National Assembly for Wales

Welcome to the Culture, Welsh Language and Communications Committee. Item 1: introductions, apologies, substitutions and declarations of interest. Welcome to Members and witnesses, and also welcome to Dai Lloyd, who's here at the meeting in the virtue of his role as the Chair of the Health, Social Care and Sport Committee, which is clearly interested in the regulations we are considering here today. Do any Members have anything to declare? No. Thank you very much. Apologies and substitutions: we have no apologies or substitutions. We're just waiting for a couple of Members to join us.

We'll move on, therefore, to item 2, the Welsh Language Standards (No. 7) Regulations 2018, evidence session 1, Welsh NHS Confederation. What we're going to do in this item today is scrutinise the Welsh language standards in health, and there's a copy of the regulations and the memorandum available for Members. I'd like to say at the outset that we've been under a very tight timescale in relation to taking evidence regarding the Government's timetable in relation to this issue, and that has caused us a bit of a problem in relation to getting more people in for scrutiny, for example the Minister, or people from various other areas, and service users in Wales also, of course. So, I'd like to put that on the record, because if we had had more time, we would have liked to do more work on these regulations. I'm sure Members would agree with that.

We are moving on, therefore, now, to the first session. The witnesses are: Sue Ball, assistant director, workforce and organisational development, Aneurin Bevan university health board—it's quite a title there; Mandy Collins, board secretary, Powys teaching health board, Sian-Marie James, head of corporate office, Hywel Dda university health board; and Enfys Williams, manager of Welsh language services, Hywel Dda university health board. Thank you all very much for coming in to us today. If you're happy, we'll go straight into questions, but of course, we will try and listen to what you have to say as much as possible. I'm going to start with some questions about what your opinion is on these particular regulations. Do you agree with the regulations in the health area? And maybe you'd like to mention any concerns or comments that you have initially on that.

Thank you. Anyone else?

We use this video and we have produced another one this year, where we focus on patients. Now, Ioan's video—he was a two-year-old boy, who was being brought up in an entirely Welsh-speaking household, and I asked him to identify parts of his body, and he could only do that through the medium of Welsh. I then asked him in English and he continued to play. So, we're trying to demonstrate to our staff how important is it to use the language that's appropriate to the patient.

This year we've produced a video with a service user within mental health and learning disabilities, where the patient was very anxious, and he received therapy through the medium of English initially and then received therapy, by chance, through the medium of Welsh. We've assessed the difference that the therapy made. We're trying to demonstrate to our staff—. We show this videos in language awareness sessions and in assimilation sessions for new staff joining the health board. So, we're trying to convey how important it is to record the patient's language choice and to implement that wherever possible.

Okay. We have received evidence from, for example, meddwl.org and Cymdeithas yr Iaith, who have noted their concerns regarding these regulations, and that, as you have described there Enfys—. They are concerned that people would not be able to have those rights to use the Welsh language, and perhaps how they are treated, or how they access primary care specifically. Do you have an opinion on that? You welcome the fact that it's less bureaucratic and that it's more pragmatic. What is your opinion regarding how users will be able to engage with primary care?

Well, at the moment, we're a long way from being perfect, but I would ask the question: what service is perfect? At the moment, certainly within Hywel Dda, we record patients' language choice at the first point of contact. There is a unified assessment sheet for patients entering the hospital. It's not always possible to provide that language of choice throughout their time in hospital, but what we tell all members of staff is that, although we do not force anyone to speak Welsh all of the time—not everyone can learn a second language, we know that—but what we ask staff to do is to be entirely aware of the patient's language choice and know what to do when action is needed in that area, so that they're aware of the other staff on shift who are able to provide services in Welsh and that they flag that up during shift change-over and so on. So, there are processes in place, although they can't perhaps help directly, but they would assist the patient during their time in the hospital.

Do you think that training should go hand-in-hand with those regulations—that you can't do one without the other?

Okay, thank you. We'll move on to clinical consultations, and Mick Antoniw is leading on this. 

Okay, thanks. We are moving therefore to Dai Lloyd on clinical consultations—additional questions.

Yes, thank you, Chair. I don't know if I've mentioned before in this Assembly that I have been a GP for 38 years and have been looking at the language standards of our health service consistently, and I've come to the conclusion that the NHS are basically dragging their feet in relation to Welsh language provision. So, that's the context. And the further context, basically, is that fluency is the issue, isn't it? That is, people always say that you don't need to provide things in Welsh to our patients because everyone can speak English anyway. Well, there are different standards of fluency in English, which means exactly the point that you just made about people who aren't fluent in Welsh being unable to transfer important information—the same point is also true and perhaps more common with first-language Welsh speakers who have to use their English, but they are not entirely fluent in English, and therefore they also lose the ability to transfer that very important information, which is very important to their treatment, of course.

Some time ago now, I lost an election, so I went back to being a GP full-time a couple of years ago, and in a practice in Townhill, in Swansea, where there were 43 different languages. I am not fluent in 41 of those. So, we had to use LanguageLine. That is, I would ring up the LanguageLine centrally, in London somewhere, and they would provide a translator who would translate to whatever language—Urdu, Pashto, Bengali, whatever—immediately—and Arabic even. So, what do you think of that—that instant provision? What do you think about that in relation to the Welsh language? I know it would cost money, of course, but what do you think about having that fluency so that someone can explain in their first language exactly how they feel?

It's a matter of rights, but it's also a matter of improving the quality of treatment, of course, as we've heard from Enfys there. That is, you improve the quality of treatment. We come to a diagnosis, as doctors, 90 per cent of the time according to what the patient tells us about their history, and that history enables you to come to the conclusion quicker, if the patient is able to use the language they are most happy speaking. So, you could explore, if the Chair wanted to go after this, whether you could come to a quicker diagnosis using a Welsh language service, with somebody who speaks Welsh as their first language, using something like LanguageLine, or not. You could then save money on different tests such as blood tests, x-rays and ultrasound scans, for example, because, as I just said, you come to a diagnosis 90 per cent of the time on the basis of what the patient tells you. You could save money then, couldn't you, on all these different interventions, such as ultrasounds?

I know that a lot of these standards here are in relation to bilingual signage and so on, but, to be honest, I couldn't care less about that. I want a better service for the patient and what I want to guarantee from these standards is better standards and better provision for the patient to come to a diagnosis more quickly and to improve the quality of care. Yes, it's a matter of right, but it's also a matter of improving the quality of care as well. I do not see the language standards, as they are, providing that guarantee at all. So, with that as context, how do you respond to that initially? I'll go on to another question shortly.

It's difficult to find the middle ground, I think, between these regulations and the regulations laid in 2016 in terms of clinical consultations, but I do see the standards, as they are now, building on what we're already doing within the health board, whereby if a patient is a Welsh speaker and is more comfortable speaking Welsh, but the doctor cannot speak Welsh, then we use the team around the patient and the doctor. Perhaps a healthcare support worker or a nurse could sit in, and she would perhaps have that conversation with a patient to ensure that the patient understands what's going on. As it happens, I was in the accident and emergency department in Glangwili some two months ago, speaking to the head there, and he said that, very often, he can actually prevent patients having to stay in the hospital because they use the nurse, and they can see that the patient is more comfortable communicating through the medium of Welsh. So, he uses the staff around him for the benefit of that patient. So, I see the five-year plan—which is to be reviewed after three, where the health board has to make a statement, in terms of where we are—I see us building on what we are already doing.

There are examples within speech and language therapy. It's very difficult for us to recruit to our posts in the highest bands, the more specialist areas of speech and language therapy, such as problems with swallowing. But with a patient who's had a stroke, for example, or when dealing with a child, we would use an assistant therapist, who may be on band 4 or 5, to work with that patient, and then that therapist could actually oversee the process. So, we're looking at the team—the team is providing the bilingual service required by the patient, rather than individuals doing it.

Yes, of course, I understand that, and every time I visit different hospitals, I do see that Glangwili provides an excellent service in the Welsh language. Many of the nurses and doctors there, and of course many of the patients, speak Welsh, and you do get a natural service there. But of course that's not the experience everywhere. Because there is still that feeling that, especially with GPs in our more rural areas, you're lucky to have a doctor anyway, and now you want one who speaks Welsh as well. Well, that's asking too much, isn't it? People forget that basic point, that you can improve the standard of care by communicating in those naturally Welsh areas in their first language. So, yes, we're lucky to have a doctor, full stop, but we need to build on that. And that's the whole point of having these standards, but I don't see these standards as being bold enough to enable that. I understand you want to build on what happens, but we need some sort of trigger, to make sure that things happen quicker.

And also, the standards assist each other. You would look at the recruitment standards after that. For example, in primary care, there are roles that are developing continuously within GP surgeries—nurse practitioners, and so on—and those do tend to be more local people. So, the cohort of people you're recruiting, because they tend to be more local, you are using those people available to you. So, in those areas where you have a high percentage of Welsh speakers, you will be more likely to recruit a Welsh speaker to those posts. So, I do see these standards actually supporting each other, in order for us to develop and improve services.

And my final point, then, in terms of one of the questions I have here: as health boards, of course, you are supposed to be proactive. It's difficult to know sometimes whether someone can speak Welsh or not—whether a nurse, a doctor, or a patient, it's not always clear. So, you need to be proactive in that. Rather than insisting that the patient always has to ask for a Welsh-medium service, it needs to be visible and natural—and more than just posters and signs. I'm talking about a standard of care on a face-to-face level—something like these lanyards, of course, make it very clear that you're a Welsh speaker. So, as Welsh speakers, I suppose we can be a bit shy, and maybe we don't like to insist on having particular services, especially when maybe we're unwell, and under a lot of stress, and we don't want to insist on having a Welsh speaker on top of everything else. So, it needs to be made clear, and it needs to be a natural thing, to show that such a service is available, by being proactive. I think that's in the standards somewhere, but can you see that that's also important?

Without doubt. And I think that the 'More than just words' framework has set the foundations for that. Every health board is proactive. The nurses do have the Iaith Gwaith badge sewn into their uniforms. There are other areas of expertise also considering that approach. And in Hywel Dda we are working proactively with GP surgeries, and our challenge now is to work with the other independent contractors—within pharmacies, and within dentistry. But we do carry out an annual survey, where we ask GP surgeries how many Welsh speakers they have on their staff, whether they use the Iaith Gwaith produce, whether they display information bilingually, and what support they need from us as a health board. And then we do that on an annual basis, and seek to make improvements on the basis of that.

Thank you. I am aware of time—I'm sorry, Chair.

Thank you. Before bringing Siân Gwenllian in, because she's going to look at primary care also, I just wanted to ask in relation to out-patients. The regulations will include in-patients, but we have had evidence to say that, if you have an eating disorder, for example, you're not always admitted to hospital unless you are extremely ill, usually, and therefore we have had evidence showing concern that there won't be sufficient service for them through the medium of Welsh, if those out-patients don't fall within the scope of the regulations. What's your opinion on that?

Once again, as a health board, we wouldn't treat them any differently—a patient is a patient. 

But what if the regulations don't treat them in the same way? 

There are things in place already, where recording language choice happens. And, therefore, I do think that the greatest challenge perhaps will be for our own systems across the health service, across Wales. Systems don't communicate with each other. Patient notes aren't all available electronically. You could be going to a speech and language therapy clinic today, for example, where everything is recorded on paper, and in three days, you may be in A&E and your record will be electronic, and those hard copies won't have been fed in. 

The problem is of course that there is no obligation therefore to do that if they are out-patients, whereas if they're treated clinically on an in-patient basis there'll be different regulations. That's what I'm trying to ask. Systems are systems, of course, and different processes are required, but if they're not included within the scope of the regulations, then you could treat patients differently. 

It does note in other standards that however an individual approaches the service, be it a complaint or over the phone, that we are to record the language of choice. Therefore, I do think that other standards would deal with that. 

Fine. Siân.

Just quickly on the clinical consultations, and of course, we are all in agreement about the importance of having that consultation through the medium of the language that people feel happiest in. We're all in agreement that that's important. Perhaps where we disagree is how we get to that situation. Perhaps we can see that the face-to-face service just isn't there now in the standards as they are set out at the moment, and I understand there are pragmatic reasons for that. But do you think that there could have been contained within the regulations, as they are now, some sort of prioritisation in certain areas; maybe standards in relation to dementia patients, for example; maybe some standards in relation to children under five years of age, where the need is very, very clear? If there were such regulations in place, would that make your work of prioritising and workforce planning, for example, easier for the future?

The Government has set out seven priority groups already, and they are set out clearly in 'Mwy na geiriau'/'More than just words', so the framework is already there.

But they're not in the standards. Would those seven priority areas be useful? That's what I'm getting at. The standards themselves don't provide rights for people to have face-to-face services through the medium of Welsh. That right just isn't there. I understand that there are pragmatic reasons for that, but what I'm trying to do is to highlight the fact—. We have the 'Mwy na geiriau'/'More than just words' strategy, which states quite clearly that the need exists, but that isn't reflected in the standards.

And I was just wondering if there is middle ground between the regulations as they were presented in 2016 and what we have now. I know that you're not lawyers, but in a pragmatic sense, is there a means of prioritising within the standards? And if that were to be possible, would that facilitate your work in terms of workforce planning for the future? I saw you nodding there.

But if you were to ask for regulations on the seven priority groups as they are set out now, well, if you don't fall within those priority groups, then what would happen?

Yes, but what I'm saying is, because of the pragmatic situation, in that there aren't specialists across Wales speaking Welsh in every area, what about trying to prioritise, and prioritise within those standards, and look at those specific aspects, such as the seven sectors, or even choose two of them?

At the moment, there is nothing in the standards that gives the right to the people who are in need in that way, who may have a member of the family who has dementia, who know that that member of the family cannot communicate through the medium of English. If there was some consideration given to that in the standards themselves, I think it would strengthen the situation of Welsh speakers. That's what I'm trying to get to here, and I can see at least one of you agrees with me there, so that's great.

Moving on, therefore, to primary care, and once again, of course, the same problem arises here. The standards do not go into the area of primary care, and I'd like to just have your general opinion on that—the fact that the standards do not look at that area. Who'd like to begin? 

Yes, just following on from that point regarding GPs in their own practices. Of course, those GPs do have to comply with rights such as accessibility—wheelchair users and so forth—and also people who are hard of hearing and those who can't see well. Those fundamental aspects must be in place, even in GP practices that are independent, according to your definition. So why, therefore, does the Welsh language not have the same right? How could anyone justify fewer rights to the Welsh language compared with accessibility, for example? 

Is it a matter of interpretation perhaps, that the language is less important to the system if it isn't part of primary care regulations, because there are other processes in place in terms of accessibility and those are included in the contracts between the health boards and the independent contractors?  

But the standards to state that responsibilities would be placed in those contracts. So, it would be seen, therefore, in the same way. 

But it would be the health boards that would have to be accountable for that, rather than the contractors themselves. How would you feel about that? 

That would fall within the contracts like anything else within— 

So, you'd be comfortable with that. Okay. Siân.

In relation to the managed practices, therefore, the standards will apply to them but, of course, the face-to-face service isn't there in the new regulations, is it? And I come back to the same point: we are all in agreement that some patients will need to speak Welsh with their GP, and, again, it's not touched upon at all in the standards. Would there be any way of starting—again, I'm talking about prioritisation—in some geographical areas, for example, where it would have been possible? Or do you think there's a more creative way? Rather than just saying, 'No, they're not going to be in the standards', is there anything that could possibly be done within the standards, in your opinion, and does it need to be done? 

I appreciate that work that you do, but I wonder would it have been helpful for you to have more included within the standards themselves in relation to that? I understand that in your area it is a challenge, but I wonder whether the geographical issue should have been considered maybe, in relation to the standards being placed in certain areas, where perhaps it's more practical to do so and where the need really is there?

Just to broaden that point and to give a creative idea, perhaps the lawyers amongst us can help with a response to this. We're given to understand that one can add primary care providers to Schedule 6, for example bodies in receipt of over £400,000. Is that something that you believe could be implemented, or, again, do you think that it would be policy decision not to do that? We're given to understand that it's legally possible to do so. So, any practice given a contract worth over £400,000 could fall within the scope of the standards.

So, you'd be happy for it to be part of the contract, but then, with the standard, you weren't clear that you would be happy to have a standard—.

Regarding the 2016 regulations, as understood by the health boards, those standards were placed on the health boards and they were responsible therefore. If it was part of the contract, it would be different because it would be like everything else within the contract.

So, you are not accountable therefore under the contract?

No, we're not. They would be accountable to us.

So, you'd be happy with it because of that. Right. So, would you agree to a new standard as has been suggested, that you would not be accountable for, but that independent GPs would be accountable for? It would mean a change in the law, but that's just something of a rhetorical question for you.

As we've already mentioned, it's about the bilingual team rather than the individual. And what we strive to do in advertising posts now, rather than simply saying 'Welsh essential' or 'Welsh desirable', is to explain that if we are advertising Welsh-essential posts, what level of Welsh is required. Very often, a porter or a healthcare support worker will not have to write anything in Welsh; they just need to be able to converse through the medium of Welsh with a patient. Therefore, we designate what exactly is required for each post. That's worked very successfully in Hywel Dda.

We have a central appointments centre in Llanelli that serves the three counties, and on the team there, half the staff are Welsh speakers—they answer the phone and book appointments through the medium of Welsh. Half the team is able to do that, and the manager is of the firm belief that we need to continue with that. About a year ago, he had about four posts that needed to be filled. So, we agreed that three of them needed to be Welsh essential. Now, the manager wasn't particularly confident that he could appoint to the three posts, but what we did was to advertise for Welsh essential level 3 and explain what that meant and what was required for the post, and it was very successful, and the manager actually filled those three posts.

We are also taking advantage of the Work Welsh courses that have been available during this financial year and will continue into the next financial year. I know that all the health boards have taken advantage to some level in that regard. We've been using the online course, and we are very excited that there's going to be an online course specifically for health and care. We've also sent 12 of our staff on a beginners course, and eight on the intermediate course. And I know that Powys has also used the intensive Welsh course that is available, and we are very supportive of that.

There are other things available, too, within the health board. We promote apps that are available to staff who are already able to speak Welsh but perhaps lack confidence in doing so. And we're working very closely—or we will be working very closely with the Coleg Cymraeg Cenedlaethol during the next financial year, whereby we will be offering placements to students, and not just in the medical professions, but also in administrative posts, where we will be offering them placements and they will be mentored by Welsh speakers in the workplace. So, I do think that plans such as those that are in the pipeline are very exciting indeed.

But to return to primary care, as Aneurin Bevan are doing, we are undertaking a pilot project during the next financial year in the Aman Gwendraeth cluster, where we will be working with the cluster and with staff from the primary care team in the health board with the lead clinician and with a business officer who is located in the local menter iaith. We will be working with those surgeries within that cluster. Some of them are further ahead than others, perhaps, and we will be working with each individual surgery to see what their needs are, and hope to take advantage of the opportunities that will exist within Work Welsh within those clusters. We are also doing some work with Menter Iaith Gorllewin Sir Gâr. Within Carmarthenshire there are priority areas that have been identified, and therefore we are working—if there are any services within those priority areas, we are collaborating with the mentrau iaith and other organisations within those areas. So, we are trying to implement the bilingual skills strategy consistently across the board.

Do any Members have any further questions? No. Thank you very much for your evidence today. If there are any further questions, I hope it will be okay for us to write to you to confirm any answers, maybe. Thank you very much for coming in today.

We're going to have a five-minute break now. Thank you very much.

We are moving on now to item 3, the Welsh Language Standards (No. 7) Regulations (2018), evidence session 2. Dr Phil White and Dr Llion Davies from BMA Cymru Wales, and also Gwerfyl Wyn Roberts, former senior lecturer in health at Bangor University—welcome to you. And also, a last-minute addition—and welcome to you—Dr Emyr Humphreys, consultant. I was struggling to say your title in Welsh, so—

Consultant rheumatologist.

Rheumatologist. Okay. Great. Thank you for coming in today. We are continuing with our scrutiny of the regulations. A first question from me, then, please. Can I ask you for your general opinion on these regulations? Are they good? Are they weak? What would you do differently? Just a general question to find your opinion, please. I'm not sure who'd like to begin.  

Well, we welcome the use of the Welsh language, particularly where I work. In the north-west of Wales, Welsh is the main language, but some of my colleagues in south Wales are a little concerned that, if strict rules were to be implemented in terms of the language, it would make things more difficult for them. From my point of view, almost 100 per cent of the people working with me speak Welsh and three in five doctors speak Welsh. So we don't see it as a problem. But people are concerned if the regulations require them to employ Welsh speakers or even to provide someone to speak Welsh on their behalf. It would make things very difficult, and there may be some risks in terms of patient health. Because if you get second-hand information through an interpreter then you may lose some of the nuance of what the patient is saying. We've had an example of this recently where we have a Syrian refugee who's a patient, and we need someone to interpret on his behalf, and very often what he says and what the interpreter says is not exactly the same.

So the answer might be to have a standard to expand on the training for staff in the sector. For example, the RCN have something along those lines. Do you think it would be possible to get over those problems in relation to the compliance notices? Do you think you could discuss it with the commissioner, to say that perhaps there's a crisis in relation to GPs in one particular area, maybe, and maybe perhaps you could work around those problems?  

There's a huge GP crisis already—10 per cent of patients in north Wales now are in a practice that is managed by the health board, and they are finding it more and more difficult to find locums. You'd be grateful to have a doctor at all, whatever language he or she speaks, and that is the situation as it currently exists.  

Are there any other initial comments from the panel?

I would echo those comments. In an ideal world, we would like to see the option of having appointments through the medium of Welsh for whoever chooses that, and for them to deal with a Welsh speaker, but also people who can communicate at the right level. That's one of the things we're concerned about, not just in terms of GPs, but also in hospitals. If a patient wants an appointment, and if they need to change the language, then that's going to take more time, and there will be a cost for the service as a whole. So, there are a few things there that are a cause for concern.

Okay. Gwerfyl? Dr Emyr Humphreys?

Thank you very much. I, of course, welcome the amended draft, and the memorandum. I do feel that there are strengths there in relation to opportunities that are presented with regard to increasing the accountability of providers. There is an opportunity to increase the understanding of the public of what can be expected, and we can also see strengths there in relation to the hope for some strategic planning—maybe more creatively and on a more structural level—of opportunities, in particular to improve in relation to developing the workforce. But—and it's a very big 'but'—the concern I have here is: are these standards really going to transform the experience of Welsh-speaking patients, who are at a disadvantage? We don't need—. The evidence is there, isn't it? We know how key an issue this is. It's not just a matter of something additional when we're talking about language; it's a very core issue in relation to the service itself. There's an opportunity here to change things and to improve the quality of care for patients in Wales.

In my opinion, there are two basic weaknesses here: one in relation to the fact that the standards, as they appear at the moment, do not give the right to Welsh speakers to receive face-to-face services through the medium of Welsh. That's a very important weakness. The second issue, I would suggest, is that those standards are inconsistent in relation to what a patient could expect in Wales, because patients who have primary services, or even out-patients—. They do not have those rights. So, there are big weaknesses, most certainly, here. But, of course, improvements can be considered to the standards and that's a good thing.

Just to confirm, would you want these regulations to be passed as they are, or would it be on condition of there being changes? Clearly, we can't table amendments as a committee, but would it be on the condition that the Minister were to make amendments?

Personally, yes. Certainly.

Okay. Dr Emyr Humphreys.

Personally, I would—. I feel that it's very important that we—. The patient journey is very important for every patient who is treated. I think perhaps these standards do not reflect the patient journey if they wish to express themselves in Welsh—express their anxieties or their concerns. I think that there is an opportunity in relation to using ICT where patients are registered during their initial contact with GPs. With regard to emergency cases, the priority, of course, is the treatment, and there is no argument in regard to that. But we're talking here about elective treatment or day-to-day treatment in relation to GPs' work. There are opportunities here to use technology to improve the patient experience in relation to being referred to specialists who are confident in the use of Welsh to serve their patients.

With regard to the standards themselves, I think there is an obligation in relation to in-patients, but there isn’t one in relation to out-patients. I think, very often, in-patients who come in for elective procedures, for example, surgery, they will have been seen as an out-patient already. So, that language choice can be recorded at the very much earlier stage in that patient's journey. So, there are opportunities for patients to express their language preference and to improve the patient's experience through giving them that option if they would like to see a Welsh-speaking specialist, so that we use ICT and the systems we have. For example, there is a system called the Welsh clinical portal that is being developed across Wales, and language preference could be recorded on that in the same way as we record allergies or any clinical issues. That means that patients would have a better experience, and also hopefully would be more confident in their discussions with their specialists.

Another point in relation to out-patients is that I deal with many long-term conditions, and therefore there is an opportunity there to develop a relationship with the patient over a longer period, and, if it's possible to use a system of appropriate referral, that would improve things for the patient in general. So, I do think, with regard to recording language preference, that standard does need to be improved. There's an opportunity to do so. On the whole, I do welcome the standards, but I think there do need to be some amendments. 

Thank you. We'll move on to some questions on clinical consultations, and Siân Gwenllian. 

In relation to what you've already mentioned, can I ask perhaps you two to begin with what would your response be to what colleagues say about a lack of doctors, a lack of consultants, making it rather difficult to have a system where it's possible for someone to have a clinical consultation through the medium of Welsh? What is the solution? You've already mentioned having some kind of system. Could you elaborate?  

I'm saying we could use the current systems in order to record and to bring the patient and the appropriate doctor together, where possible. In terms of—

Do you think that there needs to be a standard to do that, or do we need to strengthen the standard on language of choice? 

I feel that there is an opportunity to strengthen the standard so that it would make it easier for a patient to request that, but this is from the point of view of treatment that isn't acute, which is—

So, let's say that an older person in my family needs a new hip, and that older person is also suffering dementia and needs to be able to communicate through the medium of Welsh with the consultant who's going to be carrying out the hip replacement. How would that work? Would that individual express a preference at the first point of contact, or would the family express that preference, to communicate through the medium of Welsh? That's already there. That right's already contained within the standard, but what isn't there is what happens next. As far as I can see, there is no purpose in saying that you want a Welsh language service and then there is no route for you to move forward with that. Do you see—and if I could ask you too—whether it would be practicable to have such a system where there is a real need for that individual to be able to communicate, where possible? Should such a standard be put in place so that that right is in place where it is possible to provide it within the limitations? 

Perhaps I could come in here, Siân. There's been a lot of discussion about this in relation to drawing up the strategic framework 'More than just words', and there was a feeling that some leadership was required maybe from the Government themselves in relation to creating some sort of protocol or strategy, or maybe a flow chart, for example, to show what the process is that someone follows when someone finds themselves in that type of situation. We do need some guidance for our practitioners in this area, and we also need to be consistent. As we've heard from our colleagues from the BMA, there are no Welsh-speaking practitioners available in every part of Wales in order to offer this type of service, but I think we can be creative in looking at this, and it is possible to put a protocol in place. After all, the health service is based on protocol, isn't it, in relation to risk management, for example. We are very familiar with working through flow charts in that respect, so the first thing to do would be to look at whether there is a Welsh-speaking doctor available, and can they be referred to that person. If not, is there another way of looking at the multidisciplinary team to see how maybe we could work on a more creative level? And there are many ways that someone could follow some sort of process in that respect. 

Back to the point in relation to a lack of workers—there is an attempt here in the standards, isn't there, to look at building on that workforce. And we do have to remember that we have a current workforce and also a future workforce. And it's great to think about the work that the Coleg Cymraeg Cenedlaethol is currently doing with our medical school in Swansea and in Cardiff, and our universities, in the health disciplines across Wales, to try and—. It's a slow process, of course, it's not going to happen overnight, but in years to come. And we are starting to see these graduates coming now out of our universities, who are able to work through the medium of Welsh and are committed to putting that active offer into place. So, when we look at the standards, it's very important for us to recognise that they will in place for many years, and we do have to look at them within the context of the future. 

Could I have your response too, then, to this possibility of having a standard on people's rights to a Welsh language clinical consultation, as a starting point? The standards say 'where appropriate, where practicable.' So, what's wrong in putting that as an objective in order to hasten the process of getting more practitioners into the system?

Well, in the north-west, you will have a job finding an orthopaedic surgeon who is Welsh-speaking. I don't think there is anyone from Britain in the north-west of Wales. I think they're all from India, Pakistan. We have one from Spain; we have one from Australia. And one of the things that makes it difficult for people thinking of moving to rural Wales is that perception they have that they would either have to learn Welsh or speak Welsh, and people don't apply for posts because of that. And that is the major risk. In terms—

So, in that case, the answer would be, 'Well, we can't do that then, because it's not practicable.' But that doesn't mean that it shouldn't be placed there as an objective, and maybe, in other areas, perhaps if we talked about—say if I wanted neurological treatment, for example, there is somebody in Walton, isn't there, who is a specialist there. Do you see what I am saying? That standard is an objective. If it's not possible, it's not possible. But, if it's not there as an objective, where do we go?

I've worked in the health service for over 40 years now and most of my colleagues, over the years, particularly in the hospital, have been from outside of the UK. India and Pakistan for the most part. Now, we can't get doctors from those nations because of Home Office reasons, and we see more and more coming from Europe. If you're going to put that additional burden of learning Welsh on top of everything else, or if they are under the impression that they have to communicate through the medium of Welsh—. It's difficult for some of these people to communicate in English. They have to go through the—

But, for the future—

For the future, I would like to see an adequate number of doctors trained. That's the biggest problem. We're not training enough doctors. We are training a percentage of women, and, of course, you need far more given nature, or given the fact that women take time off work. Therefore, you need more doctors than the Government's plans deliver in order to actually fill those posts. 

In terms of the agenda of learning the Welsh language, I'm a little concerned about what you're saying about it being a burden. If you sell the concept to people from India and Pakistan that learning the language is a positive step for them then surely they would have a different view, rather than seeing it as being something negative. 

Well, I'm talking about—. The people who are here do learn a bit of Welsh. We do have one ear, nose and throat surgeon from Bermuda who is quite fluent in Welsh. We also have a neurology doctor who is also fluent. And we have an English person in ENT who has learnt Welsh very well and is married to a Welsh woman. But the impression that people get when coming from outside is that, if you're coming to work, especially in north Wales, and the north-west Wales and rural areas specifically, you have to be able to speak Welsh. That's the impression.

But, of course, some would argue that the ability to speak Welsh in those areas is a skill—

An additional skill, yes, and the BMA has always said that if there are two doctors with equal qualifications and one speaks Welsh that that ability to speak Welsh is considered to be a very important issue. But, unfortunately, it seems to be pushing people the other way, as things stand, so it's important not to give the impression that you have to be able to speak Welsh.

Neil Hamilton has some additional questions.

having to start somewhere and how we take these things forward. So, that's the problem. We want this to happen, but how do we make it happen so that it doesn't have a negative impact on recruitment and attracting doctors and other staff into the NHS? How do we do it in that way? I think that's the problem. The purpose of having a standard is to have a level playing field, surely, so if we have one standard in Ceredigion and then—

How would all of that work?

It's not a problem in terms of GPs. In the north-west, a high percentage of GPs are Welsh speakers, and their staff are Welsh speakers too. Anyone who wants a service through the medium of Welsh in most practices will be able to access that and have their consultations through the medium of Welsh, but it is a big problem, as you've described—.

In a way, doesn't standard 110 refer to some sort of scheme or standard? I agree completely with Dr Llion Davies in relation to the fact that we must have standards—we can't just start having different standards for different places in Wales, but surely the standard would be the protocol, that particular scheme? The great concern that I have at the moment is that the standard looks like something that we might reach in five years or so. Practitioners need a standard and need guidance immediately: 'What do I do when I come across the situation that Siân has described there?' That situation is very, very common, isn't it? So, that is what we need.

So, possibly, the standard might be to what extent someone would monitor, and to what extent the body can fulfil that particular standard. And perhaps that standard might mean, in north Wales, that it would be possible very often to offer that face-to-face consultation through the medium of Welsh. Perhaps in other areas of Wales, maybe initially, in some years, that won't be possible everywhere. But maybe, as time goes on, it might be possible for everyone to reach that standard. So, it's something to build on, isn't it? It's something to aim for, but that the standard is there, and possibly there are different bodies in different areas and specialisms that would be able to reach the standard quicker than others. I'm not sure how that works legally; we'd have to look further at that.

We'll certainly look into it. Thank you for that contribution. Emyr.

Just from our point of view, we work within clinical networks, and I do think that one could use the Welsh language within those networks. So, I would agree with the comments already made.

There is an opportunity to change that, and the medical school, as we know, is working very hard in partnership with the Coleg Cymraeg Cenedlaethol. I don't know if you heard about that incredible case where they were in Glan Llyn, working with doctors, and they succeeded to attract Welsh-speaking doctors from outside Wales. There were hundreds of them there, all working together through the medium of Welsh. So, there is change afoot in the medical school, and that's very positive.

One point that Dr White raised, which concerns me a little—when one talks about risks. I must make the point: there are risks. We know that there are risks if Welsh speakers don't receive a service through the medium of Welsh—there are risks to their health. We must ensure that that point is made.

In relation to discussing conditions using the Welsh language in a medical sense, I'd like to draw your attention to the medical association's work, which meets regularly and hold activities in the Eisteddfod. They discuss—. There are doctors outside of Wales who are Welsh speakers, but they also give lectures through the medium of Welsh in medicine, and therefore they do use the scientific medical language as well as the Welsh language used to discuss with patients. So, I do feel that there is change afoot. I have seen an increase in relation to medical students who are members of the BMA, and I think that is to be welcomed. I think the workforce will change over the next 10 years.

One further point I'd like to raise on the workforce is that there are concerns expressed often about Welsh speakers' willingness to use the Welsh language in the workplace. There is a lack of confidence, and we're aware of that. There are a number of health boards who are now working on that to seek to demonstrate to Welsh speakers that you don't need to have a full grasp of the technical language. You don't need university-standard Welsh to communicate with patients. We must ensure that that message permeates through the health service because there is a risk that Welsh speakers won't feel sufficiently confident to use their Welsh language skills in the workplace. Now, one can make a difference in just welcoming a patient, and even saying a few words in Welsh, just to start that process of creating a relationship with a patient. So, we have the disciplinary language, and we have the clinical language that we use between doctors, but there's also the patient's language, and that depends on his or her choice, doesn't it? We have to adapt our own use of language so that we are understood by our patients, and to listen to patients.

Okay, thank you. Mick Antoniw.

Gwerfyl had indicated that she wanted to—.  

Yes, just to look at the wider picture, I wondered if we should be considering the potential now for the new health body Health Education and Improvement Wales, which comes into force in April, to look at these questions of workforce planning. We do have to remember that Welsh students are taking their fees with them over the border to England and that causes a problem, does it not? In Canada, there has been a big investment in students, and up to 90 per cent of them do come back to work in their local areas. Wouldn't that be an excellent thing for us to aim towards in Wales? There's wider work to be done, isn't there, which is outwith this area? But I'm trying to show the potential of being able to build upon the workforce in Wales—moving on from this situation, which, as you have shown, is far from acceptable, to be honest. 

Given that, of course, language is something that someone can learn and that's encouraging, isn't it? So, although we see ourselves welcoming these doctors from over the border and doctors from overseas, isn't it excellent to see that many of them are prepared to learn and to start this learning journey? And it is a journey, isn't it, to learn a language? But, as I mentioned, even a few words to begin with can help the patient have that experience, which is so, so important. 

More questions now, from Jack Sargeant. 

But we do know that the right now exists and that the medical school welcomes students to undertake their interviews through the medium of Welsh. So, things have changed, and thank goodness for that. 

In terms of recruitment, I would like to see some evidence—. I do think that we need to be guarded here, in that, on the one hand we are hearing people's perceptions about what they think might happen, when we need to ask the question whether there is any specific data that would demonstrate to us that this is going to have a real impact on recruitment. That's what I'd like to see, certainly.

Sorry, Jack, Siân just wants to come in at this point, if that's okay.

Yes, to follow that point, if I may. I think what's happened in the area of local authorities, for example, is that the fact that you have a standard that gives rights to Welsh speakers has then created a career path for people. It works in a cyclical motion. You set that standard for people to have that right, but then those bodies have to make a concerted effort to recruit people with those specific skills. So, having that standard can work in a positive way in order to recruit people.

Certainly, I would agree with that. 'They come out of the woodwork', as the saying goes. It's incredible. I've had experience of that in my work, in seeing people applying for posts because we have created that post in a way that is constructive and invites people with those Welsh language skills to apply, while making sure that we do not present a threat, that we welcome skills of any level, that there is an opportunity to build on your skills, and so on. It's about making it easy for people, rather than being a threat.

I would like to look at the flip side of the coin and turn the argument on its head and look at it from the point of view of service user experience. This is the first point of contact with the NHS, and sometimes the only point of contact for service users across Wales is their GP surgery. I'll return to the fact that the quality of care is centrally important and language is so crucial to that. So, 'How does one strike that balance and compromise?' I think would be the major question here. How does one build for the future in order to create the best possible service?

I think the question is, 'Do you think it should be within the contract or should it be a standard—?'

Certainly it should be a standard. That would then enable the commissioner to look at the issue. If it's in the contract, it comes under different legislation. So, the standard would give 'the standard' in relation to this.

I assume that—. What's the BMA's opinion on this?

Are you talking here in terms of contractors?

No, I was asking whether it should be within the contract or within a standard. I asked the first panel or explained that we were given to understand that this could be placed within a standard in terms of an addition to Schedule 6, so that if you were in receipt of over £400,000 as an independent contractor, you could be included within the scope of the standards. It's not the case at the moment, but if there were to be a change you could be captured under that system. Would that be something that you would agree with?

Are you talking of a standard to aim at—something for the future?

Well, it's not part of the standards at the moment, but some people have told us in their evidence that it's not sufficient that there isn't such a standard in place on independent contractors, and we've found that it would be possible, in the future, to have such an additional standard made by Government whereby, if you are in receipt of over £400,000, then you would be captured under the standards regime.

I wouldn't be happy with any enforcement in terms of contractors having to do anything in terms of—. The health board could provide things for us, for example interpreters and translators on so on, but if you make it a burden on the contractor himself, then I think you will see people disappearing from the system. I think we've seen this already and then you would be in far worse a position than you are currently in.

Okay. Sorry. Any further questions in relation to this particular section or any further comments in relation to these issues? I think it was just an important point to note the difference, if you're a contractor, between the contract if it's managed by the health boards compared with—. Well, most of them, as I understand it, are in the independent sector, so they wouldn't come under the auspices of this particular standard. Would you like to see a change to that or would you rather not see a change?

That isn't adequate in my view, in that there isn't a right for patients. Let's be honest, it's a small percentage at the moment who aren't in that independent sector. Most patients in Wales—in terms of the standards as they currently exist—would have no right to a face-to-face service through the medium of Welsh in primary care settings, and for me, that is entirely inadequate.

But the difficult question for our committee is: would you want to agree to those regulations, and make changes in the future, or because this is something that's an important issue that some people feel should be there, would you recommend going against those particular standards as they stand and look to change them?' That's the question for us as politicians, but it would be helpful to hear your opinion on that.

It's a shame, because what we have here is a golden opportunity: an incredible opportunity to be move things forward. 'Mwy na geiriau'/'More than just words' has been a very good policy, but there is no enforcement there. Personally, from my own point of view, I wouldn't vote for in favour of these standards as they currently stand.

Improvements need to be made.

Improvements need to be made. Okay, thanks.

It's trying to find our way through this fog—that's the problem, isn't it? Suzy Davies.

Just a couple of questions to finish. Some of you have had concerns in relation to documentation and the discretion that the health boards have to decide on what documents to produce bilingually or otherwise. Would you like to add to that and explain your concerns?

From my point of view, the philosophy has changed. The active offer places a responsibility on the institution rather than returning once again to putting the pressure on the patient to request that service. So, that's what the active offer is: it's a huge shift, a cultural shift, a change of mindset.

We know that patients who speak a minority language aren't going to ask for the service through the medium of that language. They aren't going to express that desire because they feel anxious; they don't want to make a fuss; they don't want to draw attention to themselves, particularly when they are on the spot in that particular place. If one were to ask the organisation, or the institution, to make that decision on the basis of what they think the need is, then I think there is a real risk that those organisations won't provide the documentation that is truly necessary, if you understand what I mean.

Yes. Can I just ask, then, is it possible to solve that problem by just asking at the first point of contact with the patient, rather than through the standards? I'm just trying to see what would be the best way forward of solving the problem.

In my view, every document that is made available to the service user should be bilingual because that is what provides the choice for the patient. And let's be honest, the documents for patients will be documents that we will have available on the ground already. I think what these standards refer to is the more technical documentation, which is documentation used internally rather than that front-facing documentation.

Which would confuse the patient really. So, we're not talking about posters and general things here, just things that are specific to that patient. Okay.

The last thing I'd like to ask is: it's possible to have a standard that looks different in every region in Wales, so, how do the standards work in the south-west—sorry, I should say the north-west; I'm sorry, second language—which may be different to what you see in the south-east, for example? Is that going to be a problem for people to understand what those rights are? It seems to me that it depends where you are in Wales at any moment in time.

I think standards should apply across Wales because patients move from place to place in Wales and they should have that same right to the service through the medium of Welsh. Let's stay that they've moved from Bangor, or somewhere else in north Wales, down to south Wales. I do think that there are sufficient numbers of Welsh-speaking staff in place, and I think it's important that right is in place for them if they choose to use it. The main thing is that they have the appropriate clinical care, of course, but this is something that is a right that they should have, and they should be able to request that through the medium of Welsh.

Can I just come in there?

Yes, of course. You can do better than me, I think.

In the short term, if there was a standard that stated that everyone has the right to have a clinical consultation through the medium of Welsh—if there was a standard that stated that—it would then be up to the commissioner to interpret that in relation to various authorities across Wales. I would suspect that the commissioner would interpret that for Betsi Cadwaladr, perhaps, in a different way to maybe some of the boards in south Wales. So, do you see that there's a way of doing that? That is, the basic standard would be there, but the commissioner, then—. But if it's not there at all, there's nothing for the commissioner to work with. That's the point, I think, isn't it?

Well, yes, that's half the point, yes, but the other half is: is this too complex for people to understand what their rights are? Because it depends where they are.

Yes.

I think it provides clarity, to be honest with you. We must bear in my mind that the commissioner will regularly monitor these issues, and again, it's an opportunity to build and to assist and promote those areas where they perhaps aren't reaching the standard in this year, but, perhaps in two years' time, there will be plans in place where they will be able to deliver that standard, and then we will be moving forward in Wales so that there will be fewer and fewer differences geographically. We have seen that happening in the south-east already, and I see that as being encouraging, if truth be told.

Okay. Thank you very much.

Okay, if there are no further questions, then we'll bring the session to an end. Thank you very much for coming in to give evidence, and to Dr Emyr Humphreys for coming in at short notice also. Thank you for that. I hope that you will follow the developments in relation to the standards. Thank you very much.

We are going to take a break—. No, sorry. I'm just going to look at the written responses before we take a break. So, there are written responses to be noted from Cymdeithas yr Iaith Gymraeg, Meddwl.org, the Royal College of General Practitioners. Are there any comments on the written responses from Members? No.

And then, item 5, a motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting. Is everyone happy? Thank you very much.