Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd
Health, Social Care and Sport Committee - Fifth Senedd07/11/2018
Aelodau'r Pwyllgor a oedd yn bresennol
Committee Members in Attendance
|Angela Burns AM|
|Dai Lloyd AM||Cadeirydd y Pwyllgor|
|Dawn Bowden AM|
|Gareth Bennett AM||Yn dirprwo ar ran Neil Hamilton|
|Substitute for Neil Hamilton|
|Helen Mary Jones AM|
|Julie Morgan AM|
|Lynne Neagle AM|
Y rhai eraill a oedd yn bresennol
Others in Attendance
|Alan Brace||Cyfarwyddwr Cyllid, Llywodraeth Cymru|
|Director of Finance, Welsh Government|
|Albert Heaney||Cyfarwyddwr y Gwasanaethau Cymdeithasol ac Integreiddio, Llywodraeth Cymru|
|Director of Social Services and Integration, Welsh Government|
|Dr Andrew Goodall||Cyfarwyddwr Cyffredinol Iechyd a Gwasanaethau Cymdeithasol Llywodraeth Cymru a Phrif Weithredwr GIG Cymru|
|Director General for Health and Social Services, Welsh Government, and NHS Wales Chief Executive|
|Enrico Carpanini||Gwasanaethau Cyfreithiol|
|Huw Irranca-Davies AM||Y Gweinidog Plant, Pobl Hŷn a Gofal Cymdeithasol|
|Minister for Children, Older People and Social Care|
|Paul Davies AM||Yr Aelod sy’n gyfrifol am y Bil|
|Member in charge of the Bill|
|Stephen Boyce||Y Gwasanaeth Ymchwil|
|Vaughan Gething AM||Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol|
|Cabinet Secretary for Health and Social Services|
Swyddogion y Senedd a oedd yn bresennol
Senedd Officials in Attendance
|Katie Wyatt||Cynghorydd Cyfreithiol|
|Lowri Jones||Dirprwy Glerc|
|Tanwen Summers||Ail Glerc|
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 09:15.
The meeting began at 09:15.
Croeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. O dan eitem 1, a gaf i estyn croeso i'm cyd-Aelodau a datgan ein bod ni wedi derbyn ymddiheuriadau oddi wrth Rhianon Passmore? Hefyd, rydym yn deall bod Gareth Bennett yma i ddirprwyo dros Neil Hamilton. Rydym yn aros yn eiddgar am ei bresenoldeb. Fe allaf i ymhellach egluro bod y cyfarfod yma'n ddwyieithog, a gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2? Ac os bydd y larwm tân yn canu, dylid dilyn cyfarwyddiadau'r tywyswyr.
Welcome, everyone, to the latest meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales. Under item 1, I'd like to welcome my fellow Members and say that we've had apologies from Rhianon Passmore. Also, we understand that Gareth Bennett will be substituting for Neil Hamilton, and we are waiting for his attendance. I'd like to explain that this is a bilingual meeting, and you can use headsets to hear interpretation from Welsh to English on channel 1, or amplification on channel 2. In the event of a fire alarm, you should follow the directions of the ushers.
Mae hynny'n mynd â ni ymlaen yn syth, achos mae amser yn brin braidd bore yma, i eitem 2, a chraffu ar gyllideb ddrafft Llywodraeth Cymru 2019-20. Dyma sesiwn dystiolaeth gydag Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol a'r Gweinidog Plant, Pobl Hŷn a Gofal Cymdeithasol. Felly, i'r perwyl yma, gallaf groesawu i'r bwrdd Vaughan Gething, Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol—bore da—a hefyd Huw Irranca-Davies, y Gweinidog Plant, Pobl Hŷn a Gofal Cymdeithasol—bore da, Huw—ac, yn ogystal, hen ffrind, Andrew Goodall, cyfarwyddwr cyffredinol iechyd a gwasanaethau cymdeithasol a phrif weithredwr Gwasanaeth Iechyd Gwladol Cymru, Llywodraeth Cymru—bore da, Andrew—Albert Heaney, cyfarwyddwr gwasanaethau cymdeithasol ac integreiddio, Llywodraeth Cymru, ac Alan Brace, cyfarwyddwr cyllid, Llywodraeth Cymru.
Yn ôl ein harfer, rydym wedi derbyn toreth o wybodaeth fanwl, gynhwysfawr, hyd yn oed, ac yn ol ein harfer, awn yn syth i mewn i gwestiynau, ac mae Angela yn mynd i ddechrau.
That takes us on straight away, because time is a little bit tight this morning, to item 2, and scrutiny of the Welsh Government draft budget 2019-20. This is the evidence session with the Cabinet Secretary for Health and Social Services and the Minister for Children, Older People and Social Care. So, to that end, I can welcome Vaughan Gething, the Cabinet Secretary for Health and Social Services—good morning—and also Huw Irranca-Davies, the Minister for Children, Older People and Social Care—good morning, Huw—also we have Andrew Goodall, director general for health and social services and the NHS Wales chief executive, Welsh Government—good morning, Andrew—Albert Heaney, director of social services and integration from the Welsh Government, and Alan Brace, director of finance at the Welsh Government.
As usual, we have had a great deal of information, in great detail—very comprehensive, I'd even say—and as usual, we'll go straight into questions from Angela.
Diolch, Chair. Good morning. Thank you very much indeed for the papers. I am very aware that the Chair would like to move at pace, so I'm going to annoy him now by asking a very detailed first question. I just wonder if you could give us a bit of an overview about what assumptions you use when putting together the budget. I'm very keen to understand the budget process within health and social care.
We have baseline assumptions about staff costs, which are broadly predictable. We have a cost base for major organisations, health boards, trusts, and then we have 'A Healthier Wales' underpinning what we're doing as well. So, that's a guide for where we want to—. So, you start off from that basis about how you then want to use the resource available and, of course, we know about the variety of cost pressures across the system, some of which are easier to predict than others. For example, prescription medication—we've actually seen a fall in the overall cost of some of those prescription drugs, partly because of the deliberate work we've done over a number of years, for example in the use of biosimilars. There's been more pace in that over the last two years. On the other hand—[Inaudible.]—income has changed and varied, so it's sometimes not easy and simple in the one sense, if you look at all the detail. Some of them are more predictable, and the most predictable is the biggest chunk of cost, which is our staff. Again, as I regularly say, it's the only area of public service where there's a regular demand and expectation that we'll spend more money and have more staff at the end of one year than in another. Every other public service is essentially facing a period of standstill, if they're lucky, or contraction.
And as the Cabinet Secretary said, it doesn't stand alone from the 'A Healthier Wales' approach—the idea around integration, seamless provision of health and social care, more wellness, more prevention, and rather than focusing on an illness service having a wellness service. That underpins a lot of the drive behind the funding decisions as well. We're quite explicit on that, and unashamedly explicit on it—focus on the person, focus on the outcomes, as opposed to a silo mentality. So, a lot of the funding decisions have been based around that paradigm. It doesn't set itself aside from the bigger strategy that we have about this more integrated, more co-ordinated service that is focused on the needs of an individual.
Minister, that's exactly the point I was trying to get to, because the assumptions that you've talked about—you've got your policies, 'A Healthier Wales' et cetera, et cetera. At the same time as all of that, we all want to go in a very strong direction of travel on which we may have different disagreements or arguments or views about how we might get to some of it, but we know where the NHS in Wales, social care in Wales have to get to. And, of course, one of the parts of your budget is all about the transformation fund, which is a limited fund, and about trying to grow and develop brand new policies or practices, and then to be able to populate them throughout the NHS to make savings.
You say, and I'm going to read it:
'We are clear that our vision for truly integrated and seamless health and social care will ultimately be delivered over the coming years through refocusing the £9 billion that Wales spends on the NHS and social services around the Quadruple Aim.'
What I'm trying to drive at is what assumptions, what rigour—. How can you say with confidence to us that the £100 million that's going to be used for transformation, on top of that refocusing—? How are you going to be able to refocus the NHS whilst carrying on sorting out ambulances, looking after people in intensive care, trying to recruit doctors into areas where we haven't got enough doctors? It's the doing of the business. And isn't that the hard bit about it all? It's doing the day-to-day business. But this is a budget. So, we all understand the rhetoric, we understand the policy, we know we've got to do the day-to-day business and we've got to make this change. What I don't see in the budget, and I'd like you to explain to me, is where the work was that says, 'You know what, we're pretty confident that we can redeploy that £9 billion without letting current services drop.'
But that isn't just a budget choice. Look, the budget choices we make about how we try and shift our system, with the transformation fund, with the money that I'm sure we'll talk about on integration, in deliberately choosing to spend money in a way that means health and social care have to agree on what to spend, that is about delivering on our policy objectives. And you wouldn't see, in all of the budget choices, some of that harder work about how we make sure that the transformation happens, because that's often about leadership, about delivering a process of change, about culture—
No, sorry, you misunderstand me, Cabinet Secretary. I'm not challenging the policy; it's about have you got enough money in play to (a) be able to transform, and (b) be able to reconfigure the hospital services within that £9 billion. So, £100 million of transformation money is a relatively small pot as a percentage. So, within the rest of the money, what assumptions did you make that made you say, 'Well, you know what, I think, in a year's time, we're going to be able to free up, through efficiencies, or through some other process, another £12 million that'll let us do this,' or £20 million, or £1 billion, or whatever, because that's what we don't see in your budget? We see your high-level intent. We see some of the low stuff where you've said, 'Right, we're going to put £60 million here, £25 million there', but we want to understand how you're going to be able to do the two at the same time. Who sat down, with whom, how, to look at the money to say, 'We think we can free this up by doing this'?
Well, that's a more rounded conversation. There isn't a strict mathematical formula. I know you're not suggesting that there is. But it's still about a judgment on the capacity of organisations within our system, as well as our system overall, as well as a judgment on the willingness of health, social care and other partners to work together to deliver that transformation. The £100 million is about making movement on this. It is about whether we can deliver the shared vision in 'A Healthier Wales'. So, I don't think you'd expect to see, in three years' time, 'In these areas, we will release x amount of money, whereas in some other areas, for example—'. If you think about medication and prescription spend, we can talk about efficiency and the value we expect to deliver. The efficiency and value board that Andrew Goodall chairs, you can see from it a range of areas and activities where we expect to release efficiencies, make savings and make better use of our money and to release cash
And the point about the new systems that we're testing and supporting with the transformation fund is that it does allow us some double running, and it does allow us to test the bids that are made, essentially, saying, 'We can deliver a better service to release money or to use money in a more effective way.' And we actually have to get to the point at the end of this, as I know you understand, of actually saying that means that you, at some point, stop doing something. You either stop doing the transformational project because it doesn't deliver, and the evaluation will show it doesn't deliver, or you say, 'This does deliver and we need to stop doing other things to actually have a different way of working.'
And on the overall, 'Can you show you're living within your means, can you show that there's enough money?' well, there are broader challenges to that, and we just need to be honest. The overall settlement for health and social care, and being able to predict the future—we're nine years into austerity, we expect more to come, well, there are challenges we'll still have to manage through that, with a picture that changes. It changes in year, as well as year to year. But I do think that we've got the best possible advice linked into all the policies and the levers we have, for example, the planning guidance we submitted has very clear links to 'A Healthier Wales', and we expect organisations to shift the way they use resources. I think those things are in place as much as possible, and those are regular conversations that the team have. So, myself and the Minister have conversations with politicians, and with chairs, appointed members, in health boards, and Andrew Goodall and the team have conversations with people across the whole system as well. And there's quite a lot of crawling over what organisations do. You don't get to see the joint executive team meeting reports, but they really do come back in some detail about the conversations that take place, the level of challenge that takes place, and the overall judgment on the state of the organisation, and points for improvement. So, it isn't a passive system—it isn't going to say, 'You get on with it and tell us what you've done.' It very much is: there is regular oversight, regular conversations, and regular challenge, as well, of course, as the external scrutiny that we'll get in this place, in the Public Accounts Committee, and, indeed, from the wider public.
And just to add, including from a social services perspective, one of the challenges that is being put to us by leaders in local government, leaders in health boards, and others is exactly that challenge: how do we ride the bike at the same time as re-engineering the cogs and the wheels? So, there is double funding within the system; it's not only the transformation fund, it's some of the funds that we've put directly in as a result of this budget into social services, to allow that double running, so that they can re-engineer the system as they ride the bike as well.
But also, to go back to the parliamentary review, which underpinned this transformation, that made clear that it wasn't a demand on additional resources. What they did was look at the system as it currently is, looked at what was being funded through the integrated care fund over many years, what was working, and their analysis was you can achieve this transformation—they'd like to see additional funding, but you can achieve this transformation by changing the way in which you do things, by real, genuine, meaningful integration, from the front-end delivery, through the strategic level, and at all points. And that comes to the point of leadership. And it is leadership that we're consistently working, both at Welsh Government level, regional partnership boards—but it does require pace, and leadership, and commitment, relentlessly, at all levels of the system, to make it work. Some of these won't be seen within budget lines—although we've put some additional funding in there to do this transformation—but it's more to do with that core transformation of that £9 billion. And we will consistently say what we achieve through ICF, through transformation funding, in social services and health and integration, the only way of making this binding and meaningful is changing the way that we do things on a day-to-day, bread-and-butter basis, with that £9 billion.
And the leadership that, for example, in the finance functions that Alan Brace right here—there is a different relationship, we do extra finance, but also the finance delivery, and the support or the challenge provided. But that isn't just about the money, it is about how money is used. So, it's not just a series of the Cabinet saying, 'I require you to make x percentage savings'—and the health service has made, over the last eight, nine years, £1.5 billion of efficiency savings. But it's then about: to what purpose, how much of that is short term, how much of that is recurrent, how much is about delivering system shift and change? And if you want to go through the detail of that, then I'm sure Alan would be happy to give you detail on the sort of work that—
Well, it is quite important to have some of the detail, Cabinet Secretary, because it's about faith, isn't it? Absolutely, we don't expect you to give us the ins and outs of every single policy plan, et cetera. But the transformation agenda is something that we've all taken to our hearts, we all know it has to happen, we've all said—across all political parties—that we're going to support it, in one shape or another. But transformation costs money. I used to do business process re-engineering for a living before I came here, I've never seen it be done cheaply. You need experts who understand what they're doing, you need to have drive, pace, and a really clear strategy, and you need to have the funds, and funds are something we're tight on.
I understand that from my own time in work before this place as well.
So, we need to make sure that nothing's going to drop while we try to push the transformation agenda. And what your paper wasn't really clear on, or I didn't think gave enough security on, was saying, 'Look, £100 million starts lots of small projects'—excellent, and we hope that they will grow and really populate throughout Wales and make significant differences. We talk again and again and again about the pressures on social services, the pressures on the health board, the pressures on the front door of our hospitals, how people are getting more demanding, and they're getting sicker, they need more support, so that's got to increase. We're struggling with workforce recruitment. So, what I was driving at is just to see some of the assumptions—. There is very little reassurance that, actually, we think we can, as you put it, Minister, ride the bike, was it, and change the tyres at the same time or something? [Laughter.] That's not one I've heard before.
Well, you don't go to Ogmore enough. Alan, do you want to set out the detail about some of those assumptions that Angela is asking about, of the work that is being done on financial transformation and also discipline as well, because I know that's a point that people regularly ask about?
Yes. This budget has been an opportunity for us to just gather as much evidence as we can from all of the various studies, both within Wales, but also internationally, that can inform how to do these things at scale and pace. So, in terms of—. If you remember last year's budget, one of the things that I think health boards said that they struggled to plan on was certainty about what next year's allocation looked like and the year after. So, we took the Health Foundation and Nuffield Trust work that was probably internationally based, but particularly UK based, which gave a clear idea of what demand for healthcare looks like and pointed at pressures within social care and what you would need to do in financial terms to give stability to a healthcare system. But it also said what the healthcare system would need to do around efficiency. It didn't really touch on effectiveness, but I will touch on effectiveness, because that's equally important.
So, in last year's budget, we gave a clear commitment that we would be meeting the Nuffield and Health Foundation requirements and that gave boards real clarity on which to plan. There was headroom within that funding for change and to deliver improved performance. Then we put in place the efficiency productivity and, most importantly, the clinical variation group that Andrew chairs, which has got strong clinical representation around the table. That focuses on basic efficiency opportunities in terms of normal efficiencies that you would expect and lots in the areas where there remain opportunities for improvement, in medicines, in procurement, utilising our national shared services.
But we concentrated a lot on clinical variation: where was our variation in referral patterns? Where was our variation in delivery? That's become more of a feature, I think, in terms of how could we do that more efficiently and more comprehensively across Wales. But then we've also driven the value-based healthcare approach, which is really focused on outcomes and outcomes that matter to patients. We've now got a lot more measurement nationally in areas like lung cancer, heart failure, cataracts, prostate cancer, chronic obstructive pulmonary disease. What that's telling us, and it's a measurement of outcomes and cost, is that we can drive much better outcomes for the people of Wales without necessarily spending more money. So, that gives us a package of things that I think we can now legitimately expect particularly LHBs to deliver on. I think there is a lot more clarity nationally and a lot more of this is driven nationally.
Then we obviously had the parliamentary review, which says, 'Look, the policy environment in Wales is great, the focus on future generations and cross-public-service working is absolutely the right environment to make the type of change that is needed'. But what it said was there was variability in execution, and part of that was about pace and really good projects that weren't scaling quickly enough. So, with the extra funding, and then through 'A Healthier Wales', we decided that what we needed to do was just address those things. So, there is a transformation programme that is a lot bigger than the transformation fund, and that is grabbing some of these opportunities to drive them a lot more. We're clearly going to try and strengthen a national executive, because that was one of the recommendations that came out and that we tried to address in 'A Healthier Wales'. We could do things, I think, more centrally once for Wales and put a bit more pace on some of the change if we did that.
And then the other bit that was key was one of the mechanisms that we needed to really strengthen in a much more formal way, namely the health and social care interface: how could we use regional partnership boards and how could we route money to those arrangements so people generally felt that they could start to look at the resources they'd already got available—and that comes to the £9 billion. Because you're never going to really make the type of change we need just by focusing on small amounts of central funding coming through this type of route. We've got to unlock the £9 billion in a different way, and the only way you'll do that is through some of these partnership arrangements. But we've got to support those; we've got to develop regional partnership boards to be able to do this. We've got to create an environment where it's not just about legally pooling budgets, but people feel comfortable having a look at what they've already got, how they could use their existing resources better and then how could this amount of money start to make a practical difference. If that is just covering double running costs, because the transformation fund is addressing that—it's to say, 'We'll cover some of the double running costs, but we're not going to layer that one so that we've got a load of existing services and then we're doing more small projects'.
So, these are funding streams to unlock the £9 billion, but the unlocking really has got to come from different partnership working that I think has got a lot more focus on more efficient use of resources. We can't take our eye off that; there is an opportunity for greater efficiency and productivity within the £9 billion. More importantly, though, it's about outcomes—how can we start to drive a different debate about effectiveness? And that is, I guess, trying to capture, in as succinct a way as I can, what we are trying to achieve.
Yes, but it actually does bring a lot of—. It brings clarity; it really does help. Thank you for that, because it brings clarity to the process and to the expectations that you've set on different elements of the organisation. And it's interesting to know that you've built headroom in and—. So, those were the kinds of things that I was trying to sort of drive at. If I may just ask one more question, and then I'll be silent for a moment—if only for a moment. [Laughter.] Actually, does that reflect your experience, Minister? Because, actually, in some ways, you're up against it even more, because it's such a dearth of people, human resource, and the whole thing. So, how have you managed to judge the assumptions on your budgeting and, for example, whether you think that £30 million would be enough? How did you get—? Just an example of how you got to that. What kind of process was that, and how confident are you that the budget you have before us actually has the numbers in it for this year and going forward that will help us to deliver this change we need?
The first thing to say is that we genuinely do recognise the pressures within the system—I think everybody does—our population needs assessment, the ageing population, but also adults with learning difficulties, children with complex needs; all of that is building pressure within the system. However, what we've done within our budget is to do our very best to protect social services spending, but also, picking up the point made earlier, to direct spending through regional partnership boards. So, if, for example, you look at commissioning of adult social care, we know that there are gaps in provision on adult residential care, and yet we know that if, in the Gwent area, we actually pool the budgets there, combine budgets on well-being around older people and commissioning of adult residential care, it is a significant volume. Now, they've been able to move because of our thrust towards things like more collaborative working, joint commissioning, pooling of budgets. We're in a position now where we can actually say to providers out there, 'We can give you long-term certainty over significant investment within it.' Now, that's the sort of practical change that comes from our budget decisions.
But I can give you one other very good example. Money speaks, and we were talking about the double-funding aspects, in a sense. One of the ones we've talked about a lot is the Cwm Taf Stay Well@home example. The investment in that, to date, has been around—and it's a choice by the regional partnership board—£1.8 million. Now, that's a choice. This is fundamental. This is not just transformation funding, it's a choice that they've made through ICF and that they are now looking to mainstream. The savings in 2017-18 of that were that over 13,000 bed days were avoided being locked up there, which equates to something like £1.6 million in financial savings. So, that's where the practical difference of this drive comes through.
So, do I have confidence that there is sufficient in there? I'm sure we'll come later on to talk about other ways that we might want to explore going forward about levering more money in, but at this moment, it's a combination of making sure that as much money as we can is within the system of health and social care, but, secondly, we change the system so that we get more value for money. Because that £1.6 million of financial savings each year is significant savings that can be redeployed elsewhere.
Dawn, a supplementary on this point?
On this point. I'm really interested in what you were just saying there, Huw, because I had recent conversations with one of the health boards and one of the local authorities in my constituency, and what they were saying to me—I'll come to the question in a minute—was that the change, the transformation in health, seems to be working. We're getting greater throughput, so beds are being released—all the kinds of stuff that you're talking about. But that, then, is putting the additional pressure on social care, the social care packages and so on, and so the local authority is struggling to cope with that financially. Now, the extra pots of money that you've given recently, you've given to be administered by the partnership boards for social care, so that you've got that complete kind of integrated approach. Can I ask—it's probably a question for Vaughan as well—is that something that you've given thought to in the longer term about how health and social care, specifically, is funded, and whether that is the future of holding the budget—that it's not held by health or by local government, but actually held by the partnership board to be distributed as and where it's needed, as opposed to being controlled by local government or being controlled by health, which seems to create the pressure points?
There's a real practical challenge here. Lots of what you've heard about is about relationships, culture and leadership, not just at this level, but, actually, local and regional leadership as well across health and social care. But there is a trust issue and, frankly, if money is seen as being local government money or health money, then it affects the way people behave. It's a deliberate choice to put money into a partnership space because we want both big statutory partners to change the way that they behave around the service with and for the citizen. And we'll need to think about some of the governance for that money, to make sure that there's a structure, because it's very clear in 'A Healthier Wales'—regional partnership boards are a big driver for change. So, yes, it's a deliberate choice and you can expect to see more of that into that deliberate space where health and social care and other partners have to agree on what to do, because they'll need to see the whole system. If it takes pressure out of the health service, and we recognise that that's a good thing for the health service, you then need to make sure the other partnership is funded to be able to do that. So, that is a deliberate choice that we have consciously made through the parliamentary review, through 'A Healthier Wales' and with these budget choices as well. So, expect to see more of it in the future.
Okay, you've inspired Angela—
Yes, well, just—
Well, you were quiet for a moment, to be fair. [Laughter.]
One last question, which is: obviously, much of the transformation agenda focuses on primary care and community care, about keeping people well, keeping them in their home environment so that they don't then put pressures on other parts of the services. And yet, in the budget, it does seem that primary care has taken a 5 per cent real-terms cut. I just wondered if you could explain to us, very briefly, how that diminishing of the funding for primary care at a time when we're actually saying to primary care, 'We're going to put much more emphasis on you and get services out there and deliver'—and I know there's cluster working and stuff—but could you just explain how we can ask primary care to step up to the plate so much when, actually, they're having a 5 per cent real-terms cut, and would we not want to try and put a bit more money into that to help pump prime the whole community care agenda?
There is a technical explanation that I'll ask Alan to give about changing costs and what that means, but our overall primary care budget is pretty much the same, in percentage terms, as in Scotland. We make comparisons around the system, but, actually, in percentage terms, we spend the same proportion of our money as Scotland does already, and you'll see, and I've said before, rather than setting an artificial target for increasing a percentage spend, I want the money to go where activity is. That's both in social care, in terms of the conversation we've just had with Dawn Bowden, but it's also about where within health—if we're delivering the transformation and more activity in different places, we need to fund it and resource it properly. But, Alan, will you give the technical explanation about why we've seen a change in the amount of money spent?
And could I just ask, also, just because what Scotland—? We're trying to transform, and we've said very clearly, 'It's got to be in community care and primary care. You're going to shoulder this', so that we take the pressure of secondary, which is far more expensive. So, to be frank, the Scotland thing is—. We're trying to transform our health service.
It's a regular point of comparison, because we're regularly told that Scotland spend more and whatever. Actually, there's, even at present, a comparable percentage spend. You can expect to see more shift as services move around, because as those services change how they're delivering, you've got to expect to see the money go with them as well. Do you want to—?
I think the first thing is that we don't recognise that 5 per cent. I think that came from the Wales Audit Office's 'A Picture of Public Services' report, and we pointed out to them that the only difference in that comparator—. Well, there were a couple of differences, but the main one—and this goes back to that earlier debate about what we're trying to achieve—was that medicines spend, which was included in the definition of primary care, was actually being managed really well and was fairly static. And then, when they did the comparison, that looked like there was a cut in real terms, and there wasn't. Wales Audit Office agreed with that, in terms of that, technically, that wasn't the correct picture of what was going on, but it does still seem to be quoted that we have reduced it. There were other technical issues around dental income that had been counted in some of this. So, I guess, the real message is: there isn't a real-terms cut. In fact, the spend is growing. We've made significant investment directly into things like general medical services. But the other bit, and I think this is something about measurement: more and more, as we develop the cluster approach and as we put more and more staffing into the primary care clusters, they will invariably come from what we would have called, traditionally, 'secondary care' and be counted in the hospital and community services part of the budget—be it pharmacists, be it therapists working more within a cluster setting—and we've got to think about how we capture that differently.
And then, just to finish in terms of the Cab Sec's point, we've often been compared to Scotland, and if you look at the last financial year, our spend on primary care was absolutely comparable. For this financial year, we've moved slightly ahead of Scotland in terms of our investment. So, it's not a figure I recognise, but I recognise the fact that there is probably more that we can do to capture the broader investment in a slightly different way.
So, if we were to take the comments you've just made and the Wales Audit Office's interpretation being slightly different, would you be able to tell us—? Can we be confident that, one, primary care spend has increased, and would you be able to provide us with a figure of what it's increased by? And secondly—and this isn't for now, because I know that the Chair's going to glare at me for time—in your capital spend budget lines, do you have a dedicated spend for, again, primary care, the development of primary care? Because they need buildings and other things. That would be great.
We've got a dedicated pipeline of primary care developments with a dedicated capital funding pot around it and an ambition to grow that.
Yes, and we've made written and oral statements on that, so, yes. We can write to you if you prefer, Chair, because I appreciate that you are looking at Members who are deliberately not looking at you.
I'm looking at him now. Thank you, Chair. [Laughter.]
Thank you. Yes, we'll await a note, then, thank you. Yes, we are talking in terms of agility now, and one of the fervent exponents of agility is Julie Morgan.
Oh, right. [Laughter.] I was going to ask you about—
It's health board financing.
Eight and nine—that's right. Sorry, I was on the wrong page. I wanted to ask you about the updated position about the health boards: the repayment of deficits reported in 2016-17, and cash assistance. Have they been repaid or what is the situation?
For those four organisations still having annual plans in a heightened state of escalation, they're not in a position to repay deficits built up. I expect them to gain control of their finances and to move to a position where they do have three-year plans, at various points in the future—I don't expect they'll all get there. I'm more optimistic about Cardiff and Vale for the year ahead. We're looking for Abertawe Bro Morgannwg to make more progress over the next six to 12 months as well. I'm not expecting either Hywel Dda or Betsi Cadwaladr to come up with a three-year plan for the next financial year or within the next financial year, but I do expect to see further improvement. What I don't want to do is to start to introduce an expectation, and whilst those organisations are in their current position of needing to repay money in this year as well, because I don't think that will be very helpful—. Their biggest challenge is actually getting control of their finances—in two of those organisations in particular—and then to make better use of their finances. We've just had that discussion now. They'll need to then plan to repay over a period of time. That was the point of having a three-year approach rather than an annual approach. It is about that further progress, so I hope there'll be some comfort taken by the committee that we expect to see more progress within this financial year. There'll be honesty about those organisations that have made progress and the extent of it, and, in addition, in the next year I'm expecting that we'll have a further improvement, and, equally, that those organisations that have been responsible, that are living within their means, will continue to do so as well. Now, that's important, not just for colleagues in local government, it matters within the health service too, that what are at times difficult choices—that they recognise they're being made throughout the system to deliver that greater efficiency and value as well.
Why have those two health boards found it so difficult?
Betsi Cadwaladr is in special measures. We spent a significant chunk of yesterday in the Chamber talking about the challenges that they have. There are challenges about their delivery of services, as well as some of the challenges about leadership, and we expect to see some of that resolved in the coming period. And in Hywel Dda, we recently recognised over this financial year, following the zero-based budget review, that some of the challenges they had they were not in control of, but they still need to get on top of their broader financial challenge, which is linked into how they deliver services. If they deliver services currently as they do now, their prospects for living within their means are very difficult. To be fair, Members across all parties were asking us to look again at Hywel Dda, including at least one of the Members in this room, and we recognised that with the review that we've undertaken. But they now need to get on top of the remaining element of the challenge, and there is the unfinished conversation about how to deliver healthcare in Mid and West Wales, which I don't want to get drawn into because I still could have to make a decision on that.
But not a matter for today. Julie.
So, how do you respond to the Public Accounts Committee's recent concern that the pace has been disappointing with those health boards that have been subject to escalation and intervention?
It's the job of the Public Accounts Committee to be disappointed with progress. [Laughter.] That's part of the need to keep people honest, isn't it, to say, 'We're disappointed you haven't done more'? If you look at the reality of where we are and the additional discipline that we've introduced across the health system, you are seeing movement in the right direction and you're seeing movement at a level and a pace that we have not seen in the past.
I would always want to see more and, actually, as a health Secretary, I'm disappointed we're not in a different position and in a better position already. But I do try to undertake choices and decisions in the real world, and our ability to do so is practical—it's based on the capacity and the needs that we have within the system. That's why the finance delivery unit, I think, does matter and our ability to develop and grow our own capacity within the system on both a planning basis—to properly plan our system—as well as the delivery of it too.
So, I recognise the statement they've made. We don't always share the extent of their disappointment, but, as I say, you can expect to see further progress to the end of this financial year and honesty about the level of the progress and the progress that has not been made, as well as, I think, further progress still in the next year. As I say, I'm optimistic at this point that Cardiff and Vale will reach the end of the year with a particular position and have real prospects of submitting a three-year plan at some point before the next financial year or within the next financial year. And that would represent real progress: to have a health board that has gone through escalation to go up—because it was not living within its means and it was not in control of where it was—in a broadly positive strategic direction to get to the point where it's still going in a positive direction with local authority partners and others too and has got greater financial discipline. That's a positive about how we can actually manage successfully a planned system. For them to join Cwm Taf, Powys and Gwent as areas that are properly in control of their finances would be a really positive thing for the whole system, not just for Cardiff and Vale.
Okay, time to move on to mental health spend. Helen Mary.
Thank you. How confident are you that the resources being made available for, specifically, mental health services are meeting the level of need? The Welsh NHS Confederation has suggested that there's a level of unmet, and therefore, unresourced need, at the moment. Are you confident that we've got enough robust data about the level of need to enable you to plan the budgeting for mental health services efficiently?
We are looking and relooking again at the data we have. I met the Wales Alliance for Mental Health this week. We talked about the progress that is being made and the further progress we still need to make on some of the data sets—what we publish and what we share—so that we'll have better information again. 'Together for Mental Health' has taken us further forward, but the progress on mental health is only in part due the money we spend in health, and an understanding of the need that we have, because, as you know, it's a cross-Government priority to recognise that improving the mental health of the nation requires a different national conversation. It requires action outside the health service and it requires health to be an outward-looking partner with other services. The most obvious one we regularly talk about is the world of work, where positive attitudes in and around the workplace make a big difference to either coping with mental health illness or indeed avoiding it.
You'll also know, looking at the Chair of a different committee in the room, of the work that we're doing that isn't just about health, but about our partnership, in particular, with education. And that is a recognition that we do need to understand the differing level of need that exists within the country and how we properly approach it in early years. So, the whole-school approach isn't just a matter for education and isn't just a matter for health—we need to understand what each other is doing and that's why we have a jointly chaired task and finish group with stakeholders to look at how we deliver real improvement. So, it's partly about money, it's partly about understanding and need and us keeping our promises to put more money into mental health services, but it is at least as much about how we use that money and how we see the impact that other partners can and do make on improving the mental health of the nation as well as understanding the level of need that we have.
I completely take that and that's obviously true in terms of keeping people mentally well. You can argue that spending on leisure services, for example, getting people physically fit and active, is really important, but in terms of this specific budget, you mentioned there the ongoing work around data sets and knowledge and understanding. It comes back a bit, really, to the points that Angela Burns was raising more broadly across the budget. I think we need to understand a bit more what assumptions are behind the planned spending within this budget, and again, completely taking on board that there are lots of other areas of action on spending that need to happen. So, if we can understand a little bit more about what the challenges are around the existing data sets—because if the data isn't adequate, it's very difficult for you to plan what needs to be spent, isn't it?
We're actually going through and trying to agree with partners about what we should measure and how we should measure in a way that's useful. What I don't want to do is end up trying to say that we need to have data now and it's actually going to point our system in the wrong direction. We know, for example, that on a range of process measures, we're actually doing relatively well in some areas of people being seen within time and then having a therapeutic intervention in some parts of our service. We know that in the child and adolescent mental health services, we still need to do more—we have a more challenging target than other parts of the UK. It's much better than it was a couple of years ago, but that's only part of the challenge. That's why the conversation about what we measure, and how, and how and when we publish it, really does matter.
From Monday's meeting with the Mental Health Alliance, there's a keenness, not just to work together, but to make sure that we don't do all of this at the end and wait until another three or four years, when there's a wholly complete data set—so, to understand what we could publish in the interim and how that will guide the plans that we have. But also, that is work that is being done to get it not just in a health setting, but in particular with local government too, and the delivery of the Wales—
The Welsh Community Care Information System, which is still on course to be developed within the timetable we originally laid out—by 2022. It's progressing well, and the mental health core data set will feed into that as well. Because, to come back to that theme of seamless integration of services and support, it's the WCCIS that will actually provide that joined-up data sharing between front-line providers to make sure that those individuals at the end of it are having the right outcome. So, the mental health core data set, which, as the Cabinet Secretary was saying, is being developed with stakeholders at the moment—that'll feed into WCCIS as well. So, they're not in isolation or in little silos—there's seamlessness here that we're trying to engage in all decisions that we make. I think that will assist, as well, individuals who are seeking support—that we're able to share the information as well in a timely manner.
So, is the implication of that then that if the data sets are evolving, the assumptions that you're making for the current budget are based on what we know now, presumably, and that there may need to be flexibility in—. Because if we are saying—. There are stakeholders that are saying to us that they think that there's a substantial amount of unmet need, unrecognised need. Presumably, you can only plan for this budget on the basis of what you know now. So, can we expect there to be flexibility around what's spent on mental health, if, as the data sets evolve, it is proven that there are levels of unmet need?
We can, of course, plan on what we know now, without getting into known unknowns or unknown knowns. We plan on what we know now and as the robustness and the quality of information that we have change, we will, of course, look to meet the need that exists in every part of the service, including, of course, here in mental health. The ring fence is a floor, not a ceiling, for spend in this area, and it's also the need to recognise that some parts of our spend, which aren't recognised in mental health, have a real impact as well. So, this is about the level of honesty we could and should have in what we are spending and in the areas where we recognise that we need to do more, and that's why we've agreed to go through a number of different processes to reach a different conclusion about not just how we spend money, but about how effectively we think we can do that, and understanding the level of need that we have. And that is about children's and adult services as well—it isn't just one part of our system.
Okay. Lots of agility is required now, and the queen of that is Lynne—adult social care.
Thank you, Chair. The extra money that's gone in, the £20 million in the revenue support grant for social care—how confident are you that that is actually going to be used for that purpose, given that we know that local government have got a lot of worries this year about the level of the settlement in general?
I think we're as confident as can be on the basis that local government has repeatedly said to us that this is one of its big pressure points, despite the fact that we've repeatedly tried to protect, to the very best of our ability, spending on social care. They say, 'We need more to keep doing what we're doing', so we're confident. Ultimately, local authorities are democratically accountable, but based on the approach that we now have under the Social Services and Well-being (Wales) Act 2014, where they assess their local population needs and then they provide for them, we're as confident as can be that that £20 million, which we've made clear is for social services, will be used for social services.
Now, they might choose to use that in different ways in different local authority areas, according to the needs of the population, but I'd be really surprised if it slipped away into other areas, because the use of it is clearly intended. We're always told that social care is the primary cause of local authorities' overspend, so we anticipate this will going directly into social services.
So, you're not planning formal monitoring of that, then.
Not of the £20 million on its own, because we already have the set processes for monitoring how local authorities are delivering under the social services and well-being Act. They have to have their own element of local accountability and democratic accountability here. But, of course, the £20 million that has gone directly into social services doesn't stand alone from the other tranches of money that we've put in here to be determined in slightly different ways on those local needs as well.
Okay. So, even with the £20 million and the £30 million for the regional partnership boards, the Welsh Local Government Association have said that there's a funding gap of £67 million for social care. Is that a figure that you recognise, and do you think there is a risk of undermining the health service by not sufficiently funding social care?
Well, you know, I don't want to get into the wider issue of where we are generally in terms of spending. We're spending what we have available, particularly with the priority within health and within social care as well. But it does come back to this issue again of how well we spend that money in a joined-up way, and making those decisions.
You mentioned the £30 million there. The fact that that £30 million additionality is funded through the regional partnership boards means, once again, at that strategic level, they have to determine how that is used to answer local needs as well within the regional area, but also local needs. So, if that can be used in cleverer ways—we've mentioned things like Cwm Taf's Stay Well@home service, but I could refer to north Wales examples and west Wales examples as well—then that money can go a lot further.
But we are where we are with spending overall in the round. This is challenging and it's difficult, but we need to spend it well, and that does mean then, I have to say, deciding both at a regional level with the £30 million, at a local level with the money that we're putting in directly under social services, when things work, to keep on doing them. When things are less efficient, then make those choices locally as to what you actually don't do, because there's a better way of providing it.
Now, that doesn't answer the question of would we like to see loads more money going in, because we work within the envelope that we currently have.
Okay, thank you. Can you provide an update, then, on progress made by the inter-ministerial group on paying for social care, what sort of options they're looking at, and when you expect that work to be concluded?
Yes, indeed. The inter-ministerial group has already put together five work streams, and those include how best to actually raise any funding that may come forward, how best to deploy it, what would be the best points at which to use this within the system. It includes engagement with UK Government, but it also includes engagement with the wider public and wider society, because an important part of this is actually listening to where the public is on this and actually persuading them of the case as well. So, there are five work streams going forward. It's met on a couple of occasions already, but we're not rushing at this, because we've learned from previous examples, including at a UK level, that, where you don't build consensus, where you don't do the preparatory work, where you don't get this right, things have a tendency to crash and burn, or crash into the wider politics. What we want to do with this is actually bring forward the proposals in a very measured way, having really worked them through to the nth degree, and then also bring the public with us and engage with the UK Government.
So, that work is ongoing. Of course, the Cabinet Secretary for Finance as well is also taking forward additional work to the original work that was done, looking at different ways of levering money into the system. We think it's right that Welsh Government looks at this, because we recognise, in some ways, we're ahead of the game in Wales. We've done our own population-needs assessment; we've seen the results of some of the surveys looking at the impacts of a rising, ageing population. It brings lots of good opportunities with it, but it brings challenges as well. So, on that basis, we think it's right that we look at this, but we do it in a considered way, and we do the hard graft of the preparation work before we prematurely say, 'We're just going to launch ahead on this', because, that way, as I've said before, we tend to see political crash and burn. There's a lot of homework to be done before we start bringing stuff into the public, I think.
Okay. So, the Finance Committee's recent inquiry on the cost of caring for an ageing population highlighted concerns about a lack of data to anticipate future demand for social care services. What steps are you taking to ensure that we've got the information and the evidence that we need to plan for future demand?
Yes, I think we have to acknowledge that the published data on social care is not as robust as it is within healthcare. It really isn't. So, we do have to develop that. We have actually commissioned—. It's not directly in response to the report that you mentioned, but we have commissioned the Association of Directors of Social Services Cymru to provide local government's view of the pressures facing social care in the next 10 to 15 years, so a long-term view, and also to outline the priorities that it would see for any funding that might be raised, for example, through a levy or elsewhere. However, we are considering the point that was made—including the points that have been made by the Finance Committee—on this lack of parity between the data between social care, social services and health. So, we'll be responding to this very shortly as part of our formal response. I don't want to pre-empt what our response might be, because it's right that we lay that out in front of the Finance Committee, but we're looking forward to responding to that, and we do acknowledge there is a difference in the robustness of the data between the two.
This is also, of course, by the way, complicated, as well, by—. And we don't apologise for this: as we try and transition forward to a different model of delivering health and social care, that also has an effect on the cost burdens as well, because if we develop—. If we develop, if we're seeing, for example, in Cwm Taf, or other examples we can provide, we're not only providing better, seamless, integrated care that's better for the user, but we're also driving efficiencies through the system, that has an effect then on how much money you need to put into the system. So, if we can do things better, cleverer, and deliver efficiencies, then that has an effect. So, we're no longer in the paradigm of simply saying, 'How much money do we need to keep throwing into the system?' That will always be there, and that's why we're looking at things such as the social care levy, but it's also, 'Can we do things better in Wales, cleverer in Wales—deliver better outcomes and more efficiently as well?' And we're starting to see that.
Okay, thank you. And the final question from me: this committee's just begun an inquiry into support for carers. Can you give us an overview of any specific funding streams in the budget that relate to support for carers, please?
Yes, happy to. As you know, we laid out our three national priorities for carers back in November 2017. They were worked up with carers. It was to do with supporting life alongside caring so that you aren't simply a carer, you've got a life beyond that; identifying and recognising carers, because many carers do not self-identify—some don't want to be identified as carers—but using GPs, hospitals, discharge, and other organisations to actually say, 'What support can we give you?', identifying them, and then providing the information, the advice and assistance, including things like more flexible approaches to respite care. So, we've put £3 million in the revenue support grant through the previous budget to support provision of additional respite. In this budget, mainly from the funding from the social care and support action, in support of those three national priorities, we've put £1 million towards health, local government, third sector bodies to work in partnership to deliver those outcomes and to promote and improve support for carers through GP practices and hospital discharge services. Some of the organisations that we use to help us deliver this are ones like Carers Wales, Carers Trust Wales, Children in Wales and others. So, there's genuinely—beyond the statutory providers—a joined-up approach here.
The other aspect within the budget is the grant funding for carer-related projects through the sustainable social services third sector grant, which is part of the sustainable social services action. So, we've allocated there sums of money to Carers Wales for carers, citizens, communities projects, allowing carers to better manage their carers roles. So, we've got specific parts within this budget, in addition to what we put into previous budgets, to actually take forward those carers priorities.
Okay. Helen Mary's got a supplementary here.
Sorry—did Albert want to come in on this? On the carers question.
Sorry, Albert, I missed you there. I've missed you all morning, in fact. You've been very quiet there.
Now is my moment on this, so, thank you very much indeed, Chair. I just did want to come back in, because the Assembly Member raised the question in terms of funding and spoke about the £20 million going into the RSG and the £30 million for the regional partnership board, partnership collaboration, bringing that work forward. There has been some confusion in the outside world because, whilst you use the same figures of £30 million, there's another important figure—just to reference for this committee today—because there is, of course, £30 million that's been allocated directly to local authorities for social care next year in the form of a grant.
Yes. That's very important, sorry, because this does get confused in the outside world. So, there is the £20 million we put into social services, there is the £30 million, which is going in as an additional announcement, which is going specifically towards social services, and that is recognising some of the pressures in there—including things like living wage, et cetera, et cetera, workforce development—and then there is the sum of money going into the regional partnership boards as well. Now, in many ways, all of those, in different ways, are there to deliver this outcome that we want of citizen-focused, person-centred delivery, but there are slightly different tranches.
Okay. Helen Mary.
You mentioned a couple of times in your responses to Lynne the need for services to be locally appropriate and local democratic accountability, of course, through the local authorities. But you've also given us some really good examples of effective integration, where you've got health and care working closely together, not only providing better outcomes for people, but saving money, which is the best of both worlds.
Do you see a tension between the need for local accountability and people wanting to do things their own way in their own area and then the evidence base that shows that, if you do this, this works for people? And can you just tell us a little bit—I know that time is short—about how you intend to resolve that, and, in the context of today's discussions, to what extent you were able to use the budget, the funding, to say to people, 'Well, local accountability is all very well, but you're doing this and it's not working, they're doing this in this part of Wales and it is working'? So, to a certain extent, I'm a bit of a sceptic about local accountability on this, because if local accountability means that people are getting a worse service in some parts of Wales than they are in others—. But, at the same time, obviously what works well in Blaenau Ffestiniog is not necessarily going to work well in Cardiff, so—. Explore those tensions a little bit.
You just point out the tensions that exist. So, in 'A Healthier Wales', we talk about having some national principles to be delivered and adapted to local circumstances. That is not the same as tolerating just local practice that is in no way in accordance with evidence on what works. And it's part of the reason why we spent so much time in drawing local authorities and health together to deliver and develop the plan—together with the third sector and colleagues in housing—'A Healthier Wales', and why we then spent time after that in keeping people together; then we make budget choices to require that partnership to agree on what to do. And, in the transformation fund, the evaluation that exists—. So, there has to be evaluation to understand has this worked. That matters for health, local government, and other partners too as well. So, we'll be able to draw out some of those tensions, but, on a number of these things, it will simply be about the choice that the local electorate makes. There is a danger. We go out and talk to local authorities and they always say, 'Look, we've got our own democratic mandate. Give us the freedom to use the money and we'll be accountable for it to our local electorate.' And then we have the other tension where we come into rooms like this and people say, 'You should tell local authorities what to do.' You regularly have people in campaigning organisations saying, broadly, 'We don't like local authorities having freedom, because that might not meet what we want to do.' Well, that's always going to be a tension; there's never going to be a perfect answer.
What we do have, though, as I say, is a consistent approach through 'A Healthier Wales' on national design principles and on money that is deliberately designed to make sure that health and local government have to be in the same room at the same time to agree on priorities. It isn't about one partner telling the other: 'You now must do what I require you to do'. And, equally, the Government shouldn't get into the space of simply requiring and directing local authorities in every single area of activity. We really do want to develop a partnership that is driven by principles and evidence. And so we'll be sparing and appropriate where we do try to direct services.
Good. NHS workforce—Dawn is going to be agile as well.
Yes, thank you. You've allocated £195 million and a bit to Health Education and Improvement Wales—
What do you expect to be the key improvements and benefits from that, from that budget being specifically allocated there?
Well, the creation of Health Education and Improvement Wales is a step forward. It's taken quite some time to get here.
And you'll remember from your time before coming to this place about how we draw together workforce planning in a more sensible and joined up way. We're now in a—we're in a better position to have that oversight, both as a source of intelligence and knowledge about the workforce we have, as well as the ability to plan for the workforce that we'll want in the future to meet current and future need. So, it is about an organisation with that oversight and intelligence and a central role within what is, after all, a small country, and people with credibility across our system to be able to do that. So, it isn't just about saying, 'We'll draw together different organisations and change the logo.' It's really us wanting to get a greater sum of all the parts together to have a bigger impact on our system, because we know that, in terms of making choices about workforce planning, we would occasionally have bids in from organisations that—. I remember, my first year as Cabinet Secretary, being asked to spend money to train the future workforce and bids in from different health boards on what they wanted to spend, and (a) we didn't have the money and they recognised that the money didn't exist, but also we didn't have the training places to deliver everything that every organisation wanted. That highlighted that there wasn't a joined-up national conversation on how we use the capacity we have within our system to train our future staff and then how we go about making sensible use of that.
We're now in a better position, even before HEIW, because we've forced a national conversation that wasn't taking place consistently, and HEIW will now take that forward, so we have a much more coherent not just conversation, but some advice, and that should lead to decision making about how to make the best use of what we have.
And I absolutely see that whole kind of holistic approach to workforce planning. It's something that I know some stakeholders have been crying out for for a very long time. But to what extent is that budget—? And it probably goes back to the question that Angela asked right at the beginning: to what extent is that budget being utilised for workforce development, and recruitment and training, as opposed to the development of new and innovative ways of working that we've identified—or you've identified—through 'A Healthier Wales'? So, it's, again, that balance of the budget between what you need now to deliver the service, and the kind of transformation that's needed with a different type of workforce in some areas. Is that budget there to do all of that? Yes?
Well, the budget that we currently have will change, because, as we're drawing in the functions, we'll have more intelligence about what might change and what we need to do. In the supplementary budget, we may well move money around to make sure that HEIW can deliver on its mission. But I go back to the point that I made, again, at the start as well: there is, of course, the budget and how effectively we use the money that we have, but there is also the point about having that more holistic overview, having a more intelligent way of delivering against the system. Some of that won't be about money; it will be about leadership, it'll be about cultural change, and it will then be about making a smarter choice about how we use that money. So, that is part of the mission that HEIW have. You won't see that in a budget line, but you should see that in the outcomes we deliver, not just with how much money we use, but actually how those staff are trained.
Cab Sec, you've inspired Angela to ask a question. We'll come back to you then, Dawn.
Dawn was talking about the training, but actually I just wanted to ask a quick question about the current staff, because, of course, one of the big hammers on the budget line is sickness absence and we have very, very high physical sickness and mental health rates within our NHS and our social care. I think, yesterday, in the amber category review, the ambulance service said that they had the highest sickness rates of all of the home nations in terms of absence, and I remember that I looked at the figures for 2016-17 and that, on mental health alone, we had sickness rates that equated to over 900 person years of absence. So, I just wanted to know, in terms of how to protect that budget and protect our current staff, let alone talking about the new staff and their development, what Welsh Government is doing to try to keep people healthy, keep them doing their jobs. Because, you know, all these difficulties we have in filling roles could actually—a lot of that, I would have thought, could have been solved if we could keep the people we've got well and happy and feeling motivated and secure in their jobs, that they want to come to work and enjoy that quality of life.
Of course, some of that is one part of the quadruple aim, as well as measures we've taken through the pay deal and looking to better manage absence, from both the employee point of view as well as the employer point of view. I don't know, Andrew, if you want to give some more detail on that.
I think this is where we have to ensure that the role that Health Education and Improvement Wales takes as a national organisation is complemented, while, of course, the majority of the workforce costs are still within the individual health boards and trusts as organisations. The Cabinet Secretary is absolutely right—I think that one of the differences that came through very strongly from the parliamentary review process was their wish to adopt the quadruple aim to make sure that we had a real focus around the overall well-being of our staff and validated it. To some extent, I think that the NHS has to demonstrate its ability to be an exemplar in this area, but it's quite true that we know that there still is progress to be made on sickness and absence across different organisations in Wales.
Size will be a factor. So, it's probably no coincidence that Velindre, for example, has one of the lowest sickness and absence rates in Wales, but your sense is of a more intimate organisation, and it perhaps can discharge some of its relationships with the staff a little differently. I was pleased, however, that, as we're going through our mid-year review process with all of the individual health organisations this year, Aneurin Bevan health board, for example, were having six months where it was below a 5 per cent target, which was the first time that we'd seen that consistently. I felt that that chimed very strongly, actually, with the very positive staff survey set of results that they've achieved recently. So, it's absolutely clear that, for us to deliver the outcomes that we want for our population, we need the workforce to be making progress.
I still think there's some outstanding work to be done with the Welsh Ambulance Services NHS Trust, as you say—I think that was a strong feature of the amber review—but they have made genuine progress in their sickness and absence levels from where they were, certainly looking back three or four years or so ago, so I think it's work in train at this stage. But I think we are going to have to deploy a more national focus, as well as some choices that people make in their local services. Some choices are, for example, do we leave occupational health services as a local mechanism? Do we elevate that to perhaps more of a national network of occupational health services? How do we underpin and support primary care in some respects? These are some of the choices that we have to make, I think, going forward.
Will you be monitoring that through HEIW, or will you be monitoring that as part of your transformation board, because the cost savings would be extraordinary and would benefit this budget enormously?
Yes, indeed. I think that this is where getting the right balance of staff for the future and ensuring the commissioning numbers are right to make our system as safe as possible is where the HEIW role comes through. I absolutely think that us improving sickness and absence and going at other areas of workforce improvement—like the level of agency and locum work; we've actually saved about £30 million on that just over this last 12 months—is important. But it probably is an arena that fits in our performance management approaches, so it is absolutely a discussion taking place in the mid-year and end-of-year reviews, but also at the value and efficiency board, which I chair, because there is definitely scope to do more and to free up time and resources.
Fine. We're in the red zone in terms of rugby internationals now—timings. Dawn, one last question.
My final question, yes—
And then Gareth.
—and it is one that the Cabinet Secretary and his predecessor will have heard me talk about many times before, which is parity between social care staff and healthcare staff. It's something that a number of stakeholders have raised with us. You've allocated something in the region of £94 million for the 'Agenda for Change' pay award, but quite often we're seeing health and social care staff working side by side, quite often doing very similar work, and the social care sector, we know, finds it really difficult to recruit, certainly compared to health staff. You don't have to be a rocket scientist to work out why, you know, in terms of the terms and conditions and pay. So, do you recognise that disparity and what some of our stakeholders see as the lack of parity of esteem between those two groups of staff as a problem and as a barrier, and is this something that, in the longer term, we do need to address?
In the longer term we will need to, and I regularly get asked this question. Sometimes it's almost presented as a barrier to delivering the vision of a more integrated and seamless system. I think the first barrier is getting organisations to work together in a meaningful way. That's why we talked about budget choices. But, we can't avoid the reality that an occupational therapist, for example, employed in the health service or local government is likely to be on a different rate of pay. So, we will need to address that, but it is a medium to longer term challenge.
On the broader point about parity in terms of esteem and how people are seen, well, their challenge is that we're seeing through what Huw is leading on, for example, in skills in the workforce, in delivering and recognising cost pressures to make sure that the real living wage is paid. So, we are trying to be not just sensitive, but to do something practical about those. At the same time, we want to raise not just the profile, but the esteem and the dignity that staff within the care system have as well. So, I recognise the point. It's a real issue. It's not just a theoretical challenge. We know it affects the way workers feel in workplaces. But we'll have to address that over time and to be clear that we are addressing it. I think there's an element of people having faith that we recognise it and that the employing organisations do as well.
I think the first thing is acknowledging it. I don't think that it's a bad thing that the more integrated ways of working that we are now pioneering in Wales are flushing some of this out, and you are having teams of people working alongside each other very, very well, who are then looking at each other and going, 'Oh, crikey. Look at the—. There is this disparity.' Now, the first thing is acknowledging that, and then setting out that plan of work that says, 'What can we do?' Now, there are immediate things that we can do, as the Cabinet Secretary said: last year, the £90 million that we put into the living wage; the additional money that we put in this year to the living wage; dealing with things like call clipping within Wales, which we've already taken measures on; things like the professionalisation of the workforce and the voluntary move towards the registration of domiciliary care, followed by mandatory. We are looking at it now for residential care, further on as well. All of those things are to do with esteem, but alongside it has to come that look at, as we go forward—. We can't do it overnight because we know the pressures on the systems. But, we do need to look at those terms and conditions, and we want to.
So, there are things we can do now. Longer term, Social Care Wales and HEIW are working together to develop a long-term workforce strategy to underpin this work, this thinking. Part of it is developing the workforce, and part of it is so that there are ways that you can work across the system. If we have seamless provision at the front end, you also need training and development that is seamless as well, so that people see it as a career where they move across pathways. And yes, we will need to address this issue going forward, as well, about the parity of pay and conditions. That's something that we're alert to, but it's not going to be an overnight fix because we come from very different historical positions within social care and social services—quite a disparate system, as well, of providers, compared to health. But, yes, we are alive to this.
Okay. Gareth Bennett is going to round things off with a few quick questions.
Thank you, Chair. In January, the Wales Audit Office made recommendations about NHS Wales informatics systems, and the Welsh Government said that it was going to undertake a robust assessment of the investment required. Can the Cabinet Secretary update us on this and on how far the draft budget gives enough funding for the Government to deliver its vision for digital and data?
It's part of what we expect to deliver through 'A Healthier Wales', and Andrew will be able to give you an update.
It's a very strong component of the vision and the strategy for Wales. Enabling technology in support of our communities and our staff is a really important aspect. We have done an indicative approach about how much we would need to spend across different health boards and trusts in Wales. So, over a period of about five years or so, they have indicated that they feel that probably in excess of £400 million is needed at this stage. We actually spend about £160 million a year already in terms of our ICT and our staffing infrastructure around digital in Wales, but it's a very deliberate choice within the budget process to have an additional £25 million in there on the revenue side. There's already been a commitment to £25 million on the capital side. So, there's a £50 million additional sum. I actually feel that, in terms of advising Ministers, going forward, we're likely to want to expand that. There are some limitations at this stage, that if we are going to be procuring, for example, national systems, just the process of the specification and the procurement mechanisms is more likely to push that into 2021 and beyond, but, certainly, it's a starting point for next year doing that.
I should also say that, wherever there is flexibility, Ministers do take judgments about where they want to apply funding at this stage. So, we have had some slippage during this year. That's been made available. Even over the last 12 months, we've been able to put investments into areas like cyber security, for example, and those very high priority areas. So, I would say that the budget next year is an increase, and it's a starting point, on that increase, but I do think that digital needs to be more of a significant feature for the subsequent two years of the budget process, albeit subject to advice.
Fine. Last question, Gareth.
Thanks for the answer. The last question is to do with prison healthcare. How does the Government anticipate its work with health boards and HM Prison and Probation Service about developing a shared set of priorities that will help to secure increased and more sustainable funding for prison healthcare?
Well, I would still like us to have an open conversation about meeting the healthcare needs of prisoners, rather than having a one-off allocation that lasts forever more, because we recognise that the healthcare needs of our prisoner population are increasing. But that has to be a grown-up conversation between us, and also recognising that we don't actually provide all of the healthcare for all of the prisoners, because there are different arrangements depending on the ownership of the prison.
Recently, I was in Swansea prison, with the governor, looking at some of the work we're already doing on, for example, having pharmacy teams and having support that's provided. It's a whole range of need, from physical health to mental health need, in particular, but also substance misuse, too. I was really struck by the fact that hardly anyone was wearing glasses, and I don't believe that the prisoner population have uniquely brilliant eyesight that does not require the provision of glasses, and I don't believe they were all wearing contact lenses. But when I raised it with the governor, he said, 'That's a very interesting observation'. He said that he himself buys glasses for prisoners to do reading, but he'll go away and look at why that is. So, there's a challenge about understanding the need that we have, how we meet it, and there should always be a continuing conversation about meeting healthcare needs of the prisoner population, because it does affect their ability to rehabilitate and come out and not re-enter the criminal justice system after leaving custody.
Diolch yn fawr. Rydym ni wedi gor-redeg, ond diolch yn fawr iawn i chi am eich presenoldeb y bore yma ac am ateb y cwestiynau mewn ffordd mor gynhwysfawr. Diolch yn fawr iawn i chi. Yn ôl ein harfer, yn naturiol, byddwch chi’n derbyn trawsgrifiad o’r trafodaethau yma, ond gyda hynny, fe ddywedwn ni ddiolch yn fawr iawn i chi.
Fe wnawn ni dorri am egwyl o bum munud rŵan. Diolch yn fawr.
Thank you very much. We have gone over time, but thank you very much for attending this morning and for answering the questions in such a comprehensive manner. Thank you very much. As usual, you will receive a transcript of the proceedings. With those few words, I'll again thank you very much.
We will have a five-minute break now. Thank you.
Gohiriwyd y cyfarfod rhwng 10:32 a 10:40.
The meeting adjourned between 10:32 and 10:40.
[Anghlywadwy.]—awn ni ymlaen i drafod Bil Awtistiaeth (Cymru), nid am y tro cyntaf, ac, efallai, nid am y tro olaf. Ond mae'n hyfryd i groesawu Paul Davies, yr Aelod sy'n gyfrifol am y Bil. Croeso, Paul. A hefyd, yn ei gefnogi, mae Stephen Boyce, y gwasanaeth ymchwil, ac Enrico Carpanini, y gwasanaeth cyfreithiol. Croeso ichi'n dau.
Mi fyddwch yn ymwybodol ein bod ni wedi derbyn toreth o wybodaeth ynglŷn â'r pwnc yma ac, wrth gwrs, yn naturiol, rydych chi'n cofio bod o flaen y pwyllgor yma rai wythnosau yn ôl. Ac rydym ni wedi derbyn llawer darn o dystiolaeth ysgrifenedig ac ar lafar yn y cyfamser.
Felly, fel sy'n draddodiadol, gan fod amser ychydig bach yn dynn eto'r bore yma, awn ni'n syth i mewn i gwestiynau ac mae Angela Burns yn mynd i ofyn y cwestiwn cyntaf.
[Inaudible.]—reach item 3. We go on to discuss the Autism (Wales) Bill, not for the first time, and, perhaps not for the last time. But it's great to welcome Paul Davies, the Member in charge of the Bill. Welcome, Paul. And also, supporting him are Stephen Boyce, from the research service, and Enrico Carpanini, from the legal service. Welcome to you both.
You will be aware that we have received a substantial amount of information about this subject and, naturally, you remember being before this committee a few weeks ago. And we've received a number of pieces of written evidence and oral evidence in the meantime.
Therefore, as is traditional, as time is a little bit tight again this morning, we'll go straight into questions and Angela Burns is going to ask the first question.
Cadeirydd. Thank you.
Call me 'Llywydd' if you want. [Laughter.]
Good morning, Paul. Obviously, you've been following the events of the committee as we've been looking through the scrutiny process and the evidence that we've heard, particularly from other organisations and the Government. I just wandered if you'd like to give us an overview of whether or not anything that you have heard has made you want to change, improve, take out, alter in any way any aspects of the Bill that you have before us.
Yes, I've been, obviously, following the evidence sessions very closely. I'm still of the view that this primary legislation should go forward in order to improve services across Wales to ensure that we've got consistent services across Wales for people with autism. I think people have been waiting long enough to see improvements that they need. Now, my Bill identifies autism as a condition that requires greater attention and it sends out a strong message, I think, that Wales is committed to ensuring that people with autism actually receive high-quality, accessible services where they actually live in Wales on a permanent basis.
The autism strategic action plan was published some 10 years ago. Some 10 years ago, we were talking about problems with regard to healthcare, with regard to education, with regard to housing. And, unfortunately, we're still, actually, talking about those same problems, and that's why I believe that this legislation is absolutely crucial. I believe that this legislation will change people's lives, will improve thousands of people's lives by putting these services on a statutory footing.
Now, I'm aware that the Cabinet Secretary and other witnesses have said that existing legislation—the social services and well-being Act and the Additional Learning Needs and Education Tribunal (Wales) Act 2018 can actually be used as vehicles to deliver some of these improvements in autism services. But I believe that those pieces of legislation are actually limited in that respect. They are generic pieces of legislation and they weren't actually designed to address all of the needs of people with autism. And I know that anecdotal evidence suggests that, so far, the social services and well-being Act has not actually made significant improvements to social care services for people with autism. And I know that Gareth Morgan of Autism Spectrum Connections Cymru told this committee, and I quote:
'we are still seeing hundreds upon hundreds of people with autism who are unable to access assessment through social services.'
Now, I'm also aware, of course, that the Cabinet Secretary has proposed a code of practice and he's looking to introduce a code of practice. We haven't seen the specifics of that code yet, so it is, actually, difficult for us to comment on exactly what the Welsh Government's proposals are. But from the discussions that I've had with the Cabinet Secretary and with the Welsh Government, I understand there's no commitment to a shorter waiting-time target for assessment under that code of practice. There are also no measures to improve data collection on autism either under that code of practice.
I'm also aware that, as a committee, you've had evidence from witnesses who have actually questioned the effectiveness of autism legislation elsewhere in the UK, but there are clear differences, I think, between my Bill and other legislation that has been passed in other places across the United Kingdom. A major difference between my Bill and England's Autism Act 2009, for example, is that England's Act is only concerned with adults who have autism. Obviously, my Bill covers children and adults, and my Bill also sets out the key issues that a strategy must address. Legislation in England and Northern Ireland lacks this particular detail as well.
And I think there is strong support for this legislation. Obviously, as you know, I've undertaken two consultations. The majority of the people that actually fed into those two consultations actually support this piece of legislation. And, indeed, there have also been certain bodies who have welcomed this piece of legislation. The Royal College of General Practitioners said, and I quote:
'We would support the need for legislation by Welsh Government'.
Hywel Dda Local Health Board sent two response into my consultation. The mental health section of Hywel Dda university health board said
'We would welcome the introduction of this legislation in Wales to bring us into line with the other UK jurisdictions.'
And Betsi Cadwaladr University Local Health Board has also said that 'Legislation is a positive step.' So, I think there is overwhelming support for this piece of legislation, and I'm very passionate that we do see this legislation going forward, because, at the end of the day, we need to ensure that these services are actually put on a statutory footing. And it remains my firm belief that this legislation should go forward.
Okay. We'll drill down to some of the details. Lynne has got a supplementary first.
Thanks. Good morning, Paul. You said that you think there's overwhelming support for the legislation, but you'll have seen that the committee has had a lot of powerful evidence from very respected organisations like the Royal College of Paediatrics and Child Health, the community of practice practitioners in autism, who didn't just feel that this wasn't needed, but felt that it might be counterproductive because it's not sufficiently, they said, child centred, because they believe it'll lead to a drive on diagnosis rather than looking at the needs of the whole child. How do you counter those kind of arguments that we've had?
Well, I think if you look at my Bill, at the outset, it makes it absolutely clear that it is needs centred, and I'll quote this to you:
'An Act of the National Assembly for Wales to make provision for meeting the needs of children and adults with autism spectrum disorder in Wales and protecting and promoting their rights, and for connected purposes.'
So, I don't accept the premise that this is just diagnosis centred. I believe this is a holistic Bill, because it doesn't just actually look at diagnosis. Of course, yes, it does look at diagnosis. It wants to improve the waiting times as far as diagnosis is concerned. Of course the Bill wants to address that, but the Bill also wants to address many other issues as well—making sure that we collect the right data, making sure that staff dealing with people with autism get the appropriate and right training. So, there are many other issues involved here as far as this Bill is concerned.
It's concerned with, as I said, a range of services in order to ensure that people with autism can actually access healthcare, access education services, access employment services, housing services. And I understand that the social services and well-being Act, and the additional learning needs and education tribunal Act take a needs-based approach rather than a condition-based approach, but this Bill won't change that in any way. The provision of services for people with autism, as for other conditions, will continue to be made on the basis of need. People with autism may have a range of needs, not all of them related to their diagnosis. Some may not require any additional help at all.
Now, the Welsh Government, of course, has chosen to pursue a specific strategy for autism, based on diagnosis, and has also indicated that the proposed code seeks to cover much of what the Bill does. So, clearly, it thinks that such an approach can work together with existing legislation as well. Indeed, the refreshed autism spectrum disorder strategic action plan has assessment and diagnosis as one of its key priority areas. So, the Welsh Government is taking this approach as well. So, I don't accept the fact that this Bill is just diagnosis centred. It's much more than that.
Okay. The next couple of questions are with Dawn. Some of it has already been covered, but crack on, Dawn.
Yes, it has. I just want to build on that issue of the Bill being diagnosis driven. And, as you say, you do recognise that that's what a number of the professional organisations see the Bill as, so they may need some persuading that that's not the case. But one of the things that came out of that was that many of them felt that the risk of what they see as diagnostic-specific legislation—and I take the point that you've made that you don't feel it is, but that's what they feel it is—is that that in itself would have a negative impact on people who don't quite meet that diagnostic threshold, and it's to get that diagnosis that takes you into the next level and access to the various pathways. Do you accept that, or do you not accept that? What's your response to that?
I don't quite accept that, because, obviously, if people are waiting for a diagnosis, they don't know what their condition is at that stage. What's important here is that they get that timely diagnosis, that they get that diagnosis as quickly as possible. And, surely, once a professional makes a diagnosis, whether it's for autism or other conditions, they should be then referred to services that should be available. And that's the purpose of this Bill—to make sure that people with autism get the access to services that they actually deserve.
There was the issue of the threshold levels—you know, some people have levels on the spectrum that are quite low, but sometimes their needs are greater than people at higher ends of the spectrum. I don't quite understand how that works, but that's how it's been explained to me. So they may not meet, necessarily, a diagnostic threshold, which, if they don't, would mean that they don't get access to other pathways. And the Bill seems to be pigeonholing them into, 'You only get this if you've got the label'—if you like—'of autism.'
No, I don't accept that, because if you look at the Bill, for example, it makes it absolutely clear that, even if people are actually waiting for a diagnosis, then services should still be made available to those people. The Bill makes that absolutely clear.
All right. The other one that I think we did touch on when you were here last time—but, given all the evidence that you will have seen since we've been scrutinsing the Bill—is the issue that the prioritisation of ASD would be at the expense of other conditions. You said when you spoke to us the first time that you didn't accept that; you've now heard other people's evidence, and why they are concerned that that might be the case. Have you changed your view at all, or have you got a more robust defence of the position since you've heard the other evidence?
No, I don't accept that it will disadvantage other conditions. Obviously, Wales has an autism strategy at the moment. As far as I'm aware, it hasn't disadvantaged people with other conditions; no-one has suggested that the planned statutory code of practice on the delivery of autism services will actually disadvantage other groups either. Now, this Bill doesn't seek to prioritise people with autism over other groups, but to ensure that services to which they are actually entitled are in place in all areas of Wales. And I'm not aware of any concrete evidence that other groups are also clamouring in other parts of the United Kingdom, even though they've actually passed specific autism legislation in England. So, I've yet to see any evidence that people with other conditions are actually disadvantaged in those places where there is already autism legislation.
I believe that this Bill has the potential to actually benefit people with other conditions, by, for example, raising skill levels of clinical staff, which would benefit other service areas. I think it could also raise awareness of autism generally, and of its distinct features, generating a better understanding of what is and is not autism. In order to identify autism, I think practitioners need a good understanding of related and co-occurring conditions, as well as of autism itself. National Institute for Health and Care Excellence guidelines take account of comorbidity issues in the diagnosis of autism, so services should actually be addressing this issue. And I think the Bill has the potential to benefit people with other conditions, by helping to ensure that people with other conditions—whether they co-occur with autism or not—have these conditions identified earlier. We were just talking about diagnosis; if people are able to be diagnosed earlier, that will obviously benefit people with other conditions as well. So, I think this Bill will help people with other conditions, as well as helping people with autism.
Okay. Helen Mary's got a supplementary before we move on. I'll come back to you then, Dawn.
Just very quickly, and forgive me, because I've come into the process halfway through, so if this has already been discussed and established elsewhere, bear with me—I haven't had time to read it all yet. Would it be true to say, Paul, that part of the justification for autism-specific legislation is that existing legislative frameworks don't always work well for autistic people, particularly higher functioning autistic people? For example, it's been put to me by autism organisations that some of the provisions of the social services and well-being Act are actually really difficult to apply to people with higher needs, so that, in fact, the need for legislation is that there's a gap that needs to be filled, particularly for that group of service users.
Absolutely and, of course, we've already mentioned the social services and well-being Act. This Bill isn't to be in competition with that particular Act, it's to complement that particular Act, it's to supplement that particular Act, and to ensure that those gaps you've just mentioned are actually filled, because there are gaps, there are huge gaps, unfortunately, in certain areas of Wales when it comes to some of these services, and that's why it's absolutely crucial, in my view, to get this legislation passed, to make sure that these services are actually put on a statutory footing.
Just a final question, Paul, if I might. I just want to see whether you accept this point. We've heard from the speech and language therapists—the Royal College of Speech and Language Therapists, in particular—that they felt that the Bill could interfere with their ability to apply their professional judgment. What they were saying was that they were noting that prudent healthcare means that those with the greatest needs should be prioritised, but the statutory requirements in this Bill would mean that they would be directed to prioritise people with ASD first. Do you accept that point or—?
No. Why would they be directed?
Because they would say that ASD would be a priority condition within the wider services.
As I've just explained to you, I think that by passing this legislation, it will actually benefit people with other conditions. Now, obviously, when they say they'd be directed, the fact of the matter is that, surely, if people who are waiting for a diagnosis are actually seen earlier by clinicians, by professionals, then surely those professionals can then point them towards the services that they should be accessing in the first place.
Absolutely, but I think what they were talking about was in the context of the resources are the resources, and once somebody is diagnosed with a statutory condition, they may be directed to deal with that before dealing with other people who are in the system with other diagnosed conditions that have not got the benefit of legislation behind them.
I don't accept that this Bill is going to change the diagnostic criteria. It's not suggesting that at all. What this Bill is trying to do is to ensure that services are actually put on a statutory footing, and that those services are actually available. So, I don't accept that this Bill would actually change the diagnostic criteria and therefore have an impact on what you've just referred to. Enrico.
We mustn't forget the fact and the point that Paul made earlier that diagnosis is also central to the strategy and the code, and similar criticism could apply in that scenario. So, we mustn't lose sight of that. Equally, we haven't as yet seen evidence from other jurisdictions—England, Northern Ireland—that the legislation in those places has had that impact that the speech therapists are concerned about. Also, the Bill recognises that additional resource will be required to deliver it, and that's fully costed within the impact assessment. So, it recognises that additional resource may be required to deliver its purposes, including diagnosis.
Okay. Julie, you've got the next two questions.
Yes, thank you very much. These are very much on the same theme, but it seems to be one of the key themes. The evidence that we've received has been very positive about the recently developed all-Wales shared neurodevelopmental pathway, which was really felt has been very helpful in moving to more needs-based assessments and interventions. They did argue, some of the organisations, including the royal colleges, that the Bill would potentially undermine progress made with the focus on autism only. So, I don't know if you have any more you could say about that.
I don't accept that, of course, because I think, again, the Bill is clear. Yes, we want to create a clear pathway for diagnosis of autism. However, if you've received evidence to suggest that I should be looking further at these specific pathways, then, perhaps, I'd be more than happy to look at that at Stage 2.
I think what they were saying was that, with the focus on autism only in the Bill, it would undermine the development of this pathway, which they felt was going well—the wider pathway.
The Welsh Government's intending to introduce a code of practice that it says will strengthen the autism services. But I'm not aware that people are making the same point about that in relation to integrated autism services and those other—.
This was what the experts in the field were saying to us about specific legislation on autism.
But, certainly, the intention of the Bill is to work within existing developments, not to undermine them.
Right, thank you. And the Royal College of Paediatrics and Child Health told us that we need to join up current initiatives such as the neurodevelopmental work, the integrated autism services, additional learning needs and adverse childhood experiences, and they think we need a framework to tie it all together, but they felt we don't need legislation. So, that was their view to us.
I agree. There needs to be a joined-up approach. There needs to be a joining up of this range of initiatives that actually aim to address the multiple needs of people with disabilities, developmental or mental health needs, including those with autism. I don't think my Bill would be a barrier to that, and I don't believe that putting the autism strategy on a statutory footing would actually prevent the development of an overarching framework.
I know you are aware that we've had expert after expert coming in and saying legislation is not needed, but that hasn't made you reassess it at all.
Okay. Helen Mary Jones has got the floor now.
I'm going to be putting some points to you, Paul, as other Members have, that have come out of evidence that we've had. I want to be clear that, when I'm putting those points, that doesn't necessarily mean to say that I accept those points. They're points that are to be put, they're not necessarily points that I agree with.
I understand that.
So, we've already discussed with other Members the issue around diagnostic targets, and that you don't feel that there would be any inevitable impact on diagnosis times for people with other conditions. But one of the points that have been put to us is that the emphasis on diagnosis in the Bill could potentially distract and detract from post-diagnostic support and intervention, the theory being that professionals will be putting all their effort into getting everybody diagnosed, and they'll have no time to treat people. I must say I'm sceptical about that, but how would you respond to that?
Well, I would say that most of the Bill is concerned with the provision of support needed by people with autism, and if you look at section 2(1)(c), it requires that diagnostic assessments and any post-diagnostic meetings are commenced within the National Institute for Health and Care Excellence timescales, which is, of course, 13 weeks currently. In addition, section 2 requires the autism strategy to actually outline how the needs of people with autism are to be met by a range of services, including healthcare, education, employment and housing. So, I don't think that my Bill would change that in terms of post-diagnosis support.
If we were to recommend that the Bill proceeded to the next stage, would you be prepared to take a look at that, to see whether there's anything that might need to be done to strengthen the reference to post-diagnostic support? Because it may be that people have seen the diagnosis stuff, and that that's really stood out for them, and that the post-diagnosis stuff hasn't stood out as much. Whether that's because of perceptions or whether that's because—would that be something that you might be prepared to look at, to see if there was a need to strengthen?
Absolutely, and I think I made this clear to the committee in my last evidence session with you that, as people gave evidence to you as a committee, if you felt as a committee that there were areas of the Bill that you would want to strengthen, then I'm more than happy to look at that at Stage 2.
Thank you. Something else that we've heard with regard to diagnosis is that it would be relatively easy to superficially comply with the waiting-time diagnosis target, so that you respond with an initial contact, a letter or a phone call, but then the actual real process of diagnosis might still take a very long time. Other people have noted that the target is for initial assessment but that full diagnosis can still be quite slow to be completed. And certainly, I think, in the session that Dawn and I had with some family members, there was also a concern that you don't want to do the diagnosis too quickly—and this was in the context of children—that some of the children's needs are quite complex and it may be difficult, particularly for a high-functioning young person, and it may take a long time to do the diagnosis. How do you respond to those concerns, both the point that you could do that superficial first contact, and then it might be a very long time until anything really happens, or that perhaps pressure of that might—? I think the fear was that some young people would end up not being diagnosed because their level of need took longer to come through in a diagnostic process.
I think there seems to be some confusion about the three-month maximum timescale in the Bill for the period from referral to start of diagnostic assessment. Now, for clarity, the intention in the Bill is to introduce a target from referral to first appointment for assessment. Now, the relevant NICE quality standard states, and I'll quote this:
'People with possible autism who are referred to an autism team for a diagnostic assessment have the diagnostic assessment started within 3 months of their referral.'
Now, I read this as meaning that the formal diagnostic process is to be started, rather than just being an administrative process, such as sending an appointment letter, for example, which, obviously, you've suggested. But, again, to avoid ambiguity, I'm happy to introduce an amendment at Stage 2 that makes this explicit, if you feel, as a committee, that should happen.
That's helpful. I'm not sure it's necessary, but it's useful to know that you'd consider that. Something else that we've heard, and we've heard this from the Cabinet Secretary and others, is that legislation in this field would direct resources. The royal colleges told us that the resources would be focused on meeting the statutory targets and that other services, interventions and support, might be detrimentally affected. It was even put to us that this might constitute discrimination. I mean, I have to say, as a former equality professional, I'm at a loss to understand how it might, but it's been put to us, so we need to raise it. But the broad point there is about directing resources to one group of people with one set of conditions and needs at the expense of others.
Well, I think I've identified the additional resources that I believe are required to actually meet the needs of implementing this Bill. I think my explanatory memorandum and my regulatory impact assessments make it absolutely clear that, obviously, this Bill would cost some £7.4 million, over a period of five years, to implement. So, I believe that I have costed this appropriately and that those resources will actually meet the needs of this particular Bill.
So, would it be your contention, then, that rather than taking resources away from other services, putting this on a statutory basis would ensure that the Government had to put in the funding for the services that the Bill would require?
Yes, and that's why I've costed them accordingly.
That's helpful clarity for me. So, if I can move on to some workforce issues that have been raised with us, and, again, it is not to be assumed that I necessarily concur. The royal colleges have heightened concerns, basically saying that we haven't got enough people to do this. So, a lack of workforce capacity has been cited as a barrier to delivering the Bill. Have you had any discussions with the royal colleges, and would you be happy to have some discussions with the royal colleges, about what they see as the workforce issues? Or would it be your contention that the workforce issues would be addressed through the additional resources that you've identified that would be needed to deliver the Bill? I mean, basically: do we need more people to do this, and if we do, does the cost of those people come into the assessments you've already made?
I haven't had discussions with the royal colleges but the royal colleges did respond to my consultations on the Bill, and they did, obviously, highlight the workforce pressures autism services actually face. Now, while it wouldn't be appropriate to include detailed workforce provisions on the face of the Bill, I have actually taken account of staffing resources in the cost estimates that I referred to earlier. Now, I accept that increasing workforce capacity will not happen overnight, but it is an issue that needs to be addressed if we are actually serious about improving services for people with autism. And no doubt even the Welsh Government will acknowledge that, given that it's looking to introduce its code of practice. Now, my explanatory memorandum does actually highlight additional funding to actually implement this Bill, as I've just mentioned, and the impact assessment also suggests that investment will be needed over a number of years to ensure that some of these workforce capacity issues that you've mentioned are addressed.
The Royal College of Paediatrics and Child Health, which has been referred to already, has said to us that they think that the questions about capacity and workforce need to be properly considered before we put through specific legislation that impacts on—well, they say 'cuts into' the workforce, but I think they mean impacts the workforce. Would it be your contention that, in fact, it's the other way around and that we need the legislation to drive the workforce development, rather than—?
Absolutely right, yes.
Yes. That's—. I think you would acknowledge, though, that not having the right workforce would make it difficult for the Bill to be implemented.
Yes. I do.
Okay. Angela, you've got the floor, now.
Yes, thank you very much indeed. I just wanted to ask you about the integrated autism service, because we've done quite a few meetings with people who are either the parents and carers of people with autism or who have the autism condition. And our outreach team has also gone out and talked to an awful lot of people and they very clearly have come back with the message that almost, almost—I think I'm right in saying—almost without exception, they haven't been able to access the appropriate services at the right time and so on and so forth. And then, of course, the Government will counter that by saying that the integrated autism service will be able to put in place all of these things. But what we've heard as a committee is that the integrated autism service is very much a signposting service, and offering training and offering advice, which has been provided in the past by a great number of third sector organisations. But do you think that, if the integrated autism service was beefed up by the Government, that would deliver the kind of support levels that people who look after people with autism require?
This Bill isn't to undermine the integrated autism service. I think this Bill will actually underpin that particular service and strengthen that service going forward. But what this Bill will actually do is ensure that services are actually put on a statutory footing and that all health boards, all local authorities, will be mandated to actually deliver these services and ensure, therefore, that we fill some of these gaps that we were talking about earlier on. But this is not to undermine some of the measures that the Government have actually introduced over the last couple of years. I believe that this Bill is there to underpin some of those services and to make sure that those services are actually put on a statutory footing.
Also, it's clear—the intent of the Bill is clear in that regard. We included specific provisions to allow for actions that had been taken and processes and regimes that were put in place prior to the Bill coming into force to be taken into account. And, where appropriate, in that they deliver the requirements of the Bill, then they are a valid element of the overall autism delivery going forward under the Bill. So, it won't undermine existing regimes and practices; it will recognise them and incorporate them where appropriate.
Also, we built into the Bill a provision in section 3 that allows for assessments to be carried out together. Again, that was with the intention of recognising that there are other regimes out there that the Bill needs to work in harmony with. So, for example, with the Social Services and Well-being (Wales) Act 2014 or the Additional Learning Needs and Education Tribunal (Wales) Act 2018, it will work in parallel with them, rather than against them, and I believe—we believe—will address some of the gaps in that legislation.
So, if I could just flip it on its head for a moment and turn this around the other way and say to you that the wording on the Bill says that the autism strategy must
'make provision so that an appropriate range of services to deliver the autism strategy is available'
across the country, do you actually think that that's strong enough? Do you think that, if this Bill were to go ahead, that wording, 'must make provision for appropriate'—do you think that is actually strong enough, or do we need to look to strengthen that wording?
Well, if the committee feel at Stage 2 that that should be strengthened, that's something, again, I'm more than happy to look at.
Also, when interpreting legislation, there are well-established principles, and, because we've included a lot of detail in the Bill, one can glean, when interpreting that, the parameters within which the Welsh Ministers must operate and what they must deliver. Also, there's a legal principle, called the Padfield principle, which requires that, where Ministers are exercising a discretion, they must do it with a view to promoting the overall purposes of the Bill. So, if you read 'appropriate' as meaning there is a degree of discretion, that's not unfettered; Welsh Ministers still need to deliver the overall purpose of the Bill. But, as we've said, if committee thinks that the Bill needs strengthening in that regard, then at Stage 2 I'm sure Paul would consider it.
I'm sorry to keep rehearsing the same argument again, and I know that you've heard it from almost everybody else here, because, you know, it's very clear that Welsh Government are saying, 'We really don't see the need for this Bill', and the Cabinet Secretary argues that the Bill will not deliver on this aim to provide those extra support services but that his code of practice can and will. What makes you so sure that his code of practice can't and won't?
Well, because the code of practice, for example, will not create a legal requirement on the Welsh Government to publish an autism strategy, to review it and have it independently evaluated, nor will it set out in law the key issues that a strategy must address. The Bill identifies these issues, many of which are actually concerned with the provision of services for people with autism. So, I think there are clear differences between my Bill and the proposed code that the Welsh Government are looking to introduce, even though we haven't seen the specific details of that code yet.
Sorry. The code is not permanent. Also, whilst there's been a lot of talk around the force of the code and the fact that it has a statutory basis, it's not mandatory in relation to health bodies. The obligation there is to 'have regard'. There's also been some confusing evidence, or criticism, about the lack of so-called remedies under the Bill, but that's slightly misleading, because actually what's been referred to in evidence by the Government are actually powers that relate to enforcement, and that's different, and we may well go on to that, but that's not the same as a remedy. So, actually, the code does not trump the Bill. In fact, we consider it to be weaker than the Bill.
And my understanding also is that the code won't introduce a waiting-time target from referral to start of diagnosis in line with the National Institute for Health and Care Excellence standard. Of course, my Bill will do that.
And can I just ask you, just to make sure I heard this clearly: so, your Bill will be able to have an element of compulsion on health boards, as well as other organisations, to provide support services—
—but the code will not have that ability to flex muscles over the health boards? Because we know from other experiences that they're always the harder people to get to the party.
Not in the same way. It's a duty to 'have regard'. So, the Welsh Government can enforce that duty to 'have regard', but there's a degree of discretion there. They may consider that they have other means to persuade health boards, but that's a black art, possibly.
And I don't suppose it helps with consistency.
Because one of my key drivers, from the position I sit in, is I want to see consistency of services across Wales.
Lynne, you've got a supplementary—I'll come back to you now—on this point.
Just briefly, I was just going to ask: if the Welsh Government was minded to include the NICE guidance on waiting times in their statutory code, does that alter your view of how favourable that would be?
That'd be helpful, of course, but, again, as I mentioned earlier, Lynne, my Bill does more than that, it's not just about obviously—
No, I understand that.
—the waiting time referral targets, it's also about making sure that staff receive the right training, it's making sure that we collect the right data so that local authorities and local health boards can actually plan services ahead. So, my Bill is much more than the code, in my view.
Okay. Angela, or had you—
No, because I think you've talked about the financial element already.
Good. Julie then.
Right. Thank you. We've heard a lot about the barriers between the different areas—health, education, social care. Would the Bill provide new statutory powers for cross-referrals between the sectors?
I think the Bill will put the autism strategy on a statutory footing, and it will require the strategy to make provision for the development of a pathway that includes access through defined points of referral, to map the services that are available and required for persons with autism spectrum disorder. Therefore, I'd expect this to include referrals from all appropriate sources, including primary care. So, I believe, yes, my Bill will certainly help with that.
Right. The Welsh Government says it's looking at a primary care referral pathway in developing its code of practice. So, you are intending to have such a pathway in your own code of practice under the legislation.