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Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

19/06/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns AM
Dai Lloyd AM Cadeirydd y Pwyllgor
Committee Chair
David Rees AM
Helen Mary Jones AM
Jayne Bryant AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Dr Frank Atherton Prif Swyddog Meddygol, Llywodraeth Cymru
Chief Medical Officer, Welsh Government

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Rebekah James Ymchwilydd
Researcher
Sarah Beasley Clerc
Clerk
Tanwen Summers Dirprwy Glerc
Deputy Clerk

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

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

Dechreuodd y cyfarfod am 09:30.

The meeting began at 09:30.

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

Bore da i chi i gyd, a chroeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon, yma yn y Senedd. O dan eitem 1, cyflwyniadau, ymddiheuriadau, dirprwyon a datgan buddiannau, a allaf i groesawu fy nghyd-Aelodau yma i'r pwyllgor? Ymhellach, rwy'n esbonio bod y cyfarfod yma yn naturiol 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. Ac wrth gwrs, os bydd yna larwm tân yn canu—dŷn ni ddim yn disgwyl i hynny ddigwydd, yn naturiol; does yna ddim ymarfer—os bydd e yn digwydd, dylid dilyn cyfarwyddiadau'r tywyswyr. Wrth gwrs, bydd Aelodau yn ymwybodol o'r newidiadau yn aelodaeth y pwyllgor, a gytunwyd yn y Cyfarfod Llawn brynhawn ddoe. O ganlyniad i hyn, mae Dawn Bowden bellach wedi gadael y pwyllgor yma. Hoffwn gofnodi fy niolch i Dawn am ei chyfraniadau i waith y pwyllgor hwn dros y blynyddoedd diwethaf. Hefyd, dŷn ni wedi derbyn ymddiheuriadau am gyfarfod heddiw oddi wrth Lynne Neagle.

Good morning, everyone, and welcome to the latest meeting of the Health, Social Care and Sport Committee, here in the National Assembly for Wales. Item 1 is the introductions, apologies, substitutions and declarations of interest. Can I welcome my fellow Members here to the committee? And can I further explain that this meeting will be bilingual, of course. You can use the headphones to hear the interpretation from Welsh to English on channel 1, or to hear contributions in the original language amplified on channel 2. And, of course, if a fire alarm does sound—we don't expect that to happen today; there is no drill—can you please follow the ushers' instructions, should that happen? Of course, Members will be aware of the changes to the committee membership, which was agreed in Plenary yesterday afternoon. As a result, Dawn Bowden has now left the committee. I'd like to put on record my thanks to Dawn for her contribution to this committee over the past years. And we've also received apologies from Lynne Neagle today.

2. Craffu ar adroddiad blynyddol Prif Swyddog Meddygol Cymru 2018-2019
2. Scrutiny of the Chief Medical Officer for Wales' annual report 2018-2019

Felly, gyda chymaint â hynna o ragymadrodd, fe wnawn ni symud ymlaen at eitem 2—craffu ar adroddiad blynyddol Prif Swyddog Meddygol Cymru ar gyfer 2018-19. Cyhoeddodd Prif Swyddog Meddygol Cymru ei drydydd adroddiad blynyddol, 'Gwerthfawrogi ein Hiechyd', ar 7 Mai eleni. Dyma gyfle i'r Aelodau graffu ar y prif swyddog meddygol ynghylch ei adroddiad, y mae pawb, wrth gwrs, wedi ei ddarllen mewn manylder dwys. Ac felly, i'r perwyl yna, dwi'n falch iawn i groesawu i'r bwrdd Dr Frank Atherton, y prif swyddog meddygol ei hun, Llywodraeth Cymru. Croeso. Dŷch chi'n gwybod y drefn erbyn rwan—does dim angen cyffwrdd â'r meicroffonau; maen nhw'n gweithio'n awtomatig. Ac felly, yn ôl ein harfer, fe awn ni'n syth i gwestiynau, ac mae'r cwestiynau cyntaf o dan ofal Helen Mary Jones.

So, with those words of introduction, we will move on to item 2, which is the scrutiny of the Chief Medical Officer for Wales's annual report for 2018-19. The Chief Medical Officer for Wales published his third annual report, 'Valuing our Health', on 7 May this year. This is an opportunity for Members to scrutinise the CMO on his report, which, of course, everyone has read in detail. Therefore, to that effect, I am very pleased to welcome Dr Frank Atherton, who is the chief medical officer himself, for the Welsh Government. Welcome. You know how things operate by now—you don't need to touch the microphones as they work automatically. So, as usual, we'll go straight into questions, and the first questions are from Helen Mary Jones.

Good morning—bore da. Can we start with 'A Healthier Wales'? What influence did you have on the content of 'A Healthier Wales', and how is the plan reflected in your report?

Thank you—and thank you, Chair, and colleagues, for the opportunity to talk about my annual report.

There is a read-across on many of the issues here, in the Chief Medical Officer's report, to 'A Healthier Wales'—that's clear. They are separate things, of course. I was involved in helping with the drafting and providing some of the content and the thought process into 'A Healthier Wales'. If we wind back from there, of course, 'A Healthier Wales' was informed by the parliamentary review, a process led by my predecessor, Dr Ruth Hussey. And I met with the commissioners and discussed the current state of the health system with them, and the issues around the fragility of our health and care system. So, I was involved in that part of the process. But then, of course, in Welsh Government, we did move from the diagnosis of the parliamentary review into the treatment, if you like, of 'A Healthier Wales'. So, I was intimately involved in much of that.

And in terms of the link with the CMO report this year, you'll recall, I'm sure, committee members, that, last year, I chose to have a main theme, looking at gambling and health, and I'm sure we may get onto some of that later. But, this year, I chose to look a little bit more internally at some of the workings of the NHS, because it seemed an appropriate time, given that 'A Healthier Wales' was produced just about a year ago. And so, valuing health and the value-based healthcare approach that we're adopting here in Wales is one of the streams that we see in 'A Healthier Wales', and one of the ways that we expect to deliver on 'A Healthier Wales'. We need to deliver on our prudent healthcare principles, and I see value-based healthcare as the way of doing that.

Looking beyond that, there are some other big themes, of course, within 'A Healthier Wales', which I contributed to because of my role as medical advisor, chief advisor to Welsh Government. So, the fact that we have a shift—we're aspiring to a shift towards a more preventative healthcare system; it's really important—the integration of health and social care, of course, and then the efficiency and value that we get from the healthcare system were the three main areas that I was closely involved with. And I'm currently doing some work with colleagues to look at how we might develop a national clinical plan, so that we have a framework for the delivery of clinical services, based on value-based healthcare in the future.

So, looking a bit further ahead, what improvements to public health do you expect to see as a result of 'A Healthier Wales' and the transformation programme?

09:35

You mentioned already the shift to a more preventative approach.

Exactly, yes. I always try, in my CMO report, to give the picture of the health of the nation at the start, and so chapter 1 is about where we are as a nation and what our health experience is. I suppose there is a good news story to be told in that, by and large, the health and well-being of the population is improving over time. If we look at disease, specific mortality for just about any disease condition, mortality rates are reducing. There is an issue, of course, and I flag it in the report, in that life expectancy gains—which we’ve seen increasing year on year for many years now in Wales and in the rest of the UK—are, it seems, plateauing and we might want to explore why.

So, I would expect to see continued health gains. From a public health perspective, I want to see some of the proxy gains in terms of proxy markers—so, some of the process markers. So, there’s a lot of talk and a lot of description, of course, in the CMO report about healthy behaviours. We do need to increase the physical activity of our population and we do need to improve the diet and the proximal determinants of health—the things that make and keep us healthy. But, going beyond that, we also need to get better at looking at the determinants of health and issues like housing and unemployment, the unemployment rate and crime and disorder. So, all of those things impact on our health and, as committee members will recall from previous discussions, those are all issues that I think we should be tracking and monitoring and looking to improve in Wales.

Thank you. You mentioned in that answer the slowing down in the improvement of life expectancy. Can you tell us a bit about why we believe that is happening and why we've seen that recent slowdown?

The simple answer is that we don’t really know. However, there are many theories, and we need to look at the balance between those theories. Some people will argue that it’s a consequence of austerity in the UK. That seems to me too simplistic in as much as we know that—it may be a factor—the tailing off of life expectancy increases is an international phenomenon: it’s happening in most countries around the world. There are exceptions. Japan seems to be an exception, but many countries are experiencing the same change.

Some people will say, ‘Well, it’s down to demography—we had a golden generation who are passing through', and there’s a natural limit to longevity and that may be a partial factor, but, again, the fact that Japan is continuing to see rises in life expectancy rather militates against that. And, then, some people would say that we’ve had a couple, in the last 10 years, of really bad flu seasons, so maybe the flu seasons that we’ve had have been particularly bad. My suspicion is that it’s a bit of all of the above, and we don’t know, and I think the people who give you simplistic answers perhaps need to look at the broader picture.

What I would say is that we do need to continue to monitor it. We do need to continue to look at this across the UK system. I talk regularly with my fellow chief medical officers in the other three nations of the UK about this. There is a working group of statisticians and analytical folk who are looking at the data as well. It is an area, I think, that’s ripe for more research and understanding, and it’s worrying because we want to see continued increases in longevity, but we need to research it, monitor it and understand it better.

That's helpful, thank you. I've never been very impressed with the very simplistic 'it's all about this' responses. So, that makes sense. Your report, though, does talk about the significant difference in life expectancy and in healthy life expectancy, which, of course, is important too, between the most and least deprived parts of Wales, with an eight-year gap in life expectancy and an 18-year gap in healthy life expectancy. What's being done at the moment to address this and what more could we, should we, be doing?

Yes, this is difficult territory, and, again, we've discussed this with the committee. We do have in Wales intractable inequalities in health outcomes, and the report before last looked at some of this, in terms of what the health system could and should be doing to address those kinds of issues. By and large, health inequalities are remaining static; they're not really getting a lot worse, they're not getting a bit better. There are some areas you could point to and say, 'Well, there is a bit of improvement.' So, smoking rates, for example, are narrowing between the most deprived and the least deprived. But those examples of narrowing inequalities are fairly few and far between.

In terms of what's being done, one of the difficulties we face is that, of course, health inequalities mirror wealth inequalities, and one follows as day and night from the other, so we do need to look at the broader economic circumstances of people in Wales, and we can't just look to the health system as to what it's doing. We do need to look to the health system, but we do need to look beyond that.

In terms of our international understanding, we're currently working with the World Health Organization, and they have an office in Venice that looks at health equity issues. We're developing a partnership with WHO to develop a health equity status report, which will, hopefully, give us some further indications of the sorts of things we can do. We talk regularly with Sir Michael Marmot, who is, of course, the international guru on health inequalities, and he's visited Wales on a number of occasions. I've spoken with him, and the First Minister and the Minister for health have also met with him. We're exploring how we might be a country that could, perhaps, drive further with the six things that he says he's identified that will lead to a reduction in inequalities. And they are those broad determinants: they're about a healthy start for children; they're about broadening employment opportunities; and creating an environment that is conducive to health. So, there's more we need to do in that field.

As regards the NHS, I did challenge the NHS two years ago to look at the services that it provides, to make sure that they are delivering good outcomes for everybody, not just for the better off. There is, again, a link in terms of this year's CMO report, in the prudent healthcare principles of treating people in greatest need first. And so, there is a continued drive in the NHS, I believe, to make sure that the needs of the most deprived in our communities are addressed, but there's more to go. We're not alone in this—across the UK, the picture is pretty similar. They are intractable, but that shouldn't make us lose heart. We need to look at the broad determinants and continue to work on those.

09:40

Yes, it was literally just on that statistic. Good morning, Frank. 

Good morning.

Is there data available that splits the 18 per cent who will die younger or have a less healthy lifestyle, and the inequalities there? Are there any statistics that divide it across age? Because I'm just wondering if there's any good news buried at the bottom of that that says some of the prevention work that's now being employed is actually having a benefit, so the 20 and 30-year-olds of today will actually be much healthier—even though they may still be disadvantaged or in relative poverty, they may actually be a bit healthier than the 60, 70, 80-year-olds of today. I just wondered if there was anything there.

There are statistics, and you can delve deeper into that, and we do have folks who are very good at doing that. Unfortunately, my understanding of it at the moment is that the tailing off of life expectancy is something that you can see at all age groups, so it's not specific to any particular age group. And, similarly, the inequalities don't appear to be widening or narrowing for any particular groups. So, it seems to be a universal issue. There are countries where a different picture—. You'll be aware of the fact that in the US a lot of the reduction in life expectancy is actually driven by the opioid epidemic among younger people, and so a strange consequence of that is that the gap between ethnic groups is actually narrowing, because it's predominantly an issue affecting younger Caucasian people. But it's also leading to a rapid reduction in life expectancy in that younger age group, funnily enough. Now, luckily in Wales, we don't have that picture, but it is something that we need to continue to monitor.

09:45

You spoke about having—. Obviously, the determinants of this are not even predominantly in the healthcare system, but the healthcare system has got some responsibilities, hasn't it? You spoke about having challenged the healthcare system to respond and to understand this. Can you say a bit more about how you think they've responded to that challenge? Because, for example, some of us—and I'm one of them—are absolutely convinced that the awful things that we saw happening in maternity services in Merthyr Tydfil would not have persisted in a hospital that was serving a more prosperous community, because people would have been more likely to challenge it. So, I wouldn't want you to comment on that—that wouldn't be appropriate—but, generally, how do you feel the health system has responded to that challenge you've given them to really look at how they are providing services effectively to the poorest communities?

I suppose the starting point for this is that we are in a position in Wales where we should be able to do better for our populations, because we have a more integrated system than some other healthcare systems. Health boards are responsible for providing primary care and secondary care services, both—they're responsible for the whole-population health.

So, the way they respond is they do undertake needs assessments. They do that partly within their own remit, within the health boundaries. Directors of public health generally tend to lead those needs assessments. But increasingly, of course, they do them in partnership with local authorities, through the public sector boards, and so health boards are very engaged in that process of trying to understand better the health needs of the populations, and that inevitably gets into questions of who they're serving and the differential, both in terms of socioeconomic but also other inequality markers. So, we're good at the analysis.

What we're not so good at is the—. And I always guard against paralysis by analysis, because analysis has to lead to action, and so what we're not so—. What we haven't got so far, I think—and we're at an early stage of public sector board development, of course—is the ability to show that they are making a difference to those inequalities at local health board and local authority level. So, there's more to go at there that the health system needs to do.

Internally, I challenge them. We have performance management meetings with health boards every six months, and the agenda has shifted on that, so we now look increasingly at population health as the first set of questions. Inevitably, we get into questions of treatment targets, et cetera, but we are trying to take a much more holistic look at how they're meeting the health needs of populations. So, I do see health boards taking their responsibilities for population health seriously—probably more seriously—but there's certainly more to go.

That's helpful, thank you. Finally, then, from me for now, if it's possible to identify one thing, what do you consider to be the main challenge, currently, in relation to the health of the Welsh population, and is the NHS in Wales in a good position to respond to that challenge?

That's a tough question. The one thing—.

Well, or if you had to prioritise. If there was one particular challenge that we had to prioritise. There may not be; it may be we have to work on all—.

I'll give two answers. If you wanted me to give you a kind of—. I'll give you three answers. If you wanted me to give you a disease-specific one—you know, I'm a doctor, I'm a GP originally—I would say, well, we need to have a good go at cancer. Cancer outcomes are not what they should be and we need to get better at those, and I think 'A Healthier Wales' will drive us in that. If you asked me—. I'm also a public health doctor, so I would say we still have a long way to go on some of the behavioural issues. We need to get better at smoking rates. They are coming down, but we need to do better. Alcohol is a challenge to the health of our population. But then, I have to come back to my starting point, which was that, really, we need to tackle the determinants, which are about wealth and education, and if we get those right in Wales we will drive the health of the population. Are we geared up to do it? Well, I think we are geared better than many systems. We have the enabling legislation. We have the Well-being of Future Generations (Wales) Act 2015, which is attracting, as you know, a huge amount of international attention. Translating that into action, avoiding paralysis by analysis, is our challenge.

Thank you very much for that. Can I just ask one more question about health behaviours? Because, when I read your report, I was really puzzled by the alcohol consumption statistics, which basically say that more drinking is being done by more people who are more well off although, actually, it's the people who are less well off who are suffering more because of alcohol. I just wonder if you have any comment on what drives that excessive drinking, or excessive drinking in one particular population. And, because they are the more well off, do you think the minimum unit price initiative will actually have that much of a bite?

09:50

Yes. So, the trends in drinking need constant monitoring because they change very much over time. My answer to that used to be that we have two problems: we have a problem with younger people drinking large amounts, often to excess, and then we have the well-off retired people who are retiring without really a great plan of what to do and then there's a tendency for people to drink more heavily as they get older. Some of that still pertains and so I do worry about older people drinking and the impact of that, not just on the immediate things particularly in terms of mortality, but also in terms of mental health and the impact on dementia. The burden of illness is distributed across the whole of the population. There is no such thing as a safe drinking level. There are safer drinking levels. I struggle slightly to answer your question because we need to tackle both ends of the spectrum. There is harm.

In terms of the minimum unit price, the benefits will predominantly be for people who are on lower incomes, the lower socioeconomic part of our demography, because the modelling and experience elsewhere show that the biggest impact—the reduction in drinking is biggest for that group. The retired people of relatively well-off means are unlikely to be impacted in a very positive way by the minimum unit pricing. I suppose it's self-evident if you think about the affordability of alcohol. So, we need other approaches. We can't just rely on minimum unit pricing. It's one tool in our armoury, but we need to think about education; we need to think about how GPs work, because people still listen to GPs, to health professionals. So, things like 'Making Every Contact Count' and brief interventions—brief screening or brief interventions through primary care—are other things that we need to think about. So, it's a whole range of things. Minimum unit pricing I do think will have an impact on our population, but the impact will be greatest on those who are suffering the greatest harm, which perhaps is a prudent principle.

Well, you mentioned the word 'prudent', and in fact it's in relation to prudent healthcare that I wanted to discuss some of the findings in your report. I just wondered if, for the record, you could just give us a very brief overview of the interpretation we have here of prudent healthcare and also the way that value-based healthcare, which, from what I understand, would be a methodology in delivering prudent healthcare—perhaps you could just give a quick overview for the people who are interested to see what we've got up to.

Of course, yes, I'm very happy to do that. There are some amazing things in Wales, and one of the great things—in fact, one of the things that attracted me to come and work here—is the fact that we have developed a set of prudent healthcare principles. They are quite well embedded now in Wales. You'll always find somebody who will say, 'Well, I haven't heard about the prudent healthcare principles recently', but they're a really solid set of principles, which nobody would ever disagree with and which are broadly understood by healthcare workers, whenever I talk to people across the system, not just at policy level and the higher levels of the administration within health boards but at individual clinician level.

So, prudent healthcare principles are well understood. The difficulty has been in how we translate them into change. So, I've been struggling with that, and we've come up with the value-based healthcare system as a way of trying to operate and a way of trying to deliver that—a way of trying to take those four key principles into delivery. And when I look across Wales, it strikes me that there are any number—there are huge numbers of initiatives that do fit within value based. They haven't really been designed as value-based healthcare, some of them have, but many of them have just sprung up and have come up, often, from clinicians themselves working in quite difficult circumstances with good ideas, and they develop ways of doing things better for patients and often at better value for patients, at less cost for patients. So, the value is better because the outcomes are better and the cost is less. And what we're not very good at doing in Wales, of course, is understanding what those things are, of—[Inaudible.]—them out, of synthesizing them and of saying, 'Well, these are the winners; these are the things we should back in the system' and then scaling them up.

So, I see the value-based healthcare programme as—one of the main things it needs to do is to identify those things that can be done at the whole-Wales level that are making perfect sense in one health board and need to be scaled up. And a great example, and the one that's in the report, of course, is about respiratory therapy in Aneurin Bevan health board, where they've transformed the system—this is clinician led—by moving away from high-cost medications to much lower cost and higher value interventions around respiratory rehabilitation, pulmonary rehabilitation and prevention—smoking cessation. So, we get better outcomes for the population, better outcomes for individuals and reduced costs to the health service. So, it seems a win-win. But why doesn't every health board pick those up? So, part of the drive of value-based healthcare is to look at things and to scale them up across the whole of Wales.

09:55

So, looking at the four principles of prudent healthcare, can you give me some sort of feedback on how well you really think the involvement of the public with the professionals—so it's principle 1 of delivering prudent healthcare—is really working? I totally get that in a specialised area—and I think, in here, you quoted renal health, and everyone working together to come up with a new methodology for the delivery of renal health—but for most of our people who will not, perhaps, need that specialism, how will they be able to get through their particular sort of triaging systems, if you like, and have that involvement with the professionals to deliver prudent healthcare?

I suppose, while we're looking at that and we're looking at the mass who are not—. Because, to be honest, I thought a lot of your report, to me, seemed quite secondary-care based, so I'm very interested in how that principle can then apply through the general practice and primary care interface, especially when 'Valuing our health' puts such an emphasis on primary care. They don't have the resources to back up that huge weight of expectation. We're asking primary care, whether it's a GP or an allied healthcare professional, to basically stop people in their tracks and stop them from having to go any further through into the health system. So, I'm just trying to work out how the patient or the user actually feels that they've got that empowerment there in the prudent health principle and how the GP, if you like, and the primary care element does.

You touched on a lot of things there—

Sorry, yes, my questions are always long. [Laughter.]

No, no, that's fine. Although I talked about prudent healthcare being widely understood, it's widely understood, I think, on a professional basis. I think if you were to talk to the population of Wales, they probably wouldn't recognise prudent healthcare. However, I think people would recognise that the dynamic of interaction between healthcare professionals and the public and patients is changing, but it takes time to change. Some people still want to go to the doctor and be told what to do—a few—but, increasingly, people want to go to the doctor, often armed with information of their own, and have a discussion about what's the best treatment for them and then come to a conclusion. So, I think, actually, some of that co-production, as we say—it's a jargon term, isn't it—is happening.

There are some areas, and I will defer to a secondary care one, where we are trying to push that along more quickly, and one I think about often—well, there are several I think about—is end-of-life care, where people are often faced with very difficult choices to make about whether to have further chemotherapy or radiotherapy, or whether to accept palliative care as an option. And, of course, you know, these therapists, who are often—and there's an imperative, often, in doctors, in healthcare professionals generally, to try everything to save the life of a patient, but sometimes the best decision is to accept fate and the fact that we all die at some point—sorry to give you all that bad news. But a good death doesn't necessarily mean prolonging death, so we shouldn't prolong death. So, making choices together now—we've been working in Velindre to try to help people to have that conversation with clinicians, to help clinicians to be able to be receptive to those conversations, but also to support patients in having those conversations, so that you get a better decision.

There's another example in orthopaedic care—where we have an ageing demography, people are needing more hip and knee replacements because of arthritis and wear and tear on joints; what's the right timing for that? That needs to be determined by outcome measures rather than just by x-ray findings. So, trying to work with patients so that they understand when is the right time to have an operation, as opposed to just assuming that because I'm having a pain in my hip, I might get better—you might not get a better outcome, and it might be better to wait a few years rather than have the operation now.

So, there are lots of examples in secondary care. Your point about primary care is very well taken. Prudent healthcare and value-based healthcare do absolutely apply to primary care. It is under stress, under pressure, as we know, and as I'm sure this committee has discussed on many occasions, but, again, having the right person in the room to have the conversation with the patient is really important. I've been to—I'm sure many of you have—GP primary care services that have really been transformed by broadening the skill base, bringing in physiotherapists, bringing in mental health practitioners, counsellors, psychologists, and working as a team to deliver a service with patients, rather than the patient just waiting to see the doctor and queuing up to see the doctor. Llanelli was the practice I went to most recently, and it was an absolutely fantastic example of better healthcare provision, better patient satisfaction, better doctor and nurse satisfaction—everybody's happier with the system because they've re-engineered the system, and that again is a part of 'A Healthier Wales', I suppose.

10:00

You've touched on end-of-life issues, and it was interesting when you referred to those as secondary care issues, because one of the concerns that I have is how well our primary care system is set up to support people who want to make decisions to have their end-of-life experience at home, and I just don't know if you could comment on that, because, to me, an end-of-life decision ought not just to be something that you have, perhaps, with your oncologist, but your GP and your GP practice and the nurses in your GP practice have got a huge role to play there. We are told that some sections of primary healthcare are a bit nervous about having the skills to manage the medication and that kind of thing, so I don't know if you can comment on that.

Well, I suppose I mentioned it in the secondary care setting in as much as that's where people generally go for their radiotherapy, chemotherapy et cetera, so there is a job to do there. This is an excellent area, an excellent example of an area where the distinction between secondary and primary care is an artificial one, really, and we need to move away from that thinking. I would like to see clinicians from Velindre increasingly working with GP primary care clusters, and that's true in cancer care, it's true in palliative care and end-of-life care, but it's true in many other areas, actually. There are some very good initiatives around in terms of paediatrics, for example, working out in the community. So, as the nature of our hospitals changes, and the nature of healthcare changes, let's not forget that one of the other big directions in 'A Healthier Wales' is to help with that shift of care from hospital based to community based to home based. Then the boundaries between secondary and primary care need to be blurred. I think you're right to flag palliative and end-of-life care as a really important area that we should do more with first.

Going back to your report, there's a comment here under 'Care for those with the greatest health care need first', and I just wondered: does caring for those with the greatest need all the time impact on prevention? Do we end up, because of resources, waiting too long so that, by the time the person's got the care they need, they're actually sicker or they've developed comorbidities? I also wondered if you could just help me to understand this comment, which is:

'One such example is when all referrals from primary care are placed on the same waiting list for treatment, whatever their level of need.'

Now, is that a departure from clinical need, because I know, when my constituents get referred, they tend to be referred as 'urgent urgent', then there's the urgent that isn't urgent because there's a more 'urgent urgent' and then there's the routine? So, I wasn't quite clear on what you mean by that the greatest need should lead.

10:05

Well, of course, it is one of the principles, and it's interesting and you raise a good point in that the principles need to all be applied and they can sometimes come into conflict with each other, and that raises issues. But there should not be a conflict between care and prevention; they're both important elements of the system. You might want to come back to me on that one. 

On your second point, the way that we manage demand is a very blunt management, and we'd recognise that. We know that, in waiting lists, for example, although we focus very strongly on referral-to-treatment times as a marker of the effectiveness of our healthcare system, follow-up patients can often experience harm. And we need to get better at understanding where that harm is, where it might occur and how we treat the people who are at risk of harm. I suppose the example currently in play is around eye care, where we are trying to move away from a very simplistic look at, 'Well, we'll treat all the people who are coming in, the new patients, but we'll leave people on the waiting lists for follow-up appointments, even though there might be a risk of harm.' And so we need to get better at understanding where the hidden harm is. 

I'm not sure I answered your first question very well, do you want to—?

Yes, well, actually I suppose that leads on to my third question, which is actually about the whole revolving door. So, for me, what I see from my casework and from going out—I've visited quite a few hospitals, I visit a lot of doctors' surgeries and talk to people—is that you can have—. I'll just use an example of, say, an elderly person, who might need to have a replacement hip, and by the time they have waited for their replacement hip—because it's not so bad they have to go in right now, but by the time they get to it, they've slowed down, so perhaps they're starting to develop pneumonia and bronchitis more because they're not moving so much, so then they get into hospital, then they get treated for their hip, but nobody actually looks at the rest of them. And so, 28 days later, or a couple of months later, they're back in through the door, because, actually, their respiratory system has started to fail. And then, because that and that's happened, something else has gone wrong. And so the thing I look at a lot and try to figure out how we can do it—and I have no answers, sadly—is how we can get better at being that first point, so that—.

My one worry about prudent healthcare is that it can also equal—and I have seen it equal—'do the minimum', because it's more cost-effective to do less so we just deal with that, which is why I'm such a great fan of people like orthogeriatricians, who look holistically. And I noticed in your report that you made a great point in the first chapter about the fact that we have an older than average population and that, going forward, we're going to have a much older than average population, so this is a real Wales issue and we've got to get to grips with that. If we want that much older population that we're going to have than everybody else to be as healthy as possible because then they can stay in their homes longer, they can look after themselves better, there's less pressure on the care system, then when they are ill, we have absolutely got to say, 'Right, what else have you got? Let's get you totally sorted so you walk out that door and I'm not going to see you for five years, or 10 years.' We're nowhere near that and, as I say, my one worry about prudent healthcare is that I have seen it sometimes equal doing the bare minimum and just sorting out that little problem. And I noticed you mentioned the revolving-door statistics, but I actually wondered what the revolving door stood at, because when we've done our inquiries in the past on winter pressures, one of the things the doctors say again and again and again is that that really is a revolving-door season, when elderly people are in and out, in and out, in and out. Sorry, another long question. 

No, that's fine. Just to reassure everybody, I suppose, that prudent healthcare is not just about saving money; it's about getting better value, and that's why I've used the word 'value'. And in fact, there may well be instances where people are being undertreated, and that's kind of what you're describing, really. Undertreatment is as bad as overtreatment because it's wasting resources in exactly the way you describe. So, we do need to get better at that.

The example you cite raises questions of how we treat frail, elderly people, and we're going to face an increasing number of frail—. Because of our demography, we're going to see increasing numbers of frail, elderly people. And the worst thing, as you know from your casework, is for somebody of that nature to go to hospital because they very quickly become further disabled, and then you get into the revolving door.

And that's been recognised, of course, in 'A Healthier Wales', and one of the ambitions through the transformation programme and transformation programme funding is that health and social care will work together to support that specific demography, so that they're not coming into hospital, so they're enabled to stay at home, so that rather than having the hip operation, we're asking what else do they need in the house to stop them falling. All of those interventions—the social care interventions.

And I do believe that if we look at the system more holistically, and if we try and use the prudent healthcare principles and value-based healthcare to target the right treatments at the right time, that will take us in the right direction and it will help to stop some of that revolving door that you describe, which is putting far too much pressure on the health system.

So, I agree with your diagnosis but, of course, the devil is in the detail and getting it right. We are testing models across Wales now through the transformation programme. I'm hoping that—and the expectation is—from that work, from that investment of £100 million over two years, there will be models that will emerge that we can, again, scale up and use to stop that happening. 

10:10

I think—and I'll try and make this my last question; actually, I've got one more, a little one—but I think one of the real concerns I have, Frank, is that the person or the unit that can have the most holistic view of another human being is probably in the primary care service. And they're under such immense financial and resource pressure—you know, we don't have enough doctors, nurse, physios, et cetera. So, when your elderly lady has her hip operation and it's been performed exceptionally well by the consultant, what we don't then get is we don't get sufficient, for example, physiotherapy to make that person able to walk well. So, we've done the job, we've mended the hip, they've come out of hospital, but, actually, they can't go shopping, they can't get in their car and drive it, they become less mobile.

And there is nobody else who has that overview, because the consultant's done his or her job, the nurse has done his or her job, the person's exited from hospital, they're well enough to go home, and then that's when it all goes wrong. That's where the primary care could step in and say, 'Right, you now need to do more than the standard six half-hour physiotherapy treatments that you might get; you need to have adaptations in your home so when you go up and down that funny flight of steps, you don't fall over'. So, are any of your pilots that you talk about actually looking at how we can beef up that interventionist model of primary care? Because that benefit will then keep that person out of secondary care for much longer, stop a bit of that revolving door, and thereby not only increase the value of their life to themselves—the quality of it—but actually cut back on the cost that we as a state have to pay.

We have a situation in healthcare where things are becoming increasingly specialised, and that's true certainly in secondary care in hospitals; we see it all the time. What the population needs are generalists, and that's why I think you talk—and I agree with you entirely—about orthogeriatricians. Geriatricians generally are now the generalists that used to exist two or three generations ago. General physicians now are very specialised into lungs or cardiology or whatever, but the orthogeriatricians and general practitioners are the generalists who, I believe, can provide that holistic care. 

So, the question comes back to—. Well, there are two questions. One is how can primary care respond to this. We do have a problem in primary care. It's well recognised, and part of the solution is to work in a multidisciplinary way. That requires us, as a health system, to start to think about how we shift resource from hospitals. Where are the physiotherapists working? Are they working in hospitals? How do we get more physiotherapists working in primary care, and beyond primary care, into the community?

So, the answer to your question is that, yes, within that £100 million of investment, there are a number of models that are trying to get the outcome of exactly that kind of approach. So, it's work in progress. But that whole ethos of 'A Healthier Wales' of moving—because the demography is changing and the needs are changing—resource from acute settings to community settings to home settings, that's a very difficult—. That's absolutely what we need to do. Doing it is extremely difficult because of the pressures on secondary care. And in a way, the transformation fund was designed to provide the double-running to allow some of that to happen so that we can show the benefits. 

10:15

Have I got time for just one more very quick question?

I can't—. You make very little reference here to mental health, which, of course, is a huge issue for our population. I did just notice that in one of the commentaries here, when you talk about, perhaps, when people go into hospital—about not doing harm. It's the prudent principle of not doing harm, so you don't overintervene on somebody. I absolutely get that, and totally agree because of the damage that it can cause, including the mental health issues. And I wondered if, again, there were any pilots on how there can be more proactive mental health management of patients who are in hospital for fairly regular things. Because, again, I have met lots of people who have had to go into hospital for unexpected reasons, or because they've had a trauma like falling over, and they hadn't expected or understood the effect it's had on them psychologically, and that's then played out later on. And I just wondered about the training of personnel within hospitals, or whether there's a thought about having—. Do you have a physiotherapist who goes through the ward? There might be a counsellor. Or is there anybody anywhere looking at any of that, where somebody might come on to a ward and actually talk to people about how they're coping with the whole hospital experience? Because for many people, it's incredibly traumatic. 

If I may, Chair—it's a big question. 

I don't think I can address in as far as—. I absolutely recognise what you're saying, and we could spend, I'm sure, two hours quite happily talking about mental health issues, and I'm sure that's come through in the purview. It's not really in the CMO report. There are some references to mental—

There are some areas where we touch on it. I think it's something we do need to give a lot more thought to. We are—. As well as primary care struggling, we are struggling to meet the rising tide of issues around mental health, and any ideas that you have I'm sure will be gratefully received as we revise and refresh our mental health strategy and approaches. 

Ocê. Symud ymlaen at Jayne Bryant.

Okay. Moving on to Jayne Bryant. 

Thank you, Chair. Good morning. You've spoken about the importance of tracking and monitoring, and you've also said that analysis has to lead to action. What benefits does research in health and care bring to patients in Wales? 

One of the chapters, as you've seen, relates to research and the development and the importance of that to the healthcare system and to the population of Wales. And I included that this year because research and development often goes under the radar and people don't recognise it, don't see it; it's often invisible to people. And I have to say, it's often the first thing to get cut when financial pressures become tighter. It brings enormous benefit to the individual and to the system. So, for the individual, we know that if you as a patient are having treatment in a facility, in a unit, that is actively involved in research, or if you are enrolled in trials, even if you're on the placebo arm of a trial, you get better outcomes. So, there is a benefit to people being in a system that is active in research and development. 

It has an impact on our recruitment and our ability to recruit healthcare professionals into Wales. Healthcare professionals—doctors, nurses, allied health professionals—very often want to work in places that are research active, because they can then pursue their own research agendas, or they can adapt their research agendas to the local environment, and for their research potential. So, it's a draw to bring the health workforce into Wales. It has economic benefits, because we can draw in funding from elsewhere. So, although we spend about £43 million a year directly on health and care research, we garner much more from that—from other trials, from other funding sources coming into Wales. And of course, there's an economic benefit in that industry wants to be where research is being conducted. If you think about England, the golden triangle—Oxford, Cambridge, et cetera—it has huge potential, and it has huge investment from industry into that area, because there are vibrant research health facilities working in that area. And that's what I think we need to mirror in Wales, really—so, benefits to the individual, benefits to society.

10:20

Thank you. HealthWise Wales is the largest research study of its kind in Europe. What are the expectations for that?

I've been pleased, in the nearly three years that I've been here, to see the growth in the number of people registering with HealthWise Wales. It's an important part of our research infrastructure and will be increasingly going forwards. It provides us with a platform of people who are actively wanting to be engaged in research, who've submitted their data and their information and are willing to take part in research studies. So, the way I see it is it's going to be a platform to drive population health research in Wales.

It will be used by individual trials. So, it really is part of our broad infrastructure, and it's open to anybody in Wales—or beyond, indeed—to come in and use that infrastructure to design and conduct a trial. So, the actual use will be determined by the researchers who come in and use the data. In the same way—. One of the other things I mention in the report is the SAIL database, and the fact that we have a resource there that is the envy of many countries, and which provides us with data that is anonymous and secure, so that researchers can come in and use that for their research purposes.

Okay. Your report notes that Wales is leading the way in combating childhood obesity. Can you outline some of the research work that's been undertaken on that?

Yes. We've just finished the consultation on the 'Healthy Weight: Healthy Wales' approach that we're taking. We're looking to produce a 'Healthy Weight: Healthy Wales' strategy rather than an obesity strategy, just because it's a positive construct rather than a negative one. And as part of that, we worked very closely with Public Health Wales, who I think did a very good job of pulling together the international evidence around what works on obesity in general, and on childhood obesity in particular—what are the factors that might be successful here in Wales. Ad so, that analytical work did inform the construction of the draft strategy on which we've consulted, and on which we've got a lot of feedback now. And the process, from here, is to build on that—and we're currently still analysing the consultation responses—and to build those into a final strategy, which we're going to produce in the autumn. So, it's a good example of where research, synthesis of research and understanding the issue can lead to the development of a policy, which then has to have an impact.

And you're confident this could really be quite different to other past plans or ideas.

I try to be confident, because we can't afford not to be, really. There's no country in the world that has managed to turn around what's often called the tide of increasing weight, or the obesity epidemic, or however you want to phrase it. What we know is that there are—. And we've looked very closely at places that have been successful in that—Amsterdam, in particular. Leeds has been recently cited; I'm sure you're aware that they claim to have turned around childhood obesity. We had a team just going up to visit Leeds last week, and I'm going to meet with them later this week or next to find out what they've found. So, there are places where it can be done—we believe it has been done—but no country has ever done that. Well, wouldn't it be great if Wales would be the first country to adopt the lessons from those places at a national level and actually show that impact in terms of turning the corner on childhood obesity? That's the ambition, so, yes, I am optimistic, but it's not easy, because, as we all know, the complex web of interactions and the complex web of things that lead to childhood obesity are not easy to break and we have to deal with behaviour, we have to deal with society, we have to deal with the environment, and we need very strong leadership on all of these things.

10:25

Thinking about that web that you've just—about the different factors, what weight will your plan give to physical activity in children, as one of the key factors? You'll be aware that this committee recommended to the Government a specific number of hours for all schoolchildren. They decided not to accept that recommendation and feel that they can address it better through some of the other developments proposed in the new curriculum. So, I just wonder if you can comment about how important you think that physical activity is and whether you have any comment about what the role of schools ought to be in that. You may feel that you don't want to step into that particular fight, but—

In general terms, I would say that physical activity is enormously important for health and well-being and that's why—I think about the 'Healthy Weight: Healthy Wales' strategy. Physical activity, if you're thinking about obesity, is a relatively minor thing in terms of tackling obesity. It's, you know, that old phrase of, 'You can't outrun a bad diet'. So, it's largely about—it's more about the food and the environment that we have than about physical activity. 

However, physical activity is important as an adjunct and it's important in terms of general physical health and it's really important in terms of mental health. So, for all those reasons, I belive we do need to press on and to make sure that we promote physical activity and that we don't see that dip in physical activity when kids enter the teenage years.

Schools, as a setting for that, are really important. The 'daily mile'—a good initiative, needs better evaluation, generally a good thing. Most activity probably takes place outside the school, so we need to look at promoting physical activity both within and without the school setting, yes.

Thank you, Chair. Genomic medicine is an emerging technology and we know that it can advance our understanding of diseases such as Alzheimer's and cancer. Do you think that we're making the full use of the benefits of that at the moment and how are patients seeing its impact?

It's a really exciting area of health development at the moment. And when I think about genomics, I think about the broader suite of things around what's often called precision medicine. So, the technology is moving very, very quickly. Genomics—we have positioned ourselves, I think, fairly well in Wales, by developing Genomics Wales and the national approach; we do lots of statements of intent and we have a coalition of partners, including industry, working on that. 

There's another area around cell and gene therapy—what are sometimes called advanced treatment modalities. We need, in Wales, to be understanding what our role in those is. We can't do everything, but we need to be engaged in that space for the simple reason that it's going to happen, irrespective of what we do, and we want our patients in Wales to be able to access treatments in Wales if at all possible.

Outcomes—your specific point—are a little bit down the road still on some of this. There's huge promise in genomics, there's huge promise in advanced cell and gene therapies, and we're starting to see patients now coming through, particularly with the latter group, individual patients who can benefit, and the treatments can be transformative; they can be curative, where, previously, conditions had been lifelong. I think this area's going to expand, expand rapidly. It's going to challenge us as health system, because these are expensive therapies. It'll challenge our commissioning model of how we pay for these sorts of services. It'll challenge us in terms of how we work with industry, how we pay industry for these kinds of services. So, there's enormous promise, enormous potential. We have to be engaged in that space. We are engaged in that space. The outcomes are potentially very high but we need to think about how our system responds to these.

10:30

Okay, thank you. And just talking about—going on to Brexit, you mentioned about the amount of money that Wales gets in terms of research as well, and we know that European funding and money has come for that. Do you think that—? Does research in healthcare and care in Wales receive adequate funding and will Brexit impact on that?

My colleagues in research and development always say 'no' to the question of is there adequate funding, because of course you could put any amount of money into research. If you think about what industry spends on research, what a company would do, it's often quoted as 10 per cent of investment would go into research. We're nowhere near that, of course, in Wales. We spend about £43 million a year directly on research, but we leverage in additional resource from outside. The Brexit question—it does create a risk, in that, if we start to lose funding from European sources, then that would reduce our ability to conduct high-quality research in Wales. It's a risk that is currently being—it's been identified at UK level; there's a lot of discussion about how we can continue to engage with Europe on European funding schemes. I don't have the detail of that here, but it's really important that we do continue that and we manage that risk if we get into a Brexit situation.

Just finally, are there any other key areas of risk within the NHS in Wales in relation to Brexit?

So, there are obviously questions around workforce. We are less vulnerable than other UK nations in that much of our workforce that is not home grown, if you like, comes from international medical graduates, particularly from the Indian subcontinent, but we do have a pipeline of graduates coming from European countries as well. That's in medical terms, in nursing terms and care terms as well. So, there is a significant risk that would need to be managed around the workforce, the health and the care workforce, and I'm probably more worried about the care workforce than the health workforce, but both need to be managed. 

The flow of information is really important in terms of protecting the health of the population. We are working with colleagues in European centres to make sure that we try to retain access to information flows, particularly around communicable disease, so that we can manage the threats from communicable disease. Diseases don't know boundaries, and we can't afford to weaken our health protection systems.

So, those, along with the research and development, I would cite as the major ones. A lot of work preparing, of course, for disruption to supplies, whether it be food or medicines or medical devices and consumables—all of that planning is in process to try to mitigate those, but they are all risks. 

Thank you, Chair. Can I just go back to that last point and couple of points? Have you seen evidence of a reduction in EU nationals working within the NHS in Wales?

I haven't seen anything to date, no. It's something we do need to watch, but I haven't been made aware of any reduction so far. 

And in relation to—. You've talked about data. Data flows are crucial in the fight against diseases, communicable diseases, but what about the—? The question we also ask is about clinical trials, because, if we have a situation where we are no longer participating in the EMA, are we looking at challenges with being involved in clinical trials within Wales? You talked of genomic treatments, genomic medicine, for example. We will have to look at clinical trials on how we develop those. So, are we facing challenges in getting approval for clinical trials?

On getting—?

No. That's not an issue at the moment. The regulator, the EMA—. The MHRA in the UK, at UK level is currently gearing up to—they face challenges in terms of regulation of medical. But I'm not aware that it's affecting the research clinical trials as yet.

10:35

Well, it's one of many risks that we need to understand and mitigate, of course, yes—of course it is.

If I go back to your report, your fourth chapter clearly focuses upon public health threats, and you started with a section on antimicrobial resistance, and you highlighted that—I think it's a 11.9 per cent usage decrease in antibacterial within the GP sector, and you're going for, over the next five years, a 25 per cent reduction in that sector, and 10 per cent in the hospital sector. Now, is that an ambitious target, or is it a realistic target, particularly as you highlight in the very first sentence you've put in that section that antimicrobial bug resistance is an increasing problem in Wales?

So, it is to the great credit of primary care that that reduction has been achieved to date. It speaks to the fact that the profession is understanding that antimicrobial resistance is an issue, and that's, I think, becoming quite well ingrained. The targets that were contained in the UK-wide strategy, which is what we in Wales have signed up to, are ambitious; they are definitely ambitious. They have to be achievable. The primary care one is more challenging—25 per cent, as you say—than the hospital one.

I'm more confident, interestingly, in primary care than I am in secondary. I'm slightly worried about secondary care because one of the tools that we need to deliver on that in secondary care will be electronic prescribing, and it's not properly embedded yet. So, I've been talking with medical directors and with the NHS Wales Informatics Service about how we can accelerate the roll-out of electronic prescribing. So, there are things that we need to build into our system to deliver on those targets, but they are important ones.

The other points that your question perhaps refers to is, although the profession kind of gets it now—and particularly primary care—I think there's still a lot we need to develop with the public and public expectations. They have changed, and people are generally understanding, but there's more that we need to do in terms of changing the public expectations of antibiotics, I think.

I was going to ask that question, because nearly every time you end up—somebody says, 'Oh, I need antibiotics from the doctor'. So, there's a question as to the public understanding of antibiotics.

It is, and it's very difficult as a GP or a nurse prescriber when you're faced with a patient who feels that they really need those antibiotics. So, that's where the co-production issue comes in again about trying to explain the benefits and the risks of all these.

Okay. Again, talking about vaccinations—flu vaccinations—an increase to 50 per cent of two to three-year-olds and 68 per cent of seven-year-olds and eight-year-olds. That's a half and two thirds, so there's still a large group that actually has not been vaccinated. How are we encouraging more families to ensure that their children are vaccinated, so that we can hit a higher level?

So, we do tend to piggyback on UK-wide public campaigns around this. So, the messaging needs to get to the public. We try and work with the health boards. Again, directors of public health in health boards tend to lead on vaccination programmes, and we challenge them every year as to what percentage of the population is being covered. We see occasional gains, but there's a lot of variation across health boards in terms of what the coverage rates are, both for the flu vaccination, and, indeed, for the routine vaccination in childhood.

We're never going to get to 100 per cent coverage in flu vaccination. Every season, we look back at what we've achieved in the season that's just gone through, and we think about what are the implications for next year. That's why, last year, for example, we introduced vaccination in care homes of care staff because we recognised that they were at risk of transmitting flu to the very vulnerable people who are living in care homes. So, we need to constantly update our flu preparedness, our flu system. Every year is different. We don't know what flu will bring next season. We're starting the planning of that now. We know that it's a difficult year in the antipodes—Australia and New Zealand are having a difficult flu season this year—and we often follow suit the following year. So, we've started alerting the health system to that, so that they can start to prepare, so that they can order vaccines in time and get flu vaccination programmes in place.

The report also, of course, talks about the routine vaccination of children, and measles in particular has been in the news a great deal recently. We don't achieve our 95 per cent target, which is the general level that we need to achieve the herd immunity, so called, so that we don't transmit measles, so if it comes into the country it can't develop widespread transmission. In the absence of that, we are seeing small measles outbreaks across the whole of the UK, and Wales is no exception. So, we need to be vigilant about vaccines and we need to continue to work with the public so that they understand the value of vaccines. 

10:40

Since we've come on to MMR, obviously, as you say with your figures, you haven't achieved the 95 per cent and you haven't achieved the 90 per cent for the five-year-olds for the second dose either. I suppose, in a sense, I'm looking at two things. If I link the two—the flu and the MMR—it's quite a dramatic difference between a 50 per cent coverage for two-year-olds in flu and just under 95 per cent coverage for MMR. So, I just want to work out how we can get the flu vaccine up to the levels of the MMR, considering that they are the same age, in one sense. Has the case with the MMR still caused problems in your coverage? Because we know in the flu epidemic that was in Swansea and Neath Port Talbot not too long ago, we saw quite a dramatic increase in uptake. Why has that dropped off a little bit? Why have we gone back down to under those levels?

I suppose it's something to do with memories being short. When we have outbreaks and incidents, you're right, the uptake rates generally increase. Mumps is a great example. I remember various mumps outbreaks where it was terribly difficult to get the catch-up of students who had missed out on mumps vaccination when they were younger. It was really difficult to get them to come for vaccination, but once there was an outbreak at universities, they were all queuing around the block to get the vaccinations. So, there is something about memories being short and how we remind the public that these are not trivial diseases. These are serious diseases. People sometimes think of measles as a trivial illness—you know, a rash and it goes away in five or six days. Well, it can be that, but in rare cases—one in 1,000, maybe—it leads to severe neurological disease and occasionally leads to death, and so people need to know that. So, there's more need to go out with public communication, I think, and of course, we are in a difficult environment, because there is an anti-vaccination movement and we're not exempt from that. It's not as bad in Wales as it is in some other parts of the world. Italy is really facing a problem with that, and parts of the US. I think part of our challenge here is to make sure that health professionals have the information they need, that they can work with patients, work with those patients who are sceptical for whatever reason about vaccination, that they have the time and energy to do that. And it's not about GPs; it's about having staff within the team who are able to take that role on.

A couple of questions about vaccination, just following on from what you've just said to David. Can you tell us a bit more about the variations in cover, particularly for MMR? What do those look like regionally? If we've got somewhere where it's working really well in Wales, is there more we can do to read that across?

I have a bit of a question about the language we use, because if I'm a sceptical parent and you talk to me about herd immunity, my reaction is, 'My child is not a sheep,' and I wonder if we need to reframe some of the language we use a bit in response to some of this. I think you're right to say that the anti-vaccination movement, thank goodness, hasn't taken grip here, but you see a lot of stuff online, especially on parenting forums and places like that. So, do we need to start talking about 'community immunity' or something? I know that in medical terms the term 'herd immunity' is just what people are taught, but you say that to a young parent who has perhaps read some nonsense online and they're likely to be sceptical.

And the last point—. And I'm not advocating this, but of course it's the case in some countries and some states of the USA that being vaccinated is a pre-condition of being able to enter state education. I'm not advocating that here. I don't think we need to think about it; we've still got relatively high levels of coverage. But, I wonder if you've got any comment on that. 

10:45

They're all good points. There is a lot of variation between health boards. I work with the director of public health to look at what are the common things we can do across the system, what can we learn from one place to another. Those variations often reflect the populations being served, back to part of our original question, so we need different tailored approaches to different areas. Again, in terms of variations in outcomes and variations in care, we need to understand from a prudent lens why we have these variations and drive them out, so that's part of the job of the system. 

I absolutely take your point about herd immunity. I'm not sure about 'community immunity' because it's a bit of a tongue twister, isn't it? But I think you're right, we need to get a better—. I would never personally use that, if I was still a GP. I would never use that with a family or the mum. You're right.

Have you? So, perhaps we need better language, I accept that.

The question of how coercive—should I use that word—we should be. To me, mandating vaccination is certainly not somewhere we would want to be at the moment in Wales. I think you have to tailor your intervention to the situation you find yourself in. If this was a real emergency situation, if we had—let's say Ebola was around and we had a vaccine and nobody was taking it up, we might be in a different position, but with this I think we have to go down a route of persuasion, encouragement, information.

I do see what's happened in the US, and in fact they've gone further in some places, it's not just for school entry but children being in public places are expected to have—how they monitor and police that, I wouldn't have a clue, but I know New York has gone down that route. I always have caution about being coercive when other methods can work. This comes into play in Wales with flu vaccination for healthcare workers, of course, because many people would say it should be mandatory for flu. I'd like to see the regulators, the GNC, for example, the General Nursing Council, being more proactive in saying that it's a professional duty. I don't think it should be mandated, but there's more we can do.

On that point, there's actually a report out today highlighting the confidence people have in vaccinations, and in fact western Europe is one of the lowest areas of confidence in vaccinations—that they are safe. Is there more work needed, therefore, to actually communicate with people about the benefits of vaccination? Rather than coercion, perhaps to encourage them to understand what the benefits are. Because if 59 per cent of the population feel that vaccinations are safe, there's a large proportion who do not have confidence in them.

You're absolutely right. I believe we do need to think about what the message is to the public now. It's difficult. What I was saying about short memories—when I was a GP, and you'll recognise, Chair, I used to see many, many cases of measles. In the winter season, it was a daily occurrence, you'd get a round of children with measles. GPs now don't see measles very often. When was the last time any of us saw a case of diphtheria? So, in a way, the system has become a victim of its own success, because we've almost eradicated these diseases, so the community are not seeing them, and so the old messages don't work. So, we need to think about what new messages will deliver a better outcome. 

Particularly on the short memory issue, I think therefore we need to have a programme of repetitious encouragement. Because meningococcal is another example. When students come down with meningitis, all of a sudden everyone's rushing for vaccination, but your report indicates that actually only 40 per cent of students are probably vaccinated at this point in this academic year. So, 60 per cent of our students are not vaccinated. Yet we know that's a very dangerous condition and we should be looking at encouraging that. So, are you putting in place more frequent programmes continually reminding people about vaccination?

It's a rare disease, but it's a very serious one with tragic outcomes. I think it should be in the mindset of parents, of students and of universities that when people are enrolling in university, as part of your application through UCAS and in getting ready for freshers' week, you look at your vaccination status. We need to get that into people's mindsets. I think there's more that we can do with the universities to support them in this work as well, so, absolutely.

10:50

Hepatitis B and hepatitis C, clearly, are in your report and you're talking about, you know, that they pose a significant health threat. This committee has obviously done some work on hepatitis C as well, and we believe there's a possibility of actually eradicating it from Wales. I suppose: where is the Welsh Government in looking to actually deliver the eradication of hepatitis C and is it prepared to take the actions necessary to do so?

Well, we are and we're committed to WHO targets on elimination, and I was amazed and impressed when I came to Wales. I came from Nova Scotia, where the direct-acting antivirals were being debated, as to whether they were affordable for the population, and I came to Wales and found that basically everybody who has been diagnosed with hepatitis C has been treated now. The challenge here is a different one, as you well know from your inquiry; it is to identify the people who don't know they have hepatitis C. And we are committed to trying to encourage people to go for testing if they fall into those high-risk groups, so we actively want people to come forward for testing. The new treatments here have been a game-changer and transform lives, yes.

Okay, and the final question from me is on quality of air. Tomorrow is Clean Air Day. We had a statement from the Minister yesterday on clean air. I represent Port Talbot and I actually live in Port Talbot, which is one of the alleged—

No. It's one of the alleged worst for air pollution in Wales. I suppose what I'm trying to ask is: what is the Welsh Government actually going to do about this? Is it looking seriously at either legislation or some sort of action to improve air quality? Because many people continue to ask the question: what are you doing to clean our air and make life better for us?

It's a really important question and one that's really come up the agenda in terms of the health protection agenda in recent years, and rightly so. We all have a right to breathe clean air and not to have our health damaged by air pollution. So, in terms of what the Welsh Government is doing, there is an internal group looking at a clean air programme—there's a programme board or group that is looking at this. My understanding is that they are in the process of developing a plan. So, that will take us a certain way.

As to legislation, that’s for the politicians to decide down the road. There may well be issues that we may choose in Wales to legislate on. I think that’s a little bit down the road, but we absolutely do need to take it seriously.

Can I ask a question? Obviously, the Minister who made the statement yesterday was the Minister for Environment, Energy and Rural Affairs. This is a health issue, so what collaboration exists between you and the department of environment, energy and rural affairs, to ensure that we're taking the right measures in this group on air quality?

At officer level, within Welsh Government, there's a programme board, where all of those departments, across Government, are represented. And, of course, at ministerial level, the Cabinet is the place where those discussions would be held.

Just to follow up on David’s questions on this: do you feel that there's a need for a greater sense of urgency around this work? The quality of our air has been described as a public health emergency—it’s not getting better. Is there more that could be done to speed this work up? A programme board is undoubtedly a good thing and a plan will undoubtedly be a good thing, but we've still got our fellow citizens unnecessarily dying of this stuff, when we know some of the things that need to be done to stop it. Do you feel that there's sufficient urgency there in the system?

I think there needs to be a response at policy level and at political level and that's happening to a degree now. I think there are levers that local authorities can use and are using, and that needs to continue. So, yes, I sense there is a renewed urgency around this and I think that's right.

In terms of numbers of deaths, we have to be careful with numbers: they're all based on modelling, of course, and the numbers are fairly static, but they need to go down.

10:55

Can I just ask a question on this, in a sense? Obviously, we measure PM2.5 to PM10s. They're the ones that harm health, but we have also in my area nuisance dust, which is another problem that can cause other conditions. I suppose what I want to try and work out is, we're currently operating under EU regulations, and the number of days breached on those areas are, I think, so many per year. As we leave the EU, or if we leave the EU, are you looking to make recommendations that we should actually reduce the number of days in which a breach is allowed, so we can actually put tighter controls on these emissions? I think it's 28 days in a year you're allowed to breach, or maybe 35. I'm not sure of the exact figure, but it's quite a lot. When you breach it just one day less than that, that's still a number of breaches you're having. So, are you looking at, if we depart from the EU, strengthening that area, to actually reduce the number of allowable breach days?

I can't speak to the specific, and that's something that would be a question I would expect the programme board across Welsh Government to be looking at. On the general principle of the protection of the public that we get by being a member of the European Union, I would look to ensure the protections we currently have, whether it's in food safety, water quality, air quality, are not weakened. 

And this is where, actually, instead of being weakened, I was actually expecting them to be strengthened, because you can actually go beyond that.

Okay. We're nearly out of time, but Jayne is very agile when it comes to gambling. Jayne.

Thank you, Chair. In your 2016-17 report, you talked about gambling-related harm and its public health issues. You had a number of recommendations in that report. How are the outcomes from that being monitored?

So, there is a group that advises me, across Government, on what's happening, and we do keep track of that and the progress on the recommendations. I was quite pleased, in a way, that the report of last year did get a lot of recognition not just within Wales, but at UK level, and it has helped us to have a much stronger relationships with some of the main—. I was going to say 'main players'—that would be a bad term, wouldn't it—but some of the really important organisations here. So, we do have quite strong relationships now with the Gambling Commission, with GambleAware, so it's helped to build those alliances. And I do sense a move and a greater recognition of gambling as a public health issue.

To go through some of the recommendations, I recommended a lot more research, and there's been quite a lot of research conducted in Wales, and outside, in the last year. Bangor University in particular has been very active in developing heat maps of where gambling establishments are, for example, and also have done a bigger report, again, on gambling as a public health concern.

We work with and I meet with the Advertising Standards Agency. I'm still worried about advertising and the volume of advertising. They seem relatively—. Their powers do not extend to volume of advertising; they extend to the way that advertising is channelled, targeted, marketed, but not to the volume. So, there's still an issue there we need to go at.

Treatment services—there has been some movement on that. So, if I look across the broad suite of recommendations, we are making some progress, but, again, it's a year on and there's more we need to do.

I know we're short of time, Chair, but perhaps you could just touch on some of the progress being made on the treatments.

Yes. So, there are a few things that have happened and, again, I've been talking with GambleAware, who take funding, as you know, from the industry and channel that into both research and into treatment. They've set up an advisory committee in Wales—a Welsh advisory committee—so we have much better links with them now. They're working with Citizens Advice, which is where I launched the report 'Gambling with our Health' a year or so ago, and that will lead to a national network. So, they've been doing some fantastic work around Newport and Gwent, but they're going to now be developing hubs in Rhondda Cynon Taf and up in Denbighshire, and that will provide then a broader access to treatment services, and also provide hubs that can train people in the voluntary sector to recognise and to deal with issues around gambling.

GambleAware are also working through GamCare to pilot—. They have a hotline that only operates I think between 8.00 p.m. and midnight at the moment, but they're going to pilot that on a 24-hour basis and assess the need for that, because, often, gamblers come into problems out of those hours. So, there are some movements, and I've raised the issue with directors of public health and asked them what's happening at local level. They're giving me feedback that they are trying to build gambling awareness into primary care, through Making Every Contact Count, so there are initiatives through there. So, things are moving on, but there's still, I believe, an unmet need.

11:00

I think you've touched on most of the questions I was going to ask. But, going back to the recommendations 4(a) and (b) in your 2016-17 report, which that said that,

'the Welsh Government should lobby the UK Government for a compulsory levy to be introduced',

and that could then

'be used to support the reduction of gambling-related harm'

What was the response to that? Did that get moved forward?

We routed that through the Gambling Commission, which had a consultation on its latest strategy, which just launched a month or two ago, and they came to Wales and I attended the Welsh launch in St David's Hotel across the way there. We haven't got what I think we need, but, in the Gambling Commission's new strategy, they talk about continuing to put pressure on the industry to provide a fair contribution and, if that is not provided, then to move to a more mandatory level. That's where I think we should probably get to. So, some progress, but not enough, but it's on the radar of the national regulator.

Ocê, diolch yn fawr. Dyna ddiwedd y sesiwn, dyna ddiwedd y cwestiynau. Diolch yn fawr iawn i Dr Frank Atherton am ei bresenoldeb a hefyd am ateb ein cwestiynau. Gallaf i bellach gadarnhau y byddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma er mwyn ichi allu gwirio'u bod nhw'n ffeithiol gywir. Gyda hynny o ragymadrodd, diolch yn fawr iawn i chi.

Okay, thank you very much. That's the end of the session and the end of the questions. Thank you very much, Dr Frank Atherton, for your presence and for responding to our questions. I can confirm that you will receive a transcript of these discussions in order for you to check them for factual accuracy. And, with those few words, thank you very much.

Diolch. Thank you, committee.

3. Papurau i’w nodi
3. Papers to note

I'm cyd-Aelodau, fe wnawn ni symud ymlaen i eitem 3 a phapur i'w nodi. Mae yna lythyr gan Gadeirydd y Pwyllgor Deisebau ar yr ymgyrch ymwybyddiaeth gyhoeddus sepsis Cymru. Dŷn ni'n mynd i gael trafodaeth yn ystod yr eitem breifat ynglŷn â'r flaenraglen gwaith, sydd yn cynnwys sepsis. So, ydy pawb yn hapus i nodi hwnna ar hyn o bryd a chawn ni drafodaeth nawr? Diolch yn fawr.

To my fellow Members, we'll move on to item 3. We have a paper to note, which is a letter from the Chair of the Petitions Committee on the sepsis public awareness campaign Wales. We will have a discussion during the private session on the forward work programme, which includes sepsis. So, is everyone happy to note that for now? Thank you very much.

4. Cynnig o dan Reol Sefydlog 17.42(vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod
4. Motion under Standing Order 17.42 (vi) to resolve to exclude the public from the remainder of the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

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

Cynigiwyd y cynnig.

Motion moved.

Symudwn ymlaen, felly, i eitem 4 a chynnig o dan Reol Sefydlog 17.42(vi) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod. Pawb yn gytûn?

We move on, therefore, to item 4, which is a motion under Standing Order 17.42(vi) to resolve to exclude the public from the remainder of the meeting. Is everyone agreed?

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 11:03.

Motion agreed.

The public part of the meeting ended at 11:03.

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