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Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

13/12/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns AM
Dai Lloyd AM Cadeirydd y Pwyllgor
Committee Chair
Dawn Bowden AM
Helen Mary Jones AM
Julie Morgan AM
Lynne Neagle AM
Rhianon Passmore AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Catrin Edwards Hospice UK
Hospice UK
Dr John Wynn-Jones Cadeirydd Gweithgor WONCA ar Feddygfeydd Gwledig
WONCA Working Party on Rural Practice
Kathleen Caper Hospice UK
Hospice UK
Mark Isherwood AM Tyst
Witness

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Claire Morris Clerc
Clerk
Lowri Jones Dirprwy Glerc
Deputy Clerk
Philippa Watkins Ymchwilydd
Researcher

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 09:31.

The meeting began at 09:31.

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

Croeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon, yma yn y Senedd. O dan eitem 1, a gaf i estyn croeso i’m cyd-Aelodau o’r Cynulliad? Rydym ni wedi derbyn ymddiheuriadau oddi wrth Neil Hamilton. O dan ddatganiad buddiannau, mae’n rhaid i Julie Morgan a finnau hefyd ddatgan ein bod ni’n aelodau o’r grŵp trawsbleidiol yma ar ofal lliniarol, felly, yn amlwg, mae gennym ni fuddiant yn yr adroddiad rydym ni’n ei archwilio. A oes yna unrhyw fuddiannau eraill sydd angen eu datgan? Angela.

Welcome, all, to the latest meeting of the Health, Social Care and Sport Committee, here in the Senedd. Under item 1, may I welcome my fellow Members of the Assembly? We've received apologies from Neil Hamilton. Under the declarations of interest, Julie Morgan and myself also have to declare that we are members of this cross-party group on palliative care, so, clearly, we have an interest in the report that we will be examining. Are there any other declarations of interest? Angela.

Yes. I'd like to declare that I'm a voting member for Paul Sartori, which is a hospice-based homecare system in Pembrokeshire.

A oes rhywun arall ag unrhyw gysylltiadau tebyg? Nac oes. Reit. Gallaf i bellach, yn naturiol, egluro bod y cyfarfod yma’n ddwyieithog. Gellir defnyddio’r 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. Os bydd yna larwm tân, mae hynny'n golygu bod yna dân yma yn rhywle, felly dylid dilyn cyfarwyddiadau’r tywyswyr. Ac wrth gwrs, mae’r meicroffonau’n gweithio yn awtomatig; nid oes angen cyffwrdd â nhw o gwbl.

Anyone else with any similar connections? No. Right. I can now naturally explain that this meeting is bilingual. Headphones can be used for simultaneous translation from Welsh to English on channel 1, or for amplification on channel 2. In the event of a fire alarm, this means that there is a fire here somewhere, so directions from the ushers should be followed. And, of course, the microphones work automatically; there is no need to touch them at all.

2. Sesiwn dystiolaeth gyda’r Grwp Trawsbleidiol ar Hosbisau a Gofal Lliniarol
2. Evidence session with the Hospice and Palliative Care Cross-party Group

Felly, gan symud ymlaen i eitem 2: y sesiwn dystiolaeth gyda'r Grŵp Trawsbleidiol ar Ofal Lliniarol a Hosbisau.

So, moving on to item 2: the evidence session with the Hospice and Palliative Care Cross-party Group.

We have a couple of giants in the field of palliative care—oh, and Mark Isherwood—[Laughter.]—before us this morning. And the background to this is, obviously—on the health committee's forward work programme is a review into palliative care, and then, some of us, being members, also, of the cross-party group on hospices and palliative care, realised that that group was also doing a review into palliative care. So, this is where we are today, and Mark is still having a fiddle with his instrumentation. Diolch yn fawr. Right. We've read all possible documentation, so we're going straight into questions—the short, sharp, agile team are here. 'Agility' is their middle name. First question, Helen Mary.

Thank you, Dai. Based on the evidence that you received as part of your inquiry, are you satisfied that the Welsh Government has shown, and is continuing to show, strong leadership in supporting the NHS and partners to improve palliative and end-of-life care?

Bore da. Good morning, everybody, and I'm glad to see two fellow members of the cross-party group on the committee, having some detailed knowledge of this.

We welcome the fact the Welsh Government fully accepted eight of the recommendations, and three in part, but we're disappointed that several recommendations were only accepted on the basis that work was already ongoing in the given area, despite the evidence to the inquiry suggesting that progress was slow or that evidence of progress was unavailable. There was little acknowledgement of actions in relation to improving access, particularly to paediatric palliative care. But, clearly, some other priorities were identified as well. I don't know if you wish to add to that.

I think one thing we would say is that it's difficult for us to know how well we're doing as a nation—to get that national picture of where we are—and to know whether leadership is great in that field, because we don't yet have robust measurements and data in the area, and one of the recommendations that the cross-party group inquiry put forward was that we try and fill those gaps in data and collection, and, as Mark has said, that was one of the recommendations that the Welsh Government did accept fully, but on the basis that they were probably already doing that work, whereas the evidence that we received suggests that perhaps there were gaps there, or certainly that we're unable to get hold of that information.

09:35

Can you tell us a little bit about what those gaps are? What do we want to know?

So, one of the big questions—. One of the things that we do know—I'll start with that—is around how many people receive specialist palliative care. So, we have a total number of people who are receiving specialist palliative care in Wales. We also are able to know the total number of people who are known to their general practitioners as requiring palliative care, but that data is available only in terms of the services that are out there. So, we don't know about a patient's journey. We don't know whether somebody is receiving specialist palliative care and also known to their GP, where it is they're receiving specialist palliative care—so it may be that we're double counting lots of people; they're having NHS services and they're also having hospice services in various locations. So, we don't really have an accurate figure of who is getting that palliative care in Wales. And because we don't know who is getting palliative care, it's really difficult for us to know how many people in Wales are probably missing out on that care; that is really the big question. We suspect, and academic estimates would place, that we have around 6,000 people missing out on care in Wales, but it's difficult for us to know where they are and what kind of services they're not getting because they're not captured at this point.

Okay. Thank you. So, in terms of the necessary improvements, the improvements that you identified as needing to be delivered, nationally and locally, what needs to be done to increase the reach of palliative care for people with conditions other than cancer who would benefit from those services?

Well, the evidence we received, and I'll develop on that, confirmed what we all expected, which is that hospices, having been established initially, focused primarily on cancer. The perception remained that they were primarily about cancer. The commissioning of services, therefore, tended to focus more on that direction than other areas, although particularly the voluntary sector, the hospice movement, whether that's residential, but particularly in the community and in the home and day and respite, have massively diversified, as I'm sure you're aware, particularly across a range of neurological conditions—rapid progressive like motor neurone disease, but also slower progressive end-of-life Parkinson's, multiple sclerosis and so on. They're also providing a range of services; in many case, they're providing training for or with their health boards and support in other areas. Of course, health board specialists volunteer in hospices, not only in cancer but in a range of other conditions as well. So, the sector is very keen to be seen as not just a cancer service but as a broader end-of-life palliative care service for all ages and, increasingly, all conditions, but with a focus on neurological, as we move forward.

Rhianon, you had a quick supplementary at this point.

Very briefly. In regard to the data collection/collation question that's been asked and addressed, I think, by Catrin, you said that this was already ongoing, which was one of the reasons behind recommendation 9 not being progressed in any way. How are you monitoring that in terms of where it sits and how robust that is?

So, the Welsh Government's response was that this is something for the end-of-life care board to take forward, and the end-of-life care board require all health boards to report back to them annually. The shape of that report—so, they say that they use a certain kind of template for reporting to ensure that there's consistency across health boards in how they report on national priorities, but what we've seen is that that report tends to take a narrative kind of shape—

Yes. And I think we wouldn't want to get rid of the narrative because the narrative provides the context and the stories that we need to be able to understand why health boards are doing what they're doing, but it would be really helpful to have those figures to help us know how do we compare across health boards and where are the gaps.

And so where does that sit at the moment in terms of the implementation board's mandate?

09:40

The end-of-life care board had committed to looking into this as a piece of work, and I know they've had one meeting where they've discussed this. I think they consider it to be potentially quite a big piece of work, so it might be quite slow in coming forward, but—

Yes, it would certainly be useful. We would like to see that happening. 

If I could make a further comment there, one of the challenges of even doing more quantitative work at the health board level is, until there is really quite robust needs assessment done, just counting who is getting care won't be telling us much about who is not getting care as well.

Thank you, Chair. Morning. I just wanted to ask a couple of questions around the GP palliative care register, which—I think we've seen the number of people on the register has been increasing, but you're still saying, despite that, that there's still more work that needs to be done around that. So, can you tell us just a little bit more about what you're hoping to see, and what more you think needs to be done on top of the progress that's already been made?

So, I think one of the really big challenges about the GP palliative care register is that we don't know what that means for people who are put on the register. We don't know if it is a trigger for them to be referred to appropriate services or receive appropriate services through their GP. All it tells us is that a person was put on the register. So, Catrin, if you'd like to pick up from there about next steps.

Yes. In terms of this inquiry, it was looking at inequalities in access to hospice and palliative care, and one of the issues around the GP palliative care register is that all that it does is count the total number of people who are known to need palliative care. So, that means we don't actually know anything else about those people. Perhaps each GP, you'd hope, would know about the condition that has led them to be on that palliative care register, but certainly at a national or at a regional level, we don't know whether that is primarily, perhaps, capturing—as we go back to that cancer question—people with a diagnosis of cancer who are already being seen in specialist palliative care, and, therefore, it's just letting their GP know that they're receiving specialist palliative care elsewhere and that their GP might need to co-ordinate some of that care. 

I guess we're more concerned about those people who aren't already receiving specialist palliative care, so we could think about the ageing population here. So, older people with frailty or dementia who aren't necessarily receiving palliative care elsewhere, but could benefit from palliative care from a generalist delivered in a primary care setting. We don't know whether those people are being counted or identified in primary care if they're not included on that palliative care register, so what we'd really like to see is a few more measures or indicators that can tell us a bit more about the make-up of that palliative care register. Who is on there, what are their needs, and are they being seen elsewhere?

My follow-up to that, I guess—so, you're asking GPs, really, to be a little bit more proactive in terms of the people that they see coming through their doors, and if they are receiving some kind of palliative care at whatever level, that they should be on this register, and there should be more information about the type of care that they're receiving. So, am I right in saying you don't just want a list of people who are receiving palliative care, but you need more information about what has happened to get them there, and where they're going with their care—

Yes, it would help to identify who is not being seen. So, are we only seeing people with particular conditions on that palliative care register, and, therefore, do we need to do some more proactive work where we're reaching out to people with conditions such as dementia or frailty? I guess it's not as simple as that. We're not saying that the burden should always be on GPs to make that proactive offer. We know that it's very difficult to often identify people who are perhaps in their last year of life, and GPs have said that that might be a difficulty for them. So, there were training tools that various organisations have put together to support GPs to identify when someone might be entering the last year of life and might be appropriate to go on that register. But there's also the question—the register exists because of the quality and outcomes framework, which determines payments to GPs. So, GPs will get a particular sum for maintaining the palliative care register and also for ensuring that people who are on that register are discussed by a multidisciplinary team every two months, I think the figure is. 

09:45

So, there is an incentive for the GP, in a sense, to get them onto the register, but does that also mean that there will be people who are receiving palliative care who aren't on the register who you know nothing about, basically? Yes.

It's estimated that 33,000 people a year die in Wales, and it's estimated that roughly 23,000—probably fractionally more—of those will have a palliative care need. But, in 2017-18, only 10,000 of those were on the palliative care registers.

Okay, but that doesn't mean—. Sorry, just so that I'm clear, because they're not on the register, it wouldn't necessarily mean that they are not receiving palliative care, it just means that you don't know about it and the type of care. Okay. I understand that.

I just wanted to know: are patients happy to be on a palliative care register? Because I understand that the data crunchers love data, but there's no point in it, and you're spreading an awful lot of personal information about very ill people around the networks—you mentioned regional boards and, you know, on up—unless it's going to actively be acted on, I just wondered what was the driver, apart from the fact that people want to know where everybody is and what they're doing. Is there a move from patients to be on it? Do they see a benefit? Has anybody asked them? And do they have the chance to opt out?

Well, I think you've got to have a conversation. The doctor and the patient have to have a conversation in the first instance for that patient to be on the palliative care register. The presumption is that it would be a good thing to be on that register, because we presume that people on the register will get better co-ordinated care from a multi-disciplinary team. We don't know that that's the case, and so we're not advocating that people should be on palliative care registers for the sake of being on a palliative care register, we'd actually want to know the 'so what?' question: does it make a difference if you are? The presumption is that it does make a difference, but we don't know definitely that that is the case.

Certainly, various professionals are telling us that it would be helpful if they had the information when a person was put on the palliative care register. Pharmacists in particular spoke up in the inquiry saying that they don't get to know when someone's on the palliative care register; they might find out if someone has a palliative care need incidentally by looking at their medications and saying, 'Oh, this seems to be telling me that this person has this condition', and, of course, pharmacists don't just support the person, they often support the family who will be coming in with the medications, including into bereavement. So, there was something there around other professionals thinking it would be really useful to have more knowledge about who is on that register.

I do take your point. I'm just slightly uncomfortable with the wide spreading of people's personal information. If I take the pharmacist that's attached to the GP surgery that I go to, they are so busy that they never raise their heads above the paper bags that they're constantly churning out, so I then think, well, if I think about that particular pharmacy, and it's a chain, 'Are they ever going to stop long enough to talk to anybody?' and, in all the experiences I've had, and I've watched people come and go through the system, you don't see it. So, I just have a slight resistance to just a widespread assumption that we should have a palliative care register, unless it's really well-proven that the patient gets the benefit. And the patient does get—. You presume that there's a conversation between the GP and the patient before they're plopped on it, but I'd like to see something a little bit more concrete, and I wondered if you'd had any evidence from a patient's point of view. Especially towards the end of days, you're probably feeling that you don't actually want your business spread out across the net.

I don't think we received evidence from patients directly on that.

No. I'm not aware that we did. But, taking the point back, Angela, around evidence that this would be a good thing, I think we would all welcome further research that looked at, evaluates—

I'm not saying it's a bad idea; I just wanted to test that assumption. Sorry, Dawn.

No, no. We would all say that we would want to evaluate how useful it is to be on the palliative care register, because we know that there are people who are receiving palliative care who aren't on it, and that doesn't mean that they're not getting good care; they could be getting excellent care. So, there is a question there about the 'so what?'—you know, what does it mean to a person to be on that register? Does it deliver better, co-ordinated care? We presume that it does, but we don't know that it does, and it would be useful to have that information from a Wales perspective.

Can I just add that the call came, essentially, from professionals, but the pharmacists did make a big play on this and we appreciate the point you make? I go to a GP who has a pharmacy within the practice, but this was more focused on the whole piste, particularly the community pharmacists who wish to extend their use of the professional expertise and qualifications they have into given areas and become more integrated in providing primary care within their own communities and, increasingly, acute care as well. And this was seen as a mechanism that might assist that, but also help in service planning. If you have a better database, joining up the evidence that's available, then it can help, hopefully, co-ordinate primary care teams and secondary care teams with social services to better deliver. 

09:50

Okay. Thank you. Just—my final question from me about how effectively charitable hospices and health boards actually work together to promote improved awareness of palliative and hospice care. Because I think you said in your report that early access to hospices is both dependent on referral from professionals and a person's readiness to receive that care. So, how effectively are these bodies working together to ensure that happens? Did you get a sense of that?

Mixed picture. You speak for Hospices Cymru, would you—?

Well, I think the national drive to improve understanding and awareness comes from Byw Nawr, which is partly Welsh Government funded. And that supports many of the hospices and NHS providers to deliver what are often grass-roots initiatives to promote conversations about death, dying and bereavement. But that—. I guess, thinking about how well that's happening, it does have a national steer to it, but the focus is very much on that coming from the grass roots. So, various community organisations would take on their own initiatives to promote—. We have death cafes, there are theatre performances, especially during Dying Matters Week, which is in May. And all of the hospices and most of the NHS providers as well will try and co-ordinate those kind of things.

At a strategic level, I think all the health boards had formal engagement with their local hospices, where they were in the vicinity. The most effective engagement was where the hospices were working as a group in a given area. So, in north Wales, for example, the three adult hospices and increasingly Tŷ Gobaith as well work with a single voice and a single representation. The concern is that they still feel that they could be helping the health boards, in many cases, do a lot more, particularly to avert crises. One point was made, which was misrepresented in the press early this summer, when Wrexham Maelor received adverse press coverage that there were no palliative care nurses available over a weekend. When I discussed that recently with the chief exec of Nightingale House in Wrexham, he said, 'No, we had a plan in place and we were working with them and we averted what could have been a more serious problem.' So, there was something there that had helped, which may not have been there in the past. The problem they're getting is, as you probably know, the funding for hospices has been devolved to health boards, rather than having a direct line from Welsh Government, and, as a sector as a whole across Wales, health boards have had no increase in budget in absolute terms, let alone real terms, for the seventh year. So, they've flatlined, even though they are increasingly being asked to do more. It's how we can better plan—join up that planning and delivery together to meet as best as possible the needs of the communities and reflecting the wishes of people, because, still, we know that 70 per cent of people say they want to die at home but still more than half are dying in hospital. 

Okay. Helen Mary, you've got a supplementary here, before we move on.

Yes. Actually, it picks up on the very last point that Mark made. When I last looked at these issues some years ago, there was pretty strong evidence that a lot of people ended up particularly in hospital care at the end of life because GPs were fearful of palliative care. They weren't confident in prescribing some of the very, very strong drugs, and it was partly the aftermath of the Harold Shipman era. To what extent is that still an issue? Do we still have a bit of reluctance amongst GPs to engage in this kind of—? Because it's quite—you need to know what you're doing, don't you, if you're prescribing very, very strong medication, and it was quite distressing that people were—. Mark pointed out that most people want to die at home, if they can, but, if you haven't got the right medical support, you can't. Is that still a problem? 

09:55

I think there's a range of issues there. Part of it is getting the right medical support; it's also having the right social support, which is incredibly important to remaining at home. So, certainly, as we age, we're more likely to be living alone, and that presents a challenge for being able to have care at home as well if you don't have a spouse or a child who's able to co-ordinate that for you, and so forth. 

I'm not sure that we see necessarily a concern about GPs prescribing strong medication, but I think there can be a bit of a risk aversion in allowing people to remain at home, and that can come from families as well as medical care. So, one of the things that Wales does have is 24-hour telephone support for clinicians and for the public around being able to make a call, and I think that is really helpful for helping to keep people out of hospital, out of A&E, because you can call and you can ask a question. A clinician can get specialist advice and so forth, and that can make a huge difference. 

I think one of the challenges that we do have, though—and, again, it comes back to that cancer/ non-cancer diagnoses—is, for someone, say, with advanced heart failure or kidney failure, or any of those things: are they being referred to services and understood as needing a palliative approach in the same way that someone with advanced cancer would be? So, we know that, certainly, in England, the number of unplanned admissions to hospital for a person in their last year of life is becoming one of the things that clinical commissioning groups are being now measured on. So, that's a way of helping them to look at the system that they have in place locally, how they're working with specialist palliative care services, with care homes, in particular, as well, and with primary care to make sure that they're wrapping around an individual to prevent them having those really distressing unplanned admissions.  

Okay, we're drilling down into some detail. Julie, a quick one, then. 

I just wanted to pick up something that Mark said about the relationship between the health boards and the individual hospices, and the flatlining of the money. I just wondered whether you had any general comments about the fact that, is it, about 30 per cent of the funding comes from the state, so to speak, and individual hospices are responsible for raising 70 per cent of the rest of the money. Have you got any views on that? 

I think the general picture we got was that it was close to 80:20 or 77:23, but we didn't want, as a cross-party group, to get into a numbers game, so much as how the shared resources can be better utilised together, and how the hospices can help take pressure off the health boards, not just within the buildings, but very much as we develop primary care resources teams in the community, teams in the home. But I think it was closer, wasn't it, to 80:20 than the—. 

It's difficult to break down, because in Wales we use a funding formula to fund charitable hospices. That is based on population data from 2008-09. What we would say is, actually, that funding of charitable hospices needs to be based on population need, and probably 10 years down the line it would be timely for us to revisit that formula, using data from current need, and also bearing in mind that, 10 years back, service provision would have looked different. We're now requiring hospices and palliative care providers to be reaching out more to people with diagnoses other than cancer. We've got an ageing population, who also require palliative care. So, we're thinking about the sustainable funding of charitable hospices based on an accurate and up-to-date assessment of population need, not necessarily around the percentage of funding that comes from statutory sources or otherwise.   

I was just always amazed the hospices provide this care and have to spend a vast amount of resources raising millions of pounds, in some cases, you know. Sorry.

They all have fantastic fundraising officers, who are usually characters. But it was actually Baroness Ilora Finlay, who came up with the first formula, who made that recommendation to us on the urgent need to update. But there are some good practice models. We know about the compassionate communities model, which I think initially was spearheaded in Wales by Marie Curie. Some of us were present when they had a seminar a few years ago. Again, in north Wales, Nightingale House Hospice has picked that up and they're rolling out a compassionate care model. We've got models like St David's Hospice in Llandudno working with the health board on hospice in the home, but also now have taken over a health board ward on Anglesey to provide palliative care provision within NHS premises where the community otherwise might have been unable to access that. So, there are interesting models developing, but it's how we can learn that good practice and share it and fill in some of the gaps.

10:00

Good. Some agility is required now, and Rhianon is today's queen of agility. 

I'll do my best. Very briefly though, in terms of the assessment of population need that you mentioned as being critical to all this planning for the future, what is happening in that regard?

Well, we've already got two statutory population needs assessments in Wales under the Social Services and Well-being (Wales) Act 2014 and the Well-being of Future Generations (Wales) Act 2015. As far as we're aware, neither of those have looked at any palliative care needs. 

So, that's something for us to consider then. Right, in regard then to—. It has been mentioned a couple of times already that more than half of the Welsh population is dying in hospital, and that can often be the very best place for many to die. In that regard, how in regard to palliative, end-of-life care do you think that hospital-based staff are placed in terms of their training and their ability to deal with this?

Certainly, some of the evidence that we received during the inquiry from nursing sectors were suggestions that there needed to be mandatory training for all hospital-based staff on end-of-life care. I think that's one approach that you can take to it. I think that, given that so many people do die in hospital, that is one thing that could be considered. I think there's also just better working between hospices and hospitals, and we—

We see a range of different models, such as shared consultants across both sectors. We can see in-reach from hospices into hospital. We also see capacity building in terms of training and clinical supervision for those providing care. There is a telemedicine model, called Extension for Community Healthcare Outcomes, that's about providing support to clinicians, particularly in outlying areas, where they may not have the physical access to those kinds of services. 

So, in that regard, there's a whole platform of measures that you've obviously identified. 

Absolutely. 

In regard to the implementation board's work, how far advanced down that road map do you think you are?

With regard to what map, sorry?

The fleet of measures that we've just discussed, and I'm sure there are many more, in regard to where we are placed across Wales in rolling that out, how far down that road are we in terms of where we could be in Wales?

We heard evidence—and again, it's about joining up—about shortages of community palliative care nurses, particularly palliative care paediatric nurses, calling on end-of-life care boards to develop an action plan to address shortages of district nurses for adults and paediatric community nurses with palliative care skills. The context, I think, is that only 3 per cent of people with a palliative care need actually die in hospices, and only 24 per cent at home, and it's how we can join up those teams, so that that 24 per cent can go up, but the expertise is available in both hospital settings and in the community. 

So, in regard to where we're at, so that I can understand, are we at the beginning of that journey here in Wales? Are we in a sort of middle stage? We've got the ideas, we know where we need to be. So, how far down that, I'm still struggling to understand. 

I think that takes us back to the points that we were talking about right at the outset, about the fact that it's very difficult to understand the developments that are going on in different local health boards. So, each has its own initiative. Cardiff and the Vale, for example—

It is a mixed picture, and it's difficult to measure. So, Cardiff and the Vale—

So, we need to be able to measure it before we can understand where we're at. So, that's obviously of critical importance.

Okay. I'm going to try to be as agile as I can. So, in regard then to people with learning disabilities or dementia, in terms of where we are in Wales, in terms of advanced care planning, where do we sit?

Well, there was a written statement from the Cabinet Secretary, two days ago now, on advanced care planning. So, it's great that Wales is taking a strategic approach to looking at advanced care planning, and to consider those issues around people who don't have capacity to make decisions about advanced care planning and would need a best-interest decision. I think the term that's been coined is 'future care planning', to enable an electronic record for people in those circumstances.

10:05

I think so.

A lot of the evidence we've received suggested that it would be welcomed professionally, and it would help a number of people, particularly those who may have particular needs before they need palliative care, but particularly later in life if they have dementia, or they lose mental capacity further down the road.

Okay. And finally, then, in regard to that difficult conversation—I know there's an initiative that we've launched to enable healthcare professionals, and patients themselves and their families, to talk about the palliative care route and dying itself—where are we in Wales? What can we do more around this issue?

I think that's a really complex question. So, some of it is, when we're talking about health professionals, it's about ensuring that they've got the right training and support to do it. It's things like social context, such as Byw Nawr, are really important in helping, just you and me on the street, to be able to think about death and dying in a way that's less frightening, and allows us to make those kinds of plans. Again, I'm not sure that it's something that we can necessarily measure very well, but it's about making sure that we've got those kinds of systems in place, and that we can look at the progress of those over time. And I think electronic future plans are an essential part of that, particularly because it would allow then any medical professional who is engaged with a person to be able to see that plan—whether it's your GP, an ambulance staff member who may have been called to you, whether you find yourself in A&E—then that care is far more joined up, because they can see what you want. And I think that that's something that we would really want to ensure rolls out.

Can I just make one point though, briefly, which is the broader support? Most people, when thinking ahead, are also thinking about their loved ones, and the sector provides a vast amount of support for families, partners, children, and so on, before death, also during death, but also in a continuum after death. But that doesn't reach everybody. And what we have left sometimes is people like Cruse trying to fill in the gaps, and jumping from year to year, or not knowing whether they're going to have the funding for the following year. It's how, again, we can join that advanced care planning up with that wider family and community support within compassionate communities.

Okay. Angela, you've got a couple of questions. Some issues have been touched upon.

They have. In Pembrokeshire, we're very well served with a hospice at home movement called Paul Sartori. I just wondered if you could just tell us how widespread hospice at home movements are throughout Wales. Do you see a huge inconsistency? And the other question I wanted to ask was: who, if not them, provides out-of-hours palliative care to people?

And my last question is, of course, a lot of people who are at home might be under, for example, the care of social services, then they go into palliative care, then the health boards start kicking in. Have you detected, found, any funding issues and concerns over who actually is going to provide the services, and who has the financial or moral obligation to provide the services to that particular individual, if they want to stay at home? Because I think it's quite easy, you've got a cut-off point if you can go into hospital, but that's just not clear when you're at home. There you are: three questions in one.

I'll start then. I mentioned that St David's in Llandudno have worked with Betsi to develop their hospice in the community service there. I think almost every—if not every—hospice operating in Wales has developed, or is in the process of developing, a hospice in the community service. We've also got outreach. So, for instance, Claire House on the Wirral has outreach into north-east Wales, for children. So, there's some cross-border flow there as well. The funding formula introduced 10 years ago, and the plans and the implementation that followed that, saw a lot of emphasis on hospice in the community, and there has been growth accordingly.

One interesting thing that came out of our inquiry was what happens when there's bad weather, like in February this year. There was one voluntary group who gave evidence—they were medical professionals, with four-wheel drive vehicles—and they'd noted that, across England, there are voluntary teams established so that, when that arises, they can still get to people who have palliative care needs. They've established a small team up in north Wales, but their objective, for those sorts of occurrences, is to have voluntary teams established across Wales to reach people who wouldn't otherwise be reached.

10:10

Just picking up from where Mark left off there, I think that the crossover point between the NHS and the hospices' work in the community is district nurses. District nursing is absolutely the bedrock of care for people at home and if there was one thing that we could change that would make a massive difference for people to be cared for at home for as long as possible, it's investment in district nursing. That's really the coalface of it, by and large. So, I just wanted to make sure that I made that point. 

Yes, and I think it's fair to say that hospice at home models vary across Wales. Some, like Paul Sartori, will deliver the hands-on nursing as well as advice—have specialist nurses who advise—but there will be other areas across Wales where the hospice at home team is an advisory service that then relies on the district nursing service to deliver the hands-on care, day to day, working alongside GPs, including out-of-hours GPs. 

I think that one thing that came across in the inquiry in terms of out-of-hours care and was followed up—. The cross-party group does have a meeting on out-of-hours provision and gaps in that coverage coming up next year, but it came up in our last meeting, didn't it, Mark, in November, when we were talking about care homes? It was around the specialist advice lines that are available 24/7. Lots of them are run by hospices and they are for clinicians to phone in with urgent inquiries, out of hours, to get advice, but what we were hearing was that they are very much underutilised at the moment. So, there's a resource there that isn't being tapped into sufficiently, or perhaps isn't known about by everybody who could be using it, which could be supporting people to stay out of hospital in those emergency situations and to keep someone at home. But as Kathleen said: absolutely, district nursing. Without a nurse there on hand to deliver the hands-on care and the medication, then you can't keep someone at home. 

I appreciate the comment, Mark, you made about the fact that you didn't want to get into funding as part of your inquiry, but did you get any sense at all coming through that the turf war we often see between health and social services was occurring in this particular area?

Again, it was a mixed picture. In some areas, there were good models developed together and delivered together; in other areas, there were models developed by the hospices and delivered by the hospices, but welcomed by supportive health boards. I think the problems were where the gaps still existed, rather than where—. Did we hear any examples of conflict? I didn't hear of any particular problems where there was a blockage as such, but there were areas where populations still might not be reached.

Certainly in follow-up work, so in the last cross-party group meeting when we were looking at care homes, one of the recommendations of this inquiry was that we would look at pooled budgets for palliative care and care homes, and it would appear that that is probably slow in progressing, that regional partnership boards are at the outset of thinking through their pooled budgets. So, it hasn't happened yet, but we would like to see the pace accelerate.

Okay, moving seamlessly forward to care homes—Lynne.

Thank you. During the inquiry, did you receive any evidence that residents nearing the end of life in care homes were being transferred inappropriately to hospitals?

Not necessarily that they were—. We heard anecdotal evidence that people were being taken to hospital at the end of life. One of the main issues that we heard in terms of care homes was that Care Forum Wales said very eloquently that we have an aspiration in Wales that you can die at home if that's what you want—if that's your choice—but that's not always the case, if you live in a care home. So, it may be that you have lived in a care home for several years of your life, you then call it your home and that's become where you live, but perhaps you've been admitted to hospital with an acute need. You then are ready to be discharged, but your health needs have changed and the care home might not be able to manage those health needs in that setting, so that person would then be required to go to what was previously called a nursing home, where there are nursing staff on hand. So, that aspiration to enable people to stay in their preferred place of residence—the place that they call home—isn't always the case, if you have a palliative care need and you were living in a care home.

10:15

There is a sense of risk aversion sometimes in care homes too. Not to say that care homes aren't providing really amazing care for people over a long stretch of their lives, but I think there is a little bit more support needed for them to be able to manage those really final stages of somebody's life. Sometimes, there are models that we see where hospices work with care homes to embed training and support for those staff to identify and support someone right at end of life. I think that sort of capacity building is moving forward. 

So, you haven't got a sense of how widespread this is as a problem, then, really.

This is a growing issue, particularly based on the evidence session in north Wales. Up to about 10 years ago, somebody who was going to need palliative care would actually be in a nursing home, whereas increasingly it's in a care home. So, they've had to reconfigure their services and take on more responsibility accordingly. Because we have an ageing population, more of us thankfully will live longer, but often with more complex needs. So, what becomes increasingly palliative care may take several years within a residential setting, and that means bringing in teams externally and co-ordinating with the internal teams as well.

You referred to regional partnership boards and the changes that probably need to happen in terms of pooled budgets, but is there anything else they can be doing to support the better delivery of palliative care in care homes?

Money for—well, to be able to have that budget or to promote new service models, which is what they're tasked with doing, that look at that better integration between health and social care in a palliative care setting. We were hearing yesterday about some hopsices and training for care homes—it's going on in Blaneanu Gwent very well, it's going on across the Betsi Cadwaladr area. There are programmes where we're looking less at the hospice as the place where people go to to receive their care, but that staff are going out and doing that in-reach work in care homes, upskilling staff so that they have the sustainable skills to be able to deliver the palliative care in the care homes, and we'd like to see that supported and recognsied. 

Also, as was said, teams do need to include various therapists, physios, OTs and Welsh Government states that we will be addressing this through the safe nurse staffing levels—but 'will be', so this needs oversight. We've got the development of the integrated medium term plans by the health boards, which will be looking at all this, whether it's in the community or in the care home setting. Again, all this will need oversight because it's all about 'will be' rather than overseeing what's already in place.

Julie, some of your issues have been answered, but carry on having a swift trot through the issues. 

We know the legislation requires carers to have the assessment. Have you got any more you could say about that in terms of your inquiry?

We didn't hear necessarily about those statutory carers assessments under the social services and well-being Act; we heard more of the work that various organisations are doing that in many ways will prevent someone from needing that statutory assessment. So, the hospice services would support carers through early identification, and then, when the hospice perhaps would recognise that that person might be eligible for local authority support, they would be signposted on.

I suspect that, as with most carers assessments, carers of people at the end of life aren't getting picked up soon enough. We know that, if we have around 23,000 or 24,000 people in Wales who are dying, potentially we have around 48,000 carers of people at the end of life. I'm certain that that number of people aren't getting the carers assessments that they should get. I think there needs to be better joint working between local authorities and palliative care providers so that we're signposting people on to the right assessments where they're needed. 

Thank you very much. Specialist bereavement counselling is being cut back. What do you think needs to be done there to make sure people do get specialist bereavement support?

10:20

The evidence we've received indicates how critically important this is, not only, obviously, at a human and emotional level, but to ongoing mental health, suicide, social isolation, public sector costs in terms of social care and emergency interventions, and so on. So, getting this wrong is massively damaging to people, but also massively costly to the public purse, so it should be seen as a core service. The hospice sector itself has massive expertise in this area and, as you know personally from your involvement, this has been integral to their service model since inception. The need there is to join that up.

You made reference to the general funding. We know that a major provider in Wales has had to wait to receive written confirmation of their funding in order to withdraw redundancy notices from their team, which shouldn't be happening. A few years ago, we had a team working out of Glan Clwyd Hospital in Bodelwyddan, providing bereavement support where children had palliative care needs or passed on. They lost their funding, and they had been provided with free accommodation by the health board. That was removed from them. So, one of them, the volunteers, had to find redeployment. The other one went to work for a hospice in north Wales internally, providing the support that way. So, it is critical and it should be seen as a core service. There are some excellent models out there, particularly in the hospice sector, and we need to extend and join that up, support the agencies that are doing it right and help others to fill the gaps.

Okay. We need to move on to the final bit, which is on children. I was in Tŷ Hafan last Friday, so this is an important issue, and Helen Mary is going to wrap up the session.

Nobody will be surprised that I'm concerned about the children's services, and your report highlights some real issues and challenges still there. To what extent have palliative care services for children and young people improved, particularly access to 24/7 care, as a result of changes that have been made to the workforce? Are we travelling in the right direction?

I think the paediatric sector would say that there is progress, but it's been very slow and very difficult. So, partly around consultant cover and ability, in that 24/7 care, sufficient consultants to be able to manage a sustainable rota. We did only have three consultants, and it's quite a big ask for them to do 24/7 cover between the three of them. It does look like there will be an additional consultant based in north Wales for paediatric palliative care, so that's certainly welcome.

One of the solutions that the paediatric sector and the end-of-life care board were working on was around utilising the paediatric palliative care specialist nurses in health boards. I think if we went back several years, there wasn't such a nurse in every health board, but finally we've got a nurse in every health board at this point. But because of complexities in how those nurses are funded, some are completely funded at a national level, others are funded at a regional level, and some are funded part way between the national and regional. So, it's difficult to determine or to divvy up those nurses' time into how much time they should be spending at that national 24/7 advice line and how much they're only responsible to their health boards. So, I think it's been quite tricky in bringing those into that rota. I know they're trying to find a sustainable solution to it, but as yet I don't think we're there.

You've identified some of the challenges, and transition between children and adult services was one of them. Can you just tell us a bit more about what needs to be done so that children and young people have the same choices about preferred places of care and death as we're able to provide for adults? Headlines—I guess we've only got time for headlines, Dai.

I guess, in the same vein as that one request that Kathleen said, what would be the one thing that we would want to see to improve palliative care for adults is district nursing. For children, it would be the parallel, so community paediatric nurses who aren't necessarily highly skilled in palliative care but are able to deliver the hands-on care under the advice and supervision of someone who does have that specialist knowledge. So, the big inequalities that we heard from the children's sector was very much about that choice of place of care. Children's hospices are few in number, and children and families have to travel a long distance to get to them. Many would prefer to be cared for in the community or at home, and having that community nursing workforce is probably the best way, or the most sustainable way, of making that happen.

10:25

You make a valid point—as children get older and become teenagers and young adults, just like any other teenager and young adult, they don't want to be stuck with a lot of older people. I visited, several years ago, and we took evidence from, Claire House. Although, again, on the Wirral, they provide support for a fair number of young people in north-east Wales. Several years ago, they opened a teenage/young adult unit there, which is fantastic in that it's designed for, and with, those young adults themselves. I know Tŷ Gobaith has developed some of that provision in north Wales as well. So, as well as looking at the younger children, we need to be looking at the wider social and developmental needs of children as they transition to adulthood.

Okay. And the final question, then. It's an important one.

Yes. Just a last question about what next and the way forward. Has the cross-party group met with the Cabinet Secretary to talk about your findings, or has he—? I think you said, Catrin, that the Government has responded.

The Cabinet Secretary attended the report launch and responded, at the time, verbally, and then that was followed up by a detailed written response. Mark, I don't know whether you want to say what our impression of that was?

Well, I touched on it at the beginning. We felt very much it was telling us what we already knew. There are a number of initiatives on the way. As I said, several recommendations accepted on the basis work was already ongoing in the area, despite evidence received to the inquiry suggesting that progress was slow or that evidence of progress was unavailable. We had further announcements this week. You mentioned advance care planning, for example, and that's good, but it will need oversight. And we are just a cross-party group, so we're hoping you can help us do some of the heavy lifting.

That was what I was going to ask, actually, Dai. Are there particular areas that you think that, maybe as a committee, we could write to the Cabinet Secretary about—the particular places where you really think that we need to help with that heavy lifting?

We have a Blue Peter one we prepared earlier, with a couple of suggestions. [Laughter.]

We focused on three key areas: conduct perhaps a short inquiry, or refer to the Cabinet Secretary, into the community workforce delivering palliative care, including paediatric palliative care. The second one was to conduct a broader inquiry into the community nursing workforce, including paediatrics, for the reasons we've described. And thirdly to conduct a review, or refer to the Cabinet Secretary, community support for those experiencing death, dying and bereavement, including bereavement support and compassionate communities.

A review into community nursing is already on the forward work programme.

Can we have some palliative care with—?

Yes, paediatric palliative care because, certainly, as Mark was saying, the Cabinet Secretary's response was—. The cross-party group welcomed it and the recommendations have been accepted, but there was very little in terms of response in paediatrics, and we wouldn't want paediatric care to be forgotten in there.

We're going to have a forward work programme discussion early in the new year because ideas change and other issues come up. So, feel free to forward those three recommendations to us and we'll see what this committee can do as regards moving forward.

Okay. I think we're nearly out of time, so we say thank you very much. 

Diolch yn fawr iawn ichi.

Thank you very much.

Diolch. Diolch am y cyfle.

Thank you. Thank you for the opportunity.

 Nadolig llawen a blwyddyn newydd dda.

Happy Christmas and a happy new year.

Ie. Nadolig llawen.

Yes. Happy Christmas.

Da iawn. Diolch yn fawr iawn i Kathleen ac i Catrin ac i Mark. Diolch yn fawr iawn.

I’m cyd-Aelodau, gwnawn ni dorri nawr am bum munud.

Well done. Thank you very much to Kathleen and to Catrin and to Mark. Thank you very much.

We'll have a short break now for five minutes.

Gohiriwyd y cyfarfod rhwng 10:29 a 10:41.

The meeting adjourned between 10:29 and 10:41.

10:40
3. Gofal Iechyd Gwledig: Sesiwn dystiolaeth gyda Dr John Wynn-Jones
3. Rural Healthcare: Evidence session with Dr John Wynn-Jones

Croeso nôl i bawb sy'n gwylio'r trafodaethau yma ar deledu byd-eang. Dyma faterion trafodaeth y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yn y Senedd, ac rydym ni wedi cyrraedd eitem 3 nawr a'n hymchwiliad ni i ofal iechyd gwledig. Rydw i'n falch iawn o groesawu Dr John Wynn-Jones i roi tystiolaeth ger ein bron. Mae Dr John Wynn-Jones wedi bod yn feddyg teulu gwledig yn sir Drefaldwyn ers dros 30 mlynedd o'i oes. Mae o bellach wedi ymddeol o bractis clinigol, ond mae'n parhau i weithio yn rhan amser ym Mhrifysgol Keele fel uwch-ddarlithydd mewn iechyd gwledig a byd-eang. Mae o hefyd wedi cadeirio gweithgor gwledig sefydliad meddygon teulu'r byd, WONCA, ers 2013, sef y corff byd-eang i feddygon teulu sydd yn edrych ar ôl materion gwledig o ran iechyd. 

Mae'r sesiwn yma yn gyfle i egluro cefndir ac i archwilio'r heriau a'r cyfleoedd sydd yna i ddarparu gwasanaethau meddygol clinigol mewn ardaloedd gwledig, a rhai ardaloedd gwledig iawn, yn deillio o'ch profiad helaeth nid yn unig yn sir Drefaldwyn ond dros y byd i gyd. Drosodd i ti, John.

Welcome to everyone who's watching this on global tv. Here are the issues we're going to discuss in today's meeting of the Health, Social Care and Sport Committee in the Senedd, and we've reached item 3 now and our inquiry into rural healthcare. I'm pleased to welcome Dr John Wynn-Jones to give evidence to us. He has been a rural general practitioner in Montgomeryshire for some 30 years, and he has now retired from clinical practice but continues to work part-time at Keele University as a senior lecturer in rural and global health. He has also chaired the rural working party of the World Organization of Family Doctors, WONCA, since 2013. That's the global organisation looking after rural affairs in terms of health.

Today's session is an opportunity to explore the background and to explore the challenges and opportunities relating to the delivery of health and care services in rural areas, and some very rural areas, stemming from your extensive experience not only in Montgomeryshire but also across the world. Over to you, John. 

Diolch yn fawr, Dai. Rydw i'n mynd i siarad yn Saesneg, mae'n ddrwg gennyf i.

Thank you very much, Dai. I'm going to speak in English, I apologise.

Thank you very much for inviting me here. I feel very privileged. 

As Dai says, since the last five years I've chaired the rural part of the World Organization of Family Doctors, and it's always been a desire for me, really, to bring some of my experience that I've gained around the world. I think it's very relevant to Wales and increasingly becoming so.

So, some apologies, really, to start with: rural health is such a huge topic that my emphasis today is going to be on workforce. Other things will come up. I would love to have the opportunity of talking to you about configuration of services and things, but I think, really, the crisis in Wales is related to workforce. You must also forgive me—I'm going to move from doctors—the priority will probably end up being on doctors, but what I say about medicine and doctors is relevant to all the other healthcare professions, so I think that's really important. And you know, in this modern world, healthcare is really about integrated teams working together, bringing all their different skills to manage primary care. 

I'm going to emphasise a number of things. Walking down here from the station, the word that kept coming up in my mind was 'joined up'. Wales is actually really doing quite well. I think some of the things that are happening in Wales are really exciting, but it needs a joined-up approach to it. It needs a specific pathway—and that word will come up again.

The other mention I'm going to make is on something called 'fit for purpose', and it's about a workforce that works, that meets the needs of that community that they're working in. A great friend of mine who set up a medical school in Northern Ontario always used to say that rural communities are so diverse that when you've seen one rural community, you've seen one rural community. And I think the whole point is: we can have a top-down approach, but we must have bottom-up as well, and we must involve the community in how we develop those services. 

I haven't got any immediate solutions for you, and I know the depth of the crisis that's on at the moment, really. I'm going to mention the word 'generalist' or 'generalism'. Now, we tend to think—. To some people, general practice is almost a derogatory term, but generalism is something that is crucial, and it's crucial for primary care. If we don't embed generalism in primary care, we're going to destroy the secondary sector, because it's going to clog up. And I'm sure you're aware that we're moving to a world of managed care, where, if you've got diabetes you're a diabetic, if you've got hypertension you're a hypertensive. It's essentially, 'No, they're people with these diseases.' And by the age of 70, 75 per cent of the population has got a chronic disease, 50 per cent of those will actually have two chronic diseases. And, actually, the need for a generalist is for somebody who actually can look at that comorbidity, can look at that complexity. And, as you increase the number of chronic diseases—and Dai will recognise this—it becomes more and more complex. You need generalists in primary care, otherwise you'll clog up the secondary sector. 

Okay, so I've phone around—. I'm not in practice in Wales any more, so I may be a little bit out of touch, but I phoned around colleagues in Powys, and this statement really kind of worried me. This is something that stood out. And this is a GP and she said:

'As a result of the recruitment crisis, we are providing 150 less GP appointments per week than we were 5 years ago.'

And I'm sure that that will not be new to you, really.

This statement came from—. There's a group called the northern periphery group. Sadly, Wales is not part of that, but it's Scotland, Northern Ireland, Canada, Scandinavia. And this came from a study and it said, about rural. It says it

'is a wonderful place, if you are fit, if you are healthy, and if you've got a reasonable income. You don't need a fantastic income but you've got a reasonable income. It's quite a different story if you are living on the side of a hillside, you've possibly lost your partner, your health is failing or your mental health is failing, you don't have any transport and it's been described as a "beautiful prison".'

So, I think that's the kind of reality, really, of rurality sometimes.

So, just a little bit of introduction: I was a GP in mid Wales, in Montgomery, for 31 years, as Dai said. When I went there, there was no postgraduate education, there was no continuing medical education, so I and a number of GPs set up the Montgomeryshire Medical Society. We set up the Welsh rural doctors' conference and, in 1997, I took a year out of practice to start the Institute of Rural Health, which ran for 15 years. Sadly, we had to put it to bed in the end, and it was difficult managing an independent research unit in the middle of Wales. We had difficulty engaging with some of the Welsh universities. But I think we just started it going, and I think, looking back at the legacy, we actually made a difference. I also established the European rural doctors group, EURIPA. We came up with the concept of something called the 'rural campus', back in 2001. And what I was saying, actually, was that the learning opportunity is not buildings, it's actually the experiences that you get in rural practice. And we established the Welsh rural postgraduate unit. Sadly, with all the cuts that happened with the financial crisis, that disappeared as well, really. 

I'm currently a senior lecturer at Keele in global and rural health, and I take the view that, actually, global health is rural health. And the majority of the world's poor and disaffected people actually live in rural parts of the world. I was a senior lecturer in Cardiff, and I was a continuing professional development co-ordinator at the deanery here in Cardiff as well. And I'm currently chair of the working party of the World Organization of Family Doctors. 

This is where I worked in Montgomery—beautiful Montgomeryshire. My father referred to it as 'mwynder Maldwyn', this gentle area. We had about 300 square miles, so it was a big practice. 

Just really to mention one of my heroes: Professor Ian McWinney, born in the UK, was a professor of general practice in London, Ontario. And I think this epitomises what I feel about general practice, or family medicine, as it's known in other parts of the world. General practice is the only discipline that defines itself in terms of relationships. It thinks in terms of individuals, rather than diseases—what I was saying earlier—and transcends the gulf between mind and body. And as we move into this world of managed care, I think Ian McWinney's comments become even more important. 

These are my six elements of rural health and rural well-being, and I think they're really important. And I put, actually, healthcare delivery at the bottom because, in fact, it's about a healthy rural economy, it's about a healthy environment, infrastructure, population health, community development and social capital, and also the health service that we provide. 

A little about the international stuff. This is the EURIPA—I won't say much more about that. It's going well, and it's one of the major networks within WONCA in Europe. The World Organization of Family Doctors was formed in 1972, and it now represents 90 per cent of the world's population—143 countries, and we've got seven regions. So, it's a huge organisation, and there are working parties, special interest groups and young doctor movements, and I chair the one on rural practice. It's certainly the most active one, and I'll tell you a little bit about it.  

We were formed in 1995. We had our first conference and now we are up to our sixteenth world conference next year in Albuquerque in New Mexico. Our first conference was in 1996 in the rural areas outside Shanghai, and Fengxian county, and it was really an extraordinary experience to be a guest of the Chinese Medical Association when China was kind of opening up to the world. Our working party—it's really about engaging with rural doctors, rural activists, rural communities, like-minded groups around the world, and our vision is about awareness, advocacy and policy, education, research, conferencing and working in partnership. 

We've developed a number of codes, policies, statements and declarations. You're welcome to look on our website and, obviously, I'll leave the presentation here, so if it's of any help to you, then you're welcome to it, really. Some of these documents are extremely important. The one on training for rural practice has been cited so many times when it comes to rural practice, and it's extraordinary that we created this document back in 1995. It was revised in 2001, but it was created in 1995, because the only way we had of communicating around the world then was faxes. Things are instant now and you can change things, you can track changes, but it was quite a challenge producing something with faxes.

We work with other organisations. One of the most important partners we have is the World Health Organization. In 2008 to 2010, we worked with them on increasing access to workers in remote and rural areas though improved retention. It's really worth looking at this document. It's still relevant. We're in the process of revising it at the moment, but it works. It says that, actually, it's really complex how you develop rural doctors, rural health workers and a rural health system. It's not simply about money, it's not about bonded labour—it's really quite complex, and this is evidence-based, and it's really worth looking at. 

So, when I took over in 2013, my aims were really about equity. I remember when I first took over and I looked around the table, and it was full of grey men from rich, developed countries. So, my main aim was to actually have equity of age, gender, of course, geography and demography, and we've been really successful in doing that. We also wanted to bring young doctors and students into our organisation, and now we have a separate student and young doctor group, and it's not really not, essentially, a medical—. We also have nursing students, pharmacy students and other students involved in it, because there isn't anything else like it anywhere else in the world. 

And I wanted to balance—. I found the academics were taking over, and being a working doctor—or, in those days, a working doctor—I really wanted to ensure that it actually represented working doctors, and I wanted to work in partnership with other groups.

This is something that I'm really proud of. We developed something called 'The Rural Medical Education Guidebook'. It's up on our website, and it's an opportunity to look at what's happening around the world. We have 70 chapters, written by 76 authors, looking at every element of training for rural practice. We run annual conferences. We have about 1,000 delegates from around the world, so they're relatively big conferences. This one is our last one—the fifteenth in Delhi. We were delighted to have the Vice-President of India, who joined us, and he started his speech, and, after about five minutes, he threw his notes away and spoke with passion about what's happening in rural India. We're going to Albuquerque in New Mexico next year. And we're going to Bangladesh and Uganda afterwards, and my emphasis has been on going to lower and middle-income countries. 

So, the next generation. This is rural seeds, this is our group, and it's a global student young doctor network. We use social media a lot in it. We run a number of programmes—rural success stories. The person who created it is a young doctor in Brazil, called Mayara Floss, and she is really quite an extraordinary person. You come across people you feel humbled with, and Mayara falls into that category. She's a filmmaker, an author, a musician, an activist, and she said, 'You know, we just need to meet for a coffee sometimes, but, because we're rural, and because it's very difficult to do that, we can all meet online', and she developed something called the rural family medicine cafe and we run now, I think 50 different cafes. We do one every month. And we've just embarked on running a global mentoring programme, and I mentor two young health professionals—one a doctor, and the other one a pharmacist, one in Botswana and one in Rwanda. 

So, this was at our fourteenth conference in Cairns last year. We're currently working—. This is coming to the relevant, the important stuff now. We're current doing a piece of work for the World Health Organization on the development of rural health professionals and the training of rural health professionals in lower and middle-income countries. And we shall be finishing and reporting back to the WHO at the end of this month. We've done a literature review. We've identified exemplars, and we're developing a checklist. And this came from the WHO. They've been working with countries in Niger and Chad, and countries were saying 'Well, actually, we need some help in how we develop rural programmes.' And it's called the rural pipeline checklist project. I don't like the word 'pipeline'; I'll explain what I mean by pipeline later on, but I like to think of pathways. 

This is the concept of a pipeline. And this is why I talked about joined-up thinking, really, when it comes to Wales. You need a plan. You need something that actually goes through a career to actually develop rural health workers. So, it starts really with school kids, bringing rural school kids into medicine—interesting them—and into nursing and into pharmacy and into dentistry. It's saying to them, 'Look, you can come back; you can get involved in rural healthcare', then, when it comes to medical school, encouraging students to take up medicine—rural medicine, rural healthcare—by actually having placements in rural practice, going on to rural training—once they've qualified, having specific rural training programmes—and then supporting the generalist practice throughout their career and up to retirement. 

So, it's just—. These are some of the graphics that are coming out. It just to give an idea of how complex this is. It's not simple. 

One other important thing that's happened this year—. I don't know if any of you know the declaration of Alma-Ata. In 1978, there was an extremely important conference in the old Soviet Union in Kazakhstan. And it really highlighted the importance of primary care in providing healthcare around the world and the elimination of ill health and poverty. Its aims were laudable, were probably unrealistic, but it looked at the elimination of poverty by the year 2000. Now, we weren't going to do that, but a lot of things have come out of that since. At the start of the millennium, we had eight millennium development goals, which really changed things dramatically. If you look at the success of those goals: more children are going to primary school, especially more girls; we've eliminated poverty, to a large extent, around the world—it's still ghastly, but it's improved; more people are drinking piped water; more people are using toilets. It really has changed.

And, in the year 2015, when the millennium development goals ran out, we then moved to the sustainable development goals—there are 17 of them. And it takes in things like environment. And the most important one from our perspective is actually sustainable development goal 3, and 3.8 is about achieving universal health coverage. And the WHO is focused, really, on this goal of achieving universal health coverage. It is quite extraordinary to think that, in this modern world, where we can pinpoint a spot on Mars and land a vehicle on the surface of Mars, 56 per cent of the world's rural population don't have access to healthcare. I think it's a tragedy, really, that that's the case.

And this is just a map—the blue areas are the parts of the world that have universal healthcare, the green ones are ones that are trying to develop that. But things are improving. Thailand is actually moving towards it at the moment, the Philippines have just passed an Act, India is moving towards it, so the world is improving from that sense. And just to get an idea, actually, the world population—. These are ILO figures, the International Labour Organization, but, in fact, the world population is about 48 per cent rural now, but only 38 per cent of the world's nurses work in rural areas, and only 24 per cent of the world's physicians work in rural areas. And, to give you an example, eight out of 10 rural Africans do not have access to healthcare; 60 per cent of rural Indians—and that's 68 per cent of the Indian population—don't have access to healthcare. So, there's a lot to be done in the world.

And we were involved with the declaration for the fourth global forum on human resources for health, in Dublin, last year. And, after a huge amount of lobbying, we got 'rural' into the Dublin declaration. To mark 40 years of the Alma Ata declaration, we've had a new declaration this year, and it's again about primary care, and about the importance of primary care. Extraordinarily, the word 'family doctor' doesn't come into it. I think we were better lobbyists when it came to 'rural', because we actually have 'rural' in it. It was really difficult to get that in. But the World Health Organization works in blinkers. Under the past director general, Margaret Chan, I think she understood the importance of family medicine, general practice. But now that Dr Tedros is there, actually, we're going back to seeing healthcare as being the domain of healthcare community health workers.

So, we devised our own Delhi declaration at our conference in Delhi, and the WHO has actually put it on their website. We think it's a really important—we see it as a manifesto for rural health. It's about equity and access to care, it's about rural proofing. And I don't know if you're aware of the concept of rural proofing—it's just making sure that, actually, policies fit in rural, and I'll mention it briefly at the end. It's about health system development, it's developing and educating a workforce that's fit for purpose, it's about realigning the research agenda. Because, extraordinarily, 90 per cent of the world's research resources are spent on 10 per cent of the world's population. And I think Julian Tudor Hart would have—I'm sure Julian was aware of that, and that inverse care law happens in research as well, really. And it's about people and communities. And that's the website that you can find it on.

This is not new. Andrija Štampar, who was the father of the WHO, who wrote the constitution of the World Health Assembly and the WHO, actually identified that back in 1938, in a journal article I found in The New England Journal of Medicine. And it talked about the inadequacies of curricula and the effectiveness of medical education when it came to rural practice. 

Right. This is Professor Max Kamien. Max was a professor of general practice—primary medicine—in western Australia. In 1987, rural Australia was in deep crisis. There were no doctors who were prepared to go and work in the rural areas—they were all retiring; I'm sure you'll recognise the scenario. And there was great concern in Australia about what was going to happen. 

Max was directed to produce this report, called the Kamien report, and, obviously, it was based on western Australia, but it had huge implications for Australia itself. Australia's moved on an awful lot since then. If you think that, actually, 10 per cent of the Australian population is rural—only 10 per cent—whereas, in Wales, we're talking 30 per cent to 33 per cent of the population is rural—. We're an extremely rural country—probably one of the most rural in western Europe.

11:05

Sorry, Chair, can I ask a question? Are you talking semi-rural or just your definition of 'rural'? 

It—. I'm—

Yes. I'm using the England-and-Wales definition of 'rural'.

And, obviously, that definition can then be broken up into sparse and non-sparse. But in fact—. And, obviously, the issue in Australia is the huge distances, but it's a small population. And we have rural clinical schools, we have rural medical schools; we have recruitment, really—a lot of recruitment— from rural areas. We have rural training programmes. There's a college of rural remote medicine, rural research centres. There's something called the rural generalist programme, which I would try and commend to you, and now there is a rural health commissioner for Australia.

So, where are we now in Wales? I phoned around. I was actually quite shocked, really, because I'm not so much involved in practice in Wales anymore, but I was really shocked at the depth of the crisis, when it comes to morale and to workforce in parts of—and in particular in parts of Powys, where I've worked. Recruitment is a big issue; there are no locums. I think you have a de-skilled workforce. If I look at what it was like when I went into practice, we did our own obstetrics, we went to road traffic accidents, we managed community hospitals—we were actually really quite skilled. We've been de-skilled in that sense. One of my Australian colleagues refers to European GPs as actually we're trained for uselessness, in the sense that we've lost those skills and those procedural skills that you need in rural communities.

We have deteriorating ambulance response times. I spoke to a doctor recently—last night—who was involved—. One of her patients was involved in a road traffic accident and it actually took two and a half hours to remove this patient, not from the wreck of the car, but actually to get the patient into hospital. There are concerns obviously about bureaucracy and the paperwork; out-of-hours care is a worry. One of the things that they said, actually, was that they embrace having mid-level providers like physician assistants, physician associates, developing nurse practitioners, but what they're saying is that, actually, they need training and they need quite complex training and they haven't got the resources to do that.

Of course; please do.

So, when you say we haven't got the resources—. Because I know, for example, Swansea Medical School, they provided a training facility for physician associates, so can you just define—when you say they haven't got the resources, do you mean from within their practices to be able to take them forward?

Within their practices. They just feel that GMS doesn't have, you know—. And because of the fact that, actually, they're going to need more, really, in rural areas, they feel that GMS doesn't provide the resources to be able to do that. 

And is that a structured resource like, 'This is what you need to go through with them', or is it more that the GPs in rural areas haven't got the time to take on and mentor somebody—

It's actually—. It's both.

And, again, I'm passing on what people are saying. I think really what's also quite worrying is that they don't have, actually, the time to train, to teach, young doctors and students, and I think that's a concern.

There's concern about the estates strategy and what's going to happen about passing on buildings. Rural finances are causing anxiety. A special plea, really, from Powys, is to say, 'Please don't forget Powys.' A lot of the innovations that are happening are happening in Ceredigion, happening in north Wales, but actually not happening in Powys. It's a great opportunity missed if we don't actually make the most of Powys as a resource.

11:10

Powys is part of the region that I represent, it's also where I grew up. If Powys is getting left out of these initiatives, do you have a sense about why that is and what ought to be done about it?

I don't know, I don't know. I think that Powys hasn't got a university, it hasn't got—

It hasn't got a general hospital. It's a different beast, really. It's a really difficult place to move around.

And a lot of the services are provided in England. 

So, it is complex. Just briefly about the rural characteristics, I'm saying that it's a rural country, we have a real ageing population, poor transport infrastructure, district hospitals are far away and crossing—certainly in Powys—into England. I think community hospitals are a resource that's incredibly important and we musn't lose that. Recruitment and retention of all the workforce is deteriorating and, increasingly, the workforce is probably not skilled to meet the current needs. 

Again, some rural facts. As I said, 30 per cent plus. Just looking at that ageing population—these are figures that came in 2011, so slightly out of date, so I apologise for that, but we did some work on the Welsh rural health plan for the Assembly at that time, and there was a possibility that we would be looking at an increase of people over 65 in Powys of over 50 per cent. The biggest issue worldwide is chronic disease and the impact of chronic disease. If we're going to have a 50 per cent increase, and we're struggling to provide for that in Powys, we've just got to look at new models of care because we're not going to be able to sustain that, really. Just to get an idea, I mentioned the burden on the health service of older people and chronic diseases. These are some figures—again slightly out of date—but it just gives an idea that when it comes to healthcare planning, rural is going to end up being more expensive. It's going to increase as the rural population ages. 

Geographical access in Wales: again, Wales is a bit like Australia, really, because all the major settlements are around the coast and you have this deep area in the centre of Wales that actually doesn't have the services that we would wish. The important of community hospitals—this is looking at drive times. If you leave out community hospitals—the light yellow is more than 40 minutes to hospitals, put in your community hospitals and essentially there's a lot less light yellow there. So, we need to develop the community hospitals.

You came up with the Welsh rural health plan in 2011, and I'd probably like to ask you: what's happened to that? It was an extremely important document. I was involved with that, and also with coming up with the document on delivering healthcare services, and there are four recommendations that we made at that time, and this is based on evidence worldwide. You must choose students from rural communities if you want them to stay in rural areas. You need to provide significant exposure in medical schools—rural exposure. You need a rural training programme. And we also put in the idea that eventually we should look to having a centre for rural medicine or rural practice. 

Sorry, can you just explain what you think that would look like, a centre for rural medicine or practice?

I think, actually, our institute was a bit like that, you know. It was doing that. It was a postgraduate centre, it was Welsh rural training, it was doing research.

Postgrad, undergraduate—looking at rural issues, really.

'A Healthier Wales' is just an excellent document—a wonderful aspirational document. It says everything that I believe deeply about healthcare. But, really, it's about public and population health. It's a top-down approach—you may well question me on that. It needs to have an operational practical framework attached to it, and it's interesting, if you look at the WHO with their Astana declaration, which, again, is aspirational, they have an operational framework now that's out for consultation. So, perhaps we can learn from WHO. I really looked for the word 'rural' in it; I didn't find it. Perhaps I just missed it, but no mention. This country is 33 per cent rural and it doesn't mention it; not a lot about the use of technology, about workforce, about equity of access, and also about that research that drives healthcare provision, and, again, part of the reason for having a centre for rural healthcare was about that. We need to gather the information to drive policy and to drive provision.

This is a statement that many of my colleagues use: what works in urban doesn't necessarily work in rural, but actually, what works in rural almost always works in urban. It's about a different model, but it's a different model that's inclusive.

11:15

Yes. Provision of care, of—. I'm struggling a little bit. I'll come back to that.

It's a good question.

I take your point. I suppose community hospitals is one. You've got such a big, diverse population that you need to look at it in a different way. It's gathering information. It's about access. So, a lot of issues.

So, making a difference in Wales; perhaps we just need that joined-up approach, really, a holistic approach. We need a well-trained, integrated, multidisciplinary workforce that's fit for purpose. We need clear training pathways. Now, I'll show you that things are happening, and I'm really quite impressed with what's happening in Cardiff, and, slightly behind that, what's happening in Swansea. But, you know, we need to join that up and we need to have that pipeline or that pathway that actually looks at the rural workforce, or the future rural workforce. It needs to be supported and resourced, and this issue about—. Rural is more expensive. Wherever you look in the world, the figures show that rural is more expensive because you're not playing the numbers game, and distances, and that's important.

You need an integrated teamwork service, built around a local focus, and that—I've heard from a number of people. They said, 'Well, you know, we've still got teams, but, actually, they're based somewhere else.' There was an idea in Powys once called local care teams, and I'm so sad that that didn't come to fruition, but it's essentially—the health visitors are no longer based in the practices, there's talk about paramedics going to primary care but not based in the practices. I mean, it doesn't matter who leads them; it's important that, actually, they're working together and living together, and I think that that's crucial.

We need to rural-proof, and that comes to health and social care. We need public involvement in designing and creating a service, and I go back to what happened in Northern Ontario, in the Northern Ontario medical school. Roger Strasser from Australia was tasked with creating a new medical school, so the first thing he did—. And it's a diverse community, a very sparse community of English-speaking, French-speaking, First Nations peoples. He went around the communities and said, 'What kind of doctors do you want us to produce? What kind of medicine? What kind of healthcare do you want?' I think we can do that here in Wales as well, to ask the population what they want from their healthcare and, obviously, the use of new technologies, digital technologies, point-of-care testing and telehealth, telemedicine. 

We did a really interesting exercise a number of years ago now. We asked students and young doctors at our conference, 'Write your own job description; what do you want out of your career?' What really amazed me at the end was that high above everything else was that they said, 'We still want to be happy at the end of our careers and feel that we'd actually had something out of careers.' Certainly, talking to people in primary care in rural areas—and I'm sure it's the same in urban areas—I'm not hearing that any more, really. They talked about specialising in generalism, and I think that's really important. They talked about continuity of care and time with the patient. They wanted some control and empowerment. They wanted a life outside medicine, and I'm sure you're aware of that now. They wanted career flexibility and they wanted to work in teams. They wanted to have some understanding of public health, which I think is a really interesting statement that came out. And they wanted a global career. They wanted to actually be able to go and work abroad, work in other countries, to provide care in areas of distress, really. We also asked them, why—

11:20

Chair—. Sorry, before you jump on to the next slide, this is a very wide-reaching presentation; there are a number of questions that I've got, and I'm sure others have got, so will we have time after this?

Can I just ask you: do you want me to take this particular question around global careers now or do you want to wait? Because I've got about three or four others.

It's up to you.

Well, if it's short and snappy, now. If it's not, no.

You can also e-mail me afterwards.

Okay. So, very briefly with regard to global careers, I think most of the medical profession would absolutely agree with you on that. We have a particular issue in Wales, as you're very well aware—that we train doctors, we're above target in terms of training our GPs at the moment; we're doing well on that front, but we do know that many disappear from Wales, after a very short amount of time, for their international, global career, potentially. So, how would you, in your position of experience, stop that occurring, or do you think we shouldn't?

I don't think we should, actually. And I think we should make it easier for them to come back as well.

Okay. So, in terms of incentivisation programmes, you're saying that that experience would be very valuable—and I don't think anybody would disagree with you—but we do have an issue in terms of the public subsidy that we put in—

I know you do.

Yes. And, in fact, there are two groups when we talk about globalisation: there's the group who go to Australia, and those are the ones who we're worried about, because they're spending a lot of time there and some of them are settling down there. There are also the ones who actually—. They were talking about global careers, about people going to work in sub-Saharan Africa and to give back some of the things that actually they benefited from, really.

Can I just ask something on that? Because it does seem to me that whereas a number of GPs, doctors, will 'happily'—I say that in inverted commas—go to rural communities in Africa, India and places like this to expand their experience, their life experience, their medical experience and so on, but we can't get them to do that in our own rural communities. I know that's kind of what you're talking about here and addressing here, so we know that we have difficulty recruiting GPs, full stop, for a whole number of reasons. With some of the things that we've heard previously, a lot of it is now down to GPs not wanting to also be independent businesspeople. They want to be doctors, but they don't want to have the responsibility of businesses. It's about what additional barrier, I suppose, do we have to be considering trying to break down—to not only just overcome the fact that we can't get them in urban areas—but specifically, what can we make more attractive for people to practise in the rural areas?

Can I come back to that?

Please do. I'm sorry if I'm jumping ahead. I do apologise.

Because in a way, what I've done is just paint the picture.

I will come up with some suggestions, and I think that's really important, and I think it's very valuable. Thanks for asking that; it's a really important question.

Sorry. I'm kind of running ahead of you. I do apologise.

But talk about—. First of all, it's not on their radar, and very much as you say, rural practice is not on their radar. I think traditional medical curricula have been part of the problem on that. I don't know if you're aware, but the medical curricula that we have now came at the beginning of the last century. There was a report in the States called the Flexner report, and medical training at that stage was very haphazard, there were no standards, and Flexner changed all that. Flexner's influence crossed the Atlantic and went around the world, in the sense that they were rigid curricula, but essentially, they met the needs, and they had standards to them. I think we're post Flexner now and beginning to look at different ways of doing that, and we've shown that, actually, having students working in general practice for a year during their training, they do as well and probably better than ones that have stayed in the hospital system. So we're beginning to break down—it's post Flexner. But I'll come back and answer those for you, really.

The next thing is about level of responsibility and risk. John Gillies, who was a GP up in the borders in Scotland, did some really interesting work at the end of the 1990s where he looked at the aspirations of registrars in general practice and he looked at the pull and push factors when it came to choosing a career. The pull factors were things like quality of life, good schools and things, a nice place to live. The major push factor was responsibility and risk. So we have a generation of doctors who are not as bullish as we were, who didn't take the risks that we did. So, we have to deal with those.

11:25

But also, John, we have a changing so-called 'rural population' in terms of town dwellers having moved out to rural areas and expecting the same level of provision and the risk-averse doctors that they have in urban communities. So that has changed. 

Yes, it's interesting. Again, speaking to a lot of local doctors, they were actually saying that. They had some excellent young doctors who'd come to work there, but their referral rates were considerably higher than some of the traditional doctors there. At the end of the day, somebody described general practice once as the management of uncertainty. 

Those young doctors were, instead of treating the patients themselves, referring them on to specialists. 

Their anxiety meant that—

So they wouldn't say, 'I think I know what this is. I think we can manage it here.' The default position would be to get them into a hospital. 

Yes. As I was saying, one of the definitions I've heard of general practice is that it's the management of uncertainty.

It comes back to the comment you made earlier about the training—being trained less as generalists and more as the passers-through of information.

In fact, if you look at managed care, and a lot of general practice is managed care, so you have an asthma nurse, a diabetic nurse, an intensive nurse—you've all come across that—but, actually, who's there to join those up? Because if they get referred into the secondary sector, the secondary sector is all specialist. 

Yes. There aren't many generalists left anymore. We see it with care of the elderly specialists, but they're becoming specialised, too.

I also think one of the mistakes we make is we call it 'generalists', but actually it's holistic. Because we've forgotten to look—. You started at the very beginning about what it's about, and we've actually forgotten to look at people as a person rather than a product, bits of which have to be dealt with.

I totally agree. And there are so many other things about the lack of rural role models, tuition costs, obviously—that's for all medical students—and the lack of rural training programmes and pathways.

Sorry, Chair. You touched upon something. I come from a medical family and I'm the odd one out. So in regard to that community, which I do know quite well, one of the biggest issues you've touched upon is that, coming out of medical school, they are looking for areas where they can feel that there is less risk, there is a holistic centre, there is a pathway where they can specialise, and additionally, that there are good schools around them. These are issues that we constantly touch upon. How would you then devise an incentivisation programme, for instance, like the Train.Work.Live. initiative that Wales is now operating in west Wales and Pembrokeshire, and there's a new medical school as well, as you're probably well aware? How can we better target those types of issues, because it's not just about money in terms of getting somebody into a more rural practice? Because this is an issue for us, as you've very well identified, across Wales, and your experience around this matter is considerable. What would work for that cohort that may not be tempted to go into a less than leafy area with industrial health? I'm thinking in particular around the Valleys communities, where there does not seem to be an appetite from those in the medical profession to settle. 

I know, and if you look at the original documents we were involved in with the World Health Organization, there is not a single answer to it, and I haven't got—

But if you haven't got an answer, with respect, how can politicians?

But the answer is that, actually—

Yes, there are a number of answers. 

11:30

It's actually having a programme, having a policy that actually takes those things into consideration. It's interesting, there was some work done by the World Bank looking at the impact of how much money, how much extra in the way of funding, resources, salaries you have to give people to work in rural areas. There's only a certain amount that makes a difference. After that, it's about lifestyle and in low-middle income countries, it's about safety, housing and all those issues. So it's a package, I suppose. Is that a reasonable answer?

Can I come back to that?

Well, we'd better start cutting to the chase, so we have more questions. 

Okay, so quickies.

Things are happening. The widening access programme has made a difference. You probably know that as well, really. I'm told there's a 30 per cent increase in applications from Wales. How many of those are rural we don't know, but I think that's a huge, important change. You've got the Bangor hub coming up, which I think is going to make a big difference. It needs to be a rural medical school. We know from Australia that having rural medical schools makes a difference. And Swansea's not far behind. 

From a postgraduate perspective, this is probably where we need to catch up. This is where it's not happening, really. All foundation doctors need to have general practice placements. I don't know the figure in Wales, but they all need to and they all should have it, really.

I don't understand the logic either. 

It's because it's hospital-dominated medical training. 

So, basically, at that embryonic stage, there needs to be a transformation of that curriculum, if we're going to change strategically the—

Hugely so. Hugely so.

Just to be put onto the—. They have to rotate every six months, and it could just be a rotation. 

There could be a rural rotation, but they won't do it. 

But even in general practice, even if it's not rural. 

But it's actually general practice, primary care.

And if there's one message I want to give to you, really, it's about this postgraduate element that I think is crucial. 

So, rural placements for as many foundation doctors as possible. Wales needs—. My one request here is Wales needs a rural general practice training pathway. When I was involved with the deanery, I kept on saying, 'We need it, we need it'; 'No, it's generic Welsh training.' It really needs to happen. All rural GPs should have advanced life support and paediatric life support training. I have no doubt about that. And, as ambulance response times get worse, they need that. 

Sorry, that really shocks me, actually, because I assumed that's one thing the GPs would know how to do: keep you alive if you were—.

We have to do basic life support—

Advanced stuff. This is about keeping somebody alive. Not reviving them, but keeping them alive, being able to stabilise your patient and waiting for an ambulance. 

Practically being a consultant anaesthetist, am I right? Because some rural GPs are dual-qualified anaesthetists, dual-qualified obstetricians, still, because these sorts of things happen in the sticks and you have to be able to deal with it. That's why, as you've said, urban GPs don't have to anaesthetise people, hardly ever. It's a challenge for rural GPs.

I just kind of assumed that that's what you got trained on doing.

You see, you can't work in the north of Scotland unless you've got ALS training. The plea is we're going to have that funded, because it's hugely expensive. But we owe it to our communities that GPs are trained for that. 

I think also Wales should consider a rural generalist programme, and my next slide is about that. And that's really important. This is something that's come out of Australia. We need to have doctors, nurses and other health professionals who are trained to meet the needs of that community. And if that means you've got communities that are isolated, they need extra skills to be able to manage that. In Australia, they have something called the rural generalist programme, yet for a lot of the Australian doctors, it's about obstetrics, doing caesarians, doing anaesthetics, doing basic surgery, but there's a need wherever you are in the world. It depends on the context and depends on the health system, but actually we've got community hospitals. Mental health care is a crisis in rural areas. Why don't we train GPs extra as generalists to be able to do that? It may be a solution for the problem that we've got in rural Wales. So, it's worth looking at it.

What do we know works? Well, we know it works if we get young people and we target them. As I said, if we provide substantial rural exposure, it makes a difference to them going back into rural practice. It's about establishing a postgraduate training programme, because those are the three elements that really work worldwide. But, in fact, we need to talk up and promote rural practice. If you've got a training programme, think, 'Come to Wales, it's a great place to live, and we'll train you to do the things that give you that certain degree of autonomy, to give you a chance to step out from the ordinary part of general practice.' And I think that's important. And we need to think about partners—their partners. We need to work with the communities and, because of time, I'm not going to carry on, but essentially, it's about the skill mix. We need to look at rural-proofing and, again, that's a quick—.

So, finishing, from my wish list for you, I think we need a Kamien report to identify the problems and solutions of rural practice, that looks right across it. I think we need a holistic pathway approach to workforce development.  

11:35

I'm sorry, Chair. Can you extrapolate what you mean by that? 

What: holistic approach? 

So, in terms of training, in terms of a multidisciplinary—. There are so many different medical vehicles, aren't there? You have to make a choice at some point. 

It's about starting with school kids. It's about attracting people to rural practice, about training them for rural practice, it's about supporting them.

It's a whole package. It's a pathway. I don't like the word 'pipeline', but it's a pathway. [Interruption.] Yes. Pathway. 

And also, you'll find people actually can move from one pathway to another one. So, actually, somebody who's in nursing who wants to do medicine, we've got to help them. Somebody who's actually working as a healthcare assistant, moving them up to nursing. So, we need the bridges to connect the pathways up. But I think it has to be holistic—I go back to that word—it needs to be holistic.

We need to support rural practice with the resources that it needs to survive. We need to revive the concept of the Welsh rural campus—that, actually, this is a learning environment. This is somewhere you go to learn. And we want people to do Master's, we want people to do PhDs, we want to improve to get people working in that sense.  

We need to continue to attract students, as they're doing in Cardiff, but a lot more. We need to ensure that every foundation doctor is given a significant GP placement; I think that's really important. We need to develop a Welsh rural training initiative, so please, please, that's what I would like to leave with you today. In Scotland, they do it, and they do an extra year where they take a special area. They're developing it now in Northumberland, so there are other examples in the UK, and Wales can actually follow on from that, and I think we could actually become a leader. And I think we need to anchor rural practice in academic research.

So, finally, I think we just need to make rural practice an exciting and attractive option for young healthcare professionals. Let's talk it up. Let's make it an exciting place to come. Don't let's talk about the problems. Let's talk about what we can do in Wales.

Sorry, I went on a bit too long, but—. 

No, no. Excellent. Well, there were a lot of interruptions, to be fair, so, excellent.

Thank you very much. I thought that was a brilliant presentation, and it was obviously fantastic having all the international comparisons at the beginning. Just one question that I wanted to quickly ask. In terms of international comparisons, obviously you used Australia a lot. Is that where you think we have most to learn from in an international sense? 

It's always difficult comparing what happens in countries because all health systems are different, but I think we have a lot to learn from Australia, and a lot to learn from Canada, because a lot of the medical schools, specifically Northern Ontario and also—. Actually, the most successful medical school in Canada for getting people to work in the communities that they're trained in is Newfoundland. In fact, the past dean of Newfoundland is a great friend of mine. Actually, he's been advising some of the medical schools in the UK. So, there's a lot of expertise that we can call upon. And I think other parts of Europe—and, I'm sorry, I know we're in this Brexit dilemma—are also looking for leadership. Norway's actually doing quite a lot, but Norway's got so much money. [Laughter.]

11:40

I had a few others, but do you want other people to go first?

The suggestion that we need to rural-proof policy makes a lot of sense to me. Are there existing models of how you do that, because it's one thing to make a commitment to say, 'We will rural-proof it', but there's another thing about how do you ask officials to do that? Are there toolkits, skills, whatever, that we could recommend that the Government would use to do that?

Yes, there are. I will start by saying, yes, and then an apology. First of all, when we were the institute, we were asked on two occasions to provide a rural-proofing for health toolkit. We provided one. That was the Countryside Agency in England, through the Department for Environment, Food and Rural Affairs. The English Department of Health was singularly unhelpful, so we produced one. We were asked to revive it, so there are actually two. The embarrassing thing is that I'd finished with the institute when it was wound up; I wasn't working there any more. And, in fact, I can't find the second tool, which I think is really good. And I've asked—

Well, it was taken off the English Department of Health website. Richard Parish, who is heading up the new rural centre in Lincoln—. I've e-mailed Richard and said 'Look, can you help? Can you try and find this for us?' A little bit of help from the Assembly would be valuable as well, but there is a tool there. And, in fact, the second tool, I was very much more involved in the second tool because I wanted to have the patient and the community in the middle. So, there is a tool, yes. Apologies that I haven't got it at the moment. 

I was interested to hear you say that you felt community hospitals should be developed. I think you did say that, didn't you?

Yes, look at the map. 

There are 10 community hospitals in Powys, aren't there? No district general hospital, but 10 community hospitals. 

First of all, for specialist services like dialysis, chemotherapy, oncology, we have the technology now to link these up. More linkage between minor injuries units and A&E departments, I think that's really important. And we have this dilemma at the moment in Shropshire, where the A&E department may end up in Telford rather than Shrewsbury. So, it's another 15 miles for patients to go. And we know that, actually, your survival, when it comes to major trauma, deteriorates with every mile that you take, for every minute that you're going. But, actually, for minor injuries and for assessment, it saves patients an awful lot of time having to go to major centres if you can actually x-ray them and then buzz it along the lines back to the hospital for assessment and advice

A friend of mine is a GP in northern Queensland, in a very isolated place. I looked around his community hospital there, and their emergency room has got cameras everywhere, and all the monitors are linked up. It's not rocket science any more. We can do that. It's just the will to do it. 

Again, district hospitals are just full of people who need rehabilitation, who, again, don't need to be in a district general hospital. It's about managing that. It's about linking up, but it's about those strong links with social care, and that's hugely important. And perhaps, you know, to step up and step down placements as well. There are ways that I think that we can use them, and we can use them more sensibly and more cleverly really. 

We're being very broad now in terms of our transformation—

I'm being aspirational.

No, I love it; I think it's great. So, in that regard, obviously, you've mentioned Norway and Sweden, which are very, very hot on intermediate rehabilitation centres, especially around dementia care. And, obviously, our issues in Wales are the same across the UK. So, how important do you think, in your remodelled service for Wales, that that type of set-up is, because it's very common elsewhere, but less common here across the UK?

11:45

I think you've answered the question. I would agree with you. I think it's hugely important. It's trying to take people out of the district general hospital, and stopping them going there. Most of my time in general practice, if I had somebody who was struggling a bit at home, I'd get them into Welshpool or Newtown hospital, manage them there—that avoided them going into district general hospital. And you hear the tales—now as a patient, and not as a doctor—I hear the tales of patients, and how ghastly it is in a district general hospital. It's kind of Dante's 'Inferno', really. [Laughter.] Let's try and protect some of those—

But it's true. [Laughter.]

Right, before we go into any more literary comparisons—Dawn.

I'm just going back to something I asked you earlier—about GPs' reluctance to set up their own businesses; there seems to be more of a reluctance. So, are you suggesting, then, that part of the answer to the rural problem of attracting GPs would be, for instance, having primary care centres in rural locations that could be supported, managed and funded directly by the health boards, as an alternative model to independent GP practices?

I think it's going to happen. I think it's inevitable that that's going to happen. I think that generation of young doctors don't want it.

You'll get certain doctors who are entrepreneurial. And I think perhaps you need a mix—you need a public/private mix. So, there isn't one model that suits all. But I do worry about some of the practices in Powys—they've got great premises, but they're running out of doctors.

What I see—. In my constituency, for instance, I've got three—there's an other one coming online now—primary care centres. And, okay, it's a fairly urban constituency—I understand all of that. But on that one site, you have GPs, pharmacists, physios, occupational therapists, social workers—you know, they're all there, completely integrated.

Well, we've got three across Merthyr Tydfil and Rhymney, and another one coming online. And it absolutely, to me, is the model of the future—absolutely. But if we're going to do that in urban areas, we're going to have to do that in rural areas as well. But it still doesn't overcome how we get people to work there, does it, I suppose?

What we've got, though, is a lot of rural GP practices who have got good buildings that actually could be expanded to be that kind of primary care centre, but there's a huge issue with the health boards not wanting to take responsibility for the buildings. And so the doctors—you've got a potentially dwindling practice because you can't get people to be partners, but that doesn't mean to say that they don't necessarily want to work in a rural area, and that you can't get them to be partners, and some of these buildings are half empty. I'm thinking of the one in Llanfair Caereinion—there aren't the doctors there.

But if you have integrated centres that include social care and social services, you can have a joint responsibility with the local authority. So, it doesn't have to all be the health board's responsibility then.

And some practices are selling their premises to private companies, and I think that's a worry. It would be much better if, actually, the health board could take responsibility for that. But you're right—why not? It's the kind of polyclinic model, really.

Yes, which we've always had—the old-fashioned health centres.

Okay. I've got two questions. The first is: you talked a lot about the fact that rural healthcare costs more money. This is something we've had great difficulty in persuading the Welsh Government. For many, many years, health boards—rural health boards—have been saying we need a rural premium, and it's always been countered with, 'Well, we've got very built-up, or industrialised, areas that are deprived, so they outweigh each other.' So, I just wondered whether you could point us in the direction of where the evidence is that there should be a premium on the provision of healthcare in rural areas, and if there's any evidence of what kind of premium that would be. Hywel Dda, for the first time, for the first time this year, actually got a small number of extra millions because of their rurality, but we've still got Powys, we've got Betsi et cetera, et cetera, who cover great big swathes of that rurality. So, I'd like that question first, because my second question is the killer question. 

11:50

Presumably there is some international research that puts it down in—[Inaudible.] So, could you forward that to us?

I don't have that now, but, again, I'm happy to—. And perhaps, with Philippa, we could look at trying to find some evidence for you on that. I read the news yesterday, and it was looking at the allocation for Powys from Powys County Council, and this is a very rural council with a higher number of elderly patients, people, and yet it's got the lowest allocation in Wales. So, it is an issue and it really is a worry.

But if we could have the evidence, we could try and flip over that mindset.

Because otherwise you just have circular arguments, which we've had for years.

Which actually leads me very neatly on to my last question, which I think is the killer question, which is: do you think we're bad enough yet? Because, you see, I wonder if we haven't got to the state where it is so bad that we have to do what Australia did and we have to say, 'Oh my gosh, we are here; we have got to do something', whereas at the moment it's bad, but we can still put sticking plasters on it. I just wondered if we are bad enough yet, if we're getting bad enough, if we can continue to do the sticking plasters. Because, I agree: I think that we have to do some really radical stuff, and I think, to be fair, that a vision for health and the parliamentary review have put the framework together, but there's no action plan, there's no operational driver, there's no real—

Nothing's going to happen to anybody if things aren't done.

Nothing's going to happen in those things. So, I just wonder if we have got to still get worse before we can get better.

I think it's pretty bad as it is. Certainly, speaking to GPs in Powys, I think we're there, because, again, if you look at the age of these doctors, most of them are going to retire. I think we've got the second oldest workforce in the United Kingdom, and a lot of these are retiring. So, yes, perhaps we're just on the precipice at the moment.

Or we're two-tiered. Because, I mean, we do hear some outstanding examples, and we do have some health boards who do appear