is that area planning boards will still be looking to direct where that service goes. So, it's health and local authorities working together with police in the room at the same time actually, so they're still part of the conversation about how we manage and how we deliver front-line services. So, that situation is about protecting front-line services that I've made, which has a different complement in another part of the budget. That, again, neatly encapsulates that point about trade-offs in the budget. The problem is that, because I can't predict for you, with certainty, what demand will look like as new services become available, as they have different health impacts in different parts of Wales, I can tell you I think we've made the best choice. What I can't and I won't do is say, 'This means everything will be fine', because I can't tell you if there’ll be a new form of new psychoactive substances on the streets of our country in another three weeks, three months or three years. We'll always need to look at what we can do, and investing more money in this area—being blunt, this isn't an area where there are lots of votes in it, but it's an area with lots of need, and it's part of our responsibility as a Government.

11:00

I think that final point you just made is an appropriate one, given the situation I think that a lot of us are facing in our constituencies at the moment, with the effects of Spice, for instance, and the unknown long-term impacts of those sorts of substances.

If I can move on, briefly, Chair, to longer term planning for social services—I guess this is your bat now, Huw. When the Welsh Local Government Association and the Association of Directors of Social Services spoke to us, they were calling for multi-year settlements. So, this is in line with what we're getting in the health service, where we've seen that that has had, in some areas, some significant benefits. Local authorities are now calling for that around social care. Do you have any thoughts and views on that and whether that could make a difference?

I do, Dawn. First of all, it's worth saying I understand why they're asking for this, because the more certainty and clarity you can provide on multi-year settlements further down the line, the better. But I think the WLGA and its constituent partners and every local authority also recognise that the finance Secretary's hands are tied here. He's been able to provide two-year in terms of revenue funding, and three-year in terms of capital, but he has, himself, no clarity beyond that from the UK Treasury. If he had that clarity we could be in a very different conversation. So, I absolutely get the sentiment of what they're asking for. It's sort of beyond my remit here, so I don't want to speak out of turn, but I know that the finance Secretary has made it clear that he's gone as far as he can in providing that two-year certainty on the revenue budget, three-year on the capital budget, and that does provide some—and I know it's been welcomed by the WLGA and its members—ability to think a bit more flexibly in their funding.

The other thing to say is that it's not unique to local government main expenditure groups. All departments are in the same situation because of the fact we don't have certainty from a UK Government perspective. So, we've gone, I think, as far as we can. Clearly, I'm trying to give an answer, and I don't want to overstep the mark because this is actually one for the Cabinet Secretary for local government as well. But it is pertinent, in terms of our wider discussions, because the more clarity we can have, the better, but we can only go so far with the certainty that we have, quite frankly.

I understand that, absolutely, but we've been able to do it for health, so, presumably, the—. Perhaps it's not fair to ask you, because you're not the finance Minister—I appreciate that—but we were able to introduce this for health, and I think what we've heard in evidence is a sense that local authorities feel that they're not being treated as favourably as the NHS in some areas.

It's always the risk that the big blocks of the public sector argue with and about each other, and I think that the financial challenge is driving some of that, and that is really difficult. I think there are two different points here. One is that, in previous terms of the Assembly, finance Ministers were able to indicate more than one year's worth of spending for local government and for the voluntary sector, and that was really helpful to plan. That's not the same as changing the law about financial duties within those years. That was really helpful, and people enjoyed it. We're not able to do that now because of the lack of clarity, as Huw set out. There was a different point, I guess, that I understand you're making, about changing the law so that health boards have a three-year cycle to try and meet their overall duty. That's something that the Government could consider, but that's a policy question that the finance Cabinet Secretary will need to consider, and also the local government Secretary as well, about what would that do. So, that's an open question, and I don't want to try and say, 'Here is the answer', ahead of the scrutiny that I'm sure Alun Davies will be looking forward to in a sister or brother committee.

All right. I just wanted to ask you for your views on the suggestion by Professor Gerry Holtham and Tegid Roberts on the levy for social care, suggesting that we have this separate levy to raise money for the future of social care on the basis that, you know, we don't have extra money coming in, it isn't sustainable if we just have flat-cash settlements. Any thoughts on that?

11:05

Well, the Cabinet Secretary to my right has already said publicly, actually, that we need something of an open and frank debate on this, because I think part of the theme of today's discussion is about how do we win the case that there is additional funding needed to meet the very complex and challenging needs of the population that we have throughout Wales, I have to say.

Now, it's good to see that the finance Secretary has actually, within the four proposals, based on the work of Gerry Holtham that underpinned it—. One of those four proposals for new and innovative taxes is around social care. A lot of the discussion has been around others, to do with plastics and this, that and the other, but it's floated. Now, that's probably the most challenging one, and he's acknowledged this, the finance Secretary, in taking it forward. It's probably the most complex, it will require the greatest degree of inter-governmental discussion about how it could be done. It requires a lot more work as well, I have to say, and a lot of public engagement to win the case, because we've seen too often before this issue—that the public have been walked up a hill on this and there's cross-party consensus growing around this sort of area, and then it falls apart as we hit elections and so on.

We need to think through this with the data, with the analysis. I think Gerry Holtham's work has provided a useful start on this. I think it is something that we need to be open to and have a frank discussion on. I don't think we're quite there yet in taking something forward on it, but, who knows, that's one for the finance Secretary to do, in discussion with the Cabinet Secretary here. But it is absolutely the discussion we should be having, because, in order to meet those needs, we have to be realistic about how much money is in that pot at the moment and the increasing demands on it, and, from a social care perspective, there is only one way those demands are going, and it's up and up. We can be cleverer in the way that we do this, and we've talked about that in previous answers. We can be cleverer about how we pull together—co-production of clever solutions—but, ultimately, the issue then becomes: is there sufficient money in the pot, and is there a willingness from policy makers and the public to move forward together on it?

I'm, personally—and I know the Cabinet Secretary is—pleased that that debate is now starting and it's out there. And I think, probably, we all have a responsibility to engage with it as well in a constructive and in an inquisitive way, but a constructive way, because the challenges are real. So, we have to think: is there an alternative way that we can provide a social care insurance model that could actually put some more money into the pot to assist with the sort of things we want to do, and could, actually, Wales be at the forefront of doing that?

There are two big challenges here: the governance one about the relationship with the benefits system, but also the intergenerational challenge of what is fair. If you are 60 and you expect to leave your working life at some point in the medium-term future, what you pay in will be different, potentially, to what someone in their 40s or in their 20s would. And, actually, there's a broader challenge for us to discuss what is intergenerational fairness, what does it look like, how does the taxation system deliver that, and then is that going to be enough to deliver the quality of care that we recognise we would all want for ourselves and our loved ones. So, it's a really important area that I do think needs to be addressed constructively and maturely.

Again, for us, being honest as politicians in the room, you can't do this a year before an election because people will go off and look to say things to win elections. And I'm not looking at anyone in particular because we're all grown-ups in the room about what happens in the run-up to an election. So, this period of our political cycle is the time we could have this conversation and try to reach a consensus across parties about what is possible and what we think the right answer for Wales is, because every year we put it off, the challenge gets greater and the scale of money we need to put into social services and scale of the need will get greater as well. So, it isn't just a Government challenge. It absolutely is one for all of us.

And it is significant that it features as one of the five priority themes within the 'Prosperity for All' strategy. There is a commitment to open the dialogue around this, but it cannot be done by top-table Ministers alone saying, 'This is the way forward'. That way lies disaster. It's step by step, with the finance Secretary looking at the detail, including the issues in terms of the impact on welfare and wider social security that the Cabinet Secretary referred to there. But also the public—we often forget in this the behavioural science of where is the public with this, and are they ready to consider this as well.

It's an interesting direction, really, isn't it, in terms of, again, the local authorities coming here and telling us that the integrated care fund has been very successful, for instance, but saying its continued success is going to depend on significantly increased funding, which we know isn't available. So, the continued success of that fund may well depend on these kinds of innovative, different ways of funding some of these services.

11:10

I agree with you, and it comes back to this point that, within what we have at the moment, we have to think quite radically differently, and it is a transformational agenda, what we're trying to do with the ICF and other matters to do with preventative care. We can do a lot with that; we shouldn't underestimate. It is difficult, but we can do a lot with it if we all step up to the mark and jointly decide we're going to do this, rather than pointing fingers.

But it does raise that interesting question on that rising trend. We know the challenges within social care and within healthcare more widely, all the things that we've talked about today. Is there an opportunity to look at how you can actually, with big public support as well as good evidence-based policy, lever in some additional funding into it that we knew was going towards achieving the outcomes we've talked about? Now, that is interesting. Meanwhile, we have to get on with doing what we can now, because this is not a definite; this will certainly not be anything overnight. It is very, very complex indeed. But I'm personally very glad, and I know the Cabinet Secretary is, that we are now having this discussion and doing it outside of the normal electoral cycle. I think, probably, that would be our appeal to everybody, to have that very mature debate around this and throw the ideas on the table and see whether the support is there and how something like this could be taken forward if there was a will.

Yes. What do you see the benefits of pooled benefits delivering and how confident are you that the arrangements for pooled budgets will be in place by April next year?

Lynne, thank you. We see the pooled budgets very much as an evolution of where we are. It's a natural progression of where we were with joint commissioning, the idea that the regional partnerships would come together to jointly identify the opportunities where they can commission shared services that are commonly held across their area. The focus isn't on doing it for its own sake, I have to say. It is on achieving value for money, without a doubt, and that's part of the conversation we've been having today, but it's also on those outcomes. So, using that, for example, to look at how we commission integrated care, I think, is a key one.

You asked how confident we are that it will be taken forward. Well, as you know, my predecessors in the role—. This was initially consulted on in 2015. There was feedback on the basis of that consultation that suggested that some additional time was needed, so that time was built into it, and, in fact, the establishment of these pooled funds has been moved back to April 2018. We think that is sufficient. There's been a lot of dialogue with partners on this. We think this is ample time now to plan and to implement these pooled budgets, but there is continuing dialogue going on with our officials to make sure that this can happen. We remain not just hopeful, but quietly confident that this can be delivered and will be delivered. But I know that my immediate predecessor, Rebecca Evans, in her statement on 10 October made it clear that we want to get there, working with people to actually make this happen. But if we get to that point—and we wouldn't want to, by the way, do this—then direct intervention would be needed. Now, I'm confident that we can actually get there. There is a will to do this. It's variable in different areas, I have to say, and in different partnerships, but we're working hard, collectively, to get there—so, quietly confident that we will get there on the pooled budgets.

But the one area of flexibility that Huw can't really discuss is Bridgend. [Laughter.] As we're discussing changing the footprints, we'll need to think about our approach to Bridgend and be pragmatic about it. We can't, on the one hand, say Bridgend must be in a pooled budget arrangement with Neath Port Talbot, Swansea and ABM health board and, at the same time, be consulting about moving them as well. We can't pull them in those different directions at the same time.

Sorry. But that would not be the right thing to do. So, that's an area where we need to have some pragmatic and sensible flexibility in those arrangements.

11:15

I think it’s worth saying, Lynne, as well that the work we’re doing with the regional partnerships on this—and it does vary in the approach slightly, and the impetus in each area—it’s very much being done with them. This is very much working with them collectively on the ground to see where there are obstacles in bringing this forward in time with the pooled budgets, and how we overcome them. That is intense work that’s going on.

Okay, thank you. Can I ask the Cabinet Secretary about the £50 million for waiting times? How do you intend to spend that, and what impact are you expecting to be delivered from it?

I’ve agreed a range of plans put forward by health boards for using that money to improve waiting times. I’m expecting that to deliver a material improvement again in the waiting times when we look at our figures in March next year—in particular  a range of our most challenging specialities, but there’ll still be a need to think about how this money doesn’t just deliver an improvement in waiting times, but also how the money is used to help give space for service transformation as well. Because, again, orthopaedics is another area where we know there are things people could do.

Some of the guidance that has been given—. You can think about Aneurin Bevan health board—they’ve seen real savings being delivered in efficiency terms as well, and better for the patient, who now no longer go to outpatient appointments they don’t need to go to. There’s a better use of money within the service. So, I’ve already signed up a range of those, and I’m happy to come back to the committee, if you like, to confirm the elements that I’ve already agreed—the sums of money—and then we’ll see the health boards actually deliver against those. As in the previous two years, if health boards provide a plan for extra money to direct their activity and they don’t deliver it, then there is the potential for me to claw some or all of that money back. It’s important that there’s the honesty and the discipline in the arrangement for that to happen.

Okay, thank you. Just finally, then, on sustainable development: what consideration did you give to the impact on sustainable development in the budget?

Well, that affects lots of our choices. For example, in capital terms, if you think about the new buildings that we’re having, well, obviously, when you have a new estate you have the opportunity to deliver a much more sustainable estate in doing so as well, not only in terms of the way the building functions, but also in conversation with colleagues about transport arrangements to and from those sites as well. I think you’ll see that not just in the Grange, but also in the primary care products, in the new Velindre as well, but also in the continuing ways in which we use some of that capital, as I said earlier, to deliver environmental improvements that are also actually about saving money as well. So, it’s part of how we run the service, and it is definitely a consideration in the choices we make not just at budget time, but then through the year, about the detail of some of those spending choices as well.

Okay. I’ve got two questions now—one from Dawn and one from Suzy. Dawn.

 Can I just ask you—thank you, Chair—going back to the integrated care fund, I think, whether you’ve done any work on looking at what the better care fund in England has provided? Because, again, the WLGA did reference that as being a best-practice model, but my cursory investigation found that, actually, there was a lot of criticism from the Local Government Association in England of the better care fund. Have you looked at that at all in terms of whether that could be a useful model for us, or not?

Well, I think it’s fair to say from a policy context we do look at what happens in other countries. Some people have prayed in aid of the better care fund to me about what we should do, and others have said directly, ‘Don’t do it. It’s not the right approach.’ So, we need to learn from what happened as opposed to, ‘It is always better somewhere else.’ Because people always want the element of it they would rather see happen, and it has affected not just the relationship between social care and health, but, actually, within health itself, the way it was set up. So, I don’t want to get too political in this session, but there are some who say it did not deliver what it was supposed to.

Okay. Suzy, you wanted to wrap up on a previous question.

Yes. Apologies, Cabinet Secretary—I don’t think I picked this up from you earlier. When I asked about what’s going to be happening in this year in terms of money that might be held back to balance the budget—there was £95 million last year—have you a figure in mind for this year that you may need to hold back?

Well, I’m thinking about a similar sort of sum. I won’t know until later in the year, as we see the reality of performance and the confidence that we can have in each of the health boards and trusts. But in holding some of that back, actually if health boards are able to start the next year in a better position, then, actually, we can use some of that money to deliver and to incentivise an accelerating service transformation. Some of them will have more opportunities than others next year, because, of course, we’ll have the parliamentary review with a range of challenges for all of us, in Government and outside, and the maturity that went into creating that parliamentary review will need to continue to demonstrate once it's been delivered, and all of the difficult choices it will provide us. But if we have an additional sum of money that doesn't need to go in and can be held back to cover the bottom line in the health service, then, actually, there are opportunities there for a faster pace in improvement. 

11:20

Okay, thank you. Can I just do a quick supplementary to that? Have you used all the £95 million from last year? 

Well, I won't know until the end of the year, and that rather depends on what happens over the rest of this quarter and the last quarter that we face. 

Okay. When we will get the results of the financial reviews of the deficits? Are they due to be published soon? 

The financial reviews that we've commissioned—they've gone through the board papers in the September board for each of the organisations in targeted intervention. I'm expecting that the zero-base view on Hywel Dda will go into their board papers in the new year, so that will be put into the public domain as well.  

Ocê, diolch yn fawr. Dyna ddiwedd ar y cwestiynau, felly a allaf i ddiolch yn fawr i Ysgrifennydd y Cabinet, Vaughan Gething, a hefyd i'r Gweinidog Gofal Cymdeithasol a Phlant, sef Huw Irranca-Davies, a hefyd y swyddogion, Alan Brace a Simon Dean, am eu presenoldeb? Diolch yn fawr i chi am y dystiolaeth ysgrifenedig ymlaen llaw, a hefyd ar lafar y bore yma. Gallaf ymhellach gyhoeddi y byddwch yn derbyn trawsgrifiad o'r trafodaethau er mwyn eu gwirio i wneud yn siŵr eu bod nhw'n ffeithiol gywir. Ond gyda hynny, fe wnawn ni symud ymlaen o'r eitem yma ymlaen i eitem 3. Diolch yn fawr iawn ichi gyd.  

Okay, thank you very much. That's the end of the questions, so can I thank the Cabinet Secretary, Vaughan Gething, and also the Minister for Children and Social Care, Huw Irranca-Davies, and also the officials, Alan Brace and Simon Dean, for being here today? Thank you very much for your written evidence provided in advance, and also for the oral evidence provided this morning. Can I please let you know also that you will have a transcript of our discussions to check for factual accuracy? With that, we're going to move on from this item to item 3. Thank you very much.  

3. Papurau i’w nodi
3. Papers to note

Eitem 3, i fy nghyd-Aelodau, ydy'r papurau i'w nodi. Byddwch chi wedi nodi eisoes sawl llythyr ac adroddiad ynglŷn â'n hymchwiliad ni i mewn i'r defnydd o feddyginiaeth wrthseicotig mewn cartrefi gofal. Mae'r rheini i'w nodi. Pawb yn hapus?    

Item 3, for my fellow Members, is the papers to note. You will have already noted some letters regarding our inquiry into the use of antipsychotic medication in care homes. These are to be noted. Everyone happy to do so?  

4. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod
4. Motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Symudwn ymlaen i eitem 4, a'r cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd ar gyfer eitem 5. Pawb yn hapus â hynny? Ydym. Diolch yn fawr. Felly, mi awn i fewn i sesiwn breifat. Diolch yn fawr.

Moving on to item 4, then, and the motion under Standing Order 17.42 to resolve to exclude the public for item 5. Is everyone content? Yes. Thank you very much. We will move into private session. Thank you. 

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 11:22.

Motion agreed.

The public part of the meeting ended at 11:22.