Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

02/07/2020

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Dai Lloyd MS Cadeirydd y Pwyllgor
Committee Chair
David Rees MS
Jayne Bryant MS
Lynne Neagle MS
Rhun ap Iorwerth MS

Y rhai eraill a oedd yn bresennol

Others in Attendance

Alice Jones Rheolwr Polisi a Materion Cyhoeddus Cymru, Coleg Brenhinol y Llawafeddygon
Policy and Public Affairs Manager Wales, Royal College of Surgeons
David Johnson Cadeirydd Pwyllgor Deintyddiaeth Gymunedol Cymru, Cymdeithas Ddeintyddol Prydain
Chair of the Wales Committee for Community Dentistry, British Dental Association
Dr David Bailey Cadeirydd Cyngor BMA Cymru
Chair, BMA Welsh Council
Dr Phil Banfield Cadeirydd Pwyllgor yr Ymgynghorwyr, BMA Cymru
Chair, Consultants Committee, BMA Cymru Wales
Lauren Harrhy Dirprwy Gadeirydd Ymarfer Deintyddol Cyffredinol Cymru, Cymdeithas Ddeintyddol Prydain
Deputy Chair of Welsh General Dental Practice Committee, British Dental Association
Richard Johnson Cyfarwyddwr Coleg Brenhinol y Llawfeddygon, Cymru
Royal College of Surgeons, Director in Wales
Tom Bysouth Cadeirydd Pwyllgor Ymarfer Deintyddol Cyffredinol Cymru, Cymdeithas Ddeintyddol Prydain
Chair of Welsh General Dental Practice Committee, British Dental Association

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Morris Ail Glerc
Second Clerk
Dr Paul Worthington Ymchwilydd
Researcher
Lowri Jones Dirprwy Glerc
Deputy Clerk
Rebekah James Ymchwilydd
Researcher
Sarah Beasley Clerc
Clerk

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

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

Cyfarfu'r pwyllgor drwy gynhadledd fideo.

Dechreuodd y cyfarfod am 09:30.

The committee met by video-conference.

The meeting began at 09:30. 

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

Croeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon, yma drwy gyfrwng fideogynadledda Zoom, am resymau sydd yn amlwg i bawb. Dyma natur ein cyfarfodydd ni'r dyddiau yma. O dan eitem 1, allaf groesawu fy nghyd-Aelodau o'r Senedd, yn y lle cyntaf, gan nodi ein bod ni wedi derbyn ymddiheuriadau oddi wrth Angela Burns, ac nid oes dirprwy ar ei rhan?

Allaf yn bellach esbonio bod y cyfarfod yma, yn naturiol, yn ddwyieithog? Mae'r gwasanaeth cyfieithu ar y pryd ar gael o'r Gymraeg i'r Saesneg. Ac, wrth gwrs, o ddefnyddio'r cyfleuster cyfieithu ar y pryd, mae yna rywfaint o oedi rhwng diwedd y cyfieithiad a'r siaradwr nesaf yn dod nôl i'w sain lawn. Felly, mae yna ryw bum eiliad pan fo pethau yn dawel iawn ar ôl i rywun fod yn siarad yn Gymraeg.

Allaf yn bellach atgoffa pawb fod y meicroffonau'n cael eu rheoli'n ganolog? Byddwch yn derbyn neges ar y sgrin fod eich meicroffon yn cael ei droi ymlaen, a bydd angen ichi glicio i dderbyn hynna bob tro rydych chi'n dymuno siarad. Felly, cadwch eich llygaid ar y sgrin a bydd yn rhaid ichi glicio ar y lle penodol. Mae rheoli lefel y sain yn digwydd y tu ôl i'r llenni yn awtomatig. A hefyd, fel dwi wedi cyhoeddi o'r blaen, os bydd yna rywbeth yn digwydd i'm rhyngrwyd i yma yn Abertawe wyllt a bydd y band-eang yn mynd unwaith eto, rydym ni wedi cytuno y bydd Rhun ap Iorwerth yn gweithredu fel dirprwy Gadeirydd tra byddwn ni'n atgyweirio pa bynnag system fydd wedi mynd ar gyfeiliorn yn fan hyn.

Felly, gyda chymaint â hynna o ragymadrodd, dwi'n gofyn a oes yna unrhyw fuddiannau i'w datgan. Mae'n debyg, o weld y tystion sydd o'n blaenau, buasai'n well i fi ddatgan, hefyd, fy mod yn aelod o'r BMA. Oes yna unrhyw fuddiant arall gan rywun i'w ddatgan? Nac oes.

Welcome, everyone, to this latest meeting of the Health, Social Care and Sport Committee, via video-conferencing on the Zoom programme, for obvious reasons. This is the nature of our meetings these days. Under item 1, may I welcome my fellow Members of the Senedd, in the first instance, noting that we have received apologies from Angela Burns, and there are no substitutions on her behalf?

May I further explain that this meeting will, naturally, be held bilingually? An interpretation service is available from Welsh to English. And, of course, in using the interpretation facility, there is a slight delay between the end of the interpretation and the next speaker returning to full sound levels. So, there will be around a five-second delay after somebody has been contributing in Welsh.

May I remind everyone that the microphones are being controlled centrally? You may receive an on-screen message that your mike is being unmuted, and you will need to click to accept that every time that you wish to contribute. So, do keep an eye on the screen in case you do have to click to unmute your microphone. The sound levels are controlled behind the scenes automatically, as it were. And as I've announced previously, if anything should happen to my internet connection here in Swansea, in the wilds of Swansea, and the broadband should fail, then Rhun ap Iorwerth has already been decided as the deputy Chair while I try to reconnect and fix whatever fault there is in the system here.

So, with those few words of introduction, I ask whether there are any declarations of interest to be made. Seeing the current witnesses that we have in front of us, I should declare that I am a member of the British Medical Association myself. Are there any other declarations of interest to be made? I see that there are none.

2. COVID:19 - Sesiwn dystiolaeth gyda BMA Cymru a Choleg Brenhinol y Llawfeddygon
2. COVID-19: Evidence session with BMA Cymru Wales and the Royal College of Surgeons

Felly, rydym ni wedi cyrraedd eitem 2 ar ein hagenda, a pharhad ymchwiliad y pwyllgor yma mewn i ymateb y Llywodraeth a'n byrddau iechyd ni i'r pandemig COVID-19. O'n blaenau mae sesiwn dystiolaeth gyda BMA Cymru a Choleg Brenhinol y Llawfeddygon. Ac felly, i'r perwyl hwnnw, dwi'n falch iawn o groesawu i'r sgrin, fel petai, Richard Johnson, cyfarwyddwr Coleg Brenhinol y Llawfeddygon yma yng Nghymru; Alice Jones, rheolwr polisi a materion cyhoeddus yng Nghymru, Coleg Brenhinol y Llawfeddygon; Dr David Bailey, cadeirydd cyngor BMA Cymru; a Dr Phil Banfield, cadeirydd pwyllgor y meddygon ymgynghorol, BMA Cymru. Croeso i'r pedwar ohonoch chi. Diolch yn fawr iawn ichi am y dystiolaeth ysgrifenedig rydym ni wedi'i derbyn ymlaen llaw—bendigedig. Diolch am y trafodaethau rydych chi wedi'u cael efo nifer ohonom ni hefyd ymlaen llaw.

Mae gyda ni nifer helaeth o gwestiynau, ac wedyn mae yna ddigon o amser i fynd mewn i fanylder ar ba bynnag bwynt. Yn naturiol, mae gyda ni ryw awr, ond does dim rhaid i'r pedwar ohonoch chi ateb pob cwestiwn, os nad oes yn rhaid dweud rhywbeth yn ychwanegol. Felly, gyda chymaint â hynna o ragymadrodd, awn ni'n syth mewn i gwestiynau, ac mae cwestiynau'r sesiwn gyntaf yn olrhain y profiad o'r pandemig, PPE, a phrofi ac ati, o dan law Jayne Bryant. Jayne.

So, we have reached item 2 on our agenda this morning, and the continuation of our inquiry, as a committee, into the Government response and the response of our health boards to the COVID-19 pandemic. In front of us, we now have an evidence session with BMA Cymru Wales and the Royal College of Surgeons. And to that end, I'm very pleased to welcome to the screen, as it were, Richard Johnson, Royal College of Surgeons' director in Wales; Alice Jones, policy and public affairs manager Wales for the Royal College of Surgeons; Dr David Bailey, chair of the BMA Welsh council; and Dr Phil Banfield, chair of the consultants committee on behalf of BMA Cymru Wales. Welcome to the four of you. Thank you very much to all of you for the written evidence that you have submitted ahead of time—it was excellent. Thank you for the discussions that you've also had with a number of us ahead of this meeting.

We have a whole host of questions to ask you. There's plenty of time to go into detail on all of the points. We have about an hour or so, but not all four of you have to respond to every question, unless you wish to add anything on each point. So, with those few words of introduction, we'll go straight into questions, and the first questions on the experience of the coronavirus outbreak, PPE, and testing and so on, come from Jayne Bryant. Jayne.

Good morning. Your members have all been at the forefront and on the front line of dealing with the outbreak. What are their key messages from their experience throughout this time?

I think, generally speaking, things have improved throughout the course of the crisis. There were some issues on personal protective equipment at the start that appear to have been fully resolved. Welsh Government has been pretty good in terms of making contractual alterations to make life easier for various different branches of practice. I think that's worked reasonably well and that's just been renewed for another month.

People had been concerned early on about pressures on PPE and about management advice that it's not appropriate in all areas. I think the emerging evidence suggests that that advice earlier was incorrect and that we need to be a lot more careful in terms of protection, not necessarily for PPE, in non-clinical areas. I think that's something that we'll probably come back to later. But, certainly, the evidence is emerging that, because of large droplet transmission, we probably need to be a lot more careful in our hospitals, in our general practices, to make sure that we're not transmitting between staff away from the front line.

09:35

Okay. From the surgical side, Richard. You'll need to unmute.

I'd agree with that. I think part of the problem initially was the conflicting advice that was given about the use of PPE, and I think once that was clarified and there was more consistency in the approach, I think that's when the issues regarding PPE resolved to a certain extent. We did a survey of 160 members in Wales within the first few weeks of the pandemic and over 50 per cent were concerned about the supply of PPE and 35 per cent felt they didn't have adequate PPE at the time it was needed. But I'd agree with David that, since that time, and certainly with recent conversations, there have been no issues about the use of PPE and its supply.

And you feel confident going forward that those issues will, as much as we can, be resolved. 

I think so. I think that this is one of the concerns that we do have, that as we start doing more elective surgery and there's more routine diagnostics going on we would like to have an adequate supply of PPE, not just sort of running with what's there at the time. It needs to be there and be there consistently, going forward.

Yes. Can I just add two points? I think that, overwhelmingly and unusually, the profession has had a sense that it's been listened to. At the points at which we've said, 'Here is the problem, please fix it', or, 'We need this', that is being provided. And the second point I really want to emphasise is just how fantastic the public have been. We could not have done this as a profession, got over this first wave of COVID, if the public in Wales had not made their massive contribution in staying away from hospitals and going along with the distancing guidelines in the way that we've put all sorts of restrictions on them. So, they have been brilliant. 

Thank you. Have you seen a difference across health boards in Wales?

Yes. I've had some conversations with surgeons across Wales and there has been quite a significant difference in interpretation—I think it's been said before—in how the management has interpreted the guidance. As I've said before, I think that's mainly because there's lots of different conflicting guidance, and the health board could argue that they were making their decisions based on supply rather than what was required.

I'd agree with a lot of that. There appeared to be more problems in terms of supply further away from Cardiff and the M4 corridor, in fairness, and there have also been differences in interpretation of looking at relative risks for members of staff as well. We've now got a Wales-wide risk tool that we're starting to use, which is whilst not perfect at least a reasonable thing and it's being applied nationally, which is an excellent thing, because that's still not happening in the other three countries. But there certainly has been a perception that, in some areas, people have been pressed to go into clinical areas where they're not as well protected, and indeed where some members of staff, as we now know, are significantly at higher risk, whether it be age, ethnicity or underlying medical conditions.

Just moving on to testing, how confident are your members about access to testing and what sort of barriers are there to overcome?

The difficulty here is the accuracy of the tests. With the antigen test, if you have a negative test, you've got a one in three chance that that's a false negative. So, that doesn't mean that you can then make the assumption that the asymptomatic patient hasn't got COVID and that's led to some discrepancies in the way that people have been treating patients subsequently. So, for example, it's been a requirement to have two negative antigen tests to be discharged back to a care home, and yet, we're putting our doctors and staff back on the front line without any testing, just after seven days of their symptoms and 48 hours of being better. So, those kinds of inconsistencies have been problematic.

From the point of view of the antibody test, there's an issue the other way round, in that about 20 per cent of the positive tests are false positives, and we don't really know whether that translates into whether someone's got immunity. We know there are at least three strains of the COVID-19 virus.

So, actually, how this testing fits into making the overall service safe is really difficult, and, therefore, that's why we really need to be cautious still, very much so, going forwards.

09:40

Yes, I would agree with everything that Phil has said. The antibody testing really is a population tool, and perhaps something to reassure people who had symptoms early in the pandemic that they have a degree of immunity, but doesn't really have any value in terms of active testing.

The big issue with testing, and there was some misinformation around this, because obviously if the test is positive, that's pretty reliable, but actually the false negative rate, as Phil says, is about 30 per cent, so you cannot rely on that. In some areas, the advice from the testing centres has been very good: they've said that if you've got ongoing symptoms, you need to continue to isolate for seven days or until your temperature's gone for 48 hours. There is increasing evidence now that we may need to bump that up to about 10 days. That's relatively recent, and certainly not at the beginning of the pandemic, but that seems to be the case.

But, certainly, any advice that you can go back in if your test is negative when you've still got symptoms, which was certainly being given out early on, is not correct, and we need to combine the testing—and obviously for test and trace that's vital. But in terms of advice to front-line staff, we still need to remember that if they've got classic symptoms, it's almost certainly not safe for them to go back for all of their colleagues.

I may defer to Richard, but I just wanted to add that we as a college have been calling for the testing of asymptomatic staff, and that's a key element of getting services up and running. Richard, I don't know if you want to add more.

Yes, I was going to pick up on the same point, because as we're doing more urgent elective-type surgery now, we are testing patients before they come in, three days before, to at least give us some confidence they're negative. But then they're walking into a hospital where none of the staff have been tested on the same basis. So, I think we're offering a dual standard in that—

—and we need some consistency with the testing policy. We're recommending that staff are tested probably once a week if they're working in that sort of environment, at a minimum.

Okay, Rhun, you've got a—. Sorry, Jayne, Rhun has got a supplementary; I'll come back to you then.

Thank you. Just on that point, actually, I've been contacted in my constituency by primary care, in particular, who are concerned that they would like to see asymptomatic testing of GPs, community nurses and all those working within our communities. Just to confirm, you think also, as a BMA, that that kind of asymptomatic testing across primary care plus also into domiciliary care, for example, would be valuable at this point.

And does it frustrate you, then, knowing that we have capacity for, in rough terms, 10,000 plus tests a day, that it's a fraction of that that's actually being used when this is one area where that capacity could be exploited?

Yes, the World Health Organization said right at the start of this it was about testing, testing, testing, and, actually, that remains the case, and probably is the way out for us in getting anywhere near resuming normal services, pending a vaccine.

Just on the back of what was said around test, trace and protect, what has the experience been so far of that, and do you think there's enough capacity to deliver a timely result?

Well, part of the problem is that there's still a delay of 24, 48 hours, and, as other people have said, there's the issue of asymptomatic spread. We're concerned, really, about information as well, and if we're doing all this testing, it would be very helpful to have some local data coming back to health services across Wales about what the sort of testing numbers are, because we know that there are variations. We've seen recently in Anglesey that there's a big issue. At the start, where I live in Gwent, we were very much the hotspot. More recently we've been told, but quite a long time in arrears, that we're seeing very little. So, it would be very useful to share anonymously real-time data so that people will be more alert. If you're seeing an increase in your area, you're going to be looking more carefully for those symptoms. If you know there's very little going on, it will change behaviour. So, I think that sort of information would be very useful.

09:45

Just from my recent personal experience with track and trace, we lost virtually most of our department in surgery in one area because a clinical member of staff tested positive and virtually everyone else, then, from the department had to leave, and there was no service for a week. I know the same thing's happened in Cumbria, I believe, in a paediatric area. So, I think we need to be extremely careful how we're using it, and I think it then comes down to appropriate use of PPE in secondary care areas and, I presume, primary care areas as well, to avoid this sort of thing happening.

This is not directly related to test and trace, but there does seem to be wide variation in the time taken to get test results back across Wales, and that's been a key area of concern for our members.

From a personal point of view, because I had the unfortunate experience of being swabbed a couple of weeks ago, I had a phone call within 24 hours to say my result was negative, because that was from an occupational health department, but I didn't get the text through from NHS Wales till over 24 hours later. So, even though the test was always there, and the result was available, I didn't get the formal result from NHS Wales for an extended period of time.

Thank you. Just moving on to issues around workforce now, obviously you're saying that your members have been on the front line of this from the very start. How have you seen them being able to cope and having the support to cope with potential stress and burn-out arising from pressures of the outbreak?

We'd obviously like to see more mental health support. A lot of people have been getting very stressed. I think, at the moment, people are running on adrenaline. They're still, particularly in the hospital areas where they're dealing with very acute patients, very much feeling that they're at the front line. But there will be a comedown. People have had leave cancelled or deferred, and I think it's important to make sure that people look after themselves afterwards. But we do need to have proper mental health support, counselling support, right the way across the board. There was a large shutdown, really, of mental health services at the start of all this, which probably was inappropriate, because all of a sudden primary and secondary care are seeing an increase not only amongst staff, but also obviously amongst the public. Lots of my patients are getting very, very anxious, very stressed, and it's been more and more difficult to actually access the sort of talking care that they need. So, I think we do need to be looking very carefully at what we're doing in terms of support for staff and for the members of the public, because this is a very high stress and unusual environment.

Yes, thanks. The workforce has been amazing in the flexibility that it has shown and its ability to plan for really some very serious scenarios. It's tolerated redeployment, and we've had surgeons learning how to look after patients with respiratory disease, for example. Most of the health boards have set up specific well-being services, but they've tended to staff those from psychologists drawn from other services who are in downtime while their services have been restricted. We've raised concerns before about a lack of occupational health services for the workforce in the NHS in Wales, and, of course, at the point at which all these other services get going again, there's a real risk that we drop an exhausted workforce into a black hole.

Lynne, you've got a supplementary. We'll come back to you then, David. Lynne Neagle.

Thanks, Chair. I wanted to ask about childcare once Jayne had finished. Had you finished, Jayne? 

09:50

We'll come back, then, Lynne, and we'll have David Bailey now. 

Yes, the other point I wanted just to make about redeployment is that I think we've been very flexible in the current workforce, if you like, but the redeployment early of medical students and the bringing back into the workforce of the retired hasn't worked so well. Medical students have agreed to graduate early and go to temporary jobs and, actually, they've lost out in the jobs market for the real start of their work in the NHS, and that's a real concern for Welsh students. And, obviously, a lot of people volunteered to come back from the retired workforce, and I think people have recognised more and more that bringing back a group of the most vulnerable people into the front line really didn't make that much sense and, actually, that we were managing with the remote treatment of patients reasonably well. 

So, I think that's worked less well, and I think a lot of doctors who've come back and a lot of medical students who volunteered to get to the front line early have not been best served right the way across the UK, in fairness, but certainly Cardiff med students have had a particular issue with the job market. 

Yes, it was just on that point, really, because I was going to ask about the recruiting and deploying of the returning staff and how effective that's been, especially as we'd heard about the amount of people who did put themselves forward who weren't actually taken up. Do you think there are other roles within the service? I know that there's a scheme going on with Cardiff University around supporting peer support for staff in terms of counselling services, or a listening service to staff who are on the front line or who are experiencing mental health issues following that. I just wonder if you think there are other ways to deploy those returning staff who've put themselves forward. 

I think, from a surgical perspective, getting a surgeon to come back after three years of retirement and come straight back and do front-line operating, I think, is not a sensible thing to do, but using those colleagues to do the non-clinical type of work—providing assessments, maybe some remote consultations and that sort of thing—is going to be helpful going forward, if they can be retained, to allow the practising surgeons now to get on with the clinical work to clear a lot of the backlog that's developing. 

Yes, just to say that that will be a very appropriate use of older returners because most of them have got very many years of experience and, of course, you can do this sort of counselling clinical work remotely, which doesn't put them at extra risk. So, yes, I think that is an appropriate suggestion. 

It's you. The floor is yours, or the screen is yours, should I say.

I thought I was muted. I just wanted to ask about childcare, because I'm getting some concerns from staff locally because there's no provision been made so far for childcare for NHS workers over the school holidays, and I wondered if you were picking that up from your members, really.  

Okay. Who wants to have a crack at that one? David. 

I'll pass the ball down to Phil shortly in terms of secondary care, but, in primary care, yes, there hasn't been an awful lot of provision. We are able to be much more flexible because, of course, what we have set up in place is the ability for GPs to consult remotely. So, actually, certainly in my practice and other practices in Gwent, where you have childcare issues, you can actually still provide a large chunk of the job, because we're doing 80 or 90 per cent of consultations remotely now from home, if you've got childcare issues. Not nearly so easy in secondary care, and I suspect Phil probably knows more about that than me.   

Yes, it's difficult, isn't it? We were fortunate during the peak for most of Wales that that corresponded with the Easter holidays, and the teachers very kindly helped out over the Easter holidays, and that's not going to be the case in the summer. I don't think we've addressed the issue on a pan-Wales basis. Some health boards have given some local childcare provision, but, unless they resolve this, this is going to be part of what affects whether we can get back to anything resembling normality. 

09:55

There's nothing been particularly raised, or concerns raised, by my members at the present time, but I'm sure the problem is there for them. 

Okay. Moving on to changes in service delivery now. Well, in these three sections there's a fair amount of overlap, really, but it's about changes in service delivery. David Rees, you can kick off. 

Thank you, Chair. Good morning, all. I suppose, in a sense, it's about the experiences of your members in the service changes, because we've obviously gone to a situation where there is far more non-face-to-face contact. And, as you quite rightly pointed out in some of your earlier answers, there are individuals who are doing the clinical and individuals who are doing perhaps some pre-clinical work. How do you see those services continuing under the current operations, with the new approaches?

I think the main thing that we're seeing, from a surgical perspective, is the remote consultations and video consultations to reduce the number of patients having to come into hospital. And I think it's something that a lot of my members would definitely want to continue. I think, on that point, this is something that we've been talking about for a long time. And I think one of the benefits of the pandemic is that we've been allowed to bring changes in quite quickly that people have considered as an appropriate way forward. And I think the vast majority of the things that have been tried have worked, and I would hope that, once the pandemic's over, these changes that people have can be brought in at the same sort of rate as we have done this time, rather than having to go through the normal committees and project groups that seem to slow everything down and then people lose interest and they don't happen. 

Yes, I would agree very much. In primary care, we made a transition incredibly quickly really, in a matter of days, from almost entirely face to face to almost entirely remote. The sexy thing is talking about video consultation but, actually, in reality, most of it is telephone consultation, because that's easier and quicker. But there have been some very useful additions to that in terms of being able to transmit documents, sick notes, advice notes to the patient, and for patients to be able to send high-quality photographs from their phone to the doctor to enable them to do a lot of remote diagnosis.

We're still doing face to face. That's going up gradually, literally week on week. In my practice, we're seeing 15 or 20 patients every day face to face, and maybe 150, 200 remotely. That proportion I think will continue to go up, because we've been managing people and trying to just see how things go. But we're getting to a stage, more and more, where people need to be seen, need to have examinations.

I think there was a false start, really, in terms of having red hubs and green hubs, for all of the reasons that have been said earlier—that you can't actually make that distinction particularly when there's a lot of circulating virus. It's easier now because we know that circulating numbers are less. We're asking screening questions when we see people locally. But, actually, most of the local face-to-face stuff is for stuff that has nothing to do with COVID. We know more and more now that most of the people who need interventions need interventions very quickly.

So, actually, what we're doing now is trying to return to a new normal, and I think there's absolutely no doubt that the way that primary care delivers service will change. I think a lot of patients have seen how much more convenient it is for them in their working lives to be able to have remote consultations, and, in many cases, that's perfectly safe. Stuff that you think you'd need to see someone face to face for, particularly home blood pressure monitoring, with the use of oxygen work, obviously still needs some support from phlebotomy, but certainly an awful lot of care can be done still remotely. I think the big issues really are around assessment of children. I think very few of us are very comfortable about assessing acutely unwell children anything other than face to face. But an awful lot of the routine stuff can be done more conveniently, for both sides, if you like.

The other point that I think is just worth making is that a safe consultation remotely is not quicker but it's slower, because everybody has to safety net more carefully when you don't have the advantage of all the physical cues and actually the ability to lay hands on people, use a stethoscope. So, it's not an easy option; it's a more difficult option. But it's one that we're adapting to, and I think it's one that patients will want to see continued as we return to normal.

10:00

Yes, I think it's important to realise that this is going to be another tool, rather than a substitution. There are groups of people who find this difficult and intimidating—people with disabilities, et cetera. I was talking to the cancer specialist and palliative care yesterday, and they were saying that their morning clinics are finishing at two o'clock, sometimes five o'clock in the afternoon, because it just takes so much more time to make sure that you've got it right when you're not face-to-face.

Rhun, you've got a supplementary. I'll come back to you then, David Rees. Rhun.

The mute button; there it is. Too busy thinking. This is something I've discussed with the Royal College of General Practitioners, actually. Some people face barriers to engaging with remote working, be it through technology or just generally being uncomfortable with it. Do you think that there's the potential for developing a new role within healthcare—a new job—which would be a conduit, if you like, between the doctor and the patient, somebody who can take the technology to somebody's home using mobile technology, taking the screen through which the patient can speak with a doctor, and maybe doing tasks—a technician kind of job, doing a task like taking blood pressure, for example, but the responsibility for the consultation is with the GP?

Yes, I think there's something around that. We're already having consultations with British Sign Language translators remotely. The issue will be workforce, I guess. There's been a lot of volunteering going on through the pandemic, but those volunteers, fairly shortly, I suspect, will want to go back to work. And I hope that what we will be able to do is that, the people who are disadvantaged by this, we'll be able to start seeing them more face-to-face. When incidence is running down—. A lot of the people who are at a disadvantage are the elderly; they're actually probably a lower risk to staff than people who are out working, because they've been very religiously looking after themselves, being careful, self-isolating, and, actually, I think we could probably be seeing more of them face-to-face. I think it is a good idea if the staff will be there. I think, once you start delivering clinical measurements and stuff, you have to ask yourself whether we shouldn't be seeing them in the surgery anyway, frankly. But, in terms of bringing the technology to the more disadvantaged, I think it's a great idea, if it could work. On a small level—translation services, things like that—it is already being done and already working quite well. We've got a couple of profoundly deaf patients, and they've had a British Sign Language translator actually sitting in the room with them so that we can still have a consultation. That actually worked quite well. But it is very labour intensive.

Great. David Rees next, and then we'll come to you then, Richard.

I was going to ask, actually, the Royal College of Surgeons a question on similar lines, because—. The question we hear sometimes is—. We've talked about primary care, and I understand what David Bailey is saying about the primary care agenda, because there are different needs and you have to have that feel and experience of the individual. But in the surgery waits of long-term illness and other conditions and recovery period, do you think that the ability to have more video-conferencing and video links is going to be more of a permanent feature? Because not every time do you have to come in to a hospital environment. So, I just wondered whether RCS will think about how their follow-up practices, in particular, will be pursued.

I would entirely agree with that. I think we will be using the video-conferencing more frequently, particularly in the post-op patients. In one respect, you can screen the patients that you need to see. I think the issue we have, trying to see patients in hospital, is the actual number of patients you can see in a clinic is significantly reduced from what you could see before, because of social distancing and longer out-patient appointments to allow for the cleaning and the infection control procedures we need to go through. And I think, in one respect, we probably do follow-up too many patients, and I think this is a good way of trying to resolve that issue, because I think, for a lot of patients coming back to hospital for a post-op consultation, it can be relatively quick and they're often wondering why they've actually gone there in the first place.

I was just going to agree with that. One of the things that we've stopped doing in secondary care is following people up and therefore having an accurate view of what our outcomes really are. This kind of technology will allow secondary care to keep track and to know whether it's doing good or harm.

10:05

I was just going to flag that we as a college have, just this week, actually, published a toolkit for surgeons on holding virtual consultations. That's one of the bits of guidance we've released. 

We've talked about your members and the practice with healthcare professionals. I'm assuming patients are also fully behind this new approach and see this sometimes as a better way of perhaps having to avoid coming into hospital, in one sense, or having to avoid attending?

Yes. It is very common for a patient to have a question that they think is a really trivial, stupid question and they won't come to hospital to ask it, but they will get in touch with a secretary and say, 'Can you just have the consultant talk to me and then that will put my mind at rest?' So, I'm seeing a lot more—. I'm an obstetrician, for background, so I'm getting a lot of those kinds of queries, and our ability then to allay fear is enhanced by not having to drag patients into hospital.

Just a final point from me: we've heard already as well, from some of the others, that one of the problems has been supply of medicines. We are talking about patients and treatment, but the supply of medicines has been an issue; it's been a pinch point. Have you experienced other pinch points, such as supply of medicines, and difficulties during this period? I'll take PPE out of this, because we all understand the issues on PPE. 

Yes. There have been a lot of issues, but there are very few unique drugs out there. Even in anaesthetics, where there are some significant supply problems, people have actually adapted and the only pressure on that, really, has been that it's taken time. There are a number of drugs in primary care that we can't access at the moment. There are always alternatives that you can use, but all the time you're spending talking to pharmacists, seeing what they can actually get hold of and discussing with patients how you can adjust things to come to much the same result, is taking time out, and the supply issues have been a real problem. I'm not sure that that's entirely COVID-related; there have been a lot of issues around, particularly, generic supplies that have predated the crisis by some time and are continuing to happen. And they don't seem to be amenable to Government control, if you like; they're a law unto themselves. 

Yes. Richard, and then Lynne's got a supplementary.

Yes. I would support what David said. I think—he said about the issue about anaesthetics, which, I think, has been allayed by the fact we've had a significant reduction in our operating. So, I think it's helped support that in one respect, but probably for the wrong reasons. 

Thank you, Chair. We're likely now, it looks, to have a 'no deal' Brexit at the end of the year. I was just wondering how concerned you were about the impact of that on drug supplies on top of what we're already facing.

We won't go too far into this particular can of worms, but Philip Banfield. 

I was merely going to point out it was a can of worms. [Laughter.] The profession just has a complete non-understanding of Brexit and worries about what its effects will be for patients and the NHS. 

Can I just close down on that point? Just a closing point, because Lynne's highlighted an issue of, obviously, future availability, and we saw yesterday the US buying out, basically, the global supply of a particular drug. David, you indicated that it's adding more time—to actually identify alternatives. Is this a real worry you're facing? Because if there are going to be situations like this, it is meaning that you will have to look at alternatives very much more carefully. Is that a deep worry you have in the profession?

It certainly is, yes. There are significant problems in the supply line in the future and we're seeing America buying up all of the new biological drug. We've been told that we've got enough supplies. That sort of scenario's not going to get any less. We heard the point earlier that a hard Brexit is not going to help; it will have significant extra effects on the supply of drugs, so that is a real concern for us, keeping away from the wider politics of it, but that particular issue is a definite concern. And what we really need, I think, is probably a UK approach to what's happening at the moment, where we are very much at the mercy of various different drug suppliers in terms—. And the issue of drug supply predates the crisis; we get notification through every month that x, y and z drug are not available, and we know that the main reason for that is not that there are none there, it's that it's being stockpiled somewhere for manufacturing reasons or to try and sell it to the highest bidder, and that's not going to be getting any easier next year.

10:10

Indeed. Philip, you're still in this worm-filled can.

Yes, well, we need to retain as much science as we can in all of this, and I think it's worth just reiterating that, as far as remdesivir is concerned, it shortens the duration of the illness; there's no evidence that it saves lives. Dexamethasone, on the other hand—there's some evidence that it saves lives. It's cheap and it's available for us in the UK.

Moving on, we're into, well, developing these themes. Rhun is going to talk more about backlogs and demand management of that, and going forward. Rhun.

Do you have a sense of the extent of the backlog in terms of demand that has been accumulating over this pandemic period, including both on waiting lists—people waiting for diagnosis or treatment—or those waiting for rehabilitation?

Surgical first, I suppose. Richard. And then we'll come to Alice.

I think, at the start of the pandemic, the college were very supportive of stopping elective activity in order to allow hospitals to prepare, and I think that was exactly the right decision to make. Even though it's been very easy to stop services, surgical services, it's proving a lot more difficult to get things back up and running. I've got some evidence from Cancer Research UK that there are something like roughly 14,000 reduced urgent referrals from general practice into secondary care, and then, March and April of this year, there were 21,200 fewer surgical and maternity cases being treated compared to this time last year. So, I think we've got two waiting lists: there's the extensive waiting list that was there before the pandemic, and there's that waiting list that we don't actually know about yet, and this is potentially going to take a long time to get through and get it sorted out.

Just to add on that—we don't know, unless we compare year-on-year trends in terms of the actual numbers we're talking about. We have—. Because referral-to-treatment times stopped being collected in January of this year. So, we have been working with Welsh Government to try and get some modelling on projections on backlog, and that's something that we are quite keen to see.

Yes. On a wider point, really, clearly there's going to be at least a three-month lengthening of every routine waiting list, because we've stopped that. And, as Richard said, that was an appropriate decision, but the fact is that that's happened, and that three-month backlog will be there. We've seen fewer referrals. We, very sensibly, in Wales kept on doing referrals and holding those waiting lists at hospitals, but all of us have seen a significant reduction in demand for the non-COVID stuff, which will almost certainly start to peak and come back after people feel a bit safer, so there's absolutely no doubt that it's going to extend waiting lists.

What we would say is—we talked earlier about referral-to-treatment times—we do need to start having a concept now of clinical need, really. We need to be dealing with the more serious, the more life—not limiting, but life-altering conditions: hip replacements, knee replacements, that sort of thing. So, we do need to have more clinical input into how we manage this waiting list, because, inevitably, it is going to have gone up four or five months in the course of the pandemic, and we can't continue just to let it increase the size of the tail. We've got to start prioritising people a little bit more on clinical grounds, rather than on numbers. So, I think, at the moment, we really do need to be looking at who needs to be seen first, not who's been waiting the longest.

I'd support that, and the college has produced guidance on prioritisation and the length of time that people should wait. I think the waiting time—. I worry that the three-to-five month estimate is probably a gross underestimate, because I think patients are concerned about coming in, and they're going to be treating maybe painful conditions, but the non-life changing conditions, so like joint replacements, they could go on for a long, long time before they get treatment, because we haven't got any capacity to do that at the moment.

10:15

I've got three points. Firstly, that patients have been staying away from hospitals—some of that's appropriate, some of that's inappropriate and is leading to harm. The second, as far as the cancers are concerned, we really haven't got a feel for who's become harmed by the decisions that have had to be made, so some people on systemic cancer therapy have had some discussions about whether to continue that, they've been kept on that for longer than perhaps they would have been if they'd been having surgery, and we had raised concerns about access to cancer surgery and the shortage of beds and ITU beds before we came into the COVID. So, trying to work out exactly where that sits becomes one of the priorities.

But, we're in a situation where, at the point at which the height of the COVID first wave was coming about, we had some very tough discussions about how to triage patients. So, not just about who was clinically most urgent, but who would have the most benefit. And while we've got restricted capacity in the NHS as we get back into some form of normality, that kind of triage approach will still need to take place. 

Government say they don't know the extent of the impact of lost cancer services, for example. Do you have an idea? Should Welsh Government have been able to audit carefully what the likely impact is of all these lost months of treatment and people staying away for reasons that are appropriate in some cases, and inappropriate in others? Dr Johnson.

I think, from the cancer perspective, it's very difficult to say, because that's not something that we're going to potentially find out for a couple of years. I think the concern is that the patients, the people who are going to suffer the most are the younger ones who potentially are not seen as the actual priorities. I think we could be sitting on a bit of a time bomb going forward, but it's difficult to say what that's going to be.

Purely from a capacity point of view, we're still operating at the present time initially trying to do cases in COVID-lite sites, which is something that the college is pushing quite strongly with the Government to try and separate COVID treatment from non-COVID treatment. Initially, I would say that we're losing between 40 and 50 per cent of our operating capacity, because of the increased turnaround times because of infection control procedures, and it's the same in clinics. So, even if we turned everything back on that was there before, we still won't have the same—we won't have the equivalent capacity. So, we need to generate more capacity to allow us to treat the patients who are waiting.

Yes. Just following on from what Richard said, the establishment of these COVID-lite sites is really key for surgical services and wider services in Wales, and we have real concerns at the moment, both about the pace at which they're being established and the way that they're being established. It's really important that they are established on a regional basis across Wales, and there's a real risk that some patients aren't going to be able to access some surgical services in some parts of Wales, and we're going to end up with a postcode lottery. Richard, I don't know if you want to add anymore on that.

We've been working very closely with Welsh Government to try and push the issue of COVID-lite sites, and I think there's a general agreement that these are the way forward for the time being to deal with COVID and winter pressures as well. Unfortunately, it's not happening at ground level, and as Alice said, some health boards are more advanced with their plans to create green zones, and as she says, there's an inequity of access, and, along with the Academy of Medical Royal Colleges, I've written to the chief executive, Andrew Goodall, today, highlighting this concern and the need to develop COVID-lite sites as soon as possible. 

I'll just touch on the COVID-lite sites because, of course, one of our worries over the last number of years is the way that services have been attempted to be reconfigured, and one of our concerns about having COVID-lite sites is that health boards use the concept to reconfigure services without engagement or consultation with the local staff or the population. It's been a very good exercise in bypassing normal ways of making sure that things are done in proper order. 

But, to answer the question directly—should Welsh Government have been able to tell us—the short answer is 'yes', but useful clinical data in the NHS is appallingly scarce. But, you know, we went into this under-resourced, under-staffed, and we've directed all of our resources at getting through this COVID wave. So, was it inevitable that they won't have the data? Yes. Their priorities have been elsewhere.

10:20

I think a more central point that Rhun was probably alluding to initially was that we do have historic data and it's almost certain that the presentation of cancers and things has gone down at the moment. There's absolutely no biological reason to assume that that's a real reduction; it is almost certainly a reduction in reporting and diagnosis. So, we do need to look at historic data and just publish to the health service and to patients where the gap is compared to last year and the year before, so that we have some idea about the capacity we need.

I agree with my colleagues in terms of COVID-lite sites—that will be a solution up to a point in terms of cancer care, but in terms of wider return-to-normal work, we need more capacity. We've been reducing beds year-on-year for about a decade now in Wales, and I'm afraid those chickens are very much coming home to roost now. We do need to be building actual estate capacity to be able to deliver services. Whilst we've still got the same staff afterwards, the differences in the way we have to deliver services are going to mean that we are going to need more space to be able to deliver the same levels of care, notwithstanding the obvious backlog that is going to come forward once we start to see things returning to normal.

So, we need more estate, and we do need to get some historic data, because there's no reason to think that overall cancer incidences have changed significantly since last year. So, we need to be planning for that, we need to be planning for that bulge, a second wave of non-COVID issues, really, and we need to be able to deal with it.

I know that Lynne's got some questions on restoring routine healthcare, but on one point in particular to Richard Johnson, because I know you've got strong feelings on this: we talk about COVID-lite, which isn't quite a green space, because you can't be absolutely clear that there's no COVID in it, but you're pretty sure—explain to us how important it is for it to be a COVID-lite site for you to be able to conduct surgery within it, taking into consideration some of the data that we're seeing on mortality rates for people who do contract the virus in a post-operative scenario.

There's some emerging evidence that's been published recently that shows that patients who develop COVID in the peri-operative period of before, during and after surgery have got a roughly 50 per cent chance of getting major pulmonary complications and a significant mortality from that. As we're approaching 40 per cent, the mortality overall in that group was around 24 per cent, and there's some evidence from University College London that, again, has been published recently—they were running a cancer centre as a stand-alone area, there were no emergency admissions going in, patients weren't actually tested at the time but they were being screened and staff were being screened as well, and they did have a significant number of cases. The age range was relatively low, there were very few over 70s, but there were no deaths due to COVID from that. So, I think protecting that capacity is paramount, and giving patients and staff the confidence that they're having the care in the most safe environment.

Just to add, the establishment of COVID-lite sites will also help protect against future waves of the disease. So, it will obviously enable some capacity to keep going should we have further peaks, which are expected. 

Just on the capacity issue—[Interruption.] I was just going to say, on the capacity issue, we totally agree with the BMA's comments. We're pushing to see the current use of field hospitals in the independent sector extended in the more short to medium term to make sure that we've got more capacity in the system.

Thank you, Chair. Just on that particular point on COVID-lite, I understand the need and the arguments that you're putting forward. On the field hospitals, they are temporary because the spaces they occupy, for example, at some point, will have to revert back to—well, most of them will revert back to their original use. But I think David Bailey highlighted that we've lost beds over the years. Is the health system we have in Wales at this point in time capable of actually delivering COVID-lite scenarios? Because I'll take my own area: Morriston Hospital is near enough doing most things, there's no major surgery in Neath Port Talbot at the moment and there is some surgery in Singleton. Do we have the system in place to actually allow a COVID-lite situation to arise across Wales?

10:25

I think we do at the moment, because we've got very few COVID-positive patients in hospital. I think as soon as we see a peak in that, everything is going to be turned off very quickly again and we're going to be back to the same situation we were, say, about a couple of months ago, where there was no activity going through. So, I do have some concerns that some of these what they call 'green areas' or whatever terminology you want to use are okay at the moment, but a further peak will turn them red.

I was speaking to the orthopaedic surgeons in south Wales yesterday, and they were pointing out—I won't tell you the health board—but they're doing virtually no elective work at the moment, and all their beds are filled, and they haven't really got any COVID-19 patients. So, they're having difficulty getting trauma patients into hospital now. One hospital's been told that there will be no hip and knee replacements until at least the end of the year. So, I think, convincingly, that answers the question.

Thanks, Chair. Because my first question was about planning, really, with health boards, and we obviously have covered that. I mean, I understand that you don't want to name particular health boards, but what you've said is very, very worrying, really. So, I mean, I think it'd be useful for the committee to get a flavour of how consistently health boards are planning. Because it sounds to me as if you're saying that that planning isn't consistent. And, Alice, you mentioned a postcode lottery and, clearly, that would be really unacceptable going forward.

Yes. Talking to members around the country, I think it depends on your hospital facilities and the layout of your hospital—how easy it is to divide a hospital into what we can call red zones and green zones. If you've got a big building, it's easier to do that. But in a sort of standardised district general hospital, where theatres and ITU tend to be in the centre of the hospital, it's very difficult to isolate the elective cases from potential COVID and COVID-positive cases. I think that's why we're seeing this differential in treatment that's going ahead, because the facilities that we've got available to use.

My understanding is that there's a review of health boards' funding coming up at the end of July, and I think that's probably the key point. A lot of money has gone into being able to provide services where the answer is 'yes', and as a profession, what we want is, we want to be facilitated to get through the work, not managed to the nth degree that is obstructive normally. So, I think that's going to be the key part. Is there going to be further investment? Where has it come from, or where is it going to come from? And then, all sorts of flexibilities can come into play.

Yes, just to add, we've obviously had feedback from our members on facilities and developments in their areas, and I know that health boards have had to put in plans to Welsh Government—their Q1 operational plans and Q2 operational plans. Now, some of those are publicly available through board papers, but some aren't. So, we've been asking Welsh Government to make those routinely publicly available so we can see what health boards' plans are in terms of COVID-lite sites and green pathways.

I have to say that one of the recurring themes from the profession is that, as part of the bypass of red tape, of course, there are plans going on that are now not subject to scrutiny, and it kind of worries the profession that the health boards are removing a level of scrutiny from their 'what happens next'.

10:30

I think—. We were talking about capacity. I think we have to consider the extended use of the independent sector as well, because they are taking a significant number of the more low-risk type of surgeries away from the main hospital sites. We are, I think, generally struggling to staff theatre lists regularly, so there's a reduction in the number of theatre lists, because a lot of the staff in theatres have been redeployed to help support the COVID response. So, I think as much capacity as we can keep the better, to allow us to get through the significant backlog.

Thank you, yes. Just in terms of prioritisation, then, obviously, we've talked about cancer; we know there are a whole range of areas where there's going to be major catch-up work needed. I'm assuming that you would say, obviously, we've got to prioritise cancer. Which other areas would you say need to be urgently prioritised?

There we go. Okay. So, certainly, as a gynaecologist, I want to prioritise people who are in pain, but, actually, probably, we need to go back to sorting out mental health and the less glamorous bits of our health service, making sure that we have social care in place so that we can get people out of hospital 24/7. The neuro-disabled kids, they're all falling behind at the moment. So, all of these non-sexy bits of the health service, they need great attention. There's a lot of morbidity happening in the communities.

Yes, I absolutely agree with Phil in terms of mental health. I think, in terms of prioritising admissions and hospital care, it's got to be people who are in pain and people with conditions that will deteriorate in a life-threatening way—so, we're talking about cardiac, renal conditions, so those sorts of things. The bottom line is that it's got to be clinically led, it's got to be clinically prioritised, and it can't be dependent on the time and on the waiting list, unfortunately. That's really tough on people who've got unpleasant things going on that can be fixed, but we do have to prioritise people who are going to have an alteration in their life by waiting. But Phil's point on mental health is absolutely key. There's going to be an explosion of morbidity on mental health over the next six months, and we really need to be set up to cope with that.

Okay. Richard Johnson. Sorry, Lynne, Richard has got a point.

Yes, I've just come in to agree that I think there are a lot of surgical problems that are non-cancer-related that are potentially more urgent than cancer cases, depending on what the conditions are, and therefore they can't be ignored.

I'm really pleased to hear what you've said about mental health, but, of course, this committee has been told by Government that mental health provision has continued throughout the pandemic. We've been told that a specific instruction was issued to all health boards to continue mental health service provision. Now, it's sounding to me like you don't think that's happened, really, so I'd just like to unpick that a bit.

Philip, I can hear another can of worms being opened here.

I can't, because that is not the experience of our members. The experience of our members in more than one area of Wales is that there's been a sense that mental health patients have been abandoned, and it's a case of now trying to pick up their care. There was, obviously, a well-publicised example in north Wales, but I'm sure it's been going on elsewhere as well.

Just, then, to wrap up for me, because I think we've covered a lot of the areas: if this committee was going to say to Welsh Government, 'You need to do this as a priority,' what would that thing be?

Okay. Well, one thing would be to continue the management-lite approach that we've been doing over the last three months: reduce the amounts of bureaucracy, reduce the amounts of inspection and testing, and allow clinicians to get on with the job. So, I think that flexibility to respond to the crisis has been very well met, I think, by the profession and by other professions as well. I think we'd like to see, and I suspect colleagues in other front-line health professions would agree, the ability to get on with the job a lot more without a lot of micromanagement going on, which has put brakes on things. We've seen how quickly we can adapt if we have to. It would be very nice if that ability was continued beyond the pandemic.

10:35

Well, I think I'd have to emphasise the point of COVID-lite sites, which is not just for surgical care, it's for medical care as well—and to include diagnostics, and to include high dependency unit and intensive therapy unit facilities that are protected as much as possible—to allow us to get the services back up and running again. I think now, with the reduced levels of COVID in the hospital, this is the time to start looking at that quite quickly.

Can I just ask one final question, then, about the role of the public in ensuring a return to normal services? How important is that going to be, do you think? We will all, as elected representatives, have people coming to us saying, 'I want my knee operation; I want such and such.' What do we need to be doing in terms of increasing the public's understanding of the challenges in this area?

Well, we've still got the underlying observation that, pre COVID, there were large numbers of people attending emergency departments who were inappropriately using them. So, making sure that we emphasise self-care and NHS 111, pharmacists and other sources of information is hugely important. The public does get it. It would rather be safe, and is not in a rush to get out of lockdown. The public can help by making sure that it tries to stick to the physical distancing rules. It's the point at which we return to mass gatherings that's going to be the challenge for us. So, they have a massive role to play, because, if they don't give us a massive second spike, we can slowly get back to some form of normality in capacity.

Yes, I think it's worth saying that I think the Welsh public's been incredibly disciplined throughout the pandemic, which has been reflected in significantly lower death rates than across the border. I think, in terms of helping to get back to normal, we probably ought to be promoting, particularly with recent evidence about large droplet spread, the use of masks in areas where you can't socially distance. I absolutely agree with Phil about continuing to follow the existing hygiene rules, but actually there's increasing evidence that using masks indoors, where you can't keep 2m away, will reduce transmission significantly, so I think you need to be doing that.

I've been amazed by how stoical people have been. I don't know how long that's going to last when you're hobbling around on a knee that is basically bone on bone, but people have been very understanding that there's a major crisis going on, that people are dying, and I think we will have to try—. Again, I come back to the clinical prioritisation of patients. I think patients get that we should be doing the most urgent stuff first. We can push back on people who say, 'I've been on this list that length of time', because I think people do understand that there's a social partnership going on, that the most sick, the most in pain, the most likely to have their life shortened because of conditions that they've got, are the ones that we should be doing first. I genuinely think that the Welsh public gets that, and that's certainly been my experience in contact throughout the last few months, and I suspect my clinical colleagues will tell you exactly the same thing.

But of course the reason we're in this position is because we are one of the lowest-doctored and lowest-bed-provided health services of western Europe.

I think we do have a duty to patients now, to the fact that they've done their bit to help us get through the situation; we need to start doing our bit to provide the safe services that we need to give them, getting on with their treatments.

One of the things that I'm encountering locally is shielded patients who are afraid to attend medical appointments, and some of these patients are really seriously ill. I had a lady last week who didn't want to go to Velindre for her cancer treatment. Is there anything that we need to be recommending to actually help with the shielded group, to feel safe? Because there are a lot of unintended harms likely to arise from this, really.

10:40

Just on a practical point, in the clinics I'm running, we're trying to get the shielded patients right at the start of the clinic before there's been too much traffic through there. So, they're the first patient to be seen and, in a sense, should be in and out of the clinic before there are too many patients hanging around—although we don't have many anyway, because of the appointment times. 

So, one of the good things that happened during the time of the pandemic was we switched from a situation in which staff were prevented from wearing masks in other areas to advising staff to wear masks in all patient interactions. So, it wasn't about the staff catching the illness; it was about us not passing it on. So, we've tried to make our hospitals as safe as possible. I think Richard's point about COVID-lite areas/sites is hugely important in getting confidence back, but we've seen the same in things like paediatrics. People are not taking their children for their ultrasound scans for their clicky hips and, really, hospitals are working very hard, for those very short patient interactions, to make hospitals as safe as possible. Most people who are going to catch COVID in a hospital will do so because they've been in for a period of time.  

Brilliant. Well, absolutely brilliant session. 

Diolch yn fawr iawn i'r pedwar ohonoch chi—bendigedig—ac eto i bwysleisio ein bod ni'n hynod ddiolchgar am y dystiolaeth ysgrifenedig y gwnaethoch chi gyflwyno ymlaen llaw hefyd. A jest i gadarnhau, mi fyddwch chi yn derbyn trawsgrifiad o'r trafodaethau yma hefyd i allu gwirio eu bod nhw'n ffeithiol gywir. Ond, gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i'r pedwar ohonoch chi. Dyna ddiwedd yr eitem yna. Diolch yn fawr. 

Thank you very much to the four of you—excellent—and to emphasise once again that we are very grateful for the written evidence that you submitted ahead of time as well. And just to confirm, you will receive a transcript of the discussions today to check for factual accuracy. With those few words, thank you very much to the four of you. That brings us to the end of that item. Thank you. 

3. Cynnig o dan Reol Sefydlog 17.42(ix) i benderfynu gwahardd y cyhoedd o'r cyfarfod ar gyfer eitem 4
3. Motion under Standing Order 17.42(ix) to resolve to exclude the public from item 4

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o'r cyfarfod ar gyfer eitem 4 yn unol â Rheol Sefydlog 17.42(ix).

Motion:

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

Cynigiwyd y cynnig.

Motion moved.

Ac, i'm cyd-Aelodau, rydym ni wedi symud ymlaen i eitem 3 a chynnig o dan Reol Sefydlog 17.42(ix) i benderfynu gwahardd y cyhoedd o eitem 4 ar yr agenda. Ydy pawb yn gytûn? Pawb yn gytûn. Diolch yn fawr. Felly, dyna ddiwedd y cyfarfod cyhoeddus am y tro, ac mi awn i mewn i sesiwn breifat. Diolch yn fawr. 

And, to my fellow Members, we move on to item 3 and the motion under Standing Order 17.42(ix) to resolve to exclude the public from item 4 on the agenda. Is everyone agreed? I see that you are. Thank you very much. That brings us to the end of the public session for the time being, and we'll go into private session. Thank you. 

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 10:42.

Motion agreed.

The public part of the meeting ended at 10:42.

11:10

Ailymgynullodd y pwyllgor yn gyhoeddus am 11:14.

The committee reconvened in public at 11:14.

5. COVID-19: Sesiwn dystiolaeth gyda Chymdeithas Ddeintyddol Prydain yng Nghymru
5. COVID-19: Evidence session with the British Dental Association Wales

Croeso i bawb yn ôl i sesiwn ddiweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd, drwy gyfrwng fideo-gynadledda efo Zoom. Dŷn ni wedi cyrraedd eitem 5 ar yr agenda, rŵan, a pharhad o'n hymchwiliad ni i mewn i COVID-19, yn naturiol. Mae gennym ni sesiwn dystiolaeth, rŵan, gyda Chymdeithas Deintyddol Prydain yng Nghymru. I'r perwyl yna, dwi'n falch iawn o groesawu i'r bwrdd Tom Bysouth, cadeirydd pwyllgor ymarfer deintyddol cyffredinol Cymru; Lauren Harrhy, dirprwy gadeirydd pwyllgor ymarfer deintyddol cyffredinol Cymru; a Dr David Johnson, cadeirydd pwyllgor deintyddiaeth gymunedol Cymru. Diolch yn fawr i'r tri ohonoch chi am fod gyda ni. Hefyd, diolch yn fawr am ddarparu'r dystiolaeth ysgrifenedig dŷn ni wedi ei gweld ymlaen llaw—diolch yn fawr am hynna. Dwi hefyd wedi cytuno y bydd Tom Bysouth yn gwneud datganiad rhagarweiniol byr cyn inni fynd i mewn i gwestiynau gan Aelodau. Felly, gyda chymaint â hynna o ragymadrodd, Tom Bysouth.

Welcome, everyone, back to this latest session of the Health, Social Care and Sport Committee here in the virtual Senedd, via video-conference on Zoom. We've reached item 5 on the agenda today and the continuation of our inquiry into COVID-19, of course. We have an evidence session now with the British Dental Association in Wales. To that end, I'm very pleased to welcome to the table Tom Bysouth, chair of the Welsh general dental practice committee; Lauren Harrhy, deputy chair of the Welsh general dental practice committee; and Dr David Johnson, chair of the Welsh committee for community dentistry. Thank you very much to the three of you for being with us, and thank you also for providing the written evidence that we have all seen ahead of time—thank you for that. I've also agreed that Tom Bysouth will make a brief introductory statement before we go into questions from Members. So with those few words of introduction, Tom Bysouth.

11:15

Thank you, Chair. Bore da. Good morning. The Welsh general dental practice committee, or the Wales GDPC, is the negotiating committee for dentists in Wales and it represents all practitioners, not just members of the British Dental Association. The committee includes representatives from all the local dental committees across Wales. The Welsh GDPC is represented here today by me, Tom Bysouth, as chair, and Lauren Harrhy as vice-chair. The WCCD is the committee for community dentistry in Wales. It is represented here today by the chair, Dr David Johnson. 

I addressed this committee nearly two years ago. Dentistry in Wales was in crisis before this pandemic, and we welcomed the leadership that your committee took in pointing to a new way forward with your key recommendations, including the abolition of the UDA, the unit of dental activity, in NHS general dentistry. However, since those recommendations in 2018, there has been inertia by elements of health boards within contract reform to accept that the UDA needed to go. It has taken a pandemic to enable the full-scale change needed to abandon this discredited measure.

COVID-19 has now demolished the flawed foundations that the NHS dental contract of 2006 was built on. We have long worked with the failed contract that valued only activity, and now activity is impossible to deliver. The Welsh Government has accepted the case for dropping targets for now, which is a welcome lifeline, but it is not the whole answer. Hundreds of thousands of Welsh citizens have struggled to secure access to dentistry for years. A dental service now in recovery and operating at limited capacity for the foreseeable future will see patient numbers fall off a cliff.

We have practices of all types that will not be able to survive the combination of higher operational costs and fewer patients. Many practices are currently operating at a loss, even those with NHS payments. This is not a sustainable solution. The prospect of a recovery year in general dentistry is a positive move under these pandemic conditions, but it is time to embrace much-needed change so that we can keep delivering better oral health for the people of Wales.

Underlying the state of dentistry, there are three key areas that we would like to explore with you today. These are: firstly, changes to metrics within the existing general dental services contract in this, the pandemic recovery year, and the sustainability of NHS dentistry in the medium to longer term. Secondly, that private dentistry has been unsupported by the Government's business support schemes during this pandemic and faces an existential crisis. Most dental practices in Wales are mixed economies of private and NHS care. If private and mixed practices go under, NHS dentistry will not cope with increased patient demand. Thirdly, that the community dental service, or the CDS, has been manning almost all of the urgent dental care centres for the past three months. The CDS needs to step down its urgent work and treat their own special needs patients who are in urgent need now. 

In addressing these three key areas, we want to look at the underlying issues: the patient journey, how Government can better support the GDS to get care back into our own practices—authorities must understand the GDS and CDS are intimately linked and cannot be treated in isolation; the current and future impact of the pandemic on the oral health of our patients and the subsequent disease burden in the population, including impacts on mouth cancer; and the future impacts of the pandemic on the dental team, with the loss of dentists, hygienists, therapists and nurses to the system to redundancies, retirements and career change. But we are not just here to tell you the problems. We will share some possible solutions and timelines, and what we're asking for from Government with your important help. And, of course, we will happily supply further written evidence following this meeting today.

To conclude my opening remarks, thank you on behalf of dentists and dental care professionals and all our patients in Wales for giving us the opportunity today to explore these pressing issues with your committee. Thank you.  

Grêt. Diolch yn fawr am yr agoriad, y cyflwyniad arbennig yna, sy'n crisialu'r heriau. Mae gennym ni nifer o gwestiynau ar wahanol feysydd, felly mae yna ddigon o gyfle i fynd i mewn i fanylder ynglŷn â'r materion dŷch chi wedi eu codi eisoes. Gwnawn ni ddechrau, dwi'n credu, efo'r adran darparu gwasanaethau yn ystod y pandemig—y gwasanaethau sydd yn mynd ar hyn o bryd. Mae David Rees yn mynd i ddechrau efo'r cwestiynau. David Rees.

Great. Thank you very much for that presentation that crystallises some of the challenges facing us. We have a number of questions on a whole host of different areas, so we have an opportunity to go into detail on those issues. We'll begin, I believe, with service provision during the pandemic—the ongoing services. David Rees is going to start with those questions. David Rees.

11:20

Diolch, Gadeirydd. And I thank you for that opening presentation, and the three key areas will obviously come up a little bit later in the questioning. But I want to focus initially on the pandemic and the service provision during the pandemic, and how you've managed during that time. Clearly, mid March, you had a letter from the chief dental officer that indicated that normal practice, as per say, was changing and we were going to the urgent dental care centres. Has that worked? Have the urgent dental care centres worked?

Yes, as you say, since March, we've been basically dealing with emergency treatment only, and emergency treatment from a limited menu. So, Welsh Government will say that there have been a large number of patients that have been treated both in urgent centres and within practices as a whole. But what it has left is quite a large backlog of patients. Because we've been limited in the things that we've been able to do, there's been a large backlog that's been generated and created. And this backlog will take some time to work through. And it doesn't matter if your practice is NHS, a mixed practice, or a private practice, this backlog applies to all people. And it may be the stage that smaller work now becomes larger work and some things change. And I think it's important to note with this panel that we can't work twice. It will take some time to work our way through the long backlog of care that exists, and it will also take time to be able to try and then get patients back up to health again. I don't know if Dave wants to come in on his point now. 

Yes. Thank you for the question. So, yes, initially, as you pointed out, when general dentistry in Wales—. It didn't exactly stop. What happened was, with the guidance from the CDO, the community dental services, and in Cardiff, the University Dental Hospital set up 15 emergency dental clinics. That's now risen to around 25, and these have mainly been providing the more advanced work—surgical dentistry, procedures that require aerosols, and treating patients who unfortunately have not only dental problems, but are suspected of having COVID. But general dentists in Wales have still been able to see their own patients for urgent treatment that doesn't require an AGP—an aerosol-generating procedure—such as taking out a tooth or applying a simple dressing. 

So, dentistry never really shut down, but it just went down to what was pure emergencies. Has it worked? I'd say so, but it's not something that we can continue; it's not something that can continue. As Thomas alluded to, there is a backlog of patients who, myself, already having a large amount of special care patients who need to be seen and need to have that treatment completed, and with current fallow times, it's going to take us a long time to get through it. So, presently, yes, but we need to start moving these urgent dental hubs from us in the community dental service out into the general dental practices, so that patients and dentists can go back to their general relationship of, that patient sees their own dentist, and, in the community dental service, we can go back to seeing our vulnerable special needs kids and special needs adults. The community dental service and the general dental service live in symbiosis; what affects one affects the other. So, hopefully, that answers your question. 

Just for clarity, were there any practices that actually closed during the pandemic?

Yes, to come in on that one, practices that had NHS contracts were obliged to stay open to provide care initially via telephone consultation and then bringing in patients as required. Practices that were wholly private would have decided on their own arrangements largely, but should have stayed and remained open for contact, initially by telephone, and then decisions beyond that. 

Coming back to your previous question, sorry, as to whether the current situation has worked, I think some patients may say it has; some patients may say it hasn't, because of the limited amount, the limited nature of the treatment menu that it is on offer. At the moment, in terms of offering treatment for back teeth, our only option is taking the tooth out, whereas, previously, options might have included trying to salvage the tooth with root canal treatment. So, there will have been some patients who will have lost a tooth because that was the only option that was available within the current restrictions, and who, before the restrictions would not have lost that tooth because there were other options that were available for them. 

11:25

The only practices, I believe, as Tom has already alluded to, and only on from that is where it wasn't possible due to the fact that staff numbers weren't appropriate because maybe they were a single dentist practice and the dentist, due to medical conditions, may have been shielding and may have already had a letter, but I've not heard of many of those practices.

What I'm gathering, then, is that there is perhaps a difference—some patients are being seen differently as a consequence of which practice they were in. Have you got a view as to the patient's view on this? From your members, how are you commenting upon how the patient has been, considering the situation, and what challenges patients have had to put up with?

Thank you. So, what we're hearing from patients, as well as dentists, is that patients have felt largely abandoned over this period. That may be down to perception, because, actually, we have, as we've already said, we've all been there and we've been open. But our patients are used to having really quick access to us, and they form quite strong relationships with their own dentists. So, where patients have needed to be referred to urgent dental care centres, although they've been grateful for the help, they really would much prefer to be seeing their own dentist and they can't understand why other sectors are still open and dentistry hasn't been, which is such an essential service.

Lauren has made my point.

Tom, in that sense, you mentioned in an earlier answer that some patients are actually experiencing a different treatment as a consequence of this. So, there are circumstances where patients have experienced something that you would not normally have done as a consequence of the lack of availability of certain treatments in that case.

Yes, you're correct. Within the Welsh Government guidelines, there were strict limitations on what we could provide in terms of our emergency care, which meant that some things we were not allowed to do that we would usually do. The classic example is, as I said earlier, root canal treatment on back teeth—trying to save and salvage teeth. Within the guidelines produced by Welsh Government, we're referring a lot to urgent centres. You could send people to start a root canal treatment on a front tooth and the definition of where a front tooth starts and finishes has been up for debate, but most people tend to agree that it's sort of the second one from the back, but there's a degree of variation around that.

And so, that has left patients who have had problems with back teeth with a limited set of options: there have been some who have needed antibiotics, and that would have kept them going for a bit, but antibiotics are not a permanent solution to dental problems—they are not a solution to all problems and can help in some circumstances for a short amount of time, but there's a need for definitive treatment. And so, it has been the case that, some people have said, 'I usually would have had a root canal treatment done to try and salvage this tooth, but I can't wait with this pain any longer. I don't know when we're going to be able to get on with doing other treatments. Can you please take the tooth out?', and we've taken the tooth out. And that will have happened across many surgeries across the country.

Okay, thank you. You also mentioned that there are three types of practice: the main NHS practice, a mixed and a private. I know that the Welsh Government funded 80 per cent towards the NHS contracts, so that's one aspect, but how has the financial management of other practices been? Because I'm sure that that would have been—. You mentioned earlier on in your opening statement that some would have had losses, for example. So, how are practices managing financially at this point in time to be in a situation to get back into the game?

So, it very much depends on your mix between NHS and private. My practice is about 80 per cent NHS, but I'm still running at a loss, because, in real terms, I've lost 40 per cent of my income over this period, but I needed to be able to still pay my staff at 100 per cent. With that mix, I've only been allowed to furlough one member of staff. So, actually, although we're really, really grateful that we've had some NHS funding, we are still at a loss.

Now, solely private practices have had to essentially shut down to nothing, which means that cash flow is now non-existent—[Inaudible.]—come back up. They also don’t have access to any of the NHS or Government PPE. So, just to be able to start back up is going to be very expensive and very stressful for private practices.

11:30

Just following on from that point as well, that many private practices were not able to access wider Government help, for example, looking at rates relief and things like that, which would have been really helpful and given them the lifeline that could have helped to keep them sustainable. And the other thing really to say about private practice is it takes a huge strain from NHS care. There's a large number of people that are seen privately in private and mixed practices that, if suddenly that system collapses, there's an even greater number of patients that need to try and access an already squeezed NHS service to seek their dental treatment.

Can you clarify? Private practices have not been able to access financial support from the business schemes with the Governments.

Sorry, just coming back to my earlier point: in my practice, even when we were up and running, if I didn't have the private income, we would have been at a loss anyway. We cannot sustain the business purely through NHS means.

Okay. And David's point about private businesses not accessing the help, Tom.

Some are and some aren’t. It depends on the rateable value. If the rateable value were changed, more could get help.

Okay. Dental students. We've heard of medical students being encouraged and taken into the health service. What's the situation with dental students? Have they been affected in any way through the pandemic? Go on, Tom.

So, yes, dental students have been affected during the pandemic, primarily it's getting their experience within the dental school environment. A lot of dental school experience is hands-on experience. It's not time spent in a lecture theatre or spent in the library. A lot of the time it's hands on, doing the dentistry, and they've been affected the same way all practices have, that—

Does this mean that they're delayed in actually qualifying as a consequence of this?

As far as we can talk from the Cardiff perspective, no, but the likelihood is that in their what they call a foundation training year—which is the year after you qualify—there will need to be additional, potential measures put in place to try and ensure that when the dentists then leave that foundation training year, they have got all the necessary skills and capabilities.

It's more potentially a problem for the following year. We can talk about Cardiff because that's the model in Wales that we know, that it's those students who are in their fourth year now—and in Cardiff in the fourth year you get a great deal of clinical experience—that may have missed out on a larger bulk than most students who are in their fifth year. It might be a problem that might be a little bit further down the line than we're initially seeing at this moment in time.

Following on from what Tom was saying, we've got foundation dentists who spend an extra year learning the ropes at general dental practice. I'm sure you're aware of that. The concern for those has been what do they do afterwards. As you can all probably tell, at the moment we're going to have a bottleneck where the throughput of patients is so reduced that there potentially will be job losses for associate dentists. So, you can imagine that the most inexperienced members of the profession coming out now are not going to look as favourable when you've got what may potentially become quite an aggressive job market.