National Assembly for Wales

Good morning. The Chair is unable to attend today's meeting. Therefore, the first item of business is to elect a temporary Chair. I invite nominations.

Could I nominate Helen Mary Jones?

Thank you. Are there any other nominations?

No.

I see that there are none. So, Helen Mary Jones is elected as temporary Chair. Thank you.

A very warm welcome to our colleagues from Health Education and Improvement Wales and Social Care Wales. It's always good to see you all together. So, a warm welcome to Alex Howells, Julie Rogers, Sue Evans and Sarah McCarty. Croeso cynnes i chi i gyd. A very warm welcome to you all. You're very familiar with the way that things are done, so we'll go straight, I think, into questions, and if I can ask Angela Burns to make a start. 

Thank you, Chair. Good morning. Thank you very much indeed for attending today. I think that my first set of questions are probably addressed towards you, Alex. I wanted to talk about the strategy and the seven key themes that you have come out with for the strategy for the development of the workforce and workforce improvement throughout Wales.

Without being overly unkind, I trust, the seven key themes are absolutely valid, but they are pretty standard, pretty basic themes that you would expect to see in any HR department of any large major organisation. So, I wondered, when you did your consultation, was there anything really specific at all that you felt came out of that consultation that pertained to the NHS delivery of services in Wales, anything that was perhaps not so motherhood and apple pie as these seven key themes are.

Okay. Thank you. So, we've done a lot of engagement and consultation, as you can see from the document. We've been really overwhelmed, actually, by the response that we've had, which is good, because it means that workforce is very much on everybody's agenda. So, that's positive.

The first engagement that we had was at quite a high level, and we developed the themes in response to the engagement that we'd had at that point. Then, we developed a more specific set of proposals for the consultation phase, which we then had probably a better response to, because I think that we put more specific propositions in there to support how we would see those key themes going forward.

In terms of the themes themselves, I suppose that I would have a slightly different view. I think some of them you would expect to see. I think that the things that are different about this strategy are definitely the focus on workforce well-being being right at the heart of this strategy, which may sound like that is quite obvious, but I don't think it has been obvious enough in how we've dealt with our workforce issues so far, and certainly we've never had a strategic document that has really encapsulated that and put that at the centre of how we do everything. So, the fact that that underpins all of the seven themes, I think, is quite different.

I think that within the seven themes then, clearly, attraction and recruitment, you would expect to see that. The issue for us is, clearly, at the moment we're not doing it well enough, so it does need to be in there because we're by no means home and dry, but I think that other themes are more innovative.

So, digital, the fact that we put digital in there, in terms of developing the skills and capability of our workforce to cope with a digital environment, actually is quite new. You wouldn't see that in an awful lot of other workforce strategies. We recognise that it's really important that, in planning the future workforce, we have to integrate the two things, because the nature of work will be changing. And we took a lot of store from the Topol review that was published in England back in the summer, which is exactly about how you make the healthcare workforce ready for the digital world, and that actually—

Sorry, what was the name of that review? 

Topol.

Topol. Could we perhaps reference that?

It's a really excellent review, which we've got no intention of replicating, because we think all the key messages are in there. What that tells us, for example, is that in the next 20 years 90 per cent of all of our staff will need to be digitally literate. So, that gives us a really different kind of challenge going forward, and I think up to this point we've dealt with these two things very separately, and we're very keen in this strategy that we integrate them. So, I agree with you to some extent that some of the things you'd expect to see, but you would want to see, and some of the things we feel are more innovative.

What we got from the consultation then was absolutely a support for the well-being element. The other thing that we think is really ambitious about this strategy is that it's for the whole system. It's not just about the integrated bit of health and social care in the middle. It's very much about the NHS, social care and the wider sector around third sector, what we can do to support carers. And one of the things that came through the consultation was, yes, they liked that ambition, but we needed to strengthen that in relation to, for example, the commissioned services, which obviously from a social care perspective are really, really important, that we don't forget that part of our workforce as well. 

So, I think that what came through the consultation was support for the ambition, support for the approach, support for the themes actually, a sense from some that we needed to go further in the actions we're proposing, and obviously the point of the consultation is to actually test the appetite for change. And what we're currently doing now is actually developing, taking all of that intelligence, not just from the consultation, but from looking at what's happening across the UK, where should we be going in 10 years, because perhaps we're not always the best predictors of that as well. So, in a nutshell, I suppose that's where we're at at the moment. 

And have you had many dealings with the transformation board in terms of talking about the digital element of the challenge that you face?  

Yes. Sue and I both sit on the transformation advisory board. 

I didn't realise that. Good.

So, that's really helpful, and in fact there's a digital discussion on the agenda tomorrow, so, yes, very much so.

I think one of the things that probably isn't being focused on enough at the moment—I haven't discussed it with Andrew Goodall—which we see ourselves as having a role in through the strategy, is the digital education piece that probably we haven't done when we've been thinking about the systems and the software and the technology, which is actually how do we make all of our staff have the skills. In the Topol review, it will tell you that in 20 years 90 per cent need some kind of digital skills, but what are those? And we need to start now, both in terms of undergraduate, but also in terms of investing in our current staff. So, we're very much trying to drive that integration through the mechanisms that we sit on. 

Out of the seven key themes that you've identified, do you have any priorities? Or are you pretty much working on all of them at a pretty even pace? 

Do you want me to answer that? One of the things that is difficult is because we've had such overwhelming support we were almost wanting the sector to come back to us and say, 'These are the things you must do first.' One of the areas that definitely comes up as a strong is the whole focus on parity of esteem, and that's not just health and social care, but it's within health and within social care as well. So, if you think, for example, a nurse working in primary care would be under different terms and conditions to a nurse working in a hospital. Similarly, when you look at front-line care workers, those working in the independent sector wouldn't have the same advantages as those employed in local government. There's a strong message there about trying to raise that parity of esteem and make it real. 

The other two things for me that we heard stronger than I was anticipating was, when you talk about seamless working, there's much more of an appreciation of having to think about that multiprofessional, multi-agency thinking and learning right from the point of staring off your career. So, things like our joint induction framework and our qualification frameworks, designing those for health and social care means people will start learning together and then working together. So, if we can get our professional registration roles all having experience in placements in a wide range of areas—so not just the hospital setting or not just the community—we start to understand each other's territories as we're learning, as we're growing the new workforce.

So, would an example of that perhaps be that a nurse on an undergrad course might actually go and do a placement in a care home?

That's right, and that's feasible now. But we need to promote more of that, because we design these new services and then we suddenly expect people who've been trained and worked in silos to suddenly come together and then deliver an integrated service.

And then, complementing that, the other strong message we've received is the concept of collaborative leadership, and leadership at all levels, so not just at the top of the shop, but from the front line, team leaders in services, getting that understanding of what it means to work in an integrated team. So, you're not just there thinking about, 'I'm looking at it from a nursing perspective or a social work perspective.' You're focused more on what does the citizen need and how do we use our collective experiences, skills and unique skills for each profession to deliver a much more citizen-focused service. So, that does need active leadership and management. It won't just happen on its own just by describing a team or co-locating a team. There has to be active machinery and support put in place to enable that. So, that's come through for me quite strongly.

On that particular point, therefore, I understand the need, but surely that also requires a change in culture within various settings because the cultures have worked in silos, in effect, from their consultants and senior managers down. So, are you, therefore, going to be working with senior managers in health boards to ensure that culture change that allows that integration, that allows that team working? Because the worst thing that you can have is someone who's enthusiastic at the lower lever come up across a brick wall as they work up the ladder.

And, you know, it isn't just in health boards; it's everywhere. It's in local government and in the independent sector as well. If you've grown up and only delivered in one service, that will be the way you think and the way you operate, and the leadership concept that we are looking at is some of the work by Professor Michael West on collaborative and compassionate leadership. And those elements there, they're evidence based and have proven to work within teams to really start examining and picking out what those cultural things are that need to change. So, it isn't just the machinery and the structure; it's the culture that people are working in. So, we're hoping with everything from the bottom up, in terms of that early induction and your training being different, and then the leadership at all levels changing that culture, getting that much more collaborative approach, we'll have a better chance of making the system improve.

Thank you, that's been really, really helpful, actually, and positive. Very positive news.

Can I just talk very briefly about workforce numbers? How difficult is it to map the workforce needs, and what are the key barriers? Just a quick context: probably about a year and a half, two years ago maybe, we had a private briefing from a workforce specialist who tried to give us an overview of how difficult workforce planning can be. We're always talking about shortages here, shortages there, et cetera, and it's very hard to understand why we don't know where those shortages are. So, perhaps you could just give us an overview. And could you also identify for me, very clearly, where the responsibility for understanding where the gaps are lies, who it lies with? Is it with you guys now or is it actually the role of the health boards to know what staff they need, where and when?

If I give you a social care example, because that's even more complicated than the NHS. There are over 1,000 employers delivering social care of all various shapes and sizes. So, it's not a directly managed service or it's not a national service. So, to try and gather that intelligence. We're hoping the fact that we will be registering and regulating more of the social care workforce as we go forward—by April next year all the domiciliary care workers will be registered—we will have a record, at least, there of them and we will be able to factor that in. So, that adds to the complication.

All the 22 local authorities obviously have different administrative systems for collecting their data. You've got the 1,000 employers. So, for us, in the social care sector, it is particularly challenging, but, as we register more, we're hoping we'll get that intelligence, we'll know more about what the workforce looks like currently and then, using things like the population needs assessments, we'll be able to start futureproofing or trying to predict—. Bearing in mind what Alex said about technology and changes, you can't be absolutely accurate, because roles we may have now—we may have completely different roles in the future. So, the role of technology, artificial intelligence, will mean we'll have to be much more flexible, adaptable and think about different types of skills and competencies within the existing workforce rather than always thinking we have to double up the numbers just because the need is increasing. And the responsibility, obviously, is with each provider to make sure they have sufficient numbers, and the purpose, I think, of establishing HEIW was to try and make that system more easily able to capture the various health boards' intelligence and to aggregate it up into a national picture. But it's still a work in progress, I would say.

I think, in terms of the NHS—and Julie actually leads on this for HIW, but I think one of the complexities about workforce planning now is that it needs to clearly not be done in a vacuum. It needs to link to service models for the future, and, as we all know, they're going under quite a bit of change at the moment. So, we need to, in the strategy, make sure that (a) we link with key other documents and plans like the clinical plan that's being developed, like the strategic programme for primary care, which is developing, obviously, a model of care in primary care that is quite different for the future, and make sure that our workforce planning isn't based on traditional approaches to service delivery in terms of volume, but also in terms of, as Sue said, the capabilities of staff.

I think that what we need to be better at is workforce modelling, so that we look at different scenarios and then that helps us identify how flexible our workforce needs to be for the future, because we cannot—we don't have a crystal ball. We cannot say, 'In 10 years' time, we need 10 more doctors in this specialty and three fewer nurses in that specialty'. It just doesn't work like that anymore, if it ever did. So, what we need to be able to do is to have a very good source of information that helps us model different scenarios and know how we would respond to those. And I think it's a shared responsibility between us to now have that national role, but also the health boards are collecting that information. But Julie might want to—.

Yes, I'd absolutely agree with that. From the point of view of legislation, statutory responsibility does sit with the health organisations. So, they have a duty to workforce plan. So, part of our approach is to actually help them upskill their staff in relation to workforce planning. That's something that hasn't been done previously on a scale and on a national basis, but also then, I think, as a national body, working with Social Care Wales, we have a fantastic opportunity to make the data better. The project that we've done since January and the bringing together of the new organisation has given us real insight into where the gaps are in our workforce data. There are some things that have been done. There's a primary care workforce tool that's recently been released in partnership with the Welsh Government, and that will give us more information around primary care. We have an electronic staff record system in the NHS and the compliance rates with that are patchy. So, there are things that, actually, we could go at, now that we've got a national focus around this. So, the data's okay, but it could be a lot better and one of the things that we put in the consultation paper was some early ideas on how we might actually develop things like national data sets, actually how we might specify minimum requirements and get a better handle, because the data will inform the workforce planning.

Thank you. David Rees just wants to come in briefly.

It's on this point. I appreciate the workforce modelling is based upon the different models of care that now have been introduced, some of which have been introduced because we didn't have the workforce in the first place, and therefore we had different, new models, but, surely, you should be able to have also a look at the trends because, whilst I appreciate you might not know which doctor and which speciality, because you don't know what the conditions are, we can see trends in different conditions, we can see trends in different services. We can see numbers increasing in diagnostics in particular. So, you should be able to have some reasonable evidence as to what type of areas you need to focus on to ensure that those trends, because—. This committee did work on endoscopy. Clearly, there are many areas we need to address in that area. So, surely you have data on those trends that should be able to inform you as to what your needs are within, probably, the next 10 years.

Yes, absolutely. So, we do know what the key themes are. I suppose we don't have them to the level of exact detail that perhaps would be ideal when we come to making a case for additional investment, but, certainly, some of the priority areas that we're going to be identifying through the strategy, that we need to do more work on to make sure we've got the numbers exactly as right as we can, are the medical workforce. But, in doing that, we do need to look at how that impacts on other professions: domiciliary care, the nursing workforce. And then there are some key service areas where we know we haven't got a sustainable pipeline at the moment—so, primary care in particular, because we know that, at the moment, we don't train enough people in primary and community settings and therefore people don't necessarily always go and work there and perhaps don't always have the skills that they need to work there.

We're already doing work on the diagnostic issues. As you say, we can see that there's a gap there currently. I think it's just about keeping that flexibility of horizon when we're talking about the workforce that doesn't bed us in too much into a very rigid approach to what we need to develop for the future. I suppose that was the point I was making, really.

When we do the piece of work on medical, domiciliary, and nursing, we will be looking into how we can improve the data in those areas so that we get the best possible estimates for the future on what we need.

Angela.

Yes. Well, I just wanted to do a couple of quick points. So, following on from David, because David is absolutely right, and I think that with the parliamentary review, the vision for health, all the emphasis is on keeping people at home or keeping people out of the hospital setting, so, of course, the pressure's going to be on domiciliary care; there's going to be enormous pressure on residential care, primary care services. So, those are really obvious; you know you need it. And, if you want to keep somebody at home, you've got to have—you know, every doctor's going to have to have a chronic care nurse, is going to have to have paediatrics, is going to have to have all these specialisms. So, that's almost self-evident.

Can you tell us whether or not you will be in a position where you will then be recommending to Welsh Government things like—in order to fulfil your strategy, as identified in the parliamentary review, about driving everything more through primary care—'We need to have an extra 200 physiotherapists, and therefore you need to increase your training places? We need to have an extra 14 GPs, you need to increase your training places. We need to do this, you need to increase your training places'. Or are you literally just looking at the gaps element?

Okay. So, we will definitely be making proposals around investing more in education and training, and increasing the pipeline that's coming into our professional areas. We've already been doing that over recent years, as you know, and, in fact, this year, for us as a new organisation, we've recommended to Government that next year we increase that investment by another £15 million to further increase the numbers who are training across all the professional groups and a number of the medical areas as well. So, those increases are already going through.

Sometimes, they're not always based on need; sometimes, they're based on what our universities can cope with. Clinical placements are actually an issue for us as well: how do we get enough—bearing in mind the workload on our current operational staff, how do we enable them to have enough time to train the extra staff? So, it's sometimes a question of compromise and actually what's the best possible incremental move forward. But the strategy will definitely be saying that we need to continue that trajectory. And when we do the work, specifically on domiciliary care, nursing and medicine, we'll be coming up with more detailed proposals around those individual areas.

Thank you. And finally from Angela.

Yes. Can you tell me where the power sits? How much power do you have to ensure that health boards cleave to this? We heard evidence a few months ago, which was quite shocking, that, despite the fact that we have these workforce gaps, the health boards very seldom discuss workforce at any of their board meetings. Julie, you very clearly said where you felt things were patchy, what needed to be improved. How much power do you have to actually get the health boards to do what you want them to do? Because the Minister struggles to get them on board on quite a lot of issues.

I think the power sits in the fact that workforce is an absolute killer issue for them at the moment. And if we come up with a strategy that they can see is going to help them address some of the issues that—whether or not they spend the right amount of time at their executive boards, it takes up a huge amount of time in terms of their day-to-day work, but very much about the short term. So, I can speak from experience from that perspective, that, actually, you end up focusing on how you're going to staff areas day in, day out, week in, week out. You don't get enough time to look at the things that, strategically, are going to help you move forward.

So, I'm hoping that we won't need to exert any power, in one sense, because the workforce strategy, I think, is—. The engagement we've had so far has been absolutely fantastic. I think that if we can provide them with something that they can see is going to address some of those issues that takes up so much of their time and impacts on quality, impacts on staff experience, impacts on cost, then, actually, the power of the strategy lies in the quality of the strategy itself.

I love your optimism.

That's helpful. Thank you. I'll just remind Members and witnesses that we've done five of our 20-odd questions and we're almost halfway through our time, so if we can try and keep our questions and answers fairly tight, please. But I know, Lynne, you've got a specific question on this that you want to raise.

Yes. I wanted to ask about mental health, both adults and children, and what pressures you've identified in the workforce relating to both adults' and children's mental health provision. 

Interestingly, we had a conversation, both Alex and myself, with the policy lead for mental health just earlier this week, and one of the things that she's asked us to do—she realised that we've got this piece of work to do now—is to start looking particularly at mental health. And we were trying to unpick what the scope of that is, and she wants it definitely to be a workforce plan for children, adults and older adults with mental health.

There have been several national groups collecting information, collecting evidence, so there's some benchmarking information that she's going to send to us soon to start us on that—trying to understand what the situation is. So, we'll almost be a bit ahead of the game, then, when we start to think about a bit more of a strategic plan for mental health specifically, starting from next year. So, we need to get the strategy done first, submit it to Government, and then we'll start looking at various other areas—you know, the primary care plan that Alex mentioned earlier, there will probably be things emerging out of there that we may want to focus on. But mental health is a specific request, now, from our Government colleagues to try and get into some of that—the detail there. So, hopefully, we'll have a bit of a head start with more information that's already been gathered that we haven't seen yet.

Alex Howells.

So, we're already doing some work on that, so we know that recruitment into consultant posts is difficult, and trainee doctors, so there are incentives in place there that are starting to work. Nursing: we don't get much problem getting applicants into nursing programmes. Child and adolescent mental health services: we've been talking to the CAMHS network in particular about how we provide more education that helps them make the transition from mainstream mental health into that more specialist service. So, there are already some pieces of work going on.

That's really helpful.

Can I just ask specifically about psychology and whether, you know—? Because, I'm aware that the Together for Children and Young People programme is being refocused and the proposal is that the workforce planning elements of that will come to you. And there's a lot of work that needs to be done in that area, including—you know, psychology is key across children and adults.

Absolutely. And there are a lot of psychology graduates, so we need to find appropriate roles where we can make best use of their skills in that service, yes.

Thank you. David.

Thank you. Just before I go back to your question, you talked about nurses and the clinical placements agenda, and it's often been said that we can't increase the number of student nurses because the number of clinical placements are far—. Are you looking at different models of clinical placements so that we can increase the number of nurses? Because, if we don't do that, we're never going to see the increase we need in nurse levels.

Yes. So, I think there are a couple of things there. One is simulation. We're developing a simulation plan—how can we use simulation facilities differently so it's not all about necessarily working somewhere, but, actually, you can get that experience in a different way. And we're also looking at, as we've already mentioned in relation to primary and community, how do we expand our horizon around care homes, primary and community teams, to really have a better system for clinical placements.

So, we should be able to be in a position where we can actually handle an increase in student numbers as a consequence of that.

Yes, and part of—you know, what we want to be is much more self-sufficient around the workforce, so I think once we get that magic number about what we're aiming for, we need to make sure that we can use all of the levers at our disposal to do that.

Because it links into recruitment, in a sense. The strategy is a longer term strategy of how we get to a position in several years' time where we have a sufficient workforce, but we also have a shortage of workforce now. So, how are you combining the longer term strategy of recruitment with a short-term strategy of recruitment?

I think there are a number of things going on, and I think you're right, we don't have any magic bullets, unfortunately, and we haven't found any magic solutions through the consultation and engagement that would help us do anything significant in the short term, other than, as you know, you have to approach the problem from lots of different angles. So, retention is important—why are people leaving, how do we make the workplace they're in more attractive. You've been doing some more recruitment campaigns on the WeCare—

WeCare, and that's a national campaign that is branded nationally, but not as a Social Care Wales brand, it's branded for the sector, so individual local authorities and social care providers can all use all the materials that we've produced. If you haven't had a chance to look at the WeCare campaign on the website, it's got some excellent videos of real people working in Wales doing great jobs in the care sector. We're working with care ambassadors, going out into schools, colleges, trying to change the mindset. We're working with Careers Wales, Jobcentre Plus, because we know, traditionally, some advice given to youngsters has been, 'Oh, well, if you can't get a qualification, go and work in care or hair.' We're trying to dispel that myth and really show the complex work, the challenging work, but rewarding work that care offers, and trying to describe a career pathway, and across health and social care. So, you may enter at a certain level, but the opportunities for you to train to become a social worker, or a higher grade care worker, or a nurse, going forward—. I don't think we've done a good enough job yet in Wales of selling that combined career opportunity.

Obviously, that's part of the parity of esteem amongst the professions, but also there's a question here about valuing your workforce, which I think you've all identified in your themes. Alex, you mentioned clearly how we retain staff and why people are leaving, and there will be different reasons across the sectors as to why people are leaving. How are you addressing some of those points, because we are seeing people leaving? We are seeing some people go, in nursing in particular, into the agency sector as a consequence, which is costing more money in the long term. We are seeing and hearing of many people who feel they're doing a great job but just don't feel valued in that job. How are you identifying those issues that health boards need to address?

I think the We Care campaign is trying to raise the profile, and it is trying to give a much more positive image of the sector to try and dispel some of those—

But is that across the NHS as well as the social care sector, or is it just focusing on the social care sector?

At the moment it is, but one of the things we talked about in the plan is joining up some of that campaigning.

Because, in the health sector, there are a lot of people who really feel stressed and undervalued, and leaving.

Julie.

Thank you. So, we do have some information around the health sector, and some of this is common across both sectors. We know that pensions are a factor for some staff, we know about terms and conditions and low pay, but, beyond that, particularly around the nursing workforce, there's a lot of feedback that individuals are leaving because the roles they're in are not flexible or agile enough to cope with their life circumstances or the types of hours that they want to work. So, one of the focuses in the strategy is looking at that.

But there is a lot of work already under way with trade union partners and employers across NHS Wales at the moment, looking at workplace well-being. There's a set of regional conversations that have just started in the last couple of weeks, talking to staff on the ground about, actually, the things that would make them feel valued and the sorts of things that they want. So, that, again, will give us a rich body of evidence to start firming up what we're going to do around well-being. So, there are multiple reasons why people are leaving, but I think the value thing is a key one.

Sarah.

Just to build on that, it links up also through to the leadership, and where I said we need a compassionate leadership approach, of course, of which well-being would be at the heart. So, as much as there are seven themes, they are all mutually reinforcing; in many ways, we can't support one without really looking across the piece at all the others if we going to achieve that longer term vision.

David.

Just as a small point on this valuing, and I suppose this is across all sectors, in one sense, in much of the work people do, obviously, sometimes they need to keep themselves upskilled, they need to keep training. There is a problem within the sectors about ensuring people have time to do that. How are you working with the health boards to ensure that all professions, whichever level of the profession you're in, whichever part of the sector you're in, are actually given time to undertake upskilling and retraining? Because if we don't give them that time—. That's one of the reasons why they leave, because they can't get the time to do any sort of upskilling.

I think we're in a bit of a vicious circle on that, aren't we, David, because we know that it's the problem of staff shortages that causes the excessive workload that creates that horrible cycle of not releasing people. So, again, it's going to be something that we have to approach from lots of different angles through the things we've already talked about, really, to help ease the burden.

I think one of the ways that we're hoping to influence this agenda is to look at equalising the expectation across staff groups. So, doctors traditionally have a high expectation of continuous professional development, and there's a clear budget associated with it. I think we've got to really nail our colours to the mast that, actually, we want to see something similar across the next 10 years move across all of the different professional groups, and certainly there are examples across the border where movements are already being made in that direction.

I think the other thing also is that traditional approaches to CPD are sometimes about taking people into classrooms or off-site, and we don't need to always do it like that, so I think it is about being more agile in how we deliver education and CPD, as well, and not just doing it for individual professional groups. If you're doing something on infection control for doctors, why aren't you doing it for the whole multiprofessional team? So, there are different ways in which we need to deliver it as well. But, you're right—I'm not sure how we, tomorrow, would address that problem of releasing staff.

Are you in discussion with the health boards about this? You talk about the pressure on staff. It could actually make staff feel better valued, and they could stay as a consequence.

Yes, it's part of the protection, isn't it?

Thank you. Jayne.

Thank you, Chair. You've mentioned how the well-being of the workforce is underpinned by the seven key themes. How will it be achieved and how will it be monitored?

We were really pleased that well-being was something that came through 'A Healthier Wales' and, again, through all of the consultation, so I think that was a really strong message that we got from staff and from organisations. If we link it to the work that we're going to be doing around compassionate leadership, compassionate cultures, one of the things that we're aware of in Northern Ireland, for example, is that they've introduced a cultural assessment tool there, where they're actually able to start to measure organisations' performance in relation to things like well-being, colleague experience, workplace experience and also progress around compassionate cultures. So, we would be looking around the well-being area to actually get some measures in, or the system could be held to account in terms of the progress that's being made. That would be across both health and social care.

Going back to your previous question about how much attention organisations are paying to this, and what power we've got, I think including some measures around this in a performance framework that organisations are working in will really, really help drive that, because we know that they do focus on that, inevitably.

Thank you. You said in your paper that workforce data is essential to improving workforce planning, and we've heard some points on that this morning. So, knowing that we need some more intelligence on the current skills of the workforce, did the engagement and consultation process provide information on what learning staff would want? And digital—

There's a whole range of more generic skills areas that came up quite consistently—so, digital, working in a co-productive way, how to support improvement and so on, have come through as themes. We also need to reflect that, over that 10-year period, those skills needs may continue to change, so we need to be able to find a way of building in current skills needs and how we can respond to those throughout our existing training and development approaches, but also with bespoke CPD opportunities, which could be microlearning, which you can do on a short basis or be part of longer term development programmes. So, addressing the short term, but also keeping our eyes open to what might be needed over the longer term. The responses we've got now probably won't be the same ones that we've got in five or six years, so we need to make sure we're dealing with the short term but also keeping our eyes open to the future.

Linked in with the strategy, we're currently doing a review of all of our undergraduate provision. The contracts are up for renewal. So, we've had an opportunity to do quite an in-depth strategic review of what the content of those degree programmes needs to be going forward, to think about what skills we need for the future to make sure those capabilities are being built in right from the start. So, I think that will really help, as well, and will reflect some of this in the new workforce. What we need to tackle is our existing workforce.

We've again touched on parity of esteem with health and social care, and within it, as you've mentioned. What are the current challenges to achieving this, and how do you think the strategy will help?

I guess the strategy has really highlighted it as a major feature of the intention to try and improve that parity of esteem within social care, within health, but also across health and social care. Some of those solutions will be beyond the strategy; they will be decisions for future governments to make in terms of investment. So, we will be able to highlight some of the difficulties to make sure that that parity of esteem—that theme that is coming through very strongly—is one of the priorities for us to take forward together. We know the Government is looking at things like the longer term affordability of social care and maybe some sort of levy or tax in the future. That, I'm hoping, would provide an opportunity to raise some of those pay scales that we described earlier, and that's the challenge I think we have. It's a UK-wide challenge. Talking to colleagues last week, it's right across the UK; it's not unique to Wales.

Thank you. We know that, when we did the general scrutiny session back in January, more work needed to be done to ensure the status and profile of the social care workforce is raised, and there was a recruitment campaign to be launched in March. Has any progress happened? Was that good?

That's our We Care campaign, and that's a three-year programme. We launched it, and we had several million people viewing all of those events. There were tv and radio interviews, posters on buses, and it's a constant theme. We have a steering group, so it's not just us doing it nationally; it's all being used, all of that material and those resources, regionally and locally. Schools are seeing the videos. So, we're trying to spread out so that we reach all of those hard-to-reach places by using that campaign as the badge, if you like, to take those messages out there with our care career ambassadors that we have now, which we're funding in each of the regions to help promote those messages. And it will be ongoing. It's not something that's going to be fixed tomorrow, because it's changing hearts and minds, it's changing cultures, and those things do take a while. 

You've, again, touched on seamless working. Are you confident that there can be a seamless workforce and seamless consistency across both sectors?

In some parts of the system, we already have very well integrated services, with professionals from different agencies already delivering person-centred care. And I've had my own personal experience of that in trying to bring together health and social care professionals where they were paid differently and they had different pensions. And even though, as a manager of that service, I was concerned about how we were going to make this work, when you actually get to those individuals and say, 'This is what we're trying to achieve for these citizens', the issues of being with a different employer actually disappeared a bit, and people were willing to work together even though there was this lack of parity. But I don't think we can rely on the goodwill of individuals. If we're serious about making this a consistent approach, then that parity of esteem issue has to be addressed. 

Alex, do you want to come in on this?

Two quick points, just to add to that. I think we'll get a lot of learning from the work that the regional partnership boards are doing as part of the transformation proposals, because they're obviously focusing on integrated care and looking at the workforce in different ways. So, obviously, that's been emerging over the last 12 months, and we're hoping, now, that we'll be able to look at those plans as a whole to see what people have done differently so that we can help from an all-Wales perspective, to see what the levers are so that we can improve that. 

The second thing is that I think there's lots of evidence from across the UK where people have done different things that we should be building into what we're doing locally. So, we are actively looking at what the learning is from seamless working, integrated working elsewhere to see how we can improve things. And clearly, more flexibility about budgets and more trust between health and social care underpin all of the things that Sue has talked about. 

Thank you, Chair. 

Thank you. David, back to you, I think. 

I think we've done the leadership question, because they did talk about leadership earlier on. 

Okay. So, on to the use of community-based settings—question 15.

That was me as well, was it? Okay. 

I think, again, we talked earlier about the fact that your model for clinical practice is going to have a completely different look about it, because you are going to talk about community-based settings. That is one aspect. I suppose how we look at the rural areas and rural aspects of the whole provision—. How does the strategy address that aspect as well?

I think we've reflected through the strategy that we've already got a large proportion of services that are already provided out in the community. So, we need to be building on those strengths and some of the work of the primary care strategic plan and the workforce and organisational development of that, which we're well connected in with already. 

In terms of the rural agenda, if you like, you could span that across all of the themes. It doesn't just sit in one place, because I think we'd find we've got challenges from recruitment and retention through to how to ensure a seamless model of working for the citizens in more rural areas when we might not have such big populations in order to have the specialisms on hand. So, how can digital technology help us there with, say, remote consultations and so on and so forth? So, the strategy needs to support that new way of working and new models, to enable citizens in Wales to get that care closer to home. But there's not going to be one silver bullet. I think we need to be able to look across the whole of the plan and how we can then support in all settings, whether it be our high-population areas or our lower population areas. 

So, have you identified any of the seven themes that probably need different prioritisation in relation to our rural communities, compared to urban communities?

I think, in particular, the education theme would be one that I think is about really sustaining workforce in rural communities and, as far as possible, investing in very locally based, embedded education and training so that people are growing their own, in effect. And we're seeing examples of that starting across the different health boards in rural areas but, actually, they're examples rather than mainstream at the moment. I think we need to shift our focus from bringing everybody into the urban centres for education and training and to look at how we actually blend it with people who don't want to do that, but actually want to do a dole in a health or social care profession. So, I think, for us, education would be one of the key ways we start to make that more sustainable going forward in the future, rather than trying to recruit people who may be just be transient.  

I appreciate recruiting people locally to stay local is an important aspect. I'm assuming that links into your Welsh language strategy as a consequence of that.  

Absolutely, yes. 

Is there anything else in your Welsh language strategy that you need to look at? Because Welsh is actually expanding—it's not just in those rural communities—so how are you implementing that strategy in your plans, moving forward? 

We've had very interesting feedback and a lot of feedback about needing to strengthen the Welsh language element and using the strategy as a real opportunity to embed it as a key theme, not as a stand-alone add-on, but in every one of the seven themes. We had a very useful meeting with the Welsh language partnership board for health and social care, and they gave us some great intelligence and some ideas for each of those seven themes—we went through them systematically—to give us some ideas on how we could improve that. But we are seeing it very much as part of the active offer, making sure that the Welsh language is seen as a need, a right, and not just a choice option, so really using the 'Mwy na Geiriau' work and the work in Welsh that we've been pushing forward in social care in particular, and in the health service, to make sure it's bedded right throughout all of the seven themes, because there's a danger that some systems may see it as a tick-box, and we wanted to avoid that. So, we got some good ideas through those partners helping us think through how we really embed it, and we want it really embedded in. 

I think the other thing, just to build on this, is that there's already pilot work happening with the NHS boards but also in social care on Work Welsh, about how we can be actively promoting and building Welsh language skills, because there is a gap between the population need and the workforce at the moment. So, how do we try and close that gap, both through increasing the confidence of the workforce to use their Welsh where they already have it, and in building new skills where they don't? 

Okay, because, as I say, it is not just a right; the need is important, particularly if you have dementia patients who are reverting back to their first language, and that doesn't necessarily mean the rural, Welsh-speaking communities, but it's also in urban communities, because there are a lot of Welsh speakers in those communities; the older generation started by speaking only Welsh. 

Thank you. Lynne. 

Thank you. In my experience, we're very, very good at developing excellent policies in Wales; we are not always so good at implementing them on the ground. What do you see as the main challenges to implementing this strategy? 

I would first talk about what we think we've got the opportunities to do, to be honest, because I think that, as two relatively new organisations in this area, that is a real opportunity to make sure that a workforce strategy is not just left on the shelf, because, actually, it's going to inform our work programmes for the next 10 years. So, we, for certain, have an absolute vested interest in making sure that this strategy is delivered, and already some of the things that we've talked about today are being built into our plans for next year. We're already working on some of them this year. So, from that point of view, we've clearly got a vested interest in taking this forward. 

It's more the organisations out there that I'm concerned about. 

So, clearly, a process around this, and we've been always clear from the start, that this wasn't just about a strategy; it will identify implementation priorities. So, we'll bridge that gap into actually doing, and what we're in discussion with Welsh Government about at the moment is what that will look like in terms of that mechanism to hold the ring on this. We want to launch this by, ideally, talking about implementation at the same time, so that we get the roles clear—who's responsible for doing what. We want to make sure that this is kept live. We want to review it every three years, because we don't know what we don't know at the moment about the next 10 years, to make sure that it's relevant and that it's not seen as something that, 'Oh, we did that in 2019; it's not relevant any more'. And to make sure that it's underpinned by key investment areas as well. We don't know what all of those are at the moment because, as you can see, we're still at that point of nailing our fundamental building blocks. But, clearly, if you talk about leadership development, or if you talk about nursing or you talk about domiciliary care, or parity of esteem, there may well be investment associated with this. However, we know that the costs across the system of not doing it right are also significant.

So, I think there are lots of potential barriers that we need to be very aware of when we finalise this strategy and make sure that the implementation process can address, really. But you are right—I know there have been too many plans that we haven't done anything with, and we're determined not to let that happen.  

Just to build briefly on that, I think the approach that we've taken through the development of the strategy has helped us build a consensus. So, actually, when we went out with the consultation version that you've seen, the overwhelming feedback we got back was that this is in broadly the right place. So, yes, nuancing may need to change, but building that consensus, I think, is really important to then being able to support implementation as we're moving forward. So, this isn't a strategy that is being done to; this is a strategy that we've tried to develop together. So, my hope would be, as we get through to implementation, there's a motivation for all of the partners out in the sector to help support that as we move forward.

Sarah's covered my point, so that's fine.

And you referred to the fact that there's going to be a series of implementation plans underpinning this, and that discussions are ongoing with the Welsh Government about the leadership of that. Who do you think should lead on the implementation phase?

I think, for each of the themes, there will be at least one implementation plan. We can see that. So, Alex mentioned that we'd already started work. So, we've been running the implementation of the leadership aspect in parallel with the development of the strategy, and we're leading that as joint organisations and moving that forward, and we're doing that in partnership with both sectors. I think probably what we would say is it would be great if we could end up being the people that hold the ring collectively, on making sure that this lands and happens, but there will be other people who are better placed to lead some of the specific implementation areas, in partnership with us. So, we wouldn’t see this as being just our organisations leading on all of these. So, I think it'll be a 'both/and', really.

Okay. And do you have any idea at this stage about the cost implications of implementing this strategy?

'No' is the honest answer, and we're still in that drafting the strategy phase. We had over 200 detailed responses, so we're really trying to make sure we use those to start thinking about nailing down what are the key actions that will make the biggest difference. But, you know, there will be investment required. But we're trying to use this strategy to talk about investment in the workforce rather than the cost of the workforce—changing the mindset. Because as colleagues have already said, 'Well, if you have a good workforce, well retained, well-being is high, you're not going to lose so many of them, you're not got going to use so much agency, so it'll be a better system.' So, hopefully, the strategy will change that mindset.

That's covered my point.

That's how joined-up we are.

Lynne.

Your evidence references the fact that a key challenge in delivering this strategy is the extent and pace of change over the next 10 years. Can you just expand on that point and let us know what you think the main challenges are and what's been put in place to overcome that, really?

I suppose one of the ones that we were thinking of with that was digital, which we've already covered. I think the other one is the change in the age profile of the workforce—going back the flexibility issue and how we accommodate that—but also the changing expectations of people coming into the workforce. So, we know that people who are coming through the undergraduate pipeline at the moment or coming in from school have different expectations of what a work-life balance is, want more variety, don't necessarily want to be joined to a single career pathway. So, that gives us a real challenge as a sector that hasn't really thought in that way previously, where routes have been quite traditional. And that's one of the reasons why I mentioned the fact that we do see the need to not just write this strategy and think it's good for 10 years; we do see the need to keep this under review so that we can keep doing that horizon scanning and make sure we're building in that intelligence of what is changing around us.

Okay. And just finally from me, when can the health and social care workforce expect to see the benefits of this strategy on the ground?

I would say that some of the things that we've already mentioned today will hopefully give you some evidence that we're already working on these things. So, they will start to hit the ground next year, I think. So, things like increases in education and training, some of the work we're doing around primary care. Some of them are more longer term. So, the impact, for example, of embedding a different approach to leadership, we all know we can't do that in a matter of months. That's going to take a couple of years to fully embed. So, it's a longer burn. It's not necessarily an overnight sensation.

Okay. Thank you.

Thank you. Can I just, from the chair, pick up on the issues that Lynne raised on the implementation plan? And we talked about leadership and about who's going to lead that, and you said that, from your perspective, there will be aspects that you will jointly lead on, but that there will be others who will be needing to lead on other aspects. Will the implementation plans make clear and publicly known who those other leaders are and what the expectations are of them? Because I think one of the issues for me, in watching this agenda fail to progress over the last 20 years, is it's never been really clear who's supposed to be doing what. So, is the idea that the implementation plans will make clear what you're doing together, and then who is leading on the other stuff?

Yes, absolutely. That will need to happen, to make sure that this is actually landed and makes a difference. I think, at the moment, at the stage we're in, we haven't agreed with Government finally who's going to be doing what. But if we were to be ending up holding the ring across the whole piece, then what we would need to put in place is a programme structure to make sure that we've got SROs identified in lead organisations. We've had a huge amount of consensus and buy-in to what we're proposing already. We've worked really hard with the peer networks and with the different interest groups to make sure they feel engaged. So, as Sarah said, we've got a strong consensus around it. But you are right—at the end of the day, you need people who are accountable for delivering bits, and that's what we would expect to see, whether we end up holding the ring or not.

Okay. That's helpful. We've got a couple of minutes, so do Members have anything additional they'd like to ask the witnesses? If not, is there anything additional that any of the witnesses would like to add that you haven't had an opportunity to touch on? Obviously, we've had your papers as well, so we've got that evidence too. Is there anything else you'd like to mention that we haven't raised?

I don't think so.

Covered everything.

Good. Well, thank you very much. And we did catch up; we've actually got three minutes left. But, obviously, you know what happens next: you will be sent the copy of the transcript to be clear that it's factually correct, and you obviously have an opportunity to come back on that, if you need to. Thank you very much for your evidence. This is obviously an agenda that's so important to delivering everything that this committee is charged with scrutinising on behalf of the people of Wales, so I'm sure we'll be asking you back again before very much longer. I'm very grateful to you all. Thank you very much. Diolch yn fawr.

So, next on our agenda we have a series of papers to note. The first one—have I got them here, yes I have—is from the Medical Protection Society. So, are we content to note what they've said? Then we have one slightly clarifying something that was a bit of a confused issue, when we were talking to the Minister about this piece of legislation from Health Education and Improvement Wales—that they've written to clarify. And it was obviously necessary for us to put that in the public domain. Happy to note? And then we've got this letter from the Minister for Health and Social Services about endoscopy services. Are we happy to note that? Okay, that's fine.

And so, at this point, then, I need to propose to the meeting that we exclude the public from the next part of the meeting, and close down the broadcasting. Are we content with that?

Good, good, good. So, if we can make sure that happens.