Health and Social Care Committee

Welcome back to the Health and Social Care Committee. It's been an interesting day already as we pursue our inquiry into general practice in Wales. We're on our second evidence session today, and it's a great pleasure to welcome colleagues from the Royal Pharmaceutical Society and Community Pharmacy Wales. Could I ask you perhaps to introduce yourselves? Could I start with Liz?

Hi, I'm Liz Hallett. I'm representing the Welsh board for the Royal Pharmaceutical Society, and I have a background in primary care and have been a practice pharmacist in the past.

Thanks.

Hi, I'm Helen Davies. I'm also an RPS member and a Welsh board representative here today, representing primary care. I also work in a GP practice.

Thank you.

Good morning. My name is Dai Williams, I'm a community pharmacist in the Rhondda and I sit on the board of CPW.

Thank you, Dai.

Hi, I'm Steve Simmons. I'm a pharmacist. I've worked most of my life in community pharmacy until joining Community Pharmacy Wales, and I'm a member of the Community Pharmacy Wales executive team.

Great, thank you very much, and welcome again. We've got a few questions to ask you in turn, and perhaps I can kick off if that's okay. It's looking at the role of pharmacists. I just wondered what are the key enablers and barriers to maximising the contribution of pharmacists in general practice, particularly in managing those long-term conditions and supporting the preventative care agenda. Would anybody like to kick off on that? Don't feel that you all have to come in, but you're very welcome to.

I think, as pharmacists, we are the experts in medication, so our wider multidisciplinary team recognising that fact, that that's where our strengths lie, because there we can support with the polypharmacy, reducing that deprescribing. Many of us are independent prescribers now, so with that individual skill set as well to be able to make those autonomous decisions. So, those are the key enablers. We're also medicine safety experts, so assessing the risks of those medications, helping prevent those hospital admissions by that deprescribing, but having everyone be aware of what our scope is. We are not instead of GPs, we are in addition to GPs. We work best as part of that multidisciplinary team, so I think that's one of the key enablers is people knowing what a pharmacist does, and the public being aware of what a pharmacist's role is.

I'd agree with that point, if I can come in there, because I think public awareness of our unique selling point is key, but also our colleagues' awareness of what we can do as well. So, we are not just replacing GPs, as Liz said, we are adding value in terms of medicines expertise. But, for me, working within the Rhondda valley, which is where I work at the moment, we've got pockets of deprivation as well, and it's a real absolute pleasure to be able to have that longer term relationship with a patient, really optimising medications to try to reduce admissions. That long-term relationship is key. We work closely with our community pharmacy partners where we can really try to manage those conditions, and whilst you're there with that patient, you develop a relationship and you can counsel them more on a prevention agenda, because there's a limit to what we can achieve with medicines alone. I think it's key, trying to get behaviour change involved as well. So, key enablers really are making sure people are aware, the public and professionals, about what we can offer. We're not just substitutes for GPs, but offer expertise in medicines as well.

Dai.

It's a difficult question, isn't it? As medicine's evolving, no-one can know everything. The whole world is starting to revolve around multidisciplinary teams. As Helen said, the skills that pharmacists have, some of them are complementary to GPs, some are different to GPs. The system operates better when that team can communicate better together, working well to achieve the same outcomes. The barriers are the biggest issue.

Funding is always an issue and digital interoperability is an issue. We've got electronic transfer for prescriptions at the moment between GPs and community pharmacies, which is great. I'm a prescriber, so I sit in my community pharmacy, seeing patients that the GP has referred in to me. I can access the summary care record, so I can get access into the GP record and see a summary of where they are, but I don't get to see everything. I don't get to see pathology laboratory results or letters from hospitals. I don't get read-and-write access to the GP's records. So, there's a danger that the information that I'm getting isn't complete to allow me to make a decision, and I can't then write directly back into that GP record, so there's a chance that, when I communicate that back, it gets lost in the wad of documents that they have sitting there. So, read-and-write access would be a massive bonus.

That's a really helpful point, Dai. Steve, anything?

I don't think I can really add much more to that because my colleague is a practising colleague. But the role of community pharmacy is obviously changing dramatically. We started off being suppliers of medicines and dispensers and now, under Welsh Government arrangements, we've extended our range into far more clinical service provision. So, we're looking after common ailments, we're looking after prescribing for other conditions, we have a public health role, we take on all sorts of things. But, to me, it's about people not places. I think if there's anything that's a barrier it's thinking of places: 'This happens in a GP practice'; 'This happens in a community pharmacy'. To me, I want to reach a stage where an independent prescribing pharmacist working in a GP surgery, or a nurse working two rooms up in the GP practice, is part of primary care, no different to an independent prescriber working in a consultation room in a community pharmacy a couple of miles away. And in these days of digital connectivity and interoperability, we really should be thinking more and more about primary care.

Yes. That's a really good first point. Yes, come back in, Helen, please, yes.

I was going to talk a bit more about some of the barriers we face as well in terms of operating those key issues. Working in a GP practice, we can only survive with the volume of work, I think, because there's a lot of work coming up from every kind of specialty in secondary care whilst trying to maintain chronic disease management, and whilst we are the right people to do it on the ground because we are in the patient's community and we are easily accessible, thinking about where I work, actually, some people would probably struggle to travel to some of their appointments further afield. So, we are in the right geographical area, but we are limited, sometimes, by physical room space in GP practices and things like that. So, I would love to set up an extra clinic and do a polypharmacy deprescribing clinic whilst looking at the chronic disease management, but I am limited to where there's enough room availability. That can vary depending on the type of building that your GP practice is in; the newer ones tend to be a little bit better for that.

Some of the digital infrastructure, our systems don't always talk to each other, and I wonder why not, in this day and age. As David was saying, that can become an issue because if certain changes are then lost in translation, that comes with a risk, then, doesn't it, really.

Definitely.

Well, that's really important, interesting stuff, because I know how much work that you, on the pharmacy side of things, have been doing to be able to put more into the primary care system. I've met with your colleagues as well, and I've seen what great work they're trying to do in moving forward. And I heard some of that about the physical buildings. I just wonder how can pharmacy be more strategically embedded in the NHS service planning and transformation programmes, so that you can actually give all of that you've got now to give.

I think we need protected learning time, because there's an infinite amount of things that we can do, supporting with deprescribing and preventative health medication, but especially as we're getting newly qualified pharmacists who will be IPs coming out, we need to support those pharmacists throughout their whole career. So, in their early years, giving them the support and mentorship, but also, with those advanced pharmacists, enabling them to continue to expand their scopes of practice. But we also need to bear in mind that we can only do so much in a working day; the workforce pressures are immense. So, I do think we need to be looking at workforce pressures and the harm that can cause to the profession, for the whole multidisciplinary team in GP practices, not just pharmacists.

Yes. Dai.

It's quite interesting. You asked how we can embed pharmacists into the system. Helen just pointed out that space in a GP surgery is sometimes at a premium. I work in the Rhondda, and there are 10 GP practices in the Rhondda cluster, 14 buildings, because some of them have branch surgeries, but there are 10 GP practices. There are 27 community pharmacists. The community pharmacy contract has independent prescribing built into it. That's 27 consulting rooms spaced all over the Rhondda, not just in the GP surgeries. The question is a very relevant one: how can we embed that?

And how can we use what you've got?

It's there, isn't it? It's there. This is general practice we're talking about, but primary care is the whole issue. I get patients sent to me from a GP, I end up sending them to the optometrists, then they send them back to me with a prescription. It's about using the expertise of all those primary care contractors: the optometrists, the dentists, the community pharmacies and the GPs, pharmacists, advanced nurse practitioners. They've all got a part to play and we can't afford to let any of those skills go missing.

No. That's really powerful. Helen, and then I'll come to Steve.

I would agree. Prudent healthcare is key. You have to use everyone's skill sets and look at the patient's journey across the whole pathway. Where can they add most value? Where is the space to operate this? But, for me, the key thing is links. But your original question was about how do we embed pharmacists into the strategy overall, a big part of that for me is workforce planning, in terms of getting our grass-roots pharmacy trainees out into practice, out into primary care working, so that we can see the benefits: we're growing our own expertise as we're going along; the profession is visible, they can see what we add. And for me, then, the key thing there is protected time for learning and, actually, interprofessional education, because I learn a hell of a lot from my colleagues in other professions, but we give the same back. So, if we can embed those structures with Health Education and Improvement Wales and funding as well, that would be key.

I'll bring Steve in, and then I'll come to you, Altaf. I'll just bring Steve in.

I think we're at a stage where we really need to think strategically about how we're going to use pharmacy, particularly in community pharmacy. We've got—I looked it up—about 1,600 full-time equivalent GPs. In nine months' time, the first of the universities are going to be releasing pharmacists who are independent prescribers. So, within about five years' time, I'd be very surprised if at least 600 pharmacies across Wales didn't have a full-time independent prescriber in there. Now, that is a 30 per cent to 40 per cent increase in prescribing capacity within primary care. We can either let it grow organically or we can really think strategically about what needs to happen where, so that we can make sure that this new workforce, and it's going to be a huge workforce, is going to be utilised properly.

Yes. Altaf, would you like to come in?

Yes. Just a quick point about—. Each general practice surgery has a prescribing clerk. Are they pharmacists or are they, I don't know, clerks?

They're not normally pharmacists. Well, they're not pharmacists. They're normally trained individuals and there are training programmes that enable them to be upskilled to become that. There are some moves that some pharmacy technicians are slightly taking on the role of a prescription clerk, but, generally, prescription clerks were not pharmacy professionals, no.

They could be replaced by the pharmacists.

You wouldn't want to be doing that. The pharmacist would have a higher level of medical expertise than you would need for a prescription clerk. Prescription clerks add great value and have a great remit and a role, but it's not the role of a pharmacist to be a prescription clerk.

So, in my practice, we work extremely closely with our prescribing clerks, because they make sure the processes run safely and that everything is on time, whereas we add the value then in terms of the expertise, like, 'Actually, it's all well and good getting that prescription ready, but as a pharmacist, I don't think they need that prescription anymore, so book them in for a consultation with me so I can have that conversation.' Add to that, then, our pharmacy technicians, they can support a lot of the work we do by making sure the necessary blood monitoring is done, and they're professionals in their own right who can support. So, yes, there's a role for all of us, but prescribing clerks are not clinical in any way and so can't add that value.

Thanks for that for clarity. Thank you, Altaf. We've heard a lot already about how we could probably improve things, but what's your assessment of the current relationship between general practice and community pharmacy?

How long is a piece of string? It depends on relationships. I've worked in the Rhondda for 40 years. I get on really well with all my GP practices. The system works despite the system, and that's always the problem, isn't it? The system shouldn't rely on relationships. The processes should be embedded so it's not left to chance.

Yes, that's good.

Yes, I'd agree with that. Actually, the GP practice I work in is just up the road from where David works, so that works well for us because we've got that relationship, but that doesn't mean it's going to be reproducible across the patch, and that's what we need. We need systems that are reproducible and just work, and simple things, sometimes, like having open communication channels between community pharmacists and GP practices, aren't always that easy, you know. So, things like using Microsoft Teams, it's making sure you've got the right infrastructure so we can talk to each other more easily and things to solve issues and so on. It just helps. So, we just need to make sure those communication channels are easy for us all.

Yes. Sorry, Joyce, would you like to come in?

I just want to dig a little bit deeper. We talked about relationships, but there are sometimes tensions, and there's a two-way referral system that hasn't been mentioned. So, a lot of people will go to you, maybe, to have their blood pressure—let's use that one—checked, and you know that they really need to go and see their GP. So, you would, I assume, refer them, because it's this two-way referral that I wanted to draw out, and the tension is about vaccinations, maybe. I'm just asking the question. Lots and lots of pharmacists, probably most now, will administer vaccinations, and it's a paid-for service, and GPs will also administer vaccinations in a paid-for service. Are you finding any tensions between that, because you quite rightly said it's about the people, not the system?

That's a really easy one to answer, isn't it? If you develop a service that has remuneration attached to it, and the practices find that they are struggling financially, then they're going to chase that revenue, aren't they? They've got bills to pay. So, the best way to get rid of that tension is to make sure that primary care is funded properly in the first place. If you get the core funding right, then people are not fighting over the bits that make them survive. That's about core funding, and that's a bigger question.

We have less tension now with flu vaccinations than we did, as it's becoming more custom and practice. I still don't like some of the conversations I hear and I don't like some of the posts I see from my GP colleagues and my pharmacy colleagues, but they're under pressure financially. What do you expect them to do? You give them a contract, and say, 'This is what you're going to get paid, and within that contract there's a lump of money for doing vaccinations. If you don't do the vaccinations, you don't access our funding.' So, the system creates that tension, and, yes, change it. Change that system so it doesn't.

Steve.

If I can just build on Dai's point there, it's about thinking through the tensions that do occur, and a lot of tensions occur, for instance, with repeat medication. It's the usual sort of thing: who orders it, who's responsible for it, where does it sit? So, often the system itself creates the problems, the tensions within it, and this is where we're saying, 'Okay, so who should do what in primary care?' A good example of that is repeat medication. So, we've currently got someone whose expertise is in diagnosis—a GP—and puts me right as a patient, and then says to me, 'Okay, Steve, you're fairly stable, so I shouldn't really need to see you for a year, and I'll fix an appointment to see you.' But each month now, I want this to and fro about—. [Correction: But each month currently, I have to go through this to and fro.] You need to get an ordinary, [Correction: 'need to go and order'] a monthly prescription. You need to order that prescription. You need to pick it up from the pharmacy.' Some systems work, some systems don't work. Here we are. We've invested heavily in electronic prescribing and an electronic prescription service. What I would expect the GP to be able to do is to say, 'Right, Steve, you can pick up your medicine from the pharmacy now.' Ting. 'Give Steve this medicine for 12 months at an interval that works between you and the patient. I won't be seeing the patient unless you refer the patient back to me.' So, we need to get rid of this monthly chase of prescriptions. It used to be green pieces of paper whizzing all over Wales, but now it's still going to be digital messaging. So, we've got to think about how we make this system a lot smoother, a lot simpler, and who does what within the system. As far as I'm concerned, repeat medication for stable patients shouldn't belong anywhere near a GP surgery. What are we bogging them down with that sort of workload for?

Thanks, Steve. Helen, and then I'll bring Liz in.

I would agree, for the stable patients, that, actually, those batch-prescribing approaches are useful because it takes the workload off everyone and the patient. It can sometimes go wrong when we have to make changes or if you've got complex regimes that are not suitable. So, it's not suitable for everyone. And I think the process, for me, that's where we get this collaborative conversation. We actually work with our community pharmacy partners to identify people they think would be useful—'You come back to us and we'll set that up.' That releases the GP pharmacist to do more of the complex cases. So, for example, if I wanted to spend my time reducing somebody on high-risk pain medication, that's not suitable for batch prescribing, but it means, because I've released the stable patients to you guys, I can spend my time doing that.

I think processes are there sometimes to trip us up, and you are right that they can cause a problem with tensions, but it comes down to then actually planning services and having those conversations with every stakeholder around the table. What's right for the patient? What's their journey? Which part of the pathway is going to be easier for them? And, for me, when you're talking about things like having your blood pressure checked, we need to make sure the pathways are in place so that there is somewhere that you can refer somebody if you find something that goes wrong.

Liz.

And I think, once again, back to that patient education, with regard to ordering their medication, they don't need to order all their medication every single time, so only ordering what they need. That will free up resources and it will free up manpower in community pharmacy, because there's nothing more disheartening than dispensing something that isn't actually needed and then it goes straight into waste. We know there are huge amounts of medication waste. I think it's really important for that key message to go out to patients that, yes, it is on your prescription, yes, you can have it when you need it, but do only order it when you do need it. And have conversations, if you can't take that medication, with your community pharmacist and with your primary care pharmacy team as well.

Okay. I'll move us on. John, can I bring you in?

Thanks very much, Chair. Good morning to you all.

Thanks very much for coming in to give evidence to committee today. You've touched on funding a few times already and, obviously, that's always vital. We'd be interested in your views on how sustainable the current funding model is for pharmacy services in general practice and primary care, and what changes you would suggest to move to a more effective long-term planning system and service delivery.

Between 2013 and 2016, Mark Drakeford was health Minister. He had a 'shift left' policy: prudent healthcare—only do what only you can do, more people treated in primary care, fewer people in secondary care. And that's fine, but the funding has to follow that. If there's more work being done in primary care, then the funding has got to support that work. We're in a situation—I don't want to get drawn into a contract discussion—where primary care is not sustainable with the level of funding that you have at the moment. There are issues with social care and how that integrates with it. That's complex, I accept that. But if you want primary care to deliver more, you've got to pay more for it. It's as simple as that. Where does that money come from? That's a discussion you have to have.

We have a clinical service in community pharmacy where, four years ago, we had 30,000 registrations on common ailments. There are now 300,000. The budget was £28 million last year. They think it's going to be £38 million, all from within that global sum. Nothing over and above inflation has gone in for this year. That is not sustainable. I've got colleagues on burn-out. I've got independent contractors working 12 hours a day. They put their life into running a pharmacy and they're working 12 hours a day because they can't get the work done, because there's no finance to bring other people in to help them. And chucking more money at it on its own won't help. It's about deciding what is your policy for primary care. What do you want primary care to deliver? Who are the players in primary care? How are they going to work together, and how are we going to fund it? It's a massive issue, but you've got to look at the whole system of primary care, not just bits of it.

I would agree with that, in that it’s a whole-system approach. So, if a new service is being developed and it starts in secondary care with the specialties, there has to be a thought process about how that funding transfers. I am not just talking about the funding to deliver, but the funding to actually pay for the prescribing as well. All of these things are in-built.

But, for me, some of the issues—. If you take the fact that having a pharmacist in a GP practice is adding lots of medicines expertise and making it safer dealing with those chronic diseases, we cannot actually do that sustainably or consistently because a lot of practices cannot afford to employ GPs because of numerous issues and so on, because of the model, I guess. If we’ve used cluster funding in the past, for example, that varies from place to place, so what you have then is a bit of a postcode variation in the pharmacy support. You can’t really build a service on that because you don’t know whether it’s long term. If you did want pharmacist expertise within a GP practice, and I definitely think there's a place for it, there would probably need to be more of a permanent funding solution.

And there will always be those practices that won’t be able to afford their own pharmacist, so how do we support them to have this vital service, this vital person in their role to provide that medicine safety? Especially in rural areas, in single-handed GP practices, realistically, we need to work out how we are going to support those practices to enable them to have a pharmacist as well.

Thank you. Good point. John.

Okay. Helen, when you spoke about clusters and funding for clusters, we know that it is quite short term, isn't it, that funding, which also should lead, and hopefully does lead, to transformation to some extent. What is the impact of the short-term nature of that funding on the ability of the pharmacy teams to actually plan and deliver consistent and sustainable services? What changes would you like to highlight to committee today as being necessary to overcome the problems that are involved in that system?

For me, I think, because of the short term nature of it, I appreciate the premise where it is meant to be that you test something and it brings with it transformation, but where does the funding then come to continue that? It is just not there anywhere. If you then put that funding into people, which is often what we need, and expertise—so, pharmacists, for example—you can see what can be delivered in terms of medication reviews, yet we know that is going to be fleeting. You end up trying to select project-based work, which is short term. Actually, if you have just put a project in and you have spent your time delivering sustainable inhalers, doing respiratory reviews, to make sure we are increasing our decarbonisation and we are addressing those things, that cannot then continue when the funding ends. So, it is just that, whilst it is good to test things, it needs to be a constant thing, because you cannot rely on a service that you know is going to be fleeting. I don't know if I have answered your question very well there, sorry.

I think you have. It’s about the impact, isn't it? You’ve described that quite well, I think.

Okay. Thank you.

Dai.

I've been heavily involved with the Rhondda cluster over the last seven or eight years, and, picking up on Helen's point, cluster funding should be about proof of concept. It should be about allowing someone to develop a system with minimal risk to their practice to see if it works. Half the Rhondda cluster budget is now spent on cluster pharmacists, and that has been going on for about six years. That’s not what the funding was designed for, but the practices now realise they cannot do without those pharmacists. With the safety they bring to the process, the practice will not operate without them. So, that now limits the other proof of concepts we can explore, because now you’ve educated the GPs on the vital role pharmacists play and they realise they cannot do without them. So, I do not have an answer to that, I am afraid.

Unfortunately, the answer probably is more funding. We understand there is not an infinite pot, but I think, as services move down from secondary care to primary care, the money should follow, but that is not easy to fix, because you cannot just suddenly say, 'Secondary care, you won’t prescribe that and have that pot of money; we're now moving it to primary care', because that would not work either. It is how we follow those services, as well.

That example you gave there, Dai, demonstrates very clearly that, actually, looking at new models, investing in that, is worth it, because that one was proved very quickly.

Yes.

Sorry, John—anything?

No, I think that's fine, unless any of our witnesses want to add anything, Chair.

Okay. Thank you, John. Let's move on to workforce, and Lesley.

Thanks very much, Chair, and good morning, everyone. Dai's just referred to burnout and 12-hour days et cetera, but I wonder if there are any other challenges that you think are there for recruiting and, importantly, retaining pharmacists in both general practice and community pharmacy settings.

Shall I come in there, if that's okay? Yes. So, as Dai has said, burnout is a real issue. There's a lot of good will out there, I think, and that comes with our roles. We care for our patients and care for the population, so we will go above and beyond. It can't carry on like that for ever, I guess, but, you know—. I think, for me, if I was to recruit pharmacists to a GP practice, particularly where I live—. Obviously, there's a lot of travelling for a lot of people to go up to the top of the Rhondda Valley, that sometimes is a bit of an issue in that you can't recruit because of those—. It's making that attractive, I suppose. But also it's making sure they feel that they are in a secure role, because, if funding is temporary, there's a worry, then, that they might think—. People have got mortgages and bills to pay, they might think, 'Well, I'm not going to risk taking a role in a practice that I'll probably love, because I'm having a massive impact on this patient, but I can't rely on that long term.' And also it's making sure you are integrated in a team and you feel valued and that your skill set is realised. So, obviously, it's making sure patients understand what value we can add, and making sure we're embedded into the MDT early on, really.

I think it's looking at the whole structure of the GP practice as well, making sure that the rest of the team aren't understaffed and underfunded, because that just builds stress, and then, obviously, that impacts on everyone, the whole team. It's utilising our skills where they're best placed as well, given that job satisfaction. So, if you're working long, long hours with admin-like roles or things like that, then, actually, that's not making the best use of your skills. So, it's getting that—. We like patients, we're here for patients, and that's the thing that brings you joy, and that impact you have on patients is the key to everything that, as a pharmacy professional, we feel.

It's introducing those pharmacy technicians into the team as well, seeing the role that they can have in a GP practice, upskilling them. They can take on some of the monitoring, looking at reviewing medications, but then passing those then onto a pharmacist to deal with the actual clinical bits, the complex bits that a pharmacist needs to be dealing with. So, it's valuing the whole pharmacy team as well.

There's a longer term question as well, isn't there, about how we retain the workforce in Wales. We have a system now where we train pre-registration pharmacists, but places are limited through the Oriel system, and, whilst we attract a lot of good students, how many of them are going to stay in Wales? We talk about wanting to increase Welsh language skills within pharmacies, and if you want to get somebody to work in west Wales, it's much better if you can get a pharmacist who was born and bred in west Wales. So, if he finds it easy, or she finds it easy, to get into university, she'll more likely go back into the community where she grew up, or he grew up, to want to work. So, we do have to take a longer term view as well of who do we want to train as community pharmacists and GPs, where do they come from, what are their long-term ambitions. It's fine training the best students, but if they're going to go back overseas or back into England when they finish their qualification that's not serving the public of Wales very well. It may sound a bit selfish, but, at the end of the day, we have to be able to retain a workforce in our country.

That's a good point. Steve.

Yes. It's a similar point in that we have a pipeline issue in that we've developed a foundation pharmacist, or the old pre-registration programme, which most people will know it as, where, traditionally, somebody would go and work in a community pharmacy for a year and then they became registered as a pharmacist. Now we've developed a process that is a Rolls-Royce training programme. It's an excellent training programme where they spend time in community, time in primary care, time in GP practices, and then they eventually qualify. Yes, as Dai says, that attracts a lot of the premium graduates, applicants, many of whom have got no intention of ever remaining in Wales. So, that's the issue that Dai's already spoken about. But the problem is that to organise that is quite complex, and you are therefore limited to places in each of those areas. Therefore, we're fixed at about 80 to 100 pharmacists that can go through that process. So, our pipeline requirements are maybe 200 or 300, but we've put a bottle stop there that's actually stopping more and more pre-registration pharmacists graduating in Wales. We would hate to get rid of this Rolls-Royce training programme—it's brilliant—but other UK countries train their graduates in the old way, through the old programme. The solution is to allow both to operate together, but we've taken a decision that it's the Rolls-Royce service only, and CPW's fought that for many years, but it just means we're curtailing our own pipeline.

Thanks. Going back to the comments earlier around a pharmacist wanting to be valued and being part of that team and having their skill set recognised, do you think the lack of alignment with 'Agenda for Change' has an impact on the way you can recruit and retain pharmacists in primary care?

I would agree with that, actually, because I'm directly employed by a GP practice but I also have another health board role as well. I see colleagues of mine reluctant sometimes to go into the GP sector because they are worried that they might not have as good terms of employment and so on. So, that is a factor that a lot of people consider. So, 'Agenda for Change' probably does come into it to some degree, just making sure you're protected. I don't know if there's anything you can do with that. I don't think there's anything in your gift to change that, really.

I suppose, actually, going back to Steve's point as well, now that we've got this rotational training programme, if we're getting the grass-roots people coming through, they are more likely to want to stay with us, if you can treat them well. The general practice sector is the sector in most relative infancy. So, there are fewer pharmacy teams working there compared to others. So, I suppose until we can adapt those portfolio-style careers where people can work in different areas—perhaps that's a solution—. But, ultimately, we haven't got the infrastructure to manage all of this training. So, 'Agenda for Change' becomes more attractive then, I suppose, where you're going to go somewhere where you feel safer.

Sorry, if I can just add in another barrier that people may or may not be aware of, that is the pension contribution, the pensions issue, because if there is a role in general practice or in a hospital to work as a pharmacist, say at £50,000, it'll be £50,000 with a 22 per cent pension contribution by NHS Wales. If you go into a community pharmacy, £50,000, but you'll get a 5 per cent or 6 per cent pension contribution. And it is an issue out there that's stopping the flow of pharmacists between sectors that could easily maybe be addressed by allowing community pharmacists, for instance—exploring whether or not they could join the existing NHS pension scheme. But just to let you know that it is a barrier there, which is caused by the difference between pensions.

Yes. Dai.

There's another big issue for me with community pharmacists. I'm very lucky in the fact that I have another pharmacist who works with me and I've got a good network around me. When the urgent care centre was opened in Rhondda, which is based in the hospital, because all the GPs employed a GP to work and to deal with unscheduled care that day for people who couldn't be seen, I could pick up the phone to Aled, the GP there, and we had this great relationship. He would give me some advice or I could refer in. That's now closed. Many of my colleagues in community pharmacy work in a silo. They feel isolated, especially if they're younger and they haven't got any experience. Who do they pick the phone up to to say, 'I need a bit of help or a bit of advice by here'? That to me is a massive issue in personal development, because they become more reticent to get involved with something, they become reluctant to make a decision, and they end up referring somewhere else, when, if they'd had a mentor they could have picked the phone up to, or just somebody they worked with to say, 'What would you do by here?'—. It's a massive bonus, isn't it, when you have somebody you trust that you can talk to.

Yes. Sorry, Liz.

I think the isolation is true in GP practice as well for pharmacists. Because, although you are often integrated into that multidisciplinary team, you are different to the rest of that team as well. So, you do want to have those networks between GP practices of those practice pharmacists so that they can have that peer review, so that they can have conversations regarding expanding their scope of practice.

There is sometimes a reluctance to use your independent prescribing qualification. You've got it in a certain scope of practice, but you feel, I don't know, barriers to actually utilising that, because you’ve got worries. But actually having that network of people who you can turn to and say, 'I’ve seen this', or having those MDT discussions with your colleagues, your trusted colleagues, I think would be really valuable, and mentors for those people later on in their careers as well. So, you’ve got those early years careers, and designated prescribing practitioners and things, but what do we do with our existing workforce as well, and how do we mentor them to expand their scope and keep them supported and not isolated?

Yes. Helen, you wanted to come back.

Only a quick point on that, really, because I know you've addressed a bit of it. So, as we've already said, pharmacists are going to be coming out qualified as independent prescribers. A newly-qualified independent prescriber is not going to be the same as Dai, who's very experienced and could look at a patient and have more clinical judgment skills. I think what Dai touched upon as well, being isolated, that works across the patch, and I feel that we need some infrastructure to make sure that community pharmacists who are prescribing, and newly-qualified pharmacists working in the GP sector, and advanced ones, all have that ability to have someone they can have a discussion with—a case-based discussion—and feedback on their prescribing. It probably needs to be in-built into all of it, because, otherwise, there's a risk that things can go wrong.

Yes. Lesley.

Thank you. Talking about recruitment and retention, really, what gaps do you think exist in training and professional development, and then, ultimately, career progression for pharmacy staff who are working in general practice?

I think it’s back to that protected learning time. We know they’re overworked, their days are really busy. So, how are you going to fit that in at the end of a long day, that protected learning time? How are you going to find time for that for the whole pharmacy team—so for the technicians, as well as the pharmacists—to make sure that they’re using their core skills and continuing to develop? I think that’s one of the major things, that protected learning time. And funding it as well—so actually funding what that training looks like—and access to those relevant courses as well.

Helen.

Yes, so protected learning time, definitely, because, obviously, if you’re closing the practice down or—. Something needs to be able to sustain that ongoing service whilst you’re learning. But I think as well it probably just needs to be in-built, in addition to that, regularly. I’ve worked in some practices where I know that, at the end of my week, I can hot-review some of the patients with the GP and get their opinion on some of the things I’ve done. I can go and speak to one of our practice nurses, who’s very familiar with managing these conditions, and we can bounce off each other. So, it is important, in terms of retention, that we feel valued and we feel supported, because, otherwise, you can be quite isolated, I think.

Yes. Anybody else? No. Okay, Lesley.

Just finally—and, again, you mentioned, Liz, you’re an independent prescriber—if you had more people who could independently prescribe, what impact do you think that would have on a GP’s workload?

I think more—

A bit of an easy question, that, probably. [Laughter.]

I think the more people we have who can do more things, obviously that will help with the GP workload. But I think we just need to be conscious that we need to be supporting those people to use that independent prescribing competently and safely, and expanding on that as well, so that they are feeling supported. Yes, that's—.

Helen.

I think it comes down to population needs assessment as well, but then sitting down early on and discussing with your whole area and your stakeholders. So, for example, it would be pointless me saying, 'Right, I’ve got three new independent prescribers working in my GP practice with me. They’re going to start doing this', which is duplicating the good work Dai is already doing. We need to have these conversations upfront, and that needs to be part of it, where you plan for your population. There will be always be things that we can take off GPs, but it’s making sure that we’re using our unique selling point, which is medication safety as well. So, for me, it could be—. We do medication safety audits, for example, to make that sure women on hormone replacement therapy are not given the wrong treatment when they’re being treated for menopause. Why can’t we be the prescribers in that, to make sure it’s safe? Things like that.

Yes.

So, the point about not duplicating, I think, is really important.

Yes.

So, who do you think should take the lead there? Should it be the health board? Should it be—? Does Government have a role to play in that?

I think each individual area of Wales will have different issues, and I think you are going to have to look at those issues. We know there are huge pockets of deprivation in certain areas, so you may want a particular focus on that. So, I think, health board-led, but with an all-Wales strategy as well, to identify what those core needs of that particular community are, because there's just such variety, isn't there, across Wales.

Yes. Dai.

That's an interesting question, isn't it, because it depends on the skills of the people involved. I have a pharmacy up in the Rhondda that does 500 consultations a month between IP and CAS, and I've got five other colleagues who prescribe, and, every month, we've got over 1,500 consultations that would have been seen by a GP. But I can't tell you that all those pharmacists have the same skill sets or the same scope of practice. And there's a scope of practice that we aim to achieve, but not everyone is at that stage. And this is a journey. We're nowhere near. This is the start of a journey. It will depend on those relationships and surgeries understanding what can their community pharmacist do, because there's nothing worse than sending somebody to a community pharmacy to find that that prescriber is not there that day. That just creates a barrier for next time. So, it's about communication. It's about IT. It's about systems that can talk to each other, and again, it works on relationships instead of process, doesn't it? That's the problem.

The question was asked whether or not it was health board or was it a role for Government. I think the problem that pharmacy has traditionally faced, and still faces, to some extent, is that it's almost like an ancillary profession that's, like, out there, and I'm not convinced it's part of board conversations at health board level. It always seems to be that the conversation is always on a lower level within a health board, and I think that's always been a barrier for community pharmacy. But like I was trying to say to you, we could see a 30 per cent or 40 per cent increase in prescribing capacity. If health boards aren't having conversations about that, there's something amiss, but I'm not convinced that they know or think or understand, as you're understanding now, what the potential is.

Dai, did you want to come back in?

There's an elephant in the room here, isn't there, because the Government would like to get more people seen, get waiting lists down, get the population needs met, but the health board's got to stay within a budget. As we start to deliver more consultations, our work increases and we get to see more people. Is the health board's target to meet the Welsh Government's target, or is it to stay within budget? Both are not compatible, I'm afraid. That conversation has to happen between Government and health boards of, 'This is what we want, this is your budget, but how do you measure that that budget is being used to achieve your goals?' And that's the elephant in the room. They're different agendas, aren't they?

On that point, you're spot on, because obviously I work in both situations and understand that. I think as well, though, there is a role for the Welsh Government to support us with some of the key patient messaging out there as well, in terms of prevention, taking more ownership on their own health as well, not wasting medication, as well, and things like that. So, if I'm trying to say to people, 'Well, actually, I'm not going to prescribe this to you because it's something you can buy over the counter', we do need to take into account deprivation and so on, but if that message is just coming from us on the ground, it's seen as we're not looking after our patients, so I think we all need to be consistent on that message too.

Maybe just saying that with that money that we are saving in those areas, we can spend that on other services and that you might find more benefits—making people understand that as well.

Yes, that's a key point on messaging. We'll make sure we note that strongly. Lesley, back to you. You're okay, are you, Lesley? All right. Thanks for that. Let's move into something we touched on right at the beginning, and I know Mabon's quite passionate about: digital.

Thank you very much, Chair. I'm going to ask my questions through the medium of Welsh, so I'll wait for the witnesses to put their headphones on.

We have touched on it already, but it was very interesting to hear at the beginning of this presentation by you about your feelings and views on digital systems. I wonder, to start with, whether you could expand a little bit on, I suppose, your frustration with the digital systems that are working in the NHS at the moment, and how they're working together, or not, with your systems in the pharmacies.

That's a great question. Thanks. I work in a very busy GP practice and I've previously worked in a hospital setting, so I understand the different IT systems. They don't really talk to each other, and that is an issue. We need to progress this work on the single patient care record. But even things just to streamline the work, the volume of workload, the sheer volume in primary care; usually the systems that are done to prioritise appointments, to allow patients to self-book, all of these kind of things, to allow patients to take more responsibility for their own health, they are brilliant systems, and actually they've transformed how we work in my practice. They come at a cost, so that is perhaps instead of, then, another member being added to the team. So, it’s whether or not we can have investment to support with that as well.

Let me give you a great example of an IT system that’s poor. We have a service in community pharmacy called a discharge medication review. So, when somebody is discharged from a hospital, we get an electronic discharge advice letter that comes through Choose Pharmacy, it appears on my screen, my technicians manage it for me. We reconcile the medicines that the hospital has prescribed with what comes down from the GP on the next prescription, and we identify any errors that could have occurred. So, massive safety, big research done on it and it works really well. This electronic discharge advice letter prepopulates Choose Pharmacy, there are no transcription errors, it's a really good system. The health boards have now gone to new transcribing systems within hospitals, and two of the health boards have adopted a system that does not talk to Choose Pharmacy. So 10 years after this system has been developed, two health boards persevered with a system that at this stage does not talk to Choose Pharmacy. So we're back to paper systems. How does that happen in 2025?

I think that we are starting to make progress. It's been slow in Wales. We have the electronic prescription service coming, but it's not fully implemented yet. But that is going to be great for the future of pharmacy and GP services as well. And the app coming will enable patients, hopefully, when it comes and launches properly, to see their one health record and give them ownership of their health and make sure that they can see appointments and take that ownership on for themselves as well, or help them to take that literacy on. So there are issues now and still issues to overcome, but we have made progress. I think we do need to acknowledge that it's taken us a long time to get here. And then we need to look to the future as well. We've got pharmacogenomics on the horizon. How are we going to manage that pharmacogenomics testing into our systems and how are we going to see those results as well? So it's what the future looks like as well. So we need to be preparing for the future, not just what the problems are now as well.

Thank you very much. Can you explain a little about what Dai was talking about now, that process where a new digital system has been introduced in one health board but it doesn't speak to a digital system that already exists? Do you know why that is happening? Where is the problem? Where is that blockage that leads to that? And do you have an idea of how that could be solved?

We have been informed that they are working towards it. The spec that the health boards were given included that it could talk to Choose Pharmacy. I'm led to believe that there were other advantages within that system that work better for the health board in terms of transcribing, prescribing in hospitals. So they made a decision based on the overall gain to the system, but it's warts and all, isn't it? That's the problem. And a decision was made by those two health boards that that was a sacrifice worth making in the short term. I don't know where they are with that at the moment in progressing it or how it develops. But it's symptomatic of the piecemeal approach that we get rather than a whole-system approach.

Thank you. That's a very clear explanation. What I want to get at, therefore, as a result of that, Dai, is whether there should be a national process in terms of national commissioning in order to ensure digital unity between all the players in the health system. Or do you think it could work within the arrangement that health boards commission separately from each other, like at the moment?

I think that's a decision between the health Minister and the chief execs of the health boards, personally. That's beyond my pay scale, I'm afraid.

That's honest. But just to follow on from that, you're not being communicated with, you're not being asked your views on these things. You said earlier, Steve, that you're second level. You've not got a seat around the table on these big decisions, and that's a clear example of that, is it?

Don't overestimate my importance please. [Laughter.]

Yes, it's an interesting one. I sit here and think to myself, 'How can we have, in a national health service for only about three and a half million people, decisions taken on different IT systems across Wales?' I'm sorry, but to me we should have a national approach, because someone, somewhere didn't consider the linkages with all the existing IT systems, and that has to be done.

I remember, when our Choose Pharmacy system came out, it was all about, 'Let's get an IT system that will plug community pharmacy into NHS Wales.' We started with the common ailments service. And then we added another service on, 'Oh, we're not sure if Choose Pharmacy can handle that. We'll have to make some adaptations to that to be able to do that.' Okay, the same process. A couple of years later, a new service gets on.

We have the crazy system now where we're trying to give flu vaccinations and we have all these firewall issues that are stopping our contractors from getting easily into systems. It's because we're private businesses, the laptops are privately owned, so the firewalls have to be in place, as opposed to in a GP practice, and we're just not thinking about where we're going and why can't we be plugged in properly with a system that's NHS approved that sits there and we can communicate with everybody else within the NHS. But it's like being able to do that part but we're not thinking about another, because that's what we need now.

Is that an issue between you and GP practices? I'm just thinking of our inquiry, looking at improving GP practices. Is that communication, that issue with the firewall and IT—? Is it the same in that—

No. The message will get to the GP practice, it's just sometimes hard for us in community pharmacy to actually do it.

I was actually going to try to bring it to the GP practice thought process, thinking that, actually, there are these frustrations at the moment with the systems not working, but if we had one single patient care record where you could access it when you did that DMR rather than then having to send a note to the GP to say, ‘Well, actually does this need to change?’, you've got systems and pathways set up where you've got access to be able to change things and own it, rather than—. The more steps you put into a process the more likely it is that there's going to be an error. So it just feels like where are we with a single patient care record where things can be adjusted.

Picking up on Helen's point, if I see a patient in my pharmacy and prescribe something, it goes via Choose Pharmacy and that gets e-mailed to a GP as a document on the back screen. It could be two weeks before that's seen. Going back to what I said at the start, if I had read and write access, I would be straight into that patient's record and the GP then couldn't inadvertently miss it. So it is about interoperability, but there's a cost to that as well, isn't there, and I understand that.

Mabon, back to you.

Thank you. One last question in the digital area, if I may, on your feelings about the use of AI, in thinking about collaborating with surgeries, GPs, sharing information, identifying problems, perhaps identifying the sorts of medicines needed. Do you think that there's a role for AI in this, and do you think that the Government and health boards are doing enough to understand the potential of AI and invest in it?

Many of my colleagues will think any topic with intelligence and me in it don't go together, to be honest. [Laughter.] There's going to be a role for AI isn't there? It's affecting all of our lives, everywhere. There'll be a lot of people, especially the demographics where I live in the Rhondda, who will mistrust it, who won't understand it, won't have access to it. It's going to be a big challenge. It's how we use it. We certainly can't duck from it, can we? If we don't embrace AI, we're going to get left behind, but where it fits into the system and how it's paid for is, again, another big question.

I think we also need to be wary of the governance behind AI as well, making sure that it is working correctly and just be mindful of how we utilise it. It isn't going to replace our workforce; it needs to be used alongside to support our workforce, but we need to be very, very careful as to how we use it. I think it's an evolving thing. I agree that we can't hide from it because it's coming, but we need to be really mindful that we use it carefully and with due diligence as well.

Thank you. A slightly different subject now, if I may. It relates to infrastructure. In terms of the buildings infrastructure that we have in Wales when it comes to surgeries and pharmacies and that collaboration, you have touched on it already, but do you think that the infrastructure that we have and the buildings that we have are fit for purpose, considering the requirements and the ask of GPs and the working with you as pharmacists?

Liz.

I think, no, our estate is not there. We have got some new modern buildings that are really fit for purpose, but there are lots of antiquated buildings with limited space, not enough patient access, or difficult patient access. So, even with the best will in the world, if you wanted to employ a pharmacist, where are you going to put that pharmacist into that building? You do want them to have the opportunity to be part of that multidisciplinary team, to be able to go and knock on that doctor's door, to have that query about a patient. So, you do need to look at room space across all the estates, really, and have a true evaluation of what we've currently got, what the requirements are, and also possibly how we are going to make it green for the future as well. So, are the estates we've got working in the best way for the environment as well?

Dai.

I put down, 'no', that it's not fit for purpose, so we're on the same page, 100 per cent. It's a difficult question. We've only got to look at Princess of Wales Hospital with the roof and the issues. The whole of the NHS estate is in a poor state.

We have, for the first time now, last year was when we had a grant for premises improvement within pharmacy, up to 45 per cent. I've been lucky enough to get a grant this year to put an extension on the back of my pharmacy to try and increase the number of consulting rooms to a proper standard. I've still got to find £150,000 of my own money to do that. That's a massive investment at my age, where I'm thinking, 'I'm not sure where the future of primary care is.' So, yes, the infrastructure of our estates is poor. It does need investment, but it's not just the investment, it's the confidence of the people working in it to think that the risk is worthwhile of putting that investment in. So, unless you can get the assurance of a plan for primary care and confidence that it's worth investing in, then the key players won't invest in those improvements.

Steve.

Yes, it's that following on from what Dai's saying. I think, particularly from the pharmacy perspective, which I guess was part of the question, we do feel a little bit like a poor relation. We're still seen as private businesses. We're not really embraced as part of primary care, even though now these days, for most independent pharmacies, 95 per cent of their business is NHS business. It's changed dramatically.

So, if we're part of primary care, then we really need access to the estates funding that the rest of primary care has, and to get rid of some of the crazy anomalies there. For instance, a GP practice will pay business rates, a pharmacy practice will pay business rates. The GP practice sends the bill to the NHS, to the health board, to pay it; the pharmacy practice puts its hand in its pocket and writes a cheque. Either we're part of primary care or we're not, and if we are part, then 'Please treat us as equals in primary care' is the plea.

Yes, okay. Thanks for that. Helen.

So, agreeing with everyone in terms of the building infrastructure. Some of the newer buildings absolutely are fit for purpose, but particularly in the Rhondda where we work, some of the practices are old terraced houses, site buildings. There's a lot of damp in there. I remember one practice where we couldn't actually print prescriptions because the printer was becoming damp all the time. So, it's working in these conditions.

If we want to develop the professions and have multidisciplinary teams, we need more space for people to work in. So, it's making sure we are being innovative, we are doing things like hub-and-spoke models, but that's not the answer everywhere. I think we've got to remember why we're doing this: it's for our patient cohorts as well. If care is shifting left, we need to make sure that we've got enough room to sustain that care left, so we are at the doorstep of these patients.

Thinking about some of the simpler things for me is, whilst we may have better rooms, we might not then have parking facilities. Would there be something in making sure there are transport facilities to be able to get patients to and from appointments? Thinking about the greener agenda, that kind of thing, so that not everyone is jumping in the car and so on. Just things like that, really.

Yes. Okay, thanks. Thank you, Mabon. I'll move us on to Altaf and primary, secondary care interface. Altaf.

Thank you very much, Chair. I know we are running out of time, but I will try to keep my questions short, and if I have short answers as well, please. What fundamental system and communication reforms are required between primary and secondary care to establish safe, accountable and clinically joined-up patient pathways?

Sorry, would you mind repeating the question, I couldn't hear it properly? Sorry.

Right, I will. What fundamental systemic and communication reforms are required between primary and secondary care to establish safe, accountable and clinically joined-up patient pathways?

To keep it short, at your request, a single patient care record would be the main answer for that, I feel.

I agree, that's basically what we want, all community will be able to access it, primary care will be able to access it, and at discharge that discharge will just automatically be on that patient's record. There wouldn't be having to be that duplication or transcription where we know the errors occur, so I think, yes, that one health record.

I agree. Is that short enough?

Right, okay. Now coming to the public understanding, my question is: to what extent is your specific role and contribution as a member of the multidisciplinary team understood by general practitioners, GP practice staff, and the wider public?

Okay, that's Steve.

I think it's one of our biggest issues. I'll be honest with you, we have loads of wonderful services in community pharmacies, and people are finding out by word of mouth. That's the way that we're getting there. I do think if we're going to move patients to go to certain places for their care, then we really do need to think about national campaigns to do so, along the lines of, 'Yes, this is where people should go for their common ailments, move to your community pharmacy, not your GP practice', or, 'By the way, do you know they can now treat your sore throat? Do you know they can handle all urinary tract infections? Do you know?' I bet the answer is—. I bet everybody in the committee doesn't know.

I think you're right. [Laughter.] Helen, and then I'll come to Joyce.

Just to reiterate that as well, I think some campaigns are key for patients to be aware. Only recently, I had a conversation with a patient to say I was going to conduct his asthma review, and he said, 'Well, why is that you and not a doctor?' So, these perceptions still exist, and I had to explain why it was within my gift. But I think as well it's managing the message, in terms of that it's not always going to be a prescription or a medication at the end of it, because we know there's overprescribing. So, we've got to check the message we send out, and we don't want patients coming to us thinking that they're going to come out with a bag of something, because that might not be the answer.

Yes. Thanks—

Thank you very much. Chair, I have the last question, really—

Can I bring Joyce in for a minute, Altaf?

We did have a national campaign, because I remember seeing it, and being quite delighted that it was on the tv. So, my question is this: is it the right place to put a national campaign? People are accessing their information in different places now, and I think many surveys have showed that most people aren't even accessing the news on the tv anymore. So, is it the right medium? Because I know there was a campaign, and I know the Welsh Government put a lot of money into it, and I was behind pushing for that to happen and understanding the difference that you make. Maybe it's rethinking those campaigns, and where the message is dropping.

I think we overestimate, people of our generation, how people access information, okay? We had a COVID vaccination clinic in one of our pharmacies five years ago, and we had a message from the health board saying we could do a walk-in clinic on the Sunday. It was appointments the week before, it was a walk-in clinic, we had 200 appointments booked in. So, the pharmacist there put it on Facebook, 'We're having walk-in appointments', we did 500 vaccinations. That Facebook message got around the village within two hours. So, if we want to make a cultural change—that's what we're talking about, aren't we, a cultural change in the way the public access the NHS—we have to look at how the public gain that information and engage with that campaign. Because we think that they will access the information in the way we access it, and they don't—you're right, Joyce, they don't.

So, we agree on that.

We do agree on that, yes, 100 per cent.

That's a good point: go where people go. Yes. Thank you, Joyce. Altaf, you had something final you wanted to ask.

Yes, Chair. I wanted to say what has been already said, but let me repeat it. What targeted strategies are required within both primary care and public health campaigns to enhance this awareness, improve appropriate patient signposting, and ensure the effective and safe utilisation of the MDT while maintaining the ultimate clinical accountability of the general practitioner?

Okay. Does anybody want to—? It's a big question, but how can we improve some of those?

And it tells you about the accountability of the general practitioner.

Yes, yes.

The simplest answer? What I said at the start: get a plan for primary care. Get a plan for primary care, see what you want primary care to actually deliver, and then start looking at who can deliver that within that team. But until you've got an overall plan, how can you start making plans for that?

Using public health data to inform that based on your populations, and then using the education work streams to try to educate patients to take a bit more responsibility as well, whether that's with their appointment follow-ups, or whether that's actually trying to maintain their own health as well.

Yes. Liz.

I think it's the education, as well, of the future generations—how to access medications, what the benefits are of the health service, keeping that younger generation healthy, preventing them getting into ill health as well.

Schools. Again, it's schools.

Schools.

Can I ask a final question?

Yes, please do.

Because you just made me think about something. The younger generation are likely to use the same online advice and buy medication online, which we know—there are cases coming to light—that it's not what they think it is. That's the first thing. And it's costing people their lives or long-term illness. I'm sure you see that, because people will say, 'I had this online, it was cheaper.' So, there's another bit, isn't there, of work that has to be done, and it is that access to information and how we counter that. It's a huge question, and I don't know if you've done any thinking around it.

It's about where that trusted advice comes from. It's about relationships. The number of times I get a phone call from someone, 'Can I ask you something?', 'Yes, of course you can, fire away.' If they've got a face that they know, that they regularly see, and they trust you, they're more likely to listen to the advice you give, aren't they? That's about embedding healthcare professionals in the community where they work. Become part of that community, and you're more likely to effect the change you want.

Yes. Those are wise words there.

A nice way to finish.

For the younger generation, I think we need to be mindful that they may be accessing that education from different sources, so how do we get that—? The face of Dai would have been the trusted individual; how do we get that across to the individual in the future going through the internet? How do we say that, 'This is a trusted website, this is a trusted source of information'? I think that medicines misinformation needs to be key, as well.

Yes. And it goes hand in hand with that thing we talked about: AI. AI's got lots of strengths, but is a massive threat. How do you take confidence that you're not reading something that is totally incorrect? We hear evidence of that all the time.

I'm conscious that we're running out of time. Steve, is there anything you wanted to add to any of the last couple of questions?

No, I'm happy with the responses. I'm not going to add something for the sake of it.

Well, this has been an absolutely fascinating session. We're actually just spot on time. I really do thank you all for your candidness and clarity on what's needed. There will be a transcript available for you to check over. If there's anything you feel is misinterpreted or whatever, please feel free to contact us. But, once again, thank you for giving up your time for such an important discussion.

Thank you very much indeed.

Thank you for the opportunity.

Thanks for the opportunity.

Thank you. Thank you, colleagues. We're going to move into private now for a session for lunch, okay?

Good afternoon, everybody. Welcome back to the Health and Social Care Committee, where we're in the process of taking evidence sessions for our inquiry into general practice in Wales. This is our third session today and I'm delighted to welcome members of our health boards. Perhaps I could ask you to introduce yourselves for the record; could I ask you first, Paul?

Prynhawn da. Good afternoon. I'm Paul Mears, I'm chief executive of Cwm Taf Morgannwg University Health Board.

David Andrews, I'm a GP in the Rhondda and I am the medical director for primary care and community services at Cwm Taf Morgannwg University Health Board.

And Elaine, online.

Prynhawn da. Good afternoon, everyone. I'm Elaine Lorton, I'm the executive director of primary care, community and mental health for Powys Teaching Health Board.

Thank you, Elaine. Unfortunately, we were going to be having some other representatives, but they couldn't make it toward the last minute. So, thank you so much for making the time. This is a really important inquiry and it's really interesting and so important that we have your perspectives.

We have several questions. We've got about an hour and a quarter, if that's okay, and we'll try and get through as many of them as possible. Perhaps if there are any follow-ups, you won't mind if we write and we can chase those with you.

Anyway, I'll kick off, if I may. How does health boards' actual spend on general practice compare with the amount allocated by the Welsh Government for the general medical services? It would be really helpful if you could give some information around how that's changed over the last few years, and a broad insight to where we are on that.

Do you want me to start off and then Elaine can come in?

Yes, please do so. Elaine, if you put your hand up—not your electronic hand, just put your ordinary hand up—and I'll bring you in.

Thanks, Chair. As you'll appreciate, the health boards have an allocation of resource given by the Welsh Government for the totality of what we are responsible for, and that includes, obviously, primary care and GMS contracts for GPs. There is other money, obviously, that comes through for various allocations for different specific projects. For example, the work that's been done around cluster development has been funded through different resources that have come into health boards.

I think it's fair to say that the allocation for primary care, when you compare to what we spend on hospital care, is definitely significantly lower, and has been the case for quite a while. Obviously, with the pressure since COVID to continue to improve waiting times and reduce waiting times in planned care and urgent care in hospitals, that's led to quite a bit of extra resource being put into the secondary care part of what we do.

But I think we've got a collective ambition across Wales now to start to rectify that and start to bring the resources back into primary and community care, because, as we all know, the ambition through 'A Healthier Wales' and through everything we're trying to achieve in the health service in Wales is to try and look after more people in their own communities, provide more support to people in their own homes, and primary care and GPs in particular are critical to that.

If we're serious about that, then clearly the resources need to follow the rhetoric and we need to think about how we, as health boards, improve the way in which we allocate resource towards primary care. But also there's a conversation, I think, about how, within Government, the resources that get allocated to the agenda around primary care, and GPs in particular, can be reflective of the ambition.

Do you think, with hindsight, that perhaps the decision to, not disinvest, but to prioritise resources in other places has become the wrong decision?

Obviously, as we came out of COVID, there was a large backlog of activity in hospital waiting lists that needed to be addressed, and clearly, understandably, that's been resourced to try and improve that. But, of course, when you've only got a finite pot of resource within the Welsh Government, there then have to be decisions about other things that haven't been given the resource that's gone into other things. So, I think that has been the case, but I think that we are starting to see that change now. Clearly, there is a drive, and we are certainly being asked, as health boards, to look at how we reprioritise and reallocate resource into primary care. We're also being asked to report on now the percentage of resource that we are spending in primary care compared to other services, and being able to articulate how that's going to increase over the next few years.

Thank you. Elaine, would you like to come in?

Yes, to add to the points Paul has made generally about the allocation that we receive each year, and then in terms of how we spend that within health boards, equally to think about what's happened to that level of funding over the last few years. We know that the total proportion of money that is allocated and spent on GMS is a much smaller proportion now than it was, say, eight or 10 years ago. I think it's gone from about 9 per cent to about 6 per cent. That doesn't mean that general medical services have not seen uplifts. There have been uplifts, and those have been negotiated annually, but the total spend in terms of primary care and general medical services has reduced.

I think it's very difficult to say whether it's a right or wrong decision. I think the question is what are the outcomes that we are looking for. As Paul mentions, coming out of COVID, there was a significant list of people waiting for planned care procedures, for example. We know that we have rising demand and a rising demographic across Wales, particularly around older people who require unscheduled care treatment; they need to come in and they need to be supported.

My reflections on that are that I believe very strongly that, if we have a really strong whole primary care system, which sits not just within general medical services, but how general medical services, as the medical leads within our community, link in then with wider community service delivery, I genuinely believe that can have a much larger and positive, proactive and preventative space, so that we are earlier in how we're caring for people with chronic conditions, and equally, that our older or more frail population can access more responsive, proactive care, to mitigate and reduce the need or the length of time that they need secondary care treatment. I think that's something that, without thinking about how we're allocating our resources, which we are looking at within health boards, but more broadly across Wales, is always going to be constrained.

Thank you, Elaine. David, did you want to add—?

I guess I'd like to acknowledge that a well-resourced and well-functioning secondary care service, both in the planned care space and unscheduled care, benefits general practice, but at the same time I echo what Paul and Elaine were saying. If we're serious about resetting the agenda and thinking of the medium to long term future of our services, the status quo is not that way forward. So I would agree that, certainly in Cwm Taf Morgannwg, we're looking considerably at investing left, as we say, to try and work through those challenges. It's an iterative process and a progressive process, it’s not a single IMTP. It's a while.

Thank you for that. It looks like things might be heading in the right direction. Elaine, you already pre-empted, perhaps, a question I wanted to understand a little bit more about: what the levels of investment are, or rather funding as a percentage of the whole going into GP practices, primary care. Do we know how that varies across health boards? Because the reality is, even though there have been additional cash uplifts going forward, we're talking real-terms cuts, really, to primary services, because they're not keeping up with the demographic need, I doubt. And that's why I was pleased to hear, Paul, that that might be a change going forward. But some sort of clarity of understanding where we are on figures at the moment would be useful.

Both the GMS and the supplementary services budget are ring-fenced and come straight through, so we have very little discretion with regard to that. And actually, with contractual barriers, it makes it very difficult to take anything from it or to put anything into it. That's quite tricky.

Okay, that's really interesting, to understand that even if you wanted to add in for some preventative agenda, you might not be able to do that.

There are things I think we can do through supplementary services, so, if you like, add-ons to the GMS, but the core GMS has a very clear contractual negotiated set of expectations within it. Anything we want to do on top of that is something we would then negotiate at a local level through the local medical committee or other professional bodies. So there are ways you can do this, and I suppose this is where the definition of what is the primary care spend is really important, because as Elaine and David just articulated, there's GMS spend, which is the general medical services money that comes straight from Government, which is ring-fenced, but of course then as health boards we're also spending money on community services sitting around primary care, so things like district nursing services, community therapy services—those are obviously discretionary funds that we as health boards fund, and that's entirely within our gift to look at how we resource that. But in terms of core general practice contracted funds, it's the GMS ring fence.

Just to add to that, I think it's really important to point out that, when we're thinking about the utilisation of those ring-fenced GMS funds, a significant portion of those sit within supplementary services, and the delivery of supplementary services sits at the discretion of the general medical services, not at the discretion of the health board.

There will always be some variation across Wales in terms of how much those supplementary services are delivered between different practices, and the quantity of activity that is then delivered and claimed for, because different practices are all in their own individual position in terms of their workforce, their competencies, and which of those supplementary services they feel able to deliver. What can be quite challenging from a health board perspective is a desire to expand and grow those supplementary services, and yet it is only throughout the year as we see them being claimed that we understand how much resource that requires.

I think most health boards have got to a position where they are in a reasonably balanced state. I can only speak specifically for Powys. I know that I'm spending all of my GMS allocation, all of my supplementary services allocation, on that, but it has taken some considerable time to do that. We've got quite an extensive list of local supplementary services that we've delivered, but every single health board has a set of those.

On the actual GMS funding, that quantum is set, and that would be similar in all authorities. So, that's whatever it is, and what sort of figures did you—? Elaine, you talked about it being somewhere around about 5 per cent of 6 per cent now, as opposed to 9 per cent, perhaps, a few years ago.

Yes. I think we're just over 6 per cent now in terms of total health board allocation that is spent on GMS. That's across Wales. I think, eight, 10 years ago, we were about 9 per cent. So, there has been a reduction in the proportion, but there hasn't been a reduction in the amount.

Thanks for that. Just looking at systems, I just wondered what systems and processes you use as health boards to monitor and report spending on primary care. What are the main challenges in producing a clear and consistent picture of how the funding is changing over times? Do you keep that sort of data? Elaine.

Yes, I'm happy to come in on that. I recognise I'm a little bit quiet, so I'm not quite sure how to change that. So, in terms of the reporting, our shared services partnership provide us with monthly reports, both in terms of the amount of activity claimed through supplementary services and then the amount of spend. So, we can see that on a month-by-month basis within health boards.

Anything else?

No. I absolutely agree with Elaine, and, as I said, we're now being asked by the Welsh Government to actively report to the Welsh Government regularly on the amount of money being spent in primary care, and also community services as well, which I think is an attempt to try and make sure that we're able to encompass the whole spend that we're deploying in that area, because, obviously, GMS is one part of that, but there is also money that we as health boards are spending, then, on community-based care, supporting practices as well.

So, the health boards, whilst collecting that data, are pretty familiar with the challenges, then, that are being presented in primary care. So, the health boards were aware of the pressures there, in primary care.

Absolutely. Obviously, just as people like Elaine and other colleagues in other health boards, we have primary care teams who are very close to the primary care world. They know the practices, they are in regular communication with the practices. We have, certainly in our organisation, good relationships with our local medical committee, which is the formal body that acts as the interface between general practice and the health board. We are very well sighted on the challenges both from a funding perspective and also pressures, demand. If there are particular practices that are in difficulty or are having some challenges, that will be flagged through those routes. So, I think, as health boards, primary care teams are very well used to that relationship with general practice on a day-to-day basis.

Okay. Elaine.

Just in terms of that point about sustainability, across Wales there is also a monthly escalation criteria and submission that each practice submits in terms of their level of sustainability challenge. So, every month—I think that's reviewed more formally on a quarterly basis—we get a monthly report around the level and the number of practices at level 1, 2, 3, 4, through to 5, and '5' would be an immediate critical sustainability challenge.

Thanks for that. I'll hand over to Joyce, if I may.

I'm going to ask you about strategic planning and the data and source of information that health boards use to assess the needs of their local population, and how the evidence is used to inform a health board commissioner of general practice, and also primary care service.

I'll give a perspective from our organisation. Obviously, we have a great deal of intelligence from activity that's going on already. We have a lot of information from our local public health teams, who are able to talk to us about the particular health inequalities issues, the health outcome issues in particular wards or communities in our patch. In CTM, we're fortunate we have quite a detailed population segmentation tool that enables us to see the particular needs and requirements practice by practice, so we can understand what those issues are. Clearly, that helps guide how we then plan and develop services, recognising that, whilst there's a lot of commonality between practices, there are some variations, and particularly, when you expand that out across Wales, there will be different variations between different local communities. I think it's fair to say that, historically, some of that information hasn't been as easy to get hold of and play into the strategic planning perspective. Sometimes we've had more data available to us about hospital activity and services, and so that can sometimes be why some of the attention falls on that area. But I think, certainly in our organisation, we are now bringing much more of that local intelligence through from our population health data and primary care data into our planning processes so that we can make sure that we are really focusing on how we plan at a strategic level for prevention and interventions early, upstream, rather than just focusing on dealing with people when they're coming into hospital and the activity that then is generated. Elaine probably wants to give her perspective.

Come on in, Elaine.

I think that there are multiple layers of this, aren't there. From a regional footprint, there's a formal mechanism to look at the population needs and health needs of our population on a five-yearly basis. Then, at a health board level, through our IMTPs or our annual planning processes, we have to review and refresh that. And then, coming down to individual clusters, collaboratives, and then specific practices, there is information. So, everything from specific chronic disease templates all the way through to more broader population health and well-being information, that's available, and we bring that together, again, dependent on the level and the population or the geographical basis of our planning. We bring it together regionally when we are working in the regional partnership board, we bring it together in our health board in our annual planning process, and we bring it together in clusters and collaboratives as well, as they are developing their IMTPs each year—or reviewed and refreshed each year for every three years. So, there are multiple layers of the planning activity that happen from clusters, and individual practices and individual providers will deliver their own plans all the way up to that regional perspective.

Does that data take account of the complex patient needs, the increased workload from secondary care, administrative demands, for example? And do you think that that data could be improved, and where would you like to see it improved in order to improve planning, if that's the case?

This is part of the conversation. In fact, we were having conversation with David and some of the associate medical directors this morning about this very topic, because clearly there is tension. As we try to move more services out of hospitals into communities, the workload potential for GPs becomes ever more increased, and we need to be trying to work with GP colleagues to mitigate any impact, because what we don't want to do is just overload even more GPs who are already busy with very full day jobs. Having said that, I think there is an opportunity for us to be more innovative in how we work together across GPs and secondary care hospital colleagues, because we've got to a place, I think, over the years, where there is quite a big divide between hospitals and general practice. Certainly, what we're trying to do in our neck of the woods is bring that back together a bit and say, 'Well, actually, the person at the middle of this is the patient, and they don't really appreciate the differences between general practice, secondary care, different funding streams; they just want to be getting the service they need when they need it.' And it's our responsibility, I think, to make sure we do what we can do to join those services up. So, a key part of what we're trying to do is think about how we bring those things together.

I also think the digital opportunities in this space are significant. We're still working in quite manual processes a lot of the time. We do have electronic referrals now between primary care and secondary care, and that process seems to work well. I think, where things start to get a bit difficult is when patients are referred back in, come back home or go back to their GP. There can be a feeling that, in primary care, the work that is required to follow that patient up, whether that's blood tests or further monitoring, then gets handed back to the general practitioner, when, actually, would you not argue that it should be the work of the hospital doctor to monitor the ongoing implications of the treatment that they started. So, I think there is still quite a bit of tension around that particular interface, and that's difficult because it isn't always something you can quantify or describe in terms of it being this much time or this many hours or this much activity. But I do think there is an opportunity for us to join up a lot more those relationships and get those conversations going more actively so that the needs of general practice, and their role in that pathway of care, are understood by hospital clinicians as much as GPs understand the hospital doctors’ perspective. I don't know, but Elaine might have a view.

Can I just, before—?

Yes.

Is there a greater complexity, then, when that patient's out of the local health board, which will happen frequently in Wales, and then the interface with the GP in delivering it?

Obviously, if somebody, to take our example, living in Cwm Taf Morgannwg goes for a treatment in Cardiff for a specialist service, then clearly that's a different interface then with a different health board. Elaine, we will have that in the north of our patch with Aneurin Bevan patients coming to Prince Charles Hospital in Merthyr and going back to AB. So, there is that, and that's why I go back to that point about the digital interface. It shouldn't be dependent on which health board you've come from, enabling you to get the right information. We should have a standardised way of that information being shared back into the GP record so that, regardless of whether you've been treated in your own health board where you live or you've gone somewhere else, there should be the ability to see that information about the patient. So, if David had a patient who'd been into Cardiff, he could see the same amount of information post discharge of that patient as he would do if it was a patient who'd come from our own health board. So, I do think the digital record and electronic record being able to be shared actively is where we need to be getting towards to really streamline that.

I agree. It's not that the information isn't somewhere, but you have to go looking for it, and that's burdensome on an already busy person. Coming back to what you mentioned, I think that the majority of GPs would certainly say that, over the past decade, it certainly feels like an awful lot more administrative and clinical tasks have been delegated from the hospital into the general practice, and many of them will be reasonable. I think that there are some things that are less reasonable than others, and communication is the key part of it, and if communication is not prompt, that's where we run into problems. General practice and general practitioners are well placed to undertake at least some of the delegated work. The tricky thing is that they're not necessarily resourced as appropriate because of the funding envelope that we discussed earlier. That's where some potential for conflict arises. Of course, the problem, then, with our silo working is that we don't necessarily think about that person in the middle of it all whilst we're squabbling. I think that we have to make it smoother.

Elaine, would you like to come in?

I think I see three elements to this. On the information that we've got to help us with our planning, I think we've got a good level of information there, and we can bring it together for those elements and for those activities. I think there's then a question, for me, around whether we know and whether all of that information is equally shared. No, it isn't. I know, within my health board, that we have an abundance of information that we look at as a health board on a regular basis to think through what we're doing and how well we are performing. At the moment, the level of specific GMS or primary care information is low, so we're doing some work to try and increase that, to make it more visible, to make it more clear, because I think that there is misunderstanding sometimes around the work that happens in general practice, the quantity of it and the impact of it.

Then there's that piece that Paul and David have just been speaking about, which is, on a patient-specific basis or a patient-identifiable basis, whether we can join the dots between every single health, ideally, and social care provider, and maybe third sector provider, around the interventions, support, activities that happen, whether those are within our geographical area, whether that's a health board area or a cluster area, or whether that sits outside. For Powys and our population, the vast majority of our secondary care services are delivered outside of Powys by other providers. So, the information that we have on that will be limited, particularly if we cross the border and go into NHS England and the providers there, then the information we have there is less; we have to wait for letters and we have to wait for that kind of communication.

So, I think that digital piece, what is possible and what would be ideal in terms of managing whole care pathways, whole-system care pathways for our population, which requires us to use all that digital information in a place that allows that assessment. And from a general practitioner perspective, a holistic assessment and the whole variety of interventions that are happening with and for people, that at the moment isn't where it needs to be. I would be incredibly hopeful and supportive around development and better development of that across Wales, but also for me in Powys, I've got to look very clearly at what happens in NHS England in our neighbouring organisations that deliver care for our patients also.

In terms of the strategic shift of NHS resource towards primary community care—and we've talked about it being reversed—what mechanisms are in place to ensure that it's adequately resourced? I might as well go on to the next area. You've already mentioned Welsh Government recognising that GPs can have a much more prominent role in cutting lists, delays and improving patient flow, amongst other things. So, that's the strategic direction that's been announced by the Government, but you've also got to have a plan in place to deliver the shift of NHS resource. What would inform those choices beyond a Government statement? We talked about data, obviously, just now.

Can I just come in? So, just on that point, I think when we talk about resource, obviously it isn't just about the monetary resource; it's also about the people resource. If you think about the area of chronic disease, such as diabetes or heart failure, a lot of those services today still sit largely in hospital-based care. They're still being delivered in out-patient departments, they're still being delivered in acute hospitals. We're asking people with long-term chronic illness to get in their car, drive, park, sit in an out-patient appointment for perhaps a 10, 15-minute consultation with a clinician, and then go home again. What we're trying to do is say, 'Well, actually, if we're serious about this moving of services out of hospital into community, we need to be looking at all of those sorts of services and thinking how that could be done in a different way.' Because, actually, for these people living with long-term chronic illness, the large part of their chronic illness is being managed by their local GP and their practice nurse.

We heard a very interesting story this morning of an example from Cardiff, where in paediatrics now in Cardiff, the paediatricians are coming out into general practice on a monthly basis to meet with the GPs and the practice nurses to talk about the complex children who are being looked after by the hospital doctors, but also by the general practitioners. And they're talking together about how they can support each other. That GP now has a named contact paediatrician, so that if they've got a worry about a child, they can just contact that doctor in the hospital directly, thus reducing the need for the patient to travel, but also ensuring that the GP can get accurate, up-to-date advice and information quickly to make a decision about, hopefully, keeping that person in their own home and managing them in their own community. I think those sorts of models of greater degree of integration of hospital specialists coming out into general practice is part of the shift of resource we need to make.

I know when we talk about shift of resource, we always immediately think about pounds and pence, but it is also about people and resources. We've got lots of, for example, specialist nurses in respiratory disease or in heart failure, who again are sitting in hospitals, who could be out working in community settings. We've got diabetic podiatrists working in in-patient and hospital settings. They could be working out in primary care.

So, to your point about how we're doing that, certainly in my organisation, this is part of our transformation plans around primary and community care, where we're starting to look at how we develop robust structures in primary and community care, because to do all of those things I've just described, you need to make sure your core general practice is sustainable. But we also then need to be thinking about how do we, as a health board, start to signal to our hospital-based clinicians that the future in some of these specialties is going to be much more outside a hospital wall than it has been to date. Candidly, that is a cultural and mindset shift we're going to have to make with many of our clinicians who've spent many, many years sitting in hospital out-patient departments, seeing patients coming through their doors.

Can I bring Elaine in, please?

I think this is really interesting. So, I came to Wales 13 years ago, and I asked, 13 years ago, whether there was commitment in general practice and investment in general practice, and was told, 'Yes, there is', and yet, during this period of time, we've also seen that reduction in the proportionate amount going into general practice changing.

I think I also need to say that general practice already sees a significant number of people. So, if general practice is already delivering between 85 and 90 per cent of the contacts that our population receives from healthcare, we're talking about a small increase in activity, but it has to be meaningful. I absolutely agree with Paul that it's not just about GPs doing everything, and GPs doing all of this. So, our wider community services, and being able to bring our specialists out from the secondary care sector into primary care, to provide consultations for our population, but also education and peer support for our primary and community services is really sound and really solid.

When I think of Powys, though, I also think of our geography, and I think about the distances that people have to travel. Those are all single-track roads, those are all slow distances, those might well be distances for people who don't have easy access to transportation. So, the use of digital, the ability to connect with people where they are, and the ability to link our skill sets. So, I'm quite happy, for a large number of specialties or interventions, that if I've got a clinician sat in Prince Charles Hospital or somewhere else in Wales, able to connect in to a patient who's sat in Welshpool, with community staff there, we can start to have collaborative approaches, and we can start to use the skill sets that we've got across Wales differently. So, some of it is about physically coming out, some of it is about making sure those relationships are there, and that works for planned care.

For unplanned care, for the emergency that happens today, for somebody who needs an ambulance or possibly needs an admission, actually, that's about us having the right social care and healthcare resources wrapped around the people at place. So, you've got different responses that are needed, both in terms of a really strong, productive, preventative primary care model; you've then got different opportunities for planned care, and changing pathways and bringing colleagues of different specialty and different professions together; and then, I think, you've got a different proactive preventative in the community wrapped around your population response for unscheduled care. So, I think we need to be really careful and clear what it is that we're looking to achieve, and where we want to start. Because, actually, resource change, skill development, growing different pathways, does take time and, therefore, you need to be able to prioritise which of those activities you commence first.

Can I bring Altaf in a minute, please? Altaf.

I just want to make a small point, Chair. Paul, you might know that, over the years, during my consultant career, really, I would go to community hospitals. They, unfortunately, were closed. So, this is not a new thing. We have been going into the community. I would go from Prince Charles to Aberdare one week, and the next week I would be in Mountain Ash. So, it would happen everywhere, both in England and Wales. Now, the change is that we would be investing more money into GP surgeries, which are clusters we have formed, which is a new thing, because community hospitals are no more there. That's the point I wanted to make.

Do you want to reflect on that, Paul?

Yes, I would agree with Altaf, but to say we still obviously have the community hospitals—certainly, in my patch, we still have community hospitals—and there are a large number of out-patients that are being delivered there by hospital consultants coming into community hospitals. I guess, for me, it's about taking it to the next level of saying, 'Well, actually, how do you take that even further out there and have those conversations with general practice?' So, I think, to Altaf's point, that's effectively moving the out-patient out of an acute hospital setting into a community hospital setting out-patient clinic, but what I guess I'm saying is how do we take it to the next level to say, 'Let's get that consultant having conversations more actively with the general practitioner', which I know many of them do—don't get me wrong; I'm not saying otherwise—but it's how we do it in a standardised way, in a uniform way, so that it's consistent in all specialties.

If I can move us on to the next area, I'll bring Elaine in and you can answer both together, but can I go on to this one first, because in order for you to answer the question I'm going to ask, it's relevant? What we're hearing from general practice is that they're often excluded from those strategic decision-making and design services. So, do you think, in order to do the things that we're talking around this morning, that they need to be included more in the health board's deliberations about the next steps?

Elaine. Come on in, Elaine.

Yes. So, what I was going to feed back to you, Altaf, was just that I've only got community hospitals—I haven't got acute hospitals—so they're alive and well in Powys, and I know they are in other health boards. I suppose the question is: what goes through there and how do we manage that, and as Paul says, how do we grow that?

But, Joyce, I suppose, thinking about your question there as well—. No, you're going to have to come back to me because I've had a menopause moment and it's completely left my brain. Apologies for that, Joyce. I'm going to defer to Paul and then come back to you.

David.

As a GP, of course I'm going to say that I think that GPs should have more of a seat at the top tables. I mean, there are structures in place technically for this. Our local GPs vote for members of their local medical committee and their local medical committee meet extremely frequently—formally monthly, but we speak three or four times a week with our local medical committee—and that's useful, because of course it's not possible for us to speak to hundreds of GPs all of the time, so it's quite useful. The LMC do have a key role to collate themes and needs and wants and challenges and so on. So, the structures are there. We, in CTM, also have appointed three GP transformation leads, as we call them, who sit on our primary care transformation board. They also happen to be collaborative cluster leads in our patch as well, so our burgeoning GP leaders, and I think that we are going to be appointing a board director as well. So, the answer is 'yes', and we're doing it.

Yes, I absolutely agree with Joyce. There is a real need, I think, for us to elevate the GP voice within health boards, and as David said, we are, as a health board, looking to appoint a GP as an independent member on our board, so that we will have a GP in the room at the board. And that's not just to talk about GP issues; it's also to get a GP perspective on any issue that we're talking about in the health board, because we want to recognise the fact that most patients start their journey of healthcare in a GP practice, and actually it's really important, therefore, that we understand the GP perspective on all issues, whether that's a mental health issue, whether that's an acute hospital side of things. I think there is lots, also, of really good leadership in GP clusters. We've got good GP leaders who've stepped up in clusters and have said they'd like to be more actively involved, and I think there's an opportunity for us to do that. I also think there's a piece of work that's recently been started with the new chief medical officer, who is developing a programme of support in primary care and she, as part of that, is wanting to talk about, from a professional perspective, how she as the CMO gets more of the GP voice into the bigger strategic conversations in Government as well, because I think it's about that at every level, in clusters, in health boards and in Government, we need to be making sure that the perspectives and views of GPs are being listened to and shaped, and that we're able to work with them on that agenda. So, hopefully, that will start to improve things.

Elaine, come back on in.

Yes. My brain has returned. Thank you. I think that there are existing mechanisms to enable general practice and GPs to engage in strategic thinking and strategic discussions, but I think there's a fundamental piece, which is that there has to be capacity for them to be able to do that. So, when we're talking about releasing clinician time to do that, that means that they're then not available to deliver direct patient care, and, if we don't feel there's enough capacity to deliver direct patient care, how do we engage and how do we ensure that we are getting that voice, that perspective, those views, at each point that we need it?

So, within Powys, we're going through a transformational journey at the moment called 'Better Together', and we've taken several points through that (a) to try and recruit GPs to be part of that and pay for sessions of time to be in that space, then to be part of wider engagement events and to have specific events that we come to them. There are also the clusters and the collaboratives and there are other pieces of work that we do. That will work for a small number of GPs who will come and engage with us. It won't work for every single GP. So, there's also something for us around how do we work with all of our clinicians, all of our staff, because I don't think this just relates to GPs. We haven't talked about other important people that we have within primary care or within community care. Actually, we need all of those collective voices together to help us make the right strategic decisions, because I understand when people say, 'I don't feel I've been part of that strategic decision', because maybe they haven't been able to, maybe they haven't wanted to, maybe they haven't had the capacity to, or maybe they did engage and a different decision was made because that was collectively the decision that was made. So, I think that there are multiple reasons why people might not feel engaged, and multiple ways for us to engage, but, equally, we need to make sure that there's capacity to release clinical time to come and engage in that part of the process.

Thank you, Joyce. I think that it's clear from lots of evidence sessions we've had and through other key people, as Elaine pointed out, in primary care that they don't feel—. It's a common thread that they don't feel—. They feel second tier. So, I think that it's just something that we should be conscious of; it would be remiss of me not to feed that back. Can I bring Lesley in, then, please?

Yes, just before I go on to workforce planning, I'd just like to reiterate what Joyce and Peter both said. GPs that we took evidence from were absolutely adamant—. Because I was quite surprised. I represent Wrexham, so I have dealings with Betsi, and I know they've got a director of primary care et cetera, so it was quite surprising to hear the strength of feeling around GPs, and it's really interesting to hear what Elaine says.

But, yes, if I could just look at workforce planning, because I think that, in the health service, workforce planning is more important than in probably any other sector. So, I'd just like to hear from you about how you work with Health Education and Improvement Wales and other partners to make sure that the local population is absolutely served, with the correct people in place in all parts of the health service in each health board.

So, we have a process with HEIW where we work with them on the capacity that they're commissioning from universities, both from a medical perspective and also from the other health professionals perspective, and they do an information-gathering process, where they work with each of the health boards and ask, 'What sort of activity and demand do you think you're going to have?' They obviously work equally with professional bodies and other groups to look at that. And, obviously, then there are national imperatives. So, the recent uplift in the number of GP trainees is obviously something that has—. Because the places in university are obviously commissioned and paid for through Welsh Government, so there needs to be a discussion back and forth with Welsh Government about the long-term funding for those places at university for the undergraduates. I think that process works pretty well, actually. It's always a bit tricky, particularly when you're talking about the length of time it takes to train from someone being a medical student right through to being a qualified GP; that's a long time, so we've got to have a bit of a crystal ball as health boards to anticipate what we think we might need in seven years' time, eight years' time. But I think—as we know, as we've talked about—that the workforce pressures are real within primary care, so we know we are going to need more people. We're seeing a different type of workforce in primary care than perhaps we have seen previously, where GPs are looking for more hybrid, portfolio types of roles, where they perhaps work in practice two or three days a week, but look to do other things for the other couple of days. That's different probably to where it was, say, 10 years ago, where people went into a partnership, worked full-time in the one location. So, I think we've got to adapt the way we work, and I think we've got to be able to offer—. We've got to respond to that. We've got to be able to offer GPs opportunities to work in a more fluid and flexible way to expand and maintain their interest, because the risk is, otherwise, they then will jump out and go and do something different full-time, and we lose that two or three days they have in practice.

So, I think there's the strategic relationship we have with HEIW around that, but then there are also the local opportunities. I think we have got to try and work in a bit more of a collaborative way with primary care to see where we've got GPs that might want someone newly qualified who says, 'I want to go and be a GP, but I'm really interested in paediatrics', or, 'I'm really interested in—. I want to maintain my hand in emergency medicine.' Well, we've got opportunities in health boards to say to people, 'Well, actually, that's fine, you do three days in a practice and we can offer you a couple of days' work in the hospital doing paediatric work as an associate specialist.' So, I think it's about how we try and create roles also for people that are attractive. But I'm sure David will have a professional view.

Well, there are push and pull factors. Unfortunately, there are considerable push factors out of in-hours GMS. It's a hard slog, and it can feel relentless. I'm sure—. You've heard from other GPs, so I won't dwell on that. And therefore, these alternative roles can appear relatively more attractive. However, it's important to note that there are different sorts of skill sets required for different settings in general practice. So, in-hours GMS is a different skill set to out-of-hours or telephone triage in the single-point-of-access hub, where people have got to have different attitudes towards risk, for example, or see different types of caseload—children and young people or older people, frail, elderly. We need to make sure that we are harnessing the skills, the different skills that the different GPs offer, and slotting those GPs into the right place where they feel comfortable and where they will thrive, because having the wrong person in the wrong setting can just lead to disaster, I think.

Thank you. Elaine.

Not to reiterate what David and Paul have said, which I absolutely agree with, I think there's also a point for me, though, about the long period of time it takes. So, if we're talking about development of a GP, and that long period of time from starting training all the way through to being qualified and in practice—assuming that's the pathway—if we assume that that's eight to 10 years, actually, if we look back eight to 10 years, and we look into general practice, the workforce was significantly different then and it has evolved significantly. So, there are practices now—a lot of practices now—with clinical pharmacists as part of the salaried staff. The nursing workforce has developed and expanded, with more advanced nurse practitioner roles. There are often OTs and physiotherapists as part of that workforce. There's a growing and evolving workforce within general practice, and therefore I think there's something for us about being agile and being able to evolve and adapt, both in terms of what we plan and what we would like to see happening, which we do with HEIW and the commissioning of education, but then also how we evolve and adapt to new ideas, new ways of doing things, new expectations.

I think the other thing I would say, and one of the significant pieces of work with HEIW that has been very positive, is that the primary and community care academies that every single health board has, those have been really fantastic and those have enabled us to work in a different way with general practice around developing skills and competencies across the workforce. I think there's more work to be done there to enable that to grow and to develop, but, actually, that's been a really positive process and has enabled us to be more adaptive, and I think that will give us a mechanism going forward as well.

Just on a point you made there, Elaine, we heard this morning from the RCN that nurses, when they're training, don't really get the opportunity to get into primary care. They might get a three-week placement, whereas maybe now that should be reversed, and they should be spending far more time in primary care settings than they are in secondary care settings. What's your view on that?

So, I was in general practice 16 to 20 years ago, I think, something like that, which is scary to say, and we didn't have nurse students coming through, or maybe for the odd couple of days they would come and visit and sit alongside the practice nurse. Then, when my husband trained to be a nurse, he had about a week in general practice, but he had more time in the community.

I think that there is a really beneficial opportunity to extend the amount of time that student nurses have in wider primary care, so primary and community settings, because certainly, 16 years ago, going into general practice was something that was seen as the end of your career rather than the beginning of your career. The beginning of your career was on a general adult ward if you were an adult nurse, and that's what you did. I think that there are multiple opportunities, and there's a really rich opportunity in primary and community care to either be holistic and general or to specialise and become really quite expert in particular areas. So, I think it would be highly beneficial to increase the wider primary and community element of nurse training.

So, do you work with education providers to ensure that happens?

We do work with education providers. I'm not sure I would be robust enough to say I'm ensuring that is happening at this point in time. We're a teaching health board, so we have not got the same direct links with the university, so we're linking in differently. But our executive director of nursing is very positive around this, and will use that in those conversations as well.

Okay. Perhaps I could ask Paul that question as well, then, Chair.

So, we do work closely with HEIW, and also the University of South Wales, obviously, where we are, is our large provider of nurse training. I think there is something about how we as health boards and the service, if you like, shape more the placements towards the things we want people to be trained in in the future. So, if we're wanting more people to be experienced in primary and community care, as Elaine said, we need to be giving them more opportunity to be out in primary and community care, experiencing what it's like.

Actually, I think it's much more autonomous when you work out in primary care or in community than it is working on a ward where you've got four or five other trained nurses in the same ward with you whom you can seek advice from. So, there is something about how it grows skills. Now, equally, that can be a bit off-putting, perhaps, for some newly qualified nurses who perhaps feel a little bit that, if you're out there on your own, you're a bit more exposed. But I think one of the strengths of primary care and GPs generally is that team ethos. In a primary care practice, as a practice nurse, you've got the GP down the corridor. So, if there is a worry or a concern, you can just pop your head around the door and just say, 'Can I ask your advice on this?' So, there is something about how we sell primary care nursing more actively, I think, to students, and how we as health boards can help encourage the universities to think about their placement structure more actively to encourage those opportunities to give greater exposure to that in the future.

Thanks. We've taken evidence, and I've certainly come across this in Wrexham, of newly qualified GPs not being able to get a job. So, they might get a couple of days' locum in a GP practice and then go off to A&E. What are you doing as health boards to make sure that GP surgeries have enough money to recruit newly qualified GPs, but also to keep them within their practices?

The funding envelope is the funding envelope, and GP practices will make a decision as a small business as to how they spend their money. As you've just heard, lots of chronic disease management over the past 15 to 20 years has been delegated to our nursing colleagues, and it has been done exceptionally well. More recently, the unscheduled minor illness on the day need has also been delegated to non-medical people working within the practice: ANPs, pharmacists and so on.

So, when I first—. A decade ago, it was tricky to get a job and then we went through a phase of it being rather easy to get a job and suddenly, it's much more difficult again to get a job as training numbers have increased. But, I think the other part to this from a—well, I'm no longer a GP partner, but I was up until fairly recently. The trouble is that you have no financial sort of, not sustainability, but you just don't know what's happening next year and the year after and the year after. Six per cent national insurance and, suddenly, you're losing money as partners. And I think it's very difficult to make a decision to commit to employing a relatively expensive person when there is not a three or five-year funding settlement and negotiations are always stalled annually. It would be a difficult business decision for those partners to make, I think, and I suspect that that's playing into it.

Elaine.

Yes. As David said, the money is the money and how practices utilise that sits very much with them.

I was just going to say, I'm not sure that in Powys, we've quite reached that point yet, Lesley, where we've got GPs unable to get work, and I think that that's an evolving thing. So, my experience in Wales five or 10 years ago was that we had multiple practices really struggling to appoint GPs. So, I'm really positive that that is changing, but I think there still needs to be that focus on how we are supporting GPs to not just be clinically skilful, how we are also training them to understand their place in that wider primary care role. So, like Paul mentioned earlier, there's the opportunity—significant opportunity—for wider hybrid roles and careers, but there are also opportunities to be salaried GPs, partner GPs, or other roles as well—clinical leads, et cetera. So, I still think there's opportunity for us to paint that whole picture of the wide range of opportunities that are available, particularly in that first five period. So, qualified, first five years of my career, what are we doing working with first five groups to support their development and consideration of what they want their longer term career to be like? But, again, very keen and always very open and keen to have conversations with GPs that maybe haven't found that place for them. And I've done that in the past and still do that now. So, I think that there are opportunities for us all to act as good, strong leaders, enabling people to think through, work through some of the options that are available to them, because I still see a world where there are options available.

Colleagues, I'm conscious that time is going to get away from us and I'm going to have to rationalise some of the areas that we're going to talk about. So, Lesley, is there a final question within workforce you'd like to ask?

I'm happy to move on, if you want to.

Okay. Well, we're probably going to focus on sections 18, 20 and 21 for colleagues, okay? And we probably might not even make all of that and if we need to, we might follow up in writing, if that's okay.

So, I wanted to just touch on a couple of points around support for practices. I wondered how does the health board identify practices at risk of escalation or closure and what tailored interventions are offered to stabilise and support these practices.

We have a regular meeting with a sustainability panel and we utilise various metrics, both their escalation metrics from the primary care information portal, plus other numerical metrics that we see. We use their monthly data submissions that they give and also our soft intelligence to come up with a rating. And there is a sustainability assessment framework document that is published centrally. So, we utilise that and we meet regularly and make a proactive offer, if necessary.

Elaine.

I think that there are multiple mechanisms that we have to how we engage with practices to understand their sustainability, and I know that we've submitted that in writing before today's meeting, so I won't go through the detail of that.

But equally, in terms of sustainability, there is a formal sustainability process that every health board in Wales has. It's consistent, it's a two-phase process around gathering information, understanding and assessing that information, and then considering whether there is additional support that is needed. So, I know that in Powys I've got a couple of practices that are receiving some sustainability support from us as a health board, and we review that on an ongoing basis. It can be a very difficult thing, though, Chair. So, if a practice has been receiving some sustainability support for some time, that's never going to be long term, sustainable. There needs to be that focus on core funding and the ability to manage within that. So, any changes to that are always really, really quite difficult. But there are standardised cross-Wales mechanisms in place that then mirror and go alongside each health board's individual softer processes and the metrics that they've got and can review.

Okay. Thanks, Elaine. I'll move on to—. Could you give me your view or evaluation of the effectiveness of health board managed GPs? And how do they compare with the independent contractor model?

So, in Cwm Taf Morgannwg, we have one managed practice. I think it's always difficult isn't it, because obviously, as Elaine has just described, we have mechanisms of sustainability, and one level of that challenge is the point at which the practice says they can no longer continue and they hand back the contract. I think, historically, the managed practice process has been quite a negative process, in that it's tended to be the last resort, when a practice has really got into such significant trouble they don't know what to do, and the only option is to go to the health board and say, 'Can we effectively hand our contract back to you?'

I think there are things that we could be doing differently moving forward. I think we need to try and move away a little bit from that sort of slightly negative approach of a managed practice, because I think, in my experience, practices are always at different levels of risk, if you like, in terms of their sustainability. And a practice that one month can seem very sustainable, in six months down the line it only takes, I don't know, a GP to retire and another one to go off sick for a long period, and suddenly a practice that was quite stable six months ago has now become a problem. Now, I don't think we need to lurch everybody straight into a managed practice, but I think there is something about how we as health boards put the right support around practices, so that hopefully they don't get to that place. But if they do get to a place where they want to hand back the contract—and we've had this situation in CTM—what we've tried to do is look at other options, so having conversations with neighbouring practices to say, 'Well, this is something you might be interested in taking on', and bringing those practices together. Often, that is a better option than sometimes going to a managed practice.

But where we do have managed practices, and I know in other health boards they have a higher number of managed practices, I think it is really important about how you support them. And there is also that tension about not giving a preferential advantage to the managed practice, because there is a view, I think, sometimes that managed practices get subsidised almost to a greater degree, because they're being overseen and supported by the health board. But I don't know, David's probably got a view on this.

Yes. You can't be seen to be excessively supporting one practice when a practice up the road is not in receipt of the same level of support. Having said that, as Paul mentioned, these practices often come from a point where they do need more. Of course, they need more, because otherwise they would have succeeded with contractors in them. And you're right. Many practices are just about managing and can manage as they are, but it doesn't take much to tip them over.

I think that the other point I would make is that when a practice is run by the health board we lose that agility, we lose that rapid decision making and pragmatism that goes with having partners run a practice, and that can sometimes have an impact on speed of delivery.

Yes, Elaine, a quick point and then I'll move us on, because we've only got five minutes left.

Yes. In Powys, we don't have any managed practices. But in previous roles I was assistant director of primary care in another health board and had a number of managed practices. I think that point about decision making that David has just made is really key. What you've got in a partnership is GPs taking ownership for the whole delivery of the service of the practice and that enables really quick mechanisms. I think that there are issues around equity as well, in terms of managed practices, and I think there are workforce challenges. But I think they do also present an opportunity to support turnaround if need be. So, practices don't become managed practices lightly and wilfully; they become managed practices because they face significant challenge and can't continue. So, it does give the opportunity to get involved and support that turnaround. Transitioning away from a managed practice back to an independent contractor, though, can sometimes be hard, and I think that's why, in Wales, we've got some managed practices that have been managed for a good lot of years.

Okay. Thanks, Elaine. Can I move us on to the last section? Mabon, can we ask some questions about digital, please?

Thank you. I'm going to ask through the medium of Welsh. I will try to be brief, so brief answers would also be appreciated. Digital, of course, we'll all be aware of the difficulties that we've seen in the digital area. Health boards have their own separate digital systems, while the NHS in Wales, through Digital Health and Care Wales, has its own systems. We've heard that those systems don't communicate with each other, which makes the job of GPs difficult. Can you, therefore, explain briefly what that division is? Why is there a division between the health boards and DHCW, and is that sustainable?

Thanks. Who'd like to start on that?

I suppose I'd start by saying, actually, primary care GPs are probably further forward on digital than any other bit of the health service, having had electronic records for many years. And we're just moving to a position in Wales now where there will be one supplier of GP records, electronic records, for the whole of Wales. I think that's a positive thing. So, we'll have one digital supplier of records.

Now, I think Mabon's point is really valid in terms of how do we get the information that's held in primary care, in secondary care and other parts of the health service, and likewise, how do we get that information out into primary care. DHCW's role with primary care is to provide the oversight of the technical infrastructure within practices. So, all the hardware, the digital kit, PCs, everything like that, networks in primary care, is all managed through DHCW, which is, I think, useful because it provides a consistency of interface. And from what I understand, and David might correct me, largely that works pretty well, I think. But I think your point about the separate systems within health boards is very true.

One of the conversations I know we're having in CTM is that the supplier of the primary care system also has a module that enables community staff to be able to use it. So, why wouldn't we want to get our community staff to be using the same solution that our GPs are using, so that, actually, district nurses, community therapists are able to input and update the record for the GP there and then, rather than the GP having to get the information second hand.

But I think the key thing is making sure that the information and the data about the patient is available to anybody who uses it. The actual interface that we use, the actual solution we use, is, in my view, slightly less important. The most important thing is that the data and the information is available wherever the patient turns up. So, whether you turn up in a hospital—. If you live in Merthyr, but you're on holiday in north Wales and you turn up in Wrexham, they should be able to see the information about you. The fact that the user interface or the actual solution they use in Wrexham might be different to what they use in Merthyr, that's almost secondary. The most important thing is that the data and the information is available, because that's the information that the clinician needs to make the informed decision.

And I think that is where things like the national data repository, hopefully, will get us to a place where that data will be available. But the key thing, just to finish, is making sure that the data access between primary care and the rest of the system is there, because that's historically been one of the challenges. Without going into the mechanics, but the data controllership sits with the GP. So, the GPs can control who has access to that information. And I know there are conversations going on in Government at the moment about how that might be able to be adapted, but that is potentially one of the barriers that we have.

Thanks for that. Elaine.

In 2002, I moved from secondary care into general practice, and the digital system in general practice was an absolute joy. I think DHCW do work with primary care, and we're moving to a single clinical system for primary care across Wales very soon. That's a really positive thing.

The point you make, though, about the interactions is absolutely right. I'm not going to reiterate what Paul has just said. I think the sooner we can move to a place where we resolve the data controller piece and the data sharing piece, and we move to a place where we've got that interoperability interface that works effectively for the clinician with the patient in front of them, being able to see all that information in one place, is critical, and the sooner we can do that, the better.

Mabon, any further points on digital? And we'll have to close then.

Not on digital, but if I may ask one further question on estates, the state of our estates is particularly bad across Wales. We understand that there aren't enough rooms for doctors and there aren't enough spaces for people to undertake their work. Is there anything you can say briefly with regard to the kind of investment that's needed in the estate in order to improve it to the quality that we need?

Thank you, Mabon. Paul.

Yes, absolutely. We've got a very wide variation. If I look at my health board, we've got a very wide variation of estate. We have some practices that are operating out of very nice, brand-new, purpose-built facilities, and we have other people working out of premises that are substandard and not fit for purpose. As always with these things, there is a process by which you prioritise investment in those practices. We've done quite a lot of investment in CTM over the years on the primary care estate, but I'd also say there's something, going back to the earlier point, about how we get better at using the collective estate. Actually, if you look across the public sector estate, or even just the NHS estate in locations, we often have quite a bit of capacity. It's just that it's not always in the right place or being used for the right purposes.

So, I think there is work to do on that front. Sometimes it does require investment, but sometimes it requires a better use of the total resources that we have. We've seen the development of things like community health and well-being centres, where you have primary care located alongside community staff, with space for hospital clinicians to come out and work. I think that's got to be where we should be investing our resources into the future. But we also need to recognise that, in primary care, many times, the practices also own their own buildings, and there is that tension about how much of that we as a health board can control and how much of it sits with the practices.

With owner-occupied premises, I think the key message would be consistent medium-term funding streams to allow that, to facilitate that investment, which many of them are desperate to do, but are fearful.

Elaine, would you like the last word?

We've had improvement grants. They're often really beneficial. I think there are also wider capital programmes. I absolutely agree with Paul and David about the need to bring together our community services. I think there's also a cultural shift that we need to do. You can't just put people in a building together and expect them to work together. I think it is one part of an evolving piece that we need to put in place for our primary and community services that will deliver for our population as a whole.

I thank you all, and thank you for bearing with us. There may be a couple of follow-up questions; we'll decide afterwards. We really do appreciate your time and the detail you've given us and the insight. That has been really helpful. There will be a transcript available for you to check over after the meeting, to just check you haven't been misinterpreted or whatever. So, thanks again.

Thank you very much. Thank you for your time.

Diolch. Thank you.

Members, we'll go on to item 5, and that is papers to note. You'll note there are a couple of papers there. Does anybody have anything they want to raise on those, or are you happy to receive those en bloc?

Happy to note.

Happy to note, everyone? Okay, I see no dissent from that. So, we note the papers there.

That moves us on to item 6, and that's a motion under Standing Order 17.42 to resolve to exclude the public from the remainder of this meeting. Are you all happy to do so? I see you are, and we will do that now. Thank you.