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Y Pwyllgor Deisebau

Petitions Committee

06/02/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

David J. Rowlands AM Cadeirydd
Chair
Janet Finch-Saunders AM
Mike Hedges AM
Neil McEvoy AM
Rhun ap Iorwerth AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Dr Chris Jones Dirprwy Brif Swyddog Meddygol Cymru, Llywodraeth Cymru
Deputy Chief Medical Officer for Wales, Welsh Government
Vaughan Gething AM Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol
Cabinet Secretary for Health and Social Services

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Claire O'Sullivan Cynghorydd Cyfreithiol
Legal Adviser
Graeme Francis Clerc
Clerk
Kath Thomas Dirprwy Glerc
Deputy Clerk
Kayleigh Imperato Dirprwy Glerc
Deputy Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:03.

The meeting began at 09:03.

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

Bore da. Good morning, and welcome to the Petitions Committee. I just remind you to turn off your mobile phones or at least put them on mute, and we do have facilities for Welsh translation. 

The first item is apologies and substitutions. There are no apologies, although we make a note that Rhun ap Iorwerth is delayed in another meeting but will join us a little later. 

2. Deisebau newydd
2. New petitions

So, we move on to new petitions. The first of the new petitions is 'Male domestic violence victim support services to be independently run & funded'. The petition was submitted by Tom Embling and collected 138 signatures. An initial response to the petition was received from the Leader of the House and Chief Whip on 5 January. There are possible actions with regard to this, and I assume that Members will have had time to read the points for discussion. Do you have any points to make with regard to this?

09:05

Yes. I think it would be good to wait for the views of the petitioner. Just looking at the research stuff that we've been given, the Government does not disaggregate funding or state how much funding is given to males suffering domestic abuse, because it says that most of the services are available to both men and women, which is a complete nonsense really. That's my experience of referring people constantly with regard to domestic abuse. If you're male in this region, I don't know where to send you for non-prejudiced, I would say, non-discriminatory support because it doesn't exist. The services here, which are the Dyn Project, and also one other is mentioned—they discriminate against men. 

So, you're saying there's no hypothecation with regard to men. 

No, and I would really take issue with the very sexist remarks of the leader of the Chamber in acknowledging the disproportionate experience of women and girls with regard to gender-based violence. Violence isn't gender based. Men suffer violence, women suffer violence. There is a greater incidence of females suffering violence, but there's a huge number and an unreported amount of violence that men have to suffer. And if you live in south Wales—I'm saying this really for the benefit of people watching this broadcast—and you're a male, it's almost impossible sometimes to be classified as a victim of domestic abuse, and I know that through the referrals that I make myself. There was a man who was suffering all kinds of abuse recently, who wasn't classified as a victim until I wrote a letter asking for him to be considered as such. And I think this, really, in Wales today, is one of the scandals that will unfold as years go by. We all know about the stats about men killing themselves, very often as a result of the emotional abuse that men suffer, and very little is being done.

Okay. So, we're content to take this petition forward. The committee could await the views of the petitioner on the response from the leader of the house before considering further action on the petition. Are we agreed on that? Fine. Thank you. 

We move on to the next new petition, which is 'Change the National Curriculum and teach Welsh history, from a Welsh perspective, in our primary, secondary and sixth form schools.' I point out that this petition has actually reached the threshold of 5,000 signatures, having collected 5,794, and the petitioner, Elfed Wyn Jones, has collected that number. So, the initial response to the petition was received from the Cabinet Secretary for Education on 2 January. The petitioner also provided further comments, which are included in the papers for this meeting. Just to outline one or two of the details, the petitioner has outlined the aims of the petition in more detail. They are to create a united Welsh history curriculum, to provide space for the teaching of local history and to teach history in schools from a Welsh perspective. 

One of the comments from the Cabinet Secretary was that they will ensure that all aspects of learning have a Welsh dimension. Do you have any comments on that?

I think we ask to have a debate in the Chamber. The only point I take issue with is that there was a time before Wales existed and we seem to not talk about the ancient kingdoms of Wales. They've been written out of history, so I think an understanding of the whole history of what is now Wales would be very useful. 

Definitely. There's a whole history of all the kingdoms within these islands. But I'm just laughing really at the response from the Minister, which is so bad. We live in Wales. Welsh history, it says, will be a prominent part of the programme. There's nice; great. There are 'opportunities' for Welsh elements, and

'AS/A Level, learners should be given opportunities, where appropriate' 

to learn about Welsh history basically, and it's absolutely laughable. This wouldn't happen in any other country in the world—any other. There's a massive colonial mentality in Wales. I think it's a great petition. 

My daughter just finished her A-level history last year. She's got a very deep knowledge of America, a very deep knowledge of Germany up to and including the second world war, and a very deep knowledge of South Africa, but her knowledge of Wales, Britain and Europe is miniscule.

09:10

Okay. Well, obviously, having collected 5,000 signatures—. We're actually debating the petition about the Welsh language, Rhun. So, would you like to make a—.

Well, it's the teaching of Welsh history—sorry, Welsh history.

Obviously, I look forward to having a debate in committee. Personally, I would like us to put together a small paper of our own, I think, by having the petitioner come in. But also, I'd be really interested in having Elin Jones in front of the Petitions Committee, who was the chair of or led the taskforce on the teaching of history in Welsh schools, which published its report in 2015. She's an eminent historian, and she is on the record as saying that nothing has changed, really, since she made her recommendations back in 2015. And I think it would be very interesting, in the context of this petition, to hear the expert's view, as somebody who's looked in detail at how history is taught in Welsh schools, along with having put together proposals on what could change, and what she thinks has been the failure to respond to that agenda from Welsh Government. I think that would be good, before then moving on to a well-evidenced debate in Plenary, hopefully.

I think I'd like a bit more evidence before we take it to debate, to be quite honest with you. Janet, do you have any comment?

No problem with that. The only question there, as I always raise, is how are we going to fit all—. We keep on adding things to our programme. How are we going to fit it in? I think that we did say we were going to get a plan at some stage, didn't we?

During this meeting, we have a short session where the committee could look at the forward work programme in totality, and we can look at where the gaps might be.

I'm quite happy to do that, but I'm not happy to do it if, as we're putting things together, it's going to be November or December, at the end of the year.

I agree. I think, briefly, we looked at it, but it could be some time after the beginning of May. Is that right?

And I think this could be fairly brief in a way as well, because if we were able to ask Elin Jones—and the petitioner has put together his papers anyway—to put together a short paper to go alongside an oral evidence session, it could be very, very tight, I think.

Okay. So, are you happy with that? We'll seek some further information before we actually take it to Plenary.

The next new petition is P-05-800, 'Urgent Appeal for a Welsh Veterans Commissioner for the Health & Well-being of Wounded, Injured, Sick and Homeless Veterans'. Now, the petition was submitted by Nicola Hester, having collected 50 signatures. The Cabinet Secretary for Local Government and Public Services gave a response to the petition on 22 January. Obviously, the paper supporting this has been viewed by the committee. Do you have any comments that you'd like to make with regard to this petition?

Yes, fine. Okay, so the committee will wait for the petitioner's response to the Cabinet Secretary for local government.

3. Y wybodaeth ddiweddaraf am ddeisebau blaenorol
3. Updates to previous petitions

Right, we move on to updates to previous petitions. The first of these is 'Child and Adolescent Eating Disorder Service'. The petition was submitted by Helen Missen and was first considered in July 2012, having collected 246 signatures. The committee last considered this petition on 21 November and agreed to write back to the Cabinet Secretary for Health and Social Services to ask for details of the timescales in which he intends the review of the Welsh Government's eating disorder framework to be carried out. We had a response from the Cabinet Secretary on 17 January. The petitioner has welcomed the information that Dr Jacinta Tan will conduct the review and has welcomed the action that is being taken. So, do you have any comments?

09:15

Yes, just a couple of things really. I do sigh sometimes and go, 'Oh, another review', but I know she's quite eminent in this and I know that the petitioner is quite happy that it's going to this, but I do wish that, at some stage, there was provision for eating disorders and things. There was talk years ago, when I first became an AM—. Excuse me. This was very much on the agenda then and we're no further forward. So, I think we do need to see what the report comes out with and really press on those recommendations, so that they turn from words into action.

Yes. I'm wondering did the Cabinet Secretary indicate a timescale for these.

I believe the letter says that the autumn is the timescale for that being completed.

It's worth noting, not being party political in this committee, but I know that Plaid Cymru in recent budget negotiations with the Welsh Government has secured funding for eating disorder clinics in particular. So, there is movement, backed by a little bit of funding to make things happen. So I guess maybe that's why the petitioner's satisfied that things are moving in the right direction. So, keeping a watching brief is probably not a bad position to be in, considering that there is a direction of travel that we can follow.

Absolutely. We wait for the review to come out; we send them a copy of the review and if they're happy with the review, we end the petition. If they're not happy, then we decide what to do then.

Yes, fine. We're all agreed with that.

The next petition is linked to this, in that it's obviously on eating disorders, but this is actually pointing out that they want a unit, which is a specific request by this petitioner. I think we could go along with exactly the same action as with the last one. Are we agreed with that? Yes. Okay.

The next petition is the 'Lack of support for children with disabilities at crisis'. The petition was submitted by Rebecca Weale and was first considered in June 2017, having collected 200 signatures.

The committee last considered the petition on 19 September and agreed to seek the views of the petitioner on the response received from the Cabinet Secretary before deciding what further action to take on the petition. The petitioner has provided further comments, which are included in the papers for the meeting. Do any of the Members have any comments they'd like to make on this?

I have a huge amount of sympathy, obviously, with the family involved here. This is fairly symptomatic of crises in healthcare and mental health care for children under child and adolescent mental health services. There's a suggestion of a possible action of writing to the Cwm Taf Local Health Board. I'd be happy with that as a move.

It just exemplifies something that I believe, and I'm probably in a minority, very much a minority, but every time we centralise things, every time we create bigger units, the further we move things away from the people at the receiving end, the worse things seem to get. If I hear that big is beautiful—. I think that I'm more of a Schumacher friend myself.

I just wonder, when we do write, if we could ask what resources they have. I remember working in Merthyr, trying to get somebody referred, and there was just one professional for the whole of the local education authority. It was quite incredible, really. Obviously the boy wasn't seen.

I think that's a good point. We'll do that and include that in the letter.

Just to clarify, Neil: to ask for their resources around CAMHS in general or around crisis support specifically?

09:20

Both, really. I’d like to know how many professionals, how many people there are who are able to deal with referrals. Because, in terms of a crisis referral, it was non-existent. It was impossible, because the support was just not there. It would be nice to hear that from a letter, really.

Okay. Fine.

Okay. We move on to the next petition, which was 'Demand Funding from the Welsh Government to Support Autism Spectrum Connections Cymru'. This was submitted by Aled Thomas and was first considered in June 2017, having collected 148 signatures.

We wrote to the Cabinet Secretary with regard to this, and the Cabinet Secretary states that:

'The IAS is designed to enhance and not replace current provision and we expect regions to continue to work in partnership with existing services in their area including third sector providers.'

Do any of the committee have any comments with regard to this?

It is annoying, isn't it, when you see, you know, a decent sum of money, yet we don't see any performance outcomes or anything like that? And, certainly, the petitioner is very angry and makes reference to the Welsh Local Government Association and—. It must be hard. If we have problems sometimes navigating how funding is being spent, imagine somebody who has a particular issue that they want to—. It must be terrible, really. Whether we could break it down to find out exactly where the £13 million has gone and, you know, how it is actually—where they can prove to us that it's making a difference.

I think one of the other matters—and we're talking about possible actions—is that we'd like some more information with regard to why the procurement exercise was not conducted when the integrated autism service was established. We should ask that question, I think.

And we could also follow the—. I've ticked the third one, which is to look at the local provision as well. That's perhaps the information that's more useful to the petitioner in his local area.

Right, so, we're talking about, with the possible actions, there are two actions that I think we'd want to take forward, and they are: that the committee could write back to the Cabinet Secretary to ask for further information about why a procurement exercise was not conducted when the integrated autism service was established; and we would also write to Cardiff and Vale regional partnership board to ask for details of the process undertaken in rolling out the integrated autism service locally, and how the service is working with Autism Spectrum Connections Cymru. Are we agreed on that?

Right, thank you.

The next petition to consider is 'Reconsider the closure of the Welsh Independent Living Grant and support disabled people to live independently'. This was submitted by Nathan Lee Davies and was first considered in October 2017, having collected a total of 631 signatures. The committee first considered the petition on 3 October and agreed to write to the Minister for Social Services and Public Health.

The response was received on 14 November and the documents that we have to hand will outline his answer to the petition. So, do we have any comments with regard to that?

Again, this was a particular independent fund, wasn't it? An individual fund. And, of course, now, it's sort of been integrated into the bigger scene of the Act that's come forward, the Social Services and Well-being (Wales) Act 2014. And I think again, I would feel quite aggrieved if I was dependent on this funding to just see it swallowed up into something else. Sometimes, these little pots make a huge difference to somebody's life. And, you know, the response—well, I don't know, really.

Again, we have the problem that this has not been hypothecated when it has been devolved to local government—isn't that right?

And, of course, with hypothecation comes a layer of administration, which means that you lose money that way. So, I'm quite glad to see some funding pots, but when it's like this, this particular one does concern me, because we're talking about a very vulnerable group of our society, and if Government is failing them then we should all go home, really. It doesn't bode well, does it? So, I'm not really sure whether—. I mean, we could write again to the Cabinet Secretary, or we could write to the Cabinet Secretary, I should say, and see if they're monitoring it, in a way, to see whether it's having a negative impact. Because just stopping funding is not the way forward, is it?

09:25

Okay. Does anybody else want to comment on that before we go on to the possible actions?

I'd tend to agree with that. We're talking about hypothecation. Leaving aside the cost of it, if all the revenue support grant was hypothecated, it would be greater than the revenue support grant.

Yes. Okay. So, possible actions: the committee could pass the petitioner's comments to the Minister for Children and Social Care and ask for his response to the concerns raised, and the committee could also ask the Minister what monitoring is being undertaken in relation to the implementation of the Social Services and Well-being (Wales) Act. It seems to be quite a large question. We could have quite a response to that. Are we agreed on that? Okay, fine. 

We move on to the next petition, which is 'Strengthening the Legislative and Regulatory Framework Surrounding Waste Wood Processing Facilities', submitted by Alexander Williams and was first considered in May 2017, having collected 232 signatures. The committee last considered the petition on 9 January and agreed to await the views of the petitioner before considering further action. The petitioner has raised further questions in relation to the processes followed by Natural Resources Wales. Does anybody have any particular comments they'd like to make with regard to this?

I think there is more information that we could be getting from NRW. I think we could seek that information now if the petitioner is asking for it.

I think the petitioner pointed out that, when there was an inspection made of this particular facility, what happened with regard to the fact that they were storing a greater quantity than their licence permitted was that NRW simply raised the volume of the amount that they could keep at the site. So, I don't think that was a particularly sensible way to go about things.

So, possible actions are: the committee could ask Natural Resources Wales for further details on the processes they undertake when operators breach their licence conditions, which is what was requested by the petitioner; or, the committee could write to the Cabinet Secretary for Energy, Planning and Rural Affairs to ask for information about plans for future public consultation on environmental permitting regulations, as referred to by NRW.

Why don't we do both? They're not mutually exclusive.

I think that crossed my mind, actually, that we could ask both those questions. Are we content with that? Yes, fine.

The next petition is 'Suspend Marine Licence 12/45/ML to dump radioactive marine sediments from the Hinkley Point nuclear site into Wales coastal waters off Cardiff'. The petition was submitted by Tim Deere-Jones and was first considered in November 2017, having collected 7,171 signatures. The committee last considered the petition on 9 January and agreed to write to Natural Resources Wales. The petitioner submitted further comments on 29 January, and a further response from Natural Resources Wales was received on 30 January.

Technically speaking, we've heard that the Centre for Environment, Fisheries and Aquaculture Science conforms to the highest international standards with regard to this, but I don't think the committee was particularly—. Obviously, we've had information from those and we've actually held talks with those involved. So, possible actions, unless you have a particular point you want to raise at this moment.

I think we need to debate this as soon as possible, because—. I'm declaring an interest of having discussed this on Cardiff council recently. I was really staggered by the ignorance of decision makers in rejecting any further testing. If the material is so safe, why the issue with testing? It's very cheap and I think it would give us all a lot of confidence if it was done independently.

09:30

I think they've agreed to what we've asked for previously, so all we can do is wait for the response.

Yes, I agree. Well, the thing is, we specifically asked for further sampling to take place, and until we've got that information—

They're not going to do it, Chair—that's the problem.

Can we be clear on that? Because, as we heard, there are just five samples from 2009 below 5 cm—in one location, I'm told—and I think it's incredible that all this material can be dumped without testing, further testing. So, I'd like to clarify with them if they intend to pursue further testing, and also where, and how much, and with what methodology. I think it's really important.

Well, I can't see that we can move forward until we have a response to those actions we've actually requested with regard to NRW.

Yes. I think NRW agreed with us there should be a request, but we don't know whether it's actually happening. What happened on Cardiff Council is that they decided not to ask for it. They don't need to wait for Cardiff Council to ask for it, though it clearly would have been useful if Cardiff Council would have come on board. But, still, NRW have accepted our proposal as a committee to ask the licence holder to consider further sampling. But whether that is turning into an actual testing process, we need to know. So, we just need to check that with NRW.

And, also, the petitioner wants more time to review data, so I think we have to allow that time. It would be strange if we didn't.

I'm mindful of the fact that the dredging is due to start sometime in July.

Yes, fine. Okay, so, are we suggesting that we write again to the NRW to find out exactly where they are with regard to our request? Is that right?

Can you circulate the letter before it goes? Just so we can maybe agree it as a committee, with the wording.

Sure, yes. I think, in terms of writing, NRW's latest letter, they've told us they will give us the answers to these questions that are outstanding. So, they've said once they know from the licence holder whether they intend to carry out further testing, they'll tell us, and also the committee heard from Cefas, when we had the evidence session, that it's the radiation dose analysis that they consider critical. That wasn't done on the 2009 samples at the time, but NRW have requested that Cefas now undertake that analysis. NRW have said that they will write to us once they have those results. So, obviously, we can write to them and ask them to write to us at the earliest opportunity, but I think they've undertaken to come back to us anyway.

Fine. Okay. We move on to the next petition, which is 'Save our Countryside—Revise TAN 1'. It was submitted by Councillor Mike Priestley, having collected 706 signatures. I think the text of this is that local authorities are impacted by the TAN 1 in that they can't undertake intelligent, credible housing land supply assessments whilst speculative land is being developed. So—

—and, whilst it affects Conwy county borough, it affects a lot of others. Planning officers themselves, I've seen it where they are interpreting TAN 1 as being the major force for approving planning applications. Now, a current one that's going to inspector level, an inquiry coming up, councillors wanted to vote, and they did vote, against it—planning authority, I should say. But the planning officers were—. It kept coming back and coming back to committee, and the councillors were resolute because this wasn't even in the local development plan, but this land supply—. Currently, we'd have about eight years, I believe, but, because they've changed the methodology, they're starting to mention figures like three and a half years—and this affects all local authorities—and there were other TANs applicable to the particular site that caused the receipt of this petition because, frankly, it's a big issue when planning officers are interpreting TAN 1 as being the be-all and end-all. I've raised it in Plenary, in the Senedd, and the First Minister said he will have a look, he's looking to review it, but that—you know, when, how? So, I think, really, we do need to hold the feet of this Welsh Government to the fire on this one and actually see a journey through to see where it is actually reviewed, the methodology used to review it, who's reviewing it and how we can actually save our countryside, because our green fields—. Our communities, at some stage, will be joined up by the way that they're now looking at sites not already allocated in the LDP, but any prime sites of green land—you know, this is agricultural land, and I think we all need to stand up for our communities and say 'no'.

09:35

Okay. Just to put a background to this, we considered this petition on 23 November and agreed to await the views of the petitioner on the response provided by the Cabinet Secretary. The petitioner has since responded to that response from the Cabinet Secretary, and we received that on 16 January. Would anybody else like to make any comments with regard to that?

Just two quick comments: I think one is, yes, we ought to send the petitioner's comments on for the Cabinet Secretary's response, but let's just remember that less than 3 per cent of Wales is actually covered in buildings or roads.

Yes. Well, the committee—. The possible action then is the committee could provide the detailed comments from the petitioner to the Cabinet Secretary for the Environment, Planning and Rural Affairs for her consideration and ask for a response in particular to the suggestions made by the petitioner about possible alternative approaches to calculating land supply. Are we all agreed with that?

Yes, definitely. I think it's an absolute scandal the way these things go ahead.

Right. We'll move on to the next petition, which is 'Petition to Protect our High Street'. The petition was submitted by Sally Stephenson and was first considered in February 2017, having collected a total of 1,668 signatures. The committee last considered the petition on 9 September and agreed to seek the petitioner's views on the proposals contained in the current consultation published by the Welsh Government on the proposal for a new permanent small business rate relief scheme, and it was, in fact, I believe—. The petition was with regard to small business rates; I think that was at the back of the petition. So, the clerking team wrote to the petitioner on 9 January, providing a link to this, to 'Delivering a tax cut for small businesses: a permanent small business rates relief scheme for Wales', and we provided a link to the petitioner to that scheme. So, did we have a further response from the petitioner with regard to that?

No. We haven't had a response from that to date—well, actually, to the letter we wrote about the consultation back after the meeting in September, or to the link to the statement that we provided in January. But I think, on the latter point, there are obviously some detailed proposals behind the statement made by the Cabinet Secretary. So, the committee might consider that 9 January—we could give a further period of time to allow the petitioner to respond. 

I assume the petitioner will be happy with what's happened, because what's happened is what they asked for, but we need to give them time to respond to tell us that. Next meeting, we'll see what they say.

Yes, I think so. Because I think that although there is this idea from the Welsh Government that they're going to keep the small grant scheme in place, there is disparity between how that grant will work between certain communities, so you have Monmouth and Vale of Glamorgan compared to the Valleys constituencies—how that grant is actually distributed. So, I think that in light of that we ought to await further comments from the petitioner. So, in light of the Welsh Government's pronouncements on a permanent small business rates relief scheme from 1 April 2018, the committee could consider giving the petitioner further opportunity to comment before the next meeting on 27 February and to close the petition if no response is received. Are we agreed with that?

09:40
4. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o'r cyfarfod ar gyfer eitemau 5 a 7 ar yr agenda heddiw
4. Motion under Standing Order 17.42 to resolve to exclude the public from the meeting for items 5 and 7 of today's agenda

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o eitemau 5 a 7 y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from items 5 and 7 of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

The next item on the agenda is a motion under Standing Order 17.42 to resolve to exclude the public from items 5 and 7 of today's agenda.

I propose, in accordance with Standing Order 17.42, that the committee resolves to meet in private for items 5 and 7 of today's meeting. Are we agreed on that? Then the committee will resume in public for the session with the Cabinet Secretary for Health and Social Services at 10 a.m.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 09:41.

Motion agreed.

The public part of the meeting ended at 09:41.

10:00

Ailymgynullodd y pwyllgor yn gyhoeddus am 10:01.

The committee reconvened in public at 10:01.

6. Sesiwn Dystiolaeth - P-04-682 Sgrinio Rheolaidd ar gyfer Diabetes Math 1 mewn Plant a Phobl Ifanc.
6. Evidence session - P-04-682 Routine Screening for Type 1 Diabetes in Children and Young People

Bore da. Good morning, Cabinet Secretary. Can I invite you to introduce your colleague?

This is Professor Chris Jones, the Deputy Chief Medical Officer for Wales.

Good morning.

Obviously, we thank you for your attendance today and explain that there are translation facilities available. I'm sure you're quite au fait with the equipment that's needed for that. So, obviously, the idea of inviting you here, Vaughan, is that the Cabinet can get some information with regard to a petition that we are looking at at the moment with regard to type 1 diabetes. So, can I open the question session by asking, whilst it’s acknowledged that type 1 diabetes is a rare condition, the impacts of late diagnosis on patients and families and carers can be devastating, and the costs to the NHS significant, is enough focus given to type 1 diabetes in Welsh Government policy?

I think we're probably in the right place on policy and our focus. The challenge always is about implementation. If you think about the life of this petition, following on from the tragic death of Peter Baldwin and the way that the family have wanted to do the right thing and to help other people, we've gone through a process of looking at what we're doing and the diabetes implementation group that we've set up. So, the Government, the national health service and the third sector—and Diabetes UK have been a really important partner in this—have all been looking at what we're doing and looking at how and where to improve. So, I think there is real improvement in training, including the points about symptom awareness raising. I think that's interesting too, about starting from a general 'Let's make the whole public know' to taking the view that, actually, that probably isn't going to be the most effective—actually, healthcare professionals should know. That's part of where we are about that improvement, and I'm really pleased that Diabetes UK are leading on that with the implementation group. It's their campaign that's being run and promoted. So, I would want to see a continuing improvement.

We were just talking, on the way down, about the rates of DKA, diabetic ketoacidosis, which have actually reduced slightly over the last few years, whilst at the same time we are diagnosing more people with type 1 diabetes. That suggests that we're getting better at it, but I'm always interested in what we could do to further improve. In a human service it will never be perfect, but what we have to do is to look for opportunities to improve, and that means that people will get better care and better outcomes.

I think it came back to us on our enquiries, on writing out to the other institutions involved, that it was raising awareness of type 1 that was a huge priority with regard to this, from primary care right up through the whole system, I think, particularly with the primary care sector as such.

Yes, and it's the challenge about where it's undiagnosed. If it's undiagnosed and not realised—and that's where you potentially get the greatest risk—and then, of course, when we think about the whole issue about wanting to support someone, they're saying about the education to make sure they can manage their—. This really starts off with undiagnosed diabetes and where it was missed, and the outcome that produced. So, this is about making sure we want to try and avoid that risk in the future to do all that we can, and that is why I think the awareness raising in primary care is really important. But it goes alongside the effective management and treatment at that point of understanding, or that point of suspicion in the first place, and then at the point of diagnosis as well, because there isn't lots of stability at that point, and that's part of the reason why it can be so difficult.

10:05

Thank you. I'm going to invite the other committee Members to ask you some further questions, Cabinet Minister. Rhun.

Diolch yn fawr iawn. Driven, of course, by their deep loss as a family, the petitioners have been able to be very, very focused on what their asks are. The first ask is that we have systems and processes in place that prompt those key players in primary care to ask the key questions, the four Ts that we know of: toilet, thirsty, tired, thinner. And these, of course, are the National Institute for Health and Care Excellence guidelines. This is one of the key cornerstones of the NICE guidelines. What processes do you think are in place to make sure that those NICE guidelines are adhered to and that those basic questions are asked?

Do you want to deal with this about the process point, Chris?

Yes, and I think we know, because we've had a NICE liaison group in place for some years now, that all organisations have quite robust mechanisms to share NICE guidance and raise awareness within their clinical communities. Clearly, we can't monitor every single piece of NICE guidance because there's such a lot of it, but, actually, in the area of diabetes care, there is actually quite considerable quality assurance against standards through the national clinical audits.

We're very fortunate in Wales, actually, that 100 per cent of general practitioner practices participate in the national diabetes audit, which is a higher rate of participation than, for instance, in England, and all of our paediatric units participate in the national paediatrics diabetes unit too. So, it is one area where we do know more than in many other areas, in truth, about adherence to quality standards.

Does that monitoring that does go on through those auditing processes highlight where there's good practice and where there is poor practice? And is that monitoring able, then, to drive change in those areas where there perhaps does need to be a little bit of improvement, or a lot of improvement?

I think a national clinical audit is a very powerful mechanism for that type of benchmarking. The measurements are generally robust, they're consistently acquired, they're compared within Wales across organisations and GP practices, and they can also be compared across country borders as well. So, actually, it's a very powerful mechanism for just that comparison of quality of practice.

And do you have examples where you have been able to highlight, through the audit, NICE guidelines on asking the right questions that aren't being adhered to and aren't being implemented quite as well as they should here, and as a result of intervention, then, there has been improvement? Are you able to point us to where we had better outcomes as a result of the monitoring and auditing?

I don't think I can point out to specific GP practices in this case; that would be a matter more for health boards and probably for central Government. Our purpose is to assure that we participate fully—the Minister is fully aware of how we are doing as a country—and that local health boards are taking these results themselves very seriously and that their boards are aware of the results, and their quality and safety committees see this and have oversight of the improvement processes.

And this is statistically monitorable and measurable, is it? Or is it more a gathering of anecdotal evidence through auditing?

These are highly quantitative.

And where are they published? Are they published as part of general audits or diabetes audits?

The process around national clinical audits—and there are about 40 in total—is that Welsh Government funds the Healthcare Quality Improvement Partnership, HQIP, and HQIP then commissions individual audits off different providers. So, generally speaking, it would be royal colleges who tender to provide audits and they then publish these. So, the publication style may vary considerably from audit to audit, but they're still powerful tools for comparison across organisational and country borders.

And anybody could have a look at, again, how the NICE guidelines are being adhered to in relation to what we're talking about here today—asking the right questions. 

Yes. If I may just say, I think it's probably fair to say that the audits cover probably more processes of care once the diagnosis is established because, obviously, the diagnosis of type 1 diabetes is a relatively unusual event in each GP's life because it's a relatively unusual condition. So, it would be very hard to have comparative information about those very tiny numbers. But certainly, the broader picture, the processes of care and the approach to diabetes care, is described.

It might be useful if we could have a quick look at where we're at, in addition to what's in the briefing paper.

10:10

That's all available.

Yes, thanks. I just wondered what percentage of GP surgeries have appropriate blood glucose testing equipment.

Again, I don't think that's a level of detail that we necessarily would have, but we do understand, from all the enquiries we've made, that there is no reason why having even urine dipsticks, or glucometers for blood capillary glucose testing should be a barrier. There's no reason why that should be a barrier. We would anticipate that every GP practice would have one. I would hope that GPs would have that in their room.

No, I wouldn't have that detail about individual general practices. We'd have to survey them and ask them. But this is pretty standard now, the point-of-care testing. If you think about where we are now compared to where we were even five years ago, actually, the availability of equipment and the ease with which you can actually have blood glucose testing has significantly improved.

Okay, thanks. Given the seriousness of this issue, do you think that that level of detail is something that you should have?

No, because I think you have to think about, 'What information do I require, as the Minister, and what level of detail should I know about?' Should I know what is in every single GP's room? Should I survey that? You've got to ask, then, people to respond. What we have to be clear about is our expectation about the quality of care that we want, and those points about national standards. The national audit is a powerful tool, because it looks, countrywide, at what we're doing, and the awareness-raising campaign. But, actually, lots of this point-of-care testing equipment is relatively easily available and you'd expect people to have it, otherwise I am on the shoulder of every GP, and that's not the way in which I need to undertake my job.

I think maybe a good phrase to use is 'never assume', because this is a serious issue and I think a great level of detail is needed. But we'll move on to the next question—

But that's the point about improvement. It is the point about improvement and about understanding, from the audit, where we are countrywide. It's why we've actually got an awareness-raising campaign, it's why we've got an improvement programme—

Okay, I think I've made the point that you've not got the grasp of detail that some of us would like—

With respect, Neil, that's a recalibration of what you'd like to say—

No, it isn't. I'm stating my position that I'm unhappy with your answer that you haven't got that level of detail and I believe you should have, and I believe that the health board should have that level of detail also. 

If I can move on to question 4, which is the one I also want to put. I'd like an update for the new referral pathway for children with suspected diabetes. I wonder where we are with that.

In fact, I should add that that's what I was going to draw your attention to, because recognising that this is a very important matter, one aspect in which we are pleased that we have some strength is that the Children and Young People’s Wales Diabetes Network has produced a care pathway for the diagnosis of type 1 diabetes. An integral part of that pathway is whenever you suspect the diagnosis, you do undertake capillary blood glucose testing, which would require GPs to be able to do that using the equipment you describe. So, this care pathway, which is now being piloted, scrutinised and assessed in Cardiff and Vale—and this requires quite extensive training of general practitioners as well—would require GPs to have the equipment in place that you were discussing.

Okay, good. So, do you think that will be rolled out across the country?

Yes, that's the plan. It's a pilot for national roll-out.

A pilot—is there a timescale for a national roll-out if the pilot is seen as being successful?

We're expecting an evaluation at the end of this year that will then tell us about what's happened, where we are, and lessons for us to learn ahead of a national roll-out.

I understand 170 GPs have been trained in relation to the pilot already in Cardiff and Vale.

Thank you, Chairman. Good morning. The whole thrust, as I understand it, of this petition, is to build awareness so that no other family has to suffer. We know that there are 1,400 cases of type 1 diabetes, but the evidence suggests that a quarter of these are not picked up in time, and sadly, again, we have a situation where that can be very, very serious. 

Now, for me, this petition raises questions about building up the awareness. I know, in evidence that we've taken previously in this committee, there was evidence received that stated that you were prepared to roll out an e-learning module on diabetes diagnosis, and the potential for training for GP receptionists on type 1 diabetes, because I think that's interesting in itself—sometimes, when you present with a child or you're sat on the phone, it would, for me, be really quite reassuring if receptionists were aware of what to look out for. How is that moving forward?

10:15

This is work that the paediatric diabetes network is doing and it's working with the Primary Care Diabetes Society on the e-learning module that we referred to. They're still establishing that and we'll happily confirm to the committee when that's available and when we expect that to be made available.

In terms of training, I know from the Royal College of General Practitioners response to the committee that paediatric emergencies such as diabetic ketoacidosis are covered in GP training. There's a challenge always about what we expect all the staff in a local practice to know. And that's part of the point about awareness raising. There is something about wanting the healthcare professionals to know and understand, and what we can legitimately expect the receptionist staff to know as well, and how much, effectively, clinical knowledge and understanding we expect them to have. Because, actually, from the public's point of view, there are a lot of people who don't want to even go through basic triage information with the receptionist. That will require a level of training for those practice staff, if they're either on the front desk talking to a person in front of them or on the telephone.

Actually, I'm interested in how we have a more consistent, clinical triage across local healthcare and that requires some investment in either nurse-led triage or doctor-led triage. That's something on which parts of general practice are enthusiastic and others are still to be persuaded, but that's an ongoing conversation because, actually there are real gains to be made, not just in this area, but across a wide range of others that should improve access and should make it easier then to actually have the sort of awareness raising that we'd want with the right healthcare professional.

Okay, but going back to your own written evidence on 6 October, you stated that

'consideration is being given to rolling out an e-learning module...and to the potential for training for GP receptionists'.

So, I suppose I'm asking: are you progressing that or not?

Yes, but the thing is that that isn't yet complete, and so when that is complete in terms of the module and what's been done, we'll then know about the consideration that's being given. So, is that something that is just appropriate for the healthcare professionals, or is there a part of that that is appropriate for the receptionist staff? So, I don't want to try and tell you that that work is completed when it isn't and when that consideration—

Yes, the work's definitely started. That's what I said: the paediatric diabetes network and the Primary Care Diabetes Society are working together on the e-learning module.

And what will it look like? How will we know that what you said last year is what you're going to roll forward? How will we feel assured and how will the family feel assured? How will parents generally feel assured that what you've said you'll undertake—that it's actually moving forward and that receptionists will be more aware and that all medical staff will be aware?

There are two different things. There's the e-learning module as a specific part of awareness raising, and when that is completed and ready, we'll make an announcement and we can confirm when that's ready and available and how that's going to be rolled out and who to. On the broader part of awareness raising, there is already work that is ongoing. As I said earlier, in response to the Chair at the opening, Diabetes UK are leading on that with the diabetes implementation. It's part of the work that they've agreed on priorities for diabetes management across the UK. So, that awareness-raising work is already starting. The campaigns we're running—it is about raising awareness and things like the four Ts. So, that work is already starting. The importance of going back to that is that we'll then have an awareness of, from the national picture, whether we're seeing improvements in identification and the management of people with diabetes. So, these things are linked together. So, I couldn't tell you absolutely now that this is the point at which I will know definitively where we are, because it's an ongoing process of improvement—it's not one that has a neat start and end point.

So, what will be the relative timescales to where we would feel assured as a committee—and how parents would feel assured? Too often, we hear, don't we, that things are happening behind the scenes, but really until we see some tangible signs, there's a tendency to think—. Then my other question on that was: since we received this petition, and since we raised questions in Plenary on this issue, what have you done as the Cabinet Secretary to make GP surgeries aware of the four Ts and just to be extra vigilant?

That comes back, again, to the campaign that Diabetes UK are leading on awareness raising in local healthcare—

10:20

But I'm asking you. We've got you here now, so it's you I'm trying to scrutinise to see how you are committed to this campaign.

But that's the point about the whole system—my responsibility for the whole system. The campaign that Diabetes UK are running comes from agreement within the diabetes implementation group. So, there's a national perspective and architecture that we've set up to have the Government, the NHS and the third sector working together, and that comes from that structure that we've set up, and that agreement. So, it's actually about making best use of where the materials are available and the willingness to do it, and I think there's very clear leadership—that we want to see greater awareness of those symptoms within local healthcare. So that's part of what we're doing, and the public statements I've made, I think, are very clear as well about the direction that we're taking.

Okay. And then I'll finish on this point: if I was a cabinet secretary in a government, with digital technology as it is, I wouldn't hesitate if I was presented with something like that where a simple e-mail going through to a GP or to their surgery saying about the four Ts, saying that we need to build the awareness of this—I would do it.

I don't think it's as simple as sending an e-mail and then the awareness-raising job is done. 

You are a Cabinet Secretary of the Government, and I know from when I send letters out as an AM—it might be just praising somebody for something they've done in the community—that people like to receive something. And I think that if I was a GP or a receptionist or a nurse, and I received a letter to my practice from a Cabinet Secretary just reminding me to look for the four Ts, just reminding me that if there's any doubt—. I would actually adhere to that and would probably send an e-mail back and say, 'Rest assured, this practice will be extra vigilant so that we can catch that—.' As in the evidence, someone might never present to a GP, but if we can save one life, then, to me—. I can't see what the difficulty is in you as Cabinet Secretary taking some leadership on this.

Well, with respect, I think we need to look at what we're trying to achieve and how and why. I understand that the demand is well meaning because we all want to see improvement, but the way in which we're looking to deliver that improvement is working with delivery partners like Diabetes UK who are standing, and are going to get noticed. If I write a letter on a condition where there's a potentially serious impact each week, I could be writing pretty much every day to local—

I'm talking about this particular issue: the petition we've got here. I'm not talking about any other things today. 

But I've got responsibility for the whole system, and that's my job. And if I write on this issue, then there's no reason why I wouldn't write on lots of others, and, actually, I think there's something about: how many directives do you send out centrally? And if you were to have the BMA's general practice committee or the Royal College of GPs, I think they would politely, but robustly, tell you that they don't think that it's the right way to raise awareness for me to write directly to those practices.

So, for example, you talk about sending an e-mail or a letter: actually, some of what the awareness-raising campaign is doing is about the information material that goes into practices and messages that come up on screens as prompts and reminders. So, actually, as people are doing their job, those prompts and reminders are there. And it's about what's most effective. It isn't about saying, 'Unless the Cabinet Secretary's written a letter, attention isn't being paid to it.' It's about how we are going to be effective in making a difference, and that has to be the test. 

May I comment? I think it is slightly more complex. I don't know that a letter from—

Well, I have some personal experience in this in the sense that a 17-year-old boy in my household became diabetic within the last month, and although I'm very aware of diabetes, and my partner is very aware as well, it didn't stop him developing diabetic ketoacidosis. So, it is quite a difficult issue, and part of the complexity is the way people present and also understanding the urgency of the presentation, because I know in children, very often, when they do present, although the four Ts are present, often there's an infection or some other condition that dominates the clinical picture and can distract. And I know in our 17-year-old, he is fit, so he adapted and compensated and said he was fine and getting better, and we didn't really realise quite how unwell he was and how quickly we had to act. So, I don't think it's quite so simple as sending a letter out. I think there are complexities in the diagnostic process. The issue of GPs learning is really important, but, actually, there's quite a bit to learn and quite a bit of understanding there. I just don't think a letter from the Cab Sec would do it, to be frank. 

10:25

Okay. So, my final point: are you assured then, and how can you provide that reassurance, since the delivery of this petition, that things have improved in all of our GP practices, not just here and there?

That's the point about having an audit process that every general practice in the country takes part in—

Is this where they self-mark, they give the evidence themselves, or, this audit process, does it go in and examine their processes? Is it a tick-box exercise by the GP surgery?

I don't think you can dismiss clinical audit as a tick-box exercise. 

No. It's either they're doing—. Are they marking their own homework, or is somebody going in and actually assessing—

Do you want to explain how the clinical audit process works?

Yes. There's a number of SMART measures. So, these are specific, measurable, quantitative measures that they have to report on. It's not just 'Have you done this?' or 'Do you think that?' It's actually 'Is this in place?' and 'In what percentage of people is that in place?' It is quite a robust quantitative process. It is the most powerful process. When Professor Stephen Palmer reviewed mortality indices in 2014 for Welsh Government, for the previous Minister, one of his conclusions was that the national clinical audit was one of the most powerful processes for quality assurance and comparison across organisational and country boundaries and that we should we invest more. And, in fact, we have invested considerable effort in actually making national clinical audit across a wide range of different clinical areas centre stage. So, it is a powerful process, as powerful as exists. 

So, then, it would help us as a committee if we could see that evidence, really, in the audits. 

Well, the evidence from the audit is available. There's no secret to it. And on assurance and improvement, it isn't a one-off issue, because that's why you have an audit that comes back again. So, you look again at whether you've made improvement or not, and that helps provide assurance. It also helps to highlight areas for improvement. And it always depends on the language used. It can either say that there are opportunities for improvement or a need for improvement, or it can say 'This is an area where the service isn't good enough.' That depends on where you start from, but ultimately, there is still a need to look at what we're doing, what we're delivering in terms of the quality of care, outcomes of treatment and how and when we'll need to improve.

That's the point about this: this is about improving to minimise, as much as possible, avoidable ill-health, and in this area, we know there are really significant consequences potentially to undiagnosed type 1 diabetes, and the point at which it's symptomatic is often a difficult time. So, there's no disagreement with anyone in this room about the need for further improvement, or indeed, that we've made progress, and during the life of this petition, I think there's been greater engagement and awareness of what we're doing to improve, and actually this petition has helped to actually highlight what we're doing and the need to continue to do more.

So, I don't think it's an unhelpful process, and I fully expect that we'll have more to say in the rest of this term about what we're doing. For example, when we have the completed e-learning module, and we can confirm that that's available, I'm sure that people will then ask about what impact that has had and how many people have gone through that. When we've completed in Cardiff and the Vale, there'll be confirmation about where we are on the evaluation, and whether it's this committee or the health committee, people will be interested. So, there won't be a lack of awareness or scrutiny, and we'll be able to transparently see what progress we are making. 

Yes, just to follow up on what my colleague Janet Finch-Saunders said about your personal involvement. I didn't really pick up much of a response there. I just wondered what harm it would do for you to lead an awareness-raising campaign and contribute in that way. 

It's not about the harm that it will do, it's about how is, and what is, the most effective way to raise awareness and how we do that. And, actually, in the conversations that I have, whether it's with the cross-party group, whether it's meeting the petitioners, whether it's meeting individual Assembly Members, whether it's meeting with Diabetes UK, I don't think there's any lack of personal engagement from me in improvement in this area. 

Okay. You weren't available to meet the family, the committee were told before, and you had to be asked to meet the family. I would hope you did apologise to them. I just wonder whether you'd undertake to make yourself more available in future, really.

I understand the willingness and desire to make personalised comments, Neil, but the reality is that I was asked to meet at a certain point in time when I genuinely wasn't available. I then met the petitioners in this room, actually, with a group of people. I'd actually met Beth Baldwin, incidentally, with her Assembly Member at a different event as well. And, as I say, there's no lack of willingness to see improvement made. And the reality of the role that I have is that you can't always meet all of the people that you'd like to, because there isn't enough time in the day to do that. For all the causes that are important, where you recognise you can improve, the fact that I'm here today, the fact that this committee is undertaking this inquiry, shows that there is a recognition of the importance of the issue. I've met the petitioner, and I know she's in the gallery, and I'm sure I'll meet her again at some point in the future as well. And I hope that we can come back and look again at what we have done to make further improvements. And, again, I'm sure we'll then be able to regather and say what further improvements we wish to make.

10:30

I want to go back a stage. We've talked about what happens when people get to the doctors, a general practitioner. One of the problems is the people who don't get to their general practitioner. And personal experience of two occasions: one which, fortunately, was resolved eventually, and one which, unfortunately, wasn't.

But the point is: should there be greater public awareness? You talk about prudent healthcare; I talk about personal responsibility for people's healthcare. But for people to be able to do that, they need information. The British Medical Association suggested investment should be prioritised towards raising awareness of signs/symptoms, as this is

'by far the most vital element of early diagnosis'.

General practitioners will say that they're not short of patients coming in, but it is important that people know enough about their own health to realise when they need to go. What is being done to try and pass that information on, not just to healthcare professionals, but people in schools, parents and carers, and just other healthcare professionals, so that people will recognise when it happens?

On the one occasion where the person was fortunately diagnosed, albeit exceptionally late, and ended up in hospital 24 hours after they went down to be seen, it was because their friends and colleagues were saying, 'Are you sure the amount you're drinking doesn't mean you've got diabetes?' That sort of information. I visited a GP surgery a couple of weeks ago, as an Assembly Member, and they had lots of things on the boards in there, but there wasn't one saying, 'These are the symptoms of type 1 diabetes.'

When I go to my own GP surgery, as I have to from time to time—either as a dad, or just to have my own medication reviews—there's lots and lots of information on the boards. And, actually, if we run a public awareness-raising campaign on this issue, we'll very quickly be running awareness campaigns on a range of others. I have recently, in a different committee, said that I wouldn't commit to running a public awareness-raising campaign, because there's limited space to do that. And it's about what is the most effective way to do that. Through the life of this petition, I think there's been a change from running a public awareness-raising campaign, which was one of the asks through the petition, to now recognising that it's more effective to run that awareness-raising campaign with healthcare professionals. We're talking about schools, of course, in the school nursing framework; we've got a range of things that people want to do. So, there are healthcare professionals in different settings.

I think it's about recognising when you're unwell, or people around you recognising that your behaviour is unusual, whether it's about drinking too much. And it's also what then happens. Because most people recognise, particularly if you're a parent—. The point of most of the diagnoses taking place is sort of end of primary school to sort of middle of high school, that's the rough sort of age—getting into the teenage years—when most type 1 diabetes becomes symptomatic. Actually, most parents will have an idea at that point if something isn't quite right, although, as you've heard, it can be covered and masked. So it's about, at that point, where you think there's something wrong, is there going to be a healthcare professional who understands, 'Well, actually, here are the things that we should be concerned about'? Because it is a relatively rare condition, and if you want to run awareness-raising campaigns of every rare condition, then, actually, you'll find the space crowded out.

So, it is about healthcare professionals being properly trained, understanding the different things they need to consider—and we ask a lot of our healthcare professionals—and then pointing people in the right direction. That's why you've got improvement work taking place; that's why we were talking earlier about the e-learning model; that's why we were talking earlier about the pilot taking place with 170 GPs in Cardiff and Vale; and it's why we're talking about the awareness-raising campaign that Diabetes UK are fronting. So, there's more than one thing. I would like everyone to be really aware of their own health and what they can do to improve it, but we have to start at the point that, actually, we still can't get health messages about smoking, alcohol, exercise and diet consistently understood and acted on. To then say, in addition to those that we're not doing as well on as we want to in persuading the public to make different choices, we'll run condition-specific campaigns, I don't think that actually is the best way to deploy our resources and I don't think we'll see the right improvement in health that we'd want to. That's why we've chosen to focus attention and awareness-raising with healthcare professionals.

10:35

The point I was making was about those who aren't appearing before healthcare professionals. The two cases I know: neither were particularly unwell; one was nagged into going by friends and colleagues and did so and was actually dealt with in a hospital setting to make them okay; the second one wasn't nagged by friends and colleagues and ended up unfortunately passing away. A basic knowledge of different things, such as: if people are doing these things, the four Ts, they probably need a GP. It's the sort of thing that you can get across to people. You're right that there is a difficulty getting information. People are taking a risk with alcohol, they're taking a risk with smoking, they're taking a risk with their diet and lack of exercise. People know they shouldn't do these things; they're just prepared to take that risk. I think that what we're saying with this is that there's no downside to this. You're not missing something you enjoy or having to do something you don't enjoy, you're just showing that you have the symptoms.

Well, look, I still think it's about—. Most people know if they're actually not feeling great. We also know that lots of people avoid contact with healthcare professionals because they're worried about being told they're unwell on a whole range of conditions, and so it's still about persuading the public to engage appropriately with the health service, both in terms of having advice about how to avoid ill health as well as, if people aren't feeling well, about going to the right healthcare professional or, frankly, any healthcare professional because if somebody wandered into a pharmacy and said, 'I feel really thirsty and I'm drinking lots and lots and lots, much more than usual, and I'm a bit worried about it but I don't want to go to the doctor', I'd expect that they'd get some appropriate advice about what to do. So, it's about all the different parts of our health and care system where that advice could and should be taken, as opposed to trying to get population awareness, because I think we'd have to spend an awful lot of money to do that, and I think we could make bigger and better improvements in the care and treatment of people with diabetes by deploying that money in another way. That's certainly not just my view; that's the diabetes implementation group's view as well, which, as I say, includes the Government, the NHS and the third sector, in particular Diabetes UK Cymru, who are involved and engaged in that. So, it isn't their view that this would be the best way to spend money on improvement in this area.

On the point you made about going to the pharmacist because you're drinking a lot, my experience of it—and I've only seen two cases and you probably know a lot more than me—is that the increase in the amount of liquid they're taking is not going from two glasses of water in a day to 20 glasses of water a day, it's going from two glasses of water to three, to four, ending up drinking two or three bottles, six litres. It's an incremental increase, so you don't see yourself drinking much more today than you did last week, and you don't really think back to what you were drinking two years ago or 12 months ago.

Just a general comment first, if I may, before perhaps speaking from personal experience recently as well. My understanding from the public health literature is that condition-specific public awareness-raising generally is not effective, partly because it's not effective in raising public awareness and because it's not sustained. Really that's probably not the way to go. It's often seen to be the solution.

I don't know how many people with newly diagnosed type 1 diabetes don't go and see a healthcare professional. I would imagine that nearly everybody does because I know from experience that, with Harry, even though we didn't realise quite how quickly he would become very ill, we knew there was something wrong. He'd lost a stone in about two weeks. So, we were aware, but that didn't stop the process following through. The issue, in a way, is how healthcare professionals respond. I would doubt that people don't consult health services when type 1 diabetes comes on because it is very florid; it's obvious there is something seriously wrong. That's my experience of it recently.

To me, the request and the thing this is about is a simple blood test. A simple finger-prick would and could. Do you envisage, Cabinet Secretary, more finger-prick testing to be carried out as a result of this petition, as a result of what we're asking, as the Petitions Committee? Because, at the end of the day, it's better that those tests—the prick—are taken, even if it's not diabetes. There's hardly any cost to it. It's quickly done. I'd like to see—I'd like to know, at some stage, that people are so aware of this now that they will routinely just do that finger-prick test.

10:40

Well, the finger-prick test is part of it, not the only part of it, but—

—but we do expect that to be widely available in any event. We think the learning from the pilot pathway will reinforce that. And, on a more general point, there'll be more point-of-care testing in the future—lots more. So, this is part of this, and important in this area, but important in lots of others too, as well. High blood glucose can obviously be an indicator of diabetes, but a range of other potential issues as well.

It certainly shows someone is unwell, and it's about what you then need to consider. And that's the point about the awareness—not saying, 'Think only about diabetes', but to have that in the healthcare professional's mind when they're considering what could be wrong as well, and how to go about understanding that. It goes back to where you started about, 'Do you have screening or appropriate testing?' This, really, is about appropriate testing and making sure that the information is available and the healthcare professionals understand what they should be doing, and the advice and support they'll give for people's care and treatment.

Okay. Thank you very much, Cabinet Secretary. I want to end this session by making more of a comment than a question to you, and it's with regard to the earlier question by my colleague Neil McEvoy with regard to equipment. I want to reassure people listening to this evidence session now that our inquiry showed that there was diagnostic equipment widely available in doctors' surgeries and, also, it was often carried by district nurses, et cetera. I don't want them to go away from this session believing that that equipment is not available generally.

It is very commonly available and used appropriately by healthcare professionals. The challenge always is: what more can we do to improve overall care and outcomes?

Fine. So, thank you very much, Cabinet Secretary, for attending and for your explicit answers to our questions. And I thank you for your time.

Thank you very much. Obviously, a transcript of this will be made available to you.

Thank you very much. I'd just like to note that we are now going back into a private meeting. Thank you.

Daeth rhan gyhoeddus y cyfarfod i ben am 10:43.

The public part of the meeting ended at 10:43.

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