Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd

Health, Social Care and Sport Committee - Fifth Senedd


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
Lynne Neagle AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Alan Brace Cyfarwyddwr Cyllid, Llywodraeth Cymru
Director of Finance, Welsh Government
Albert Heaney Cyfarwyddwr y Gwasanaethau Cymdeithasol ac Integreiddio, Llywodraeth Cymru
Director of Social Services and Integration, Welsh Government
Yr Arglwydd / Lord Elis-Thomas AM Y Dirprwy Weinidog Diwylliant, Chwaraeon a Thwristiaeth
Deputy Minister for Culture, Sport and Tourism
David Rosser Prif Swyddog Rhanbarthol, Llywodraeth Cymru
Chief Regional Officer, Welsh Government
Dr Andrew Goodall Cyfarwyddwr Cyffredinol Iechyd, Llywodraeth Cymru
Director General, Health, Welsh Government
Jon Beynon Dirprwy Bennaeth yr Is- Adran Chwaraeon, Llywodraeth Cymru
Deputy Head of Sport Branch, Welsh Government
Julie Morgan AM Y Dirprwy Weinidog Iechyd a Gwasanaethau Cymdeithasol
Deputy Minister for Health and Social Services
Vaughan Gething AM Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol
Minister for Health and Social Services

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Morris Ail Glerc
Second Clerk
Lowri Jones Dirprwy Glerc
Deputy Clerk
Philippa Watkins Ymchwilydd
Rebekah James Ymchwilydd

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 09:29.

The meeting began at 09:29.

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

Bore da i bawb, a chroeso i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd.

O dan eitem 1, gaf i groesawu yn gyntaf oll fy nghyd-Aelodau? Mae pawb yma'n bresennol. Gallaf i'n bellach egluro, yn naturiol, fod y cyfarfod yma yn ddwyieithog. Gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. Dydyn ni ddim yn disgwyl larwm tân y bore yma, felly os bydd y larwm tân yn canu, dylid dilyn cyfarwyddiadau'r tywyswyr. Mae'r meicroffonau yn gweithio yn awtomatig, fel mae pawb yn gwybod, felly nid oes angen eu cyffwrdd o gwbl.

Good morning, all, and welcome to the latest meeting of the Health, Social Care and Sport Committee here in the Senedd.

Under item 1, may I welcome, first of all, my fellow Members? All are in attendance. I can further explain that, naturally, this meeting is bilingual. Headphones can be used for simultaneous translation from Welsh to English on channel 1, or for amplification on channel 2. We're not expecting a fire alarm this morning, so in the event of a fire alarm, directions from the ushers should be followed. The microphones do operate automatically, as we all know, so there's no need to touch them at all.

2. Cyllideb Ddrafft Llywodraeth Cymru 2020-21: Sesiwn dystiolaeth gyda’r Dirprwy Weinidog Diwylliant, Chwaraeon a Thwristiaeth
2. Welsh Government Draft Budget 2020-21: Evidence session with the Deputy Minister for Culture, Sport and Tourism

Gyda chymaint â hynny o ragymadrodd, mi wnawn ni symud ymlaen yn syth, achos mae amser yn dynn y bore yma, i eitem 2: cyllideb ddrafft Llywodraeth Cymru 2020-1—sesiwn dystiolaeth gyda'r Dirprwy Weinidog Diwylliant, Chwaraeon a Thwristiaeth. Ac i'r perwyl yna, dwi'n falch iawn o groesawu at y bwrdd Dafydd Elis-Thomas, y Dirprwy Weinidog Diwylliant, Chwaraeon a Thwristiaeth; David Rosser, prif swyddog rhanbarthol Llywodraeth Cymru; a Jon Beynon, dirprwy bennaeth cangen chwaraeon Llywodraeth Cymru. Diolch yn fawr am eich presenoldeb a diolch yn fawr am y papur ymlaen llaw. Ac yn ôl ein harfer a thraddodiad, felly, awn ni'n syth i mewn i gwestiynau, ac mae'r cwestiwn cyntaf gan Lynne Neagle. Lynne.

With those few words of introduction, we'll move on straight away, because time is tight this morning, to item 2: Welsh Government draft budget 2020-1. This is the evidence session with the Deputy Minister for Culture, Sport and Tourism. And to that end, I'm very pleased to welcome to the table Dafydd Elis-Thomas, the Deputy Minister for Culture, Sport and Tourism; David Rosser, chief regional officer, Welsh Government; and Jon Beynon, deputy head of sport branch, Welsh Government. Thank you very much for your attendance and thank you very much for the paper that we received beforehand. And as usual, and in accordance with our tradition, we'll go straight into questions, and the first question is from Lynne Neagle. Lynne.

Thank you, Chair. Can you tell us how this draft budget is going to deliver Sport Wales's vision of making sport accessible to everyone throughout their life?

Well, the key thing that I enjoy, actually, about my job is that I've got two, three, four very well-established delivery bodies who have their own statutory position. So, Sport Wales is our main delivery mechanism, and we work through Sport Wales with all the governing bodies, within the various sports.

Now, our objective, and one which Sport Wales are very keen to implement through the close relationship we have with them, is to get more people in Wales involved in physical activity—that's the overall responsibility that I have within Government for physical activity—but also, in order to facilitate that, to get a choice of different sports. So, the emphasis is, then, for people to be able to make a choice of their preferred activity, and that hopefully will help to increase the percentage that undertake physical activity. National surveys show that some 60 per cent of the people of Wales undertake some physical activity at least once a week. Well, that's not enough, obviously, but 32 per cent do nothing. So, we need to tackle that.

Thank you. Good morning. In the budget line 'Support for Sport', there's a reduction of £95,000 per annum, and I understand where that's been reallocated, but I just wanted to have your overview on what impact you think that will make on the current provision of the scheme Support for Sport?

Well, the approach that I had as soon as I got this post was to look at where funding was being directed already, and where there were opportunities to shift funding in order to provide for more flexibility, we aim to do that. And what we have done here—it's not a loss to sport here, I can assure you. In fact, there is an additional allocation of £3 million in the 2020-1 budget for a strategic sport facilities fund, and it's through that that we have priority for developing greater activities throughout Wales.

I do understand that, and I do understand, clearly, reading your budget figures, where the £95,000 has gone. What I'm just trying to get a handle on is what it will affect. What projects will cease to be funded or will have to go and seek funding from other sources in order to make up that shortfall?

I don't make the decision on individual projects of that kind—that is for the sports council, if the funding is directed through them.

So, they simply will have £95,000 less, and then they're the ones who've got to make that decision.

Well, it doesn't exactly work like that. I will ask David if he wants to comment in greater detail on the way in which the budget is—[Inaudible.]

The particular budget line that you're referring to is one that's held within the department for individual opportunities and projects that might arise during the year. The overwhelming majority of the funding goes to Sport Wales. That funding would have increased this year, in line with other arm's-length bodies, in addition to the additional capital funding that Sport Wales will be getting. So, the overall budget for sport is increasing quite substantially, I'm delighted to say. But the small amount held within the department for use, by the Minister's discretion, will go down slightly, but the Minister will manage priorities across his whole portfolio, and if opportunities arise during the year, he has the opportunity, if he chooses, to reallocate budgets.


Okay. So, the support for sport funding, which is at ministerial discretion, will reduce by £95,000. I'll rephrase my question one more time—

Are there any current projects that will now cease to be funded?

Thank you very much indeed. There's an additional £3 million for the strategic sports facilities fund. Do you have a view on what priorities you would like to have delivered through this additional funding? And how will you monitor and evaluate that delivery?

As I've made clear, I think, I'm very keen to ensure that our statutory bodies, where they exist within my department, undertake that work for us, and this is why, in the important decisions that we've had to make about sport funding during the last two years, all the activity is monitored by Sport Wales—in the case of sport, obviously—and they have given us detailed analysis of the effectiveness of the spend and made recommendations to change, and, of course, when that happens, quite rightly, Members of this Assembly raise issues. But I think it's important to work using the arm's-length principle wherever possible, because Sport Wales are our expert body on delivery, and when they make recommendations to me as Minister, I generally tend to implement them.

Well, can I just move over, then, to the Place for Sport fund? I'm not actually clear—is that a capital or revenue budget?

It is a capital budget. So, obviously, we've got a big drive, haven't we, in our 'A Healthier Wales' and all the rest of it, and 'Prosperity for All', to try to increase the overall health of the population? I understand that an awful lot of clubs and organisations are seeking funding for a Place for Sport. Do you think the funding that you've allocated will be enough to be able to help to sustain and develop some of the capital projects that are required to develop these organisations?

Well, we know it's not enough because this has been substantially oversubscribed, if you like, in terms of applications. But just to make it clear that what I'm trying to do is to ensure that there is a strong partnership, through what is called the Welsh physical activity partnership, which is a joint partnership between Public Health Wales, Sport Wales and Natural Resources Wales, that these bodies work together so that we have access now to the budgets that are there for the enjoyment of the natural environment as well as physical sporting activity, along with the preventative health agenda. But what we haven't yet got is the strategic approach that encompasses all those, and I'm determined that we will get it. And the way that we've done that is—and I'm very grateful to them for their collaboration—that they have been meeting together. There's a development of a physical activity observatory and there's a development of networking across these bodies. So, I'm looking to see a more substantial piece of work that will bring us recommendations in Government later this year so that we can then organise our budget priorities for the next financial year and beyond on the basis of collaborative activity in order to encourage physical activity in the population in Wales. That's my priority.

Yes. If the fund is oversubscribed, can you just tell us how you prioritise, then?

Well, on the recommendation of Sport Wales and on the recommendation of my officials, basically.

We've asked Sport Wales to focus on community sports facilities to make sure that the money is spread across a range of different sports, and geographically spread as well, and the first £5 million was spent that way. It's gone on everything from improved grass-cutting facilities for bowls clubs, through to sports pavilions, through to slightly more strategic opportunities. So, the intent is for community sports facilities that enable local populations to access improved facilities locally. Sport Wales are going through a process at the moment of learning the lessons from the £5 million, analysing where the overdemand came from, and they will be planning the next £3 million to be spent in light of that. But the drive is community facilities.


I think you might be very interested in the inter-generational gardening, which is one of my pet projects.

You mentioned the physical activity partnership just now. Could you tell us a little bit more about how the funding in the draft budget will support the work that you expect the partnership to deliver for you?

Well, what we have done is ensured that we are able to get transfers, basically, out of what was the health budget into these areas. And if you look at how this process began, it was with the £5 million that we had in the past financial year, and that is continued now and has been mainstreamed in relation to the budget. And this is the way that we intend to continue to work, but it is for the delivery bodies themselves to assist us in recommending the best way forward to using public money more effectively in the fields that they're currently delivering for us, and that, I think, is the best approach. So, anything that we do, anything that I approve, certainly, is done in partnership with the delivery bodies and their recommendations.

And you said you'll be expecting some recommendations from them later this year in terms of that partnership.

Well, they are doing a serious piece of work that is looking at the way that these three public bodies—I mean, I don't know why it wasn't done before, quite honestly—but it happens to be, because of where I live and what I do, and my particular lifestyle choices as an elderly member of the population, it's the enjoyment of landscape along with physical activity. These things should be available to as much of the population as possible, and as a result of that, that is the best and the simplest way to deliver preventative health activity. So, get out walking, get out running, whatever you want to do, and to show people that there is a value in this choice, without making it too preachy. That's another difficulty. I mean, I don't want to be seen as someone who is going to be telling people to get off their butts and get out doing physical activity, but that, basically, is the message.

Which we know doesn't work, does it, the preachy approach? It just makes people feel miserable.

Could you tell us, if we can turn to the healthy and active fund, a bit more about the sort of projects that you expect to be funding from that fund and whether that will contribute towards tackling inequality in access to physical activity and sporting opportunities?

Well, I already mentioned the inter-generational gardening, but there are exercise classes for people in care homes. That's a very important priority. What Peter Townsend described as people sitting around the room in care homes 30 years ago—that has changed now; there is more physical activity.

I'm also very interested—and it's a project that I've followed and been involved with directly—in training and qualification placements for young people aged 14 to 19 to become play ambassadors in a neighbourhood and in the younger school cohort. So, these, basically, are people who are in the further education sector, most of them, and they are usually training in the relevant disciplines in that sector. But as part of their training, they have an opportunity to become coaches or people who stimulate physical activity of a different kind in a younger age cohort. And that works very well because it gives practical experience to the people who are in FE qualifications training, but it also is an easier way of facing the difficulty I described earlier. If you have a cohort of a fairly close age group talking to another one, it's a much better approach than the top-down one that might otherwise operate.

That sounds really interesting, and very good for people who are participating in it as well.


We're also doing some interesting work in sport and exercise activity for BME women and families, and we're looking to try to ensure that people in disadvantaged communities are able to see physical activity, inexpensive physical activity, of all kinds as a way of improving their well-being. This message is one I don't think we put about strongly enough—how close is the relationship between physical well-being and mental well-being, even in a difficult situation in life circumstances? 

That brings me on nicely to the final question from me, which we've raised with you in the past in discussions around budgets, which is the issue of inequality of access, which you've just referred to, and the need to address those disparities and try and increase participation levels. Overall across the budget, in terms of allocating the funding, how much of an emphasis has there been on the need to address those inequalities? Are you able to tell us about any kind of progress that's been made in that regard since the last budget? It's interesting to hear about some of the individual projects, but across the portfolio, are we—well, your delivery bodies really, more than you yourself—are they beginning to get traction in, for example, getting more women and girls active?

Well, this is where the healthy and active fund money has been targeted at organisations that actively promote and enable healthy activity from groups that we are encouraging our implementation bodies to work with: children and young people; people with a disability or a long-term illness; people who are seen as economically inactive or live in areas of deprivation; and older people, especially around the age of retirement. So, the emphasis there has been very much to try to improve the take-up of a whole range of sports. No doubt, somebody will ask the question, so I will refer to the swimming question myself here—

No, but I don't want to—. Let's get the bigger picture before we start going down there. The reason why we took the advice of Sport Wales in relation to the swimming initiative was entirely to do with the fact that, of the over-60s, only 6 per cent were benefiting, and that was not good enough; that was not a good use of public resource. What we've been looking for was to provide people with a choice of physical activity and that includes now working with the leisure centres and with the local authorities, and we haven't yet got the full evidence on how this is going. Sport Wales are working very hard with our local authorities and with the WLGA and so on, in order to try to increase the choice available in communities for people—the choice of physical activity so that people who don't want to go swimming will see that they can do simple things like running or walking or going with walking groups. I've spent a lot of time with different walking groups throughout Wales, which seems to me to be ideally suited to the needs of the elderly population. Do you want to say anything on this?

There are a number of priorities we're asking Sport Wales to tackle on equality of access and outcomes. I think, after two or three years of significant increase in overall activity levels, that's plateaued a little. But interestingly, the last survey showed that participation amongst BME communities and other protected characteristic cohorts has improved, so I think we are making some progress. There's an awful long way to go, but we are making some progress.

And Sport Wales, under the Minister's direction, have been looking at their investment model, because they're a grant distributor themselves, and they are going to be—they're working through now, with the governing bodies and with local authorities, a new investment model based less on membership numbers that sports can lay claim to and much more around what the surveys are telling us people want to do more of, and the evidence in the population about demand to do more sports. So, the money is going to follow the direction that the Minister is giving Sport Wales in a very clear fashion, and that, I think, will be worked through and delivered over the course of this year, and you can be questioning us on it this time next year, I'm sure. 


Thank you, Chair. Since you've talked about free swimming, let's go on to that one because, as you know, Minister, I've had an issue regarding this decision. I understand the argument you've just put forward—that the review gave only 6 per cent, but perhaps one of the questions I would ask is: why didn't the Welsh Government take a decision to look at why it was only 6 per cent and how we could increase that, rather than actually cutting the funding? I understand the review actually talked about an estimate of the actual cost of providing free swimming as a maximum of £1.5 million, therefore you've cut £1.5 million, but as a consequence of that, we are seeing cuts in provision to the over-60s. So, in a sense, I can't match the two together, because there is a cut in provision, and I'm sure you've got evidence from across the local authorities of how the provision has changed. 

One of the Welsh Government's priorities, according to your own written submission, is getting more people active at every stage of their life, including when they retire. How does the cut in funding actually deliver the increase in people's activity when you're reducing the options? Now, you say that the options are available to people, but I've yet to see an increase in choice to people as a consequence of that cut and the reduction in provision. So can you tell me how the money is going to give you that wider choice as a consequence of cutting the free swimming?

The free swimming budget for 2020 onwards is £1.6 million: £1.5 million in distributable grants plus £100,000 for promotion, monitoring and independent evaluation of the spend. And this is the focus that I have, and it's a focus that I've been recommended to take with Sport Wales and is supported by my officials, and it's an approach I take to all the public spending for which I have responsibility. This must be seen to be effective, because, after all, we are promoting physical activity as a whole. And what I'm looking for is an increase in physical activity. So, of the remaining 1.4 per cent, £750,000 will be utilised on the healthy and active fund, and there are continuing discussions with Sport Wales and with health promotion colleagues in terms of the allocation of another £650,000. So, this funding is going directly into promoting physical activity across the board. That was the problem I was given by Sport Wales—this figure, which I've already quoted, that, of the over-60s, only 6 per cent were taking part in that particular activity. So it was an attempt, I think, to offer people support for one kind of physical activity, rather than give people the choice. And that's the change of direction that we've undertaken. So it is not a cut in the overall promotion of physical activity. I would never countenance such a thing. 

Okay. Let's take that argument. It is a cut to a particular form of activity, because it's a cut in funding to a particular form. And, as a consequence of that, there are considerations as to how that form of activity, swimming, is supported on a wider basis, because obviously everyone who knows, particularly local authorities, will understand that swimming pools being kept open is not necessarily a profitable business. It's something that has to be subsidised, because that's an important activity. But it applies to all age groups. So, have you done an estimate as to what implications this would have for swimming per se, because this is a cut to swimming, because that limits not just the free swimming activity, but maybe other opportunities for people to take up swimming in the normal time? This is quite a dramatic cut to many pools that are relying upon some of the funding. 

Yes, but nobody has convinced me that this opening out of the funding, as I've just described, to a broad range of physical activities will actually result in a reduction in physical activity. There may be a change in the way that people choose to undertake that activity, but I'm not convinced that this will result in the diminution of the overall participation of the population, particularly the over-60s, in physical activity. 

David, do you want to—

Do you have evidence, therefore, that says, 'Actually, if I take this away, they'll do that'?

Well, no, we couldn't possibly know, could we? We take the advice that we see and we look at what is likely to be positive. I go back to my original figure: 6 per cent of the potential beneficiaries is not good enough in terms of the use of public resource. David. 

I think the situation facing the Minister is that one seventh of all the money we gave for Sport Wales was being used on the free swimming initiative, in addition to the money that Swim Wales would have got as the national governing body from Sport Wales. So a significant proportion of the total Welsh Government budget for sport was going into this initiative. It delivered for 6 per cent for over-60s who used it, and an increasingly small number of under-16s who used it. Half of that money has been retained for free swimming. The priority has been given to local authorities to address, particularly young people from disadvantaged communities—and it comes back to the previous question that we had on equality of access—but also to retain a free swimming offer.

The scheme is ultimately being delivered by local authorities; they own the pools. Some local authorities have responded very well, very imaginatively, actually have worked more on a marginal costing basis. Once a pool is open, it costs very little, if anything, for an additional swimmer to use it. Other local authorities have reacted in the way that you suggest—by slashing provisions. So, I think Sport Wales are going through an exercise now with local authorities to understand why some have reacted in a different way to others.

The money is being retained and the money for sport is actually increasing. We're convinced it will be used to deliver more opportunities for more people. We could have, as you say, gone through an exercise of trying to increase the usage of the free swimming initiative. If we doubled the usage, we'd have got to 12 per cent of the cohort using it. It still wouldn't have seemed a particularly impactful way of using a seventh of the overall sport budget.

We are working with the health department at the moment to jointly use some of the money that we will repurpose to come up with a wider physical activity offer for over-60s. And the Deputy Minister and the Minister for health will make some announcements on that shortly. Sport Wales are talking to the local authorities now because they, again, will have to deliver it; it'll be their facilities. So, I think much of the money, if not more of the money, will end up going into local authorities to support their leisure facilities, but will have a wider offering to over-60s. Some people, many people, just don't want to swim, and no matter how free you make it, they still won't want to swim.


Can I ask a question? It might be the case where—. Quite a lot of my constituents have complained about the situation. My question is: when will you be able to provide an evaluation of the changes that have been introduced as a consequence of the funding changes, and also, an evaluation as to whether there has been an increase in uptake of other activities as a consequence, which is what your assumption is?

This is what we're asking Sport Wales to do; it's part of the monitoring of the whole change of funding.

I appreciate that you're asking them, but I asked when we could see any evaluation.

Well, we're working with them on this, and when we have that information, we will publish it, obviously. You can have a debate on it. I want people to discuss the priorities that we've decided on, but so far, I'm absolutely convinced that the move towards widening participation of physical activity requires a greater choice, and it wasn't about funding one particular activity over others.

I appreciate what your talking about the fact that we can have a discussion about this, but I'm sure that the Government must have a position as to a date by which it expects an evaluation to be available to you.

The changes went live on 1 October. We've asked Sport Wales to be much more directional and authoritative in their funding of local authorities for this scheme and to work with local authorities to do periodic evaluation. So, we would expect an initial review after six months and another one after 12 months. We will still be putting £1.5 million into free swimming, and we want that money to be much more rigorously evaluated in future than it has been in the past. We hope that a new replacement wider activity scheme will be live very soon in the new financial year when the budget becomes available, and, again, we will expect that to be rigorously evaluated so that we understand what the take-up is.

So, is it fair to say, then, that by October at the end of this year, after 12 months, you should be in a situation where they have completed their 12-month evaluation, and by the end of this year, you should be able to report on that evaluation?

Well, no, I won't commit to doing that, because this also involves ensuring that we have sufficient spend in the budget on Natural Resources Wales and the support of health promotion Wales to make it clear that there are all these other options of physical activity in a landscape that is a very simple thing to do. You just get out and walk, whether that's in parkland or whether it's in hill country or wherever people happen to live, and I'm very strongly encouraging the development of walking groups and I've walked in Cardiff and the Vale. I've walked in Treorchy with a wonderful group of people up there. So, I think this is a way forward where people will participate in their own communities in physical activity. So, that is a socially useful thing as well as physically usefully for people.


I can go further and further, but I'll stop there, because I know, Chair, time is limited. 

Yes, but luckily we've got our leader in agility terms in being able to be succinct, so Jayne is going to round off the session with the final couple of questions. 

Thank you, Chair. Good morning, Minister. Following the draft budget, this committee expressed our serious concerns about the sustainability of funding for sport in Wales, and I know you shared our serious concerns. You've mentioned this morning about collaboration and strategic approaches that are needed. Has the situation improved as a result of the measures put in place, such as pooled budgets? And how will the draft budget progress this further? 

The situation, I think, is improving, but clearly it is going to take another financial year for the new way of working between bodies that I've just described to actually bite in budgetary terms and in delivery terms. This is why I am looking forward to this more developed way of thinking between the three bodies that will provide us with a clearer direction and that then there will be a move towards implementation. But we feel we've got the vehicle to deliver this through the healthy and active fund, because that is a way of transferring resources into sport and physical activity that previously might have been available in general promotion by the three bodies concerned.  

Well, it's early days. We've been trying to encourage this joint working and, as I say, I am looking forward. I've met the bodies together and separately. I'm looking forward to what they will have to recommend, and I expect it to be a significant document that will transform the way in which we prioritise public funding for physical activity in Wales, otherwise I will not have done my job.  

And just finally, looking at elite sport, do you think there's sufficient funding provided to enable progression to elite sport, particularly from those from lower-income backgrounds and those who face barriers to entering this type of sport? 

Well, I think the relationship that we have with lottery funding on elite sports, where such funding primarily works through Sport Wales's use of lottery funding— I think this does work. I'm very conscious myself of the importance of role models in elite sports and their effect on the whole of sporting activity. And, as we come up to the Olympics, Commonwealth Games and these—especially the Commonwealth Games, where Wales has a strong national team—the fact that the next games are close to us in Birmingham will be a stimulus to physical activity throughout Wales and there will be a substantial increased interest in all the activities which are represented, both in the Olympics and in the Commonwealth Games. And I'm particularly interested in the development of the new activities in the coming games, so that the various sporting activities and so on—skateboarding and other activities—will become something that young people will follow even more actively, as people see what might have been their community pastime suddenly become an internationally recognised sport. That is a really good opportunity to get people more interested in realising that physical activity isn't something for the elite; it can be participation for everyone as well. But when the elite participants manage to get international recognition for those, basically, community sports—or that's how they originated—then that's a real important driver for our policies. 

Ocê. Diolch yn yn fawr. Dyna ddiwedd y sesiwn. Diolch am eich presenoldeb unwaith eto a hefyd am y dystiolaeth ar bapur ymlaen llaw. Mi fyddwch, yn naturiol, yn derbyn trawsgrifiad o'r trafodaethau er mwyn i chi allu gwirio eu bod nhw'n ffeithiol gywir. Ond, gyda hynny o ragymadrodd, diolch yn fawr, a dyna ddiwedd yr eitem. 

Okay. Thank you very much. That's the end of the session. Thank you for your attendance once more and also for the evidence on paper in advance. Naturally, you will receive a transcript of the proceedings so that you can check them for factual accuracy. But, with those few words, thank you very much, and that's the end of the item.

3. Cynnig o dan Reol Sefydlog 17.42(vi) i benderfynu gwahardd y cyhoedd o eitem 4 y cyfarfod heddiw
3. Motion under Standing Order 17.42 (vi) to resolve to exclude the public from item 4 of today's meeting


bod y pwyllgor yn penderfynu gwahardd y cyhoedd o eitem 4 y cyfarfod heddiw yn unol â Rheol Sefydlog 17.42(vi).


that the committee resolves to exclude the public from item 4 of today's meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Symud ymlaen i eitem 3—i'm cyd-Aelodau rŵan—a chynnig o dan Reol Sefydlog 17.42(vi) i benderfynu gwahardd y cyhoedd o eitem 4 y cyfarfod yma heddiw. Ydy pawb yn gytûn i fynd yn breifat? Diolch yn fawr.

Moving on to item 3—for my fellow Members now—and a motion under Standing Order 17.42(vi) to resolve to exclude the public from item 4 of today's meeting. All agreed that we go private? Thank you very much.  

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 10:05. 

Motion agreed.

The public part of the meeting ended at 10:05. 


Ailymgynullodd y pwyllgor yn gyhoeddus am 10:21.

The committee reconvened in public at 10:21.

5. Cyllideb Ddrafft Llywodraeth Cymru 2020-21: Sesiwn dystiolaeth gyda'r Gweinidog Iechyd a Gwasanaethau Cymdeithasol a'r Dirprwy Weinidog Iechyd a Gwasanaethau Cymdeithasol
5. Welsh Government Draft Budget 2020-21: Evidence session with the Minister for Health and Social Services and the Deputy Minister for Health and Social Services

Croeso yn ôl i bawb ar ôl y toriad i gyfarfod y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd. Dŷn ni wedi cyrraedd eitem 5 erbyn rŵan: cyllideb ddrafft Llywodraeth Cymru 2020-21, sesiwn dystiolaeth gyda'r Gweinidog Iechyd a Gwasanaethau Cymdeithasol a'r Dirprwy Weinidog Iechyd a Gwasanaethau Cymdeithasol. Felly, i'r perwyl yna, dwi'n falch iawn o groesawu i'r bwrdd Vaughan Gething, y Gweinidog Iechyd a Gwasanaethau Cymdeithasol; Julie Morgan, y Dirprwy Weinidog Iechyd a Gwasanaethau Cymdeithasol; Dr Andrew Goodall, cyfarwyddwr cyffredinol iechyd Llywodraeth Cymru; Alan Brace, cyfarwyddwr cyllid Llywodraeth Cymru; ac Albert Heaney, cyfarwyddwr gwasanaethau cymdeithasol ac integreiddio Llywodraeth Cymru. Dŷn ni'n ddiolchgar iawn am y dystiolaeth ysgrifenedig ymlaen llaw. Felly, yn ôl ein harfer, mae gyda ni rhyw awr a hanner o graffu. Awn ni'n syth fewn i gwestiynu. David Rees. 

Welcome back, everyone, after the break to this meeting of the Health, Social Care and Sport Committee here in the Senedd. We've reached item 5, on the Welsh Government's draft budget for 2020-21, and this is an evidence session with the Minister for Health and Social Services and the Deputy Minister for Health and Social Services. So, to that end, I'm very pleased to welcome to the table Vaughan Gething, Minister for Health and Social Services; Julie Morgan, Deputy Minister for Health and Social Services; Dr Andrew Goodall, director general health at the Welsh Government; Alan Brace, director of finance at the Welsh Government; and Albert Heaney, director of social services and integration at the Welsh Government. We're very grateful to you for the written evidence you've submitted ahead of time, and, so, as is customary, we have an hour and a half of scrutiny time. We'll go straight to questions. David Rees.

Let's start off with the financial performance of the health boards. The annual plans—actually, we had five, I think, of the boards indicating that they would break even. The evidence from the board papers themselves gives the latest data that four of those are not going to hit that break-even target. They are in deficit, and I think the figure that's projected at the moment—and I emphasise at the moment, because we haven't got clarity on all the data at this point in time on all the months; we've still got a couple of months to go of the financial year—is that £57 million will be the deficit. How are you actually going to manage that overspend, at the moment projected to be £57 million—it might go down, it might go up?

Well, my understanding is that three health boards are not likely to balance their books, and that's Betsi, Hywel Dda and Swansea Bay. We think the others will. That's our expectation at the end of the year. But regardless of whether it's three or four that don't, we do expect that there will be an overall deficit from those health boards and their budgets, and, as last year, we're looking to make provision within the overall budget to make sure that all those bills get covered and paid.

I guess there are two broad points to make. The first is that, at the start of the year, we didn't expect certainly north Wales to balance. That doesn't mean it's acceptable, but they've set a control total for a deficit. We'd want to see more progress made in the other two health boards. But, in all of this, we've made provision at the start of the year to want to think about how we balance that. What I've been really keen to do since I've been the Cabinet Minister is to honestly reflect the level of performance of health boards and the progress they do or don't make. We still need to pay the bills to make sure that care is provided, that people are paid their wages, but if, again, you look at the starting point at the start of this term to where we are now, there's been real progress and improvement in financial discipline and performance.

It still isn't where we want it to be, and this is about how much further along we are on the journey at the end of this year. There are things you expect to happen and things that you don't expect to happen, so we may get there a bit later in terms of the Her Majesty's Revenue and Customs impact on tax and pension changes and what's that done, and in the performance in money and the way that's used. So, there are some things that happen that are out of your control but, actually, the big bulk of it is things that we expect health boards to want to manage and get on with.

And the second point I'd make more broadly is that having the overall budget balance is one thing but, of course, I'm interested, and I'm sure the committee are, in how effectively we use the money. And, if the finance function was more in balance with delivering services, we could make different investment choices. So, the greater the discipline we have in the system, the better we can make use of the money and the greater value we can derive from it. 


On that basis, then, are you comfortable that health boards are making appropriate use of the funding, even if there's a deficit at this point in time, and that that funding is actually delivering the care you expect? 

Broadly, yes, and the reason I say 'broadly, yes' is I'm not trying to be a politician and 'yes and no', but it's that, if you look at the quality of care and people's response to and their own experience of care, then we have very high satisfaction rates within the health service. We've got a transformation budget that is about improving care for the future and about the sustainability of that care. But, within all of that, there's always got to be a view that there are some things that we could do better, and there are concerns about quality in parts of the system, and we know that from a range of publicly reported areas. So, part of the drive to get on with this is not just to balance the books, as important that that is, but it's also because, in delivering better value with that money, we think we'll deliver better care as well. 

So, if you looked overall at the system and what the health system in Wales provides and, indeed, across the rest of the UK, I'd say that, yes, people can be confident—and Ministers too—about the quality of care being provided. That does not mean that's a blanket that every single part of our system is perfect and there are no particular worries at all, because large parts of this job are the anxieties of things that might go wrong. 

The three health boards you mentioned—Swansea Bay, Hywel Dda and Betsi, that you are now predicting to have a deficit at the end of the year—are three of the four health boards that are in either targeted or special measures. In your evaluation, is that having an impact upon the financial positions of the health boards? 

Well, the progress through each of those measures isn't just about their finance function; there is something about the overall ability of the organisation to make use of their resources and to make progress. But, again, that isn't strictly tied to where they are at one particular point in the escalation framework. In north Wales, it's more of an issue I'd say, because it's one of the reasons why we're particularly concerned, and it's one of the reasons why there's been a difficult intervention with the health board making a decision—you know, colleagues in the Public Accounts Committee recommended external advice, but that's always bumpy, because the person that came in to do that is very well-remunerated and more so than is usually the case. But, actually, there's an element of discipline now within that finance function that wasn't there before.

So, finances are more of a concern about that organisation's overall status than I would say with the other two, although we obviously want to see progress on those, and if they made progress on their financial performance that will be part of the rounded discussion about where they are in the escalation framework. I don't think you can just draw a straight line between where they are in terms of their financial performance and where exactly they are in terms of the escalation framework. I'll be issuing a statement later this week about the escalation status of each organisation after considering the advice, but that is a properly rounded discussion of where they are on a range of factors, which is exactly what the framework was designed to do.  

I understand that, but the question I want to ask, I suppose, is: the resource requirement or the resource implications of those targeted statuses and special measures may have an impact on the financial position of those boards, because it means they have to spend more money on tackling some of those issues—is that taken into consideration when allocating the budgets to those boards, or are the boards going to have to work with the budget they would normally be given and look at how they can improve their measurements within that budget whilst they are still in those measures? 

Well, finance is part of the consideration. So, you'll know that we've made additional investments in north Wales. Some of that is support around special measures; I've issued statements on that and in terms of answering written questions on that too. And that's about helping the organisation to get through to get to the point where it should be able to de-escalate more of its services, and that should impact the overall organisation. We've provided additional support to Hywel Dda that isn't linked to their status in the escalation framework—it's work we've done on the formula—and we have another choice to make about the new funding formula for the future, and that will see some shift around the system about the base budgets for each organisation.

So, finance is part of it and, obviously, we've funded intervention to support those organisations in terms of their financial planning over this year and, again, that's covered in both the evidence I've provided and in previous statements too. So, it's a part of it, but I wouldn't say that it determines every single part of anything, and you'd expect that if an organisation is further up the escalation framework than others, some additional resource may be part of the answer to helping them to resolve their challenges.


Okay. Based upon all those answers and the discussions we've had to date, what do you think are any assumptions you've made in readiness for next year, 2020-1, the financial management, and are you expecting to have to basically have a similar deficit level, or are you looking to actually be in a position where you have more health boards either breaking even or doing better?

I certainly expect that next year we'll see a better performance within the NHS when it comes to finance. The honest truth is there are a number of factors that I'll have to take into account in making choices and in the advice I get from some of the people at the table today. So, it'll partly be about the nature and the quality of the plans that each health board submits, whether it's an annual operating plan or a three-year plan. It'll be about their performance over this year and about the assessment of their prospects for further improvement, about whether there's a pause or whether, actually, they've got the capacity and the capability to not just understand the challenges but to move on with them as well. There will also be the choice that I referred to about a choice that I need to make about a new NHS funding formula for growth into the NHS, and when and how to apply that. So, all of those things will make a difference.

But, again, as in previous years, when it comes to not just an expectation about there being improvement but then what that level of improvement is, I'll be transparent about what that is when I confirm not just choices about integrated medium-term plans, but more broadly the context of what our expectation is on the financial performance, too, because we don't hide what the expectation is on whether we think someone will or won't break even, or whether we think that they're being set a control total to minimise their deficit. But I certainly expect that if we were having this conversation in, if you like, the normal part of scrutiny in the autumn around the budget and we had had part of the year's performance, I would certainly expect that we'd be looking at an improvement again on the end-of-year outcome for the NHS. And that's really important to me, and it's really important to not just the healthcare system but wider public services as well, that the NHS is able to use the money that it has effectively and deliver within its means.

Do you expect all health boards to have a three-year plan approved this year? 

No. I'd be delighted if they did but I'm not starting the year by saying that I think every single health board will end this next period with me approving their three-year plan. I'm looking for health boards to develop a strategy for the future. So, Hywel Dda has an approach for the future and, again, there's plenty of noise getting there as there always will be when you're looking to have a direction of travel for the future, but they don't yet have a three-year plan. So, I'm looking for every health board to make sure that over the next year it's got a plan for the future about what it wants to do, even if it doesn't yet have a three-year plan. If I tried to tell you that north Wales will have a three-year plan and a three-year IMTP by, say, May this year, I think you'd either ask me to sit down and to calm down, or you'd say that that just isn't believable. So, it's not credible for me to try and say that every health board will have an approved IMTP at the end of the next round of the process.

Angela, did you want to—? I'll come back to you now. 

It was just following up on David's point about the special measures and the health boards that are in special measures, and I just wondered if you could clarify—

And in different forms of targeted intervention. Could you please clarify for the committee how you monitor the money that you give to a health board for either special measures or targeted intervention? So, for example, Betsi Cadwaladr over the last four years has had £83 million, which is an eye-wateringly high amount of money, specifically for intervention and improvement support. How do you monitor that £83 million—that it's been deployed effectively to get the results that are hopefully going to drag that health board finally out of special measures?

Okay. I'll ask Andrew to come in on some of the detail, but what I would say is that in any of the organisations that we've put money into that's for a targeted purpose, there's a level of evaluation and oversight. Even for an organisation in normal monitoring, there's still contact with the team here, there are the joint executive team meetings that are deliberately demanding and challenging. And for organisations in either targeted intervention or in special measures, then, of course, there's an additional level to that. There's an additional level of contact and oversight in terms of what that organisation is doing. So, the £83 million that's gone into north Wales over three years, against its operating budget of nearly £1 billion, that's actually about trying to direct itself at some of the particular challenges within those services, but a number of those are not about money.

So, the progress that's been made in mental health is partly about the leadership within that service, and it's still partly because of a challenge about ill health in the leadership. That shows something about needing to develop a structure that isn't reliant upon one person. But in developing a strategy, that wasn't necessarily about money; it was actually about taking the time to go through a proper process of engagement with people delivering and taking part in the service, and then having an approach for the future. So, the—


I understand that, Minister. I actually said that in my question. 

So, the money is part of it and the monitoring of that money is part of it as well, but in north Wales we have a special measures framework to assess and measure progress against as well. So, it isn't simply a counting exercise of the money; it is then a proper process, as you'd expect, of what progress has been made with that additional financial intervention, as well as the other steps and approaches you'd expect to be made that are not about money in terms of improvement within each of the organisations.

I totally understand that the £83 million was going to be used on a whole range of activities in order to support that health board. My question was, actually: how do you monitor and evaluate that that £83 million, which was for, and I quote, 'intervention and improvement support' has been used effectively? This is about the effective use of a very large sum of money.

Yes, and that comes through the special measures framework that we have and the regular engagement that that health board has with Welsh Government officers as well. So, it isn't that we take a laissez-faire approach—'Look, we've given you the money, have a go.' It is much more detailed than that in terms of the plans that are expected to be in place, about the oversight and the regular contact that that board has with the Government, which is what you'd expect about the choices it makes but also about the direct performance and delivery of that.

Despite some of the operational meetings that take place, we do come back to the framework. We try to make sure that there are milestones that can be clearly tracked. Within the £83 million, a significant aspect of that over the last three years has been money, and we've similarly targeted that for referral to treatment times across Wales. So, for example, through the last financial year we were tracking, as you would expect, where we wanted to show an impact of what the waiting list could be in north Wales, and to make sure that that could be recovered and improved in areas like mental health, for example, where we did put in some particular money. We can obviously track physical aspects, capital funding was put in, and we can make sure that the work has actually happened. The operational support we've put in, actually, we think has translated into mental health services feeling more sustainable in north Wales. And certainly against the framework at the moment, as a very discrete service we can see traction, progress and improvement over the last two years or so. But all of the monitoring, irrespective of the detailed contacts that we have with the organisation, we do try to bring it all back to the special measures framework and, obviously, that was recently enhanced and there are regular quarterly reports that are received on that.

Your figures for the annually managed expenditure for NHS impairments and provisions have increased by almost a third in this budget, in particular, compared to the first supplementary budget of 2019-20. I suppose the question on that is: how much of that proportion is to the impairments and how much of it is to the provisions, or proposed liabilities? Do you have a reason as to why these are increasing?

Yes. So, AME is a budget that is there to try and cover those things that can't be precisely planned and managed year on year, and particularly within year. And for us, that primarily covers things like clinical negligence, but future liabilities for clinical negligence rather than the in-year clinical negligence settlement. And then, invariably, it will be valuations around new constructions where the district valuer will value it at a different number than what was spent on construction. They will vary throughout the year. So, we normally provide three estimates to Treasury throughout the year, and each of those estimates will vary. So, I guess the—. Just looking at the question, I think you're asking about the first supplementary budget and then the difference between the budget of £162 million. If you look at the figures—


No, the first supplementary budget for AME was £120 million; the last figure at December was £161 million; and next year's budget is £162 million. So, the movement between the latest figure in December 2019 to the budget is only a £1 million move. The move between the first supplementary budget was—the most material amount in there was an impairment for the asbestos removal work in Glan Clwyd hospital. So, that was the primary difference between the first supplementary budget and the £162 million, but it's also primarily the difference between the last figure that we have agreed with Treasury for December. 

Okay. So, the liability of cost of removal of asbestos has actually been one of the main reasons for the increase in those figures. 

Yes, I mean, basically. I suppose the easiest example of the way that they measure it, to translate it into everyday life, is: you may have £10,000-worth of work done on your house and then you come to sell it, and you might only gain another £2,000 on the valuation of your house because that doesn't translate to some of the valuation. So, that's exactly what happened, with the money that we spent on Glan Clwyd for asbestos removal against what the district valuer therefore valued the new development at. Well, it was a difference in terms of about £40-odd million on that.

On your other question, I guess, on the balance, because there's probably a few other things in the mix as well that it covers, but if you look at £162 million for next year, about £70 million of that is for future liabilities on clinical negligence and then the balance will be for impairment and other things. So, that's roughly the split, but that split could change throughout the year given the nature of the expenditure and what it covers.

Okay. I understand that. I understand, therefore, the cost depreciation as a consequence of that. I fully appreciate that. It's just important for us to know where that money has been identified as depreciation and where it has been identified as liabilities. It is important to understand that.

The paper also highlights the cost of NHS services. We know you're going to get an extra pot of about £80-odd-plus million in your budget because it is the largest budget in the Welsh Government's budget, in health. About £55 million has been transferred to other budget headings within the MEG and about £8 million has been transferred to a budget for the core delivery of NHS services. The breakdown of the transfers is not clear in the papers. I just wondered if you could give us some more detail as to the reasoning for these transfers, where they're coming from, where they're going to. Because, you know, we've always argued that the health budget has been so big sometimes that the breakdown isn't perhaps as detailed as we want to see sometimes. It's understandable because of the complexity of it, but if you're doing transfers in, it's good to know where those transfers are coming from, where they're going to and why you're doing it.

I'll run through some of the transfers that have been made. So, the social services grant, there's an additional £10 million this year that I've decided to add in. We recognise the huge pressure that social services are under generally and of course the link to the healthcare system as well. A large part of the challenge we're seeing in winter is because of the join between health and social care and our ability to move people through different parts of the system. More generally, of course, there's the work that the Government is doing on the potential for paying for care in the future. There's £20 million for the childcare offer that's been moved around. There's £5.5 million gone into Healthy Weight: Healthy Wales. The first programme and oversight board for that was yesterday—Monday, not yesterday. Days of the week. There's nearly £5 million gone into national health protection services and an extra £3.5 million being invested in Flying Start. That's set out in the paper, though; that is additional money that's been transferred out. And then there's more money going to Improvement Cymru, which is the next stage, the new 1000 Lives. And there's also money that's gone into adoption support. That's £2.3 million. I think that gets you to your £55-odd million figure. And there's also money that's gone into the mental health ring fence as well. So, I think that sets out that chunk of it, the £50-odd million that you've referred to, and others.

On the more specific things, there's something about, not just how you're using the money, but how it's presented, and there are useful things on the presentation of the budget. Because I know you were saying, you know, 'We can't always tell what's there.' Because a big chunk of it goes out into health board budgets and we don't set lines within those about every single area because we don't set the detail of all of those budgets. But in terms of the part of your question that was about the presentation of the budget and the clarity in it, I'm not completely sure that I understand what you're looking for. It may be that that will be a different conversation to have with clerks, officials—


We're getting better, Minister, as you know. In the past, you used to be on the health committee yourself, many years ago—

And you'll remember the presentations of the budgets then. We are getting better at seeing it but, of course, it's such a large budget with so many areas, it is important for us to try to get as much detail as we can in terms of the budget. But it's a discussion to be had between officials and clerks, I'm sure. 

And I guess the character of what you want to see to be able to scrutinise it as well, because otherwise, the honest truth is that we could provide you with reams of detail and you'd then be looking for needles in a haystack. So I don't want to try and do something that looks like we're deliberately overburdening you with detail to make sure you can't see what's there.

Well, I've been on that side of the table as well, and I'm not quite sure that's true. But there's a conversation about how to improve this part of the process, and I'm happy to engage in that properly. 

What resource implications, if any, are there in actually beefing up, supporting, training and developing within the directorate the management of the health service? We always talk about more money for hospitals, more money for primary care, blah blah blah, but actually I'm really conscious that the hole that we don't talk much about is Welsh Government officials, the people in your directorate, and their capability and capacity to manage all these sums of money, to manage health boards that are in various forms of intervention, to bring to the joint executive meetings between Government and health boards the right levels of skill and the right levels of knowledge so that they can understand what is going on. We've seen that with Cwm Taf, which for years was tick, tick, ticking the box and financially met performance measures, but actually there wasn't a drilling down, perhaps, into some of the issues because they weren't highlighted until recently. So I'm just interested to know if you have training budgets, what your plans are and what kind of sum of money out of all of these allocations that you make goes into, or back into, that part of the NHS services. 

Obviously, we still have to ensure that organisations are fit for purpose and can oversee themselves, and escalation isn't the answer to everything. We have to make sure that boards are able to discharge their governance. But it is absolutely right to say that we, obviously, have oversight of the system and that requires a level of detailed knowledge and understanding. And whilst there are some colleagues, including me, Alan and Albert, who have got operational experience of working within the care system ourselves, we obviously have officials who will have come through civil service structures and have to have a way of supporting them. So, yes, we do look to support colleagues in their understanding when they come into teams.

I think the real answer, however, is more prospectively, so that, when the parliamentary review was undertaken and we responded to it, the agreement by the Minister to establish the NHS executive is basically to respond to the need to enhance our level of central and national capacity to oversee the system and equally to drive it and to ensure better compliance on a range of different areas. And we are in train with the establishment of that unit to discharge those purposes. On the one hand, there is a benefit to aligning existing intervention-type support and bringing it into that area. So, the finance delivery unit, the delivery support unit, the Improvement Cymru mechanisms. We can make sure that we can utilise, I think, better some of the resources now in the system, but even in this year's budget, we've allowed for the fact that there would need to be an enhancement because of the NHS executive—not to turn it into a bureaucracy, but rather to recognise that there are some gaps in terms of some of the operational challenge that needs to happen to make sure that we are content and can advise the Minister that things are in train. So that is taking place through this year.

We're expecting at the moment, with the Minister's direction, to have the NHS executive established, I hope, by the autumn. That might be in shadow form. There are still technicalities about the establishment of the legal organisation, but even at this stage, we're already aligning that aspect. And, of course, we have our own experience of the escalation process and we do know that we've had to draw in external support, partly because we've not had that internal ability to respond as you would see fit. So, I think that will continue to grow and develop, but the NHS executive, I think, is the substantive response to that. 

Don't get me wrong, I'm actually quite a fan of bringing in specialists to help you achieve a specific aim. So, you've drawn in external support with the escalation processes. Have you also done the same for the transformation agenda that was very much talked of in the parliamentary review? We talked about it being a massive ask for existing staff to be able to beef themselves up and, of course, an enormous increase in skills, and a different set of skills. Transforming and making a cultural change is hugely different to running an organisation on a day-to-day basis. So is that all part of it? And also, why is it taking—? Has it been because of financial constraint that it's taken so long for the NHS executive to really get going? If you're talking about autumn of 2020, that's quite a timescale. 


Minister, you may want to comment on the NHS executive.

There were some events around Brexit that were just intervening in the process of us going for it at a particular time, not least at the end of October, of course, and that did—

That was a civil servant being polite. The 'no deal' scenarios really did interrupt it and at one point it was possible that the NHS executive would get shelved altogether for this term, depending on what happened with Brexit, because you couldn't say that the delivery of the NHS executive would be a bigger issue in terms of Government time and our ability to have staff to deal with that compared to potentially having a 'no deal' and all of the work that was not just in the preparation, but if that had happened. And so the Brexit process, regardless of your views on it, had a very real impact on what we were able to do as a Government. This is just one example of that. 

In respect of your broader questions, again, not everything can be about, 'We've put it into a box with the label of an NHS executive', but absolutely we need to think about the skills that are required more broadly within the system. The enhancement of Improvement Cymru is one of those answers for looking at transformation through the quality lens, making sure that that is support that is plugged in locally with organisations, but actually one of the changes there is to make sure it's a reflection of support for the integrated system as well, extending out into social care. 

It's also important we don't just gather a series of experts to do transformation. We're looking for a way in which transformation could be the thing that clinical teams feel that they can simply be supported to get on with. So we are trying to make sure that that support is happening. One of our approaches in Wales is to have improvement hubs across all organisations. They are in place now with most of them. There's a centre for improvement in Aneurin Bevan, and Betsi Cadwaladr are introducing that, and there was an improvement hub launch that I attended for Hywel Dda, and they are focused on trying to raise the level of skills around transformation. And although I can't give you a comprehensive answer, it's probably also worth saying that there's a discussion—in fact, I think that will be revisited this week with the Deputy Minister—about regional partnership boards and the extent to which they feel they've got the capacity to move on transformation when it's being done by organisations joining each other together. And, again, we're looking at some of the capacity needs for that particular part of the structure as well. 

So the funding for that kind of event, timeline, is not so much discrete funding, 'Here's x million to go and do that', it's more that it takes a bit of funding from all of the areas that are participating in it.

It will do. But I could tell you, for example, on the budget, that £1.9 million is going into Improvement Cymru to enhance the level of support and infrastructure already there. And that may still be insufficient over the course of the next two or three years, but that is a genuine step up in that kind of structure. And we would probably look at some of the 'A Healthier Wales' funding levels to see whether we can put some capacity towards regional partnership boards, for example. They would all be covered off on very broad labels within the budget. 

I was just going to come back in on Angela's point, actually, first of all, about the establishment of the NHS executive. Is there any more about the budget implications that the establishment of that has had? What budget implications has that had?

Well, we've yet to establish it and it's something that we're looking to create over the next year, so we'll know more about the budget implications as the work goes in—because we've got people currently in the system who are looking to create it—and what that means about either drawing together functions or, indeed, about additional resources around the new organisation when I formally sign it into being. So I can't be exact at the moment. We'll need to talk more about how we bring things into that and its impact directly out into the system. So, I'm not looking to create something that's going to soak up a large part of the budget. 

Okay. Thank you. Just moving on to transformation more generally, the paper that you've provided states that the long-term feature of the transformation fund is under consideration. Is it now anticipated that the fund will continue beyond the two years?

I've indicated that the fund will go on to and end at the end of March 2021. I think it was right to extend the fund and the time frame for the projects to conclude, but I just think that, if I say that the fund will be extended for another year and another year, we'd end up with what we said we wouldn't do, where we don't understand whether something has worked and we don't actually turn the tap off to something that isn't delivering value. So, the statement that I made yesterday in the Chamber confirmed again that the fund comes to an end at the end of March 2021, with the allocation of the remaining £11 million and a process for each partnership board to come up with a proposal for how to use that as well. 


Okay, so that's the timescale and that's the evaluation for the roll-out of any transformation. 

What has the Welsh Government done differently in this budget to drive transformation forward at the pace and scale that's needed?

Well, there's the continuation of the transformation fund, which we've just gone through, but then in terms of the rest of that, some of that is about money and some of that isn't about money. So, for example, with the additional £10 million going into clusters, actually, our clusters are driving a fair amount of transformation and change to the way that primary care is delivered. And the national primary care conference at the end of the last calendar year was really positive. Each cluster in the book that had been produced described what they were doing and why, and the impact that they thought it had had. And meeting all of those cluster leads, some of whom I'd met before but lots of whom I hadn't, from across the country—north, south, east, west and the middle of Wales—was really positive in terms of where they're going and their recognition that they're at different stages. The leaders are enthusiastic. They've got some people who are more reluctant and others who are more enthusiastic. They could all describe how they'd already made a difference and, actually, that gave the confidence to me to invest an extra £10 million for them to do that. And that really is about driving transformative work. So, that's an area where money is being used. The money we've put into the regional partnership boards this winter is, again, about helping to continue to drive and transform those relationships by people actually making choices together.

The other part of it I don't think is necessarily about money in terms of driving transformation are some of the points about—before the NHS executive comes into being, but even afterwards—choices that we may make, that I may make, about things that the system will need to do. So, we made a previous choice, for example, on the whole system getting direct access to physiotherapy in primary care. Well, that isn't necessarily a direct financial choice. There was a choice made about this being a service we wanted to see across the country. So, there will be choices that we make that these are things that we expect to be delivered across the country where that isn't about me saying, 'I have a sum of money', but it is about a requirement for the system to get on and deliver. And you can expect to see some more of that, about the difference between national direction, in a programme like the nationally directed endoscopy programme, where there's some money, but a clear national direction that is really driving what's happening there, and other areas, where money is being used to help drive the transformation and the service then gets on to do that in a way that the £10 million in clusters, I think, was a better example of that.

So, through the clusters, is that how you ensure that health boards allocate funding for making sure that it's really focused on transformation and not just really maintaining existing services?

It's also going back to the plans as well. So, whether they have a one-year or a three-year plan, that isn't just about how we keep what we've got, it is about how we make sure that what we have is sustainable and meets the need that we have, and the partnerships that those health organisations have with others, not just through the regional partnership boards, because that comes back to the central message in the parliamentary review that our current services and the way that we deliver healthcare is not fit for the future and requires transformation and change. And so in approving any of those plans, that has to get into, 'What of this is about maintaining what we currently have and is important and where can we see the drive for planning and delivering something different that isn't just about—?' That isn't only held in the £100 million transformation fund space, that is still about how we see improvement.

And the good news on that is, and I've said this before, that the future is already here, because you can look at every health board and see an area of practice that is leading and innovating and the challenge always is: how do we take on board what our staff are already doing that is working and is a better way of delivering healthcare to actually make sure that that is more widely spread? And that's part of the challenge, as well as an encouraging point. And if you went to any health or social care awards evening, you'd find examples of excellent practice, leadership and enthusiasm. Capturing that and delivering that across the system is our big challenge, and I don't think I can just set a single budget for that to happen. But, as I said in the Chamber yesterday, money is part of it. 

And just with the regional partnership boards, what's your assessment on how well they're working, and what sort of stage of development are they all at? Do you feel that there's some improvement, with them all being at a similar level, or do you feel—

I actually think that the transformation fund has really helped regional partnership boards, together with the integrated care fund in terms of having to make real choices about real money for service improvement and delivery and transformation. So, every organisation has known that they need to be around the table to decide how that money is spent to deliver a different service.

So, if you look at the transformation fund proposals from north Wales, having a proper portfolio of areas they've agreed they want to go at, and the fact that the health board is in special measures hasn't prevented people agreeing on the choice to make there across health and social care. And then, at the other end of Wales, Aneurin Bevan and their partners in the Gwent regional partnership board have a big project looking at transforming children's services.

There are differences in each one of them, and that's part of the encouragement—that you can look at different areas of transformation across the picture. And you do see a maturing of relationships. That isn't always easy, so I wouldn't try to pretend to you or an outsider, in this meeting or outside it, that everything is fine and there are no bumps to get over at all, but having to make real choices, I think, has been helpful in the maturing of the relationship, and I'm determined that, in the next year, we'll find more ways for regional partnership boards to continue making those choices together. In the conversations I had with a number of chairs and chief executives of health boards, they've all been really positive about the impact of allocating some of the winter money through regional partnership boards on a more joined-up, whole-system response. And we need to make sure that that conversation isn't too crowded, that we don't have a conference every time those organisations need to meet together and decide, but we do still reiterate the importance of them. I think it's about £180 million that regional partnership boards have oversight of spending at present, so it's a real material sum of money into the health and social care system. 


And if I may just add to the Minister's comments, I think there are probably two really important things here. One is that the Wales Audit Office report on the integrated care fund was very helpful to us and, actually, one of the strengths in Wales—there are areas that we have to develop, of course, but one of the strengths was really how partners have begun that journey of really working together, mainstreaming services and doing things very differently. But then, the second comment is to help us on effectiveness, out of 'A Healthier Wales'. There are actions in 'A Healthier Wales' that are around how we inspect, how we look at and how we understand the effective work at a regional partnership board level. And one of the co-production works that we have done over the last six months has been to produce an assessment tool that we're now about to pilot. And the reason we're piloting it—. We're piloting it in two RPBs, and the reason we're going in two is that we had a methodology that we'd agreed together, but the WAO were very helpful with us in talking about some of the approaches that they have taken around SenseMaker. So we aim to go out and actually pilot two approaches and then set up the way forward. 

Another important way that the RPBs are developing is that they now include housing, education and the third sector, and I think that's a very important development that means that they've been evolving. 

Brilliant, thank you. And on that, what you've just mentioned, Albert, will that help as a mechanism to track the impact of the funding that's used for our regional partnership boards?

Well, what we've done over a number of years is strengthen our approach to regional partnership boards, learning year on year. So, we have quite a robust monitoring process that's in place. We get, at a local level, which is across the region, very rich intelligence in terms of monitoring and local evaluation in terms of the effectiveness and outcomes, and there are lots of really good examples of progress, recognising that the partners are working in a very challenging environment, with increasing complexity and demographic changes in terms of the numbers that are taking place. But we do have good evidence of certain services really working well. Some of the front-door services around preventing older people from going into hospital have been proven to be very effective, but equally in a Welsh context, partners have been working together in Home First and doing things differently and taking different approaches to actually make sure that people who go into our hospitals are supported quickly, in a timely way, in their communities. 

And, of course, you would expect me to say this, there are—and I'm sure you'll come on to some of the social care issues—there are some pressures in the system where some of this money is really particularly helpful. So, if we look at the Minister's investment of an additional £10 million on top of the £30 million invested in this current financial year around the workforce for social care, and given the demands within domiciliary care services, then that really is a very welcome investment.  

And there's a regional partnership board learning event to draw people together on a range of things coming up in February that the Deputy Minister and I will be at as well. So, we're deliberately wanting to learn the different stages that people are at and what's working in different parts of Wales as well. 

I think the transformational thing that has happened is the partners working together, and that's what the WAO did pick up. 

Brilliant, thank you. Just finally, how much of the health and social services budget for 2020-21 is intended for preventative activity? And how does it compare to last year's budget? I think your paper describes a number of specific projects and activities with a preventative focus, but it has been quite difficult for us to get a clear overall idea. We've found it a bit harder this year to see where that's changed.


Funnily enough, I was talking about this this morning actually. There's still something about how definitive you want to be and what is prevention and what isn't. But, last year, we thought the estimate was about 6 per cent and with some of the investment we're making that's more in the preventative space as well. So, the money we're investing in 'A Healthier Wales' is about transforming and making our system more sustainable. And that is about earlier intervention and prevention. The £10 million I mentioned earlier about the additional money into clusters: investing in primary care is broadly more preventative spend as well. And the additional money that we're putting into Flying Start. So, the paper gives some discrete examples, some specific examples where deliberate choices have been made that are around prevention.

But, before I hand over to Alan, I think that if you also look, for example, at the additional money that I've put into the mental health ring fence, some of that money will go into a more preventative and early intervention space, but that comes back to the priorities that are set in the delivery plan that I will be imminently signing off. But you couldn't say within that money in the ring fence, 'There is a particular percentage that is definitively preventative spend.' So, we can get so far, and I think we've made more progress than last year, but I wouldn't want to get too lost in saying that if we identify, for the sake of argument, 7 per cent of preventative spend this year that means that 93 per cent isn't, because I don't think it's quite as simple as that. But Alan had some information on some of the work that the Organisation for Economic Co-operation and Development has done as well, on how we compare with similar countries.

Yes, thanks, Minister. If I just put it into context generally, I think what we're trying to do across all of the system is to make sure that we're clear on the resources that we're allocating based on the needs of the population and we're increasingly drilling that down to local authority and cluster level. We've got a huge amount of data on how well those resources are being utilised and then, increasingly, we're increasing our measurement on the outcomes that that's delivering. So, we're conscious of trying to make sure that we keep that joined up.

I think that prevention just feels like one of those really difficult areas because we then end up trying to track resources to a narrow set of definitions. If you looked at our evidence paper for last time, using the framework that we all agreed to measure prevention, we calculated that was around about 6 per cent. Interestingly, the OECD just published their country analysis for 31 countries and the average for all of the 31 countries, using broadly similar definitions, was 3 per cent. The UK was at the highest at 5 per cent. There were only seven countries above the average. So the spread was quite significant. And only two countries were then closest to the UK and that was Finland and Italy at 4 per cent. So, our 6 per cent feels like we're at the right end of the OECD countries.

We've tried to grow that investment, as the Minister has said, through healthy weight, the health protection, the cluster money, but we're also trying to make it a little bit more real—back to my analysis about all of our resources, the way we're allocating them, how well they're being utilised and that they're driving the right outcomes. We know that we've got really poor outcomes in lung cancer and, to some extent, if you look at the way that we're currently allocating the resources and the measurement that we've put on it, what it's telling us is that late presentation is a significant issue—late presentation into primary care and then difficulty in terms of accessing diagnostics. So, you'll see in the news the work that was done in Neath Port Talbot, and Cwm Taf have done the same, about rapid access diagnostics. And then, obviously, through some of the work that we're targeting on prevalence, we're making sure that some of the smoking cessation is actually much more targeted at a health board level, and then we're moving broadly up to better respiratory health, we're working with other groups in Welsh Government around air pollution and trying to make sure that we play our part in there. So, we're trying to make sure that we're also doing things very practically at a pathway level, to try and shift the money that we're currently spending on oncology into rapid access diagnostics, more on smoking cessation and then, increasingly, trying to get more into the broader agenda about better respiratory health. So, there's a very practical bit that we're trying to also do and that's what we're trying to pick up more year on year, working with some of the national clinical leads.

Sorry, but can I just say—? On the baseline of what we think is preventative spend, Public Health Wales are doing some work to try and come up with that as well, and once that's completed, to give an idea about where we are, I'd be happy to share that with the committee, once we have an idea and you can then—. We can track and I'm sure you will want to track about whether we're making progress forwards or backwards from that line as well.


Okay. Helen Mary's got a supplementary on this point.

This is a bit of a process question, but I think it's quite important as we move forward and it ties into the preventative agenda. I wonder if you can tell us how the requirements of the Well-being of Future Generations (Wales) Act 2015 were built into your budgeting processes. I know that the commissioner has raised some concerns, not specifically about the health budget, but about the Government's budgeting processes overall, and in a sense it relates back to an earlier question Angela Burns asked about the capacity of the staff who are doing the nitty-gritty of the budgeting work to understand what the future generations and well-being Act ought to mean for where resources get prioritised in the long term.

Well, that is not only a part of the decisions that we make when we make choices here, but it's also a part of the planning guidance, so that when we get plans for how the bulk of the money is going to be spent by health boards and trusts in their allocations, it's really clear. And, in fact, it's been highlighted again in the planning guidance for this year, for the planning framework, but also in the national integrated medium-term plan that we produced as well. So actually, I think it's really visible, the way that we make those choices over not just what we do, but actually what that then means in terms of how people actually deliver those services.

In terms of investing in staff that do the doing, and all the rest of it, the reality is that we've put more money, in a constrained time of overall finance, into investing in the future of planning within the system as well. I don't expect lots of people to praise me for saying we've got a new qualification, and there are going to be more planners in the health service, but actually, to run a planning system, you need people who can do that, and if we didn't invest in that then we would be handicapping the system to deliver what our overall objectives are for it. So, I think it's pretty clear, and there are really clear references in the planning framework to that. And to be fair, in the IMTPs that we get provided to us, whether they get approved or not, I think health boards are making an honest attempt to go through and understand the five ways of working that are required.

Okay. Well, time is marching on, so we'll turn to primary care. Angela.

We all know, don't we, that to reduce hospital activity, we need to make additional investment in out-of-hospital alternatives? However, in October 2019 the Wales Audit Office said that although they could see evidence of that shift from secondary resources into primary resources, they found it very difficult to measure exactly how much is spent in primary care in NHS Wales, and I wondered if you could give us that answer, because I've tried looking, too.

We occasionally get this question and we give an answer that doesn't always satisfy some of the groups that ask questions around the percentage in the budget. We've tried to use the same definition they've agreed in Scotland on areas that are spent for our primary care contractors, and actually, we're ahead of Scotland as a percentage. I can't remember the exact figures now, but the additional money we're investing in clusters, there'll be more money into that; the additional money we put got into the general medical services contract; the end of our negotiations on contract reform and improvement for both high street opticians or optometrists, as is their more technically correct term, and indeed community pharmacy, as well. We've seen more money going into primary care, and indeed the transformation fund is largely about primary care, not secondary care. If you look at all the transformation projects that we have had submitted, and the ones that I've approved, very few are about acute care. They're actually about getting people out of the hospital system and back into the join between primary care and social care. So, I'll happily come back, because I don't know the figure offhand about the percentage of spend, but I'll happily send a note to the committee on the definition that's been used, and accepted in Scotland, what that makes up, and then how we compare with that and how this budget moves that forward as well.

I think it's to allow ourselves to ensure that we can capture an expansion into the community services. So I do think the transformation fund shift, as the Minister said, was a deliberate attempt. Last year's budget was framed by 'A Healthier Wales', as a 10-year outlook that was very different, but I think sometimes when we are defining 'primary care', it inevitably comes back to the contractors, whether that's the GPs or the dentists. I don't think we're always capturing the district nursing and community nursing figures, for example, that are held within health boards. I look at the expansion of frailty services as alternatives to hospital admission that has happened across Wales, and they fit in the primary care sphere, but they aren't necessarily captured by the technical definition of 'primary care' as well. So I think, Minister, we could probably do something that is the precise definition, but maybe we could just open it up to demonstrate some of the community investment that's going into the system as well.

Yes, let me rephrase my question, in that I'm interested in primary care and all the community care services. We have two issues, don't we? One is that we've got to persuade people to go to the most appropriate outlet for the service that they require at that time. So, if you've got a bad tooth, go to the dentist, don't go to the doctor. And the second issue we have is ensuring that we've got the funds going into there.

We know that hospitals, specialist services, are expensive things, they gobble up lots of money. We are all very well aware of the pressures in primary care: we haven't got enough staff, we haven't got big enough buildings in the right places, and it goes on and on. Which is fine, because we're trying to change it, so that's all accepted. But what I don't see in the budget, and I haven't been able to identify, is a proper shift from the finances going in one direction to another direction.

I do note that, again, the Wales Audit Office said that you should ask the health boards to really clarify and standardise how they record their expenditure in primary—and when I say 'primary', I'm talking primary and community—and community services. I wonder how well are you getting on with that and how well are they responding to that request for really identifying within each health board how they're going to shift it out. Is there still that real tension in play between a state-funded system—i.e. hospitals, health boards—and of course the private enterprise that is the GP?


On the last point first, then I'll ask Alan to deal with some of the detail about how we're trying to track and understand the expenditure, in terms of how our whole system works, for each of the primary care contractors—GPs being the most obvious ones, but of course optometry, dentistry and pharmacy are very obvious ones where they're a large part of the service—more investment and more shift will go to those services over the future in a deliberate way. But they won't be going to a private enterprise in that sense, because they're going to people who are NHS contractors. So, they're providing a national health service. I don't think Dai Lloyd, when he was a jobbing GP, ever thought of himself as part of the private sector.

But there's a balance in how we deliver that and everything around that. We were talking yesterday about changing the law on indemnity and the state standing behind the indemnity scheme. For a straight private enterprise, you wouldn't expect the Government to do that. It's because of the reality of the health service—what we expect them to deliver, and making sure people can deliver it. So that's the broader point. I don't think there is that conflict between saying that because GPs are largely independent contractors we don't want to invest in general medical services. Actually, we are deliberately shifting more, not just the £10 million extra going into clusters, around primary and community care. So I'm more than happy, to come back to your first point about primary care and community services and how that's described—I think Alan might be able to help to describe it, and it would be helpful to have an idea about how we track what that does look like in terms of expenditure shift.

Thanks, Minister. In terms of the health board accounts, they absolutely have to report their spend on primary care. Unfortunately, they report it net of prescribing, because obviously GP prescribing is quite a big element. If you look at the last four years in terms of the reported position in the LHB accounts, the spend on primary care has grown around about 15 per cent; so, in the accounting definition and what they report to us, there is a growth in their spend on primary care.

The bit that we're obviously doing then is really broadening that definition around multidisciplinary team working within clusters, and to some extent the pace and scale of that development is variable, but we are going to have to start thinking about putting more definitions around that. What we're doing in the meantime, the new resource allocation formula will—its building blocks will be local authorities, and then we'll aggregate it to LHBs, but we're also going down to cluster level. So, we're having a look at needs of population down to cluster level in terms of resource allocation, so that will give us a line of sight about how the health boards are starting to shift resources below health board level, and are they shifting it to the clusters that are showing the greatest need in terms of the population.

On our utilisation framework, then, we are analysing a huge amount of variation, down to patient level, around variation in access, variation in cardiovascular disease, respiratory disease, et cetera. So, we're also creating a picture of how boards are tackling—how they're utilising their current resources to try and tackle some of those needs as well.

And then the final piece is we are increasing our measurement of outcomes in a number of key areas. We are the only UK country now part of the OECD study called the PaRIS study, which is trying to measure outcomes in primary care. There are no agreed internationally validated outcomes for primary care. And obviously, as we're starting to shift these resources, we want to see that they're very visible in terms of people and services. The more important bit is evidencing that they are actually driving better outcomes. We all believe they will, but we need to make sure that we measure it.

I would hope, as we get into the measurement, it will be much more of a persuasive argument, I guess, for any board to think about: if you can drive far better outcomes out of hospital, why would you be providing lesser outcomes in a hospital service that are better delivered out there? So, we've got to increase the scale, I think, of some of our measurement of outcomes outside the hospital setting. There's a huge amount of outcome measurements within hospital.

The other bit that I think is proving really interesting is those boards that have taken outcomes that matter to patients. Where they've applied some of the more universally validated outcomes measurements, PROMs, what it's showing us is big issues around equality and inequalities in terms of access to services between communities. I think that's really important for boards to start targeting that issue we see in things like perhaps lung cancer, Alzheimer's, which is that late presentation in some communities is a real issue around inequality. It's something really for boards to target in terms of services out of hospital and access to primary care.


And do you think the board's driving that or the clusters? I know they're part of the board. At what level would you see that sort of ambition for trying to target neatly to reflect a local population?

Part of the point about having clusters is their understanding of their local population and wanting to actually address local need. So, it's not simply one or the other, because the board has got the whole-population responsibility. So, they can't say, 'We divest ourselves of our responsibility for the differing level of need within the organisation.' Healthcare inequalities are an essential part of the 'A Healthier Wales' plan and actually actively addressing those.

Okay. I just wanted to ask a quick question on primary care—well, on capital funding. In your evidence paper, you say:

'As well as schemes within the acute sector, the capital budget includes the third tranche of the
£72m over three years to deliver a pipeline of primary and community care projects...This pipeline will see 19 projects across Wales being delivered by 2021.'

First of all, would it be possible to have a bit more detail on those 19 projects? And secondly, is this also where—. For example, a GP surgery that wants to deliver this broader brush of support in the community—whether it's more occupational therapists, having social care bedded in with them, perhaps a chemist—is this where they can go to have improvements to surgeries? Because one of the things that I see around Wales, and particularly in my patch, is an awful lot of old buildings. You've got frustrated GPs who'd like to offer more of this integrated community service, but they simply do not have the buildings to do it. So is this the budget that would look at that?

Yes, partly. I've already announced the 19 projects, and I'd be happy to update the committee on the stage of each of those. You're right, in each of those, we're looking to remodel; it's not just about providing a new building just to provide a general practice in, but to think again about what are the opportunities to reshape what's there. We've had some really good examples with a range of partners. So, in Mountain Ash, for example, the local authority is getting on board as well with the health board and looking at how that new service could work for the local authority and the services they want to provide, as well as a general practice. So, there's a deliberate look at trying to bring different services together and understand how they support each other.

And of course, where those services are sited matters as well in terms of local access. Having something in or near a town centre can make a difference for lots of people, and more broadly about the town itself and a sense of place, as well as people's practical access to it as well. I do know that the 19 areas we've invested in—you'll see a real difference in each of those, and if you got to see some of them, you'd find people are very happy. I'm due to go and open some of them formally.

But we also know that that doesn't resolve the whole picture. There's a deliberate need to move ahead with what's the next stage of reshaping the estate in primary care. And there are some difficult questions there where people own buildings themselves, where retired partners own buildings, and that's part of the challenge. Again, in terms of a phrase I've heard used, it's about 'de-risking' primary care for people who work in it, so that it's more sustainable, and making sure that we still have a bargain between the state, the taxpayer, the people who need the service and the people delivering it. Resolving some of the issues around the estate is part of that as well.

So, in the next stage, after this programme has finished, we'll need to look again at what's the next stage, and look to see what we can do to reshape the estate to deliver better care in it that's more sustainable and provides somewhere where our doctors and other healthcare professionals want to work.


Okay. Last quick question, and it'll be a very quick answer, I'm sure. The joint executive team process: the Wales Audit Office suggested that the health boards should report annually on their progress in shifting resources towards primary care. I appreciate the Wales Audit Office report was in October 2019, but when would you hope to have the first of those reports that could then be scrutinised?

We are making it a requirement, and obviously we've been doing that for quite a while. I think, when we do the joint executive process, we really start with population health and prevention and work our way back, interestingly enough, to some of the more specific performance issues that tend to be around hospital services. We are now starting to capture that. What we can do is, I guess, write separately to you, if you want, and just give you an update on that and where we are and the next steps of development.

Yes, we'd just like to know when the first reports might start being produced, so we can scrutinise them in committee. 

Just a final point from me from the Chair, because we've had several representations. In terms of outcomes that matter to patients, and Mr Brace's contribution earlier, I mean, obviously high-level stuff is important, lung cancer and stuff, but also fairly low-level stuff is important, like ear wax removal. It's not sexy, nobody dies, but lots of people are deaf. That was largely a primary care activity; now it doesn't seem to be. Increasingly, people are on secondary care waiting lists or going for expensive private ear wax removal. Is there some sort of issue to handling that situation, if we're saying more things—and they should—should happen in the community? Because that's not a secondary care activity, but increasingly it is, or it's private. Are we tackling that sort of situation as well, in terms of outcomes that matter to patients?

I think, honestly, ear wax management services are a challenge, because I do know that in different parts of the country there's been a retreat from primary care in providing those. That's largely due to some concern about methods of removal and potential claims. So, people have said that they don't want to do it; they don't want to provide that service locally. They're not absolutely required to within the contract, and so people are then being bounced from primary care to secondary care, and that's both waits and also just a potential inconvenience.

We've also got some development work using parts of the audiology profession. Actually, in your part of the world, in Clydach, they've been trialling it and they're really positive about it as well. It has a direct impact on people's quality of life, because you're right that it doesn't end someone's life, but if you can't hear properly it has a really big impact on it, particularly if it's something that is normally relatively easy to do in terms of removing it.

So, I've already committed to having a look again at where we are on ear wax management and to look at what that means across the country and the varying picture, trying to get a more coherent answer. I can say that as someone who occasionally has had to use the service myself, so I know exactly about the level of inconvenience that people are undergoing.

Thank you. There are quite big questions around resourcing, obviously, here. We've had lots of reviews and commissions and we've been talking about the interface between health and social care for pretty much as long as any of us can remember. And I think that there are a lot of people, not just in this room, who are frustrated about, despite attempts, the lack of progress. We know that things like some of the winter pressures stuff get much worse because people can't get out of hospital into appropriate care.

Do we have a timeline as to when—? We've had some discussions as well with the Minister last year about trying to look, moving to the 2021 election, if there are ways in which we can develop some sort of cross-party consensus around what might a way forward be. Can you tell us today when you are likely to be in a position to come up with a suggested way forward?

Additionally to that, do we have the right evidence base about what future care needs are likely to be? Because, obviously, any changes to the system need to be predicated—especially long-term changes—on the best evidence we can have about what future demand is likely to be like. Because I'd certainly suggest, Chair, that we are never going to crack the pressures on the health service if we don't crack this. Nobody's saying, of course, that it's easy; because if it was easy we'd have done it long ago.

Three things. The first is, I hoping to be in a position to have this conversation in more detail before the end of the last calendar year, but there was another event that got in the way of some of that, and things rather got paused. The second is that I expect to make a statement within the coming weeks, I'm not sure if it's in the business statement yet, but I will be making a statement in the Chamber. And the third thing is that, yes, ahead of that, I do want to share some of those points about, not just options for the finance side of it, but options to look at what 'better' could look like.

And what I want to offer, Chair, is the opportunity for the committee to have a technical briefing with officials around what's in that as well. Because I think that there's a really important point that, being grown-ups, the gap is narrowing for us to have an honest conversation with each other about the competing demands of promises on expenditure, how that's raised and what that means in terms of delivering care. And none of us should expect that there's going to be a Green Paper any time soon from the UK Government. Look, that's not going to happen, we've been waiting for that for a long time, so we shouldn't proceed on that basis.

And, if the UK Government delivers on its manifesto pledge and puts £1 billion into social care from the next financial year onwards, that will help; that will help a bit, but it won't actually deal with the pressures we've already seen. So, actually, I don't think that that's going to be the answer. And like I said, we will need to have a conversation over the next coming months, because then I think the window will close fairly quickly. So, yes, I'll be making a statement, and I'm happy to offer a technical briefing and I'll get my officials to meet the Chair to see how that could work for every member of the committee to attend and take part in that, together with a statement as well.


That's encouraging. I think you're right about the window and not wanting the window to close before we can be co-operative about these issues. If I can turn now to some of the things that the Government's trying to do to address some of this, short term, and take a bit of a look at the integrated care fund. Albert Heaney has already referred to the Wales Audit Office report and said that that was helpful. Just to remind us of some of the things that the report said: it said that there was little sign of successful projects being mainstreamed, which is of course crucial, and that its overall impact on improving outcomes for service users wasn't clear. So, you're investing a further £130 million in the integrated care fund—and nobody would be asking you not to do that, least of all me—but what contribution is the short-term funding making to local and regional projects and to scaling those up where they are proved to work?

Yes, I think we did find the WAO report very useful, and I think what it did highlight so strongly was the development in partnership working. I think that has been really a transformation in terms of the way that projects have been developed, because they've been done jointly. So, I think that's one of the really important things about the ICF fund.

We have got a lot of examples of how projects have developed and then have been scaled up to operate across a region. For example, the Stay Well at Home project in Cwm Taf, which, following a great deal of success under the ICF, now operates across the whole region. So, there are examples, certainly, of that in the ICF funding. But, obviously, we need more of the development of the scaling up. 

In terms of evaluation, it is evaluated at a local level; there is evaluation. I'm publishing, tomorrow, an annual report of the ICF funding that will give an opportunity to have a look at it as a whole. And I would've said that, really, it has been very successful in developing initiatives.

That's positive to hear. So, it's been successful in developing initiatives and you've seen some upscaling at regional level. How will you use resources to drive that upscaling to national level, where that's appropriate? It won't always be, of course, there'll be some initiatives that are, let's say, particularly to respond to particular issues in a rural community that wouldn't be useful in a more urban one. But, are you beginning to see that progress towards national upscaling?

I think we do see this funding as not an end in itself, but as something that can be used as a lever to develop on a national level. I think we're at the early stages, to be absolutely honest, but I think that we are moving towards that and we are using it as a lever to make that happen. I don't know if you wanted to add anything to that, Albert, do you?


Yes. Thank you, Minister. I think it's something that we're very mindful of. The first challenge is how we get mainstreaming, and we believe that with some of the services now the evidence is there across Wales to say that they should become mainstream in how we do business in Wales and what good practice looks like. So, there's learning. But the challenge around that, sometimes, is how you get into what is the £9 billion funding across the system, rather than perhaps a smaller fund of money, but a significant fund of money that has allowed the demonstration of what 'good' looks like.

In terms of national, we're beginning to see some of the issues beginning to be discussed across the regions, and what we're aiming to do is use a couple of things: one is the local communities of practice, so that practitioners, clinicians and colleagues are really at the heart of those developments, but then spread that out into the national learning events. One of the things that we then want to see with that national learning work that Ministers have asked officials to do with regional partnership boards is then to really focus, going forward, on thinking about the last part of this Government term and potentially moving forward with ICF and what should its focus be in delivering, then, at a national level, some of those things that we know absolutely work. 

The other thing I would say is perhaps in Wales, sometimes, we unfortunately wish to call a similar thing by a different title. There really is a great deal of commonness in terms of approaches, but often they're labelled as something different in different areas, and perhaps we need to examine that at the heart of what we do as well.

Given that that is the case, that makes it very difficult for us to do our scrutiny job, because if it is the same in different places, we ought to be calling it roughly the same thing. Or perhaps they can call it different things locally if they like, but then you put it under some kind of national heading that says, 'These are all about dealing with delayed transfers of care', or whatever it is.

Can you tell us a little bit more about how the integrated care fund, specifically, is aligning with other short-term funding streams, like the transformation fund, like the sustainable social services third sector grant? I think Lynne wants to ask some more about that. How are you ensuring that there isn't duplication in the way that short-term funding streams are used? I think it's been very helpful—and the Minister was very clear again yesterday—about the transformation fund, 'This is short-term funding and it's to deliver that transformation.' So, how are you making sure that the funds are complementary to each other and are not delivering duplication?

Well, they are complementary in nature and they're all focused on creating integrated seamless services that are preventative in nature and that will deliver better outcomes for service users. They are complementary to each other, but each one has its own unique component. The ICF was initially designed to support new models of delivery, the transformation fund is focusing on accelerating and upscaling transformational models and approaches, and the social services grant is specifically focused on supporting the third sector to play, as we all know, its very valuable role in delivering health and social care in the wider system. Obviously, I know from your background as well, we all know the importance of the third sector, which is why we've been very pleased to increase the amount of funding that we've been able to give to that grant, but I would also say that we could have filled it twice over in terms of the quality of the applications and the projects that we had.

Yes. I wanted to raise this, as I did in the Chamber yesterday, the Government paper says that the funded schemes under the sustainable social services scheme will support carers, children, young people, physical and sensory disabilities, learning disabilities and older people. I raised with you last week in children's committee the cut to funding for Adoption UK, and I was grateful for your assurances that you would look at that. But Wales Council of the Blind have also had their funding stopped and the Learning Disability Helpline. I understand that Disability Wales and Wales Council for Deaf People have also had their funding cut under the programme. At least three of those organisations haven't even had replies off the Welsh Government to the letters that they've sent. I mean, you've sat on committees with me, Minister, here and in the children's committee, and you've heard the really valuable role that third sector organisations are playing, often having many, many referrals from social services and health boards—none of which are contributing to their funding. I mean, this is something that we really need to look at, isn't it, really? Because as far as I can see, third sector funding is anything but sustainable. 


I absolutely agree with you about the importance of the third sector and the importance of this grant, and I can assure you the Government is totally committed to the third sector, but the sum is finite, and that is the problem. We had, as I say, double the number of valuable applications that we could have filled. We have been able to increase the grant. It stands at £21 million, but it's going up to £25.9 million over the next three years, which shows the commitment of the Government to this sector. This year, there will be a £1.2 million rise.

But in terms of the number of applications, it's obviously very difficult to actually choose the ones that are actually going to have the grant, and I think that is a very difficult task for the Government to do. But we are very aware that there are implications for those that don't have the grant. I mean, when we talk about their funding being cut, of course, the funding was only granted for a certain period of time. And so, we're looking at each organisation that has not been successful; they will all be offered interviews to discuss it. I assured you about After Adoption Wales at the children's committee, and I can assure you that these organisations will all have an interview with our officials to discuss their position and the implications.

But, obviously, I just have to reiterate that it's a finite sum of money. But I hope you do accept that the fact that we've been able to raise this money does mean that our commitment to the third sector—because I know what they bring is absolutely invaluable. Having worked in the third sector for many years myself, I can't emphasise how important it is, and I'm committed to getting as much help as we possibly can for the third sector. 

Okay. Some agility is required now, because time is pressing. Now, the queen of agility today is Helen Mary. Some agility in the answers would be good as well. Helen Mary.