National Assembly for Wales

Croeso, bawb. Welcome to the Health and Social Care Committee this morning. Welcome to Members and others watching in. This is a virtual session this morning, so Members and witnesses are all attending by video-conference. Standing Orders remain as they normally are, and questions and answers can be in Welsh or English. Just before the meeting, we agreed that Mike Hedges would step in if something dramatic happens with my connection. So, thank you for that. I move to item 1. We have apologies this morning from Joyce Watson, and Jack Sargeant is leaving us just after our lunch break as well. With that, I move to item 2 today—. Sorry; declarations of interest—if there are any, say so now. No. Thank you.

Our session today under item 2 is our first meeting dedicated to taking oral evidence from stakeholders to inform our inquiry on hospital discharge and the impact on hospital flow. I should say there is a large pack of evidence that's also available on the public website, which is publicly accessible, to be viewed as well with regard to all the consultation responses for this piece of work that we're undertaking. We've got three sessions today, and this is the first of the three. We've got three witnesses with us. I'd be very grateful if you could introduce yourselves for the public record.

Good morning. My name is Nicky Hughes, I'm associate director of nursing for the Royal College of Nursing.

Good morning. My name is Yvette Cloete. I'm a paediatric consultant and clinical director at Aneurin Bevan University Health Board, and I'm representing the Royal College of Paediatrics and Child Health today.

I'm Dr Karl Davis. I'm a consultant geriatrician, based at the University Hospital of Wales. Today I'm representing the British Geriatrics Society in my role as the vice-chair for Wales.

Thank you ever so much for being with us. I think this is, certainly, I suspect, going to be a very interesting session for us as well. Perhaps if I can start off with a very general question. Give us an idea of the scale in terms of delayed hospital discharge and the impact that that is having for both hospitals and for patients. You're all welcome to make some sort of general observations on that first question. Who would like to indicate first? If you would like to speak, just lift your hand, or pen, or something up so I can just see as well. Nicky, did I see your hand go up? Lovely. Thanks ever so much. Nicky Hughes.

Thank you, and thank you for inviting us today. There is a huge problem at the moment with flow through hospitals, and one can see that quite easily when going past some of the accident and emergency departments and seeing the ambulances outside—it's quite stark at the moment. We know that, in February 2020, there were 448 delayed transfers of care, and I understand now that's over 1,000, so the problem has worsened. COVID has probably had a part to play in that, but possibly there are other factors at play at the moment as well, with winter pressures.

One of the major issues is the capacity and resources in the community. I suppose the first element is that if we can stop people coming into hospital in the first place, then actually you don't have the problem of flow through the hospital. Sometimes, that's not safe to do and there aren't the resources to do that. So, there needs to be a relook at the resources and the capacity in the community, both in care homes but in community services. There has been investment in community services, but certainly not in district nursing. We have to remember that district nursing is the core to all community services. A lot of other services will offer six weeks, or short term, but for a district nurse, that could be a lifelong impact that they have for that individual.

We really need to be looking at the resources and capacity in the community. We need to consider extending the Nurse Staffing Levels (Wales) Act 2016, section 25B, to be looking at have we got the right numbers of staff within the community and how we can make that happen. We need to make sure that we've got post-registration strategies. Also, thinking about children, we know that we need more children's nurses. So, for me, one of the biggest things, to start with, is to be looking at the resources, both in the community but in care homes, which play a major part in caring for people in the community, often quite complex people, where placements are quite limited.

Thank you, Nicky. And if I ask other witnesses to come in, but perhaps I could also add to the question as well: in our consultation responses, there was a common theme of rushed, inappropriate discharges without support in place. And there was also a number of examples of readmission to hospitals when people have been discharged inappropriately, according to the consultation responses. So, perhaps I could ask Dr Yvette and Dr Karl just to also address that point. Dr Yvette.

Thank you very much. So, I'll probably start off by saying, I'm in the luckier position of paediatrics and the other extreme to Karl, where we're dealing with largely healthy children. And so, in paediatrics, it's not nearly as much of a problem as it is in adult medicine with delayed discharges. We have a very rapid turnover, so we have a large number of patients coming in on a daily basis, going home within a day or two. But there has been a very big increase in the number of children attending accident and emergency post COVID, certainly, so there's an increased demand at the front door.

Paediatrics are very hands-on, so there are very often consultants at the front door, making those decisions and ensuring that patients don't come in. Because if we look at the increased number of patients coming in, if they ended up as admissions to hospital, because we have very limited beds in paediatrics—. Because paediatrics can't put their children onto an adult ward, you only have your paediatrics area to keep those children, so we do need to constantly be making sure that we aren't admitting patients that we don't need to admit. 

There's obviously great variation across Wales as to what we have and I can't agree more with Nicky that what we really need are those community nurses, the district nurses. In Aneurin Bevan, we're very lucky to have care closer to home, where we have a team of nurses. We can discharge patients much earlier. As soon as we feel they're clinically stable, they go home and the nurses go in for one, two, three, a week, two weeks, three weeks. We've had patients up to sever or eight weeks, having a nurse going in every day at home, giving antibiotics or checking up on children with respiratory problems. So, getting them out safely with that safety net makes a massive difference to our capacity within the ward.

But, as I said, in paediatrics overall—. In Aneurin Bevan, for example, 66 per cent of patients go home within two days; 92 per cent of them are there for less than four days. But almost always, there will be one or two patients who are there for over eight days. And in Cardiff and Vale, where they have a lot more complex patients because they have all the tertiary specialists there, they will sometimes have patients there for longer and waiting for a more complex package of care at home. And so, it's that joined-up work in the partnerships between social care and paediatrics and our district nurses that is making the difference.

Any opening comments from yourself, Dr Karl?

Thank you very much for asking us to speak. I have so many comments, I have to constrain myself, I do apologise. I'm absolutely on board, as Nicky says, and as we all know, if you could be looked after in your own home, if that service is available, that is far more preferable for the vast majority of problems than coming to a strange, often frightening environment, for older people. 

When I talk about older people, I have to remember and we all have to remember the range of people. I currently work on the trauma unit, so I have the joy of working with 84-year-olds who've fallen off their motorcycle or crashed a paraglider—honestly—versus those who are frail and suffer minor falls, but major consequences and major injuries as a consequence. The scale of the problem, I think, is really quite marked. The Lakeside unit that was built through the COVID pandemic is already in quite high usage. We've developed discharge delay units so that there is nurse-led, nurse-provided care, supported by a multidisciplinary team to a degree, for people who really should have been discharged, but the capacity is simply not there for them. 

In terms of moving people through the system, it's that whole journey and you've seen in the written evidence statements about admission and statements about discharge and statements about the whole process in between, particularly with older people. And Yvette's small children, I really don't understand as well as older people, but actually we have many shared problems, many shared challenges. So, in terms of the discharge issue around some of the problems, did you want me to talk about that as well?

Hold fire, Dr Karl, because I'd imagine that some Members are going to pick up some more specifics, actually, so that's—. I mean, you set out the problems, and I think some Members will want to dig into, perhaps, some of the solutions as well. So, Gareth Davies.

There we go—unmuted now. Thank you, Chair, and good morning, everyone. I haven't got a great deal to add to what the Chair has already asked in this particular area, other than the working relationship between the NHS and the private sector, particularly in relation to social care, and whether that presents any barriers to a good discharge to start trying to free up the system, really. And whether the relationship is a barrier between your discharge liaison nurses and care home managers. So, just to put that question into context, really. I don't know whether you've got a particular view on that.

Nicky Hughes.

Prior to coming to the RCN two years ago, I managed services in the community, and certainly commissioned care from nursing homes all the time. We had a really good working relationship with our care home managers. We were able to have frank and honest conversations about whether the mix of clients within their home would suit certain clients coming in. Obviously there was a commissioning element and an observation of levels of care and safeguarding and all that, but actually, we developed really good relationships with the homes. I'm not sure—. I'm hearing that maybe some of the issues through COVID have maybe shaken that relationship slightly, when we heard of people being discharged but they hadn't had the right tests, or they were being discharged and they were positive and that had a huge impact on the home. So, I think that maybe has shaken some of those relationships a little, and there is some way to go to rebuild that.

You know, with working with the private sector as well, I suppose an additional to that is the working relationship with local authorities as well, because I've seen cases over time where things like retainers are being lost for funding for care homes during people's stay in hospital, and that's obviously been exacerbated by COVID. So, where essentially somebody has had care home funding and that's stopped due to a delay in discharge, is that something as well that you've seen as an issue, this relationship working with local authorities to try and tie in a sort of holistic care package, and whether that's a bit of a block to discharging as well?

Nicky, do you want to come back on that? I don't know if anyone else does.

Yes, thank you. Yes, I have experienced that. Sometimes funding has stopped, or indeed things have changed and the home then say that they don't feel that they can take that person back, which then restarts the whole assessment process, which can be lengthy, particularly if we're talking continuing healthcare. My experience, and I can only talk about my own experience, is that where we have good integration, where we have good relationships with social services, with the local council, then things tend to move smoothly and we work really well together and we've seen some of the integrated teams. Sometimes, obviously, with the different funding streams, that can create tension in those relationships, and that can be a barrier sometimes to trying to get people to the right place to have the right care that they need.

Thanks, Nicky. Mike Hedges.

Diolch, Gadeirydd. The first question I'd like to ask is: what do you think is the key barrier to effective discharge? And can you explain to me, or is my experience different, that people go in for operations—orthopaedics especially—where they should come out better, and the operation works, but they end up needing substantial care or discharge into a care home after having their knee or hip replaced, whereas before they'd be able to get around? Is this unusual, and I've just been unlucky with the cases I've dealt with, or is there something happening where people are becoming deskilled in hospital?

Thanks, Mike. I think I might have missed Dr Karl's hand go up in the last session, so if you want to respond to anything on that last question as well, and move on to this.

Be careful. Thank you. Sorry, Mike, just to draw on Nicky's comment about integrated teams; it's so important, Gareth. Social care and the distance that sometimes, as a hospital clinician, you find yourself from that private provider means that there is often uncertainty from the ward staff as to what's going on on the funding stream, on where you are in maybe the allocating and identifying of a care home or the care process.

Historically, I used to speak to care home providers; we used to talk about falls and fall prevention strategies, trying to align the local policies with the care home policies and, of course, they've got their own business models and their own drives, so there is that tension. But we, as health and social care providers, do need to be making sure that the provision that we have is supported positively. And absolutely, as Nicky started saying, at the outset of what happened at the front stage of COVID where we could not test, we did not know what the future would hold. It's hard to go back and remember those times now, but it was a wave of, 'We don't know what's going to come across, and we can't really test for it.' You all might remember how hard it was.

We've got to differentiate between emergency surgery, which is the usual scenario where people end up in so much more frailty. So, often that's a hip replacement as a consequence of a fractured neck of femur, and people who suffer a fractured neck of femur are generally quite frail and we've put into our submissions some of the real issues, but usually when somebody has a minor fall causing a major hip fracture, it's often part of a functional deterioration; it's somebody closer in terms of higher levels of frailty. And so that person is very vulnerable, and post operatively, if they have confusion that's acute or dementia and chronic illnesses, that might make it hard for them to engage with rehabilitation—not because they don't want to, but because they don't quite understand what's going on—or if they have an intercurrent illness.

And one of the things about COVID, as Nicky in the nursing submission drew on very importantly, was around this PJ paralysis or deconditioning, where patients get into a hospital and, as I think you were alluding to, they sit and they don't wash themselves. They let people wash them, maybe because they're feeling ill; they sit in that chair for so many hours of the day, they're not dressed, they're not active and before the—. We, across Wales, had large engagements with the PJ paralysis about making sure our older people were getting out of bed and getting dressed, and of course, that finished—not 'of course'—that just finished as COVID came in, so that learning that we had developed, the importance of that was compromised, because we weren't able to go into the bays of the COVID patients in the same way, the family weren't able to bring in their clothes and, of course, for a short period of time, the nature of the patients in the hospital changed massively. So, if we want to try and prevent deconditioning and functional deterioration, we need to get back to that, and that requires nursing, therapy, integrated staff and indeed, I'd say, medical lead to be encouraging people from the outset to get back, to get better, to do all that they can.

It is worrying, of course—sorry, I will go—where elective patients, who absolutely should go out far better, deteriorate, and that might be in some cases because of complications, some of which can be avoided, some of which can't, prehabilitation, optimising function before surgery, making sure we choose the right people. Because there are some people whose background frailty has got to a point that, whilst it might seem it's the knee or the hip that's the problem, there's much more morbidity in the background. Mike, is that—?

That's exactly what I wanted to hear said. Can I just carry on from that? Swansea council, which you probably know a little about, use Bonymaen House as an enablement centre, so people who come out go into Bonymaen House for a week or so to see if they can enable them again to go back to living in their own homes. I think it's very few people's ambition in life to end up in a nursing home or a care home, and I think the easiest thing for a hospital to do is to discharge somebody to a nursing home and a care home. So, that becomes the battle, between what is easy for the health service and for the health beneficial service, but not necessarily beneficial for the patient. How can we get more enablement being done by local authorities so that people do end up back in their own home? We've all seen examples of this, where somebody goes in with a bad knee and ends up in a nursing home or a care home, and they were muddling along okay at home with a bit of pain, and go to ending up sat in a care home.

I'm just wondering, do you want to bring Nicky in on this point, Mike, because Nicky indicated to come in? Nicky Hughes.

Thank you. Going a little bit back to what Karl was saying, it's absolutely imperative that we get patients up as soon as we can. We know that people lose their muscle mass and things when they aren't able to mobilise as much as they can, and there are number of issues around that. But what we have to remember is we have to have the nursing staff and the access to the multidisciplinary team, as Karl said, to enable those patients, those individuals, to be able to get up, to have the support they can to become independent. We know at the moment we've got a huge staffing shortage in nursing particularly, but I'm sure in other areas—so, having the people working on the ground and safe staffing has to be a key element to that. 

I think the reablement is certainly a really good idea. And I think, looking back probably 20 years, the amount of convalescence beds that we had that did exactly this function: people had their acute stay, they then went into a convalescence-type hospital environment, as it was then, and then they went home. But all those beds have been shut or decreased over time, and we've then become more reliant on nursing home or care home environments. So, I think the move to a more reablement model, however that is done, would be really good to be resourced, but, obviously, that's probably the main key, isn't it?

Can I come back and say that my sister-in-law is a district nurse? I don't think I have to declare that, but I think I ought to make that as a point. The final point on this, if I can talk about children services, is that if you got everybody who could be discharged out of hospital in the next seven days, that would not solve the problem, would it? Because, unless you've got a continual throughput, then you'll just end up where you were, you'll just be three or four months down the line. So, really, how do we get that continual throughput?

Oh, don't let me—. I suppose that's true, but also, at the same time, you said it yourself, and Nicky, it's easier to do some things that are not good. It's easier to wash somebody who takes time than it is to encourage them to do things for themselves, and so it's easy to inadvertently help somebody's long-term care needs to increase, instead of taking time to let them decrease over. Rehabilitation in step-down units, I think, has a lot to be said, but it is a worry where there are risks of—. And, of course, we're talking about frail older people. They do get ill again, and sometimes, when we're faced with readmission, it's the trajectory of the background condition, or it was a risk, that somebody was desperately keen to go home. And it is social services much more strongly now, I think, and often very appropriately, cautioning us that home first, that's what we would all—almost all—want. And it's almost always the right—not always, but almost always the right—decision for individuals. One of the problems about the community hospitals is that many of those now, rather than being rehabilitation-focused in the short sense, are dealing with people with very high levels of frailty, some of whom would struggle in a nursing home, whose well-being is challenged on a daily basis, and the most minor deterioration can cause a worsening of the scenario.

I dealt with a constituent who was in for seven days for assessment, and he said, 'If I'd been in another seven days, I wouldn't have been able to go home.' That's the sort of thing that has stuck with me.

But can I move on to children? Are there particular pressure points to be aware of for children and young people?

Shall I bring in Dr Yvette here? Yes, Dr Yvette.

Okay, yes. Thank you very much. Certainly, there are pressure points for children. It's when there's a safeguarding or a mental health issue that then we sometimes need to find placements for them, and you need a foster placement after a hospital admission. Sometimes, they have very complex needs and you need a very specialist foster placement and that can cause delays. Some of our children who get admitted to hospital when they are in crisis with their mental health, they're physically fit and it's not the right place for them, you need large numbers of staff trying to support these young children, and what we really need is somewhere out of hospital for them, and it's really hard to get a tier 4 child and adolescent mental health services placement and a child or young person can be waiting in the hospital for weeks, sometimes months, to try and find that right placement.

What we need is more investment in places. I know that, in Newport, they're going to be opening Windmill Farm soon and that's a really exciting move forward, where there'll be a very appropriate place to be able to have children in a more homely environment to support them to get back home, rather than being in a hospital where they don't see their friends and they don't see their family, particularly with COVID, with limited visiting times, and they miss out on education. And in COVID, we all know that the children are the ones who have not suffered much from a health perspective, but suffered a lot from the loss of education and the loss of socialising. We don't know, in five years' time, what the implications will be for 10-year-olds, having lost two years of normal socialising and normal sporting activities and education. So, there's a lot there that we don't know what's going to happen to children because of COVID.

There's long COVID that's coming in now. Children with chronic pain can sit in hospital for weeks or months, because there really isn't a service for children in Wales with chronic pain; they'll be waiting to get to Bath. I know, with chronic fatigue at the moment and long COVID, that there is—. I think there's a meeting next week to look at cross-Wales solutions. Certainly, in Aneurin Bevan, we've started looking at a pilot for patients with those problems, and they can be patients who can be with us for a while because they really are struggling, but, actually, it's very rare that they're there because of health problems. The children who stay in hospital for a long time occasionally have complex health problems and need health interventions, but, more often than not, when they're staying for a long time, it's because they need that support. And, once again, it's the issue of different local authorities having different levels of support. In Aneurin Bevan, we have five local authorities attached to us. The one that has the most looked-after children has no residential placements available for children, so it's that working together between them, for different local authorities to be able to give what's best for the child, irrespective of their postcode or where they live. It's time to ensure that as well.

There are a lot of other things I'd like to ask you, but the Chair would be really angry with me if I keep on asking them. Would it be possible to write to you with additional questions after this meeting?

Absolutely. Please do.

Is that okay, Chair?

That's very helpful. Thank you, Mike. Rhun ap Iorwerth. Oh, sorry, Dr Karl, did you want to come back in?

I just wanted to say that one of the themes, reading the children's submission as well, was around mental health and that fits across all ages, really. The discharge of older, frail people with primary mental health problems, or even the healthcare of older people with mental health problems, the services are much more constrained in terms of the bed numbers. When somebody does need a dementia-based nursing home, it's a real problem in terms of extending that length of stay and delaying their onward discharge.

Thanks, Karl. We've got some other work coming up later in the year in that regard as well. Thank you. Rhun ap Iorwerth.

Oh, don't make me. [Laughter.]

Carry on. Carry on, Dr Davis.

Sorry, Rhun. So, there are some real variations. We were talking with some colleagues—and we're not going to name the area, primarily because I can't remember, but when we have very complex discharge—and we talked about the discharge process, but ones where there's contention or potential involvement of the court of protection—. So, for Cardiff, as far as we've been able to ascertain so far, we have possibly one older person who's at the threshold of a court-of-protection action, probably led by the health service in this case. In other local authorities—they're smaller areas—there are up to eight patients waiting. So, this variation in how we interpret what is some very unclear, I would suggest, legislation on how to apply it—the legislation's clear, but the application at the individual level is more challenging—that leads to very big delays in terms of hospital care, and, of course, leads to that frustration of that person stuck in hospital, at risk of deconditioning, at risk of further deterioration. And whilst the discharge decision has got to be made, those need to be done in a timely—. And we need clarity, I think, for the local authorities, to try and highlight to them when they are at the fringes of the standards, and to have a look at what's going on there, and I know there are some attempts to do that.

The evidence we submitted around fractured neck of femur I think was very interesting. When we were faced with the very first days of COVID, the risks to an anaesthetic, the risks to hospital staff, the risks of operating on somebody with a disease we couldn't treat, with a disease we could barely test for, was extremely high. So, some hospitals almost stopped operating for fractured neck of femurs; others, such as our own, moved the whole system away from the core hospital beds. And you can see in the evidence the marked divergence in lengths of stay. Unsurprisingly, if you've got a broken hip and you don't operate, the patient is going to be in a hospital for weeks.

What came through, I think, strongly from what we did as an unexpected experiment was, by having surgeons who could not operate, we had them available to the wards more often. The physiotherapists who would have been working community services were available to rehabilitate seven days a week. That seven-day-a-week service, that avoidance of five days of team base trying to rehabilitate and two days of minimal team rehabilitation—. The nursing staff on the weekends will do what they can, but we don't have extra nurses to fill the backdrop. We don't have as many physiotherapy staff on the weekend. That makes a difference. So, across the whole of Wales, we saw variations in how those additional staff were utilised, and the resultant changes in lengths of stay.

And, of course, that wasn't sustained after COVID, but we'll come back to that in—

No, it couldn't be. It couldn't be.

We'll come back to that. Nicky Hughes.

Thank you. One of the fundamental differences across Wales is the district nursing teams going back to district nursing. Certainly, where I worked in Cardiff, we had a 24-hour service, so providing that care throughout the night as well, which is absolutely essential. But we know across Wales that that's not always the case, and we had patients who were on the border who particularly had palliative care needs, which also are differing across Wales. It's very difficult when you've got somebody on a border and there's, sort of, 'Whose care is it?' if you've got all different services. And in fact, I know one patient, we had three different services going in just to get them—from different areas as well—to give them the care that they required, and that's not continuity of care for that individual.

I think the other thing that is really important, alongside the discharge liaison team, is the fact the ward manager needs to be leading on board round, leading on discharging, being aware of the patients on the ward. Even before COVID, and I appreciate COVID's been a particular issue, we saw that, often, ward managers weren't supernumerary; they were part of the numbers. That's got worse during COVID—quite rightly, we need to focus on patient care—but, actually, unless you've got that leader who has that ability to step away and have some supernumerary time to really drive this through and drive everybody's pathway, then that's really difficult. So, supernumerary status across Wales for ward managers or ward sisters is really key, and I don't think we've got that consistency at the moment. 

Okay. Dr Cloete, what makes one area good and another bad at quick discharge or effective discharge? 

I think it's very similar to what Nicky just said there, and I can't emphasise enough how useful it is when we have a nurse in charge and a patient flow co-ordinator who are supernumerary and you can have that constant discussion, feeling that the transport's going to happen quickly for the patient once the decision is made. Again, the community nursing, the district nursing, the care-closer-to-home team have made an incredible impact when, with combining Nevill Hall and the Gwent hospital into the Grange, our bed numbers in paediatrics have gone down. We've seen more patients at the front door, and yet our number of patients in the ward is less, and that's largely because the community and the care-closer-to-home team, although we were thinking about it before COVID pushed it much more quickly because of visiting times—. We wanted to get patients home more quickly and safely, and so the care-closer-to-home team has had an incredible impact on keeping patients at home safely, because consultants wouldn't send a child home if they weren't sure the child would be safe, and having that reassurance that the nurses are going in once or twice or three times a day to see their patient makes a massive difference. Certainly, when we were gathering the information for today, other health boards have said they don't have that and that does mean that they aren't able to get patients necessarily home as quickly. So, the two things, I'd say, are having nurses in the community and having the supernumerary nurse on the ward—they are massively different.

You mentioned there that, in preparing for today, and we're really grateful that you have clearly put the work in, you have gathered evidence from across health boards. The three of you represent organisations that work nationally. How confident are you that you as organisations and that we all have a handle on what's happening right across Wales so that we can really pick up on those examples of good practice? Bronglais in Aberystwyth being really good at quick discharge and low mortality. There are other good examples. Are we able to learn and pass on that good practice?

I do think we can do more of that. Certainly, what COVID has pushed forward, which has been great, is that the leads across Wales for paediatrics meet once a month now. We needed to do it initially because of COVID, and we've all agreed it would be an useful thing to continue, and once the focus can move away from COVID, we'll be able to look a lot more at good practice and share that. We've already had discussions on various things, and people have said, 'Oh, yes, I'd love to pull that in—what Swansea are doing,' or 'I want to pull that in from Bangor.' So, there's that happening already, but certainly I think we can do a whole load more of that, going forward.

Dr Davis.

So, BGS isn't really statutory, but we're there as representatives of interested professionals, and multi-professionals, with nursing besides. So, our primary tool here is around our learning and our education. We have managed to maintain our meetings, and also that networking and those conversations, because we're not a huge specialty in terms of numbers in many ways, but we're significant in terms of the reach that we have. So, a lot of our learning, sharing and spreading of good practice is through our own meetings, is through presentations, and presentations at national and academic meetings of neighbouring initiatives, and often those are presented first internally so we can check and work with each other on those. 

Should there be, though, a more explicit effort to get other hospitals, health boards to emulate what Bronglais is doing? I accept that different communities have different characteristics and so on, but if we have one really good example there, well, everybody look at them and see what they're doing.

Yes, I think we should, and within a service as huge as the health service, trying to get that success message to the right people within the right building—. I think of how many messages I get each week that are not relevant to me. Yvette has an important job, but I get messages about what's going on in paediatrics, and it's going to cause fatigue because I can't read and deal with all of those. So, there is some shared learning, don't get me wrong. So, it is important that we have a strategy that involves the sharing of excellent practice, and maybe even, dare we say it, highlighting where good ideas just don't work, because there's a lot of those in medicine. It seems a good idea, and then you'll see it resurface—I'm old enough now to have seen it resurface five years later—and have to say to somebody, 'That's exactly what we did, and it didn't work. Please don't do it again.'

And we're all encouraged to innovate all the time, of course, and come forward with new ideas. Dr Cloete, you wanted to come in.

Yes. I think it's always data—you need data and you need that information being gathered and held centrally so that you can compare and contrast. But then you also mustn't use the data to punish. You mustn't decide, 'Well, they're doing really well.' You're going to have to look, if they're doing not so well, at what's the difference. If it's a different population group, different geography, different deprivation status, there are going to be differences, but you do need to learn from each other. So, you need to find out what is Bronglais doing that's good, what's Bangor doing, what's Swansea doing, or Cardiff, and sharing that in a forward-thinking way. Similar to Karl, we have the Welsh Paediatric Society meeting that runs twice a year, where we also present lots of work, and we now have this monthly meeting for the clinical leads to share work. And then, I guess, the best of each specialty can then be shared with other specialities. But, like Karl says, our inboxes are full—we can't take everything from everyone, but it would be really good to have a central way of sharing that, and the ones that are impactful and can be spread to other areas should be spread.

Yes. And the last word on that one to Nicky Hughes. 

Yes. I agree with everything that's been said, and I think, quite often, what happens is individuals or teams have really good ideas, sometimes money is put into that, and you see really good outcomes. We know the Buurtzorg model in the community has been trialled as well. But, actually, how do we get it from that small team or that individual who is really passionate about it and leading it to a truly sustainable, embedded model across Wales? Quite often, we see money put into something, we see the benefits, those individuals then move on or something happens, and all that good work is lost. So, I suppose, going back to what Karl and Yvette are saying, 'Have we got a strategic approach to this where we've mapped out what's out there, we've mapped out what's good, what's working well, what's working for the public and for our patients, and actually how do we streamline that and get that right across Wales?' Obviously, as you've quite rightly said, Rhun, different areas have got slightly different issues and they may implement it in a slightly different way, but how do we actually look at that more strategically and get it actually embedded and sustainable? 

Could I ask for one short answer from Dr Davis on one other thing? On the good practice during COVID in Cardiff and Vale, you said, 'Yes. Well, it had to end. We couldn't sustain that long term.' How frustrating is it that when you do find something that really works you're not able to roll it out long term basically because of a lack of resource? Is it acceptable, really, that we let that kind of thing go?

What can I say? It's devastating, because we've known in our hearts, haven't we, that seven-day working makes sense. We've got the evidence that is makes a difference from previously. We've got the evidence reinforced now. But, of course, the staff that we used to do this were the ones that do prehabilitation for knee surgery, and they're the ones who rehabilitate the patients after their electives. What we did was have a massive availability of community staff from therapies who are not now able to do that—they can do some other role. So, absolutely, but it's around that investment and staffing numbers. We don't quite have the right numbers of staff, we don't have the right numbers of nurses, and the cost of that is going to be huge. So, we have to find a way to work as effectively as we—. Sorry, you wanted a short answer. I'll stop. 

No, that's great. I can feel the beginnings of a recommendation coming there somewhere, Chair.

Thank you. Yes, absolutely, Rhun. Jack Sargeant. 

Perhaps I will try and just take that recommendation out shortly and prise it out of you, Doctor. But before I do, can I just touch on communication, before we do move on to workforce? I'm picking up a common theme here. The RCN, in their written evidence, said that,

'There is a lack of consistent communication across professions and between health, social care and third sector organisation which adds to delays'.

Age Cymru go on to say there is poor or no communication with next of kin. They also then further add that the common thread, through poor practice, is poor communication. Two weeks ago, we were sat here in committee looking at the other end of the scale on waiting times, when we said and we heard evidence that suggested that health boards, perhaps, should be more open and transparent with regard to communicating directly with patients with communication. At the start of this year, we debated in the Senedd a health matter because of flawed communication policies within Public Health Wales, and I just see the common theme here is clearly comms. Are there structures in place, or do they need a complete overhaul? Or is it something else—am I picking up the wrong end of this stick here? Are there, perhaps, workforce—? Do they not have the time to communicate effectively? I don't want to seek blame, I just want to try and find a solution, because there clearly is a theme right throughout healthcare at the moment, and that is comms. I appreciate that's quite a big question, but I wonder if someone does have an answer to that. Nicky, you wanted to come in first.  

Yes, I think, over time, we've put in posts like the discharge liaison nurses to try and assist this. We have a problem, so we build another team, usually to help that. It could be seen as positive, it could be seen as otherwise. The role of the discharge liaison nurse is critical, and they take on, particularly for the complex discharges, quite a lot of this work. They are the conduit where you've got integrated teams where health and social care are sitting together during that. Obviously, then, that's a more seamless area. But we have to remember that the majority of more simple discharges should be undertaken by ward staff, by the staff nurse or hopefully the ward manager would have some input as well if supernumerary. It would be the staff nurse looking after that patient, who knows that patient the best, to be able to communicate that out. But again, back to: have we got enough staff on the ground to be able to undertake this? Do we spend an hour on the phone trying to chase lots of people, trying to co-ordinate everything, or do we look after the person who's really ill? And we have to make sure that that's our priority.

So, I think, sometimes, some of the simplest things that could be done in 5 minutes get lost because that individual has other priorities within the day and we haven't got the nurses on the ground—we know about vacancies and the retention issues. But also, we can't underestimate how much time it takes to try and ring people, to try and get other people, and we're asking registered nurses often to be the person that rings pharmacy to chase up the medications, to ring to make a referral to a physiotherapist. Are they the right person to be doing that initial referral? Yes, they know the patient most, but if they gave some basic information, could more of an administrative post do that? So, I think we have to look at whether the right people doing the right jobs. In an ideal world, yes, your registered nurse that would know that individual would do it all, but we're not in an ideal situation. We haven't got that ability, and things do get lost in translation, particularly referring out to district nurses, because we have to make sure that the right information follows the patient. So, if a patient's being discharged to a district nurse and they've got, for instance, a key safe outside the house, unless that district nurse knows the code to that, they can't get in to that patient. So, some of it's fairly basic, but quite easily missed when you're very, very busy and looking after lots of patients.

I think Dr Yvette wanted to come in on this point as well.

Thanks. I'm sure Karl will want to too. In healthcare as, I suspect, in every sphere of life, communication is such a massive thing. I think we need to think of communication at three levels. There's communication of individual—. So, as Nicky said, speaking to the patient, getting the patient home. There's communication between specialities within healthcare, between the health boards and healthcare, and between healthcare and the other sectors. At all of those levels, there are problems. So, in the first instance, during every patient contact, discharge should be part of the discussion—'You'll be able to go home when the child doesn't need additional help with feeding, doesn't need oxygen, and we think that's going to be one day, two days, a week'—so they can start planning. The day before you think—or depending how much time they need—start planning, start thinking about discharge, start getting everything in place, and have a checklist to make sure that's all done.

But then there's communication between specialties and between health boards. As Nicky said, you can spend hours trying to find the right person to speak to. There's something simple called Consultant Connect, which the GPs can contact in individual specialities easily, but only some specialties and some health boards are piloting that. So, that's not easy. Once everyone's carrying that, and you can at the press of a button get the right person who's on call that day, you can speak to the right person first time. Within other sectors, there are so many different local authorities, everyone does things slightly differently, it's a slightly different system to get hold of someone, and all of that adds to the communication. You already have so many things that the doctors and the nurses are having to do, constant new problems, and then they're having to spend their time trying to find the right people to speak to, and forget to say the things they need to, and things get forgotten along the way, and very important information isn't passed on, and that's where it all falls down.

Jack, can I just ask whether you've got any further questions? Any last questions, and I'll bring Dr Karl Davis in if you've got any final question, Jack.

Thanks, Chair. Because it seems we are not helping ourselves, or not helping the over-tired and stretched workforce that we already have, I was going to ask, perhaps, Chair, as Mike suggested earlier, whether there are any specific recommendations that the witnesses think we could make, and perhaps they could form that in some words that we could take forward as a committee after this session. I think that would be helpful. And it's worth noting, Nicky, that you have said in your report you want the Welsh Government and NHS to promote discharge liaison nurses to hopefully address some of the topics there.

Karl, if I may, just on my final point there, try and prise that recommendation you were getting to. On Rhun's question you were saying that we don't have the right number of staff; that's, again, a common theme right throughout. But is there a way we can equip the current workforce to deal with situations better? We do have to acknowledge—. Again, I'm not putting blame on absolutely anyone; the workforce is fantastic and remarkable, and I certainly couldn't do that job, and we have to recognise the situation they are in, and the pressures they are under, and have been under. How can Government and top-level NHS management assist the workforce in discharging patients better and more effectively? Is there a recommendation there that I can try and get out?

Oh, guys, that's hard. Briefly, Jack, many years ago we had social workers that were often team based, that worked with you, and that made a huge difference. There's a delay towards the tail of somebody's discharge because you have to wait until the person's ready for discharge before you can bring them in. Imagine the family, you've got the relative on the ward, they can barely see them, and we can't really start talking in detail about discharge decisions because that is the local authority's realm and responsibility. If we start making predictions, it can get undermined. So, I would love to have more liaison throughout our hospital admissions with local authorities, communication across the services, and that then eases the communication into that third sector, into the private providers. I think it's so important.

Some of our colleagues might be tired and exhausted, and sometimes it is hard to pick up the phone and talk to a family member, but heavens, it's hard for them to sit at home not knowing what's going on in that building, which could be many miles away. It can be halfway across Wales, for heaven's sake. You need to try and do it, but it is, and can be, quite hard. Sometimes it's easy, but sometimes it's very challenging. It's important there's that leadership within the health service—I'm as likely to pick up the phone and call as anyone else, maybe even answer it sometimes. I'll tell you what we could—

Just briefly there, I'm just going to get some more time in to get Gareth Davies in.

Can I just do one last statement?

Absolutely, absolutely.

No more fax machines. We have just bought a fax machine for the new hospital. For heavens' sake. What are we doing? GPs fax referrals into the emergency unit. I never see it. Why is that not e-mailed to me? Because I can't deal with the emergency information if the emergency information doesn't get to me.

It can't have been a new fax machine, can it? Do they exist? Do they still manufacture them?

We were going to challenge them next to buy a VCR, Betamax, and see if they could do that. Sorry, probably not appropriate for council, but, yes. [Laughter.]

Okay, that is astounding, yes. Okay. Thanks, Dr Karl. 

Sorry. 

No, not at all. Before I come to Gareth, I just wanted to ask a question I asked at the beginning. I didn't really get time to go into this, but it's quite an important one, and I think Dr Karl Davis may have addressed these points. We had lots of responses to our consultation in terms of rushed, inappropriate discharges without plans in place, and I just want to get your sense of how big an issue that is, from Nicky Hughes and Dr Cloete, and what are the consequences of this, in particular. We haven't got much time left, but if you could just briefly address that, because we missed it, perhaps, at the beginning, and it's quite an important question. Who would like to go on that? Nicky Hughes.

Yes, it is an issue, and particularly when people go home, they haven't got the right equipment, they're maybe not as well as they should be to go home, things haven't been set up so they haven't got the support networks they need at home to support them. And that's when things can degenerate really, really quickly. So, some of the more simple things like incontinence products, or continence products, if people go home and they haven't got those, then that could very quickly spiral into quite a difficult situation. And that might be a very simple thing, but actually for that individual and their family, it's a really key thing. So, I think rushed discharges do happen, we know that people need beds, we know that people are going out as quickly as they can sometimes, but that often means that patients haven't got to the point that they need to to actually be well enough to go home and they often don't have the equipment and support in their own home, and that means that they end up coming back into hospital. 

So, rushed discharges, do these occur on some occasions or are they a more significant regular occurrence?

I'd have to pass over to Karl for that, really. 

I'll come back to Karl, then. Dr Yvette. 

As I said earlier, in paediatrics it's a bit different. We have patients who turn over very quickly, and for the vast majority of patients, the families are well equipped, happy and keen to get them home as soon as possible. So, it's a clinical decision, and more often than not, we can do that very safely at the right time. When you have something like care closer to home, you know you've got that safety net as well. But the challenge in paediatrics is our massive peaks and troughs. So, we can go from having 10 or 20 beds available on our ward to having no beds available on our ward within a 24-hour period when we have a sudden peak of one of the seasonal viral illnesses, and that's when we have more of the rushed discharges, because we don't have the capacity to expand. We have our number of beds and our nurses. We can't nurse a child anywhere other than on a children's ward, and so that's when you then have to balance that risk/benefit and make a decision on getting a child home possibly sooner than you would have otherwise. But, we always safety net, and we try as often as not not to send them home earlier than they need to go, with very specific advice, and they always have open access to come back. And, yes, we do get our re-attenders, and most hospitals have very specific re-attender policies to look very carefully at those patients again.

Thanks, Dr Yvette. And then, Dr Karl, we haven't got much time left, but—[Interruption.] Please, yes.

I think there are some discharges that are rushed, I think there are some that are too slow. I think some of those rushed ones we have to take down and say that those are people pushing for themselves to be taken home, who might sometimes not accept or believe—. And sometimes, especially now when families can't visit, they don't realise how much care somebody needs. As Mike described earlier on, a patient who goes home may need so much more support than they expected. But, there's no doubt that, with complex discharges, the simple elements sometimes get overlooked, and that can be rushed, or it can be not that it was rushed but that an error was made. And I think those two are different. I don't think rushed discharges on the whole are a big issue, and what Nicky's team often pick up are unanticipated problems. So, you think somebody's going to be okay, they're desperate to be at home, and when they get home, suddenly there's a recognition that a need wasn't identified—maybe it could have been, but not always. So, certainly, it's a problem and it is about working together with families harder now.

That's interesting. Okay, we've got about five minutes left, so please be succinct with answers so we can get finished by 10:35, if that's okay with all. Gareth Davies.

Thank you, Chair. I enjoyed the little piece there about the fax machine earlier, and the VCR. I thought it was like a bit of a throwback to the 1980s and 1990s, wasn't it? [Laughter.] When I did work in the NHS, it was deemed to be a safe method of communication, but technology has taken over and there are more high-tech encryption methods than a fax machine.

But, I just want to steer us back to social care, if I may, specifically, and ask—. Could you tell us more about the specific impact of delays associated with social care, and where efforts should be focused to address those issues and to find solutions?

Who'd like to tackle that one? I can see Dr Karl Davis looking like he wants to answer.

I would love to have integrated social worker. I would love social services to have enough social work staff that they could work consistently on individual teams, so you'd get to know them, you'd build a relationship, and they could step in to see the patients, the people, the citizens, early in their admission, liaise and develop plans going forwards. That's my ideal. That's the old standard. Nicky's nodding—she remembers those days just as well as I do. In children's services, I think you still have much more integrated social services. If we can't get the social services and local authority staff working that closely, then the earlier that we can get them, the more sharing of communications—. And, sometimes, doing joint assessments, there's a tendency to want to work in a silo. We need to work together, because this is for the person in the bed. This isn't about how the services are configured; it's about how we get the best together, and we have skills, they have skills, and we have knowledge. And, sometimes, I fear these days we're not working as closely together as we should.

Thank you, Dr Karl. Nicky Hughes. 

Yes, I agree absolutely with Karl, and more integration would be really good. But, actually, there's sometimes a lack of knowledge on the ward areas about what is actually out there. Sometimes, there is a service out there, or there is an ability to get something, but there's just not that ability for the communication to be out there to know exactly what's out there so that they could signpost people to different services. Sometimes that's social care, sometimes that's the voluntary sector, but I think, sometimes, social care have put in things that people just aren't aware of. An integrated approach has to be taken; that's the only way to get a seamless service for the patient, and to get them home in a safe and quick manner.

Interesting. One of the solutions locally that Cardiff has got is that we do have local authority, but they're quite junior members of staff coming and monitoring, but it's more of a monitoring rather than a proactive intervention, and I think that's about the resource that they have available. It's good to have the monitoring, but it would be even better to have the intervention earlier. Sorry, Gareth.

Thank you for that. Just to wrap it up and considering everything that we've discussed this morning, quite wide-ranging issues that span quite a few sectors and professions and things, considering all that, what would be the one key message that you'd like to leave the committee with today? That's a question for the three of you to answer individually, what your key message would be leaving today's committee. 

You're all putting your hands up. I suppose the message here from us is that there are short-term and long-term solutions, and ultimately, out of this piece of work, we want to make recommendations to the Government, so we're seeking what those recommendations should be for the long and short term. I'll go in this order: Nicky Hughes, Dr Yvette and Dr Karl. Nicky Hughes.

Yes. And we've talked about this a lot, I appreciate that, but one of the fundamental things is about safe staffing levels and having enough staff—whether that's nurses, whether that's multi-disciplinary teams, whether that's porters or whatever—to be able to find out what people's needs are and get them discharged in a safe way. Extending the nurse staffing Act, particularly into the community, into mental health, would be one way of helping to make sure that we've got the right staff to look after the patients. 

I expected you might say that. [Laughter.] Dr Yvette.

I think it's improving child health through early intervention and prevention, making sure we have the staff to take care of patients in the right setting, which is often not the hospital, and encouraging and funding more partnerships across local authorities, getting the various local authorities to work together with health, to ensure that we can deliver the right care in the right place for our children, and in the first place stop them coming in by the prevention and improving health inequality.

Thank you, Dr Yvette. And Dr Karl.

Older people have such a range of functional abilities, of physical and mental health needs, and they will be seen in communities and in hospitals by a wide range of specialities. They need care from integrated, sufficiently resourced teams going across that local authority and into the private sector. So, it's about trying to make sure that we have sufficient skill mix, shared not just by specialists but by all of those coming into contact with older people. Yes, expansion of numbers is important, but it's making sure we've got the right services aligned to the needs of the people that they're now looking after, maybe not the ones that originally were making use of those services.

Thank you. Thank you all for your evidence this morning. That's been a really useful session, so we really appreciate your time. We'll send you a record of the proceedings today, and if you want to add to that or add anything further—. This is the first session of a number of sessions that we've got, so if you do have the time to dip in and listen to any other discussions and you want to comment back then please do so, we'd very much welcome that. I think there are a couple of questions that we're going to write to you about separately that Mike wanted to pick up on as well. So, diolch yn fawr iawn, thank you very much, and we appreciate your time today. Have a good rest of the day. With that, we'll take a short break and we'll be back for 10:45, so seven or eight minutes.

Welcome back to the Health and Social Care Committee. I move to item 3. This is our second session today in regards to our piece of work, our inquiry, on hospital discharge and patient flow through hospitals, and we've got a number of health professionals with us for this session, and I'd be very grateful if you could introduce yourselves for the public record. 

Hello. I'm Dai Davies, I'm the professional practice lead for Wales for the Royal College of Occupational Therapists. 

Hi. I'm Calum Higgins, I'm the public affairs and policy manager for the Chartered Society of Physiotherapy.

Good morning. I'm Pippa Cotterill, I'm head of the Wales office for the Royal College of Speech and Language Therapists.

Lovely. Thanks, all, for being with us. If I kick off with the first question, really, I suppose just some initial views in terms of the scale of the problem when it comes to hospital discharge and the consequences that's having on both hospitals and patient flow as well. But if I could also add, we've had, including yours, a lot of consultation responses, particularly in regards to rushed and inappropriate discharges, and there have been a number of examples presented in that regard. I just want to get a sense of how big of an issue you think that is as well, and ultimately what should be done to address this issue.

So, wide-ranging questions to start with, but that will help to set the scene perhaps for some other Members to come in with more specific questions. Who would like to make a start?

Do you want me to start? 

Yes, thank you. Dai Davies. 

Yes. So, I've spoken quite a bit to our managers throughout Wales over the last couple of weeks. This period of time is always difficult. January, February, December is always a difficult period for discharge. So, basically, every occupational therapist that's working in a district general hospital has got delayed transfers of care on their caseloads. Most who are waiting for packages of care, they're generally all delayed, so there are quite significant issues. Our therapists are saying that, when people are coming into hospital now, they're actually more frail than they've been in the recent past because of, obviously, the period of isolation. So, the complexity is higher, so that's definitely an issue.

Redeployment is really difficult for allied health professionals, so getting moved away from the actual programmes that are there to improve flow, so that's the discharge to recover then assess—. So, AHPs should be at all points of access, such as accident and emergency, GP surgeries. Sometimes, they've been moved. Lots of our OTs are stating they don't have enough time to complete the 'what matters' conversation. So, under the Social Services and Well-being (Wales) Act 2014, every patient should have a 'what matters' conversation. So, patients are sometimes not being heard, so they are stuck in hospital when, actually, if they'd had that 20-, 30-minute conversation with an AHP, we could discharge them quicker, with fewer services. We have a few examples of over-prescription of care, and people waiting needlessly as well, so that's a major problem.

And social care is a major problem. So, our OTs that work in social care, the waiting list times are substantial, so that causes two problems. So, it causes problems with emergency discharges from hospital, and it causes lots of problems with people not being seen, so they are more frail and more likely to fall. So, obviously, you want to concentrate on the discharge impacts, you want to concentrate on stopping people coming into hospital in the first place. So those people who are waiting for things like stair lifts and adaptations and then fall, that fills up the pathway. So, there are problems in each pathway, not just discharge, but prevention as well. Frailty is the main thing. So, if you could have some more AHPs in those areas, it would improve circumstances.

Can I add to that, Chair? To give you an idea of scale, the physiotherapy waiting list relates very much to discharge. I know you've had separate inquiries, but people come onto the waiting list with physiotherapy because they're being discharged from hospital, in the main. And to give you an idea of the scale of it, in November, before the pandemic, there were 129 people waiting more than 14 weeks for that physiotherapy; it's now over 4,000. So, that's just off the scale, really, in terms of the increase in waiting times. And that's people being discharged from hospital who then can't access the physiotherapy in a timely manner.

What I'm hearing from my managers and my members is that it's a blockage in getting people out of the hospital to get them the correct packages to be at home. Social care is working at capacity, they have staffing problems and vacancies, and we all know the demands on social care. But that means that you can't safely discharge somebody from hospital. And it's interesting to hear that you've heard of inappropriate discharge from other professions, or other people giving evidence. I've heard as well from members that, in an ideal world, they'd give people better packages, with more support, with more calls per day from social care. I'm hearing that it is something they're having to cut back on to get people discharged in a more timely manner. That then puts pressure on other healthcare professionals who may be doing the community work to go and visit those patients. So, there's a lot of work to be done around those packages people are receiving when they leave hospital, and whether it's appropriate, actually, that they are discharged so quickly. In reality, it's just purely to get people out of the hospital because it's causing a blockage all the way through the pathways, all the way to A&E. And that's something that has been reflected back to us by our members.

Thank you, Calum. Pippa Cotterill.

Thank you. I think, from a speech and language therapy perspective, there are two sides of it, really. It's really about stopping people going into the hospital in the first place, and that's about that community care, and that's not necessarily happening as much as it should be and across everywhere. So, there's both of those. And I think there have been instances where trying to get people out of hospital has been the priority, but that has meant pulling on people who would be doing that work in the community, so that's kind of shifting that problem.

You asked about the scale of the problem, Chair, and that's both in numbers, but absolutely in complexity. So, restrictions over the last 23 months have meant that mental health issues have been raised. So, people are suffering with speech, language, communication needs; whether they have progressive neurological issues that are coming on more slowly or whether there is a sudden onset incident, all of those things are being affected. And as for everybody, social interaction has been affected. They might not be socialising in the same way. But when people are in hospital, socialisation is absolutely affected with everything that's going on, and I'm sure it's the same for my colleagues in physio and OT. That hospital stay has a huge impact, and so it really is about making sure that people don't go into hospital. So, yes, that scale is both number and complexity, and severity.

Thanks, Pippa. I'll come back to you, Dai Davies. In your evidence paper, you talked about discharge procedures not always being followed and that some hospitals were worse than others at this. I wonder if you could just elaborate a little more on that.

It's just the different variations of the model of discharge to recover then assess throughout Wales, and where OTs and AHPs are placed. Generally, where we get the hospitals where OTs and physios and speech and language therapist colleagues are embedded right the way through the process, you seem to get better outcomes then. What the managers feed back is that it's the hospitals where they come to us later on where problems seem to mount—where, obviously, the referral is too late, we don't get to speak to the person as quickly as possible, and, generally, where the hospitals don't have decent relationships with the local councils as well. That's problematic as well. Some hospitals are better than others on that. There are some hospitals where they allow social care OTs to come in and see the patients so that they can move them through. I wouldn't blame individual hospitals—it's just the variation throughout Wales is a major problem and we don't seem to share good practice in relation to the discharge to recover then assess model.

That's interesting on the sharing of good practice. Why isn't that good practice being shared? What needs to happen for it to be shared?

Again, we've got this transformation stuff and the integrated care fund stuff. It's hugely frustrating for us, to be honest, and it's hugely frustrating for our members, especially if you've got an excellent example like in Cwm Taf, with the 'home first' service with OTs, but that doesn't seem to be replicated throughout Wales. The funding models around this transformation stuff are problematic. Actually, the flow through the hospitals shouldn't be on transformation funding really; it should be core funding—do you know what I mean? It's a core process of a hospital system, but too often, these 'home first' services are funded from transformation, from ICF, and they've got little tiny bits of funding for different types of therapists. So, it's always really fragile, and our managers are always worrying about what's going to happen next year. Those different funding packages have different measurements as well. So, they might be focused on the patient, they might have got a discharge, but they also report different outcomes because of the different pots of funding, which is really problematic. Actually, our AHP colleagues, we all think, actually, this discharge process should be core funding rather than transformation, and transformation should be other things. I don't know if my colleagues agree with that.

For the record, they're both nodding. Thanks for that. That's really interesting, thank you. Gareth Davies.

Thanks, Chair, and good morning, everybody. You actually addressed a lot of my questions in your answers to the initial questions, but I just want to use my time really to just perhaps address a little bit further some of the points that you've made. You've set out quite well really what the main causes and the problems and the key barriers are to effective discharges. So, could you set out the delays associated with the current pressures on social care, including things like assessments and care placement packages, and where you think those efforts need to be targeted to address some of these issues?

Calum, I think, wants to kick off on that one.

I'm happy to pick up, because I think I mentioned social care in my first reply. It's clearly down to pressures that they are facing in social care that we can't discharge people as quickly as possible. I mentioned that there's definitely a compromise in the packages that physiotherapists are seeing being given to patients that are discharged, and that's a big worry. At the other end of the pathway, I've got physios in emergency settings, in A&E, who tell me that people who haven't had those packages or haven't had the support at home are falling, having accidents, and there's an increase of those kinds of patients coming through the emergency setting, and they come back into the system again.

A proper discharge package with all the support in the community and through the local authority and joint working is really crucial to ensuring that people don't come back into the healthcare system later on because their problem wasn't addressed properly. I think that comes down to what Dai was saying; we definitely agree, with the way that the funding is set up, that it's different in most health board areas, how projects have been funded through transformation. There's no consistency. One project that works really well in one area might not be replicated somewhere else. It doesn't necessarily mean it's bad somewhere else; it just means that they're not being as effective as has been learnt somewhere where it's gone well. We really want to see the discharge process being consistent and that local authority and health working being consistent across Wales as well, with core funding at its heart.

Pippa, did you want to come in on this as well? I wasn't sure if I saw your hand go up or not.

I would like to, if that's okay, Chair. Thank you.

Okay. Pippa and then Dai next.

Thank you. Speech and language therapists work with individuals and their families and their carers, who could be a variety of people, and the speech and language therapist will develop personalised strategies for those people to manage their speech, language, communication and swallowing difficulties. It's vital that that continues and happens throughout that home setting. As my colleague Calum has said, that's what's important in preventing that cycle of emergency readmissions. So, it is going to prevent the first one if we've got that community care right in the first place, and if it carries on, it's going to prevent further ones after that, so that's very important. I would add to what Calum has said about the funding. Managers are talking about having 0.5 of a post until March 2022. Depending on when that came in—it might have come in in April 2021 or it might have come in later than that—does that give us a good opportunity to provide that evidence and then do something about it with the evidence that we have?

Thank you, Pippa. Dai.

There are major problems in social care, Gareth. OTs are quite a significant workforce in local authorities. There are two roles that they do: obviously the calls come into the council that people are struggling at home, and there's another thing that we do called right-sizing care. That's working with our social work colleagues and going out to visit people who have got packages of care and making sure they've got the most efficient package of care possible. That's been quite delayed over the last two years. When you get a package of care from hospital, you shouldn't have that forever; it should always be consistently reviewed. But that doesn't seem to have happened as much over the last couple of years. For example, an OT with a social work colleague going in to see a two-handled call can maybe look at the equipment they've got and change that to a one-handled call. That, then, reduces the need of that social care provider to have two people visiting that house.

So, it's those sorts of problems we've got: obviously, the recruitment issues in our social care providers, and the reviews of the packages of care that are not as frequent as they should be. Maybe there is over-prescription of care, so it's not efficient. We need our OTs to be able to work with our social care providers and care homes to ensure that the equipment they're using and the type of services and amount of care they're using is as efficient as possible. Unfortunately, the waiting list is so severe at the moment just to get people out of hospital, that it's been not neglected, but been unable to happen because of our low staffing levels. So, it's not as efficient as it could be, because the right-sizing care model is really, really good, and we've reduced lots of packages of care, so that needs to start happening again.

Thanks for that. I just want to explore, really, the communication between the professions and whether you see that as a barrier to delays. Because in my experience of working in the NHS—. I worked in physiotherapy until about 12 months ago, and in my experience, when you're working in a hospital setting, there's a lot of cross-over between the AHP professions and there's a lot of joint working. So, are there communication issues across the professions? And that's probably even going into nursing, medicine and the whole package. Is that a problem, or is it less of a problem than what we initially think?

The best practice we've seen in the pandemic has actually been when this has happened, when the multidisciplinary teams have been set up, sometimes at haste, to deal with avoiding admissions into hospital. There were lots of examples of that across all health boards, to be honest, where the AHPs were leading in that area as a team. It was highly effective and we'd like to keep that. That's a model that we have been pushing for a long time. The pandemic accelerated that change, and it was good to see that interdisciplinary working. The communication of the teams with AHPs in leadership positions was really key to meeting that need of the patient. The AHPs—we say it all the time—have a very holistic view of a patient; it's not medicalised, it's the person as a whole and their needs to carry on living to their best of their ability and to do the things they want. So, I think the AHPs are in a key position to be able to deliver that kind of care in the community to patients, and definitely there are very good examples of team working. Again, it's about consistency; it's about getting that core funding for the future, rather than letting it slip now post pandemic and we think everything is fine. It should be here to stay.

Thanks. I'll just bring Jack in quickly. He wanted to come in with a supplementary.

Diolch, Chair. Calum, it's great to hear that there are some good examples of communication and good practice across all health boards, and you've made a recommendation there about the funding, the core funding of the service, to make sure that carries on. Can I just ask you, then—? You mentioned all health boards—how was that good practice shared between health boards, or how is that communicated through health boards? Because we often see that it's not. It might be in Betsi, but it won't be in Cardiff, and vice versa. Is that practice taking place, or is it four different sets of good practice?

That's a great question. The learning is happening, probably not to the best it could be. The one thing I really want to point out as a positive is that we've had AHPs now being put in leadership positions, seconded to Welsh Government, seconded to HEIW. That's not only been recent, that's been during the pandemic and continuing now. So, there are now key people who are looking at this work, who are drawing things together across Wales, but that's a relatively new thing. It's a positive step, definitely. We want to push for that learning to be continual, for it to be set up as a business-as-usual in Welsh Government that we have these cross-Wales positions that carry on the learning consistently. Before that, it was really reliant on our managers talking to each other in their Welsh committees, and they're pushed for time. They were always managing their own health boards and getting on with their own jobs. But there are now people dedicated to doing some of that learning, which is definitely positive.

Diolch yn fawr.

Thank you. Dai, you wanted to come in.

Obviously, I won't repeat what Calum said. On the communication between health and social care, there's some good practice and there's some not so good practice. One of our therapists has explained it: especially with the Welsh community care information system, it's good that they're all living in the same house now, but they're still in separate rooms. So, there are still some problems with how the systems are set up in what can be looked at and what can be shared. There are some areas where it's not so good. We hope that the WCCIS system actually could improve the communication between health and social care, which is problematic at times. You've heard this countless times in countless evidence sessions, so that still needs to improve. And the same as Calum, the good practice is generally shared through managers, through our informal groups, and I know they've got this digital health authority in Wales that just got set up last year, so hopefully that will improve systems of communication.

Any further—? Sorry, Pippa.

Just to say I think that multidisciplinary working, which comes with AHPs, but also with our colleagues in nursing and other areas, does take time to do. It takes time to do that communication. And yes, absolutely, joint assessments of patients are very, very valuable. Professionals get things from them, but the patients do get a lot from them. That takes time to organise and time to do. If you've got a 0.5 post and there's a physio doing a 0.5 post and they never have a crossover, then that's not going to happen in the same way. So, those logistical operational aspects are also very, very important. Thank you.

Thank you, Pippa. Gareth, any further questions from you?

Yes. Thanks, Chair. I suppose my last question is a bit of a niche one to Pippa around neurorehab. In my time in the NHS, I did quite a lot of training around this specifically, and have probably got an educated guess as to why that's such a significant cause of delays in discharge. I imagine it's probably down to the acuteness of neurorehab and some of the complexities that surround the problem. Because, a lot of the time, it's people who have had strokes or acquired brain injuries and need quite a lot of intense rehab, which can be intensified better in a hospital setting, rather than in the community where you get discharged and you might be lucky to see an allied health professional once or twice a week, whereas in hospital, it's a daily programme. Am I right in saying that, or am I missing something out there? Can you tell us a bit more about that issue with neurorehab?

Who would like to address that? Pippa.

Thank you. Absolutely. Yes, it is a huge problem. There are a lot of people who are suffering huge consequences from examples such as you've given, Gareth. Obviously, if they need that medical attention, then, absolutely, that's where they need to be. But a lot of services are hugely focusing on that community element, because we know that if somebody is medically fit and they can be at home, if they have the right environment around them, then that's going to be better for them. That's going to give them the environment that they're used to, that they're comfortable in, as long as it's safe, and often the people that they would communicate with. We know, where there have been restrictions on visiting in hospital or people have been doing things over screen, such as we're doing today, with family in hospital, that's a very different communication from a face-to-face discussion that you'd have with a family member. So, absolutely, we want them to be in the setting that they can be, as long as that's safe to do.

There should be no reason why community services cannot be provided two or three times a week, if that's what's needed. If that's the package that's needed, then absolutely that should be provided. Yes, it takes time. It takes a lot longer to drive to somebody's house than it does to pop up to a ward if you're based in that place, and that's why we need to think about the resource that's required. And, yes, it may be something that's progressive and/or long-standing, or maybe it might be that sudden onset—the strokes that you talked about, Gareth. And that rehab that speech and language therapy can provide in putting in place communication, whether it's indicating 'yes' or 'no' in answer to a carer, or having a conversation about the thing that you want to talk about the most in the world today with a friendly face, that's absolutely vital and that's what speech and language therapists can do.

There have been some increases in funding, which I appreciate is a little bit different from the question that you've asked, Gareth, when it comes to neurorehab and neuropsychiatry, from a speech and language therapy perspective. But I guess it's some increases in funding and making sure that it's consistent, and all the things that we've talked about regarding funding also apply to those as well. Does that answer your question?

Yes. I don't know whether Dai or Calum might be able to expand on that from an OT or physio perspective, just to broaden the conversation.

Pip answered that really quite fully, actually, and they're the same sort of issues we have in OT. Obviously, OT's quite an important aspect of neurorehab and neuropsychiatry. It's getting that rehab into the person's home where they live, that's the main thing, because that's the place they're going to thrive and be able to assess. So, the funding has been good. Our OT's have appointed generic therapy assistants or physio OTs. Speech and language therapy assistants seem to be helping, but funding's always an issue. So, it's how that model is funded and how quickly it goes into core funding, and the managers are not waiting for the next year to see where that funding is. So, Pippa's points were all really good.

I agree. It's all about consistency and funding across Wales.

Thank you. Thanks, both. Mike Hedges.

Thank you. Diolch, Cadeirydd. I was going to talk about rehabilitation. We've talked a little bit about it already. I don't know if you heard the evidence from Dr Davis in the session before you, but he agreed with me on something, which is that people get deskilled in hospital, they get dressed, they get sat in a chair and they rarely, certainly during COVID times, but at other times, they have very little conversation and they can become deskilled. What about—? What is happening regarding getting people rehabilitated before they go out? I know that Swansea, at Bonymaen House, has an enablement centre where people then start making their way through to being enabled so that they can actually go home, rather than the simple answer of sending them to a nursing home or care home.

Yes. I know that therapists feel quite despondent about seeing people wasting away in front of their eyes on the hospital wards. There's an issue with facilities, so our OT kitchens, OT bedrooms, physio gyms are being reused, so they're not able to have that therapy that they would have, which is really problematic. Like you said, they should be seen at home before they get admitted, so OTs, physios, podiatrists are based in primary care locations, like GP practices and stuff, so they can pick up people who've got some frailty issues and get the community resource teams to go and see them, to be perfectly honest. And then, it's ensuring that we follow the discharge to recover to assess. So, if you go to A&E and you could be sent home, you should be sent home with a rehab package there, then. So, making sure that, when people access the health service or the social care service at different times, actually, that's the time you start the rehab journey, not two days before they're going to get discharged.

And actually, at the moment, they're starting to open these intermediate care wards and stuff; there's only a finite number of OTs and physios, so we've really got to look at those wards and make sure that, actually, there is an appropriate level of care that's happening on those intermediate wards. You can't just shift them on from the district general hospitals into these intermediate wards and not have a proper rehab package there. So, they're the sorts of issues. But facilities are a problem at the moment.

I'll agree with that. We raised it in the last inquiry when giving evidence. I won't go into too much detail, but we've definitely seen a reduction in the space available for rehab in hospitals, to the point where you had dedicated space before for stroke patients who were rehabilitating, and at one point, it was being done on the side of the bed in the middle of the pandemic. And some of that space hasn't been returned. That makes the job more difficult for physios or for any allied health professional or social care worker later on in the community, if the person hasn't had the rehab in hospital and isn't in a good enough condition, really, to have been discharged.

So, there is a need, despite our support for community rehab, and we really want to move as much as possible into the community, for a basic level of rehab facilities in hospitals. And there's also a need to have that space for families to come in. And Dai mentioned things like the kitchen space—you'd want the family involved in coming in, seeing the patient and seeing what condition they're in and being able to offer them support. We've not been able to do that in the last couple of years because of restrictions. So, that makes the job again more difficult in the community, when it's transferred to the community. So, there's a definite longer term problem from making the adaptations in hospitals that we had in the pandemic. We need to reassess, really, where that is and try and return as much of that rehab space back to normal to get the best impact for the patients.

We haven't got a nutritionist, I don't think, on this panel, but can I just ask if you agree with me that there's a serious role for nutritionists? Far too many people go into hospital and they tend to eat very little and their weight drops. At one stage, hospitals would weigh people when they came in and before discharge, but I think the results were so poor they stopped wanting to do that. But a role for nutritionists to ensure that people who are going out are well fed and fit. Leaving aside any of the things that you can do, if somebody hasn't been eating and they have substantial muscle wastage, they've got a problem, haven't they?

Pippa.

Sorry. Is that okay?

We can hear you now. Go ahead.

Thank you. Absolutely, and speech and language therapists work very closely with dieticians to look at the nutrition and hydration of patients, both in hospital and in the community, and it is really important. And there are critical periods when it comes to working with people, especially if they've had a stroke, and the rehabilitation that we do, and working with our colleagues in dietetics is absolutely vital. But, again, and going back to what you said before, looking at that closer to home, the move to closer to home is very, very much welcomed. We just need to make sure that we do it in the right way and that it's planned strategically.

Moving on to variations—I'm supposed to talk about variations across Wales—I'd like to ask about variations within health boards: different hospitals having different policies, different consultants working better with GPs and others, different consultants working better with allied health professionals and others. I mean, I'd love to see consistency across Wales. Are we anywhere near consistency within hospitals and within health boards?

Yes, Calum. Please, go ahead.

Back to the space issues—yes, I'd say it was even down to hospital variations, not just health boards. So, you are right: there is some work to be done to get consistency across health boards. But we're lucky, I think, in the set-up we have in Wales that we have managers who represent each of our professions within a health board who we can go to as a point of contact, and they meet on a Welsh level, which is different, maybe, to in England, where you don't get all the managers of physiotherapy meeting in one place. So, that is a positive in Wales. We've got some structures in place, but even then, yes, in terms of dealing with health board facility management, you're talking about several different hospitals in one health board having different approaches.

Thank you for that. I wanted to move on now to where should the allied health professionals be. There's a limited number. I'd love to ask you questions on the workforce, but I'm not allowed to do that; somebody else is going to talk about that, possibly my friend Jack Sargeant. But, really, what I'm asking is: you've got a finite number, where do you want them? In the community, at A&E, in the ward, or, if you're splitting them up between the three, how are you going to split them up? Because, too often—we as politicians are guilty—we start off with an infinite number of members in the healthcare profession, therefore we can put them everywhere. We know we're working within limited numbers, so how do you think it ought to be split up?

Go on, Dai.

We've got policies in place, the 'A Healthier Wales', a parliamentary review that we're meant to be strategically planning towards. So, that is all about moving services into the community and looking at that quadruple aim. And we were fully on board with that when the parliamentary review started, and, obviously, 'A Healthier Wales' came up. So, our AHPs should really be situated in the community more than in district general hospitals, because people shouldn't really be in district general hospitals in relation to the model, if you know what I mean. So, the model of the parliamentary review states that, actually, secondary care should be—you should be just going in there for very complex surgical procedures, and everything else should be in the community. So, the programme's going on, especially the strategic programme in relation to primary care. It's something that we've all been involved with, so getting AHPs to work closely with GP clusters is something that we support, do you know what I mean? And that's why transformation funding was started, that's why ICF is there. It is frustrating to our members that secondary care, as important as it is, seems to get all the focus, but it's a never-ending circle then, isn't it? That's the issue. So, we support the Welsh Government and the Welsh Parliament's view of the parliamentary review, and we'd quite like that to crack on now, after the pandemic has stopped, and get things back into the community.

It's about a shift of emphasis. You're always going to need AHPs in secondary care in hospital. You're going to have physios in ITU dealing with people who've had serious accidents, but it's shifting, then, into preventative work that we can do on people's general health and stopping people with chronic conditions ending up in a position where they have to go to hospital. So, it's about shifting the workforce more down that end, where, historically, they haven't been. So, I think that's the change we want to see.

Pippa.

Thank you. And it's looking at those routes in. How do you contact a speech and language therapist if you've got a problem? In some places, I know that they've installed a request-for-help line, so you speak to a speech and language therapist straight away. It's not about going to the GP and then going somewhere else. It is about being closer to home, so they can phone from their home and speak to a speech and language therapist straight away and things might move on from there, because it's about speaking to the right person at the right time, and doing that in the most timely way. So, closer to home, definitely.

I agree with you entirely, but is it not true since we've had health boards, with primary and secondary care coming under them, primary care has lost out dramatically as a proportion of the budget being spent on primary care? That's a matter of fact that you can check back over the period of time.

The second point is that Dai Davies mentioned policies—brilliant. I can give you an example of a policy, it's a Welsh Government policy, it's the policy of every health board that patients should be able to be helped by relatives or friends to eat during meal times. I can take you to wards not more than 2 miles away from where I am sat at the moment, where they say, 'No visitors during meal times,' and they send the visitors out. So, policies are great, but the operational manager at ward level, actually, if they don't follow those policies, they're the only people that matter on this policy level.

Anybody want to come in at all?

We're part of the evaluation of the social services and well-being Act, and it may be that operational realities haven't caught up with the legislative rhetoric yet, so it's frustrating for our members.

I'll just finish on this point and I don't expect you to answer, but, strategically, management and tactical management can be absolutely right and can be working quite well—they do in lots of places—but you go down to the operational managers, the whole thing falls apart, and if you disagree with me, say you do, otherwise I'll pass it back to the Chair.

There we are. I think, for the record, that all are agreeing with you, Mike. By all means, Mike, come back in after Jack's raised some workforce issues if you want to come back on workforce, but, Jack, it looks like you're asking questions on workforce.

Thank you, Chair. I hope I do my good friend Mike Hedges justice with some questions around the workforce, but just to follow on from Mike there, who suggested where we perhaps move our current workforce. I'm looking at, maybe, how we can equip them better or whether a re-prioritisation is needed. Calum, you mentioned shifting the workforce to preventative measures, and earlier we heard that discharge liaison nurses should play more of a key role, supported by Welsh Government. So, I'm trying to get some specifics, really, in terms of key roles that you see would play an important part in that, on either side, whether that is the preventative side or actually the logistics of discharge, and so on. I'm not sure who would—. I did mention your name, Calum, so perhaps you would like to go first and then we could pass over to our other colleagues.

Thank you, Jack. We're seeing a general growth in the workforce, the commissioning numbers have been very good. We've had an increase in the number of training providers, universities providing courses, I think, for all the AHPs. That means a general growth in the workforce is planned. We really welcome that, and, longer term, the key issue is growing the workforce so that it can be in every healthcare setting. There is a limited number of people at the minute.

But if you're working with a limited number of people, the key thing, I think, is upskilling. You've mentioned extra skills. We have advanced practice roles. First-contact practitioners are a fairly new concept in AHPs—they're like nurse practitioners, for the uninitiated on it. It's about AHPs going up to advanced level, taking prescriber courses, being able to be the first point of contact in a GP surgery and being able to refer then to any other services, just like a GP could. That's a really key bit of development we're pushing in the primary care sector. That, again, means money, core funding, consistency across Wales for those people who want to go down that route of training and development. That's how, I think, you could very quickly upskill the workforce is offering more of those kinds of opportunities, and also supporting the support workers out there in the apprenticeships that they may want to do and upskilling them to provide better care and give them more skills.

So, there are definitely things you can do with the existing workforce, but also the longer term growth is what we really welcome, so that we can go into the other settings and have the number of people we need.

Thanks for that. Before I pass over for other comments—and it's a question to everybody as well—would you agree as well that there's a piece of work to be done on parity of esteem for social care workers with regard to health workers? Perhaps you could maybe comment on that as well before we pass over to colleagues. 

Definitely. There needs to be parity of esteem between the professions and also between the social care setting and the health setting, definitely. These days, everything's joint. It needs to have that esteem at a similar level across the board to attract people into social care, as I said, which is where we're really seeing the backlog being caused, it's really in their capacity. So, I think the professions here would welcome that parity of esteem across the board.

Thanks, Calum. Dai, key roles.

So, I know I go on about this discharge to recover then assess model, but that's the model that we work on in Wales. So, AHPs in leadership positions in each of those pathways. We shouldn't just focus on one particular profession; it needs to be multidisciplinary, and must be multidisciplinary-led as well, especially focusing on point zero, which is the prevention, and the one that is keeping people out of hospital. So, really working with the 'A Healthier Wales' plan in relation to upskilling those staff to be able to work autonomously and independently in community settings, but not with a one-profession sort of model, but a multidisciplinary model that meets the patient's needs. So, it's the patient that's the important person, so the services should be based around them.

I know I've said this before, but we have major problems in social care recruiting occupational therapists because they get paid less than their NHS counterparts. So, they go to the same universities, they do the same courses, and then one decides to go and work in the NHS and the other works in social care, and they get paid about £3,000 to £4,000 less. So, that's a major, major problem for our members, to be perfectly honest. But, it's looking at the patient in relation to that pathway rather than looking at a particular profession that is the important thing, and making sure that on each pathway, through the discharge to recover then assess model, there are multidisciplinary processes where OTs, physios, speech and language therapists and AHPs are allowed to be a part of that senior leadership team, to be able to strategically plan that service.

I might be being naive, but can I ask, is that happening, then, or is that something that should happen?

Should happen. It does happen—again, it's fragmentation. So, we would say, whenever the OTs, physios and speech and language therapists are involved, the services are better. Again, there's a cultural issue of respect between professions that still needs to be highlighted. All professions in the NHS should be as respected as everyone else.

Thank you for that, Dai. Has anyone else got anything to add?

Pippa. 

Thank you. Absolutely. In thinking not only about AHPs, but the whole wider workforce and the sorts of things that Mike talked about, because it is about the family, supporting them as well, as AHPs, but our colleagues in social care as well. They have a huge role to play in supporting people and their families in things that they can do in everyday life. Yes, it might be advised by a speech and language therapist, but it doesn't need a speech and language therapist to deliver it to that person. Thank you.

Okay. That's very useful. I'll stop there, Chair.

Thanks, Jack. Rhun ap Iorwerth.

Dai, if you had to choose one thing or two things that could really make a difference now if they were introduced as changes, what would they be?

To ensure you don't redeploy AHPs away from their core business is the first one. I know there's been lots of different types of pressure on the health service over the last year, but our core function is to make sure people are as independent as possible, right the way through the pathway. So, for health managers and social care managers, it's to really think hard about redeployment as a No. 1 step, Rhun. That would help. So, I think it's almost like turning the tap off for people coming in. So, a real good focus on redeployment.

And the second one then is working to the principles of discharge to recover and assess, because that is a sound policy, and not moving our therapists away from their programmes.

And that's, kind of, longer term, is it? Or is that, again, something that could be done—?

It links in with the redeployment as well. Do you know what I mean? So, let's focus our staff on those areas of flow instead of moving them away from that.

Pippa, firstly, just that snap, quick action that could make a difference.

Absolutely, I agree with what Dai was saying about prioritising, and I'm thinking of the impact of that redeployment on patients, but also on staff as well. So, I think that can't be stressed enough.

I think it is that communication, and it's getting the message across as to what speech and language therapists do and where they do it best, and making sure that we are looking at preventing the admission in the first place. We know that that's the most important thing. So, where we've got people with progressive neurological disorders, and we know that they're going to change, what can we do to make sure that they don't have to go into hospital in the first place? And that's about communication and getting the message out there to the families that speech and language therapists can help them before they get to that emergency situation and having to go into hospital.

Do you put that under 'sharp, quick action', or is that a longer term goal? Because there's no reason, if you move quickly, why that message couldn't get out. It's key, isn't it?

It is. It is absolutely key. And I guess it is a longer term thing, but I think it's something that we need to start doing now, and people will see the impact of that now, so that's why I've put it in the 'now' category.

Okay. 

You're nodding away there, Pippa, to Calum's comments. Any other further, long-term thoughts?

Yes. Just quickly, I've thought of one, if you'd indulge me. Open our facilities back up, so the physio gym and the occupational therapy kitchen, that would help in the short term.

Longer term, it's following the policies that we have in Wales in relation to 'A Healthier Wales'. It's all about getting services back into the community. I've talked about this discharge to recover then assess model, because that's the accepted model, and managers like it. So, making sure that the staff and the structures are properly funded so that we're not always worrying every year where our staff are going to go. So, if we want to keep people out of hospital, it's not part of a fancy transformation package, it's actually co-funded.

And the last word to you, Pippa.

Thank you very much. Absolutely, all of the closer to home work and that is going to be important. But we have to remember that people will end up going into hospital as emergencies and, therefore, we can't just take everything away from that, because there are still going to be patients that need speech and language therapy, OT and physio at that stage, so it's remembering that right for patients as well, in addition to what my colleagues said. Thank you.

Yes, thanks to the three of you. Diolch yn fawr iawn ichi.

Mike Hedges.

Two very brief questions. The first one is: we need more of all the additional health professionals. How do we set about it? Is there capacity in universities, is there capacity in places, for them to be trained? If we wanted a 20 per cent increase in speech and language therapists, how do we go about it?

Absolutely, there's that route, there's that track, isn't there? And that starts with the university placements. We want to be able to train people in different ways, apprenticeships. At the moment, we only have one speech and language therapy degree course in Wales, in south Wales. There's another one coming on board in Wrexham in the next year, which will be great, because that will train speech and language therapists within Wales outside of that south-east area. But, yes, and there are lots of implications to that. It's the training places, it's the placements for people to have, and then it's the working through and the recruitment and feeding them through to be the workforce in Wales, but also having that diversity of students. We know that students come from lots of different places, and they train in different ways and different areas, and that's important to the profession as well. So, yes, having that diversity is really important to feed in.

Why can't we have one in south-west Wales? I'm sure Calum would agree with me that far too often Wales is seen as, by having somebody up in the north, somebody in Cardiff or the Cardiff and Vale area, then that's Wales done. There's the Swansea bay region, which takes in Pembrokeshire, Carmarthenshire, Swansea and Neath Port Talbot. Why can't we have it in one of those universities? My knowledge of universities is it's quite straightforward—if you tell them they've got funding, they'll run courses. 

I'll jump in there. There has been an increase now in the number of providers across Wales for the AHPs in the universities; you can also do a Master's level to come into some of the professions now as well, so there are different routes in.

In terms of geography, historically, yes, Mike is right. We had Cardiff providing physiotherapy, and then most students want to work in Cardiff straight after and we'd have recruitment problems in west and north Wales. There's been a tender—HIW have now gone out to tender—and my understanding is that there now should be provision across Wales for training, and there has been an increase in the number of providers, the number of universities, that are doing this. So, we're hoping that will mean that there'll be more people training in places like west Wales and then staying there to work. I think all the other professions have similar problems and would agree.

The one problem we're finding that's worth mentioning, I think, because the committee may have to look at it in the future, is that the priority is obviously the bursary students in Wales, who've received the NHS bursary. That does mean that, when they're applying for jobs after they've graduated, students in England aren't allowed to apply to that process. So, there's a situation right now where students in Wales are getting priority for those posts, and health boards need to invest more in those posts to make sure they can attract a wider pool of students, not just the students in Wales. There are students who've gone to train in England who might want to come and work in Wales and live in Wales to start their careers. So, we need to attract students across the border and have a system that is open to people applying from across the UK. 

Can I come back to Calum for my last question? Occupational health—are they still constrained by rules that are not necessarily beneficial? I dealt with an elderly lady who had mobility difficulties, and they wanted to cover her house with grab rails. Actually, her problem was she had lino on the floor that was slippery and she was slipping on it. The chief executive had to approve this on the council, because it couldn't be approved at any lower level, but we actually put carpets in the living room, in the kitchen, on the stairs and in the bedroom, rather than having lino and other slippery things, and she didn't need any grab rails, she just needed carpet. But that was outside what occupational health could provide, so it had to go to the chief executive to approve it. So, instead of spending £20,000 on work that would be not particularly beneficial, we spent less than £1,000 on carpet, which solved the problem.

Dai Davies, go ahead.

Yes, there are issues in relation to different Acts of law in relation to that. So, under the Social Services and Well-being (Wales) Act 2014, we should be able to provide that, but there's a housing and regeneration Act, pre devolution, that is very much focused on just threshold management, coming in the house, on and off the toilet and stuff like that. So, sometimes the stuff like carpets and stuff are not under the legislation and it has to be under discretionary funding. Our OTs think, actually, we should be able to prescribe anything that helps that person, but there is still a traditional model of it would have to be grab rails and stuff like that, but actually it's not. So, there are some problems with the legislation and interpretation there, Mike.

Who—? I assume we're not going to have legislation on this. Would a letter from the health Minister—? Sorry to go on, Chair, but would a letter from the health Minister to local authorities telling them that they could use their discretion to do this actually help?

Yes, and it's the same with the motor neurone disease stuff and the suggestion that we remove the means testing. But, ultimately, as you know, Mike, it's up to the local authority how they spend that money, and the goodwill of the technical officers and the occupational therapists. But it is a struggle. It is a struggle. It is.

Thank you, Dai. There are a lot of officers in local authorities whose first rule is, 'Don't do anything that will get me into any trouble', and that is the first thing they want to do. And, 'If this doesn't fit neatly into what I've been told can be done, then I'm not going to do it in case somebody complains.' 

The witnesses are reluctant to comment either way on that. So, thank you. Thanks, Mike. I appreciate it. Okay. Diolch yn fawr iawn, thank you to the witnesses this morning. You're all seasoned people attending committee, so you know the drill, but we'll send you the copy of the Record of Proceedings and if you want to add or change anything, then please come back to us. Thank you very much as well for your written evidence ahead of this session, we very much appreciate it. You're welcome to stay with us for the next two items, but you can also disappear if you want to as well. So thanks, all, for being with us today. 

Item 4. Under papers to note, we have two papers there, one a letter from the Chair of the Petitions Committee, who is sat with us in this meeting today as well, and a reply from me. So, are Members happy to note those two papers? Diolch yn fawr. Great. 

In that case, we move to item 5, and I propose, in accordance with Standing Order 17.42, that the committee resolves to exclude the public from items 6, 7 and 9 of today's meeting. Are Members content? Yes, they are. In that case, our public session will be back at 1 o'clock today, where we'll continue our evidence session on hospital discharge. We've got witnesses, a panel, from various NHS bodies, and that's at 1 o'clock. So, that brings our public session to a close for the current time. 

Croeso, bawb. Welcome back. I move to item 8 of the Health and Social Care Committee, and this is in regards to our further evidence session on hospital discharge. And we have evidence this afternoon from various NHS bodies, and I shall ask our witnesses just to introduce themselves for the public record, please. 

Good afternoon. Hello, my name is Gill Harris. I'm the executive nurse director from Betsi Cadwaladr University Health Board, and deputy chief exec. 

Good afternoon. I'm Anthony Gibson. I'm representing Cwm Taf Morgannwg University Health Board. I'm the integrated locality director for the Bridgend locality. 

Prynhawn da. Afternoon, everyone. I'm Carol Shillabeer and I'm the chief executive of Powys Teaching Health Board. 

Hello, everyone, and I'm Jason Killens. I'm the chief executive for the Welsh Ambulance Services NHS Trust. 

Diolch yn fawr. Thanks ever so much for being with us. So, Members will have a series of questions, but if I could kick off with a very overarching question, which is the subject of our discussion this afternoon. Tell us about the scale of the impact that delayed hospital discharges are currently having, each on your specific organisations. Is there anybody that would like to kick off with that? Carol, please come in. Carol Shillabeer. 

Thanks very much. Thank you for the question. I'm going to start at the discharge end of the hospital flow, but I'm going to expand the answer to cover the whole system, if I may. So, specifically for Powys, colleagues may well know that Powys doesn't have a district general hospital within its boundaries. It works across five health economies, and so has the equivalent of about 250 to 300 beds in district general hospitals in our partner organisations, both in England and Wales. So, for us, in terms of scale of impact on hospital discharge, we work very closely with trusts in England and health boards in Wales on supporting patients back to Powys. Ideally, we support patients directly back into their own homes, but, for some people, they do need a longer period of rehabilitation and pre-hospital discharge, and that takes place in Powys community hospitals. At any one time on any day, it varies between two and eight patients, being able to bring those back into Powys community hospitals, and a few more back into the community. So, for us, one of our core purposes is to ensure that, from a Powys community hospital provision point of view, we are supporting district general hospitals to bring patients back into Powys, hence freeing-up district general hospital beds. So, that's one aspect.

The other aspect is discharge from community hospitals. In Powys, we have a network of nine of those and one health and social care centre, all of which have been established with a small number of beds, important for the community, and, at any one time, certainly over the last few months and particularly during the winter period, we will see extended lengths of stay. And, at the moment, we have somewhere between 30 and 40 patients delayed in community hospitals. That does impact on patients, primarily, and their ability to maintain their recovery and that is a key concern, but it also does provide a concern in terms of being able to actively support patients, both in terms of step up into community hospitals, but also step down from district general hospitals.

Just a note on the broader impact of delayed discharging and flow through the system, and that moves all the way through district general hospital capacity to emergency departments and into ambulance service. So, as a health board, we've been very concerned to ensure that we're doing all we can to prevent hospital admissions where they can be prevented but also to support our colleagues in the ambulance service and in other district general hospital providers to ensure that we're bringing our patients back into Powys as quickly as possible. But you will already know, I'm sure, as a committee that that is a significant challenge in terms of keeping the whole system moving through. So, if that's all right, just as an introductory comment from Powys, thank you.

Thank you, Carol. Actually, let's stick with the health boards, perhaps, and then we'll come to Jason at the end. So, perhaps I'll ask Dr Anthony Gibson to respond next.

Yes. I think building, really, on what Carol has said, the impact of poor hospital discharge is actually a measure of the whole-system pressure, because actually what we're reflecting here is a difficulty to move patients through an integrated health and social care system.

So, purely from a health board point of view, over the last two to three months, we've had anything between 70 to 100 patients on each of our hospital sites who are medically optimised and are awaiting discharge to a more appropriate care or place setting. Now, that's a reflection of pressure in all parts of the system, both health and social care, but that impacts then throughout the healthcare system within the health board, so that will lead to increasing numbers of patients and pressures within the emergency departments.

We're then having impacts across how we're able to support WAST colleagues, and then there are also the impacts then on our elective care and the ability to deal with the increasing backlog of patients that we're seeing on waiting lists as a result of COVID. As those beds become used up by patients who are awaiting movement through the system, we can't bring an elective patient in, for example, to carry out an operation.

So, in terms of the health board, we are being supported by colleagues in Welsh Government to invest very heavily in ambulatory and same day emergency care to try and support and turn around as many patients as possible, working with WAST colleagues around having alternatives to conveyance, so that colleagues don't feel that the only place that they can bring patients to is the front door of the hospital—so, how can we find and support ways to support paramedic colleagues to bring patients away from those front doors—and working with local authority colleagues around how we can develop and work up our integrated service so that the automatic place isn't a hospital, for particularly those frail, elderly patients, who we're really starting to see the impact of the pandemic on now in terms of their ability to remain independent and function at home. 

So, the bit that we're talking about in terms of hospital discharge is a function, just in summary, of a whole-system pressure, and we're trying to work with all our partners, really, to work on different ways to respond and support patients and our communities to stay independent and at home for as long as possible.

Thanks, Dr Gibson. Gill, it's probably more difficult for you, because some of the issues may have been addressed, but anything that's not been addressed that you think's valuable to bring in at this point.

I think most of the points have been made, but I think the other point I'd like to make is that we have had to escalate areas, so add additional beds into the system, in order to support the patients. That has also meant a stretch on our already stretched workforce. So, I absolutely agree with everything that's been said about the whole-system pressures and the wish to release ambulances when sometimes we're unable to do so, and understand the impact that that has on people in the communities, but it is also having an impact on our staff, who are already severely challenged, because we are escalating additional beds across the system to support those who perhaps could be cared for elsewhere in different times.

Thanks, Gill. So, finally, I'll come to you, Jason, in terms of the question again of course being the impact that delayed hospital discharges is having on each of your organisations. So, from the ambulance service, of course, we'd appreciate your response.

Thank you. So, of course, the impact for us is slightly different to health board colleagues, but to give committee a sense of the proportion, in December, 25 per cent of our available capacity, our fleet, was lost in delayed handover in emergency departments. Of course, that's a direct consequence, as colleagues have already said, of pressure across the system and delayed discharge. What that means for us, of course, is that we've got patients and our crews waiting at the emergency department to enter the hospital and continue treatment, but, importantly, as Gill just touched on, there are patients in the community that we are unable to respond to as a result of the fleet, that capacity, being held at the emergency department. 

So, the impact of delayed discharge is quite profound on us, and particularly patients in the community, with no care around them, that, often, wait very long periods of time whilst considerable amounts of our capacity are unavailable to us to be able to respond to those patients in the community. And, of course, that has an impact, not only on those individual patients, but also on our people, our staff, too. 

Thank you, Jason. I suspect Members will want to dig into some of that a bit later on as well. Quite a lot of the evidence that we received—. We had quite a high level of response to this consultation, but many highlighted, along with the delays, issues around rushed and inappropriate discharges without support in place. I'm just gauging your view on that, and whether you consider that to be an issue within your organisation, and, if so, how that could be addressed. That's probably to everyone here, apart from perhaps Jason, on this one. Who wants to go first? Carol put her hand up. There we are. Carol first. Thank you. 

Thanks very much. So, there is a real balance to be struck, I think, when you're trying to ensure that people can get home and also make sure that we get people home safely. There's quite a bit of preparation that goes into discharge, including multidisciplinary team planning. Clearly, for some patients, discharge is far more complex because their own individual circumstances may have changed significantly as a result of an illness, and that does require some considerable planning. 

Why I talk about the balance being struck is trying to ensure that we find the right time, the optimum time, before a patient may start to deteriorate through deconditioning—staying too long in hospital and then requiring more care. So, I've seen quite a bit of the evidence that has been submitted raising that red flag about deconditioning of patients if you leave people too long. 

The key question then is about managing risk and the support that's available in the community, the follow-up support, be that in terms of voluntary sector visits—and they contribute hugely in the Powys area—our community connecters, our other voluntary groups, as well as services such as district nursing, but we've also got in place something called virtual wards, which are really based around our GP practices, and, for those patients who are leaving hospital who may need a little extra follow-up, that safety net, so to speak, we've put those mechanisms in place. 

So, there is a balance to ensuring that discharge is at the optimum time, but ensuring that we don't hold on to patients for too long. But, wherever possible, we put in that safety net and that wraparound, with patients going back in often very different circumstances to those that they lived in previously. 

Thank you, Carol. Dr Gibson or Gill Harris. Don't feel that you all have to contribute on every question, I should say, but, Gill, you wanted to come in. Gill. 

Yes, I completely support what Carol said about the balance of risk, and we need to remember that we're living in strange times where already high risks that we put upon patients in terms of care within hospital settings are exacerbated with infection risk. So, that is another balance that we have to take into consideration, that we don't want them to be exposed to those types of risks any longer than we have to. 

I think I just want to add as well about the involvement of carers in discharge, and this has been more difficult during the COVID pandemic, but, actually, we have tried to work around this in terms of virtual involvement of carers, but also, for those most in need of carer presence, we have facilitated that happening. But it is, as Carol said, a balance of risk.

Thank you, Gill. So, in terms of the issues that you've talked about so far, what are your predictions for the future? Who would like to address that? Dr Gibson.

In terms of where we see ourselves in terms of bottlenecks in the system?

Right, I'm thinking in particular that we are—. Is the current situation, in terms of the delayed discharge from hospitals, is the situation going to improve or is it going to get worse, or is it going to get better in the immediate short and long term? I suppose that's the nub of the question. Carol's got her hand up as well. Carol, do you want to come in first, or do you want to address that, Dr Gibson?

I'm happy to just go through. I think, in terms of short-term gains, as we move out from the COVID pandemic and we move away from having to manage different streams and segregate beds within the hospital, which is an inefficient way to manage our bed base, that will improve some of the pressure, particularly giving us more capacity at the front door to support Jason and his WAST team in terms of unloading, because that is contributing to the pressure.

Some of the other issues are around two things, I would argue. One is around availability of social care provision, and that is going to be a medium-term solution. I know there are national campaigns and work going ahead, but, until there is a significant change in how that profession is seen, valued, remunerated, I would suggest, we're going to see ongoing recruitment problems within the social care setting, especially as there are now more attractive places for those people to work in less hard-working areas, I would argue. And also there are recruitment issues in our core therapy teams, and our therapy teams are crucial in how we move patients through the system and allow them to recover. So, those issues are not going to have immediate improvements, although we are hopeful that people will be more willing to move jobs. People have felt quite loyal to their current posts at the moment, with the pandemic and not wanting to leave teams short. So, we may see increasing movement as we come out of the pandemic, people wanting to take on promotions, new roles, and feeling more able to do that.

But I think the key part for this is around developing integrated community-based services and investing in those up, giving us more capacity within those teams, in step-up, step-down capacity within the community, to prevent admissions. And while there's work going on, as you know, those pieces of work take time to reach steady state; it's anything between six months to four years, if you look at the research, before you can see the full benefit. So, I'd say there are some short-term ones, but most of this is going to be medium- and long-term improvements.

Understood. Carol, you wanted to come in. So, again, I'm asking for your predictions for the future in terms of how confident you are that there are plans in place to address the delayed discharge from hospitals. Carol.

Thanks very much. And I'll just add to Dr Gibson's views there, because I completely agree with them. This has not been—. The whole issue of delays in hospitals has not been a short-term issue, but it absolutely has been exacerbated by the pandemic. So, there are twice as many delays in hospitals now than there were pre-pandemic, for some of the reasons that Dr Gibson has given. And we have seen, I think, a more acute shortage in social care, for lots of varying reasons. So, I completely agree that some of the keys to unlocking this are around that community provision, in particular social care—so, real living wage, terms and conditions, career progression, parity between social care and healthcare, and that real value that we should be giving and aspire to give to people who work in that social care sector. The pandemic has completely underlined the need for us to make progress on that. There's an issue of the balance of provision as well, in terms of the models of care, our social care community-based care, and of course the key issue of sustainability. They all get wrapped up together. And then when you are talking about the community service responses beyond that of social care, we talk much more about those integrated teams being able to offer an alternative to hospital.

I still believe we're admitting too many people to hospital who could have a different and alternative care and support arrangement in place. I think about my own very elderly grandfather who, the last thing he wants or needs now is an admission to secondary care, and fantastically, that wraparound has enabled him not to have to choose that option. But we've got to expand that, I think, given the demographic that we have.

So, will it get better? It's a really good question. I think it has to get better. We generally know what we need to do and the constraining factors are that workforce development and putting those expansions in place.

Okay, thank you, Carol, I appreciate that. I suppose the question to Jason Killens is asking you about your predictions, but this is in—. I suppose from your perspective, a lot of these issues are out of your hands, but it's important that predictions are made for you in terms of how you are designing your services into the future. So, if I can ask you—I mean, are you confident that things in terms of hospital delayed discharges are going to be improved in the coming months and years or are you—? What concerns have you got in that regard?

Well, indeed, as Carol and others have said, of course, it has to improve, given the situation that we currently face. Our short-term planning assumptions are that we will continue to see the current level of delayed ambulance handover that we currently do, certainly for the next few months, into quarter 1. We do expect to see, as we go through next year—quarter 2 and quarter 3—some reduction. But we need to work with the rest of the system to ensure that those reductions are sustained. We do have a part to play in this as an organisation. There is a part for us to play in conveying fewer patients to the emergency department, and as has been touched on by Dr Gibson, using different pathways for our clinicians to refer patients to—[Inaudible.]—of care in the community with advanced paramedic practitioners working in our organisation so that we convey fewer patients to the emergency department. 

All that said, when you benchmark the conveyance rate that we have here in Wales, compared to the rest of the UK, we actually do quite well already, but we do believe there is more for us to go at, so we have a part to play in reducing the pressure in ED and the number of patients being admitted and so on. But in terms of the impact of the current situation, certainly in the short term and across the next three-to-six months, we expect the current position to remain and we're planning on that basis.

Okay. Just hearing that last sentence, that's concerning in itself of course. Because the slides that have been presented to us by yourselves, Jason, paint a concerning picture of course, don't they? Okay, Rhun ap Iorwerth.

Thank you. Yes, it's at the worst point that our records show us. So, December was the worst month on record for us in terms of delays at the emergency department, and we expect January, this month, to be worse than December. We lost something in the order of 25 per cent of our emergency ambulance capacity across the month of December, with our crews waiting with patients in the back of their ambulances outside our emergency departments across Wales. So, the position is extreme and sustained and as a result of that, regrettably, many patients—far too many patients—are waiting far too long in the community for us to arrive. I'm clear that the level of service that we're offering to those patients is unacceptable, and we're doing everything we can to improve that. All the while, we've got this level of capacity constraint; it is very difficult for us to get to patients in a timely way.

And figuratively speaking, you'll be peeking in through the door of the ED and seeing what's going on there, and no doubt there are issues, actually, in terms of capacity within EDs, and pressure on EDs. But what's your assessment of what's happening further inside that hospital and on to social care? What assessment do you make of the scale of the impact of that delayed discharge from hospital on you?

I think it's quite difficult for me to respond to that question with any certainty. What I would say, as Carol and Gill and Dr Gibson have already touched on this afternoon, is these are complex issues. The ability to discharge patients that are medically optimised and essentially fit for discharge is part of the problem, and those numbers have grown considerably in recent months, complicated, as Carol has already touched on, by the pandemic, and of course what that's done is exacerbated some of the challenges that were already there before. But for us, we do see a direct impact of delayed discharge in the inability to flow patients through the hospital—[Inaudible.] Of course that impacts on our patients and our staff being able to respond to calls—[Inaudible.] But as I say, there is a role for us to play, and that's more about avoiding the emergency department and conveying to hospital, where we can safely do that.

There's a slight issue with your microphone. I'm not sure if it's covered or something, so while you perhaps have a look to see if it might be able to move closer to you, I'll just ask, perhaps, Gill Harris, a question. Looking out from the hospital at that row of waiting ambulances, what are your thoughts on what you should be doing to make sure that they can offload quicker and get back out to treat more people?

So, that's a complex question, as I'm sure you understand and clearly support the need that we need to offload those ambulances safely, and we need to allow those ambulances to attend to the patients in the community, which are a significant concern to ourselves, because we know those delays will impact on their treatment requirements. I think there are a number of things, some of which we've already articulated, in terms of the ability of social care to be able to respond, because of their own workforce challenges and some of the points that Carol has already articulated very well. There is some work that we're working on with Jason's team in terms of our improvement plan about signposting patients to alternatives other than an ED department, because ED, for many people, is a first choice. And that includes giving abilities to our GPs, which they've taken up, on things like Consultant Connect, who prevent those transfers of care, and Jason has worked closely with us in considering how we can extend those offers, I think, not only to our GPs but to the ambulance services as well, to not just signpost them to the right place, but potentially to do that in a way that moves them straight into the hospital as opposed to leaves them waiting in our ED department.

What about the preventative role of ambulances, Jason Killens? Your teams can, working effectively, stop people from having to end up in hospital at all. Are individuals ending up in hospital, making their own way there, perhaps, because you are tied up at the back door and are unable to do that work out in the community?

There is a role for us in prevention. Indeed, we were the first service, just before the pandemic in the UK, to have a public health plan. So, we do see a role for us in the prevention space. Of course, our clinicians are in people's home. Either through contacting the 111 or the 999 service, we touch something in the order of 2 million people a year across the country, so we do have an ability to influence the prevention agenda, and, as I say, we've got a plan to do that. It's early for us. It's the first kind of step for us into the prevention space, but we do see a role for us. 

Expanding, perhaps, on a point that Gill's just made, of course our clinicians—now being degree educated, many with Master's in extended practice and so on—do have the ability to treat and close episodes of care where it's safe and appropriate for us to do that in the community, or convey patients, refer patients into other bits of the system. So, gone are the days where the ambulance service was simply a transport organisation; we are a provider of clinical care in the community that happens to do transport now, rather than being a transport, essentially logistics, organisation.

So, we do see a growing future for our clinicians, particularly our paramedics, and our advanced paramedic practitioners to offer different alternatives to the traditional—[Inaudible.]—episodes of care in the community to avoid conveyance to ED, or where it's necessary, as has been touched on, refer those patients to other bits of the health system, avoiding the bottleneck.

That's what I was getting at, and I apologise if my question wasn't clear. And, of course, that work is curtailed when your ambulances are parked outside EDs. It's a vicious circle.

It is a bit of a vicious circle. It is a vicious circle, but, of course, we do have different schemes, so I'll just share two examples. So, in Swansea, we've developed a group of specialist paramedics who are working in the community palliative care team. That's going really well, and that avoids a traditional ambulance being sent and potentially those patients at end of life being conveyed to the emergency department. Another scheme that I'd just offer by way of example is some of our advanced paramedic practitioners are now independent prescribers, so they're able to prescribe medications to patients in the community, whereas historically we would have needed to convey those patients somewhere else for that onward care. So, there are alternatives we're developing internally, which afford us the opportunity to prevent a conveyance, and therefore free up the resource because it's not stuck—to your point—at the emergency department.

One last question specifically on ambulances, and it's on that capacity that you currently have. You have been able to tap into military support; that comes to an end in March. Is that of concern to you and would you like it extended, or a third phase of that?

So, the military support we've got at the moment is the third time we've had the military with us throughout the pandemic. We've got just about 250 defence personnel deployed on front-line duties next to our clinicians now. That's in a context of having grown the organisation by over 300 patient-facing staff in the last 24 months, and we are in discussion with commissioners already about what happens from the new financial year onwards. The current military support will conclude on 31 March. Between now and then, we've got about just under 100 new people joining us and will be on the streets through April and early May and, of course, we've got other contingencies we can deploy, but we do need to see improvements from our perspective. We do need to see improvements in the handover position to free up that resource and get them back responding to patients in the community.

Thank you. Let's broaden it back out, then, and look at some of the causes of delayed discharge in general. And perhaps, Carol Shillabeer, if I could turn to you on the question of the relationship and the communication between different parts of health and care: we all hear, 'We'll support integration to the nth degree, because that's what we need', but is it happening, and much of the blockages in the system are down quite often to poor communication between different sectors?

Thanks very much for that question. It's a really helpful question, because it brings a focus on to issues such as assessment, and you'll have seen in the submission—and I'm sure mine isn't the only one that talks about assessment—about joint multidisciplinary assessment with family members, with carers being part of that process, and, of course, with the patient sort of steering that in terms of what they feel is the most important thing. Assessment has been quite an area of focus, because it in itself can become a bit of a delaying issue.

So, for example, a nurse on a ward may assess, or a doctor, then you need a physio, you may need someone else and you then need social care to come in. Speed of assessment and effectiveness of assessment is a really key issue. That really talks to your question about how effective is the communication. There are different models working across Wales. In the old days, we used to have hospital social workers, and we are moving back to that model a lot more—to have social workers as a core part of that multidisciplinary team in the hospital setting that can help to speed up assessment. I think there is an improving picture there, where that resource is available.

We know that social workers and the workforce around that are challenged as well, so that's not an easy solution in and of itself. And we also know that our social worker colleagues have a significant caseload of people in the community who are also, perhaps, on that vulnerable list of needing additional care or going into hospital as well. So, they're pretty stretched in terms of being able to, in a really timely way, plan discharge most effectively.

One of the things that has developed over the last couple of years that I think feels as though it's a game changer if we implement it well is about helping people to get back to their home environment, their usual environment of care, giving them that support to reable and rehabilitate, and then assessing for long-term needs. Previously, we've been assessing people for their long-term care needs whilst they were in hospital, and often in acute settings. That does distort what they need. And so we do need—which is why I talked about the risk balance earlier, about discharging—to support people to have a period of recuperation for an assessment then to take place around what the long-term care needs are.

So, there's been quite a change of practice. There's much more to do, I would say, in this area. And, again, social care colleagues are quite stretched in terms of supporting community and hospital patients on this. 

Do you feel a part of that? Are you a part of seeking a solution to that, or is that 'them in social care'? I'm sure you have good personal relations with them and wish them well in sorting it out, but do you actually play a practical part in trying to resolve those issues? Because they affect you and your teams directly. 

If I can just give you a real-life example of the way we're working at the moment. We've had to step up the pace on this, not just because it's winter, but because of, clearly, the pressures in the system at the moment with the COVID pandemic. Each day, in my own health board, there is a meeting, a huddle, for half an hour or so, between health and social care colleagues, solution finding for assessment delays, for delays in discharge, to help unlock things. Back in November, we put in place a bit more resource around trying to accelerate the discharge of patients to their home with that guaranteed follow-up assessment booked in. We have had some benefit from that. Clearly, the intense focus on that and us working together and bringing results, we need to hold that through. But I can be absolutely clear that we feel as invested in solving these matters, rather than it being, 'Over to you, social care'.

What's your experience in the Bridgend area, Anthony Gibson?

Very similar to Carol, we have daily meetings now with colleagues from Bridgend County Borough Council where we're escalating issues across both health and social care in terms of where we can support anything. But I think, on top of that, then, there is also the longer term planning. Because actually, there's the day-to-day operational very close working, which has really developed through the pandemic—and I think one of the positives that's come through that is it has brought organisations closer together—but then there's the longer term planning around the long solutions that are going to give us the capacity within the system to move people through quicker. In those planning meetings, we are planning services together.

We have quite a long history in Bridgend of integrated services jointly run and funded by health and social care, and we're working really closely now on how we develop that and how we upskill those. We're looking at how we can be, together, short term, looking to purchase some capacity in the care home sector to give us more of that space that Carol was talking about: allowing someone to get better in a more normalised environment, ideally in their home, but some aren't ready to go home. We're looking at how we can jointly use some of that capacity within our care home sector to support patients on that transition home to free up some early capacity. So, those are the sorts of things that we're doing, and they are part of our emergency escalation process—our gold, silver, bronze. All our local authority colleagues are in all of those meetings with us working on solutions. 

I'm sure that every board—and local authority, for that matter—is trying to innovate and find new ways of working. Is it problematic that you are, ultimately, having to make up these systems yourselves because we haven't got those national frameworks to bring the two together in a formalised way?

I do understand what you're saying, but I think sometimes, a national framework that fits all—. With our populations in Wales, the needs of our populations are so different. If you take the Bridgend patch, what we'd need to be providing at the top of the Llynfi valley is probably very different to what I would need to provide in Porthcawl. And similarly in the Rhondda, what I would need to provide in Miskin is very different to that. So—

But when we're talking about patient-centred care, the patient is the same at the top of the Llynfi valley and in the middle of Bridgend in terms of the need for us to provide for them the care that they want at that point in their lives. 

I think a patient is a patient, but the need and what that patient requires and what that community needs to be able to support those patients to be able to remain at home is very different. For example—if I give you an example, maybe that's helpful—up in some of our valleys up in Maesteg and Llynfi, we still have very close family networks around elderly patients who can provide support and help in their homes. So, the sort of services that we'd need to provide there are very different from Porthcawl, where we've had a lot of people who've moved there, elderly patients, who are socially isolated, so they need more support in that way. So, frameworks are great, but the needs of a population—. Yes, we're individuals within that population, but when you're designing the service needs, that is going to be different based on the communities that we're looking after.

That's a very good point. If you look at somewhere like my constituency, where you have lots of incomers who've come in—who can blame them for wanting to enjoy the autumn of their lives in a wonderful place like Anglesey—it does put pressures, doesn't it, on social care in a particular way.

Gill Harris, I have had the pleasure—if that's the word—of coming into a huddle a couple of times at Ysbyty Gwynedd and I've seen quite starkly the number of people who are medically fit for discharge and who are causing issues for you at Ysbyty Gwynedd, say. I don't remember social care being represented at those huddles. What then happens to make sure that there is that bridge between that stark number—as high as 80 for Ysbyty Gwynedd once when I was there, I think, or even higher—and making sure that health and care are working together to get those care packages in place?

You're right, they're not in every huddle, but what I can assure you is that there are very regular meetings between our local authority colleagues and our healthcare colleagues about what the options are and how we can support one another. Those conversations are taking place between the clinical teams, between social care systems and health systems, literally on a patient-by-patient basis. We're also working with them very innovatively to think about different models of care that Carol has described. And certainly, the recent opening of the Marleyfield development in Flintshire to support a more integrated approach to support health and social care will prove to be very successful and it is a model that we are looking really closely at across the whole of the patch.

I think the assessment that Carol has alluded to is critical. One of the other things that we have picked up is that we have introduced—and it's working really well across our central patch—a criteria-led discharge, where therapists are working to support that discharge. That, again, is proving extremely successful and is being very well received by both patients and by the clinicians who are caring for them, and it's enabling a different type of assessment. So, that is something that we're looking at across north Wales.

Just a couple more questions from me. There used to be more of a step down between secondary care and a home or an individual's home where they'd be cared for afterwards. We've lost many, many community hospital beds over the years in Wales. Where does that stand in the list of things that are helping to cause the backlog and delayed discharges in hospitals now? Who fancies answering that? Carol Shillabeer.

Maybe I'm in a more unique position than other colleagues across the health boards in that our hospitals are community hospitals. Some of them are significantly larger community hospitals and do other things, such as day surgery and endoscopy and things. That network of community hospitals has been really highly valued, continues to be really highly valued by the community, but the shape of that is changing and needs to be quite flexible. Community hospitals, as you say, sort of disappeared from the health landscape a bit, I don't know, two decades ago, I guess. There is a question, certainly in my mind, around dynamic community hospitals and what more they can do to support. And we must not get too obsessed with beds, but it's the broader range of services that can be provided in a community hospital. So, it's not just about the beds. In fact, if we can use our community facilities really well, the beds become less of a feature; it's more about being able to step up physio and assessments and other social-model activity as well. But I would want to stress that, wherever possible, we should be able to get people to their own home, because that is where they do best.

The big challenge for us, in Powys, certainly—and I think this is a challenge elsewhere—is where people can be supported at home but there are issues such as night sitting, overnight safety nets, making sure the 24-hour wraparound service is there, and that we've got that position to be able to step up. You may have picked up, in our evidence submitted from Powys, that we want to use our community hospital beds much more in that step up, very short stay, 48 hours or so. I used to work with a consultant physician who used to say, 'I need to bring Mrs So-and-so in for a wash and brush-up'. What they meant by that was they need a medication review, they need a bit of an assessment here and there, to make sure they're okay to be back at home. And although we don't really want to destabilise homes, we do need something, I think, that offers an alternative between home and district general hospital for that short, short period. So, I'm glad I've still got these community hospitals, but the shape of them is needing to change.

Okay. Dr Gibson, or Gill Harris, really, on that question: are we paying the price for the loss of community facilities, including beds, of course? Dr Gibson.

We have two very large community facilities within our health board area. I think there is an argument that those beds are not used in a modern way; they are used as an assessment space rather than what we want to be getting to, which is a discharge to recover and assess model, a step-up and step-down model. I completely agree with Carol, strongly agree, that that doesn't have to be in a formal hospital setting. That can be in a variety of community settings, far closer to home and family, which, actually, will promote recovery better. There's a lot of work going on, as I'm sure you're aware, around that whole discharge to recover and assess capacity assessment within communities, using the John Bolton model, where all the health boards are working with the delivery unit around understanding the needs and capacity of their community. But I think the only thing we just need to understand, of course, is that this is a reflection of an ageing, elderly population with more chronic health problems and comorbidities, and we're still running a system that is 20 or 30 years old in its approach to how we provide care. So, that whole transforming mindsets, communities, in terms of how we deliver care, I think, is really important. But you're right in terms of that ability to be able to support people almost in a halfway space and back again. But, as we know, large settings of elderly in-patients come with their own complications, whether that be the risk of falls, the risk of infection, the risk of deconditioning. So, the setting, I think, rather than the principle, is the most important thing.

Yes. So, a hospital-at-home model could be developed. I've benefited, in my family, from a hospice-at-home model, I remember. A hospital at home, not just handing over to the district nurse, but a specific model where the hospital continues that care somewhere else, including even in a patient's home. Gill Harris—oh, sorry, Dr Gibson.

I would argue, possibly, even, that actually this is something that's provided before the patient gets to hospital so that that deterioration is detected at home, that is the team come in, treat at home and prevent the deterioration that requires hospital admission. That's the model that's run in, for example, Bridgend, in their acute care team that is there to support primary care to prevent that level of deterioration. It's something we'd like to scale and move forward. 

I'm sure the Chair would like me to move on. Gill Harris, did you want to come in?

Yes, just very quickly, because the model you describe about the hospital at home and GP support works very well in parts of north Wales, and it's something we do want to invest in. I think the second point is the work that we have done in conjunction with health and social care partners around the Marleyfield model is looking at day care support, so not necessarily in-patient beds, but facilitating some of the loneliness, some of the other support service that may be required, and giving them access to swift reablement, Carol's wash-up and brush-up type of principles. So, I think it's a model as well as that we need to focus on more than the beds.

Thank you. Thank you, Chair.

Thank you, Rhun. Can I just ask and pick up on—? Jason Killens, you outlined the additional staff coming in at April time, I think you said—March or April. In terms of ambulance vehicles themselves, at what capacity is a lack of vehicles an issue, or is the issue all about staffing numbers? 

The fleet in total, across both the emergency and the non-emergency fleet is about 700 nationally. The size of the emergency fleet is not a constraining feature for us currently, so with the additional support we've got from the military, we are providing something in the order of 115 to 120 per cent of our planned capacity. So, our fleet size does enable us to flex a little, and isn't a constraining feature at the moment for us, but, of course, if we were to see a large injection of people, then the fleet would have to go with that. So, we've got a regular fleet replacement programme, we keep the age of all of our vehicles somewhere around five to seven years, and, as I say, the size of the fleet is not a constraining feature at the moment for us. 

Okay, I'm just asking that in the context of the military no longer being available and to what extent do you need to invest in the fleet in that regard, but you're saying that's not the key issue here, the key issue is staffing.

So, when military leave us at the end of March, it's just people, so it's 250 individuals, military personnel—there are no vehicles—[Inaudible.]—using our vehicles, our fleet.

Of course. So, okay, it's not a constraining feature in terms of fleet capacity, thank you. Okay, thank you. Gareth Davies. 

Thank you, Chair, and good afternoon, everybody. I just want to kick off, really, and I suppose I can throw out this question for any takers: how well do you think that the discharge to assess and the recovery models are being implemented in Wales? And the NHS Confederation said it would welcome an all-Wales approach to guidance and standards for discharge. What are your views on this, because a lot of the time we can be critical of all-Wales models and in favour of more regional approaches and we can be critical of a one-size-fits-all sort of culture. So, with that in mind, do you think that's the case, or do you think there are certain areas where an all-Wales approach could be more deliverable in regards to this? I'm just wondering.

Okay, who wants to address that? You don't all have to address it, just if one person addresses it and then other people can come in, but if you've got nothing to add—. Who wants to take that? Carol.

I'm happy to pick that up. So, I think there are a couple of things in there, there are the specifics about the D2RA model itself, and then there's this national, regional, local sort of perspective. My own sense is that they're too tied together. So, I'm completely supportive of the national principles. It makes good sense, doesn't it, to support people to get home to recover, to have that support, and then we assess what they need for the long term? That has been a bit of a culture shift and a practice change for us because people of my generation were brought up to make sure it was a safe discharge, 'Don't take any risks', 'Everything's got to be nailed down before we let anyone out of hospital', whereas now, we're sort of saying, 'Well, people aren't yet fully recovered. They're part way through their journey of recovery. We're going to support them to go home and we're going to enable them to recover in their own setting because we think they'll do better.' So, it has taken a bit of a culture change and a culture shift on that, and probably not just on the part of the professionals, but on the part of patients and family members as well. We need to be very mindful of wrapping around that.

So, I think it's brought a lot of value to individuals. I spent some time pre pandemic out with the reablement service, talking to people who have experienced that service, that they're very, very pleased to have had it. They don't want to be in hospital for very long. Some of our challenge is, 'Have we expanded it enough and have we got enough sustainable workforce around that?' So, one of the things that we've done in Powys is to move our therapy service from being hospital based—community hospital based—to being community based, within reach, to sort of support people out. And it's those subtle changes, I hope, that help to recentre that, actually, recovery is taking place at home and not necessarily just in hospital. So, the national approach on that has been very useful and I know that reference was made earlier to the demand and the capacity, because is there more mileage in this approach if we were to staff appropriately—more appropriately—expand these services, and hence reduce the length of stay in district general hospitals, for example? There will always be, I think, local application and nuances, so I think there does need to be a bit of flexibility in these models, but my sense is that that's been a generally good national principle to follow.

Thanks, all. I was only coming in to ask if you feel like you've got a new point to add. Otherwise, Gareth.

Okay. So, being a glass-half-full sort of person, can you tell us briefly about any successful schemes that you've been involved in around improving hospital discharges, patient flow, and using them as an example to influence other areas? Rhun was talking this morning about a successful scheme in Aberystwyth hospital, and it's just looking at these positive models and where they've been successful and implementing them across other areas to ensure a bit more of a wider successful scheme. So, has there been anything in particular that you've been involved in, or schemes that you know of that have been successful?

Okay—Dr Gibson.

Yes. I'll just give two examples of one within an acute setting and one, then, within the community to show the extent of what you can do. So, we've introduced a same-day emergency surgical service where patients who come straight into that unit don't have to go into the emergency department. They're seen and assessed by senior surgeons, and often managed completely as an out-patient until the time they need their operation, and then they go home very quickly. And that's reduced the requirement for those patients to be in hospital beds, sitting in emergency departments, and reducing length of stay significantly. So, there's one example.

The other example is around our acute community team, who pull patients from the hospital into the community. So, if a patient turns up, for example, with an infection in the skin's soft tissues that needs intravenous antibiotics, traditionally you'd stay in hospital for seven to 10 days, having that delivered through a drip in your arm. Now, that team will visit you at home two or three times a day, provide that care in your home, so you can continue to be maintained in your home and free up hospital beds.

So, those are the two examples of services that are proven to work and we'd be really keen to try and scale up and move forward.

Thanks. Gill.

I completely support the SDEC model. We are similarly rolling that out across the organisation—really good success on that. But the other one, and I have alluded to it, is our criteria-led discharge. So, we're running this from some of our community hospitals, and it is nurse and therapy-led, and I'd put the emphasis on therapy here, actually. That's ensuring that patients are suitably reabled so that they can be discharged sooner, and it's not dependent on a medical review. I think that has been really successful, it's been received positively by patients and carers, and it's been received really positively by the staff. That has enabled us to move people through the system in a very different way, and a successful way. 

I appreciate that, thank you very much. The next question is to Dr Gibson specifically. Your evidence states, and I'm quoting from the evidence, that despite various schemes, including short-term funding designed to support discharge, discharge rates have remained fairly static. Why do you think that's the case, and why have you failed to make progress? How do you intend to improve on that?

,I think there are a number of factors to that. We've discussed a couple of those, and I'm sure you've had evidence of those throughout your earlier sessions, around the ability of providers in the community to provide domiciliary care packages. If you look at the evidence and the numbers in there that we submitted, actually the numbers of patients coming through to need input and joint working with ourselves and social care are roughly static, but the complexity of that is higher, so the patients that we're seeing are needing more support, and more complex support, which hasn't helped. But also, I think recruitment with short-term funding has been really challenging, so bringing in experience, particularly around that therapies team that really support and push through discharge, is really challenging when you're dealing in short-term funding, short-term contracts. Actually recruiting into those positions the people of the quality who can make the decision making, do the system change, is really challenging, and we have struggled to recruit. So, the ability to be able to plan a service over three, four, five years is very different in how you can recruit, structure and implement service change rather than when you're doing it on a rolling nine, 12-month basis. But I think that we have a lot of work to do, and I think that some of the work—. We're all in danger, I think, sometimes of maybe hiding behind COVID, but I think this is where COVID has really hampered some of that pathway change, some of that recruitment into those key therapy posts, to allow us to push our processes through much faster. 

So, I think there's a lot of ambition, but we haven't made the progress we have to make, predominantly around recruitment. We've got a number of key elements that we've managed to recruit into the last three months, to completely revamp that process, and a number of trial processes around—. One of the things is we're all fishing in a pond of a limited workforce, aren't we? So, if we recruit heavily into one area, we'll deplete another area. So, one of the things we're really focusing on is how do we support our experienced clinicians—and by 'clinicians' I mean doctors, nurses and therapy teams—to work at the top of their licence? Because, actually, if you look at what they're doing, a lot of the time they're getting sucked into basic admin, chasing, phone calls, whereas we need to use them where their skills could give most benefit and most value to our patients. So, we're bringing in discharge co-ordinators and supporters to allow those teams to work at top of licence to try, then, to free that extra capacity up to push things through faster.

I read also that you're working with the local authority to block-book care home beds. Could you possibly expand on this? Do you see that as a step to addressing some of the problems that I mentioned in the first question?

I think there's not been a huge uptake from private care home providers in terms of short-term contracts. Some of the feedback we've had is that their business model, their staffing constraints, are limiting the amount they can build up. I think it is a short-term problem to help us through while some of the recruitment into social care takes place, and it's certainly something worth pursuing. Longer term, it's more looking at that balance of step-up, step-down discharge to recover and assess accommodation rather than traditional care home accommodation. I think we do have a piece of work, particularly across our locality, looking at the balance of care home provision, because, if you look just at the totality of empty beds, there are empty beds there, but actually what we need to look at is what those beds are. So, we have a slight imbalance in terms of residential versus some of the care home capacity to support patients with long-term dementia, cognitive impairment. So, those are the sort of things, rather than just block-booking care home placements, because people get stuck there and then they don't get home. And the other part we're looking at is what support do we need to provide in those care home places we've bought to continue the journey to get people home, so that they continue to get the therapy and the reablement support. So, short term, yes; long term, it's more around step-up, step-down, intermediate care, discharge to recover and assess for us.  

Thanks. So, my next question is to Gill, regarding Betsi. The Wrexham Maelor Hospital is regularly in the news about long A&E waiting times, and, as a Member for the Vale of Clwyd, I'm acutely aware of the issues at Ysbyty Glan Clwyd, and Rhun will probably be aware of some of the issues at Ysbyty Gwynedd as well. But what specifically is it, do you think, about Wrexham Maelor Hospital as to why it keeps perennially coming up in the news about these issues? Is it the catchment area? I know it's got a wide catchment area—Wrexham itself, parts of Flintshire and north Powys as well. Is it the catchment area, or are there any other issues that might be causing this, because it doesn't seem to be going away, does it?

Gill. 

I think, again, none of these things are straightforward. There are a number of issues that are quite unique to Wrexham, not least its locality. You'll know it's very, very close to the town centre. It's extremely accessible for walk-ins, so its emergency department is impacted in that way. It doesn't have the same support of community beds that we have across the system, but that is something that, as we've said, we want to modernise, and we have seen some impact in the Marleyfield development. I can't dodge the fact that the infrastructure in Wrexham itself is very, very difficult as well in order to deliver care, in terms of the lack of isolation facilities we've had that has impacted on some of the outbreaks, which has meant a loss of beds in itself, because, in some of the infection prevention and control guidance that we have put in, it has meant a loss of beds because of increasing the spacing, but it also has meant that we've been acutely aware of some of the isolation impacts that we have had. 

The other thing—across the whole of the health board but we do see it in Wrexham—is workforce challenges. We have worked on an improvement plan, which does include increasing the workforce, particularly for the front door, in Wrexham Maelor to be able to support that, and a very different workforce, including consultant nurses in our ED department, consultant therapists to support the elderly care. So, it's not one solution, it's a number of solutions. And included in that is the ability to separate out some of our planned care, which—. As I'm sure you're aware, we have plans in place to see what we can do to separate the logistics of planned and unscheduled care across the health board.

I appreciate that, and I do appreciate the complexities around it. It's a funny building, isn't it, Wrexham Maelor? You can walk probably up to about a mile without going outdoors, which is quite unique. 

And from one era to another. [Laughter.]

Yes. Yes. Just finally, I just wanted to pick up on part of your evidence note, which talks about the differences in Wales and England in the discharge to recover and assess models. I just wonder if you could tell us a bit more about that, and just expand a little bit more about some of those points about choice and the general sort of approach to that. Sorry, that was directed to Gill again, sorry. 

Gill Harris. 

Sorry, sorry. So, particularly around discharge to recover and assess?

Yes. Yes. 

So, I think Carol said a lot of it already, actually. It is a model that we've been using across the health board and has been very successful in the east area, actually. It is something that we're building on, we're building the teams to be able to support it, but, again, as I think Dr Gibson alluded to, some of this has been on short-term funding and we need to really invest in the long term. But it also needs to be reflected in the way that we deliver care, and I've talked around the criteria-led discharge and how this leads into discharge to recover and assess. So, I think it is developing those pathways in a stronger way, having those options available to us to make that care unique to the individual needs of that patient. I think there is learning not just from the rest of the UK, but outwith the UK, in terms of what models are available to us that we perhaps need to test in parts of Wales, and are being tested and shared across Wales. As you've seen today, I don't think there's anything that's coming out that's particularly that we're not trying across the whole of Wales. 

Thank you. Thank you, Chair.

Thanks, Gill. Thanks, Gareth. Mike Hedges.

On discharge, before I move on to support for the family, the question I've got is: my experience from a number of constituents is that discharges have been delayed because they've been waiting for pharmacy. Do you recognise that? It doesn't matter—[Inaudible.]

Gill. Gill Harris.

I think there have been times when—. We have picked up times where pharmacy has been delayed, so they may have been waiting for something from the dispensary to be received on the ward, but these are isolated cases in the main. And we've worked with our pharmacy to increase the hours that they are available to support that dispensing so that it is out of hours, as well as the normal in hours, if that's what you're referring to. Apologies if I've misunderstood. 

You haven't misunderstood me. The examples I've had are of somebody who was medically able to be discharged on a Friday, but couldn't get discharged until the Monday because the pharmacy was not available for them until Monday morning. 

Dr Gibson.

I'd say that's not something that I would recognise. We have our pharmacy in to support discharge prescriptions on all the acute sites seven days a week. I think there are issues around these patient docket boxes, where patients require each individual medication to be done at a dose that they can push through. And there have been times where we've experienced delays in getting that because, obviously, it's very time consuming. And that's done by community pharmacists. But those are the only delays I would sometimes see.

The other ones, the other delays we have had some issues with, are around those patients who need supervision with their medication to go home, because it's a different workforce that needs to support that individual. So, there's a different, smaller pool of the workforce that can actually give someone a tablet, make somebody a tablet, rather than that being, maybe, somebody who's coming in to provide basic hygiene care. So, those are the only two areas I've seen. I've not had issues around internal acute hospital pharmacy delays. 

Okay. Well, if I move on now, Age Cymru reports that a recurring theme they hear from older people is poor or no communication with the next of kin and sometimes with the patient themselves. Do you recognise that, and, if you do, what are you doing to rectify it? 

Who would like to address that? Carol.

Thanks very much. I do believe that the pandemic has, in amongst all the challenges, brought some changes of practice into place that we'll build on. If I just take Powys for a moment, we have patients in our community hospitals who have family who are far, far away. And therefore ensuring that we've got the right mechanisms of permissions to speak with whoever the patient wants and all of that and the ease of that—. We have had to look at that because of the pandemic, as much as we did a bit before that, really. So, I think we have been challenged on that very factor of, people who particularly live far away, have got busy lives, how do we include them in the multi-disciplinary team planning with their loved one, and we're having to find very creative ways to ensure that that can happen. 

In terms of the issues of the individual themselves, we are very keen to ensure that patients feel that they've got advocates, and it might not be that it's a formal advocate, but they've got somebody who can be with them. We've introduced schemes such as volunteers, people that they can chat with if they've still got queries about their care et cetera. And of course I pointed to community connectors, I mentioned those earlier, and our community connectors are part of our multi-disciplinary teams now, both in the community but also linking into the wards. And they will support patients and families who feel they need more encouragement, more access, to planning for discharge. 

It is really important just to stress that we work on the principle of 'what matters', and that's about what that individual wants, and so it is particularly important that we raise this profile, that actually all of our care planning is about what matters to that individual, and making sure the voice of the individual is heard is key. So, we're always looking for suggestions to try and improve that if we can.

Okay. Can I move on now to, perhaps, solutions? Something I believe, and you might tell me I'm absolutely wrong, but I think one of the problems with delayed discharge is too many people coming to the emergency department who shouldn't be there, who are coming there because they cannot get a GP appointment. So, you fail to get a GP appointment for three days, 'I know, I'll go and queue in the emergency department, and within seven to eight hours I'll see a doctor.' What happens is, when they see a doctor, they see a relatively junior doctor, who's not going to be the person to send somebody home and discover they die and destroy the whole of their career, they'll keep them in for 12 hours or 24 hours observation. Do you recognise that?

I'm happy to start it off. I can perhaps give less of an up-to-date picture about the emergency department and the decision making in there, but I do hear the scenario that you put forward in terms of can't access a GP and therefore people choose to go to ED. I'm afraid to say I've failed to find the real evidence and the numbers behind that, but I do accept the story, because I've heard it on a number of occasions. So, what are we doing about that perception? Certainly, urgent primary care services are being expanded. It is a real focus across Wales, and I know that Welsh Government, in their plans, are strongly encouraging us and supporting us with some financial contribution to expanding urgent primary care.

I would say that the primary care changes that have happened through the pandemic have had very mixed reviews. So, some people like them and actually think they can access their primary care consultations much more swiftly, and other people don't. So, what's really clear is we need to continue now to provide different modes of accessing that. And I think we need to be asking people, 'Why did you choose ED today?' I can't imagine that a six- to eight-hour wait is something that people would wish to choose very easily. So, substantiating this issue about lack of access to primary care, but also to find those alternative sources of support, rather than it necessarily be GPs.

Jason may touch on the service that 111 provides, and that's an important tool for people to be able to access advice and support without even needing to leave their home. So, we've got to be providing a broader range of options for people to be able to access.

Gill, do you want to come in?

Yes, just to follow on from Carol, really. It is looking at different offers that are available to our patients in the community. Again, we're working with Jason's teams about what some of those offers can be. But it does include, as Carol has described, working with community pharmacies, for example, to expand their minor illness options. For some of our communities, that's really valuable, because getting to an ED department is quite a trek. Again, we're expanding our primary urgent care facilities and looking at the model. We've already described how we've got consultant therapists; we've got consultant primary care nurses, advanced nurse practitioners that are supporting those models across the whole of the healthcare system. And we're working really closely with Jason's 111 team to offer a different alternative, including the SICAT service that we have. I know that Jason's team accesses that, and there's a really good relationship there. 

In terms of admit to assess, I think that is a real challenge for ED departments because of the numbers of patients that are there; I'm conscious that we need to give those individuals a full assessment. So, I think it is well recognised that patients can be admitted to assess and that does prolong their length of stay, and that happens more frequently when we do have ambulances outside, for example, or we've got a crowded ED department. 

Jason will want to come in on this, I imagine. 

Yes, thank you. Just a couple of things to say on it. I think the suggestion that patients, citizens, access the emergency ambulance service or the emergency department because they can't access primary care is certainly one that we hear, but like Carol, nailing down and substantiating that is much harder. There is a proportion of the work that we receive where patients that contact us through the 999 system simply don't need an emergency ambulance. So, on an average day, 10 to 12 per cent of the 999 calls that we receive we now manage without responding to the scene, but we might provide advice over the phone. Increasingly, we'll do more of that. We want to push that up to about 15 per cent of daily contacts, and then, of course, we want to, where we have to go to scene, close more episodes of care in the community. 

On the 111 piece, of course this is an important service nationally. It will be national in the next six weeks or so when Cardiff and Vale come on board. That service has been developed, and continues to develop. We've grown the online symptom checkers, for argument's sake, so people can get live advice online, and, of course, they do get advice from clinicians also in the 111 service for urgent care needs. So, there are alternatives to the emergency department that exist, but, of course, we need to continue to, I guess, effectively signpost patients to the right alternative to inform the choices that they make. 

Thank you. If I can move on, what short-term actions could be implemented quickly to relieve pressures on the system?

It's a key question, isn't it, really? Who wants to go? Carol. You're always good to go first, Carol.

It is a really good question. I'll just spin back a couple of months. Coming into September, October, November, we had a very, very busy summer, much busier than we'd usually have, with the delta variant et cetera, and all sorts of things impacting. We were asking those very questions. To be fair, we are often asked those questions by Government officials in terms of what more can we do to support and get ready for this winter. There are pros and cons of short-term actions, because, as Dr Gibson said, some of the funding means it's short term and it's hard to fulfil. This year, the focus, I think, has been on how do we expand and build on the fantastic contribution of the third sector. In particular, supporting care at home, carers, has been key, and money has been given to the voluntary sector, through the Wales Council for Voluntary Action routes, in order to try to boost that contribution as well, and to support people to maintain that contact at home, particularly recognising the shortage of social care, or formal social care. So, a short-term action has happened in relation to that. Now, that will be evaluated. But my sense here is that we need to implement actions that will take us through the medium and the longer term, and not only focus on short term, hence the discussion that we had earlier about consistently now building a very strong community infrastructure, those different models of care, relentlessly implementing those, checking our demand and capacity for that, and seeing the issues across the system, rather than necessarily the focus on secondary care. So, the investment in that part of the system is going to be really key.

Jason, you wanted to come in.

Thank you. It's just to build on and emphasise the point that Carol has made there. Of course, we have deployed and we do need some short-term solutions and fixes, but that cannot be at the expense of what we do need, which is transformation, medium to long-term change, in how we deliver care. And we've heard much of that this afternoon, from the three or four of us, about things that we're currently doing across a health and social care—[Inaudible.]—perhaps could change. And so, it's about both; we need short-term actions that—[Inaudible.]—are focused on, doing the best we can with what we've got now, but that has to be concurrently, certainly in my view, with real change in how we do it. And from an ambulance perspective, certainly from the 999 service perspective, that's about going to fewer patients, closing more episodes of care in the community, and only conveying those that we really, really need to.

Everybody talks to us about the importance of primary care, the importance of care in the community, yet the figures I've seen—and tell me if they're wrong—is that the proportion of health board money, in every health board, spent on primary care compared to secondary care—. As a percentage, secondary care has gone up and primary care has gone down. Do you recognise those figures, or have you got different ones? And if so, how are you going to change that?

Carol again.

Thanks very much. I thought Dr Gibson wanted to come in there—sorry if I jumped in ahead. I recognise what you say. I recognise that challenge, the desire, the thrust to shift left. I do believe we have been doing that, certainly over the last decade. But I also caution that there are a number of other pressing priorities as well, in areas such as specialised services, the development of genomics, and those types of developments, which are often extremely costly. And so, the balance across the system is one that is a real challenge for us. There is, increasingly, partnership funding that has come through—it used to be called the integrated care fund, now it's going to be called the regional investment fund, I understand—which really tries to deal much more with that community development space. So, we should be including that. But I think it's a fair challenge. And just to say, from my own health board's perspective, one of our key objectives is to ensure that we're allocating our £340 million we have as an organisation to those areas where we can get the greatest value—so that's outcome, experience and cost value. And we know that there's a significant return on investment when you invest in community and social care, primary care investment. So, we will continue to keep pushing that forward.

I think Carol has, as usual, made all the good points. For me, the key point is that, you're right, there has been, historically, a very marked difference in the investment in primary and community services compared to those secondary and even tertiary services. We know that medicine gets more expensive; delivering healthcare does not get cheaper as we go forward. So, how do we use those value-based principles that Carol has talked about to determine how we want to use the money that we have? And we know, for example, that the best value intervention you can provide is to get someone to stop smoking in the community and then 20 years later, you will have a lot fewer people turning up at your front door. And what we spend on prevention, never mind just primary and community care, is even smaller. So, how do we support that change in communities, change in healthier lifestyles? How do we support the whole system around those social determinants of health that are going to actually have the biggest impact on our services over 20 years?

And then the other point that I would probably just very quickly make is that where there have been attempts elsewhere in the UK to move resource from secondary care to primary care, there is always a lag in terms of how those services catch up. They are almost having to be double run, those services, and you never completely release all the resource from secondary into primary care. So, it is a real challenge in how we do that, going forward, but I think we would all agree that we would want to invest where we can do in developing those community and primary services to prevent illness from occurring that we then have to treat in an acute hospital and cause problems in the parts of the system we've talked about today.

On the additional money you're going to have next year, assuming the budget goes through, which I'm fairly confident it will, how much of that additional money—5 per cent, 10 per cent, 8 per cent is probably the norm—will you be putting into primary care as opposed to secondary care?

I'm afraid that's not a question I can answer at the moment. I'm not sure if anyone else can, but I can't—

Carol has put her hand up.

I can't be drawn on 5 per cent or 10 per cent et cetera, but what I can tell you is that we are absolutely in that space now in terms of our plans for the next three years, our integrated medium-term plan. Just from a Powys perspective, we have a health and care strategy, which Russell George will know well, that looks to try to focus on well-being, early help and support. So, we have deliberately changed that strategy to try and ensure that we are allocating sufficient time, effort, energy and resource into those aspects. There is quite a big list in the specialised services end of the spectrum as well and we're going to be having to make some choices even with that additional investment. 

Thanks, all. Is that the end of your questions, Mike?

Gill wants to come in.