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

Health, Social Care and Sport Committee - Fifth Senedd

05/07/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns
Caroline Jones
Dai Lloyd Cadeirydd y Pwyllgor
Committee Chair
Dawn Bowden
Jayne Bryant
Julie Morgan
Lynne Neagle
Rhun ap Iorwerth

Y rhai eraill a oedd yn bresennol

Others in Attendance

Dr Quentin Sandifer Cyfarwyddwr Gweithredol y Gwasanaeth Iechyd Cyhoeddus / Cyfarwyddwr Meddygol, Iechyd Cyhoeddus Cymru
Executive Director of Public Health Service/Medical Director, Public Health Wales
Dr Tracey Cooper Prif Weithredwr Iechyd Cyhoeddus Cymru
Chief Executive, Public Health Wales
Huw George Dirprwy Brif Weithredwr, Cyfarwyddwr Gweithredol Gweithrediadau a Chyllid, Iechyd Cyhoeddus Cymru
Deputy CEO, Executive Director of Operations and Finance, Public Health Wales

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Catherine Hunt Dirprwy Glerc
Deputy Clerk
Claire Morris Clerc
Clerk
Sarah Hatherley 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 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 9:31.

The meeting began at 9:31.

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

Croeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. A gaf i estyn croeso i'm cyd-Aelodau? Mae pawb yn bresennol y bore yma, felly nid oes unrhyw ymddiheuriadau. Gallaf ymhellach egluro bod y cyfarfod yma yn ddwyieithog. Gellir defnyddio'r 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. Os bydd y larwm tân yn canu, dylid dilyn cyfarwyddiadau'r tywyswyr, os bydd hynny yn digwydd. 

Welcome, everyone, to the latest meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales. May I extend a welcome to my fellow Members? Everyone is present today, so there are no apologies. May I also explain that this meeting is bilingual? Headsets are available to hear simultaneous translation from Welsh to English on channel 1, or to hear the original contributions better on channel 2. If the alarm should sound this morning, you should follow the instructions of the ushers, if that should happen. 

2. Craffu cyffredinol: Sesiwn dystiolaeth gyda Iechyd Cyhoeddus Cymru
2. General scrutiny: Evidence session with Public Health Wales

Symudwn syth ymlaen, felly, i eitem 2 ar ein hagenda y bore yma, a chraffu ar Iechyd Cyhoeddus Cymru. Ac i'r perwyl yna, rwy'n falch iawn o groesawu Dr Tracey Cooper, prif weithredwr Iechyd Cyhoeddus Cymru, yn ogystal â Huw George, dirprwy brif weithredwr a chyfarwyddwr gweithredol gweithrediadau a chyllid, ac hefyd Dr Quentin Sandifer, cyfarwyddwr gweithredol gwasanaethau iechyd cyhoeddus a chyfarwyddwr meddygol. Diolch yn fawr iawn i chi am eich presenoldeb. Diolch yn fawr iawn hefyd am baratoi yr adroddiad swmpus o'n blaenau. Fel rwyf wedi ei grybwyll eisoes, mae Aelodau wedi darllen pob gair mewn manylder. Felly, gyda'ch caniatâd ac fel sy'n draddodiadol yn y pwyllgor yma, awn yn syth mewn i gwestiynau, ac mae'r cwestiynau cyntaf o dan ofal Rhun ap Iorwerth.  

We move straight on, therefore, to item 2 this morning, which is our general scrutiny of Public Health Wales. And to that end, I'm very happy to welcome Dr Tracey Cooper, who is the chief executive of Public Health Wales, as well as Huw George, who is deputy CEO and executive director of operations and finance, and also Dr Quentin Sandifer, executive director of public health services and medical director. Thank you very much for your attendance. Thank you very much for your written submission and this comprehensive report in front of us. As we've already mentioned, Members have read every word in detail. So, as is customary in this committee, we will go straight into questions, and the first question comes from Rhun ap Iorwerth.  

Bore da i'r tri ohonoch chi, a diolch am ddod atom ni i'r pwyllgor y bore yma. Rwyf am gychwyn efo cwestiwn cyffredinol a gofyn ichi fod mor hunanfeirniadol ag ydych chi'n teimlo sy'n addas i fod. Rydym yn gwybod beth ydy rôl Iechyd Cyhoeddus Cymru: i fod yn llais awdurdodol ar iechyd y cyhoedd yng Nghymru. Pa mor dda ydych chi'n meddwl ydych chi ar wireddu'r swyddogaeth honno?  

Good morning to all three of you, and thank you for joining us at the committee this morning. I'd like to begin with a general question and ask you to be as self-critical as you feel is appropriate. We know what the role of Public Health Wales is, which is to be an authoritative voice on public health in Wales. How well do you think you are delivering on that function? 

Bore da. If I may, Chair—a great question to open with—if I could just recognise that it's the seventieth birthday of the NHS today, so it's a good milestone to challenge the impact that we're having.

Being self-critical, I think we've been on a journey. We were established in 2009, and we have grown, as you've seen with the documentation, quite significantly since then. Over the last two and a half years, and particularly the last year, we have spent an increasing time challenging ourselves. So, we've undertaken a number of strategic reviews of our screening programmes, because there's a lot of change coming down the line. I'm sure Quentin may want to say something about that. We have new technologies in screening and we've got more to do to make sure that we can encourage uptake in some of the harder-to-reach parts of Wales. We've also reviewed all our health intelligence, which is where we provide information to help people plan better and make decisions better. And last year, we invited, through an international association for national public health institutes, a peer-to-peer review of us. So, we had colleagues—my equivalents from Finland, from Quebec, from Slovenia and from the Robert Koch Institute in Germany—to assess our effectiveness as a national public health institute, and the report is going to the board this month. 

So, it's been very helpful for us to say, 'How can we be the best that we can be from the background that we've come from?' We think it's particularly important, because we've got a lot of challenges, obviously; we read it and hear it every day. So, with the resources that we have and whatever resources we're going to have in the future, what we've been focusing on in the last year to 18 months is providing the evidence that's easily understandable that shows where the most impact is to improve health and well-being—whether it's housing, whether it's employment, whether it's communities, the NHS—and what return on investment we get for that. In 2016—we've got fantastic people across Public Health Wales—we produced a report called 'Making a Difference', which we've referred to, and that was pre Assembly Government election, to hand over to whoever was going to be in the new Government, and other parties, with the 10 most important prevention interventions that yield the biggest impact and the biggest return on investment. I think that part of our impact, as you say, as a national public health institute, is providing people with the information to make the decisions that will have the biggest impact.

My final point on that is: the NHS only contributes about 10 per cent to 20 per cent of the overall impact in health and well-being. So, our growth and focus with partners over the last 18 months has actually been the wider determinant, and I think that's where, going forward, we need to be making sure that we're contributing the most whilst safeguarding the country around the threats.

09:35

Would it be helpful for me to say a little bit about what the IANPHI peer review found? Clearly we'll be taking our report to our public board meeting at the end of the month, but we have shared the report with key stakeholders, including in Welsh Government.

There are three general areas where they've commented on our current performance. The first was about us as an organisation and our focus on the public health priorities of Wales. They gave us very strong messages to say that we are focusing on the right priorities, that the reports, such as the burden of disease and 'Making a Difference' reports, have ensured that we can demonstrate that, and that in addition to that we are aligning our resources—we'll talk about our strategy as we go forward—we're orientating ourselves in the right way. The one thing they did say that they thought we probably needed to focus more on was some of the broader determinants of health, and some of the health risk behaviours such as alcohol, smoking and so on. We had already recognised that, and they're now key planks in our new long-term strategy. So, that was the first section.

The second area was about the way we conducted business. They noted that we've grown, particularly in the last two or three years under Tracey, taking on a wider range of responsibilities, establishing a broader range of service offers, and they're challenging us now to say, 'Well, given the resources allocated to you, you need to think about your internal priorities and where you want to allocate those resources internally to get the most effective and efficient output'. Linked to that, they encouraged us to make greater use of social media, other modern communication methods, technology and automation.

Then the last area they commented on was about our relationships with others, both within Wales and outside Wales. Now, we drew to their attention that we were engaged in work with Welsh Government looking at the relationship with the local health boards and how we strengthen those—a piece of work that was just starting then and is now coming to a conclusion—and they noted that and they commended us for taking that approach. They'll be keen to see, I'm sure, in due course how that has worked out. They also commented on our national—with the UK, within the UK—and international relationships, where we've got some really strong and effective relationships, and commended us for those. So, those are the broad areas that they've commented on, and the detailed report then expands on those.

Thank you for a pretty comprehensive response. One thing perhaps you didn't focus on there was the pace of change that we are currently seeing and the ever-increasing pressure on you to transform attitudes and to stay ahead of the curve. Are you able to do that considering the current quite frightening pace of change? You mentioned technology, but there's demographic change and financial pressures and all of that.

There is, yes. If I may answer in two ways. One of the areas that has just grown across Wales is around adverse childhood experiences. We did some research—2016 was the first report and we did another report last year. In short, adverse childhood experiences are experiences like verbal and physical abuse, parental separation and incarceration et cetera. We know that if you've had four or more adverse childhood experiences you're 20 times more likely to be incarcerated and 16 times more likely to take crack cocaine. When you look at different sectors, you're four times more likely to be diabetic, you're six times more likely to contact your GP and so on and so on.

For us, it's about what's the Trojan horse to change a nation, that housing can see their bit of, schools can see their bit of, Welsh Government and all colleagues, parties, communities—and ACEs has become one of those. So, the way that the team have portrayed evidence that could be complex on one side of an infographic has created a lot of traction. We know that within a couple of years you start to see changes, because the biggest test is are we healthier, are we a more sustainable society—that's the test that you should have of us and maybe we can come back in, year on year, and account for that.

We've established an ACEs support hub, funded through education—it was funded through the communities and health Cabinet Secretaries. This is working with all different sectors across Wales. We've got training programmes, we've got engagements, we're engaging with communities, the third sector, foster carers and schools. Last year, building on work we've done with the south Wales police and crime commissioner, we secured £6.7 million into Wales to immerse the trauma-informed police and criminal justice service. So, ACEs, for me, is one of the fastest ways to create a healthier generation. It provides evidence to focus on—. Sorry.

09:40

Well, on this point, Lynne's got an issue on ACEs. Do you want to jump in now?

I've got a few questions if you want me to do them now.

I'm familiar with the work you're doing on ACEs. It's a no-brainer, isn't it? Bad things happen to children then their health suffers. But what I'm not actually convinced about is that we are matching that rhetoric with action. I've got a few questions. If you look at the section of your report—of your strategic plan—where you talk about the importance of the first 1,000 days, you talk about children developing the right skills, smoking in pregnancy, breastfeeding, low birth weight, they're all very important, but there's nothing there about mental health and nothing there about developing secure attachment. If you are arguing that tackling adverse childhood experiences is the way to stem the flow of ill health in Wales, why isn't that in there?

I think that's really key. Mental health and mental well-being and resilience is at the heart of it, as you rightly say. The ACEs programme is actually all about resilience, whether that's resilience of how we support parents to provide a resilient environment or—you talked about attachment—how do we support families, schools, health visitors, et cetera, to encourage that young person or that child to identify someone who is a constant person for attachment, because we know that's the biggest impact on mental well-being and mental ill health.

So, you're absolutely right, and that's at the centre point of the knowledge and skills framework that's being developed for teachers, for health visitors, for housing. We recognise that as an organisation we haven't done anywhere near enough around mental well-being and resilience. It's now one of our new strategic priorities. With the shorter version—I know we sent you the long version—it just outlines the kind of things that we're doing.

For us, we did a further research study last year on the relationship between factors in a community that impact on resilience and mental health, specifically around ACEs, again as an infographic, and we can send it on to you. But things like sports and physical activity make a really big difference to young people around their mental health and mental well-being.

The First 1000 Days programme, as you say, is now rolling out across Wales. The chief nursing officer chairs the programme board and it plugs into a collaborative partnership, Cymru Well Wales. Mental well-being, mental health, without calling it so, is at the heart of some of the programmes, and the Every Child Wales programme for parents. Attachment is a key part of what we call the—

It's not in your strategic plan, is it? It's not mentioned.

It's in the 350-page one, I'm afraid, the detailed one. There's a whole preamble in the introductions of each section. I think we sent you two things. We sent you a PowerPoint shorter version and we sent you the very long IMTP. So, there are two elements in our—. There's a strategic priority specifically about mental well-being and resilience, which is all of the aspects that you are talking about; and there's a second one around creating a good start in life and healthy generations, which again has got similar elements.

09:45

Okay. I've got a couple of others, because this is very important, especially as you've put it centre stage now, in what you see as your vision for improving health in Wales. I don't know if you saw it, but there was a powerful debate in the Assembly yesterday on children's mental health, and one of the many bugbears that Members had in that debate was the fact that the Government had initially rejected a recommendation that we should move from a medical model to access mental health services for children to one that acknowledges distress. So, it is a direct recommendation to tackle adverse childhood experiences and their impact. What's your view on that?

I think it's both. I think it's both, and our challenge with children and adolescent mental health is that, as you know, we have got an increasing referral process— an increasing demand—and some of that may be absolutely that a child or a young person has got mental ill health concerns. 

Exactly. Personally, I think that part of the increase in demand is because we are not actually embedding a more resilient approach to preventing mental ill health, and that actually, it can be quite dangerous to be classified on a mental ill health pathway when, actually, it's about the factors in your home setting, in your school setting, with social media. So, that resilience, for us, is absolutely fundamental. If we haven't articulated, and I can send you some more information on it—.

We know that, across the life course, mental well-being is becoming an increasing concern for us, whether we are talking about older people with social isolation—. Quentin referenced that we did some work earlier this year looking at, if you like, the school photograph of ill health in Wales. We know that mental ill health is the biggest cause in the workplace of people not being at work now, and that's going up. So, how do we prevent it, and how do we focus—? We can't just stop providing support for mental ill health, but we have to do far more about mental well-being and resilience. 

Yes, and I would encourage you to maybe read the committee's report, which was debated yesterday.

Yes. Thank you.

I've got one final question, but if Angela wants to—

Just on that point. I hear what you were saying to Lynne, and your reasons why it's not sort of up front and centre in your documentation to us. But, with great respect, we don't need you to tell us what the problems are because we actually know what the problems are. Where we are frustrated is that no Government body seems to be really getting to grips with it. Whether it's public health or other organisations, we seem to have this wall of inertia, and that's why we really are going to press you on this point. We understand it. We don't need you to tell us that it's loneliness and isolation and ACEs and all the rest of it. We know what it is. We just can't get the traction.

I'm not disagreeing with you at all. When I say it's centre stage for us, it's that we've got three of our seven strategic priorities that interrelate to this, because they are all connected. The mental well-being and resilience puts it right at the heart of what we do. So, we go into how we look at building resilient communities, working with the third sector, and working through the third sector. How do we work with Natural Resources Wales and Sport Wales? How do we promote physical activity? How do we start training teachers? How do we work with police and housing? We're working closely around the new curriculum—so, that is from a mental health and mental well-being perspective.

We know that, with the ACEs work, that attachment is fundamental. So, I will give you, if I may, just one example. We have been working very closely with Cymorth Cymru and the ACEs hub. They've recently trained over 1,000 people in housing to be trauma-informed around well-being and resilience. They've gone and done an after-action evaluation. We've worked with them for the whole curriculum for this, and they are hearing people saying, 'I would have evicted that person before. I'm not doing it now because I now understand and I can connect in with the police.' 

So, I am in violent agreement with you. Sorry, Chair, if I can just—. The early years strategic priority for us, and the wider determinants of strategic priority for us, are all about doing exactly what you say: what works, what do we need to focus on? We are doing a lot of work this year to absolutely get down and dirty around the mental well-being evidence, and we'd be delighted to come back in and present that to you. 

Good. Well, you've got Members excited now. I've got Rhun first and then Dawn. 

I was just going to ask: what if that isn't working? That's what has been suggested through the report that was debated wonderfully in the Assembly yesterday. Either something hugely dramatic has happened in the last few months that we're not seeing the benefits of yet, or the kind of approach that has been implemented, however well-meaning, isn't working. 

09:50

And it does take a bit of time to start to see the improvements around outcomes on this.  

So, the First 1000 Days programme for us has been going for 18 months now. It started in Torfaen and Wrexham. About six months ago, myself and Steve Thomas, chief executive of the WLGA—we work in partnership on this—wrote to all chairs of PSBs saying, 'There's a new model for the First 1000 Days programme now, with outcomes that we measure', so that we can be agile to say, 'This is working here, this isn't working here, how do we change it?', because it's not about concrete. So, we've now got just under 50 per cent of all the PSBs involved around this programme—sorry, of all local authorities involved in the programme. We think it takes about two to two and a half years, which is quite a short period of time for public health, to start to see the changes around the first 1,000 days. So, we're evaluating. We've got a whole outcomes framework to make sure that we're doing this.

The final thing is about sharing good practice. What we're not very good at in Wales is where something is done well and we evaluate it as so, we don't scale it up. So, that's a really key part of the ACEs work and also the First 1000 Days programme work. 

Just going back on the wider picture of mental health really, and we've referred to the debate yesterday. Angela also mentioned in that debate yesterday that we've had 15 reports come through various committees on the issue of mental health. Maybe I'm reading this wrong, and if I am, then I stand to be corrected, because having picked up from your report the actions that you're intending to take forward around various priorities, if we look at priority 6, which is around sustainable systems and early interventions, which we know are very important, you've got something in the region of 93 actions that you've got planned over the next three years, but on mental health you've only got 10. Given what we've said about 15 reports around mental health that haven't been fully implemented and haven't produced the results, I would have expected a priority around mental health to have considerably more than 10 actions, but it could be that those 10 actions are very detailed. That's what I'm saying: I say this with a note of caution but—

We had a big discussion when we were setting the strategic priorities and we did a year of engagement with people on this, we looked at evidence, we did a whole engagement with our public. We did the first ever study, and I know there have been some discussions, which we really appreciate, in committee and Plenary around this, to see what our public feel about health and well-being. We had a big discussion about mental health and mental well-being, because they are different—

—although they are inter-connected, and if you can't get mental well-being right, someone who has a predisposition could tip into a mental ill health perspective, and mental well-being keeps people who do have mental health challenges slightly more stable. So, from a public health perspective, mental well-being is absolutely most important for the resilient society. However, you're absolutely right about mental health. The reason why the reference—. In fact, we also have some actions around learning support for people with learning disabilities as well in there. If you like, the part of our new strategy that interfaces most with the NHS is that strategic priority. Given that the NHS has the responsibility about mental health services, our quality improvement team—the 1000 Lives Improvement service—that's where that team, which is the very strong touch-point with the NHS, that is where that conduit is around supporting them with mental health. That said, Carol Shillabeer, who you may know as the chief executive of Powys, who chairs the Together for Children and Young People, which is the mental health programme, is getting more and more involved around the mental well-being elements, because you can't separate the two as well as mental ill health, and obviously we support them. So, we think our biggest contribution actually is about mental well-being, but we also think that we need to do very targeted support about supporting mental ill health services, which is exactly where it is around that contact point with the NHS, if that makes sense. 

Last year, in Wales, 43 per cent of child protection referrals were for reasons of neglect, yet, in Wales, the model that Public Health Wales has developed of adverse childhood experiences doesn't include neglect. I met with the children's Minister and Professor Mark Bellis from Public Health Wales, who's done all these reports last summer, and I was told that there would be a fourth ACE report that was going to be published in the autumn. I haven't seen it. Can you confirm that the report is there? Will you publish it? And will you confirm that, as in America, where the ACEs model came from, neglect is absolutely an ACE that we need to tackle?

09:55

Yes, it was published. We can send that through to you. This was the report that I referred to that looked—. It took the ACE work—. As you rightly say, we need to understand it more and respond more to the bits that are specific to Wales, but also incorporate the neglect areas. This was looking at the relationship between factors in communities that build resilience for individuals and mental health, and for the first time we also did the research across Wales around neglect as well, so, we introduced that. That was published a couple of months ago and shows some fascinating relationships about the totality and, obviously, neglect is a factor in it. I'm trying to remember now, because it's not fresh in my mind, but the manifestations of the harm of neglect are very similar to the totality of the manifestations of ACEs in general.

We've worked very closely with the States. Washington, I'm sure you know, has led the way around this. There's a lot of work happening in Australia. We continue to seek to understand to make sure that we're targeting in the way that is most appropriate. What I would say is, what we know works around ACEs, most of that are the very issues also that try and prevent or reduce neglect. But I agree, and we had a big discussion a year or so ago, which is why we incorporated it into that latest survey.

So, neglect is now considered to be an adverse child experience.

It's incorporated into the survey, into the research for us. It's an added component of the research. 

Okay. That's not entirely clear, but there we are.

Okay, moving on, because we've wandered a bit off script, team. But with very good reason. Caroline, on healthy behaviours, some of which has been covered.

Diolch, Cadeirydd. I'd like to say to you that, obviously, we have many causes of premature death in Wales—heart attacks, stroke, cancer and that's to name just a few. But they are all linked to behavioural risk factors, for example, smoking, alcohol and a lack of physical activity. How can we accelerate a positive change in behaviour?

I think it's at the heart of everything, isn't it? It really is. You'll see with the new strategic priorities, promoting healthy behaviour is a really key one. I would say, I don't think that we as an organisation, we as a system, have been sufficiently targeted about really understanding behaviours. For example, we used to have adverts on the television, you may have seen them, you know, 'Stop Smoking'. No-one's going to stop smoking, and we've turned that into Help me Quit and it's a very different interaction around, if you like, the science of behaviours around this. So, we've been investing time and some funding around really understanding more about the market.

We rebranded it Help me Quit, if we pick smoking for a minute. Smoking is the biggest risk factor that's causing a lot of our disease at the moment, and we need to be doing more around that. So, we rebranded some of the Stop Smoking into Help me Quit, which we launched earlier this year. We worked with a company to do some segmentation of our ages and our markets to understand—I don't smoke, but if I did smoke—why, at my age, I would find it difficult to seek support, and it may be different from a 15-year-old or an 80-year-old. So, one message does not suit all. We used geo-location tracking of adverts, of billboards. We've been using social media targeted adverts for people according to that grouping. We know, with behaviour science, that that starts to be far more conducive to our normal lifestyle than how we've approached it. So, there's a modernisation for us about what social marketing and behaviour science look like.

Around physical activity—. Everyone's had bits and bobs to do with physical activity and you may have seen, the former Minister for Social Services and Public Health asked ourselves and Natural Resources Wales and Sport Wales, 'Can you not just get it sorted and create some sort of national impetus around physical activity?' So, our organisations are working together to have a joint approach. However, the magic doesn't happen nationally; it's how we work with communities, how we work with schools. You're absolutely right that they're very similar.

So, we used to do brief interventions for alcohol or for exercise, but we're human beings, so how do we make the most of how we interact to enable people to make different choices by treating them holistically? So, what are those messages around smoking, around physical activity, around healthy eating? So, for us, it's about modernising those approaches, because we are where we are, and obviously what we've been doing hasn't sufficiently worked as a nation.

10:00

One positive approach towards behavioural changes is making every contact count. For example, when you visit your GP for a routine consultation, this can be brought into the consultation, obviously. So, do you have any robust evidence to show that healthcare staff in Wales are raising lifestyle issues with their patients?

I think it's variable. We haven't done any direct evidence across the NHS to see the extent to which that happens. Interestingly enough, in our public survey, our public had a view around missed opportunities for primary care to have those conversations with them. We've got a very informed public. I'd urge you to have a look at the report. So, we've got 80,000 people working in the NHS, and, if you add all public services, we've got a couple of 100,000 people. Are we systematising making every contact count? I don't think we are. For us, again, one of our future areas is about: how do we mobilise a nation of public servants, how do we train people up? In the conversation around what does social prescribing look like, how do we create a system where—? We're doing a lot of work around social prescribing with primary care; we have a primary care innovation hub that we run for Wales. So, how do we do that in a way that just training people up in making every contact count—? If they don't understand the philosophy of what they're trying to achieve, it isn't going to work. So, how do we train up a primary and community care sector, as well as hospital sector, in understanding what those key messages are and what they do after that conversation? So, it's a model approach. I think it's an area that we know we're not exploiting enough as a system, and, for us, the only way that we're going to be able to make the most of those contacts is through that. What I would say is that we're doing a lot of work with the police around this as well, and fire and rescue. We've got a whole falls prevention programme nationally that we run with fire, postal services coming on board, health, et cetera, and they're making every contact count when they're in somebody's home. So, for us it's about systematising it: moving from variation to trying to systematise it across Wales. 

Is it fair to ask an already overworked GP to incorporate this into the consultation, when they are pushed for time anyway?

I think that's the never-ending challenge, isn't it? I mean, it's interesting, because, if you look at the return on investment, actually, that moment of conversation—. Forgive me for talking about the adverse childhood experiences again, but primary care has been one of those areas that they know, through just having that conversation, the evidence shows that it reduces the subsequent presentation to a GP and emergency admission. So, there is a return on investment there. The question is: does it have to be the GP that has that conversation? Could it be the practice nurse? Could it be somebody in the community? So, we have to make it easy for people, but we need to find a way of making sure it can be done.

Yes, I think so. And, finally, there are many examples of Welsh legislation and policies being used to support people to make healthier lifestyle choices and changes, such as the ban on smoking in public places. I mean, that's to be welcomed, but what further legislation—fiscal or policy levers—are needed to deliver strong health improvements?

If I kick off, and Quentin may want to say—. The challenge we have is that, for some of the wider determinants, control over that legislation isn't devolved. For us—and we do this probably about twice a year—we will lobby and we will advocate through Welsh Government or directly into UK Government about specific things like 20 mph in urban areas for example. So, that said, some of the things like some of the sugar taxation is a challenge for us, and some of the legislation relating to industry is a problem. However, there are still a lot of opportunities that we can go at. Obviously, minimum unit pricing is something that could make a significant difference, not only to lives lost, illness, costs to NHS and costs to a wider sector. You've mentioned the smoking ban—there's also a lot in the area of active travel and planning that can be done. So, the decisions that are made about planning can make the difference to, 'What is convenient for me?', 'What's easy for me to—?' So, active travel is really important. I think there's also policy as well—it's how we use our money. We're having—. I, myself, and our chair, Jan Williams, have just finished meeting with all Cabinet Secretaries—apart from one who we'll be meeting in the next few weeks—and Ministers, and we're talking about investment in prevention. So, how do we invest in prevention through policy decisions that are made, be it housing, be it economy, be it through procurement? So, how do we influence and create a healthier society by using the financial flows that we have in the decisions as well as legislation?

10:05

You mentioned the sugar tax, and you also mentioned the importance of investing in prevention, yet the £57 million from the sugar tax is largely being spent on things like the NHS transformation fund. There's some money going into immunisation, which is, of course, fundamental prevention, but I would say the core business of the NHS. Are you satisfied that we're doing enough with that money when we know that we've got this huge problem of childhood obesity?

I don't know where that money will end up going. All I can say is we're having a lot of conversations with the Cabinet Secretary and colleagues in Welsh Government and NHS about changing the use of the flow of the money. So, for us, we're spending a lot on what we call 'spending on restorative services'—you know, after the fact, and we want to, within that, start to shift that money, the same amount, to start to increase into investing in prevention. So, the job for us is to say—people say, 'So, what do we spend it on, then? So, if you're saying you're going to make a difference, where's the biggest bang for buck?' So, an example is screening for some cardiac problems in primary care—for atrial fibrillation, which is an abnormal heartbeat. We know there's really big evidence that that could make a big difference for cardiovascular complications and for stroke. That's a good investment. So, even in the last couple of weeks, as chairs and chief execs, we were with the Cabinet Secretary and Government officials the week before last, with a paper that suggested, actually, we could start to invest in prevention through the allocation of money on a regular basis, but also potentially through additional transformation money, and I know the Cabinet Secretary's very keen to use some of that money around investing in prevention. For us, it's saying, 'Where's the biggest bang for buck?'

Okay. Julie, you had a point about another healthy behaviour.

Yes. First of all, I declare an interest because my daughter works for Public Health Wales—

Does she enjoy her job? Sorry. [Laughter.]

What I wanted to ask about was breastfeeding as a healthy behaviour and a preventative behaviour, and to ask you what your view is on where we are in Wales and what's the plan for moving forward.

Yes. I mean, we're interesting in Wales. We've got—. As I'm sure you know, if you're interested in it, we don't have as many women taking on breastfeeding as we would like, and we know that that's pivotal for a healthier destiny going forward, and that is the case particularly in some of our higher deprivation areas. Some people will never take on breastfeeding. So, we're doing a lot of engagement with the sector—with third sector and with Government at the moment. So, we're working with Swansea and Cardiff University for our people of Wales to understand, with evidence from Wales, rather than elsewhere, about why people find it difficult to take up breastfeeding. We've also been working very closely around the network for—. There's a project being run out of Keele University about understanding how we can mobilise a peer network of parents and supporters us around breastfeeding to give people the confidence. We have incorporated it—. I'm not sure if you've seen it, but we launched what we call Every Child Wales earlier this year, and it's really simple. It's just 10 steps—. Part of this is about 10 steps to a healthy weight for the baby and, obviously, it impacts on the mother, the parents, the carers. One of those is around breastfeeding, and we're working with partners across the NHS about are we training people in the right way, could we be providing more guidance. Key for us is about parenting and pre-parenting—so, what is it we're doing in schools for children before they reach that stage. So, we're doing a lot around breastfeeding and you know that there's a task and finish group that's recently, you may know, produced some recommendations on where we need to go. Our team was with the chief nursing officer just a week or so ago working on how we can best support that. So, we see it as a really key priority. The thing though is making sure that we are focusing on what really is important to people and the evidence for that, rather than—. We've had some historic approaches, I think, that haven't really made a difference, and, if we don't have the evidence, we need to create it. So, it is key for us and we recognise it, and it's about doing the right thing to try and increase breastfeeding rates.

10:10

I suppose I'm disappointed that you say that there are some women who will never take on breastfeeding, because that is going to perpetuate the health inequalities for ever, so I really think we should start off—

Oh, absolutely—

—with the assumption that we're going to reach everybody.

Please—sorry if I led to a misunderstanding. For us, obviously, we would want 100 per cent of women breastfeeding—

At the moment, it's 17 per cent though, in Wales.

So, our task—

I'm not sure—

I think it's different at different stages, but after six weeks—it's probably 17 per cent after six weeks.

So, sorry, just to be clear: we absolutely recognise—and we would like 100 per cent of women to breastfeed full stop. However, there will be people in every country who make a choice for whatever reason. So, for us, that, we would hope, would be very much the minority. They also need support about what else they need to be doing to make sure that that baby has the healthiest start that they can. But we recognise—it's at the heart of our First 1000 Days programme; it's at the heart of our Every Child Wales programme. We absolutely need to be achieving or striving to achieve 100 per cent.

So, have you got targets that you're working towards to go up from the 17 per cent the Chair referred to?

Well, it's for the system, because we all have different roles and responsibilities. So, the NHS, through the health visitors and through midwives, has got a really key role to play on this, and one of the areas in the task and finish group was really to do that—to align what we are trying to achieve as a system—and we need to work out what our bit of it is to help address that and what the delivery arm, if you like, of it is to address that. And it is very variable. There are parts of Wales where, similar to on teenage pregnancy, they have made a significant impact, but there are some that we know are intractable. So, part of the recommendations is saying, 'How do we take an all-system approach, rather than we do a little bit, the NHS does a little bit?' Because we have to, because we know it's causing harm and it's creating ill health in later years. 

One last question, then. I understand that there are going to be breastfeeding—I don't know what they're called—co-ordinators specifically appointed to every health board. Is that something that comes under you or—

No, not as the individuals, but we have established a network so that those individuals will be able to plug in and learn together and share together. But it's the health boards that would be responsible for—. It's back to the whole system having to align about what works, isn't it?

Yes. It just seems very important, though, that there is a strategic lead from Public Health Wales, from the Welsh Government—

And from the NHS.

Yes, it's just to follow on from Julie, really, because I do see it as being a key point, as you mentioned, about the First 1000 Days. Some of the—. You know, in the response that you've given, it feels like—. You know, we're talking about something that's well known; there's a lot of evidence behind this, and it feels like we are almost starting again to look for evidence for how this works, and I just feel like we seem to be a little bit behind the times, perhaps. I wonder how you're going to address that.

We, for Wales, reviewed the evidence as far back as 2015 on this. We know what works at a population level, so we've established—. Forgive me, I couldn't remember the name. So, we have a Wales infant feeding network that we've established across Wales that does exactly what you were saying. The research bit that I was referring to is where we have real difficulties and persistent difficulties in some communities in Wales—whatever we've been doing just isn't cracking it. So, understanding for those areas—getting, if you like, under the hood a bit more as to, for those areas, what it is that's preventing people, because our mainstreaming, which should work for most of the country, is not dealing with it. So, I'm not saying that we reinvent the primary evidence that we all know; I'm saying we need to do a little bit additional for areas where we think we need to customise our support better.

And are we learning from good practice in areas—? I've got an example in my constituency where Carol Walton's been doing some great work over many, many years, and I just wonder how that gets fed out to other areas, because she's been working in difficult and hard-to-reach communities, and I'm just keen that we do share that good practice because it is out there.

10:15

It is. It is, and I mentioned the network—the network is to mobilise. I mentioned earlier that we're not very good in Wales at sharing good practice. That example would be great for us to link in. If we are creating some of the research questions of where communities have really struggled, it would be great to feed in with you. But the network—one of the purposes is to do exactly that.

Okay. We need some agility with questioning now, team. So, Lynne, you've got the next section, and most about funding are covered anyway, so carry on.

Yes, but I wanted to ask about parenting and the pre-parenting support that you mentioned. Everybody gets an offer of antenatal classes, but more well-off parents can purchase the National Childbirth Trust classes, which are really, really good. Have you done any research on the quality of the antenatal offer, which is fundamental for things like breastfeeding, and are you doing anything to promote the provision of high-quality, evidence-based antenatal provision for all mothers in Wales—and fathers?

Yes, I could take about three hours to answer. Just for us to be clear, the responsibility, as you know, around the provision of courses and access to courses is the health board's. Back to not reinventing the evidence, we just know that good parenting not only—obviously stating the obvious—has a significant impact on the health of the child but also a significant impact around return on investment. So, we've been doing a lot over the last couple of years around what a parenting programme looks like. We've been revisiting that in relation to the resilience conversation that we've been talking about. So, we've been changing some of the modules or adding some modules in because we weren't doing enough around resilience for the individual and for the family. I couldn't comment, to be honest, around the quality of all of the parenting programmes delivered within the NHS, but I'm more than happy to go and find some information and come back to you.

Okay, thank you. Can you just clarify, then, on a funding issue, whether the funding for clinical networks is ring-fenced within the Public Health Wales budget, and what the expenditure is for clinical networks and NHS Wales Health Collaborative?

Huw, do you want to—?

Yes. We host the NHS Wales Health Collaborative. We have a hosting agreement, and we do it on behalf of the NHS—all the other health boards in Wales. So, the funding is essentially ring-fenced.  So, that doesn't come into our—. It comes into our allocation, but we then don't spend that ourselves at all. So, any underspend is actually passed back to health boards, and the overspend is underwritten by the health boards. So, it is entirely ring-fenced outside our control. In terms of the actual figures, the collaborative's budget this year is £12.1 million, which includes clinical networks—and I'd have to look up that figure for you in terms of how much the clinical networks are. The clinical networks in there are about £9 million—just over £9 million of the £12 million.

Okay, thank you. And just sticking with the money, are you able to give us any indication of how the Public Health Wales budget is spent on the different sorts of areas, such as maternal health, early years, children and young people, working-age adults and older people, just so that we can get a sense of where the prioritisation is of resources?

Okay, well, on the way we normally manage our budgets in the organisation, we have Quentin's public health services, which is screening, microbiology, health protection, health and well-being, which are all the health improvement programmes at the observatory and 1000 Lives. So, we split it in that way. We do analyse it, and so I've got a list and we could prepare for you in that way, if you'd like, in terms of—. Would you like for me to do that?

Could I just add—? We were talking about prioritisation. So, during this year, with a new strategy, we're doing exactly that, which is aligning rather than the directorate aligning against the priorities, which is a good indicator.

When you're preparing that note, could I ask that you say where the staff are? Because I've looked in appendix 1—I'm sorry, this is under the public health workforce—but I just wanted to know the breakdown of your 1,000 and something or other staff. What do they actually do, and how much is the balance between research of the direction forward and those who actually go out and implement and deliver? So, if you could tie that in, because it was very confusing to understand in appendix 1—.

Sure. So, if I can give you some headlines, we're about 1,600 staff. About 1,000 staff actually work within the public health services directorate. So, these are the staff supporting or delivering screening programmes, our laboratory and clinical microbiology, and our health protection services. So, if you like, our direct delivery arm is about 1,000 of the 1,600 staff. A lot of those staff do research. We encourage research across the organisation; we encourage staff in all sectors of the organisation. But we do have a specific directorate with about 60 or 70 staff—our policy, research and international development directorate—and within that, one of the divisions, obviously the research division, will focus specifically on research, developing research strategy and guiding and overseeing the research delivery across the organisation. Likewise, we can provide you breakdowns for the health and well-being.

10:20

Jayne has got a specific question about microbiology.

Thank you, Chair. There are several areas, suggested in the paper, that are already experiencing workforce challenges, and one of those areas that you've identified is microbiology. What challenges do you face, particularly with microbiology, and the medical and scientific workforce capacity, and how are you addressing that?

Okay. First of all, thank you for recognising it's not just the medical but also the scientific workforce that is a challenge for us. And there are similarities to the approach we're taking, but there are some distinct differences.

So, if I start with the medical microbiology workforce—the consultants. We've got a particular challenge in north Wales. We are established for five whole-time microbiology consultants in north Wales. We have two substantively appointed, so we've got three vacancies. At the moment, we're using locums to fill those vacancies, plus some other activities that I'll come back to in just a moment. Clearly, on the medical microbiology workforce, our first priority is to recruit substantively to fill those vacancies. The problem is that we're competing in a UK market, where there are vacancies right across all four parts of the UK, and in the context of changes to the way microbiology training has taken place. So, over the last two or three years, we've moved from a microbiology consultant who had much more of a laboratory focus to one, in more recent years, who has extended their reach into the clinical environment. We turned that around. So, now, we train people who are much more, if you like, physicians with infectious disease expertise, who are clinically focused, but with some laboratory awareness and experience. That transformational change has resulted in quite significant workforce challenges across the country.

We clearly need to train people and grow our own medical workforce to fill that, and therein lies a number of other challenges. Training posts are established in south-east Wales, and we're talking to the deanery about establishing posts, particularly in north Wales, but further west as well. In the meantime, we've got an immediate problem. So, the things that we're doing is making use of the wider network. And just to say that the network covers five out of seven of the health boards; just Aneurin Bevan and Cwm Taf have their own microbiology service provision. So, across all the other health boards, we've got a network that is UKAS accredited—one of only three in the pathology networks in the country. So, we've got a very strong network, and what we're doing is, we are either using—. Our clinical lead spends a day a week in north Wales to provide support, and we're moving samples, in real time, to other parts of Wales where we can get them analysed and returned very quickly. We're looking at, potentially, point-of-care testing so that we can, if you like, enable more rapid testing without the delay of transport, and we're looking at the use of medical staff elsewhere in Wales, for example to do remote authorisation of results. So, we're using the network in an agile way to address the medical.

The scientific workforce challenge has a slightly different genesis—it's a longer, slow-burning issue. The issue for us is that in the middle banding level, particularly at band 6, as in other places, we have increasingly a gap for a variety of reasons. So, our approach here is to go, if you like, in crude terms, back up the value chain. So, we're approaching undergraduates entering higher education who are looking at scientific careers, who may not have thought about microbiology, and we're actively offering them placements in the hope that we can encourage them to specialise in microbiology in their undergraduate degree. We're capturing the graduates when they come out and we're offering them placements whereby we will then train them into laboratory scientific roles. We're taking our existing, more junior banded scientific staff and we're putting in additional training support and external learning and development to enable them to progress into higher roles. And in that way, we're creating a training pipeline.

Now, we've only really started that in the last year or so and, to be honest, that's a three to five-year journey. But we're seeing progress already on the scientific workforce. Swansea, I think, has turned around a lot, pretty well in the last 12 months, and we're putting that into north Wales, so that we'll be able to see the same results over the next year or so in north Wales. Developing our scientific workforce helps with the medical workforce, because if we get our most senior scientists competent to take clinical decisions—and that is something that is happening in some parts of the UK—then that can take away some of the pressure on our medical workforce.

10:25

Okay. I'm anxious to get two major issues in before we have to finish, and those are on public health campaigns. The first one is going to be sepsis, led by Angela, and then hepatitis C, led by Julie. So, Angela.

Thank you very much indeed. I wanted to understand how you measure the success of a public health campaign and how you believe we are doing on the sepsis public health campaign.

If I take the second point first, I'm sure you may be familiar with the fact that we've been doing a huge amount of work around sepsis over the last number of years, particularly through the lens of how we prevent people deteriorating rapidly, and sepsis is part of that. So, we've been doing, if you like, a professional campaign for the last number of years, and I'll come back to the public in a second. Our 1000 Lives Improvement service interacts with the NHS, and we've been putting people through substantial training and it's now part of their mandatory training modules around early deterioration and sepsis specifically.

Can you just define that for us, though? When you say that you've put 'substantial numbers of people', are we talking hospital staff or are we talking about general practice?

It's mainly hospital staff. General practice is a really important one, because we know that a considerable number of people who will progress to sepsis are coming in at quite a late stage from the primary and community area. So, our focus has been, over the last couple of years, more around the secondary care hospital areas, but, in the last 12 months, we've increased our approach around primary and community care, providing more guidance and providing support around sepsis screening.

Also, through our 1000 Lives team, shortly we'll be embarking on a programme for care homes, as well, because we know, particularly around urinary tract infections, skin infections and infected pressure ulcers—. So, how do we train people up more generally around quality improvement and sepsis being part of that? So, that's a really important area.

We've also been doing a lot around the alert. A lot of sepsis can be avoided, as you know, and some sepsis can't be avoided. So, what does an alert in a hospital environment look like? What we call the early warning score in any part of an environment in a hospital is what the signs and symptoms are of someone, at the early stages, starting to manifest sepsis and what they do about it. Because, sometimes, people watch and watch and watch, and we compensate and then we deteriorate very quickly. So, we know that, through that work, we've had a significant reduction in people requiring intensive care and people deteriorating. We're doing another round of outcome measurements around how many lives have been saved as a result of this programme, obviously, because that's going to be absolutely key.

With the improvements around reducing sepsis, though, we were actually recognised in Wales as one of the global professional campaigns of systematising an approach to sepsis through early warning in a way that other countries haven't. But obviously that needs to translate into reducing it. At the moment we have around about 2,200 deaths per year in Wales, and 13 per cent of those are in hospitals. So, again, going back to how we've systematised this, we've been doing a lot of education and training for people. I accept your point around primary and community care, which is a really important phase for us—the surveillance, detection and alert. So, now health boards are required to alert Welsh Government if there's a person that goes into sepsis, and then demonstrate how they've learned from that, which I think is really key—

10:30

Can I just ask you—? Because I'm conscious that the Chair will breathe down my neck in a minute. Can I just ask you a couple of questions on that bit of it, before we get to the public health element of it? Do you monitor how many people contract sepsis and survive, but survive poorly—i.e. they have multiple issues, they may have lost a number of limbs, they may have had mental health issues as a result, they may have had brain incapacity as a result? Because you're right; in pure terms, there is a small—and I emphasise the words 'very small'—reduction in the number of sepsis deaths. But what I cannot find out—and I'm the chair of the cross-party group on sepsis, and believe me, I've burrowed through data, but I cannot find out—is how many people are surviving, but you wouldn't necessarily say they had a great quality of life afterwards. Are you able to provide that kind of figure work? Do you measure that anywhere? Because of course that is whether or not we're being successful.

Absolutely. The short answer is that I'm not aware that we are—. We look at it, as you say, at that point of time, for that episode, that the patient didn't deteriorate, didn't die from sepsis. The extent to which we then do the follow ups—because it may not be just that they're in the hospital stage of subsequent complications; it could be further down the line. I'm not aware that we do, but I'm very happy to go and research it and get back to you.

I'd be really interested in that. Also, when it comes to the analysis of the data, it would be very helpful to find out where people are being referred from, because we have a clear—. I think the RRAILS programme is actually very good, and I think it has made substantial changes to the way sepsis is managed within a hospital environment. However, again, what we're unable to really track well is how many people are admitted to hospital having not been handled appropriately in either a care home setting or in a GP setting. I've done quite a bit of research with GPs who—. It's very difficult. You don't know if this person's got flu, or it's going to go into sepsis, or they've got a urinary tract infection and it's going to develop. But again we could have a commonality, particularly in care homes, about who gets looked at in a care home or not looked at in a care home, particularly if it's not a medically based care home, and is left then too long and is suddenly taken in as sepsis. So, I'd like to have a feel for that, and then I'd like to have just a brief word on whether or not you think a public health campaign to explain to people what they need to look at, the signs of sepsis, or just being sepsis aware, or asking, 'Could it be sepsis?'—whether or not you think that would be of benefit.

We know that 80 per cent of people who attend hospital and become septic originate from primary and community care. So, we have historically been targeted at the hospital, probably because it's actually easier to try and control people. As I was saying earlier, we recognise that, actually, primary and community care is key. My background is as an emergency medical physician, and I was a regulator in a different country, so the quality of care in care homes was fundamental to us, and I would suggest it's about building an understanding quite quickly around deterioration that could be from sepsis. It may be as a result of something else, but actually, it's the fact that sometimes people aren't detected as clinically deteriorating.

The other challenge is about primary care, and the thresholds for calling a GP into a care home setting. So, part of the conversation we're having even around immunisation and vaccinations and flu, potentially, is whether there are opportunities to train other people up—registered nurses in care homes and others—around those early signs of deterioration. So, we are developing a quality improvement programme—not solely sepsis, but sepsis is part of that—around care homes, for that very reason, because we know it's like a rotating door. I'm very happy to give you more detail or meet with you if that would be helpful to give you some more information on that. 

In relation to the public health campaign or public campaign around sepsis, it's a really interesting one. We have similar discussions around many campaigns, actually. You may be aware that in 2016 England launched a public sepsis campaign. Scotland did some work as well. What we don't know—we haven't been privy to it; it may be working through—is the evidence that, actually, that made a difference to reducing the incidences of sepsis and the outcome of care as a result of sepsis. We've had discussions on and off, I'd say for about a year or so, with Welsh Government officials about this very issue. We get asked quite a lot about doing public campaigns, understandably, on areas. What I would say is that there are campaigns around a lot of areas that people invest a lot of public money in and, actually, that may not be the way of really getting to the people who can make a decision to control something, to prevent something. 

10:35

I do totally understand that and, of course, I think one of the dangers with politicians is that we all have a little hobby horse. I'm prepared to admit that mine is sepsis, so I completely get that—you can't rush off and do campaigns around everything. However, sepsis does kill more people per year than the top three cancers. Now, you could ask almost anybody anywhere in Great Britain what cancer is, and they will tell you. You can go almost anywhere in Great Britain and say to people, 'Do you know what sepsis is?' and a huge number will not know what on earth you're talking about. Now, you cannot drive down a road in England—if you pass an ambulance it will have the sepsis warning signs. Every ambulance. I've travelled around and I've taken photos of the things to prove to Wales that there are small things that we could do. To be frank, it's—what do you call it—an orphan event; it's not one of the big ones. We all get cancer and we all understand what it means, but it's killing people. But worse than killing people—and I mean worse than killing people—is that it leaves people devastated afterwards. Very few people walk away from sepsis clean and clear. There are multiple amputations. There is always a side effect. I've yet to meet a sepsis survivor who's had it and has been A-okay afterwards. So, again, on the public health and the benefits in the long term, the pick-up that the state has to do is phenomenal, so I don't quite understand why we wouldn't want to start elevating this up the process, because of those very sort of lifestyle changes that will happen.  

Yes. I would say it's a priority for us. It's been a continued, very focused piece of work for 1000 Lives, and we've increased progress on that. I'd be delighted to meet and have a conversation about this, because it used to be one of my bugbears in a former world. Yes, it's about what are the messages to which audience. I think one of the challenges is that people may go to their GPs, and at that point it may not be picked up. So, it is about making sure that, actually, we don't just focus on one at the cost of another. It's what the best—we were talking a bit about behaviour change earlier—what's the best message for the public through what medium, what's the best message and guidance, support and direction to professionals through what medium. But I'd love to meet up and have a more detailed discussion about it. 

Right. You're on. Just one last very small question—and again, other Members here may be more aware of this than I am. I'm chair of the group, but it was only at the last group that I heard of the early warning score. Now, that's supposed to be a public health initiative. So, essentially, we all have a card—I don't know if everybody else is aware of this—and basically it says what is your normal baseline: what is your normal temperature, what is your normal blood pressure, what's your normal—  

—pulse rate; you know, all of the things, so that if your score—. And it's on a card, so that if you then are unwell there's a baseline that a medical professional will be able to judge you from. I think that's a brilliant idea, and if everyone in Wales had one then you've got something to start measuring people on. But I'd never heard of it. How far out is that? Why isn't that kind of thing being more promoted in public health? Because that would be a good baseline for a gazillion illnesses.

10:40

Certainly, the national early warning score, we've embedded it in—again, it's more hospital based—for the last number of years. It is absolutely fundamental to start to understand if someone is going to clinically deteriorate in exactly the way that you've just said, particularly if it's a pregnant woman whose physiology is different. We've investigated a sepsis case of someone who sadly died in another country because the clinicians, the people looking after her, didn't understand that her body responds differently in the third trimester than it does when you're wandering around the streets. So, we have a national early warning score that is mainly—and the approach has been—in hospital. It's also about what an obstetric early warning score is and what a paediatric early warning score is. Actually, there's some good stuff that's happened, which again I'm happy to discuss with you. The challenge of having it out and about with you is that your body changes. So, my baseline today could be—. When I'm running, which I really need to do later today, my baseline would be different. The important thing is, while you have observations, if you go to your GP periodically or if you're in a hospital—the only way they can do that is baselining what's normal for you at that point in time and what are the red flags.

Okay. I think we've done sepsis. Can we do hepatitis C now, Julie?

Yes. Thank you, Chair. A number of us have been involved in the campaign about hepatitis C and I know the commitment is to eliminate hepatitis C by 2030. I wondered whether you could report on progress with that aim.

I'll pick this one up, if you like, Chair. As you know, your daughter, who works for Public Health Wales, has been involved in some of the work around blood-borne viruses. This, for us, has been a key platform for the development of all our interventions for the wide range of blood-borne viruses. But specifically on hepatitis C, as you say, the Welsh health circular, released late last year, set out for health boards three very specific requirements: to reduce and ultimately prevent ongoing transmission of hepatitis C within Wales, secondly to identify individuals who are currently infected with hepatitis C wherever that occurred, and then thirdly to treat individuals identified with hepatitis C, particularly those engaged in behaviours likely to lead to further transmission—so, for example, in substance misuse settings. We as an organisation have taken that and incorporated it as one of our strategic objectives for 2030.So, Public Health Wales have said that. The WHO have made that as a challenge. We've accepted that and we've built now a programme to work towards that target.

Quite separately to my direct activities within Public Health Wales, I happen to chair the liver disease implementation group in Wales, and this is one of our work streams. A viral hepatitis sub-group has been established, led by one of our infectious diseases doctors and microbiologists, who you may or may not know, Dr Brendan Healy, who's got a keen and active interest in this area. I'll come back to the achievements to date in just a moment, but our focus has been multifactorial. The first is on community-based activity, particularly with regard to those people who, because of their lifestyles or vulnerabilities—for example, substance misusers, the homeless and others—may not be in contact with health services and therefore may not either be aware of or be receiving treatment, or who would need support anyway, if they weren't infected, with protecting themselves from acquiring hepatitis C. So, we've recently appointed a national lead nurse to support that particular programme of work.

The second area we've looked at is pilot testing for hepatitis C within community pharmacies. Again, we've set funding aside now to appoint a national pharmacist role, and we're in the process of recruiting, and we'd hope that that person would be in post within the next two or three months. So, we'll pilot, and when we’ve got the results and we've evaluated them, we may well roll that particular initiative out.

The third area we've looked at is the prison sector. As you may know or may not know, we've got an opt-out scheme for blood-borne virus screening established now in Welsh prisons, as of November 2016. Last year, a third of all men admitted to prisons in Wales were screened, and we estimate—and we suspect it may be still be a conservative estimate—that about one in 10 of prisoners—. Obviously, all of the prisons in Wales currently house male prisoners, but one in 10 of that prison population is likely to be carrying hepatitis C. So, we're now developing pathways for rapid access to treatment for those individuals.

The next piece of work that we're doing is to link our hepatitis C programme to our substance misuse services. So, we're specifically now training up and enabling people working within our substance misuse services to recognise and contribute to the hepatitis C. Within our laboratories, we've introduced point-of-care testing, and we've also introduced automated dried blood spot testing. It's new testing to enable us rapidly to determine whether somebody, particularly in a community setting where we need a result quickly if we are going to be able to intervene and not lose the individual—to establish a diagnosis.

So, what have we achieved so far? Well, now, with the introduction of very effective therapy—. Direct-acting antivirals are well established. They've been in place now for about three to four years globally. So, Wales now has taken a very assertive approach to the treatment of hepatitis C, and over the last two years, we have treated over 1,300 individuals, achieving a 95 per cent cure rate in those individuals. Our target to treat in the last financial year was 900. In fact, we only managed to treat 578—64 per cent. That, of course, was a target for health boards, and the health board variability was from 25 per cent to 111 per cent. So, clearly, we will work with those health boards that are not managing to reach that successfully. So, that's the current position with hepatitis C.

10:45

I mean, certainly, it does seem as if it is a success story with the result of those drugs coming on and then you being able to follow it up. But the people you need to treat now are the ones you have to go out and seek, isn't it, because everybody who presents themselves can get treated straight away?

And we're actively talking with the Welsh Government and the health boards about an initiative to effectively case-find in the community those unknown hepatitis C carriers.

So, my team—it's always easy to say 12 years out—are optimistic. At the risk of colleagues across Offa's Dyke hearing this transmission, we are talking—

It's not just across Offa's Dyke. It's going worldwide, Quentin. [Laughter.]

All right, Dai. I will be mindful of that. We are obviously aware that Public Health England have set a similar ambition, and we talk closely with them. We think that if there is full commitment from within the NHS, we could do this by 2025. But 2030 is our target.

Excellent. We've only got a few minutes left—[Interruption.]—and the queen of agility is Dawn. [Laughter.]

10:50

Thank you, Chair. Can you just explain why it is that you don't publicly report the full breadth of your business activities in terms of progress monitoring? That's what I'm talking about. This is this something that was highlighted by the Wales Audit Office. 

Huw, do you want to pick that up?

I think most probably you're referring to the issues in terms of what our local public health teams do in the health boards—

Yes, and just basically performance measures that cover things like the 1000 Lives and the First 1000 Days and all of these kind of programmes. There doesn't seem to be any public reporting of progress. 

One of our challenges for the next year, when we've got our new strategy, is actually how we measure, and how we measure in a meaningful way, the outcomes of all the work. Traditionally, a lot of the measurements have been measurements of outputs or even measurements of inputs, so that's one of the challenges. Now, most of those programmes will be reported on on a regular basis. So, 1000 Lives would regularly be reporting what they're doing, and regularly reporting in terms of the impact of what they're doing. But, certainly, in terms of our corporate performance reporting now, the challenge for us going through this year is actually how we measure the impact of each of those programmes and how we do that in a consistent way. One of the difficulties is clearly Public Health Wales is a very wide-ranging organisation, so what are the key things? I think we're confident, and we're working with health boards as well to be sure that, in terms of what is reported through health boards and what is reported through the director of public health reports on the work that they're doing with us in terms of how we incorporate all of that together—.

Can I just build on that? So, every year, we have a plan, and through our formal board mechanism all the progress against that plan is publicly reported. Whether it's done in a way that's easy to understand is a different area. Now, as Huw said, we have targets. We have a performance report, which I haven't got with me, actually, that we'd be very happy to share with you, which is a very comprehensive detailed performance report that goes to every board and which looks at all of our targets, for example screening programmes, microbiology, smoking cessation, and we have a national exercise referral scheme, which as you'd expect is a dashboard against a target and an indicator. Where we have more qualitative work—some of the collaborative partnerships or where we provide support: some of  the 1000 Lives or ACEs work—it's more of a narrative of reporting, which isn't necessarily showing 'and the so what', which is the area that we really want to move into. It's an interesting one. So, the local public health teams are our people and they're very much a resource to support health boards in the wider locality. Where we have synergy with what health boards are doing around their public health priorities and us, a lot of the work of our local public health teams, as Huw said, tends to be reported through the health boards' performance against public health. We could do more to join that up I think in the reporting.  

That was going to be my next question, actually, about the collaborative working. You're conscious that there's also this criticism by the Welsh audit office of the collaborative working between the health boards, Public Health Wales and local public health agencies. So, you're kind of on that, are you?  

Yes, and part of the challenge is that there has never really been an articulation of what the different roles of responsibility are across what we call the specialist public health system. So, Huw's actually lead on quite an intense piece of work over the last number of months with Welsh Government. Do you want to say something about that? 

I think we welcomed the report, actually, because we work with Welsh Government and then with all the health boards and ourselves to actually try and define those roles, because I think the organisation has evolved since 2010, and to some extent it's done us a lot of good now to step back and actually try and define what people's roles are. A lot of work has been done over the last six to nine months now in terms of agreeing disease priorities. So, all the directors of public health, the health boards and us have agreed the priority areas of work. There is a lot more open and sharing of plans, working together on plans during training and making sure the training opportunities for the staff are completely transparent and prioritised. So, I think there's been real progress over the last six to nine months to actually bring that system to work together. 

The contentious—it was solely in the area of health improvement activity, not the health protection or the intelligence. So, it's actually quite useful just to air it and sort it out.  

Okay. My final question is a quick question, but it may not be a quick answer, so I don't know quite how you're going to answer, given the time. How are you ensuring value for money in terms of public health at the moment? 

I think that goes back slightly to the last answer. I think that's the challenge for public health. If you look at worldwide research, that is often the challenge in terms of how you measure public health. Traditionally, I think a lot of what we've been doing is actually, 'Are we hitting the targets we've been set? Are we using the money wisely? When we compare ourselves to elsewhere, do we look favourable?' It's different across the organisation. In areas like microbiology and screening, we look at, you know, 'Are we spending in the same way that others would be? Are we properly benchmarked? Are we properly procuring using standard operating procedures?', and stuff like that. So, we've done a lot of work on that area. I think the more challenging areas are on health improvement.

10:55

Sure. That's kind of an invest-to-save model, isn't it, really?

Yes, and now were investing in terms of some of our own internal investment, because, each year, one of the challenges we give ourselves is that we make savings each year to invest in ourselves, because we recognise that there's a challenging financial environment. One of the investments we're making this year is in health economics, as part of the policy research and international development team. So, we've built some of that health economics into our research methodology going forward.

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

Mae amser am un cwestiwn olaf. Jayne—

We've got time for one other question. Jayne—

you've got question 19.

Thank you, Chair. You deliver seven national screening programmes and we've heard some recent concerns around the low uptake in the bowel screening programme. What action are you taking to ensure that this uptake is increased, and particularly amongst young men in areas of higher social deprivation? 

Do you want to kick off?

You're absolutely right, we've been concerned about male uptake of the bowel screening for a couple of years now, particularly in less deprived communities. We've run traditional campaigns—print media, television, more and more so social media—and I think this is one of the interesting things about discussions we've had. We often think that just telling the population will result in a change. It's actually extremely difficult to effect population-level change, particularly through some of the more traditional campaigns. However, there is a place for them.

But what we are doing in addition to that is a number of very specific initiatives, and then one larger one. So, in the interest of time, very briefly—we're training community leaders in those communities who have contact with people, such as you describe—males who are less likely to take this test up—in an effort to try and directly engage with them and encourage uptake. Likewise, we're working with GP clusters to work on a local level. We've had some early success in Cwm Taf and we're intending to replicate that approach more broadly elsewhere.

The one thing that we think might well change things is a change of test. For those of you who know what the test is like—it's a fiddly, messy test, and I think it's not the appropriate environment to describe the gory details—

It is not the appropriate environment, indeed, Quentin. [Laughter.]

There is a new test coming along called faecal immunochemical testing, FIT testing, starting in January next year. Scotland, which has already introduced FIT testing, has already seen the uptake, across the social gradient, increase. Now, obviously, we need to be mindful of inequalities and the risks associated with that, but it is encouraging that even in the communities and target populations who've been least inclined to take the test up, that has gone up substantially as a result of FIT testing.

Just quickly on that point, because the obvious consequence of a high take-up is the capacity to do the testing. That opens up a whole, in the last minute—

I think we'll need another one and a half-hour session for that one— 

I throw that hand grenade in right at the last minute, because it is critical. We we're involved with bowel cancer awareness earlier in the year. Lynne and I did some joint campaigning across some of the Valleys constituencies to do exactly what you're suggesting. Bowel Cancer Wales were telling us that the tests are great, and the new test will be even better, but they do have significant concerns about the capacity to actually be able to deal with the increased uptake. 

We'll have to come back to that one; it's a very big subject.

All I would say is that we're working very closely with all health boards and the Welsh Government. In fact, we even had a meeting at the end of last week to try and anticipate, address and review what's needed to fit any gaps.  

Diolch yn fawr. Yn rhyfeddol, rydym ni wedi llwyddo i fynd trwy'r cwestiynau bron i gyd, ac felly, diolch yn fawr iawn i'r tri ohonoch chi, aelodau o Iechyd Cyhoeddus Cymru. Diolch yn fawr i Dr Tracey Cooper, Dr Quentin Sandifer, ac i Huw George am eu presenoldeb, a hefyd am yr adroddiad swmpus yna roeddech chi wedi'i baratoi i ni ymlaen llaw. Efallai y bydd gyda ni ambell i gwestiwn i ddilyn i fyny gyda nodyn, a hefyd rydych chi wedi cytuno i yrru ambell nodyn i ninnau hefyd, felly diolch yn fawr iawn i chi ymlaen llaw am hynny. Ac mi fyddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma i'ch galluogi chi i'w gwireddu nhw, eu bod nhw'n ffeithiol gywir. Felly, diolch yn fawr iawn i chi am hynny, a diolch yn fawr iawn am eich presenoldeb. Diolch yn fawr.

Thank you very much. Amazingly, we have managed to get through nearly all of the questions, so I'd like to say thank you very much to all three of you from Public Health Wales. Thank you, Dr Tracey Cooper, Dr Quentin Sandifer and Huw George for joining us and for the comprehensive report that you prepared for us beforehand. Perhaps we may have a few questions to follow up with in a note, and you have agreed to send a few notes to us also, so we would like to thank you beforehand for that, and inform you that you will receive a transcript of these discussions for you to check that they are factually accurate. So, thank you very much once again, and thank you for your attendance. Thank you.

11:00
3. Papurau i'w nodi
3. Paper(s) to note

I'm cyd-Aelodau, rydym ni'n symud ymlaen i eitem 3, a phapurau i'w nodi. Byddwch chi wedi darllen y llythyr gan Gadeirydd y Pwyllgor Plant, Pobl Ifanc ac Addysg ynglŷn â blaenraglen waith y pwyllgor a meysydd o ddiddordeb cyffredin—diolch yn fawr i Lynne am ysgrifennu ataf—a hefyd y llythyr gan Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol ynglŷn â gwasanaethau y tu allan i oriau. Wyt ti eisiau nodi rhywbeth?

Fellow Members, we will move on to item 3, which is papers to note. You will have read the letter from the Chair of the Children, Young People and Education Committee regarding their forward work programme and areas of shared interest—I'd like to thank Lynne for writing to me—and also the letter from the Cabinet Secretary for Health and Social Services, regarding out-of-hours services. Would you like to note something?

Ie, jest cwestiwn sydyn ynglŷn â'r cynnig i edrych ar sut y gall y ddau bwyllgor gydweithio. Pa mor bell allwn ni wthio'r cydweithio?

Yes, just a question on the proposal to look at the way that the two committees could work collaboratively. How far can we push that collaboration?

Rydw i'n agored i syniadau.

I'm open to suggestions.

Absolutely. I think that's a very valuable thing to discuss, because there's a lot of overlap and there's strength in numbers.

Yes. I mean, have we seen joint reports in the past—proper joint reports?

The only example of that that I can recall was when we were scrutinising the Social Services and Well-being (Wales) Bill in this committee and the children's committee kind of did a little supplementary report on the children's aspect. I don't think it was terribly well received—the two committees doing it together.

Yes, we did have something with the Additional Learning Needs and Education Tribunal (Wales) Bill.

Maybe this, what we're suggesting working together on, is easier than that. I don't know.

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

Cynnig:

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

Motion:

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

Cynigiwyd y cynnig.

Motion moved.

Wel, fe wnawn ni symud ymlaen i eitem 4, a chynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod. Pawb yn cytuno? Diolch.

Well, we'll move on to item 4, and I move, under Standing Order 17.42, to resolve to exclude the public from the remainder of the meeting. Is everyone agreed? Thank you.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 11:02.

Motion agreed.

The public part of the meeting ended at 11:02.