National Assembly for Wales

Good morning. Thank you, Chair, and good morning to all of our witnesses. Good morning, Minister. It's very welcome news, obviously, that COVID rates are falling, but I think, Andrew Goodall, you were on television recently just saying that the pressures on the NHS are still very extreme. So, could you just outline what key differences you're seeing between the current position and the first wave of the pandemic?

Perhaps if I start, but then I think Andrew may be able to give you more of the detail to flesh that out. So, in the first wave, it was entirely new, apart from anything else, and we saw significant waves of mortality. We're probably further along the curve of case increase than we were when we were taking steps in both the firebreak and later. That's because we didn't have the surveillance available to us. So, there will be people who will have had COVID but won't have come into hospital and won't have been tested in the first wave.

The first wave peak of hospital activity was just a bit under 1,400 beds I think, but the intensive care peak was over 160 intensive care beds. Now we also, of course, had people in intensive care for non-COVID-related reasons, and we all recognise the development that had to go on during that first wave, where we learned lots move very, very quickly.

So, the way we've addressed it is different. We've had more tools available this time because of what we've been through the first time round and, obviously, during this second wave, we actually had the start of the vaccination programme as well. And if we didn't have a vaccine, then I'm pretty, terribly confident that we'd have seen a much greater level of mortality and harm come into our system and people who wouldn't have left the hospital system too. So, we've learned lots more.

And if you look at the second wave, it's been more sustained. We've had a higher peak in terms of bed usage, as we went well above 2,000 beds compared to the peak in the first time. We are also still at the point today—. Even though we're seeing reducing case numbers, we still have more people in an acute bed for COVID-related reasons than at the peak of the first wave. But we actually have had less intensive care use. So, the peak in this wave was about 150 people in intensive care with COVID-related reasons. So, we're seeing some differences in the figures, but we've got people who have been in hospital longer term with COVID, we've got better surveillance in terms of picking things up, and I think we've also been better at preventing harm. But we still had a really significant mortality toll, and you'll recall from early modelling that went through that we thought that a winter peak would be much more harmful, and it's proved to be the case.

So, I think those are the outline messages, but as we move out of the second wave, there are still risks for the future, and so that's why we haven't been able to exit our current levels earlier. The other thing, of course, is we have a new variant. If we were dealing with the previous dominant strain or strains of coronavirus, then I think our appetite for moving out of lockdown would be different. But the fact that the Kent variant is significantly more contagious is a real challenge for us as well, both in terms of how that's led to a sustained number of cases coming through and being confirmed, but also then with the reservoir that we recognise still exists, because positivity figures are still over 5 per cent at present. That makes a difference about not just choices that we'll make about broader societal measures, but about the health service and what we are going to have to keep on doing in terms of protecting our staff with personal protective equipment, but also the way that we'll have a testing regime for patients coming in to our system as well. So, there's quite a lot that I think has changed and will continue to be factored in to how the health service will continue to operate in the future.

Dr Goodall.

Just to build on the Minister's comments, I think he's quite right to say that the volume impact has obviously been very different this time. We did reach as high as twice the number of patients in hospital beds of the first wave, and the fact that even with the very visible improvements over recent weeks, it is rather salutary to say that we're still in a worse position from an NHS capacity perspective than back during the first wave. And I think the volume translates in a number of ways.

Whilst on the one hand there are successful treatments and interventions, because we've learnt more about what we can do to mitigate the impact of COVID-19 in our system, and there are examples of earlier interventions and drug regimes that can be applied, it's interesting, as we look at the nature of the patients who've come into our system, but in very general terms, the length of stay of patients coming in during the first wave for coronavirus is pretty much the same during this second wave at this stage, and the age of patients coming in is actually consistent as well. But, obviously, if you're looking at this through the lens of critical care as an example, even if, as the Minister said, we've contained some of those pressures there, because of those higher volumes, there is still a more significant impact on patients. So, sadly, we've seen more deaths within the critical care environment in this stage, even though the overall proportion of patients have probably not necessarily moved through in that stage.

I think a second factor is, actually, that we've managed to maintain a much broader range of NHS activities. The significant national decision to step away from routine activities to prepare to get the workforce ready was an important part of our steps there, but we have needed to maintain a focus on the fact that we need to mitigate other harms within the system. And at whatever stage that the NHS has seen a growth in coronavirus during the second wave, we've always had a much higher level of activity going on in the hospital system in itself, because we've tried to make sure that there has been flexibility to have other activities going on and the level to which urgent and even some routine activity's happening. But, I think, a really important difference has been the maintenance of a range of primary and community-based services that has meant that we've been able to provide that access throughout. And if you look at areas like optometry and dentistry, for example, they have got a much more significant level of activity happening at this time. Having said that, that has a very direct impact on the flexibility of staff and the staff that we have available, so, given that we have asked staff to step away to be ready to commission new capacity within our system, if you have staff doing their normal activities, it puts an awful lot of pressure on our residual staff, of course.

And, I think, a third area I would highlight during this second wave is simply seeing the resilience of staff really tested. You know, we have got very tired and exhausted staff who've been consistently managing the front-line pressures in this, and it's been very difficult for them to step away from this.

And the Minister is right, finally, in terms of some comments: the differences around the new variant and the transmissibility clearly do affect the way in which the NHS is approaching things. We do know that when this has traction in any of our areas, including in our hospital sector, that can be very difficult to manage. So, lots of things that we've learnt and practice that we've been able to apply, but just the overall volumes on the system, I think, has been very material and very visible during this second phase.

Thank you very much for that overview, and I think I hoisted in most of it, but I am just going to go back to one particular area, because I'm just trying to understand something about the figures. So, analysis by the Office for National Statistics shows that death by COVID, or because of COVID, is the highest for the last three months than any other cause—much more so than in the previous year. And yet, the number of invasive ventilated beds in use in January was less than in April 2020. So, we've got more people dying of COVID at the moment, we're using fewer invasive intensive care ventilated beds, and, of course, I think we've all come to associate, perhaps, that when somebody gets to the point where they're on a ventilated bed, their risk of mortality may be significantly higher. The Minister also mentioned earlier that we've got a better suite of things at our disposal: we know a bit more about coronavirus, we've got different treatments that we can use and so on and so forth.

So, I just wanted to know why those mortality rates are higher now, or is it simply because of the proportions, because of the numbers? So, I'm going to sound so stupid—I know I am—but I've just got to ask it this way: fewer people are dying of anything else apart from COVID than they would normally. If it's because they're not getting into hospital because they're worried, scared, et cetera, et cetera, you would expect them then to be dying elsewhere, because death rate is death rate. So, what I don't quite understand is, given that we know so much more, given we're using fewer ventilated beds, how come we've still got more people dying of coronavirus at the moment compared to overall figures? Does that question make any sense? So, I think my ultimate bit was: is it because people are dying elsewhere and we're just not picking it up until afterwards?

Minister—a bit of philosophy here.

There is some confoundedness within this. I don't know if Andrew or Frank want to come in again, but it's partly because we're not seeing other activity. Deaths on the road have decreased through this year because we've had less travel, so you're seeing other causes of mortality not having the same effect. But also the delays in activity mean that some of that harm is stored up for future. We may, again, talk about this later—about non-COVID harm that we are definitely building up for the future and the challenges of recovery. But it's also a feature of the way that our service has run, and it's also because people with other underlying health conditions, who may have suffered harm as a result of those in the course of a normal year—if they've then acquired COVID, then, actually, that can lead to an advanced mortality rate. And so you then have a challenge of can you really tell which people would have died within nine months but the end of their life has been brought forward. But it's hard to forecast in a completely scientific way. I haven't seen anything that tells us that, but Frank may have a better idea of if we're going to get any science around that. I still think our excess death rate is probably the best guide to the overall harm that COVID has caused compared to other years. And it's also worth pointing this out with the ONS figures: ONS have this five-year average for excess deaths, but I don't think they're going to include—and our stats team are not going to include—2020 as we move into 2021, because, of course, 2020 was largely a COVID year. So, we're still going to look at the five years before the pandemic to get an idea of excess death rates, because otherwise I think we'll be giving ourselves a misleading impression of the level of harm that's been caused.

I do follow that, and I'm not trying to ask this for any sort of super tricky reasons.

No, no, I understand.

I'm just slightly more worried that, because we're using fewer intensive care beds, we're missing people who've got COVID who then subsequently go on to die of COVID, and they're somehow out of our normal framework of, 'You get really bad, you go into hospital, you get worse, you progress through the hospital system.' It's just more about making sure we don't have a reservoir of people somewhere out there that we're not getting to who are the people who, essentially, are pushing up these rates.

I think that's the balance of what we've learnt and understood about how to keep people well. Frank may want to come in to give you a view on this in particular, but we've learnt a lot during the first wave about how to try and keep people well and alive, and it's affected the way that the NHS has treated people, but actually we've always had capacity to use a bit more. As I've said, we didn't get to the same peak in critical care beds that we did, but it was a more sustained amount of harm that came in over a longer period of time.

Frank, you've had the build-up.

Just a couple of points. The Minister has already mentioned that all-age, all-cause mortality, of course, did increase last year during the first wave, and there's an increase during the second wave. It's now likely falling, and part of that is down to the fact that we have a pool of people who have suffered from COVID who have passed away, sadly, before their time. So, death rates now are actually reducing. We saw after the first wave, actually, that the rates dropped down below seasonal norms, and I expect the same to happen in the second wave. The death rates of people actually going through the system are lower in the second wave than they were in the first wave, and that's partly down to the things we've learnt about how better to ventilate people, how steroids, in particular, work, but other drugs and therapeutics as well. So, fewer people are moving into those intensive care beds. Many more COVID patients are actually being managed effectively with other forms of non-invasive ventilation than was the case in the first wave. The overall point—and it is a complex issue, Angela, absolutely—is that I haven't seen anything to suggest that we've got a pool of people who are dying because they're not accessing treatment. There's nothing that I've seen that would suggest that is the case.

Okay. Angela.

Thank you. I'm not going to pursue this any further. I take on board, for example, Minister, what you said about people travelling less by car so fewer people are involved in car accidents to terminal effect, but, you know, if somebody's going to die of cancer, they're going to die of cancer wherever they may be. So, I kind of understand part of your argument, but there's a bit of it I still don't quite follow through. But I shall badger our researchers to explain it to me in words of one syllable so I really get it. You mentioned—

There'll be challenges for all of us. I don't think it's an unfair point you're making, Angela, about understanding the impact on all-cause mortality and the impact on non-COVID conditions we know have an impact on people's health. Those are things, as I said, we're going to have stored up for us for some time to come, so we may see some of that mortality come through in future years. We may see harm the NHS can't recover, which is part of this challenge. I don't think it's an unreasonable point at all, and, as ever, we're all still learning.

Could I just move on to the question of field hospitals? Because we've been hearing very powerful evidence from health boards that they've used their field hospitals really effectively, in the main to deal with people who are recovering from COVID, to try and put in rehabilitation services and so on and so forth. We know that people with COVID are spending longer in hospital. How do you anticipate the deployment of field hospitals might carry on over the next couple of months, and will you be keeping them as well in case—? I know some people are talking about a possible wave again at the end of this year. What are your plans there?

You're right to point out that a wave in the autumn/winter of this year is entirely possible. That's been pointed out in the Scientific Advisory Group for Emergencies papers and it's something that we're obviously concerned about and will need to plan for. Whoever is in Government after the first Thursday in May, when the votes are counted, will have to factor that in as a real challenge to account for. The mission of field hospitals changed a bit as well, because, in the first wave, we thought we'd need field hospitals because we were anticipating having to deal with a reasonable worst-case scenario that we thought might happen given what we'd seen in other parts of Europe, in particular, where we might find that field hospitals would be used for significant end-of-life care, as opposed to rehabilitation and recovery. In the second wave, they've more been in that space, and you're right to point that out. We've had a different way of planning. Again, learning from the first wave, we didn't need as much field hospital capacity to be created.

Ultimately, the operational choice lies with the health board, but the biggest factor is really the ability to staff them for their mission, because part of the concern is that if you're using them for recovery and rehab, you need staff who can aid them in doing that and you need facilities that are appropriate for them to use. In terms of how long they'll be needed for, that still depends on the long tail we've got, because we've still got today more people in our hospitals who are recovering than are coming in as new cases, but those are still people who need an acute hospital bed. If those people recover to a point where they still need some support, where a field hospital is then an appropriate place rather than their own home, that's a judgment that needs to be made. But we're still looking to get people into their own homes as soon as is appropriate. So, the mission of field hospitals is slightly different, and it's a balance that won't be something that I think that whoever the Minister is in the future will dictate centrally, because there's going to need to be a balance between the support that a health board may need to maintain a field hospital—there's the capital and other additional costs as well—and, crucially, the ability for every health board to properly staff the field hospital to fulfil that part of its mission. That will have to be balanced against wanting to have a broader NHS recovery in activity as conditions allow us to do so. 

Dr Goodall, you indicated.

Yes, just to comment on the progress that we've made on this. It's been the data modelling and our assessment of the additional numbers of patients that could come into the system that have affected our decisions to date, but also where we go prospectively with field hospitals as well. We called out a number on behalf of the system based on the original first-wave modelling just to have the confidence that the beds were there, and we were able to reduce those to allow some of the field hospital capacity to be released during the second wave. So, we went down from 19 field hospitals across Wales to 10, for example, which were all part of local judgments that were made by local health boards.

Just to say that the maximum number of patients we've had across Wales in our field hospitals has been around 227. The technical field hospital capacity, rather than just extra within the NHS generally, was 2,700. People may be saying, 'Well, that's a dreadful thing, because we should have been fully using them.' Just to say that they were always there for extraordinary and exceptional use, because they have to use the extant workforce and distribute it in a different way. The fact that they have had that extra flexibility in the system—the size of a small district general hospital—I think has helped us in our resilience through the winter, and if we'd needed to go further, even with some of the consequences, they were there to be available if the system had become overwhelmed to a very significant degree.

But I think, also, they've come into play for different reasons, because they've been able to give us opportunities about being reused as testing centres, and, of course, most recently, a number of the field hospitals across Wales have been able to be used as mass vaccination centres as we've actually stepped up the vaccination approach and seen the real increase in our numbers recently. So, looking ahead, as we look at the data modelling in the background, as we assess the impact of vaccination, and as we have to plan for an expectation that coronavirus is still something to be lived with during the winter months, we will want to call out again, I think, for the NHS, the level of extra capacity we may need as a contingency in the system to be used for the winter. It wouldn't be to the level that we saw last April, for example, but I still think we're going to need to have a very material and visible level of choices around field hospitals during this winter ahead of us as well.

Angela—to wrap up, hopefully. 

That's a very gentle hint, Chair. Thank you so much. I will not call you out on field hospitals, because I feel that they've been a really, really good policy decision to build that sort of capacity into the NHS. I know it's difficult, though, because you need the people to support those beds, but we've known that if push came to shove, we have that capability. Elective care, of course, is an area that has suffered, and we've seen that Ysbyty Gwynedd has closed to elective care. Some of the witnesses we've heard from have called for an all-Wales approach across health and social care to infection control practices and standards. Do you agree with that? Because that has been quite a strong cry from a great many witnesses, actually, 

We have taken an all-Wales approach. The committee that reviews this is co-chaired by the deputy chief medical officer and the chief nurse, and there has been national advice issued by Public Health Wales, so it's the same approach to maintaining good infection prevention and control practice across the country. So, we do have a national approach; it's about making sure that is applied consistently in each setting. It's also a factor of the reality that when you have higher levels of community transmission, you have a greater likelihood of seeing that transmission taking place and have an outbreak in a closed setting, whether that's a hospital or any other closed setting that we'll be aware of as well. And what's happening at present in Ysbyty Gwynedd is the only significant outbreak in an NHS hospital site at present. Of course, north Wales was able to maintain a level of elective activity when other parts of the country had to cease elective activities because of the varying stages of the pandemic and community transmission at that point in time. So, you're going to see some unevenness, because the local picture will vary slightly, but on the national approach to good infection prevention and control, that is exactly the approach we've been trying to take to try to get that consistency of application, and accepting that there is still a risk that despite that, you might get an outbreak within a hospital. That's even with the testing that takes place, even with the PPE protocols and requirements. It's still a risk. Even while we're running positivity levels of just over 5 per cent and our case rates are falling under 60, there's still a significant risk again with an even more contagious variant of the virus in wide circulation.

I understand the risk, and I understand that outbreaks in hospitals have diminished; we did have quite a lot at one point. But I would just point out to you that the witnesses who've come before us to talk about this have been health board chiefs, senior management, and our royal colleges, and if they're asking about an-all Wales national plan for infection control and prevention, then you have to ask where's the communication, despite what you've just said. 

It's coming from Dr Goodall.

I'm very happy to recirculate my correspondence and my guidance that I've issued at various stages into the system and also to recirculate all of the guidance that's come out of the nosocomial infection group. I think it would be true to say that we've had to continue to learn and adapt on these areas, and obviously, we also have the opportunity to link across the UK, and make sure we're actually learning from that kind of practice together. But as the Minister said, I'm pretty clear that we have given very significant national frameworks. Even the outbreak management approach that is taken with Public Health Wales support is actually a part of a national co-ordination of efforts across Wales, so it's not just a local dynamic; it's something that feeds in nationally as well. During this, I've issued my own personal correspondence to chief executives in terms of expectations for the management of infection control as well. So, I will pick that up with the NHS executive board this month, just to make sure that people are very clear on both the expectations but also the available guidance.

Thank you very much. Thank you, Chair.

I'm not sure what you mean by figures for people who weren't in the priority groups, because, of course, within the priority groups, they're not all neatly in age brackets. So, front-line health and social care staff will be of varying ages, people who are clinically extremely vulnerable will be of varying ages, and people who are in group 6, like myself, will be of varying ages as well. And there are times when putting them back neatly into one of those areas is—there's always the bane of statisticians, about an 'other' category. I'm not sure which figures you're quoting from, Rhun, so maybe we're talking at cross purposes.

As of 25 February, 890,000 had received a first dose; 705,000 were reported as being in one of the priority groups. So, there were 20 per cent who didn’t sit comfortably in the priority groups, and I was wondering how that figure was quite so high.

Well, that is about the data reconciliation. As you go through the figures that we're providing, you'll see that every day we have an updated table that looks at people in their priority groups, and it is then about getting information through the Welsh immunisation system that allows us to categorise people. But invites should be going out to people in groups 1 to 9. There could be a small leakage outside that, because, as we've discussed many times before, there have been some challenges about literal end-of-day supply, where we've not wanted to see that wasted, but the overall figure shouldn't be a real figure of 20 per cent of people being outside those priority groups. We wouldn't have been able to achieve the percentages of confirmed priority groups if that were the case. I know that Frank wants to come in.

Dr Atherton.

Thank you, Chair. We've tried to be very clear in Wales that we have followed the Joint Committee on Vaccination and Immunisation guidance, and broadly I think we've been very successful in doing that. As we've worked our way down through those groups 1 to 9, it hasn't been exactly a linear process. We don't do group 1, then group 2, then group 3. A broad approach by the health boards has been that, whenever they've covered about 50 per cent of any of those categories, they move on and start vaccinating the next one, so it's not an entirely linear process.

There also was an issue, particularly in the early days, where the Pfizer vaccine, which of course requires very careful storage, management, handling et cetera—it was really important that we didn't waste that vaccine, and in fact Wales has extremely low wastage figures for vaccination, figures that I'm very proud of. But to do that, some of the vaccine slots were opened up to other people who perhaps were not in the first priorities. So, part of it may be in that, part of it may be in, as the Minister says, some reconciliation. But the point is that, by following the JCVI guidance, we've been able to get through those first—certainly the four or five—groups; group 6 is a very large group, but we've got very high coverage rates in all of those groups.

If we look at, for example, care home residents, over 95 per cent now have had the first dose et cetera, and, as we work down those it's between 80 and 90 per cent for those groups. So, that's been the strength, I think, of the programme here in Wales, that we've been very clear about following the guidance and working through. Of course, there are local variations. This is a huge national project. We've never delivered anything of this scale or complexity before, and I'm very grateful not just to the people in the health boards who've been helping to plan, manage and administer the vaccines, but also to the colleagues in the military who've come in and helped us with some of the machinery around making this work. I went for my vaccine this morning, actually; it was extremely slick and very, very well run.

Okay. Rhun. 

The other gap in the figures—. As I say, the figures, they're about a week old, these ones, and they'll be even better by now, but there's one gap on healthcare workers and social care workers. With healthcare workers, the group size isn't available; on social care workers, the number vaccinated and the group size are not available. Again, could you just try to pad out those gaps for us as much as possible to give people confidence that, when it comes to healthcare workers and social care workers, things are on track?

Well, it's part of our challenge about the definition between people who work for the NHS and people who are front-line workers, and this has been—. And again, you'll, I'm sure, if not in the committee, in your local representative capacity, have had people making bids in talking to you about why they should or shouldn't be considered front line. And so it's about trying to find a definition that works and that allows us to have a cohort that Public Health Wales can then assign people into. But, actually, that's why, for a long period of time, we had the numbers of healthcare workers without, then, trying to give what I think the statisticians call a denominator, so you get the overall total of people within that and you're then given a percentage of it. But, at one point, it looked like there was some mixing between front-line social care workers and health workers in one of the categories. So, one of the health boards reported that they'd vaccinated 104 per cent of their healthcare workforce, because, actually, it was the mixing in of people who were front-line social care workers. So, it's challenges about how that's presented. That's why we, for a long time, presented the figure of front-line staff, but it does show the significance of the coverage we're generating with the numbers of people who are getting access to it very quickly. 

Dr Goodall. 

There has been a focus on front-line staff. Just to give a sense of the order at the moment, even our normal NHS staffing figures are around 86,000 members of staff employed by the NHS directly. The figures that we are reporting in respect of 2 March, yesterday, for example, would be in excess of 120,000. What we've had to do is to expand out. That doesn't mean that all NHS-employed staff have been done, because the focus has been on front line, but we have, of course, included contractors and expanded out into those primary care contractor areas and pharmacists et cetera, to make sure that they're covered as well.

So, some of the normal information that we would have within the workforce for our denominators has been rather different, and, given the range of independent providers who provide domiciliary care, for example, as well as the independent care homes, the dynamics are rather different from if this was just wholly about the NHS staff only, who, of course, we have on our books, because we have the payroll arrangements. But, yes, just to give you a feel for the numbers, they're already much higher and very different even from the core NHS staffing, for example. So, there's been very good coverage. 

If I could move on to another issue that there has been a little bit of a focus on—importantly so, but there's still a lot of work to do on it—and that's the differences between vaccination figures for different ethnic groups and socioeconomic groups, we know, if you're white and over 80, you're more likely to have been vaccinated than somebody from a black, Asian and minority ethnic background. Could you bring us up to speed on what is actually being done, other than talking to communities and getting the message across, to try to increase those figures and get rid of those inequalities? 

Minister. 

So, we've done not just talking, but the talking with those communities is actually one of the key things to do, and it's the point about who's doing the talking and who is a trusted source of information. So, that's faith leaders, whether it's the local imam or the local pastor. We know that in lots of our Afro-Caribbean communities and African-origin communities, there's a higher level of church attendance than in the local white population. So, we're going and looking to use those faith leaders and the influence they have, but also our health and care staff who are from those communities as well, are trusted people.

Look, I can go and talk in some of those groups, and people will take an interest in me because of what I look like, but, actually, for lots of them I'm just a politician. But, actually, if they have someone who looks like me who is a doctor or a nurse, a front-line member of staff or a pharmacist, actually, that's different. And so it is recognising that there's a variety of different messages, and the way that our communications are working, you won't necessarily see all of that, because we're working with a range of different community networks.

It's also about trying to interrupt some of the misinformation, because some people are getting lots of their sources from, if you like, the organic spread of things that are being circulated on WhatsApp, so not traditional social media, but actually how that's taken and then used on a private messaging service. And that's quite hard to interrupt. So, it's about getting into the local community conversation—that's actually really important. And it's also about reminding people and reiterating that there is a 'no-one left behind' approach. So, if you haven't had your vaccine for whatever reason and if you then do subsequently change your mind, then you can go and get your vaccine; you won't have lost your opportunity. Because there's quite a high rate of people who, once they talk to a healthcare professional, their concerns will then disappear. And so it's a challenge, because it will take quite a lot of work over a sustained period of time.

You'll note that, in the JCVI advice for the next phase, once we get past mid April, and we're into the rest of the adult population outside the first nine priority groups, we'll need to continue to make a particular effort with a range of groups, not just people of black and Asian origin, but actually there's a greater level of mistrust amongst men as well. And of course, men have a higher mortality rate and higher harm rate from coronavirus than women. So, we're finding that people who are most likely to suffer harm are the people who are also most likely to be hesitant about taking the vaccine and the people who are most likely to be susceptible to some of the vaccine conspiracy and anti-vax propaganda that we all know is circulating. I'm sure all of us in the committee have seen examples of that within our own communities and networks, I'm afraid. 

And regular correspondence online. Rhun.

Indeed, yes. 

Prisons, quickly. People living in prisons are more susceptible because of the environment; we've seen that. There'll be people within the prison population who belong to the top priority groups, but we've heard suggestions in the press, for example, that prison populations will be vaccinated en masse, rather than going through the priority groups. Could you just paint us a picture of what exactly is happening with vaccination within prisons?

We've, again, tried to take a pragmatic approach. So, in the prisoner population, you're more likely to find people with underlying healthcare conditions and underlying vulnerabilities. We know that the health of prisoners is not good compared to the rest of the public, not just on the visit that I did to Swansea, where going to visit the prisoner pharmacy was interesting, but, oddly, no-one was wearing glasses, and I don't believe that's because prisoners all have excellent eyesight, but also they had regular, big problems with their dental health as well, and actually dental health is also a good marker for other public health issues too.

So, what we've been doing is we've been trying to deal with everyone in the tranches of priority groups. So, when we've gone into a prison, in the first four, we've tried to deal with everyone in the first four. Now, we're going in to try to deal with everyone who is in a priority group as we go through the next phase as well, because otherwise it'd be really inefficient for the whole programme, not just for prisoners, but for the whole population who are being covered, if you've got to go back on multiple visits. So, that's the way that we're trying to organise the programme. That makes sense for the prisoner population, but also the staff who are working with them as well. But I would expect that, within the prisoner population, we've got a higher group of people who are in group 4, clinically extremely vulnerable, and in group 6, with underlying healthcare conditions, than the population at large. 

It's also worth pointing out that I think it's Usk that has a prisoner population that are older prisoners. So, actually, they will have had lots of people in age-based categories in any event, and we'd be much more worried about outbreaks in that setting because of the reality of what the make-up of the prisoner population is. And it also, of course, affects the staff who work in that setting as well. So, we've tried to take a pragmatic approach, and that is about getting the greatest not just efficiency in the programme but the greatest protection, given what we all understand about prisoner health. 

Thank you for that. And one question—I think it's worth just asking for an explanation, perhaps from one of the gentlemen who are with you this morning, or Jo-Anne Daniels, about the question of exposure and the risk that comes from exposure, possibly through occupation. We have a debate on this in the Senedd this afternoon. The JCVI guidelines, of course, do people by age. If everybody behaved in the same way and were exposed to the virus, potentially, in the same way, that makes absolute sense, but of course people are exposed, potentially, to the virus in different ways because of, potentially, their occupation. Can you give us a sense of how those considerations will be brought into decisions on vaccination in the weeks and months to come, and potentially looking at the risk of long COVID too, because, yes, absolutely, you're more likely to become really acutely ill or die, perhaps, if you're older or more vulnerable; you can get long COVID at any age, so actually stopping people from being exposed to the virus at all is a good thing.

Well, I think you're talking about a number of different things there, with respect, Rhun. And I think this is probably the third time in the last few days we've had the opportunity to discuss this particular issue. But the priority for the vaccination programme was to prevent significant harm and mortality, and so we're taking an approach that addresses that. That's the advice we asked the JCVI to give, and that's how they've formulated their advice, and they have considered occupational risk as well.

When it comes to exposure, that's actually not just about vaccination—that's also about the control measures we're taking, with all of the restrictions we have in place and the requests for people to behave and live their lives still in a different way to the old normal. So, it isn't just about the vaccination programme. But there has been proper consideration. In terms of what the JCVI have set out, I think it's relatively clear about the assessment of those risks. Age is still the biggest factor. And it's also the case that, when you look at the risks that there are, you then have to factor in the ability to get the vaccination programme out as quickly as possible. The greater, if you like, targeting means that you need to understand more about how to target and how then to implement that. The NHS knows how old you are, but it doesn't know what job you do, typically. And so, actually, if you want to go through an occupational risk matrix, well it's more complex. And you then have this difficult challenge of you may well get very quickly drawn in to making value judgements about essential workers—people who continue to go out to work, but have different levels of exposure, and whether actually mixing that in means you then have a slower rate of progress. And you then, actually, don't provide the most rapid protection for the population at large. It's also the case that if you are in your 20s, doing the same job as someone in their 40s, the person in their 40s has a greater level of risk to you.

So, there's lots of logic behind the age-related advice that we've received from the JCVI, the chief medical officers in every part of the UK have endorsed, and the four different health Ministers, from really quite different political traditions and backgrounds, across the UK, have all indicated that we're going to follow in each nation. So, there is a consistent approach. It doesn't mean that there aren't questions that can be asked, but, ultimately, you have to settle on making a decision. And if you prioritise other groups of people, whoever they are, then you deprioritise other groups too as well. The age categories are the fairest and most efficient way to get through the remainder of the population—that's the clear advice from the JCVI. And I don't think that, as a decision-making Minister, I can in any good conscience attempt to instruct the health service to not follow the advice of the JCVI, and to not follow the advice of the chief medical officer on this. So, I'm just trying to be as clear as I can be that there are, of course, questions, but I think this is the right choice.

Yes, and I'll ask the question a fourth time if I think it's important to ask as well, because that's how scrutiny works. And we can point to lots of things over the past year where there has been scientific evidence perhaps that you've decided to take a different position on, and it's very, very important that we keep pursuing this, and it's about giving people confidence in why decisions are taken too.

On testing and tracing, could you just tell—

Rhun, before we move on to testing, Angela had a supplementary on vaccination. Angela, you've been very patient.

Thank you. And in fact, Minister, I wanted to go back to Rhun's first question, about the disparity in numbers. Because you know I've got a bit of a thing about data, and the accuracy of data within the NHS. And as Rhun pointed out, 183,948 vaccines were given out to people who were not deemed to be in a priority group. Now, you can say, 'Well, the priority groups changed and flexed, and different people came in and out of it'—totally get that. But I would have thought that, if somebody who'd received the vaccination who, for example, was an unpaid carer, then you would actually say, 'Well, that was priority group 6, because we've now made unpaid carers priority group 6.' So, I just wanted to know if you felt that this actually came to the—[Inaudible.]—and is there a uniform system for collecting this data—? Are you confident that there is a uniform system for collecting the data on who gets the vaccines, what priority groups they are in, throughout all of our health boards in Wales?

The data is all put through the Welsh immunisation system, so there's a common collection point, and there are common data definitions that people are supposed to use in that. But, you know, we're dealing with information on a daily basis, and even the weekly summaries, we don't normally provide official statistics on that basis. So, it will take some time at various points to make sure that we've correctly assigned everyone to each data group. It's simply a point of catch-up, I think, rather than, 'There is a huge leakage outside of the priority groups', and it's why you always see a lull on the weekends. So, if you look consistently at Monday's figures, then you'll see that there's a lag with data that then catches up in the rest of the week. That's still a function of the way that we are working and delivering the programme. But there is a consistent, national system and the Welsh immunisation system allows us to do that—it's allowed us to understand where there is variance and it's why we've got some of the data we've got already on some of the disparities in take-up from different groups. So, I think the way that that works and Public Health Wales look at the figures does provide us with, I think, real assurance about, not just the speed we're going at, but who we're getting to as well and who we still need to get to with the rest of the programme and our current priority groups and then the task of getting to the rest of the adult population. 

Okay. We need to move on. Back to Rhun on testing.

Well, we've outlined an updated testing strategy, which puts in a number of different areas and reflects the fact that, compared to where we were a year ago, our testing infrastructure has significantly moved on. So, there's the testing to diagnose, which will still take place, as people are coming in—the suspected cases coming into our hospital system, for example; that's a clearly understood purpose. There's the testing to find as well, and Jo-Anne Daniels may want to say a bit more about that. There's a test to maintain and our testing approach around workplaces in particular as well. So, in terms of our approach, it may be helpful if Jo-Anne just sets out the five strands to our future testing strategy and how we're then using the developments we now have compared to a year ago, not just with much greater use of polymerase chain reaction testing, not just with the genomic testing that Rob Orford may want to talk to you more about, but also about how we're using lateral flow tests as part of what we're able to do now, and that, for example, is really important for the return to school, but also about, as I said, workplace testing as well.

Jo-Anne Daniels, you've been invited.

Thank you, Minister. As the Minister said, the revised testing strategy sets out our purposes for testing: test to diagnose, as the Minister outlined; test to safeguard, which will remain important—so, how we ensure that testing protects the most vulnerable in care homes and the extension of testing to domiciliary care and to NHS front-line staff as well, as part of that wider effort around nosocomial transmission, for example.

It also articulates our approach to test-to-find, where I think the lateral flow devices that the Minister has referenced potentially give us much greater opportunities than we've had with just the lab-based PCR testing. So, with the lateral flow devices, we can undertake far more asymptomatic testing than we've really had the capacity to do in the past. And so, we can test in a targeted way in our communities, for example. So, following the pilot that was undertaken in Merthyr and the lower Cynon Valley, with the mass testing there, we've now got further community testing activities being taken forward. We can test in workplaces as well. So, there are a number of workplaces across Wales now that are routinely and regularly testing their staff to detect any infections. That also enables us then to test to maintain and, in particular, around some of our critical services and some of our public services, for example, making sure that we can identify infection early, isolate individuals and stop spread within the workplace that might otherwise put the ongoing services at risk. So, for example, the Welsh Ambulance Service NHS Trust now are testing their workforce on a regular basis, enabling them to, as I say, maintain.

And then, finally, and I suppose this is the most tentative area of the strategy, is whether and if there will come a point when we are able to use testing to enable certain activities, so, for example, around events and the like. But I think that's very much the most tentative aspect at the moment because there's still an awful lot that we need to learn and that we need to understand about the potential risks that are associated with that approach. So, as I say, lateral flow testing—I think we're in quite a different position to when we came out of lockdown last time and as restrictions were being eased, where we had relatively limited capacity for asymptomatic testing and to search out and find potential reservoirs of infection and potential residual transmission in our communities. Now we've got the opportunity to do that at a scale and, obviously, at pace because of the speed with which results are available and that hasn't been there before now.  

In addition, Dr Orford, you've had a name check from the Minister. Now's your chance to shine.

Thank you very much. There's an incredible amount of work that's been done around testing, and we're really, really dependent on the will of the public as well in coming forward for tests if they're symptomatic. So, I can only think that lateral flow assays that will shorten that period of test to result are positive, and they will identify more people that are infectious and break chains of transmission. So, the Swiss cheese defence is still necessary, where we have to do lots of different things. Some things will work better than others. We know that self-isolation works. We know if people are symptomatic, coming forward and seeking a test is really important. So, for all of this, we are really, really dependent on the behaviours of the public, and to date they've been absolutely amazing. So, just to stress that.

One thing that we're excelling at in Wales is our genomic sequencing. We're doing a very good job at picking positives and sequencing them in the Public Health Wales labs, and the infrastructure and the work going on there is accelerating. I think, currently, we're sequencing about 25 per cent of positives. The UK average is around about 10 per cent, so we are global leaders in that area, and we need to do more. So, there's a lot that we can do with testing, but it's part of a Swiss cheese defence. We still need good hand washing, social distancing, isolation on symptoms. So, it's part of the puzzle. Thank you.

I like a bit of Swiss cheese, so I'll take that analogy. And thank you for those really comprehensive answers as well from both of you.

On tracing and the test, trace, protect teams, I don't know if there are any elements on how they will be strengthened moving forward, and also on the flow of information from them to people. There's been some concern. It was a Swansea University study, I think, that suggested maybe there wasn't enough signposting to financial support and support for isolation and that kind of thing. Is that being addressed?  

Jo-Anne runs the team who have got oversight from the Government point of view for TTP. It's fair to say we have invested significantly in our teams, and if you compare where we were from the start of the significant resurgence we saw post the firebreak to now, our teams have strengthened significantly. And so, we're looking at some data, last week I think, showing about 70,000 tests being undertaken in a week, and the last, going back to October, when we were running at about a similar level of 70,000 tests per week. And actually, our ability, through our contact tracing team, to get to people—we're getting to more people as a percentage. But we're also getting to those people much more quickly as well. So, the investment we've made has actually paid dividends in terms of the service that is provided. I think that with the Swansea research—I think it was actually conducted during December, when the teams were under maximum pressure. I think—correct me if I'm wrong, Jo-Anne—we actually invited someone from Swansea to come and talk to the team about their research, because I think there are definite things to take on board and to want to improve.

Jo-Anne Daniels.

Just to say that we are maintaining our investment in our contact tracing workforce moving forward and, as the Minister has indicated, the performance that we've seen over the last couple of weeks has really been quite exceptional, with the proportion of cases being traced and the proportion of contacts in the 90 per cents. But also, the timeliness of that being—. We're tracing people faster than we've ever been able to do before. So, we're really keen to maintain that. And given the strong position that we're in, we're now also able to ensure that every case is also subject to full backward contact tracing as well as forward contact tracing, and, as case rates come down, again as we ease out of lockdown, making sure that we're able to track back, as best we can, to the source of transmission in order to be able to prevent that wider spread.

On the isolation payments, we—. Just a couple of weeks ago, in fact, we updated the contact tracing scripts to ensure that the new, more generous self-isolation support scheme and the payment associated with that is now mentioned, or should be mentioned, if the contact tracer follows the script, which most of them do very effectively—it should be mentioned during that initial conversation as standard, so that people, when they're asked to self-isolate, know that that support is available to them.

Lovely. Thank you. Thank you, Chair.

We've come to a natural break time now, so 10 minutes off screen for everybody. Back at 10:40, and Jack Sargeant will be starting the questions then. So, 10:40, and that's the end of the public meeting for now. Diolch yn fawr.

Diolch yn fawr, Chair, and good morning, Minister and officials. The waiting list position for hospital services is rather daunting. I just want to understand, Minister, what the Welsh Government can do to support health boards in tackling the backlog.

We're going to publish, before the end of March, an NHS recovery plan that will look at the whole service and will also need to link to our relationships with social care. It won't just be about waiting times for planned care, though; we're going to need to take a broad look as well, so you can expect that recovery to also reference the increased demand that we expect in mental health services for some time to come as well. That's both the public and, of course, our staff themselves as well. So, we're already working with them, and actually a range of different stakeholders, not just the Royal College of Surgeons but others, have already offered some helpful advice and thoughts about that. We're working with planners in each health board. So, that's work that Dr Goodall's team are taking on board. Simon Dean, the deputy chief executive, is doing lots of that work. You can expect a broader recovery plan to be provided.

But we also expect that the health board plans that they would normally be submitting to come to the Government by the end of March will also have to sketch out what they're planning to do anyway. We're going to have this balance between what health boards need to do themselves, but also regional and national choices as well. So, there'll be a need to set out a framework for that recovery, but, again, whatever happens after early May, next year, the next Minister is going to need to be prepared to make some regional or national choices, I think, because the way that we have recovered and made progress—and we did make real progress on a sustained basis before—was about both waiting list initiatives within the NHS and some use of independent sector and English capacity as well. Well, the independent sector as it is isn't big enough to deal with the scale of the challenge we have, and England will be full. They're not going to have lots of spare capacity floating around, because they too have an enormous waiting list backlog to deal with as well. So, we're going to need a very different approach, and the opportunity is to get to a point where we have both a sustainable service that is able to deal with our own demand as well, but then the challenge of dealing with that really big chunk of demand that we know we've had to put off and the significant backlog that has been generated.

Dr Goodall.

As the Minister has said, clearly, the numbers have grown very significantly just because of the impact of decisions and the protection measures that have been necessary across the system. I was giving evidence at the Public Accounts Committee on Monday and just reminding Senedd Members around the table that it was only back in March 2019 when we'd got to a position where we had seen really significant progress on waiting times across all of the health boards and, bar one, they were almost down to zero in all of those levels. And obviously the pandemic has completely changed that position from almost getting to a point where the targets were being met—they were in the best position for a number of years—to a position where now, across the UK, we are all dealing with waiting times that will be the worst that we have seen at this stage.

I think that, as we deal with the recovery process for our waiting times in the context of everything else, as I was saying earlier, we need to recognise that, whilst there is prevalence of whatever level of coronavirus in our communities, and, even if it's a lower level, the NHS still has to face the activity as if patients could be coming in with coronavirus—so, the physical changes, the streaming mechanisms, the testing regimes. And one of my concerns is that, clearly, through the pandemic responses, we have seen a much lower level of elective activity possible. And it won't just be a switch that happens—we won't suddenly just declare that now we're in recovery mode; we're going to have those arrangements in place for some months to come, even as we try to restore a range of activities happening right across the NHS. 

Okay. Jack. 

Thank you both for those answers. Minister, I'd particularly mention that you mentioned mental health in your opening statement, and especially for our NHS staff, and I know our colleague on the committee Jayne Bryant, works very hard to raise that to attention. So, I think that's excellent, what you've said there. You mentioned within your statement then recovery, and Dr Andrew Goodall, you mentioned elective care. One of our witnesses has called for a national elective care recovery plan. Would that be something you'd be supportive of as an approach?

Yes, look, we'll have this overall recovery approach. We know we're going to need something that addresses planned care that builds in the work that's already being done by health boards to both understand how to assess the current group of people waiting and how to have a proper clinical risk assessment for those people; how to deal with those people who would otherwise have to wait a long time; and how you manage people who are long waiters with planned care challenges that are not of the same urgency as others—and that's going to be difficult, actually, in terms of a conversation with the public and with professionals as well—and then how we actually get into the activity, and the activity that takes account of Dr Goodall's point about the reality that we won't be able to operate in the same way we did in the past. 

The other thing that's also important—and, you know, put your politics aside on all of this—is we did see an increase in waiting lists just before the pandemic because of the tax and pension issues. And you will probably recall receiving correspondence from doctors and the British Medical Association about this at the time, and then the UK did look to move backwards a bit to try to reset matters. So, any changes in that field again—we've got a budget coming up—could make a difference about people's willingness or otherwise to undertake activity in a certain way. So, you can't take away the reality that those tax and pension choices will make a difference to our staff, and we're still going to need to look after our staff, because we have this challenge of, 'Phew, we're through the pandemic, things look a bit better', and you're then expected in the NHS to deal with this huge backlog as well. Now, that's going to be difficult to manage on a human level, so the choice about tax and pensions will matter and then affect people's willingness to do things, against a backdrop of the huge level of activity. But, yes, you can expect there to be a planned care recovery, and specific commentary about what that's going to look like as well, because that is plainly going to be necessary. 

Okay. Jack.

Yes, thanks again, Chair. Some of the significant pressures that the figures show are in orthopaedics. We've had one witness say that there have, effectively, been no hip replacements throughout the pandemic. We've also had several pleas for working across health board areas and boundaries to tackle the waiting time pressures. Would that be desirable, and in what service areas? Would orthopaedics be one, for example? 

Yes, I think orthopaedics is a reasonable area to look at, where we're going to need different delivery models and organising not just within health boards but potentially across health boards for different forms of activity. And I do think there's a willingness within parts of our clinical leadership to actually do that. The way that we've had to work by necessity through the pandemic, we know we're going to have a huge challenge waiting for us at the end of it, and trying to go back to the previous position as a default isn't going to work, and I don't think that's where our staff want to go either. So, not just in orthopaedics do I think it would be reasonable to expect that part of any recovery for planned care is going to have to come up with a different answer for how we deliver orthopaedic activity. There's a huge demand that we know has been put off and we know that harm will come to people as they're waiting in some cases as well. There are all sorts of very definite drivers, but not just a plan that I get to sign off, but then there are quite a lot of choices still left that are going to be pretty urgent in the inbox of whoever sits in the seat that I currently occupy after the election.

Okay. Jack.

I think it's an opportunity to be bold, isn't it, in our recovery? That goes for not just the health service but everything across Wales. The health boards have talked to the committee about developing business cases for increased capacity through the development of diagnostic treatment centres. Are you aware of these proposals and would you be prepared to support them, or would you encourage, perhaps, the next health Minister to support those?

Our capacity in diagnostic activity is hugely important for so many activities. I met the cancer alliance last week and they in particular talked about diagnostic activity and its importance for cancer, but it's not just cancer; there's a whole range of areas where your first port of call is the diagnostic activity before then going on somewhere else. So, we know we need to do more, and the plan—. I do have an open mind about what the future models should look like, and I know that Andrew and Simon Dean are doing some work on it, but as I said, there's a really positive and, at present, a real can-do attitude from people in the diagnostic community as well, who recognise that what they do could change and could improve and could make a real difference for the whole pathway of care for people, in either giving them assurance they don't need further investigation or treatment or in clarifying what is required.

And Dr Goodall.

There is sometimes a danger as well of the discussions on diagnostic being seen to be only about planned care, but, obviously, we're very reliant on diagnostic infrastructure for what we need to do around emergency care, but also of course the urgent patients within our system. I just wanted to be really clear that rather than developing proposals in isolation from us in Welsh Government and our oversight of the NHS, we have facilitated, we've received, and we've actually worked through these proposals ourselves. I think there's a balance between organisations wanting to develop only their local diagnostic centres, and I do think that, on the back of your question about regional arrangements, there will be a very significant need for an increase in our diagnostic capacity across Wales, and some of that will have to be regional solutions.

So, I personally, on the back of the proposals that I've seen, do want to see perhaps a balance between enhancing the local capacity and making sure that we also really do step up some of the regional diagnostic choices as well. I know there's a very strong level of support there for our clinicians across Wales, and I hope that we'll be able to make those happen, but we'll also need to look at the resources that are associated with those. And really, I think this is not just about addressing a backlog; I think this is making sure that our diagnostic infrastructure is sufficient to meet the future demand as well, particularly as we see a range of changing clinical practices and technologies as well.

Jack.

Thanks for that. It's important that the Minister mentioned cancer services, and we've actually heard from Macmillan Cancer Support about the hidden demand. So, perhaps what you're talking about has already answered my question with regard to that, bringing everyone together to get the right solutions. So, just one final question, if I may, Chair. There are different assessments, quite clearly, of how long it's going to take to tackle this backlog, and they vary significantly. Is there a danger that we're going to see a significant difference emerging between health boards in terms of how quickly a patient is seen, perhaps in north Wales versus south Wales, or vice versa? I think that's something we really need to address. I assume you're hoping that that won't be the case with your national and regional approach in working across health boards, but could you see that being a real concern for patients across Wales?

Excellent future for you, Jack—not only are you asking the questions, you're answering them as well. But, anyway, Minister.

No, we'll definitely want to see an approach that doesn't leave one part of the country behind. We started the pandemic with people at different ends of this scale in terms of the level of activity that was over our waiting times expectations and not. And I don't want the recovery to be something where we just tolerate a level of unevenness. We were already going to have to invest in new ways of delivering services pre the pandemic. This is an opportunity to make sure that we have a sustainable service in each part of the country, and this will need both a local, regional and national focus. So, whichever part of the country you live in, you can expect there to be a determined NHS approach to recover that activity, but to do that in a way that recognises the needs of the population and the requirement to keep on looking after our staff to make sure they're still with us, because otherwise we could have expectations that are unrealistic and drive our staff out of the service. As Dr Goodall said, the requirement for PPE and for different ways of behaving will be with us for some time to come, so we won't automatically be making big gouges in the waiting times mountain in the first few months of the next term.

Okay, Jack?

Yes, thanks, Chair. All I would say is a plea from me that we listen to our wonderful staff to help shape the future of our NHS, because that's the least they deserve. I know that's a commitment from the officials and the Minister here. Cheers, Chair.

Well said. Time to move on. Jayne Bryant.

Thank you, Chair. Good morning. Following on from Jack's questions, really, we've talked this morning about the resilience of the staff being tested, and all the non-COVID harm building up for the future. You've mentioned that there's an urgent need for rest, recuperation and a time to recover, and some will also need to return to their usual speciality or department after a long period of redeployment. How are you ensuring that health boards are able to support staff and manage that change?

I spend quite a lot of time talking to the staff side, the trade union side. We have had regular engagement with them, and it's a point that they've regularly raised, but it's also a point that I've raised in a range of other fora as well, about how we need to take care of our staff. I know it's part of the regular partnership arrangements that Dr Goodall and others take part in as well, and the awareness of the conversations that employers and managers need to have with staff representatives to make sure that we really are living our values about being compassionate in the leadership and the way that the team works together. Because what our staff have not just been through, but are still going through, we know that that will come back. We know that some of our staff will have post-traumatic stress disorder-like challenges in the future, and it's important to look after them, because otherwise we leave ourselves with a huge practical problem. So, there's an ethical point about doing the right thing, but also, just in very practical terms, if we don't do that, we'll leave ourselves with a bigger challenge.

I know that the partnership forum in NHS Wales has recently issued a statement about wanting people to take their leave. I know that they're looking to reset and look again at how partnership has worked over this period of time, both about where it's worked really well, but also where they've had challenges to work through as well, because that's important, to make sure everyone is going on a commonly understood basis in the future. So, there's going to be a need for a constant review of how successful we are at managing a workforce that is still going to be under sustained pressure for some time to come, and to make sure that we're actually living the values that all of us would recognise and sign up to when we talk about our NHS.

Thank you for that answer. Another point that was mentioned this morning is around capacity. Do you think there's sufficient physical and service capacity, and the right clinical environments within Welsh hospitals, to address the challenges that we've mentioned this morning, from tackling waiting times, delivering more routine services, but, obviously, potentially still dealing with the demands of COVID?

I think the way that our hospitals are configured, they're built for the time they were built. So, in your and Lynne's part of the world, although it's just outside Lynne's constituency, we've got a new modern hospital. The way that's configured has actually made a real difference—a hospital started within this term, completed on budget, on time, a real success story for public build within time, and it's been a real factor in how Aneurin Bevan have managed the pandemic. The space that's there has made a really big difference. We have other parts of our hospital estate that aren't in that place, so actually our physical estate is built for a different time. We're having to constantly readapt it, and you have a choice: you do what we've done in Ysbyty Glan Clwyd and what we're still doing in Merthyr at Prince Charles, and you substantially remodel the hospital, which is a big challenge in itself, or you need to create new infrastructure. They're both really big and expensive challenges.

But, actually, our capacity to deliver is still not just about the physical environment, it's also about our staff as well. And even in the Grange University Hospital, you still need to have the additional infection and prevention controls, you still have a reduced level of activity. So, even with the different estate, you're still going to have some really common challenges that will affect our capacity and the timeliness of how we're able to get through this and, frankly, what that means for staff and where they go to work. If you talk to people who go to work in the new Grange, then there's very, very positive feedback from people who are going there about the environment they're working in. So, it does make a difference to how our staff feel about going in to do their job, and that makes a difference to the sort of care that people get. 

Dr Goodall. 

I said earlier about field hospital capacity and looking forward about, maybe, some of the additional residual support that we're going to need within the system, and I think that will have to be a factor, certainly through this next 12 to 18 months, and probably beyond. I think we also need to, given the changes that have happened across our system, make sure that the NHS for the right reasons doesn't just simply snap back to some of the traditional ways of delivering services. So, I do think that some of the resilience of hospitals for the future is going to be about ensuring that models that have changed are built upon, and continue to be the regular day-to-day experience across Wales, rather than just something that is tied into the pandemic response. 

We will need, I think, to learn a little more about the balance of bed capacity that we do need in our system to manage normal year-round pressures, and also including, inevitably, what is a greater focus in the winter. And I think what we've learnt by the excess capacity that we've put in this time is perhaps that is a pattern of us needing to do something a bit different about our resilience, because whilst we've been under tremendous pressure, we have been able to contain the pressures within the capacity that we've been put in place during this last winter, even with a once-in-a-century pandemic response.

And then, the final point is to make sure that different actions that we've already been putting in place recently, anyway—. We have the workforce strategy in place that the Minister launched last November, which is absolutely relevant because of the pandemic response. We have got a pipeline of workforce expansion that we have been putting in place over the last two to three years, and as well as having grown, inevitably, the workforce over the last year because of the pandemic response, we will need to start to deploy staff, again over the next three to five years, who start to come into our system on the back of the expanded places, for example in nursing, physiotherapy and some of the other paramedic specialties as well, and, of course, doctors and GPs, because we've been able to secure very high access to the GP training schemes even whilst we've been going through this very difficult period of time. So, I think the long-term plans for workforce are as important as us dealing with the very immediate pressures of the pandemic. 

Dr Orford. 

Thank you. Just to come in, there are a number of uncertainties that we have, and perhaps some certainty that this virus isn't going to go away. It has spread across the globe. There are reservoirs in laboratories, in animals, in humans. It will keep coming back at us. We don't know how long our immune response or the vaccine response will keep us protected. There is much that we don't know about long COVID, and there are uncertainties around seasonalities. So, I think we anticipate that we will need to continue to be vigilant and respond to what we're seeing, and so making sure we're prepared is really important. Thank you. 

Wise words. Jayne Bryant. 

Thank you. Just moving on to talk about support for patients, we've talked about the challenges of those people who have been waiting perhaps for routine operations, and they've been very understanding about the situation that we're in. But the challenge will always be how we keep those patients, who are, in their own way, in a lot of pain, informed about what's happening with the service, making sure that they feel comfortable and safe in accessing the health service when they need it as well. How satisfied are you that health boards have been managing those communications sensitively and effectively, and what support have you been able to offer them? 

Okay. Minister. 

It's part of the way that we expect health boards and the NHS to have a relationship between them and the people they're caring for. And, again, this is part of not just the regular conversations we've had, but, in terms of the recovery conversation, it's definitely been a feature of the concerns the NHS have raised as we've gone through that conversation about how to take account of the reality that people are anxious and concerned. For some people, we need to persuade them to come back. They know they've got a physical health problem but they're worried about going back in. There's always the challenge about the risk and the challenge to people's mental health when they are generally concerned about the broader situation and the deterioration in their physical health if they don't see an end in sight. How we balance those needs is not straightforward, but it is what our health boards are already starting to do. I know that it's been part of the conversations that, as I said, have taken place in the recovery, and it will go into the planned care element, as well as when we're looking at the recovery we're going to need to see in mental health terms as well. I don't think—. The challenge is, it's easier to describe the problem than it is to say, 'Here is the answer', because the answer will depend on individual circumstances. It will depend on people's relationships with their clinicians. It will depend on how successful we are at getting people to use different ways of working, the assurance that provides people, and then getting to people in the greatest need at the earliest point in time. That sort of general description I'm sure makes sense to everyone, but our challenge then comes in what does it mean if one of your constituents comes to you and says, 'But I am still worried and I have waited a long time and I am living in pain; why can't I be seen earlier?' That's where it gets much more difficult on that human level.

Jayne.

Thank you, Minister. We've heard about the need to reshape the relationship between patients and health services. How do you think that is, and what practical steps are being taken to equip patients to take greater control over the management of their own health?

This is a consistent challenge we've tried to address from the previous Senedd term into this one. You'll see it in the parliamentary review and in 'A Healthier Wales', in prudent healthcare and, indeed, in value-based care as well, about how you have a more even and equal relationship, where the member of the public isn't simply a patient as a recipient, but they are a participant in choices around their care. Actually, if you recall the short debate last week that David Melding led, on outcomes from the Cumberlege review around informed consent, there is a recognition that we need to get to where there is a genuine understanding from both sides about those treatment options and about people's differing risk appetite as well.

So, this is part of what we need to do even more of, and again, I've said this in the past: I think social care has been a bit ahead of the NHS on some of this, in terms of people's ability to influence their choices and make decisions about care decisions. We aren't where we want to be yet, but I do think that people should take some positives from where we are in Wales and our approach around value-based healthcare, where we've got international interest in what we're doing. You'll have heard from Alan Brace what we're doing. The interests that other systems have about how we're looking to generate and drive this in, and the work of Sally Lewis, as well, in terms of leading value-based healthcare. It's part of what I do want to see driven into our approach in the recovery, and I think 'A Healthier Wales' is the direction that we will still be taking. If anything, it's reinforced the need to deliver the reform and the progress 'A Healthier Wales' set out, and actually, this sort of area of activity is part of the reason why the chief medical officer was interested in coming to Wales, because of the journey we'd started off on prudent healthcare and the greater equality and co-decision making is a key part of that in making better choices and better use of the resources we have within our healthcare system.

Thank you, Minister. Thank you, Chair.

Right, moving on and we've got Lynne Neagle and her questions.

Thanks, Chair. I've got a couple of questions, first of all, on transformation of services. Obviously, there has been some transformation during the pandemic, particularly in relation to the use of digital technology and online communications. Going forward, are the changes we've seen sufficient in scale to have a real impact on the delivery of health services, going forward, and how is the good practice and any learning being rolled out across Wales?

Well, I'd say that the changes to date aren't sufficient for the future. We'll need to do more. So, that's why we're creating Digital Health and Care Wales. It's why we're looking at how we go about this, not if we should go about this, and I think that's important as a recognition that the journey we started has actually been accelerated by the pandemic. I can't remember exactly off the top of my head the figures, but I think we're undertaking 5,000 video consultations a week in the health service now, so you're seeing a very different shift in the way that care is delivered, but not only that, you're seeing changing expectations that I don't think are going to walk backwards, both for our staff and the public.

So, it's still about how we do more, because there's more opportunity to deliver good-quality care using digital answers and solutions, but that doesn't mean that you'll get away from or get rid of the personal relationship that still matters in lots of our care—that's both for primary care and, indeed, hospital-based care as well. So, I expect that we will need to do even more, but I actually think that, again, we're in a moment where we've got willingness to do so from both the public and from our clinicians. But I do think that the new digital body will help us to deliver more of that progress.

Okay, Lynne?

I think Andrew wanted to come in.

Oh yes. Dr Goodall.

Yes. We obviously have ongoing discussions and conversations with health organisations, but obviously, with staff who were involved in arranging the changes, we've just been going through an exercise, through the autumn, of capturing just the range of innovation and change that's actually happening. We've been doing some work, liaising with Swansea University, helping to facilitate that, so that, basically, we have a framework for a consistent approach across Wales, and really setting an expectation that these changes should stick. I think the thing that we have learnt more from the pandemic response is the ability to turn what, in the past, has been the local evidence of good practice into a consistent national, universal approach.

If you just think about some of the services that have changed at scale and from scratch over the course of the last 12 months, you know, the establishment of the whole test, trace and protect system, the vaccination system from scratch, the way in which we shifted to remote working and the Teams infrastructure across Wales that we've been able to use. And even the remote and video consultations, whilst these were on the back of some experiences within the system, where the NHS had done them in part, we've been able to manoeuvre them forward in days and weeks, basically. So, these are changes that would have taken many years to have delivered in a normal experience for the NHS. I think we've all learnt, in our oversight of the NHS, that actually we can make proper decisions on an urgent basis and still have all the relevant governance in place, but we can actually make it happen more quickly within our system.

Thank you. Can I ask about primary care, then? The evidence we've heard has told us that primary care needs to play a really key role in transforming services. Do you feel that there's the capacity within primary care to undertake that transformation and is there any additional support that the primary care sector needs?

Yes on both, I think is the starting point. So, I think there is the willingness, certainly, within primary care to continue to do even more, and that means that we need to see the reform across the whole of primary care. So, general practice has been as busy as ever during the pandemic, but busy in a different way. We've also seen more people shift to using other primary care practitioners as well, so, more people have gone to pharmacies than would've done previously. We've seen optometrists really stepping up as well. So, your high street optician has done even more and actually has kept even more people out of needing to go into a hospital during the pandemic as well. And equally, the reform programme in dentistry is hugely important too. So, the contract reform in those four areas is hugely important for getting people to work in a different way, and actually, again, the way that our clusters have worked in the past—I know that the committee has taken an interest in clusters through the whole of this term, as you'd expect—we've seen a lot more working at cluster level to make sure that we're dealing with people's care needs by people working successfully across their clusters. And I think we're going to see even more of that in the future.

So, there is the capacity in the sense that there's a willingness to do it, but that capacity needs to continue to move forward, both in contract reform, but also our ability to keep on getting staff to come into the right part of the system. So, this is all linked into the comments that Dr Goodall made earlier about our successful ability to keep on recruiting, to have people coming to Wales to train and to stay in Wales. We're going to see more of that, as well as making choices about making sure that primary care is resourced for the tasks that we ask it to undertake, as well. So, the detail of budget choices will be important to make sure that the ask we have of primary care is one that builds on what's worked effectively—and again, I think clusters in the primary care model for Wales have been shown to be the right things to do—and how we can go further, given that we're still learning in a different world. But if we try to go back to the way things were, then I think that that would be the worst thing possible for staff and the public.

Thank you. I'd like to ask now about the easing of restrictions. The Minister won't be surprised that I want to focus on schools to start off with, really, and the announcement today about years 7 and 8 is incredibly welcome, because I think many of us are becoming deeply worried about the impact on children of being out of school for this length of time.

But, given what the Scientific Advisory Group for Emergencies has said about cases increasing when restrictions are eased, and I've also seen coverage of Professor Russell Viner's research, and I believe he sits on SAGE, who said that the only safe way, really, to open schools is to keep most other things closed, how does the Welsh Government intend to deliver on its stated priority of getting children back to school?

Well, that's the conversation that we regularly have. I can honestly tell you that every day this week I've had a version of that conversation about the good news that we're seeing fewer people in our hospitals, the case rates are slowly coming down, but still coming down, after the first phase of school reopening, and the good news around vaccination. Those are all positive things, but the confounders are that, actually, the more you open up and the more mixing there is, the more likely you are to have a levelling out, if not a rise, in cases.

The reality is that the easing means—. It's the point that Frank, the chief medical officer, and the chief scientific adviser on health, Rob Orford, make, which is that the challenge about schools is only in part about activity within the school. It's actually about what adults can then do when their children are at school. That's both around the school, but it's also the opportunities when you don't have other things to do, because we're already seeing in the information that we've published that there is a range of people who are already in each other's houses on a social basis as we are now, in the level 4 period of time.

So, we're having to watch the data really carefully, and it's why we haven't had a long-term set of goals and dates. But, the position that we're in means that the education Minister has been able to confirm that those check-ins will take place for years 7, 8 and 9 in the last two weeks of this term before Easter. That's really good news.

We're looking at the package for any future set of easements to make sure that we don't take out the headroom that we need to make sure that schools can return to face-to-face learning after the Easter break. That's both the challenge and the task that we set Dr Orford in the modelling advice that he gives us, and we'll look to publish that in the coming days, so that the public and Members can see more of the advice that we're getting, but also the advice that we get from the chief medical officer and his department about the balance in the measures.

It's completely fair to say that TAG advice has recognised the concern you raise that, actually, there is a real impact on children and young people from not having face-to-face learning, and that has to be factored in. That's consistent with the chief medical officer's framework for looking at easements and the room that we have. The advice that we expect will be about, 'Well, is this package of measures something that does or doesn't compromise the overarching objective of the Government, which is to get our schools reopened in as normal a way as possible first before other wider easements?' The challenge is, though, that if we have additional room for manoeuvre, then should we not undertake those until all schools are back, even if the advice is that we can safely do that? That then comes back to whether there's a proportionate approach to each of the easements.

So, there is a balance in all of this, but I do think the fact that, hopefully, all of our secondary school pupils will have had the opportunity to have some form of contact with their school—a check-in—before we get to the Easter break will be good news for families and for schools. I know lots of our staff want to have that opportunity to check in with people, and then to have that full opening after Easter.

But, the balance and the advice is what we'll have to consider, and if the data changes then we'll have to make choices that are in line with that, rather than a hard set of dates that we have to work towards. You know, we have a different approach to England; they're taking a very big-bang approach on 8 March. That isn't the advice that we've had from either the chief medical officer or from the technical advisory group.

Okay, thank you, and I do absolutely support following the scientific advice. I've been very clear about that, but what I'm interested in is this balance, really, in the easing. I'd be keen to get Dr Orford's view on that, particularly in light of the fact that when you ease something, it's not just that easing—it sends a message, doesn't it? We saw lots of household mixing in the autumn, because people thought it was okay to do that, because four people were able to meet in a pub. What sort of message does opening hairdressers—as important as that is—send to people about what is safe to do in their behaviour? I'd be keen to get Dr Orford's view on that and how we really drill down on this priority of getting all children back to school safely.

We're in really tricky times right now. There are a number of uncertainties about how quickly we can vaccinate enough of the population such that fewer people are susceptible to disease, and how the vaccine will be effective in different groups. I think the evidence is looking positive, but it does take time for people to become protected. As soon as you have your jab—the CMO said he's had his today, but it will take two to three weeks before he starts to feel the benefits of that protection, and then a second dose later on. The population need to understand that there is still a large reservoir of people, a large proportion of our population, that are susceptible to infection, and that a third of people that find their way into hospital are under 65. It's going to take us some time to get to those, and until we do that, there is every chance that we can have a resurgence and another spike.

A huge part of this is people's behaviours. If people are sensible, and they socially distance, and they don't go round to each other's houses—that's really, really important—then we'll get on top of it. In every modelling scenario we've looked at, it's those behaviours of the public—the wider behaviours. Some of those may be associated with opening schools, and so, if people think the signal is, 'If it's okay for schools, it's okay for me to go round my auntie's house and have a party night', that's not okay. We know schools are a safe environment. We've seen from occupational studies that teachers are no worse off than other parts of the population, which is really positive. We've got lateral flow assays going in there, testing teachers periodically, which is really good. We've got bubbles, and we know from evidence from testing in schools that the incidence and the prevalence in schools is lower than the general population. So, that's really good. However, it's that wider mixing outside. We have to be really clear on our communications that it's not gone away, but we are absolutely prioritising the education of our children in this period.

But the vaccines are coming. They will take some time to come, and, in that period from now until the vaccines have been deployed wider, we need to be really, really careful. So, we get our numbers low, and that gives our public health system a chance to do that forward and backward contact tracing. We ask people to be really sensible, and stick with us. We know levels of adherence are really, really high—people understand, people are adopting the right behaviours. And then we need to get vaccinating as quickly as we can. We've modelled lots of different scenarios. I think our colleagues in Swansea University have modelled about 576 different scenarios. We're carefully looking at those, and we're really, really closely monitoring lots of indicators, like hospital admissions, like per cent positivity, to see what's happening, and looking at waste water, to see if we can see virus in waste water. So, we're looking at everything, but we really, really closely need to follow the data, and if we see changes, then we need to react accordingly. Thank you.

Okay. Thank you. Can I ask, then, about what assessment you've made of the ability to achieve herd immunity, given that we are only able at the moment to vaccinate the adult population against COVID? I'd also like to ask about what assessment you're making on an ongoing basis of the potential of other variants to derail our attempts to get back to normal. There was a study this week that was published, which showed that the Brazil variant evaded immunity in 60 per cent of people that you would expect to be immune from COVID. How is all that being factored into the planning for easing of restrictions?

Perhaps if the chief medical officer starts, and then perhaps Rob might want to talk a bit about the new variants and how we factor those in.

The question of herd immunity is one that comes back periodically. You do need extremely high coverage levels of a very effective vaccine to get herd immunity. Measles is a good example. You need well over 90 per cent of people to have been vaccinated with a very effective vaccine. The prime aim of the COVID vaccines is still, at the moment, as we've heard before, not to reduce transmission. We hope, and we could start to see, that it can interrupt transmission, but the main aim is to keep people out of hospital, to stop people getting serious diseases. So, the herd immunity question, really, is for later, and we cannot rely on it as our sole way out of this. I think, as Rob has been saying, we just need to use those other things that we absolutely know keep us safe—the social distancing, not least—and that will keep us safe. 

Just on the variants, the big risk of the variants is that they may be more transmissible or they may bypass the vaccines, and that's why we pay so much attention to them, and why there's been so much coverage of the issue around the Brazil variant this week. The reality, of course, is that the virus will continue to evolve. Even when we have low levels of transmission in this country—and that is the best thing we can do to keep local home-grown variants at bay; get community transmission as low as we can and keep it there—variants will arise in other parts of the world. So, we do need to look to our border controls and our quarantine arrangements, and we do need to think about travel and travel arrangements. All of those things will keep us safe from the variants.

The other good bit of news on that is that it's looking likely that the vaccines are modifiable, and that as variants do emerge, the biotech industries, of which the UK, to be fair, has led a very good—globally, we've been leading on a lot of the work around this. But those industries should be able to produce vaccines—maybe a seasonal vaccine, we don't know yet—that can meet the challenges from new variants. 

Dr Orford, anything to add?  

No, I think the CMO has covered it. But it's certainly that adaptive approach to managing it and being very watchful. We work very closely with the other nations and internationally to look at new variants and then react accordingly. But there's a lot to learn from things like seasonal flu, there's antigenic drift that changes over time, and so we'll need to change possibly our vaccines and the way in which we react to new variants as they occur. 

Thank you. Is there anything any of you would like to add, then, in terms of how you intend to try and keep the numbers of cases et cetera low as we go through an easing process over the summer, and then head back into the autumn and winter? Dr Atherton, you've previously indicated that it could be a difficult winter again. 

I think it comes back to your first question in this section, Lynne, about the balance in people's behaviour and then the restrictions that are or aren't in place. Because the biggest reason why we have seen a success this lockdown has been the public response. We've also had the vaccination take place through that, but we wouldn't be seeing our case rates falling if it weren't for the overwhelming public support for the measures we've taken. And I think that's because there are all these different things—the currency of the messaging and the point and the purpose, the fact that's been reinforced by other trusted voices, not just Dr Orford and Dr Atherton, but other NHS and other staff as well, who are broadly trusted, despite the abuse that unfortunately lots of our NHS staff are getting. But it is also, I think, because lots of members of the public have seen the amount of harm that has been caused.

There are some people who believe that everything we're living through isn't real, but the great majority of us know it's painfully real, because most of us know people who have been ill, and a lot of people know someone who's lost their life. So, actually, you can see the cost of what we're living through, and that, I think, helps with the public response. As we move out, the balance is not just what we're opening and being able to explain why that's happening, but also why, to allow those things to happen, other things still need to be restricted. So, there is a point there about messaging, and I think that goes with your point about schools and other activity, about why other things have to be closed to allow those to happen, and not to allow this to accelerate and get out of hand, because we've seen the harm that can be caused.

We know with the Kent variant that growth can be much quicker, with the variant that's now dominant. We know there are new variants that are an additional risk as well. So, actually keeping rates low is an important defence against a generation of new variants, again, in the future as well as the challenges of international travel and otherwise. I think there is the honesty of the data that we publish, the clarity in how far we can honestly forecast the future, but also the appeals to the public to keep on doing the right thing to keep us all safe. Because if people don't believe or trust what's being said and we see greater mixing between people, then we will be into very difficult times. That could happen sooner, if that's the response, as opposed to later. But I do think that, within the next few days, when we're able to publish some modelling advice, that will set out the impact of the behavioural response and how that can generate a very different set of outcomes in terms of the number of people going into hospital and the number of people who could lose their lives, in addition to all the other things we're going to need to do. So, I wish it were as simple as one thing to do or one thing to say, but it'll be a range of factors, and the key to all of this is how the public choose to behave.

Can I just ask one final question? I'm not trying to score a political point here, but obviously Boris Johnson has indicated that we would largely be back to normal from 21 June, and that has led to some festival organisers et cetera arranging events. We've had articles in WalesOnline saying, 'Where can you go on holiday in the summer?' There's a real challenge there, isn't there, with the messaging, when so much of the media in Wales take the messages from England? 

Whatever the Prime Minister says, whatever party they are, makes a big difference across the UK in terms of the public messaging and understanding, now more than ever. I don't see a path to renormalising international travel in May, and May is a long way ahead. The third week in May is a long time in terms of the course of the pandemic. And the June date—again, I think that is optimism rather than taking a data-led approach. I'd love to be in a position where you can have music festivals and full stadia, whether you're watching Lions games or if Euro 2021 were moved here. That'd be fantastic. If we could do that safely, I'd be delighted. It's one of those occasions where you'd be delighted to be wrong, but that isn't the advice that I see. That isn't the advice that either Dr Orford or Dr Atherton are giving—that actually we can tell you with some confidence to allow you to go out in public to say that these things will be possible in June.

So, with the messaging, I think caution is important, because I don't think people are expecting us really to give a three-month forecast, and, actually, it was more like a six-month forecast when it was given. And you've heard the deputy chief medical officer saying that he doesn't think that it is possible to give a realistic and credible forecast for that period of time. So, we're not doing the same thing here, but there is a real conflict in the messaging. I don't know if you watch Gogglebox, but I saw Gogglebox, and they were talking about the reaction to the Prime Minister's debate, and they were saying, 'Right, get your diary out; that's when you can go to the pub'. There was the sense of relief people had—you can understand that—but we've all then got to deal with the reality of what's happening, and the step-by-step approach is the right thing to do so that we're not building up people's hopes and expectations. Because if you can't then do that, there's a massive loss of trust and that potentially affects people's willingness to do the right thing, if we do need to carry on living with restrictions to keep us all safe. Maybe Dr Atherton might want to say something, because I'm sort of speaking for him on his advice, but I don't think I've misrepresented the tenor of the advice that we're getting and that we'll have to continue to address.

No, indeed not. Lynne, to go back to your question, the recipe for success here has five things. We have to vaccinate people as quickly as we can. We have to ease out of the lockdown slowly and cautiously. As we do that, we have to monitor, and, as Rob says, we have to be ready to react as needed. We have to keep the variants down and out as much as we possibly can, and we absolutely have to maintain public confidence and public compliance with the residual measures. If we do those five things, then we have a way through this.

Thank you. Thank you, Chair.

Summer holidays in Cwmbran for you then, Lynne. [Laughter.]

Lovely.

Angela had a supplementary, before we close.

Yes. Thank you for that. To be honest, you've answered an awful lot of it, particularly Rob and Frank, in your response to Lynne. My question was marginally more philosophical, if you like. I suppose, in a way, it is slightly what the Prime Minister's trying to do, and, on a non-political basis, I'll just add that he caveated it with 'if, if, if'—there were lots and lots of 'ifs'. And, of course, we're all so desperate and miserable with what's going on that we don't want to hear the 'ifs', and we just want to hear the good news bit.

Frank, I think you just said the restrictions are to keep people safe, and you're absolutely right. But, given that herd immunity is going to be difficult to achieve unless we have over 90 per cent of us carrying that vaccine within ourselves—the antibodies in some shape or other—what thoughts, what plans are Welsh Government putting, Minister, into actually planning not to the end of this year and a possible other way, but actually the slightly longer term? Because we obviously can't keep on living in this either/or situation. Either businesses can start opening up and livelihoods can be restored, or schools can be open. We need a bit of everything, don't we? It's a very difficult dynamic, I understand that, but I'm assuming that all four nations are actually talking about what that future might look like in the long term. Two years down the line, are we going to be treating this more like the flu vaccine—everyone has it every year or has top-ups throughout the year—and we just have this extraordinary logistical operation that continues ad infinitum? Or are we going to say that there's going to be a point where we accept that we're not going to keep everybody safe all of the time, but that we have to do that in an effort to ensure that the mental health and well-being of everybody else, for example, has to come slightly more to the fore? Or our young children or—. I don't have any answers, but I just wanted to know if the thought process is going on, if anybody's actually studying this and trying think about what our new future will look like.

Those are very definitely things that scientific advisors, chief medical officers and others are turning their minds to about that longer term future, because I guess the whole thing about, 'You can't keep everyone safe all of the time', is that, well, we don't with the flu. We live with the flu, but that's because it's something that we understand, there's a range of risks that we understand, and even with the flu, one of the things that I hope is a real positive that comes out of this—there are a couple of positives—is that the seasonal flu campaign will see more people take it up, because there should be greater awareness that we lose people unnecessarily every year to the flu because we don't have a high enough take-up of the vaccine that offers a measure of protection. It may be possible to have joint vaccination in the future. We're not quite there yet. But if it were treated more like that, where we don't have to have the extraordinary society-wide interventions, that is what we think is the most likely end point. We can't say, at this point in time, when that will come. There's still a fair amount of uncertainty about when that point would come.

The other thing that we haven't talked about today is that I hope that one of the things we get from this is a better and more normalised and positive conversation about end-of-life care, because so many people have experienced loss, and loss in very difficult circumstances, and there have been lots of people talking about the things that matter to them, and, if you couldn't physically be with someone, the efforts that were made to make sure there was some form of contact via screen, but equally the harm that's done to people who live on if you don't get any of that contact at all. Actually, we haven't been very good as a country in talking about what good end-of-life care looks like, and I hope that we won't lose sight of that, because I think we can make real improvements in our attitudes to a lot of this in the future as well.

But as to the longer term future, yes, we hope that it will be more like the flu in the way that we deal with it in having a regular vaccination programme. We hope we'll have higher take-up of that to reduce the unavoidable harm. But it would be optimistic, without good reason, to give you a figure, to try to pluck a figure out of the—

Totally, and I'm not asking you for that.

But I do think that it's important that we have some optimism about the future. So, getting all of our children back to face-to-face learning is a really positive step, not just for those children and their families, but actually it gives all of us a sense of optimism about what else can be possible and comes in the next phase. So, in all of this, it's about balancing the optimism that I think people do want to hear with some realism about the state—. And, actually, I think that, in the surveys we have coming back and that Public Health Wales do as well, that is where most of the public are. They want a cautious approach that doesn't risk the hard-won gains, and they accept it will take some time. They would rather we took time to do this safely rather than having a larger rush for activity that could see the brakes come on again later. And, as ever, there's a balance, but, like you, I hope that the future—a post-pandemic future—will come sooner rather than later. But plenty of challenges for this Government, in our remaining weeks, and for whoever forms the next one, to negotiate in the months ahead.