National Assembly for Wales

Thank you, Chair. I'd like to extend my thanks for your detailed papers that you provided for the committee; they were very useful.

The figures indicate now that COVID rates are falling, which we're all thankful for, but there is still a lot of pressure on healthcare services. What are the key differences you're seeing on the front line between the current position and the first wave of the pandemic? And are you concerned or prepared for a third wave? And on that, how many of the health boards are using the field hospitals, and how do long do you think that that additional capacity is needed? Thank you.

Who wants to kick off? Obviously, not all six of you have to answer all of the questions—I'll say that at the start. Steve wants to kick off.

Thank you, and thank you for the question. It is really positive to see COVID rates, as you mentioned, are starting to reduce in our communities, and indeed our hospitals are starting to see the impact of that now. And that's at the end of what's been, I think, a remarkable unprecedented year for all of us and what we've been trying to deal with.

I think there are a number of key differences—and Andrew may want to come in on the operational pressures—but I guess the first one to say is that this wave has come 10 months into this pandemic, and, therefore, where our staff have been in terms of what they've been dealing with for that time has meant it's probably been more exhausting from that point of view. And, of course, added to that, we've had our normal winter pressures, which we didn't have in the first wave, to deal with, which has simply piled on that pressure for our staff on the front line. And our overall numbers for Hywel Dda have been significantly higher than they were in the first wave for COVID. So, I think when you put all of that together—and of course we're still in the midst of this now, our numbers in our hospitals today are about where they were at the peak back in April and May—when you put all that together, it has been a really tough winter, and we're not out of it yet.

We have been using our field hospitals. We've got a number of them on standby, but we've been physically using the field hospitals down in Carreg Las-Bluestone and in the Selwyn Samuels centre in Llanelli. That's been really helpful for pressures and getting flow through the hospitals.

In terms of looking forward, I think it's very difficult to know what the future holds. There are so many variables at the moment, particularly around the transmissibility of the new variants, the emergence of different variants over time, but, of course, more positively, the impact of the vaccination programme, which has been a huge success, I think, in Wales, and I'm very proud of what our staff have done locally in that regard. But there is also a pressure to unlock, and I completely understand that because of the wider issues around the social and economic implications of it. So, I think at the moment we are working with Welsh Government around what that modelling will look like. I think we're going to have to spend the next year being ready for potential surges, if not in COVID, then in some of the consequentials of COVID, or indeed flu. So, I think it's going to be a really complicated, winding path out of this pandemic, rather than maybe a sudden ending.

Yes, thank you. Thank you for the opportunity to answer these questions, and I would agree with everything that's been said by my colleague. It does feel very different this time. In north Wales, we are still seeing a wave that has crossed north Wales, from east through to west. So, we are seeing pressures across north Wales still, albeit that we are seeing a reduction in admissions and we are seeing a reduction in sickness from our staff. But, I'm conscious again that our staff are very tired, many of them haven't taken annual leave, and so that is building up and causing pressures in the system as well.

We do have one of our enfys hospitals accepting patients. That is our Deeside enfys hospital, and it continues to have in-patients in there who are supported by our staff as well. The other two are supporting mass vaccination, as well as Deeside, and that has been a very, very good success story. We are, obviously, preparing for the next wave in terms of preparedness for our planned care and, as far as possible, separating that from where we're seeing the COVID-positive red wards that we've had.

Just to add to that, one of the things that we have done and been able to do is work as a system across north Wales, working with partners, working with our staff to take forward a once-for-north-Wales approach that has enabled us to keep some activity going, with staff and patients moving up and down north Wales to ensure that they get the care that they require. But I would agree, our staff are tired, it's felt very different and we are operating one of our field hospitals as surge capacity, and our critical cares are still surged in places.

And the overview from Cwm Taf. Paul Mears.

Thank you. I very much concur with what Steve and Gill have said in relation to staff. Obviously, as we said in our evidence, we've had a particularly challenging time in Cwm Taf Morgannwg over the past few months, with high levels of activity linked to the high prevalence rates in our community, and that's definitely played through into a very, very challenging winter, as Steve described. We are, in common with other colleagues, now beginning to see that easing, that the level of COVID activity in our intensive care units has reduced significantly. Our general COVID beds are also much reduced, but we are still operating our field hospital at Ysbyty'r Seren down in Bridgend, and I have to say that's been a very successful model for us. It's been operating since October, and it's been operating through the whole peak of the winter, and, frankly, we would have been in a much, much more difficult place had we not had that capacity to use. It's taking patients who are recovering from COVID. So, they're all COVID-recovery patients, but we've had a really innovative model there, where we've worked with primary care colleagues and voluntary sector organisations to actually focus on the rehabilitation of those patients. So, it's not just about holding them in a field hospital before they go home, it's also actively working with them to rehabilitate them. So, if anything positive has come out of this situation, it has meant that we have been able to provide a good level of care to the patients who have been through that field hospital. It currently has 50 patients still in it, so I think a big part of our plan is to maintain that capacity at the moment, but we're obviously just planning now what we may need in the future, looking to make sure we've got the contingencies we may need should there be any future peaks.

Great. Laura, just to wrap up before we move on.

Yes—. Shall I move on to the next one?

Yes.

Yes. Okay, that was interesting, what you said, particularly about the field hospitals, which I wasn't aware of, so that's great. 

COVID-19 is magnifying inequalities across the health and care system, as you all know. It's a seismic upheaval that has disproportionately affected some more than others and risks turning fault lines into chasms, as you well know. As we adjust to the COVID age, though, the focus must be on achieving a fairer health and care system. Would you say that, overall, the quality of care has been maintained, despite the impact of the pandemic, across the board? And also, are there any groups and areas that you feel are being particularly affected by the pandemic? Thanks. 

There we go. Who wants to kick off? Kelechi, you're the star of the show, usually. Crack on. You're muted. [Laughter.]

Thank you. Absolutely, you are right, Laura. The two things that we've already become very aware of with this pandemic is not only has it widened inequalities that we were already aware of in terms of the health outcomes for people in our population spot, it's also widened them. So, that double impact is a very significant one. And when we think about what has happened in some of our deprived communities, we know that the vulnerabilities that resulted in more adverse outcomes from COVID were already predominant in some of our communities, whether it's the prevalence of diabetes or whether it's prevalence of respiratory infection, and, fundamentally, poverty. So, as we come out of this pandemic, in whatever form we come out of it, one of the things that we're going to have to take a very critical look at is the subject of inequalities and poverty, because at the end of the day it was fundamentally about poverty. So, our understanding of how poverty led to this and the preparation for, you know, if we're ever going to face another pandemic, how we ensure that people in our communities don't have the sort of experience that they've had again. That real laser focus on poverty has got to be one of the key resolves that we have to have collectively as we come out of this pandemic.

And talking about the quality of care, clearly there are many dimensions of quality, whether it's patient safety, effectiveness of care, timeliness of care. The impact on quality has had a number of dimensions. There hasn't been, in my view, a significant impact on patient safety because whatever we've done we've tried our very best possible to ensure that the services that remain onstream are safe. But, of course, it has had an effect on the timeliness of access to care for the reasons that we're all very familiar with. So, I think the impact on the quality of services has been multidimensional. Some aspects of quality would naturally have suffered, such as timeliness, but I don't think there's been any compromise on the safety of the services that we have kept onstream.  

I can see everybody else nodding, so back to Laura.

Thank you. We're becoming increasingly aware now of the impact of COVID, particularly the emergence of post-COVID-19 syndrome, known as long COVID now, which are the long-term impacts of COVID. Have you heard anything from patients who have had COVID about the longer term effects it's having on them? I'm assuming it's different for everybody, and symptoms last longer in some than others, but are there particular groups that are being affected by the long-term impacts more than others? I'd just be interested to know that.

We'll start with Professor Guha this time, because you indicated.

Thanks very much for that. Bore da, everyone. Thanks for the opportunity to attend. I think long COVID, as you quite rightly say, is such a diverse and heterogeneous sort of groupings of symptoms that we are beginning to see—and, clearly, from my particular perspective as a clinician who works in critical care medicine—some of the patients who we had treated in the first wave coming back with symptoms that one might not normally expect, and they are sometimes very specific in terms of fatigue that cannot be explained away by exclusion of other diagnoses, and sometimes what has been described in the press as 'brain fog', the inability to coherently analyse information et cetera when they were previously able to do so. So, this is clearly something that I think we will be dealing with more and more.

Certainly in Betsi Cadwaladr, we have nominated one of the executive director of therapies, to be precise, as the lead executive to look at this, examine it and come up with a comprehensive plan. Because, certainly, the emerging data from across the UK seems to suggest that as much as 29 per cent of patients who have had COVID, unfortunately, may be seeking help in the very near future for long COVID-related symptoms. So, we're very aware of this. It's certainly something, as Steve was saying, where there's an uncertain future ahead in terms of the process that we are just about beginning to understand and come to grips with.

It's good you've got someone specifically looking into that. It just shows what we're going to be looking at and discussing in this committee in the future, I expect. Yes, thank you for that, for all those answers. Chair, thank you.

Thank you, Laura. Paul did indicate.

I was just going to say, to follow on from my colleague in north Wales, we've had a service set up for patients with long COVID now, and, similar to my colleague at Betsi Cadwaldr, that's been very much led by our therapists—so, our physiotherapy and occupational therapy teams along with psychology. There is an element of medical input into the conversation, but, actually, a lot of this is coming to terms with living with the effects of long COVID, which are often more physiological, and our therapeutic interventions are often better. So, we have a service that GPs locally can refer into if they've got patients who they're treating with the symptoms. I think we're looking at how we expand and develop that service moving forward. As colleagues were saying, it's still a little bit of an unknown quantity, we're working with something that is still evolving as we go, but I think it's important, actually, as we say, that we've got services that those patients are able to access.

Great, thank you for that. Thank you, Laura. Turning to another important aspect, vaccines. Jayne Bryant.

Thank you, Chair. Good morning. I think Steve mentioned already how well the vaccination programme has gone in Wales so far. We've heard some evidence from community health councils who were saying that many people were finding it difficult to understand the different variations within the vaccination roll-out in different areas or different health board areas. I'm just wondering how you're dealing with that as a challenge and how you can improve on that so that clear communication is given to patients within each area.

Okay. Steve.

Thank you for that. Clearly, this programme has got started from nothing at the beginning of December to something that now has delivered, I think, getting close to a million doses across Wales. Of course, it would absolutely be fair to say there have been bumps in the road for all of us as we've been trying to ramp that up. I think there are different patterns across Wales.

So, just speaking for my own health board, we have, obviously, a very rural community that suits quite well the delivery of the Oxford-AstraZeneca vaccine, because that's obviously much easier to handle, and, due to the great work of our GP colleagues, they were able to start vaccinating in all practices in about the third week of January and then ramped up from there. So, for very large numbers of our general population, actually getting your vaccine in your local practice was seen as really important. However, we've had this dynamic of also having the Pfizer vaccine, which really doesn't lend itself particularly well to splitting it up and ensuring that it isn't wasted because of the shelf-life issues, which get shorter the further along the pathway that you get. So, we have got six mass vaccination centres across our patch, which I think, in terms of the population coverage, is what we needed, but it's been a big challenge for us to get that many up and running. And what we've tried to do—because you're right, the communication is really important here—is to identify specific cohorts of people who can go into those mass vaccination centres, so people know who to expect contact from. So, in the first stages, our mass vaccination centres were focused on our care home front-line staff, our own health board staff and social care staff.

When we got down into the next priority groups, we then had the extra complication of needing to match the amount of vaccine we had, of the two different vaccines, with the cohorts, which meant that the health board had to ask the 75 to 79-year-olds to come to mass vaccination centres whilst the GPs did the 70 to 74-year-olds, and those who were clinically extremely vulnerable under the Joint Committee on Vaccination and Immunisation definition. That was because the other cohorts weren't of the right size for us to deal with, and we didn't want to send out communications saying that some over-70s were coming and some weren't. That's going to get more and more complicated as we go down through the lists, I think, and it's something that we're going to need to continue to work on. But the heart of your question I would absolutely agree with—it's about really clear communication, telling people what they can expect, from who and when, and, as the supply becomes clearer, we'll be able to do that with more and more notice to people. But it has been a huge challenge, I think, to get to this stage.

The view from the north, Gill Harris. Anything to add?

Yes. I would agree with what's been said. We have three mass vaccination centres that are being operated out of north Wales, and I think one of the challenges has been communications. We also have a number of local vaccination centres that have been identified because of the rurality of parts of our population. We're now working really closely with our clusters to develop those plans that meet the needs of the local population. That wasn't something we had the opportunity to do properly when we first started vaccinating, but it's something as we're going into the next phases of the plan where we're looking at a blended approach with our clusters, so that people can get that vaccine as close to home as possible.

We're really conscious that, for some of our communities, getting to a mass vaccination centre means long journeys, perhaps multiple changes in public transport, and expense, and that's not somewhere we want to be. We have had successful primary care-led Pfizer pilots that we're building upon, and we're now working with our clusters and local pharmacies as well so that we can bolster that support across the patch. But, again, I want to acknowledge the staff that have done this and the support of the military and partners in supporting this initiative, because, again, it's another ask of our staff at a time when they're under pressure, and they've done a phenomenal job.

'Phenomenal' is the word. The view from Cwm Taf, Kelechi.

Absolutely just to concur with what Steve and Gill have said, from a public health perspective, to think about a vaccination programme that was started in December, and by February we've vaccinated nearly a million people in Wales, I think that's a phenomenal achievement, and I think we have a lot to be grateful for for the incredible staff across all of our health boards and communities who have done this incredible work. I think the communication challenge is something quite significant. This programme, like we said, went live in December, with so many things, so many difficulties to deal with, but the importance of regular communication with local partners and local populations has come to the fore so significantly, and we have learnt a lot. Along the way there have been bumps; we haven't always got it right, and so sometimes we have had patients and people in our communities who have had the sort of experiences that we wouldn't have wanted them to have. But I think all of that has been an opportunity for us to learn and, going forward, we will put all of that learning, I suppose, and implement it as we roll out this programme more widely.

I think the other thing to say about this vaccination programme is the fact that it gives us an opportunity to—. People talk about the fact that we don't want to end up in a situation where we look at the inequality reports that Public Health Wales produced and highlighted the inequalities in ethnicity and poverty. I come back to poverty again not just because it affects Cwm Taf Morgannwg particularly, but it affects many of our communities represented here. Going forward into the wider population, our consideration of the impact of deprivation and the impact of topographical challenges and access challenges means that we're taking all of that into account. For example, in Cwm Taf Morgannwg, we went with four mass vaccination centres delivered at general practices, delivered in district general hospitals, and by peripatetic teams that were visiting care homes to deliver. Now, as we go forward into the rest of the JCVI priority groups, we're widening this into about seven community vaccination centres that are closer to those communities, because access is really, really important, and all of those changes simply mean that we have to be very, very forward in terms of how we regularly, routinely communicate and use all of our channels and partnerships in our communities to get that message across. So, I think it's been challenging in terms of communication, but we've learnt a lot, and I think the expectation is that we take those lessons forward as we roll out the vaccination to the rest of our population.

Great. Jayne.

Thank you, Chair. That moves me right into my next question, really, because you've just identified ethnic groups and poverty and areas of deprivation where there are going to be challenges in people taking up the vaccine, perhaps. You've touched on a couple of things that you're looking at doing in your health board area as well, and it would be interesting to hear from others. But how else are you communicating with local populations to try and encourage them to take up the vaccine and to try and dispel any myths, as well? I know there are so many myths going around on social media, even door to door—leaflets going door to door. I'm just wondering how you can help in trying to encourage your local populations to have the vaccine.

Okay, who wants to kick off? Paul Mears first, then Steve. Paul.

You're absolutely right. Part of the challenge in this has been—and I think it's probably becoming more apparent now, as we go down the list of age groups—that we're finding that there are a greater number of people that are starting to query the vaccine. There have been some particular challenges with younger members of staff working in care homes, for example, particularly women who've got concerns about fertility impacts, and in trying to dispel that myth we are, for example, getting some of our clinicians in obstetrics and fertility services to do a video that we can put out on social media to try and remind people that there is absolutely no evidence of any impact in that regard, to try and dispel that particular myth.

I think that how we work with our local councillor colleagues, people who are very active in the local community, is really important, because messaging through those routes is really important, and indeed we've had great support from our MS colleagues in our patch, who've been great in terms of disseminating messages through their various social media channels and through their conversations. I think there are some particular challenges for certain groups. For example, we're doing quite a bit of work at the moment with our council colleagues on homeless people, because obviously they are a group of people who are very much at risk of COVID. They are, at the moment, being housed temporarily by many of our council colleagues, so we are doing an active piece of work, for example, with that cohort of people, to go out and vaccinate them proactively, but also take the opportunity to do wider health checks with those groups of people to make sure that their general health needs are being met as well, not just giving them the vaccination. So, as we get into the wider groups of population I think it's going to be a much more targeted approach in terms of our interactions but also in our communications with certain groups of people.

Steve.

I think all I would add, just on a positive note for our first four priority groups, is that I think we've all achieved really high percentages, probably unprecedented percentages. So, in Hywel Dda we're at about 92 per cent of that cohort, which you wouldn't see—. Even the very highest tends to be 75 to 80 per cent. But I think Paul's right—it's going to become more of a challenge as we go down through the priority groups.

Just as a couple of extra things from us, we've used expert panels both for our staff and in our general population as we've rolled this out, so, getting some of those people who know this, and, obviously, our social media channels, with videos. I think Public Health Wales have been great in putting out specific videos dealing with specific myths that are out there. Also, one of the things that we did in the first wave of the pandemic was that we established a BAME reference group within our organisation that our chair, Maria Battle, sits on. That's been a really important sounding board for a whole range of issues, not just COVID related, but we are working with them to ensure that we are focusing for our staff, and into their communities, of course, any particular issues related to that group to ensure that that sort of vaccine hesitancy doesn't become an issue. At the moment, I don't think it is for us, but I think it will grow as we go down the list. 

Okay. Anything to add from the north? Gill. 

I agree with what's been said. One of the things that we're now doing is working with some of our equality partners—[Inaudible.]—bringing them forwards, if you like, and we're developing that trusting relationship. I'd also—[Inaudible.]—the 90 per cent plus mark. But we're analysing those groups that haven't taken it up to say, 'How do we reach those and what are the reasons why they've chosen not to take up the vaccination?' Some of them have come forward now because the myth busting is working. The fertility issues, for example, is one where we've seen people who've declined the vaccine are now coming forward, from people who have been working in care homes. But we are actually now looking at those groups that have refused it to see why, what can we do, what can we learn to persuade. I think working on a multi-agency basis with our third sector, as well as our local authority partners, is helping us to get to those hard to reach, and learn from across Wales, I would say, because there are some good initiatives across Wales that we're stealing shamelessly to ensure that the vaccination gets in the arm of the right person. 

An all-Wales roll out, it's called. Jayne. 

Thank you, Chair. That's really helpful and reassuring. We know that the vaccine programme is enormous, the work that's going in from the staff that are doing the vaccine programme and the long time that's going to take. Have you got any concerns around sustaining progress, particularly in terms of vaccine supply, venue availability and/or staffing? Do you think you'd have the capacity to deliver any booster vaccine, if needed, alongside the flu vaccine in the autumn and winter of this year? 

Steve. 

Just in terms of venues, it gives me an opportunity to publicly thank particularly our universities locally, who have just given us free access to their sites both in Aberystwyth and down in Carmarthen, but also our local authorities for what they've done to support us. At the moment, we don't have any concerns about that, but, of course, we will need to work with them as those parts of the local economy open up again. 

I think what we've had over the last couple of weeks, which has been well reported just in terms of staffing and continuity, is that the slowdown we've seen last week and this week in the supply, which was part of the plan, has given us the opportunity both to train more people coming in and to streamline, because we've set these things up very quickly. So, by the end of this week, we will have a much more streamlined approach for our MVCs.  

Of course, I would say that the backbone of all of this, particularly in Hywel Dda, although not uniquely, is our GP practices, and they are very, very used to giving vaccines; it's what they do every year. So, in relation to the third part of your question around potential boosters, if that comes, I can see that being very much delivered through what are very well-developed processes in primary care and, indeed, with our community pharmacists and others out there. So, at the moment, I don't wish to be 'famous last words', but I think we're fairly confident that if that happens in the winter, we'll have the ability to be able to rise to that challenge. 

Excellent. Kelechi.  

Very much like Steve said, if I'm honest, as far as supply is concerned, we understood the issues around supply. They've been planned for, we expected them, so they don't necessarily represent for us at this point a significant concern. We work very well with our local authority colleagues, and they have done an incredible amount of work in terms of identifying the right venues. So, again, I don't feel like we have any concerns around venues and, as Steve said, the lull we've had has given us the opportunity to remodel vaccination centres and identify ones that are more responsive to the needs of our communities. I think the places where we're probably going to have the biggest concern, in my view, are two areas. One is about our capacity, so primary care. If we need booster doses, I think we can refer to primary care. They have done excellently. They are very familiar with vaccination programmes. They will be our first reference point. But actually, they will also, at the same time, be picking up other pressures as more work comes back normally, so that's going to be one that we have to watch out very closely for.

From where we are in Cwm Taf Morgannwg—and I'm not ashamed to say this in my role as director of public health—I am very worried about inequalities in uptake, and as those inequalities in uptake widen, we risk getting into a situation where we have a divide in society where the richer parts of our communities have a higher uptake and the poorer parts have a lower uptake, and of course we know, with vaccination, no-one is protected until everyone is protected. So, that it going to be something that we're going to have to keep a very, very close eye on. Yesterday, I was reading a reference from the chair of Runnymede Trust, who said that we may have to do some thinking out of the box and go door to door, knocking and vaccinating people. When I heard that, I thought to myself that we may have to find ourselves in Cwm Taf Morgannwg doing that, because to live with the consequences of those inequalities in uptake would, for me, not be acceptable. So, the inequalities in uptake cause me significant concerns. I will have to keep a very, very close eye on that, definitely.

A good point there, Kelechi; as we mentioned in the Senedd yesterday, celebrating 50 years of Julian Tudor Hart's breakthrough paper on the inverse care law, it seems as though the inverse care law is still with us.

Moving on to testing now, so whoever the testing gurus are, listen up, because Laura's got some questions.

Thank you, Chair. I just wanted to know what has been your overall impression and opinion on how testing has been rolled out. What is your experience of your staff and patients in terms of getting access to testing throughout the pandemic, and how has it changed over time?

Kelechi.

By no means am I a testing guru, but we have had very rich experiences around testing across the health board in Cwm Taf Morgannwg. One key difference in comparison with the first wave was that during the first wave access to testing was restricted to people, essentially, who were symptomatic. As the second wave came, we had greater access to testing, which was absolutely the right thing. In my view, one of the strengths of our approach nationally to testing is a very clear national testing strategy that then allowed local interpretation and regional interpretation. That's got to be a strength that we must recognise. I'm not being political here, but credit to the Welsh Government for setting out consistently a very clear, national framework that, regionally, in the health boards and with our local authorities and community partners, we've been able to interpret. So, greater access, as I said, to testing, inclusion of much more diverse testing opportunities, like the introduction of the LumiraDx, lateral flow devices, as well as PCR—I think what it's done is it's diversified and increased our capacity for testing.

We've got our community testing units and mobile testing units all operating, so all the time we have seen great testing capacity, and in a sense at this point what we're dealing with is that we're having significant headroom in terms of capacity for testing, because currently we are at about 30 to 50 per cent of the capacity across all of our testing. At one point, we were having significant pressures in terms of testing turnaround times, but with the reduction in community infection rates and the increase in testing headroom, what we've also seen is consistent improvement in testing turnaround times. So, I think there have been some successes that we've had with testing. In Cwm Taf Morgannwg, we trialled the whole-area testing pilots in Merthyr and lower Cynon, and we have responded to the community testing framework, and I know that there has been a decision on our proposal. Again, that's another opportunity to broaden our testing strategy locally. On the point about 'testing, testing, testing', I think we've heard that loud and clear and we're putting that to use, with very great benefits for us in the region. Thank you.

Great. Hywel Dda, then—there we are, Steve. I'm trying to get Andrew in, but he's being very shy. I can understand shyness, mind you. But anyway, Steve.

I would also say I'm not a testing guru at all, but I think, again, very similar to vaccinations, the national testing strategy was put together very, very quickly. It was remarkable how quick it was in those early days. I know there were bumps in the road, particularly around turnaround times, which are now significantly better through both the lighthouse labs and the local labs in Wales. I guess the only point I wanted to make in addition to Kelechi's, which I agree with, is we've seen a growing number of tools around testing, from the PCR originally, through lateral flow and LumiraDx. I'm starting to sound like a guru, but I'm really not; these are words to me—don't scratch the surface. I think that's going to be very important, because vaccination is going to give us a potential way out, but it needs to be alongside that 'testing, testing, testing' strategy. And the one thing we need to be very careful of is that all of these different testing tools are imperfect in different ways, and therefore we need to use them with care and consideration, particularly around false positive and false negative issues, so they aren't seen as a panacea, but they are seen, actually, as an important weapon at our disposal and a way in which we can help to control this pandemic into the medium term.

Okay. Anything to add from the north? Professor Guha.

Just to add on to that, and agreeing with everything that's been said thus far, the experience in the north is not dissimilar. But on very specific points, we have submitted to the Welsh Government on the fifteenth of this month our community testing plan, and I think that that will enable us to deal with that aspect of it. Because, as we've learnt, although the community transmission rates are reducing, we are still keeping a very close eye on a number of areas in the north where there is still a higher prevalence compared to other areas.

In terms of staff testing, that has obviously been a renewed focus and we've introduced lateral flow testing devices to staff. As of the last count, about 2,000 members of staff have received the lateral flow kits and that's going to be improved and distributed further. There are plans to provide twice-weekly PCR tests on top of that. And one of the things, of course, with the overall testing strategy, is to keep an eye on the variants of concern, which are obviously being monitored, and that is a particular area that we are keeping our beady eyes on.

Excellent. Laura, briefly. I'm trying to squeeze in one more section before we have our break.

Those seemed like relatively positive responses, which is good. It's interesting how important you feel that testing is going forward, particularly picking up the new variants. This question is mainly for Paul from Cwm Taf Morgannwg health board. There have been some concerns expressed about the value and efficiency of lateral flow tests, and we're still awaiting the formal evaluation report on the mass testing campaigns in Merthyr Tydfil and the Cynon valley, which involve those lateral flow tests. In your opinion, what learning can we take from those campaigns?

I'm going to hand over to Kelechi, because he's a lot more expert on this topic than I am and he'll probably be able to give you a much more rounded answer to that. 

Thank you, Paul and thank you, Laura. Lateral flow devices, as we've come to understand, are not PCR; they are very different tests from PCR and they serve a clear purpose that is different from the purpose that standard PCR tests offer. Our experience, having done the pilots in Merthyr and lower Cynon from November to December last year, was that we were able to do more than 40,000 tests across those communities in that short period of time, and public acceptability was very high. We detected positives in asymptomatics that we wouldn't ordinarily have detected. Although we're still in the process of writing up the evaluation—that will be the final evaluation and will be published a couple of weeks from now—we have done an interim analysis, and that included modelling analysis that our colleagues in the communicable disease surveillance centre in Public Health Wales have done. That hasn't been published, but I've seen the first drafts of it. It's incredibly detailed modelling.

It actually suggests that that whole area of testing did suppress infections, and that's understandable because those were infections that we would ordinarily not have found because they were in asymptomatic people. So, I think our key learning is that lateral flow devices have their limitations in the sense that they don't give you—. No test does give you perfect sensitivity and specificity. Its positive predictive value is very high when prevalence is very high, but at a period of low prevalence like this, you've got to think very carefully about the context in which you deploy them.

So, as long as you think about the context in which you deploy them, as long as you understand that they are very different from polymerase chain reactions, and you wrap around conformity with PCRs around them in the proper settings, they do have a very, very clear role in the overall public health response to this pandemic. That's been our experience, and that's exactly why we put forward a proposal to commence a testing framework, and we will be deploying, in Cwm Taf Morgannwg, lateral flow testing in specific settings. 

Very interesting. 

Are you done, Laura?

Just quickly then, Chair, last question. The committee have had a number of sessions regarding concerns about the process of hospital discharge during the pandemic, particularly where the testing has been undertaken before people are discharged back into care homes and in the community. What's the current position, please?

Hospital discharges. Who wants to lead on that? Andrew. Excellent. [Laughter.]

I thought I had to pick up the gauntlet you threw down, Chair. [Laughter.] I think the situation with regard to hospital discharges now is sort of where we've been for a period of time now, with the framework and the guidance that's been in place. Quite rightly, there was a framework put in that put more stringent guidance on thresholds that needed to be reached before we could discharge people out of hospital back into social care and back into the community, and we've all been adhering to those and working to those. I think, naturally though, when you put those in place, you necessarily see an extension in length of stay in some of the acute and community sites that we all operate as health boards. 

And, certainly, from a local experience, that's where our field hospital capacity has become really important to us because it's enabled us to create, as Paul was outlining earlier for Cwm Taf, we've all adopted fairly similar models across Wales to the use of those facilities. And the ability they've had to enable us to rehabilitate patients and manage those extended lengths of stay because we've seen length of stays extended by anything from eight to 14 days, depending on locality and region and some of the local service challenges we've seen, because, obviously, when you've got a COVID outbreak in the community, it's not just health services that are impacted, or health staff or members of the community that are impacted; staff across the public sector workforce have an impact, and that's all played into that situation. 

But, I think, obviously, the criteria are the right ones, but they definitely have an impact on our ability to maintain flow and manage capacity through the system. But working with partners, using our field hospital capacity, looking at how we now start to access, in an appropriate and safe way, some of the void capacity we've got in care homes, and in residential care homes, and independent sector care homes, we'll find as we go through this now ways of managing those delays that we've been experiencing. 

Excellent. Laura, we need to move on, so thank you very much indeed. 

Thank you.

We'll squeeze in an important, huge issue. You intimated at the start how we're going to deal with other aspects of this COVID pandemic. David Rees. 

Diolch, Gadeirydd. Good morning, all, and firstly, can you please pass on my thanks to all your staff for the work you're doing under these pressures? It's almost 12 months since the pandemic started and we had lockdown one. As we came out of it, your staff faced the challenges of having to catch up with other things, and then, wave 2, and as we're coming out of this, we're now facing challenges of coming out, and again, the consequences. 

And that's what I want to ask about, really, is the waiting lists agenda, because we will have seen the waiting lists obviously dramatically change. Whilst waiting lists over Wales have only changed by about 60,000, what we've seen is a change from the under 26 weeks, basically, where there was quite a large number under 26 weeks and a lower number above 36 weeks. That's reversed, and we now have a larger group of people above 36 weeks, and a lot of people above 12 months. I suppose, in a sense, what we're trying to work out is what is the Welsh Government's expectation to deliver on those waiting lists. We can't use initiatives as we've had before because we were using English hospitals and English services, and they've been facing the same challenges over there. So, how are you anticipating getting the waiting list agenda under control?

Right. Andrew, you're on a roll.

I noticed I was the only hand that went up then. Probably, as the executive director of operations in the group, it's probably right that I take the first answer in that question from David. Firstly, I will make sure we pass on the thanks of yourself and the committee for everything. I continue to be, in my role, inspired everyday by the response that our staff have given over the last year and the commitment, the courage and dedication they've shown, and personal sacrifice they often have to make to look after our population.

When I attended the committee, I think in July, with colleagues, we talked a little bit around how actually the complexity of planning the recovery was more significant than we possibly had realised when we entered the pandemic. I think we all thought we would suspend surgery for a period, respond to the COVID incidents, and then restart services. I think the complexity that COVID-19 has brought in the way we plan and deliver services, and particularly have to organise services, is significant. As long as we've got that ongoing level of demand through our acute system, there's always going to be that challenge in terms of having to manage what we've described as red and green pathways, the COVID pathways and non-COVID pathways, and also just what that means for our staffing. So, for example, to maintain a theatre rota we've got to have staff that can—[Inaudible.]—rota. So dealing with, potentially, patients that have COVID, because we won't necessarily know if they're coming in as an emergency, and staff that are dealing with the green elective workload as that comes through. So, perhaps some of our urgent cancer activity that we've been dealing with.

For a number of us, certainly in Hywel Dda, we had staffing problems in those areas before. So, going forward, some of the ways we're having to stretch staff and work in a different way is going to continue to cause a problem. Coupled with that, therefore, and some of the infection prevention and control advice at the moment, which is necessary—we've talked before and you'll have heard about the reduced productivity that we're all able to reach as a result of the situation we're in. So, for most of us, I think, certainly for us, that's around 40 per cent to 50 per cent. We reckon we could operate at 40 per cent to 50 per cent of our previous levels of productivity pre-COVID to now.

So, the scale of the challenge as we go forward is really significant, as you rightly pointed out. I think there's a challenge for us at the moment, in terms of understanding what the future holds and the forecast. So, the one thing we know about COVID so far in our experience is the minute we start to reduce restrictions, incidence starts to increase, because it's driven by individual contact. We've got some encouraging signs and research and evidence coming out early from some nations around the impact of the vaccine on that incidence. But whilst we've got those unknowns and the potential for other variants, it's really quite difficult to plan a long way into the future at the moment, in terms of what we're going to be able to deliver and at what pace.

What I will say is that with the scale of the challenge, and for us in Hywel Dda, if I sat here a year ago and spoke to you about our waiting list position, we were on track to deliver zero patients over 36 weeks, which was the target last year. As I sit here today, we're estimating we'll have around 26,000 patients over 36 weeks at the end of March, which is, obviously, a position that we don't want to accept, and it's something that we want to work urgently and diligently to address. With that, it's quite clear, as you've intimated in your question, David, that a traditional approach to taking forward a response to this isn't going to work, and even before that's involved a lot of individual health boards working in isolation, it's involved a lot of waiting list initiative-type activity, and really trying to sweat all of the capacity you've got available. We're going to have to find different ways of working as a system to address some of these challenges.

We've already seen in the out-patient sense that whereas a year ago we were doing 1 per cent of our activity virtually and via digital technology, for us, I think up to nearly 30 per cent of all of our out-patient activity now is digital and remote and virtual. That doesn't work in all cases, because, in some cases, there's a need for face-to-face contact, and the digital technologies are now enabling us to maximise the space we do have, then, for the elements that are face to face.

But we also need to look at how we do things. So, spending money in the way, perhaps, we have before isn't going to be the answer. So, certainly for us, we're looking at how we can increase our capacity within our acute sites, and we're looking at potentials for demountable units that would bring in extra theatre capacity, extra ward capacity, that would enable us, because of some of our estates and environment, to create a more dedicated segregation between red and green pathways for us to be able to maintain elective services, even if there were further waves or spikes in incidence and transmission.

We're also—we were anyway, but I think what COVID has helped do is accelerate the purpose with which we've been exploring conversations with some of our neighbouring health boards. So, we've been talking with Swansea Bay around how—for particularly some of the high-volume specialties like ophthalmology, trauma and orthopaedics, endoscopy, those sorts of areas—we can work together to come up with a regional solution for addressing some of the challenges we've got. And, I think, the context of that is, this is going to be something as a legacy of COVID that we're probably looking at more years than months to be able to address the challenge we've got, which is why those traditional approaches of response need to be reviewed, and we need to go to a different type of response this time around.

I'm assuming that's common across the health boards, in a sense.

Gill.

Yes. I support everything that's been said, but I think one of the opportunities it has brought us is to refocus on different ways of doing things. So, as a health board, I alluded to earlier the fact that we've gone through once-for-north-Wales, which has meant, for some of our essential services, we've been able to maintain them by clinicians—and I mean our clinicians—literally going to another site in order to undertake surgery where it's impossible to do it elsewhere. So, I think that principle of a whole system has very much been endorsed.

One of the things it's also identified is, where possible, how we split surgical: so, planned, elective versus unplanned activity. In any normal winter we would see planned activity displaced. So, we are very much pursuing and we are putting together a case for a diagnostic treatment centre that would separate those two. So, if there is another wave of any pandemic, we could continue in a different way, staffing permitted.

Again, we are seeing significant waits; we had significant waits to begin with, but we're now looking at significant over-52-week waits. We know what our most concerning priority specialties are, not least orthopaedics, urology, ophthalmology. So, we know where they are, and we are pursuing alternatives. Again, we are already planning to bring in additional demountable theatres and wards to support that separation of elective. And we have plans in place to increase our virtual capacity, and that's virtual follow-up as well. Orthopaedic surgeons are working with the Bevan Foundation and the Getting It Right First Time project to see how they can streamline those pathways. So, we're looking at things through a very different lens.

I would agree also that the recovery is between three and five years to get back to where we need to be, and our clinicians are working particularly innovatively. But I would say, as well, that the principles of the four harms that were adopted early on in the pandemic, and the unintended consequence of harm—the P1, to P4—has helped us very much in terms of the conversations we're having with our clinicians, the multidisciplinary reviews that are taking place. So, we ensure that those most in need of that planned care are getting it, albeit that we recognise that the longer the wait, they may move across those P1 to P4, and that's why that process is ongoing.

Paul.

Paul.

I agree completely with what both colleagues have said from the other health boards with regard to our surgery. What I was also going to highlight is that we shouldn't forget also there's a big implication from the waiting list for our colleagues in primary care as well, because, obviously, many of these patients are going back to their GPs to ask, 'What's happening with my appointment?' or say, 'My pain's getting worse,' or that sort of thing. So, whilst we're very much focused on, as are other colleagues, our operation efficiency and what we can try and do within the confines of our limitations with COVID being there and an ever-present challenge, we're also making sure that we involve our primary care colleagues in the discussions about how we manage the waiting list going forward, because I think it's really important that we approach it as a whole system, not just as the hospital's problem to deal with. This is a whole-health system at a local level and we need to be working collaboratively, and, indeed, we've also been having conversations with our local authority colleagues to try and help them understand what the challenges are, because I think it's really important that—. I personally think this is going to be like the next vaccination challenge in terms of explaining to the population about how we're going to manage the situation going forward. So, it's really important that there's a good level of understanding across everybody about the scale of the challenge, the expectations that we need to set with our populations, but also how we're going to communicate on an ongoing basis with our patients and communities about the approach, and how the successes, hopefully, will be starting to make some inroads into this.

Professor Guha next and then Steve Moore.

Thanks very much, Chair. Just to add on to this, I think the view we have adopted and we've seen that is providing us with some degree of success is the re-enablement of the clinical leadership and the innovativeness that it provides, and I think I need to articulate that to add on to some of the operational strategies that have been described thus far. What this really means is that we will not be successful if we think in traditional models, and it is about how we reinvent and re-energise and think differently about new models of care.

To illustrate what has just been described by Paul just now, primary care, absolutely, so we are developing new ambulatory care models where primary care clinicians get direct access to diagnostics, and that is a completely different model of care than we have had previously in north Wales. The other example would be—. Orthopaedics has been described, so we have embraced, with a degree of energy, the escape-pain programme and prehabilitation. So, how do you keep patients who are awaiting surgical procedures better and stronger in their homes? We have actually trained up a large number of therapists and other colleagues to help patients who are waiting for their surgery, which has obviously been delayed due to COVID, so that when they actually present for surgery, they have not worsened, but keep their physiological status. I could come up with a number of other observations as well. I think it is about re-engaging with our clinical colleagues to devise new models of care that we should be able to share across Wales, and have that sort of adoption and spread of good practice and learn from each other.

Final word before the break, then, to Steve Moore.

Thank you. I'll be brief, I don't want to come between you and a break, but, actually, Professor Guha's made one of my points, which is we've seen a huge amount of innovation led by our clinical and managerial teams on the front line during the response to the pandemic. We've got to maintain that level of innovation as we come out into this phase of needing to recover and restore our services.

The only point I wanted to add to everything that has been said, because I don't think it's been acknowledged around the table yet: we need to ensure that our staff have a rest. What we have at the moment are people who have been through 12 months of either direct war with the virus, or indeed turning their lives upside down, their professional and personal lives, to be able to do this. They're the ones who are going to care for these patients. So, it's just an acknowledgement that I know there will be, for lots of very, very good reasons, a huge desire just to get on with this, but I think our staff need a bit of a moment of downtime, rest and recuperation, and, indeed, reflection and processing of what they've just been through.

Excellent point. We'll have that break now, 10 minutes off screen, and David Rees will take up the cudgels again at 10:45. Diolch yn fawr, bawb.

Diolch, Cadeirydd. We were talking about waiting lists before the break, so I want to continue with that agenda if I can. You've highlighted very much the issues around ophthalmology or endoscopy, and you've talked about those aspects, but also one of the big issues we've got is diagnostics and I think Gill mentioned it—she talked about the diagnostics centre. But diagnostics at the moment, we know, are also under pressure. Their numbers are going up dramatically and they were under normal circumstances still challenging, so we know there are going to be additional requirements upon diagnostics to be able to deal with this, and I'm assuming that as we come out of COVID, those who did not present themselves prior to COVID will now present themselves as well, which adds to that.

So, what discussions are you having with Welsh Government to look at how you're going to increase the diagnostics? So, it's diagnostics with both capital and staffing resources. You were challenged beforehand, so with those extra numbers, you're going to be challenged even more now, so what discussions are you having with Welsh Government to look at the capacity of diagnostics that you will need to deliver as more people come in?

Okay. Steve.

Yes, I'll kick off. Thank you, David, and yes, you're absolutely right to say diagnostics is going to be a key challenge for us, both because pre pandemic we were already challenged for staffing, particularly for radiological staff and others, but also because of some of the ageing equipment that we had, and I think COVID has exacerbated that, and I think in common with what Andrew said around generally our planned care services, a loss of capacity as a result of the need for infection prevention and control procedures, for example.

I just wanted to mention that I'm the imaging CEO lead for Wales, which sounds very grand; it doesn't mean I'm an expert by any means. I'd describe myself more as a slight figurehead, but I've been leading a piece of work by the imaging essential services group in Wales to look at what the implications are coming out at the other side of the pandemic for increasing capacity within the service. It's likely there's going to need to be short-term solutions to that as well as much longer term ones; as Gill mentioned, the potential for things like diagnostic hubs, which I think will be part of the mix, particularly if you're in a rural area like mine. Clearly, having hubs means people have to travel, so we'd need to balance that with rurality and keeping our services local. But I can see, for the scale of the challenge we've got, which is not dissimilar to that for the rest of our planned care services, this is going to be something of a major focus for us as we go through it. As you say, we've got the issue of the current waiting list, but what we don't know, one of the big unknowns, is pent-up demand for people who haven't yet presented, who maybe should have done through the pandemic.

Can I ask on that—? One of my concerns and worries is the pent-up demand that's coming down the line because people haven't presented. What is your anticipation about the impact that will have, and have you yet assessed the likelihood—? Because, for example in cancer, we know the number of people presenting dropped by 75 per cent at one stage, compared to previous years, so what expectations are you going to be working on to look at not just the waiting lists we've got, but the waiting lists that are, shall we say, hidden at this point in time?

It is quite a difficult one, and I'm sure other colleagues might want to come in. I can see Andrew's got his hand up. It's quite a difficult one to answer. You mentioned cancer, and actually we certainly saw a huge drop in cancer demand referrals into the system in the first part of the pandemic. I think it was over 50 per cent and, in some modalities, it was sort of 65, 70 per cent locally. Actually, we've seen that start to return to previous pre-pandemic levels now. So, it's difficult to know whether that is also the case for diagnostic services, but I think we're going to see pent-up demand coming through in many different ways—mental health services, diagnostic services, and potentially others as well. If I've got—just on cancer—a particular concern, it's not so much now around the referrals coming into the system with suspected cancer, it's the fact that we may have missed incidental cancers. Quite a few cancers get picked up in emergency departments, for example, and we know the activity there has been less across the pandemic, although it's changed over time. So, I think we've got a lot of work to do and a lot of analysis to do about what that might look like for the future, on top of what we already know is on our waiting lists for all of those services.

Okay. Andrew.

Thanks. Just to add to that, really, I think, in terms of our overall referral rates, when I look at 2020 compared to 2019, we've seen around a 25 per cent reduction in referrals from GPs during the course of that 12-month period. So, we had circa 126,000, 130,000 referrals in 2019; we've seen just around 92,000 to 93,000 through the course of 2020. That said, a lot of that drop-off happened very early in the pandemic, and as we were getting back towards Christmas and before the second wave, we'd started to see our weekly referral levels getting back to somewhere near where they were pre COVID. So, there's an indication there that, certainly over the course of this calendar year, if the COVID position continues to improve, and incidence in the community continues to improve, then we'll probably see that level of GP referral get back to where it was. And I would anticipate, just because there will be, as we've talked about, an element of demand that maybe has gone unmet so far, that may then start to, at some point, exceed levels that we've seen before. 

I think the other angle of this is something that we, in terms of demand and which will impact on some of the diagnostics, but also just some of the things we will need to do pathway wise, is we're also quite worried about the impact that the extended waiting times will have on patients, and other things we will need to help prehabilitate patients prior to their treatment. So, if you've been on an orthopaedic waiting list for a period of time, there may be a need for an enhanced level of prehabilitation before you'll be fit enough, before we would consider wanting to do the surgery. So, there are other hidden elements of demand in the system that we will need to manage.

But I think it's fair to say at the moment that all health boards are currently working through the modelling and the data and trying to get a real detailed understanding of what that trajectory looks like, and whether any of the demand that we've seen fall away over the last year—whatever that is—whether that continues, or whether we end up getting back to where we've been. And, as I say, my anticipation would be that, at some point over the next 12 months, if the COVID pandemic continues on the trajectory it's on at the moment—and, as I've said, there are all sorts of uncertainties and unknowns—I would probably anticipate that we would at least get back to where we were previously in terms of referral numbers. But I would imagine there'd be some kind of catch-up as well for all of those people that have been worried about maybe presenting sooner.

Okay. David, to wrap things up.

I think, on waiting lists, what I want to try and get down to is how prepared the health boards are for the—I think—flood that will come ahead of us, because there are definitely going to be large numbers. And also how are you going to ensure people are communicated with, because there'll be huge expectations upon your patients to be able to be addressed quickly? They have to be told truthfully, so how are you going to have that communication with them?

Paul. Paul's the man.

Well, I completely agree. I guess we're dealing with a multitude of factors here, aren't we? We're dealing with the waiting lists that pre COVID were already quite high, we've had a period of activity that's been reduced because of COVID, and now we've got the pent-up demand of people who haven't accessed care during the past year. So, you're absolutely right to highlight it's a big challenge, and, as I said earlier, I think this is going to be the biggest challenge facing us all moving forward.

I think the point about communication expectation setting is really important, and I think that's about expectation setting for the people who are already on the waiting list, and explaining to people how we're going to prioritise, because the reality is that we will have to prioritise people based on clinical need, not necessarily the time they've been on the waiting list. And that's a difficult message to explain to people when somebody who's been on the waiting list say nine months hears that their friend down the road, who's only been on the list for three months, is being treated first, and you have to explain to them that it's being done on clinical need not just the length of time waited. So, there is definitely that angle. And I think there's also something about expectation setting for newly referred patients. So, where we've got patients who are being referred by their GP or another professional, being very clear with them about the time that they can expect that that process will take, and also being clear and having conversations about alternatives to treatment.

It's slightly odd to say it, but in some ways we need to try and turn some of this into a positive. If you go back to the principles of things like value-based healthcare, are we absolutely sure this person is being referred for the appropriate procedure? Do they actually need this procedure? Is there an alternative option that could be therapy led, or a specialist intervention? So, it isn't always about necessarily just being referred to a consultant for a procedure or a treatment. So, I think we've got to do a lot of expectation setting, and I think one of the things we're thinking about locally in CTM is looking at—. In the way we have a vaccination helpline to provide the public with the opportunity to phone up and ask a question or query about vaccination, it may be that we need to think about that type of model as well—that we could provide a communication channel for people to be able to get in contact if they've got concerns. Because, as I said, my concern otherwise is that we're going to see GP colleagues and medical secretaries of consultants inundated with people ringing up and enquiring about where they are on a waiting list. So, I think we need to be able to be proactively communicating with the patients on the list to explain to them what the process is and where they can expect to be treated.

Yes, that's a cracking idea. Steve, briefly.

Yes, just a couple of things to pick up there. I guess, looking at this from a rounded point of view, I think it's fair to acknowledge, David, that what we've had is the biggest system shock in the NHS's history through this, and actually a shock for our communities on a similar scale. So, I think it is probably fair to acknowledge that some of this is a little bit of an unknown quantity for us going forward about what the ripples are going to be, what are the consequences going to be, into the long term. We did a piece of work over the summer, our discover report, which, amongst other things, looked back at previous pandemics and what had happened as a result of those, right back to the Black Death, actually, to try and get some learning, but it's fair to say it's a different world. There are things we're going to need to work out as we go along, and the scale of the challenge, I think, will emerge, even if we know the early parts of it.

I guess the positive, though, as I mentioned earlier, is the amount of innovation we've seen and thinking differently from our clinical and managerial front-line staff. I think that will enable us to do some of the things that Paul has mentioned around how do we completely rethink what we do—the role of self-care, primary care, when it is necessary to come and see a clinician. And needing to keep in contact—particularly over the next few years, with the scale of the waiting list that we have—with all of our patients is also going to be really important, as Paul said. We started a project in September to establish a comprehensive system of staying in contact—personalised contact—with all patients who are waiting for our care. That's starting to roll out now. We'll have the first stage of that by the end of February. It's quite a complicated thing to get right, but actually it's something we think will again stand us in good stead beyond the end of this pandemic and the restoration of our services.

Gill, had you indicated?

Yes. Again, I think a lot of initiatives are being taken in the north that have been reflected here. I think communication is ongoing; it's an ongoing challenge. I'm really concerned that, when we do see more referrals coming in through GPs, we may see a higher incidence of those requiring priority diagnostics, which may then make the wait still longer, and people will move across there. So, I agree with Steve's point that many patients who have got cancer will present via other means rather than via an urgent pathway, so I am concerned that we're trying to model for that, but I think that is unknown.

We are also trying to work with our booking staff so that they can recognise stress. People out there—. There are a lot of impacts here. There's the physical harm, there's the mental harm and there's the socioeconomic harm that patients are seeing as a consequence of that. If you're waiting for an orthopaedic procedure, that may be preventing you from being able to undertake work fully, for example, and that's got an impact. So, we're, again, working with our booking teams so that they can start to pick this up so that we can start to individualise some of that care. Again, we're looking at virtual physio, virtual follow-up, and we do have consult and connect, where GPs can contact a consultant specialist to talk through an individual patient and thus formulate a pathway virtually, which could prevent that referral but, equally, could fast-track that referral or give local advice.

Excellent. David, all right?

Yes, thank you, Chair.

Great, because we need some agility now, and we've got some expert questioners who are very agile, and Lynne Neagle is foremost amongst them. Lynne. 

Thanks, Chair. I think quite a few of my questions have overlapped with David's, so have been covered, so you'll be pleased to know I'm going to be quite brief. I wanted to probe a bit more on the issues around workforce. You've all referred to the huge challenges in terms of catch-up because the workforce is tired, but also some of those members of staff are going to have to go back to different departments. What are the particular challenges, do you think, of managing that change now to make sure the NHS can catch up?  

Okay. Paul Mears. 

So, yes, you're absolutely right. I think if you were to say to me what's my biggest concern about the potential coming out of COVID, I think it is the impact on our staff. We were already dealing with a scenario before COVID where some of our areas were already stretched in terms of recruitment and retention of staff. So, we've piled the pandemic on top of an already fragile system. Having said all of that, as we've already described, the staff have been amazing in the way they've risen to the challenge and have gone above and beyond.

Just to give you some examples, our field hospitals, for example, have only been able to be resourced because staff have been redeployed from other areas, and when I say 'redeployed', these were, for example, staff used to working in mental health units being redeployed to work in a care-of-the-elderly facility, or paediatric specialist nurses coming out of children's services and working with elderly patients—quite difficult, very difficult, scenarios for them to manage professionally, having never been involved, or not been involved with elderly patients for a very, very long time. And again, they've risen to that challenge enormously well and, indeed, actually, having spoken to some of those staff, oddly, they have found some of the skills they've acquired during this period of time very useful to take back to their original area. So, again, taking a little bit of positivity out of some of the things we've had to deal with, there is that.

But I think you're absolutely right to highlight it, and you think about, particularly, our colleagues who work in theatres, many of whom have been redeployed to critical care during the peak. They are the very same staff now that we're going to be asking to ramp up their activity and look at getting extra operating lists through to try and catch up on the elective workload. I think at the minute we probably haven't yet seen the full impact of COVID on our staff, as Gill was describing, I think, earlier on. I wouldn't be at all surprised if we get some members of our staff who start to think about whether they want to carry on working in certain areas, and whether they'd see a career in a different part of nursing or medicine perhaps being more attractive down the line, rather than the intensity of working in some of the very high end—critical care, theatres, those sorts of places.

I think what we just have to make sure is that we are supporting our staff, and I know all of our health boards have all put in an enormous amount of effort and energy into a range of services to support staff at these really challenging times. We've certainly put in a lot of work around occupational psychology to go in and work alongside staff who've been dealing with the really difficult consequences of the pandemic, dealing with a lot of deaths and mortality in the units that they're working in. That has a huge impact on our staff when they're dealing with that on a day-to-day basis. 

But I think it's also about having a range of options that are open to our staff to access, and not being overly prescriptive, because different staff I think like to access things in different ways. Some of our staff really benefit from the psychological support; others want to be able to have good support from their line manager or talk to someone else in the organisation. We've used people like our chaplains very actively across our organisation to try and provide support to our staff. So, I think we've done a huge amount for our staff, but I'm concerned that we perhaps haven't yet seen the full impact, and I think that will start to play through over the next few months. 

Okay. Steve Moore, then Professor Guha. 

Yes. I think what's been remarkable through all of this has been the willingness of our staff at all levels to run towards the danger. I think it has shown just the NHS, and probably public services more generally—just the strength of it, really. I remember in early October, before we'd really started to see the second wave impacting us, but knowing it was coming, I was in Glangwili Hospital and dropped into the out-patient department. I didn't know at the time, but that was the day that they were going to be asked to be redeployed into the wards, and these are nurses who are used to running out-patient clinics. The senior nurse took me to one side—I'm sure she won't mind me saying this—she had tears in her eyes because of the fear she had for her staff going into unfamiliar environments, facing COVID on a daily basis, and yet they did it. 

And we've seen that with our therapists, supporting the ITU. We've seen it with our apprentices. We took on a whole range of 16 and 17-year-olds just before COVID hit. They would not have predicted, and neither did we, that they would be out in our testing centres, they'd be in our field hospitals, they'd be providing support across a whole range of services. That's why, at the end of the first part of this session, that need for time to process and reflect, I think, is really important. For those of you who may have seen the Radio 5 Live broadcast from Hywel Dda—was it last week—I think there are two other things at play here. One is, as Paul has mentioned, that worry about staff who have really been particularly through a very difficult time, who have been at war with this virus for so long, who may be tempted to retire early, to go, and we saw that with Meryl Jenkins, one of our nurses in Glangwili, who was really quite tearful in what she said to the Radio 5 Live reporter, but really gave an unvarnished, honest view of just the challenges and the need to keep hope up, and, for some people, that hope may have gone. But, actually, on the other end, we've seen a massive upswelling of people wanting to come into the NHS. So, there's something like 950 new recruits since September into Hywel Dda—bearing in mind our workforce is around 10,000-ish—people who really want to join. The sense of mission, the sense of vocation that it gives, I think, has really been underlined.

So, again, a bit like the waiting list, there are a lot of things to work through here, and, similar to what Paul said, we've had a whole range of services in place through the pandemic response around psychological support and other things. We've got to continue to do that and continue to find ways of allowing staff to recuperate in all aspects of their life over the next few years. That is as important, I think, as getting the services restarted.

Excellent. Professor Guha, in addition.

Thanks, Chair. Yes, in addition, and certainly I'll remove my medical director hat and just speak as an active shop-floor clinician, because on a daily basis I'm seeing the effects of this on clinical colleagues of all varieties, and indeed from cleaners to nurses and allied health professionals and doctors as well, and it's a balance that I think we need to recognise as we try and ramp up our business as usual and how we serve the waiting lists and the patients in front of us and how we support our staff. The well-being aspect has been well articulated, but the other additionality for me is the staff recognition. It's the recognition by all of us of the 200 per cent and more that many of them have actually given, and still feel guilty, surprisingly. The number of nurses I meet now who will say, 'Well, I don't think I've done enough, because there were so many patients I had to look after in the surge' is really a sobering moment and has been, for me, over the months. So, it is actually about striking that balance, recognising the pressures we are under, because it's the same staff and yet they want to give more. I know a medical colleague who on off-days is coming in and being a vaccinator, when I think he should be resting, but they are not, and I think it's that recognition, as well as the provision of the well-being, that I think is important, and for us to address. Thank you.

Lynne.

Yes, thank you. There aren't really any words, are there, to describe how awesome the staff have been, really. Do you feel that Government recognises these messages you're giving? Do you think that you're going to get whatever support you need, really, to help staff to recover from what they've been through, which is really like a collective trauma, isn't it?

I think there is a large amount of interest to support these kinds of activities, and, as we go forward, certainly, we are finding that that support is forthcoming in that way. There is that difficulty, isn't there, which has been articulated by other colleagues as well, that we have one staff. So, for me, it is that retention part that is very important, that we mustn't lose the staff that we already have, and any other intervention that comes from members of this panel and, indeed, Government, in terms of that support, would be very welcome. Of course, we are looking for new ways of working as well to try and serve the patients who have been waiting for such a long time.

Great. Paul Mears.

I was just going to say that I think we've certainly had the support over the past 12 months. If you think about the challenge with our staff, the message has very much been, 'We'll get in place whatever we need to get in place to support you'. And there have been, obviously, additional resources provided to support that, so I think it's been very helpful. The important thing that we need to take away is that there isn't just a hard stop to that and it all just goes back to normal; this is going to be ongoing, as we've just described. There may be a slightly different framing of the challenge, moving forward, but there is still going to be that ongoing challenge and I think it's really important that we understand that COVID is still with us and it is still impacting the way we work on a daily basis. And it's important that that sort of approach is continued with our staff.  

Thank you. Can I just ask, then, about some of the people who came back to help? We had retired NHS staff who came back and lots of students, and you've referred to apprentices as well. Is there scope to continue that way of working as we try and recover from COVID, do you think?

Who wants to start? Steve.

As you say, we saw a huge coming together of our communities of our retired staff locally, as this pandemic evolved, and very many of those retirees have now been enrolled onto our bank staff, because they continue to want to give, and that's partly in recognition of the fact that the pandemic, of course, isn't over. I think that that's something that we're going to want to continue to work on in time. Of course, we've also got a number of our staff who are currently shielding at home and working, and we need to ensure that we continue to support them and that they are able to work, and we keep in touch with them from a well-being perspective as well, because it can feel quite isolating being at home on your own. So, I'm hoping that we can really capitalise on those people who have stepped forward who have never worked in the NHS before, but also those who've chosen to come back into the profession. It's going to be incumbent on health boards to be very flexible about how they do that and how they can help people to do the sort of work that they want to do and that will help us.

Great. Gill Harris.

Steve's picked up some of the points I wanted to make, but I think we too have got a lot of people on our bank and are accessing them. They've stepped forward. I met a retired district nurse who was supporting our critical care service, so they're way out of their comfort zones, but they've stepped forward. I think it's yet to be seen whether any of those will continue after this wave is complete, but what we are seeing is a different use of our communities and volunteers and people, now, who are wanting to access the profession. I think that gives us different opportunities. We've used our students, but we've also used other qualified staff who are stepping onto our banks and we can give them, I think, a good lift-up, if you like, to access professional qualifications, be that in nursing or therapies or others, and I think this has given an opportunity to see the art of the possible within these careers. I see that as really positive, and I think keeping those people on our banks, moving forward, but also supporting them through different career options is going to be a real opportunity for us, but equally a challenge.

I do go back, as well, to supporting the current staff so that they are prepared to stay with us, prepared to move forward, and that may be a pause, it may be a step back before they step back in, but I do think we've got to be flexible and recognise what they've been through. I spoke to a nurse the other day who said she was luckier than most because she'd had some time off, and when I said, 'I'm pleased you managed to get a break', she said, 'Well, I had COVID and they wouldn't let me back', and I said, 'That's not a break'. But I think that that demonstrates the guilt that people are feeling with their colleagues, so we do need to give them, I think, some respite and some time, to encourage them to stay with us for the next unintended consequences.

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

I'll have a go at starting that, if that's okay. I think, for us, the first point in terms of keeping contact with everyone is just the sheer volume of people there are to communicate with. As I outlined, for us in Hywel Dda, we've got a total of around 30,000 people on waiting lists at the moment. So, it's how do you, in a sensible way, communicate with them, and not just make it feel like it's just simply a mail shot and tokenistic gesture, but that you're actually contacting them in a way that gives them meaningful update and information that helps them understand what's happening. We're taking a number of approaches locally. From the first wave, in oncology our cancer nurse specialist, as an example, set up a cancer helpline, and we've had over 3,500 contacts from patients, carers and families, and clinicians, looking for advice and seeking support and updates on various aspects of a patient's journey, and the cancer nurse specialist has been able to provide that. 

And in terms of our other waiting lists, we're in the process at the moment of working through formally communicating with our long-wait orthopaedic, surgical and paediatric patients, and we envisage we will have completed that, I think, by the end of February. I think in our original submission we might have said we would have completed that by the end of January, but there was a technical issue with the production of the letter that delayed it slightly. So, I just wanted to correct that whilst we had the opportunity, for the record. 

But we're also undertaking a large-scale validation of patients relating to follow-up care, and making sure patients still require the appointments or ongoing contact. We're using the intranet and social media to keep in touch with patients more generally, and we're using things like PROMs and Patient Knows Best to communicate with patients in different ways and be able to track their outcomes, and that's helping inform our ability to risk stratify and manage on a risk basis patients and prioritise patients coming back in. 

I think the other thing that we are really keen to do is—. Again, early on in the pandemic, we established as a health board a command centre to act as something of a single point of contact for everything really to do with COVID, for staff, our partner agencies and for the public. So, if you needed a test, that would be the way and the number you would have phoned, for example. We're looking at—and we've got a formal project that we've established that I'm leading with our director of nursing quality, safety and patient experience; that's a mouthful to get out in a setting like this—how we develop a single point of contact for this cohort of patients as well. So, a bit like the cancer helpline, if you like, but that kind of model where there's a dedicated number they can ring, a single number they can ring, and they'll be directed then into the right part of the system to get the requisite advice and input they need. We're starting the journey on that with orthopaedics just because of the sheer volume of patients we've got. 

I think the only thing I would like to add to that is that the challenge has been that the information we're giving them is ever-changing. So, when they do call, we can't give them anything definitive, and I think that is really, really difficult. In addition, one of the things that we are learning from the contact centre that we put up as part of our vaccination response is looking how we can morph that in to support the communication with patients in our planned care as it moves forward. 

I think you're absolutely right, and I think that this is where technology can help in some of the things we're doing. So, for example, we're looking at how we could develop—and this has been across Wales—a patient portal to enable patients to be able to interact remotely with clinical teams, to self-report some of their symptoms and things like that. So, you can actually track—. So, say for example someone's recording how their pain is or how their rheumatoid arthritis is, or some of those long-term conditions that patients are managing, often many of these patients will be able to report how they're feeling, and a clinician, whether that's a specialist nurse or a doctor, can track that and, actually, if people are managing fine, then they don't need to be brought back in. But, obviously, if their pain score or their self-reported outcome deviates from a norm, then the specialist nurse or whoever can pick up the phone and have a chat with them and say, 'Do you want me to give you some advice over the phone?' and they can assess whether that person needs to be brought in. So, I do think it's about trying to shift the mindset and saying, 'Actually, rather than just having people passively waiting on a waiting list, how can we use some of these devices and technology to enable people to interact more actively?' and clinicians can then prioritise based on the self-reported nature of the care. But it also gives the opportunity for the clinician to communicate proactively with that patient and just provide them with regular updates.

I think part of what we're doing is a good example of some of the innovation that COVID has brought. The out-patient model that's existed pretty much in a static way since the NHS was founded, I think, has completely been turned on its head during COVID, and it actually gives us the opportunity to try and reframe that relationship with patients and actually get a much more active, ongoing dialogue, recognising completely that there are going to be also cohorts of patients for whom that isn't appropriate and it's therefore appropriate we find alternative arrangements for them to make sure they can have the planned interactions that they would expect.

Thank you. Again, I'll invite anybody who wants to add to that, with any particular aspects. Gill Harris again.

Just to add to that, really, I absolutely agree that this has been turned on its head. I think it was mentioned earlier that, certainly with some of our orthopaedic patients working with our therapists, we're looking at initiatives—that escape from pain—to prevent follow-ups and people being managed in a very, very different way. It's already been referred to, but we're acknowledging that we're going to have patient-initiated follow-ups. So, they can contact us and say, 'We have concerns'—the 'see on symptom' type principle, that they can access services and we can prioritise those in different ways, and, again, similarly on the virtual platforms. And we're also looking at developing and are developing apps so that we can educate, particularly remote physio, prompting people to undertake their physio. So, it's looking at different initiatives to be able to keep people at home, negating the need for an out-patient appointment, but ensuring they're getting the care and interventions that they require. So, it is making our clinicians—I use that in the widest sense—think very differently to ensure that they can support their patients.

I've seen Andrew Carruthers and Steve Moore indicate they want to come in. Time is running out, ish, so if I can ask you to be fairly brief.

I'll be very brief. It was just to add that the other thing was just in terms of the way—. I think Gill probably commented on what I was going say actually towards the end, but just to add that as well as some of the individual appointments and the use of technology for those, we're also trying to increasingly use technology to undertake some of our group therapy interventions and classes that maybe otherwise would have been lost, because you need to be in a big single venue or hall to accommodate 10 or 12 people in the modern context. So, another way we're using technology is to help us maintain some of those group and class therapy interventions.  

Thank you. Steve Moore.

The only thing I would very briefly add to all of that is that one of the things that I think has characterised our response to the pandemic is we've done things at speed, at scale. Actually, one of the challenges going forward is: how do we nail that and make it comprehensive, make it consistent across all patient groups? You know, some of these things were put together very quickly. I think it's just worth acknowledging, part of the work we've got to do about recovery is to really nail this now. But, as others have said, as Paul said in particular, it's turned our system on its head; the trick is not to allow ourselves to fall back into what we were doing previously.

Thank you. On service transformation, we clearly haven't got time in five minutes to look at all the different aspects of the way services have had to be transformed. We tend to think how all of this has negatively impacted on health and care, but, actually, there are positives that have come out of it because things have been forced upon us. So, I'm just after your general thoughts on how you as organisations will now try to bottle some of those really positive innovations and make sure that they don't turn into things that are transient, that happened during that year—or two or three, whatever—of COVID, but became permanent things. Steve Moore.

Actually, I referred to our 'Strategic Discover Report' earlier. The main function of that over the summer, as we came out of the first wave, was to try and capture all of the significant changes that had happened, because we felt there was a bit of a window of opportunity for that, and if we lost it, actually, we may never have really known what had happened on the ground, because things were happening at such speed back in March and April.

Just in terms of the themes that came out of that—and it's a public document; we'd be very happy to share it with the committee—there were probably a number of themes: one of them was the acknowledgement, as we've already mentioned, that the fear of digital has significantly reduced, both for our patients and also for our staff, for our clinicians in particular. One of the other things that perhaps is going to be more difficult to bottle, but something we're really determined to do our best at is the sense of very fast decision making of changed governance arrangements. Now, it was a very different time for us, but that sense of empowerment that allowed that innovation to happen, that gave people on the front line the ability to make decisions, is something, I think, certainly from my level, I'm desperate to try and keep a hold of. Because one of my senior managers, the manager who runs Prince Philip, he very memorably said, in the summer, 'We can be as innovative as Apple and as fast moving as the army if we're given permission.' There is something about being able to hold on to all of that. But, as I say, I'm very happy to share that report. It was a bit of a moment in time, but I think it was a really important document for us.

That would be really useful, and any other of your organisations that have gone through similar exercises, that would be really useful. Dr Nnoaham.

Thank you, and I'm sure, like many of us here, it's been a year of reflection and lessons learnt. Three things for me that, I think, we've seen work so well in the very difficult last year we've had: one is technology, and pretty much as Steve has mentioned; two is partnerships. We've done a lot of the things we've been able to do because we have been incredibly innovative in our relationships in our regions, and the partnerships have come to the fore. And I'm not just talking about partnerships in the public sector; I'm talking about those partnerships as well as the partnerships with our communities. That has really come to the fore. And the third one for me is how we have used data and intelligence, in real time, to shape our response. I think these are disciplines that—to use your word—we want to bottle them, and whenever we come out of COVID, these are things that we want to mainstream in the way we are and in the way we deliver services across the public sector.

Thanks. Who else wants to come in on that? You don't have to, but if there's something specific you want to add.

I have one other specific question, which is linked to that. Will there also be things like a rethinking on a clinical level, even? I know, for example, that, in Betsi Cadwaladr in recent years, the rate of referral for hip surgery has been higher than the Welsh average, i.e. that suggests there are people being referred for surgery that perhaps could be treated in other ways, and, actually, could well in other health boards be more likely to be referred for intensive physiotherapy. Will there be a change in clinical focus in that way, in order to try to take pressure off in that way, by treating people in different ways? Gill Harris.

So, you've made a really good point, and it is something that we need to bottle, to use your term. So, one of the things—. We haven't been alone across Wales. We've really enabled the clinicians to think differently, and we've done that across pathways—so, with both primary and secondary care and therapists and nurses, as well as medics, in the room, to define what the best outcome for the patient would be, and it may not necessarily be surgery. So, that is making us think very differently, is making us think about, 'Is this the right procedure for you? Is it the right time to refer?' So, the work that we're doing, as I alluded to earlier, with the Getting It Right First Time programme and the Bevan Commission, around orthopaedics, for example, is absolutely directed at that, but we've seen it in other areas as well. The principle of our diagnostic treatment centres, which I know you're familiar with in terms of our direction of travel, is to enable GPs to have access to diagnostics early and support that, so that can inform their referrals, and inform their decision making, and inform their conversations with the specialist as well. So, I think it's a responsibility for us to enable the innovation that our clinicians have displayed, and to actually mainstream that moving forward.

Thank you. And looking into the Chair's eyes, I think I'll probably give the last comment to Steve Moore.

I'm not sure if I'm worthy of that honour, but just a couple of things to add to that. I think probably all health boards across Wales—and actually it was in the 'A Healthier Wales' strategy—were already thinking very much in these terms about how do we change the way our systems work. We described it locally as a shift from a medical model of health towards a social model for health and well-being. So, it was already in train.

I guess the only other thing I'd add to what Gill said about what's happened so far is I think patients are also thinking differently now, in a way that perhaps we hadn't seen previously. And I think that's partly down to the fact that I think that COVID has underlined that there are risks to going into hospital, and indeed to having surgery. And I think that change in behaviour is going to be as much a driver in the future as clinical change will be.

And it could be a problem as well, of course. You've got people making a decision not to go and check out that symptom because of pressure on the system, when we actually still want them to go in.

Thank you, all.