Health and Social Care Committee

Thank you very much. Bore da, bawb. Good morning, everyone. Apologies for my voice—I hope it will hold out. I'll see how we go. I'll just offer a presentation, hopefully to give us a few starter points to lead into discussion.

Just to confirm my interests, I was a GP partner for 25 years, and it was a practice that then resigned its general medical services contract a few years ago. So, I've been there and done that, and you know the experiences from your constituencies about how that affects everybody. I was then a salaried GP for five years and actually retired from practice earlier this year, but still working at Cardiff University. And just to make the point, this is not a party political presentation. The points that I refer to go way back over many years of politics. All colours and stripes of Governments have been in charge. It's just where we are in the NHS.

Much of this material I actually presented at the UK COVID inquiry a few months ago. Just to start us all off, as we know, at least 70 per cent of healthcare encounters in the NHS are in primary care. And by the way, we did more than 70 per cent of all the COVID-19 vaccinations. There is evidence that investing in primary care services is cost-effective at the societal level. Each £1 that's invested leads to £14 delivered in productivity across the working community. It's remarkable. These are not our figures. These are from the NHS Confederation.

Let's have a look at where we are in terms of provision of general practitioners. Per 100,000 population, let's compare with some reasonable comparator countries. Australia: 121 full-time equivalent GPs per 100,000 people, and that figure is rising. There's an arrow behind those pictures on the side of the screen. So, 121 and rising in Australia; 74 per 100,000 in New Zealand and rising; 103 per 100,000 in Canada, and actually decreasing a little; and the UK, 45 per 100,000 and decreasing.

Where does that put us within the UK league table? Actually, Scotland is pretty good, right up there, followed by Northern Ireland, then Wales, then England. But actually, those figures were 2023 and 2024—sorry, there are some figures behind those screens. The latest figures that I've been able to get from HEIW show that Wales is actually right down at the bottom now. We've fallen behind England in terms of the provision of general practitioners per 100,000 of population. And what we all know is that patient experience is declining. We know it from our switchboards and you know it from your mailbags. We're not going to contest that point today.

And the inverse care law, which we do hope to talk about in discussion later—let's just remind ourselves exactly what it says. It's from Julian Tudor Hart who was, of course, a GP in Glyncorrwg, and he wrote this over 50 years ago, that the availability of good medical care tends to vary inversely with the need for it in the population served. And the further point that he made, which is a party-political one, is that the inverse care law operates more completely where medical care is most exposed to market forces and less so where such exposure is reduced.

Let's just quickly look at the workforce. These figures are actually from NHS England Digital. It's actually easier to get figures about what's going on in England than Wales, but I think the situation is very much the same. I'll show you a graph from Wales in a second. In these figures from England, the top line of the coloured area of the graph shows that the number of workforce GPs has stayed largely the same over 10 years, but the proportions of different types of GP have changed a bit. The dark blue columns at the bottom there are the GP partners, and you'll see that declining every year for 10 years, and to some extent being replaced by salaried GPs and also trainees at the top. But the overall numbers are the same, and we note, obviously, that various Governments at various times have committed themselves to increasing numbers, but it hasn't happened. These are the figures in Wales, which show very much the same thing: a top line of a declining number of partners to some extent being replaced by salaried GPs and others.

It's not all about GPs, of course; other staff are changing in the service. The number of nurses is the top line. That's been largely flat, actually, but other staff are coming in to the primary care team, and that's a good thing. They can range from healthcare assistants through to highly qualified pharmacists and so on. So, there's a wide variety within that group, but it is increasing over the years.

What do we know about workload? This is now testing my eyesight, probably as much as anyone else's. The figure is the number of patients per full-time GP, and it's going up from somewhere around about 1,600 at the start of that graph to close to 2,000 by the end of the graph. So, the number of patients per GP is rising. And the number of appointments provided in general practice is rising year on year. There's a dip there in 2020 with the pandemic, which was then largely replaced with COVID vaccination and other activities, and the dark blue blocks are the total number of regular consultations, which are rising year on year.

What we also have is the inverse workload law. In the affluent areas of Wales, the average number of patients per GP is 2,100, and in deprived areas, it's 2,400. And by the way, those practices get 7 per cent less income to provide those services. When we look at what's actually happening with those patients, the doctor has got more patients to start with in a deprived area, and then those patients are actually presenting more often as well. This is a graph that shows the deprivation quintile. The top dark line is the poorest quintile in our population, and the bottom line is the most affluent. You'll see at a glance that people in the deprived population are presenting about twice as much as people in the affluent areas of our communities.

As to what's happening across our Welsh health board areas in terms of provision of GPs to meet this demand, we've got the seven health board areas here, and the yellow line across the middle is an average. So, you'll see that the fifth one across, Cwm Taf, is below average for GP provision, and we all know that that is an area of high deprivation, if not the highest, and Powys has the highest number of GPs provided per population, although there are some differences about Powys because it doesn't have a hospital. So, there are differences about the ways that healthcare is provided. But, nevertheless, definitely for Cwm Taf, the area with the greatest need has the fewest doctors.

Just a few background points about workload in general. The number of people living with disability is increasing substantially. There are some figures there: it's increased by over a sixth from 1990 to 2016 with the ageing population. Between 2003 and 2016, the number of people with a single long-term condition rose by 4 per cent per year, and the number of people with multimorbidity rose by 8 per cent per year. The number of over-65s is forecast to rise by over two-thirds in the next 10 years, and the number of over-85s is forecast to rise by 55 per cent by 12 years' time.

A study from several years back showed that, within the 10-minute consultation, a GP was dealing with 2.3 problems for each patient showing up, and that was 10 years ago. So, what's it doing now? Many of you will know a luminary from public health circles, Professor Sir Muir Gray, and he had a saying one time: he said that the GP morning surgery is one of the wonders of modern medicine. I agree with him. If we look at what goes on, the complexity and scale of what's going on, it really is astonishing.

At the start, my slides said that I'm the director of the Health and Care Research Wales Evidence Centre as well. We did a study for the Welsh Government last year, looking at the prevalence of several conditions—what's forecast over the next 10 years—so that they can start to forecast and build that into provision in relation to need in NHS Wales. Perhaps unsurprisingly, all these chronic conditions—cancer, cardiovascular, dementia, mental health, multimorbidity—are all forecast to rise over the next 10 years.

We would all like to think that prevention was better than cure, wouldn't we? What have we been doing in the NHS over all these years? This graph goes right back to the start of the NHS, and it shows the number of doctors, the number of GPs, the number of consultants. GPs is the bottom—it has largely flatlined ever since 1947. The line in the middle is the number of other doctors, therefore mostly consultants. So, what have we been doing? We've been putting our resource into hospitals, trying to do cure and not doing prevention.

Budget is very important. Again, figures are slightly easier to come by for England, but I think they're largely showing a similar pattern for Wales. But in England, the proportion of NHS budget spent on general practice fell from around 11 per cent 20 years ago, now to 8.4 per cent. And the figure I was able to find was that Wales was 7.6 per cent. I believe it was discussed in this session with colleagues from the British Medical Association and the Royal College of General Practitioners a couple of weeks ago. I saw a figure quoted in the transcript of 6.2 per cent in Wales for primary care. I don't know where they got that figure from, but that's what was presented here.

There has been a real-terms increase in spend across the NHS, but it has disproportionately not gone to primary care. So, primary care has risen by 14 per cent over these last 10 years, but in other areas of the NHS, their real-terms spend has increased by 17 per cent to 45 per cent. So, someone's getting a huge slice of the cake. Remember, resourcing primary care is cost-effective at societal level.

So what should we do? There are discussions about redistributing within primary care—the Carr-Hill. I'm actually not going to dwell on that. You discussed it last time with those colleagues. But I'll just make the point that it is a zero-sum game. If you help someone, you're taking away from someone else. So, I don't think that's really a big part of the solution.

We do need to make moves to get back at least to 11 per cent of the NHS budget. But actually, I think that's a minimum, because of those massively rising workloads that are forecast. What we need to do alongside is a transparent assessment of what budget we need in relation to workforce, workload and population need. That needs to be a regular process, at least annually, and the likes of Public Health Wales and ourselves in academia could be a vehicle to do that.

The workforce: we definitely need to expand and sustain the primary care workforce across the disciplines, and it needs to expand fast enough to meet those challenges of increasing workload. One possible tool for that in general practice could be the academic fellows scheme. So, colleagues may know about that very much, but just in case: it's been going for 20-plus years, funded by Welsh Government, and motivated GPs, usually early, sometimes mid-career, come into our department in the university and they do a two-year post of teaching and research and a postgraduate diploma, and they work in practices in the deprived areas of south-east Wales, and there's a parallel scheme in Swansea and north Wales. And it's a great recruiting sergeant: 70 per cent of those graduates from that scheme work in those practices in deprived areas. But it's only producing five GPs per year. So, proof of concept, yes; scale, no. It could be really useful.

Other ways to enhance capacity: there are reimbursement schemes that directly reimburse practices when they appoint or give existing staff extra hours. There's one called the additional roles reimbursement scheme in England, which reimburses 17 other roles, but not doctors, but does give them full reimbursement for those roles. We have one in Wales called the additional capacity scheme. It started during COVID and is still going on, but it gives 50 per cent reimbursement. I think that could be a vehicle if it was scaled up. It could allow practices to recruit staff, to provide services, and maybe the reimbursement could be differential according to levels of deprivation, so that, yes, all practices need help, including in affluent areas, but the deprived areas need more help.

We also need to be looking at student and training place numbers. In other countries, they have quotas. They say 40 per cent of all training doctor places should be in primary care, like Canada. Should we be looking at that in Wales or the UK more widely? When we do all this training, we need to ensure that the supervision capacity is there for GPs, because at the moment, it's falling on the GP partners, and we saw that graph, the number of GP partners is trickling away, and it won't be there in another five or 10 years to actually do the job.

Last couple of points. The urgency. So, in 2023, 10 per cent of the GP workforce aged under 40 left the workforce. We're haemorrhaging. We've got to do something about it immediately. On the other hand, there is strong interest in training. There are three times more applicants for each place, so let's use it.

Those are the points that I started with. I won't dwell.

No, well, thank you so much. That was excellent in laying some context, and we will be reflecting on many of those points during our questions this morning, but I think there were some very powerful messages there as well, which are food for thought and will no doubt help us in our deliberations. So, thank you once again for that.

We've got, obviously, as you can imagine, several questions we'd like to go through. Please feel free to come in on each question, but don't feel you have to if you feel it's been answered well enough. We'll probably get enough time then to get through everything. So, perhaps I'll kick off, and some of these points we would have touched on, Adrian, through the presentation, possibly, but this will give us an opportunity to perhaps explore a little deeper.

So, I'd like to start with funding and the inverse care law. I wonder could you provide examples of how underinvestment in general practice has impacted patient outcomes, particularly in areas of high deprivation. I'm not sure who would like to start on that. Yes, please, Jonny.

Thank you, Chair. I just want to say 'thank you' for the invitation this morning. I want to give a big credit to all the work of Deep End in the last few years, which we know has been supported by Welsh Government; it’s meant a lot.

We came here a number of weeks ago, colleagues, remember, to present to you, and mentioned the analysis that we published last year—supported by Cardiff University, obviously—and I think the easy answer, in all fairness, is that we don't know, because we can't see the data. So, we don't know what impacts we're seeing and having when it comes to equity of general practice, the NHS and the community. But what we do know, building on what Professor Edwards just shared, is for every 10 per cent increase in practices' populations with patients in the poorest areas—. So, my practice in Ringland, you mentioned before, has got 65 per cent of our patients from the poorest 20 per cent areas across Wales. Julian Tudor Hart's practice, I think, was still sitting at about 80 per cent the last time I checked. Most practices are about zero or one; it's very skewed. For every 10 per cent increase in patients in the poorest areas, your practice income, on average, goes down by 1 per cent. It doesn't sound a lot, but when you start to add this up with maybe 5 per cent, maybe 10 per cent less income, given that we know your average GP practice in Wales is differentially less funded than your average practice in England, which you might want to come on to this morning, we're looking at tens of thousands less money coming in to general practice in Deep End areas, despite the fact that Professor Edwards talked about the demand, the need, the premature mortality, the morbidity.

And this doesn't just affect us as GPs and doesn't just affect our patients; we know that there are huge pressures in hospital and a huge focus on waiting lists, which is necessary since the pandemic. But if we look to forecast everything that Professor Edwards has talked about in terms of where do we get to by 2040, where do we get to by the mid 2030s, all those people with all those chronic diseases and ageing populations are going to hugely affect emergency hospital services, which we know are already stretched to the limit. So, this has to be the time to do something.

Yes. Neil.

Thanks, Jonny. Thank you for inviting us, once again. Just to maybe add a little bit of context to that, I work in the Rhymney valley, in a highly deprived practice. And we have tried to produce evidence—and Professor Edwards's talk talked about hard facts and evidence—but qualitatively, up in the Valleys or in the inner cities, working in practice is very challenged. And what we have seen is practices collapsing, going to the wall, in many of these areas. And you asked about what the effect is on patient care. If a practice collapses and hands a contract back, you lose all the goodwill in that practice. It's very hard to pull that practice back from that situation. You will probably know that local health boards try different models. They are usually unsuccessful. They have to bring in other providers like eHarley Street, you might have heard of, with a different business model, which again hasn't worked.

So, once you've lost the practice, you've lost goodwill, but more importantly, it's disastrous for patient health. Because in deprived areas, in Deep End, continuity is important; it's far more important than access. And we have been emphasising, for too long, access over continuity. For people with multiple chronic problems, continuity is vital, and when a practice goes to the wall and hands a contract back, you lose all that continuity. It doesn't take a rocket scientist to understand the effect that that will have on patient health. You don't even need the data, though we need to provide the data as evidence.

I have been seeing this in Rhymney, at the top end of the Rhymney valley, for 20 years. We knew the issues 20 years ago. And if you actually go back, even to the advent of the NHS, inverse care has always affected us. I mean, I'm from Senghenydd in the Valleys, and having lived and worked in the Valleys—I spent some time outside the Valleys as well—I've seen societal disintegration, and the effect that has on patient health has been profound. So, patient care has—. We have endeavoured to provide good patient care, but it's a beleaguered environment.

Thank you, Neil. Joanna, would you like to—?

Yes. I'd just like to say 'thank you' for having us this morning. The other thing that I think we need to bear in mind is that we have the option, in primary care, of doing enhanced services. So, we get an option to do an enhanced service to provide, say, ADHD monitoring or frailty monitoring. What we need to think about in the more deprived areas, when we're struggling for staff, is actually whether or not we can provide that service to our patients. If we can't provide that service, then our patients don't get it. So, if you've got a practice that's really robust with workflow, they have enough capacity to take on some of these wonderful projects, like the frailty project, which is amazing for the older patients. It's looking at them holistically, which is what we want. We want prevention; we don't want cure particularly. But, actually, what we have to work out is: do I have enough capacity to do that without taking that away from my daily capacity? So, there is an impact then on your patients as to whether they're getting the same standard of care as another practice that can provide that service.

Yes. Thank you for that. Adrian, anything?

Just to add one stat for you on that concept that Neil's describing, because you said, 'How do we know it's particularly affecting people in deprived areas?' So, in the Deep End practices that we're talking about, in this poorest quintile, 10 per cent of the practices closed or merged in the last three years, compared to 2.8 per cent elsewhere. So, it really is targeting these areas.

Yes. There's clearly a huge amount of pressure in those practices and I can understand how challenging it seems to be. So, clearly, I was going to touch on the Carr-Hill formula, but clearly the Carr-Hill formula isn't helping. It's not addressing this, it's not recognising this. Anything you want to share about the Carr-Hill formula? Yes, Jonny.

Again, to rehearse what we said a number of weeks and months ago, Wales doesn't have a technical committee that is able to robustly produce advice and evidence to feed into that when it comes to health service planning and funding. There are welcome messages we've heard across the UK, including in Wales in recent weeks, around what road map we might see ahead of us in terms of funding finally coming to general practice. If we were to go along the lines of, from where we are just now, with about 7 per cent of NHS Wales funding going into general practice, to 11 per cent, I think you have to question how you do that stably and respectfully, because we don't want to destabilise any other parts of the health ecosystem.

But in parallel to that, I think we have to consider equity, and Scotland has, in previous years, produced its own funding formula for general practice. It may not be perfect, but at least they've tried. There seem to be signals from across the border in England, which we don't need to copy necessarily, obviously, that there is going to be a revision of Carr-Hill undertaken by the National Institute for Health and Care Research. It's still at an early point, and we don't know what's going to happen, but it looks as though into next year there may be announcements that would suddenly skew funding, fresh funding, going in to Deep End practices across the border in England. It would be hopeful that we could be in a position in Wales, with all of that happening around the rest of the UK, that there is precedence, there's evidence, there's data, there's clearly a lot of will, and, I think, we just have to be careful around the framing.

It is a challenging environment to practice a Deep End practice, but it's very inspiring too. I think we just have to be careful to say, 'We really want to inspire the next generation.' We really want to look at, as Professor Edwards talks about, anyone that comes in to train with us, works with us in a stable practice that is committed to continuity of care, that is committed to continuous improvement. At the moment in Wales, we still don't have that training infrastructure that can really encourage people.

So, whilst we recognise that the current system isn't addressing certainly that area of inverse care, we know it looks like other countries are doing some further work on seeing how they can address things. So, for Wales, what would a fair needs-based funding model in general practice look like? We recognise the problems. Because it's got to recognise the differences, the challenges that you have in Deep End areas, compared with other areas as well. So, it's got to have some sort of flexibility, hasn't it? Have you given any thought to what a needs-based model might look like, if it were to work?

I don't have insight into the detail of the Car-Hill formula, but the Car-Hill formula seems to favour age over deprivation. So, if you want a needs-based formula, it needs to favour deprivation as much, equally, or perhaps greater than age. So, at the moment, practices with high elderly populations benefit from the Carr-Hill formula, even though those elderly populations may be in very affluent areas. And it doesn't take account of the fact that younger deprived communities can outstrip the demand of elderly populations in affluent areas. So, it needs to recognise deprivation.

Also, we are no longer naive. For the last generation, there's been an element of systemic naivety. It's not malign intent, but we haven't understood the issues properly, and that's influenced the way funding has gone. There have also been perverse drivers in the system. So, there have been elements of funding that have actually, because the data haven't been there and haven't been understood—. It's driven health inequality. So, we have the opportunity to be smart now, because we have better data, though it's not perfect, as Professor Edwards said.

Yes. Just to be super blunt, as you say: how should the formula be adjusted? Yes, lots of fine tuning, but as Neil says, it's favouring age over deprivation. In the deprived areas, people are dying before they get old enough to score in the system. That's what needs to be fixed.

Yes, I get that. Any further points before I bring in—. James has a question. James, would you like to come in? You're muted at the moment. You're still muted, James.

Am I back?

Yes, you're back now.

Great. Lovely. Because you touched on funding, Chair, I think it would be remiss of me not to ask: during the presentation that Professor Edwards gave about restoring the funding from 8 per cent to 11 per cent, at a minimum—. I'm just interested if any work has been done on where that money could come from. Obviously, there's no more extra funding in the system, within the budgets that the Welsh Government has got. So, I'm just interested in whether any work has been done by Professor Edwards or others on where they think that additional money could come from within the current NHS funding structure that we currently have. Thank you, Chair.

Thank you, James. Adrian.

I haven't—. I'm not actually aware, but I think that it's as described by Jonny just now: it needs to be done incrementally because, essentially, it is going to be coming out of hospital-based services. And yes, clearly, they are stretched, but what they have had is that redistribution, over 75 years, of the NHS—that all of this money has been put into treatment services and not enough into prevention. So, we need to understand it and shift that culture so that, gradually, without destabilising hospital services, we're actually putting money where it will save money.

I think we'll come on to prevention in some detail a little later, but I can absolutely see that point. You've had to be very innovative in Deep End practices, I'm sure, to try and counter the inverse situation. Have you got any examples of things that you've been doing that have helped mitigate the effects of inverse law?

Well, speaking from my experience as a GP of 22 years in Rhymney, we have followed a merger process. So, we have actually had to merge on a number of occasions to maintain viability and sustainability. We've reached a point of sustainability, I think, and part of that is by offering multiple services—all the services that we can. But the other thing is being a training practice. Adrian touched a little bit on this. Training practice status is a marker of excellence, and it enables practices to train young GPs or other health professionals. That, in itself, leads to a higher likelihood of those professionals staying in the practice and staying in the area. So, for example, in my partnership, four of our partners are ex-trainees of ours.

So, training practice status is very important, I think, and it's one of the key—. At the moment, with the funding situation as it is, it's one of the key indicators of stability. It enables continuity by enabling you to maintain your clinical staff. Aspiring to training is an important thing. The problem is, in Deep End areas, there's a paucity of training practices, because people are so busy at the coalface, they don't actually sometimes have the capacity to actually engage in other activities and to invest in other aspects of practice. That's a problem. So, developing training practice, I would say, is a key issue in trying to increase the flow of doctors and clinical staff into Deep End areas.

Thanks. Adrian.

Thank you. Just to illustrate that point, as you say, the distribution of training practices is an issue. It was mentioned earlier about the practices that had been taken over by a private provider from health board management in the Gwent area. So, in Pontypool, for example, that's exactly where the problem is. It's no longer a training practice town. All three practices are not training, and then they end up with those problems, because they haven't got that pool of people to be able to draw upon, even though people would like to do a great job in these areas. That's what it actually looks like in real life—the whole medical service in Pontypool falls over, and then has to have urgent attention to resuscitate.

If I could answer the question—you asked what's also being done in Deep End areas. An example is the academic fellow scheme. I mentioned what happens with the doctors who go there as the fellows. They get some extra training, they work in those areas, they get exposed to the way of working and they very often like it and they want to stay. But what I didn't say was what the practices do with that allocation of resource. So, what actually happens is that the academic fellow goes and works there for two days a week, and that frees up the GP partners to do some other work, which is the development that Joanna was talking about that we haven't otherwise had the time to do. What can we do about getting this enhanced service up and running to do with ADHD, frailty, or whatever it is? And that enables those practices to get their head above water and do it. That's an example of targeting resource into a Deep End area and helping them to get further on.

Jonny. Thank you.

I just wanted to echo those thoughts. So, I joined Ringland in 2021. At the time, I was working two days a week as a GP there, salaried. The model we had with the staffing base, bearing in mind what Neil has cogently shared, was a GP and a locum, with a population of 9,000 patients, climbing up and down. It wasn't safe, it wasn't dignified, and there's been a lot of blood and sweat and tears over the years, really. But we've had an academic fellow twice. We had one for six months in 2022, I think, or 2023. You need a lot of time to consider, even when you back for that member of staff, because it's a multidisciplinary team. So, you need to engage the admin team, the management team. We've had a lot of issues there, but we've come a long way. And I do think that that time to breathe, that time to just be able to stay still for a period, the time to be able to look at your data and go, 'Where are we trying to go?'—. General practices don't always have the facility to look at their own data. And I think, going back to the point we made before around what innovations have we seen, it's difficult to know, because so many practices across the whole system, whether Deep End or not, are firefighting to keep the doors open and the lights on.

Deep End is obviously differentially impacted by that, but bearing in mind what Professor Edwards said at the beginning, we're innovating every single day, to be honest, with what we do. But Deep End, I think, has been the final time that—. General practice is a lonely business. You're seeing people in your room most of the day. Bearing in mind the graphs and the stats that you've seen, it used to be that you'd be able to have a break for tea or coffee, maybe at 10.00 a.m. or 11.00 a.m. Back in the day, the kind of cliché was always that a GP goes off for golf in the afternoon. Whether that's true or not, I don't know. But those days are numbered and long since gone. We don't have time to build relationships with our teams, never mind with the local services, never mind with that lack of any interface and relationship with hospital consultants, which has made it very adversarial. But doctors don't always have the training and the background from an undergraduate point onwards to really consider inequalities and to really consider population health. We consider what is it that you do that you have to do everywhere, but maybe a little bit more of in a Deep End practice or Deep End context. So, we train these people up, we don't have enough money going to general practice, and then we scratch our heads with, ‘Well, what did we do 10, 20 years into that doctor's career to get them to go to a Deep End area?’

This isn't about robbing Peter to pay Paul, but rurality has its challenges, considerable challenges that are very different contextually to Deep End areas, but they have incentive schemes. They have golden hellos and golden handshakes to get people to go there. Rural practices get dispensing pharmacies, understandably, because otherwise, where are you going to go to to get your medicine and your prescriptions? And that dispensing fee that the practice gets supplements their income, so it's another added drop in.

But I just wanted to finish by saying, without Deep End as a network—which I think we're so proud of being able to have in Wales, finally, thanks to the funding from Welsh Government at the moment—I think we haven't been able to really prove it, because it's very difficult to measure these things, but I suspect a number of colleagues might not be still doing the same job they're doing now without that camaraderie and that intervention to address that loneliness and isolation, because it has made a huge impact for me personally, and it seems to be the case for a number of others too.

Thank you. I'm going to move us on to the next section, but thank you for that insight. That was really, really helpful. Can I bring in John Griffiths, please?

Diolch, Cadeirydd. I'd like to start by thanking all our witnesses for coming in today, because these health inequalities, inequalities in good health, inequalities in healthy life expectancy and life expectancy itself, between different communities in Wales are very stark, and we need to do an awful lot of work in very many different ways and different areas of Government policy and activity if we're going to make major inroads into lessening those inequalities. And we certainly need lived experience, as we always say, and ideas around that, and I think today is very, very useful.

I'd like to ask some questions about strategic representation, really. Obviously, primary care, general practice, is not being heard, or at least its concerns are not being acted upon to the extent that they should be, in the light of the presentation that Adrian has given us and other evidence that we've heard. So, in terms of where the decisions are made, and the strategic decisions are made, how can we strengthen that voice of general practice in the health boards in Welsh Government at a Wales national level? I just wonder if any of our witnesses would like to make any specific comments as to how that might be achieved.

Thanks, John. Who would like to start on that? Neil.

Yes, in my experience of being with Deep End, bearing in mind I've been a GP siloed in my practice for 20 years, in interacting with various organisations within Government and outside Government, it's clear that there is a lack of a GP voice throughout all levels. So, we need, I think, to be strengthening that voice, looking to have primary care people in important areas of influence within all levels of government and the NHS infrastructure.

But actually more important is having those representatives to be well versed in matters of health inequality. Because if you think about it, in Wales over 50 per cent of our households are said to be deprived. It's a huge proportion of the population. So, when you have a voice of primary care, that voice of primary care needs also to be a voice of health inequality. The problem is that, in a democracy, you depend upon votes and a collective voice to have influence. And Deep End practices haven't had a collective voice for the very reasons that we've talked about—people are hard at it at the coalface. People from Deep End practices are under-represented in all bodies that make decisions. Hence, we've had inverse care for a long, long time. We need to be moving in the other direction.

Part of the answer to that also is to help enable primary care representatives from Deep End practices to move into roles of influence and leadership because, at the moment, they are largely hard at it and under-represented. So, we need to think of a means of going to those areas and developing leadership from within those areas to influence NHS policy.

Thank you. A sound point. Would anybody else like to contribute to that? Adrian.

Yes. Thank you, Peter. If I could maybe just offer a perspective. As you say, we find this problem of lack of influence. There seems to be a lack—. I'm not sure if it's about representation; that's what I'm really coming to. I guess, from my experience of being in the Aneurin Bevan University Health Board for many, many years, the assistant medical directors who led for primary care were extremely in tune with our needs and difficulties. So, it seems to me like there's an issue that those people who are meant to be in a position of influence within a health board are not managing to influence decisions. It probably very much overlaps with that graph I showed about the investment into consultants and other doctors, and not into general practice. It's the same issue, I think. It's a culture. How could that culture be changed? That's the question we need to grapple with.

So, I'm wondering if, in the health boards, general practice is seen as something else, something other. Sure, it's contracted out, isn't it? It's somebody else's job. And I'm just wondering if that's some part of the issue. As we've said a couple of times, health boards have increasingly had to manage practices lately because of the closures and mergers. I don't know whether that is getting enough attention in health boards. Maybe there is an opportunity right now to be looking at different models of provision of care. I'm probably going out on a limb here from my colleagues—I actually think there could be more to be said for salaried models in the culture, in the ecosystem of primary care, not to the exclusion of the contracted partner model, but I think there could be more in the way of salaried provision. There appears to be a workforce right now that is gasping for jobs. Let's employ them in practices managed by health boards. Maybe that would move the needle a bit so that health boards felt it was more of their issue. Definitely not to the exclusion of the partner model, but I wonder if we need to do more of that right now, and that could help with changing this culture about leadership and influence.

John.

Thanks for that. One thing that we know is that the Welsh Government is recognising the particular issues of Deep End practices and providing some funding, which is very welcome. Is that in itself useful in terms of the issues that Neil raised—that it's not just about the GP voice, as it were, but the voice of practices that are in these areas that have the worst health inequalities? Are the developments around Deep End itself very significant in terms of getting that voice to the table?

Can I—?

Yes, please, Joanna.

Hi, John. I would say 'absolutely'. This funding that we kindly receive from the Welsh Government allows us the time to be backfilled in our practices. That's tremendously important. I happen to be sitting in this role purely and simply because my GPs did not have the headspace to attend the first ever Deep End meeting, so I was sent along. And I'm very grateful for that, because I'm able to bring a voice from the practice management side of things, but also from the wider practice teams as well. So, yes, it's incredibly important. It gives us, as areas of deprivation, a voice. It gives us a chance to sit with each other and talk about our problems and understand that we are not alone—that when we talk to our colleagues about how terrible our days are or how awful the things that we see are in our practices, we do not sit alone. We are able to talk to each other, we're able to look at collective problems that we all need to address.

We've got an event coming up in December now, where we'll talk about the world of digital and artificial intelligence. And, actually, as areas of deprivation, we don't have the headspace to sit and look at those things. So, as a collective, we are able to do some of that, I suppose, donkey work, for want of a better description. So, I don't think I speak alone, though, when I say that, for us, Deep End is absolutely critical. And also, as a collective now, we do have a voice, and we are starting to knock doors, we are starting to be heard, and that, I think, has been really, really, really important for all of the practices that engage. Interestingly, we've only recently had engagement from one of the managed practices in Gwent, because, actually, those managed practices, categorically do not have the headspace. But also they don't have the buy-in because there's nobody there that takes the ownership for the practice, because it's a managed practice, it's a health board-managed practice. I will disclose now that I used to manage a health board-managed practice, so I kind of know the ins and outs of them. But there isn't that interest, because, as GMS contractors, we are all independent contractors.

Jonny.

Senedd Member Griffiths will be aware, as our constituency Senedd Member, that lived experience is something that some of us do try to build in, and I just wanted to respond by saying this isn't just about GPs. Deep End, with the resources we've had available in the time, has wanted to be participatory in how we arrive at the message that we think needs attention brought to it, the goals we want to achieve, but also what we want to be advocating for, both locally, regionally and also at a national level, obviously. We are multidisciplinary. We have had great engagement from colleagues that aren't just nurses. Obviously, Jo is a practice manager, which sets us distinctly to other Deep End networks across the UK, at times, but we've had fantastic engagement from local nurses, health boards, primary care nurses.

I think we need to continue doing what we're doing, but we just have so many assets in Wales. We have a fantastic public health agency that is armed with data and that's got fantastic resources of people who want to tackle inequalities. We've had a devolved Parliament in Wales that wants to tackle inequalities for a long period of time. I think debates around the models of care and the models of funding are long and complex ones. But we're not getting through nationally. It seems to be that there's been a stalemate for a long time when it comes to contract negotiation at a national level, which is why, funding or not—we hope it would be there to remain for the long term—we know that, at Deep End, we really want to continue to share our reflections and experiences at a national level, and we'd be most pleased and privileged to be able to continue to come to the Welsh Government, to be giving information, to be supplementing what the professions are saying, at the GP committee, the BMA, because we each have different messages, I think, that we need to convey, really.

Thank you. John.

Thanks very much for that and, yes, I know Jonny's practice very well in Ringland in Newport East, and I'm very grateful for the work that's done there. If I could just ask one further question, Chair, to Adrian, really. It's about the need that we always come across as a committee for quality data, quality evidence, Wales-specific facts in trying to shape policy and do the work that we're tasked with. So, Adrian, in addition to your presentation and other things that you've said, would you like to bring anything to the committee's attention now as to how the Welsh Government and NHS Wales can strengthen that link between academic research and front-line general practice so that we can be confident that we get a more evidence-based design for these vital front-line services?

Thanks very much indeed. So, there are maybe two areas to cover off there. One I alluded to in my presentation was that it is, in my experience of trying to collate data from across the UK for the UK COVID inquiry, much harder to find relevant figures from Wales, and also Scotland and Northern Ireland. Actually, England does this better in terms of not just collecting the data, I think, but also making them available in presentable formats that are actually digestible for us, like those graphs that we showed. It's just easier to get figures. I actually genuinely believe the phenomena are the same, of the workforce and the workload in Wales, Scotland and England, but the figures are much more easily available in England. And I don't think that's just technical; I think it's cultural. So, whether we can, again, develop that culture to more transparency and availability of data, I think that's a discussion in itself.

And then there's the actual academic role for developing general practice. So, yes, general practice has come a long way in the last 25 to 30 years in terms of its standing in the medical profession. In medical schools, the departments of general practice very often now are parts of bigger groups influencing public health and population medicine approaches. I think we can do more, and we definitely need to do more. Research in general practice and on general practice are not quite the same thing. There's quite a bit of research going on in general practice. You might be looking for patients with diabetes or patients with asthma. Actually, what we need to do is more research on general practice, which is the way we're working. So, that's about funding UK-wide National Institute for Health and Care Research and so on, as well as Health and Care Research Wales, putting money into research on general practice so that we can strengthen the evidence base. So, there is a need for that as well as what we've already been doing.

Thank you, John. Can I invite Joyce in, please?

I'm going to talk about workforce—you've all already talked about workforce—and the barriers. You've mentioned lots of those barriers already. We need to understand the relationship, really, between recruitment in all areas of Wales. So, some are deprived, some are rural, and each has its own challenge. I looked at the Powys—because I cover it—model, where recruitment was higher. But within those areas, there was a statement about them being perhaps more affluent, but nonetheless, if you dig deep into a rural area, you'll find high levels of deprivation within that. So, I just wanted to draw that to your attention if it's not already there, and I'm sure it is. So, what are the barriers? Or do you have anything more to add about those barriers than you've already stated?

I can answer that initially, if I may. Deep End doesn't seek to be an exclusive organisation. Currently, we define it as the top 100 practices of deprivation, by the deprivation index, to have some sort of identity, but the intention isn't for it to be an exclusive organisation, and we recognise that all—well, not all practices—very many practices have populations of deprivation within them. I think the evidence, though, is unarguable that, in Deep End practices, it's just the extent of that deprivation. I mean, in my practice, it is, as somebody once said, wall-to-wall deprivation—over 90 per cent of the population are deprived. That has a massive effect on the practice, and proportionally much more so than a practice that may have 30 per cent of its population deprived. There are pockets of deprivation in many practices, but it’s just the extent of it, and what that entails.

In terms of recruitment, one of the things I’d like to mention is that we talked about training practice, and currently, there is an idea that there is a glut of doctors, and suddenly, for some reason, there’s all these doctors waiting to be employed, looking for jobs. And it makes a headline. Actually, if you dig down into it, one of the problems is that, particularly in areas of deprivation, those practices don’t have the financial capacity to be able to take on more doctors, who are an expensive resource, even though those practices need those additional doctors. So, we have to dig under the headlines sometimes and understand what is actually going on. That has partly answered your question, I know.

We have recently recruited. We sit on the edge of the Brecons; it’s a lovely little practice. But, actually, our issue is around travel. You’ll understand this if you cover Powys. We recruited, we had to dig deep to match financially some of the inner-city practices, and the GP stayed with us for four weeks before he realised the commute was too much.

But it’s not just about that. The commute was too much, and then, actually, when he got into work, there is a lot of work in our practice. There’s a lot of deprivation, so the consultations are longer. They’re more complex. You can’t necessarily see a patient—. It’s very rare—. I think the doctors will always say, 'It’s quite nice when they get a chest infection', because it’s a chest infection and it's done. But most consultations have multiple issues in them. What that meant was that he was staying later and later and later, and then, with his commute on top, it became untenable.

So, it is really difficult. I think we also need to be aware of the financial constraints that we face. Like Neil said, doctors are an expensive commodity, a necessary one, but it’s working that out. Actually, it’s making sure you get the right doctor who is happy to stay and work with the patients. It’s not always straightforward.

Having said that, and moving on, on the same theme, how can we support those newly qualified GPs that you've both mentioned—I'm assuming they were newly qualified, maybe they weren't—into sustainable employment, particularly in the areas that you're talking about, the underserved areas? Jonny.

Thank you, Joyce. Our experience obviously draws on work in programmes across the UK. There have been thoughts for some time around how we could replicate a programme, I believe it’s in Sheffield, in the north-west of England. Because, what keeps you in a job? Having a good team. That team being stable. We keep coming back to data. I think one of the challenges nationally is there’s not disaggregated data on training places by deprivation quintile, even down to deprivation quintile by health board. I believe we asked HEIW for that a couple of years back. We didn’t get it. Anyway, moving on. But it's that role modelling and mentoring, and, I suppose, kind of teasing out some of the things and the disentangling that we have been able to in Deep End, largely for colleagues that have come through the professional training and have been GPs for some years.

Sheffield has a programme that’s funded to take those newly qualified GPs out of work—I believe it’s once a week—for a chunk of time, recognising that, perhaps at an undergraduate level in medical school, talking about doctors, for instance, but also at postgraduate level and GP training, there are things that we probably don’t get sight of, or access to, in terms of, 'Right, what are some of the issues that come up in those multiproblem consultations?' It’s debt, it’s housing issues, it’s safeguarding issues. It’s supporting people through personal independence payment applications that we know are challenging and complex for a number of reasons. It's also many more things. It's giving the newly qualified GPs those skills and training sessions, but also the chance to develop the camaraderie amongst their peer group, which will have lifelong consequences for those doctors.

That's a big resource, and that needs a lot of careful thinking through. And I think that would be, whilst it's not something we've put a lot of thought into in Deep End in recent times, bearing in mind that we have said we feel we need a Deep End training programme, building on what has happened across the water in Ireland very successfully, and has been done in a few cases across the UK, bearing in mind that that is where it needs to start—. It needs to start before medical school, to be honest, really, about how we select people and how we role-model people in medical school too.

But if you were to have that programme to keep people, because it's the retention where people drop off—. You know, the number of people who are still fleeing to Australia and sunny climates is massive. A number of people are going, 'I can't imagine being a partner at the moment really, I'm not even sure I want to be salaried—I'm going to locum', but if they just had a few things that would just keep them on board along the way, and that inspiration as well, the experience in that part of England seems to be very promising.

I just want to support and add to some of those points, very much so. Fundamentally, it's about the strength of the primary care system that encourages and enables people to stay in that system. The stronger your primary healthcare system, the stronger your whole healthcare system is. But it's not strong at the moment. There was reference to that last meeting with BMA and RCGP colleagues, where they kept on talking about a quantum, didn't they? I thought, 'That's an interesting word in this context', but what they're talking about is the whole amount of funding to primary care. As Neil says, it just isn't enough to enable practices at the moment to take on those doctors without taking a financial hit. We need to increase that envelope—that might be the other word that we're more used to using—going to primary care, so that practices can take on the staff, so that they can be stronger environments that people want to work in, and we'd address some of this problem of people drifting off.

As you said, we've got this problem of recruitment, but also retention, and by the way in the middle we've got this issue of resilience, and that's where we're falling down as well, and various things can be done. Jonny was talking about some of the professional development activities, and indeed released time to do other activities and so on, and peer support. We should definitely at this point mention the work that the royal college does in supporting doctors in their first five years of their career—very much so. So, there are a number of things that are being done. Just one brief signpost, perhaps, from my own perspective: in the Health and Care Research Wales Evidence Centre, we've also reviewed the evidence about what can be done for recruitment and retention in general practice, health visiting, ambulance staff, worldwide evidence and what can we learn about that to take forward in what we do in these sorts of ways.

Neil, do you want to have the last word and I'll move us on?

Only to add to what Professor Edwards and Jonny said. A small issue, but it's also a big issue, to add to that conversation is estates. Primary care estates are incredibly variable. I know that's not an easy solution because it involves capital investment, but estates make a big difference. The quality of the estate, the premises, makes a big difference on the working environment. I know there aren't many terraced houses out there that also serve as GP surgeries anymore, but still, many of them are dated and not particularly aesthetically nice places or professional places to work, to add to that.

That's a really good point to finish on. Can I invite Mabon to come in, please?

Thank you. I'll be asking questions through the medium of Welsh. I want to dig a little deeper on some of the points that you've already made, and a number of very important points have been made. You've mentioned quite a bit about that preventative element. How, therefore, can we see GPs move from this more reactive form of care to a more preventative form of care, especially considering that you represent areas with high levels of multimorbidity? What can you do to see that shift happen into more preventative care?

I'll try to answer in Welsh, but it's quite technical. Currently, in a lot of practices, that link between the practice and the community is sometimes quite weak, not in terms of the patient but in terms of the services that are there in the community. Unfortunately, traditionally, there is funding that comes in to services that are community based and there's no link with the practice. So, there are a lot of things happening, but they aren't interconnected. So, we need to strengthen that link between the practice and those community-based services.

And that also therefore includes services that the local authority, the county council, provides.

Yes. An example is perhaps the district nurse service. Originally, when I started in Rhymney, the district nurses worked within the practice and there was a strong link between those district nurses and the GPs. But, over time, they have been taken out of the practice and you've lost that link, and that has had an influence on community health. And a lot of services—. We have a social prescriber currently, but we aren't using her properly because she isn't linked in properly with us.

Professor Edwards touched on this earlier. Our understanding of general practice has come on in leaps and bounds over the last 25 years, and I think that, for a long time, a lot of our activity was quite hidden. I think that one of the things that's helped with that has been digitalisation, because up until we had an electronic patient record, we couldn't actually be accounting for what was done activity wise, we couldn't be looking at any outcomes very easily. And obviously, over the years, we've managed to demonstrate that, whilst the NHS, including general practice at times, can be reactive, and of course preventative activity or what general practice does is a contractual question, general practice has a lot of variation, it has lots of examples of innovation, but predominantly, particularly under the funding envelope, what is done largely is demonstrating continuing activity and achievement of contractual obligations and expectations.

We've touched on the lack of data in general practice across the UK; it's not just a Welsh problem. But one of the distinctions—and this applies to Scotland, actually, as well as applying to Wales—given that we got rid of the quality outcomes framework years ago, is the lack of granular, detailed, local practice-level data on activity and outcomes. You can see this—Professor Edwards touched on it—from year to year. Quality and outcomes framework data is published in England, and there is a huge, very sophisticated analysis of that that I would really encourage colleagues to go and read. It's done by the Health Equity Evidence Centre, with Queen Mary University of London, where they've looked at patient satisfaction, they've looked at workforce statistics, they've looked at funding, they've looked at QOF outcomes, they've looked at vaccination, the list goes on. It's all socially patterned, which doesn't surprise us.

But I think until we can address the contractual side of things, to what extent general practice—. Despite the fact that we've realised, with the evidence and data that we have, over the last 10, 20 years, that general practice has a huge impact on public health. It has a huge role in prevention. Obviously, that goes to seeing people and trying to coach them and do the motivational interviewing bit around their health behaviours, but with people diagnosing conditions, managing those conditions, the medical bit, which is obviously key, probably accounts for something around 20 per cent of the entire life expectancy gap that we have between the deprived and least-deprived areas in Wales, but I don't think we always carry that narrative or message into how we plan and fund and deliver and hold services to account.

Sorry, I'd just like to say something about some of the fantastic projects that have been launched over various years that are piloted, and we have a wonderful pilot that lasts for 12 or 18 months, just long enough for us to embed it, and then the funding is pulled. And that's really challenging, we find. You have to get patients to buy into a service. They won't just accept it straight off. So, once they get used to that brilliant service, then it disappears, or the expectation is that the GMS contractor will take on the financial burden, but we can't necessarily afford to take that financial burden. So, I think there needs to be some way of looking at these really brilliant projects and working out how we make those provided for our patients rather than something that we have to find the funding for in order to provide.

I'll take you at your word on that. We've heard a lot of evidence from other people saying that there are very good pilots out there—we have more pilots than EasyJet in Wales. But I wonder whether you have any examples of that those kinds of pilots that you could share with us. That would be useful so that we could put that on record.

A few years ago, I worked in the Blaenau Gwent valleys, and we had a wonderful audiology service that was home-based, and it had been running for about 12 months. And they came and presented to our cluster this fantastic service. And then at the end of the presentation, they said, 'So, we haven't got any funding for next year; it stops in a couple of weeks' time, and we would really like to know whether the cluster can pick up the funding for this.' And we don't have that kind of flexibility within our systems to be able to do that. And particularly now, cluster funding is going to become more challenging, because of the framework that we'll all have to go to in order for it to be able to be spent. That was—. Everyone sat there going, 'Gosh, this is amazing'. It was brilliant; it was fantastic for our patients, and then, poof, it all went.

We also had, while I was in Aneurin Bevan, a link worker, if you will, between the hospitals and the practices. So, they did discharge liaison from a practice end. So, the patient would be discharged out into the community. We would then contact them, depending on which area of the hospital they'd come out from, and we would ask them whether they were coping at home: were they managing their pain? Did they have anyone to do their shopping? And then we could signpost them to the relevant front doors of information, advice and assistance and things like that. But, again, that was short-term funded, and then there was the expectation that the practices would start picking up the funding for that. Does that help?

Thank you. Just to briefly add, mirroring Jo's comments there, my practice has a link worker. They are seconded from Newport City Council, very kindly, at two half-days a week—a community connector. We've had lots of discussions in Deep End that general practice, NHS, has had a rich, long history of a plethora of stop-start, pilot-funded, grant-funded, initially successful and then hard-stop roles. I believe, off the top of my head, because I don't think we've mentioned it this morning, that we need to talk about austerity. The NHS is a single service that was richly funded in Wales, like the rest of the UK, and I think the NHS has started to try to think, 'Well, we need to address the social bit too, so, how do we bring in that support?' But I believe, when I last checked, Newport City Council had something around four full-time community connectors for the city population, which is clearly not enough.

But, borrowing on examples from the rest of the UK, which have been done very well internationally, around community health workers, we know that the more these roles are practice-based, a core part of the practice team, so that they have that relationship and trust, they've got the same access to data and the same record, that are there sustainably—. The patients we see, as we try to support them with their acute needs, but also their long-term conditions, their housing situation impacts that, what income they have to keep going from day to day obviously impacts that, the food and the environment around them they have to get healthy food and all the rest of it clearly impacts those conditions too. So, whilst all general practices clearly need ancillary and support services that doesn't just sit in the NHS, it has to sit outside too, one of the things we clearly have arrived at knowing that we need is to make sure we have that multidisciplinary support—bearing in mind Welsh Government, I believe, a couple of years back published a very promising framework for social prescribing, but we've yet to see the data on what the breakdown of those link workers is by deprivation by area. We need the support around our practices to deliver those outcomes.

Mabon, I’m just conscious we’ve got 10 minutes left.

Fine.

Thank you. If I could just add a comment, I think you asked what should be done for prevention, and I just want to revisit the conversation we had earlier on about this trade-off between access and continuity, and in the context of resources as well. So, the economist will tell you, 'Good, fast and cheap—pick two', won't they? So, what have we got here? We've got cheap. Actually, we've got reduced resources into primary care. So, therefore we've got a trade-off now between access, which is the quick, and the continuity, which is the good. And continuity is not just nice for doctors and patients—it is, very much so—but it's actually good. It saves lives. There's research evidence about it saving lives. But also it's where the prevention goes on; that’s the key point here. In that long-term relationship with people dealing with their multimorbidity and the complexity of it all, interfacing also with the social care factors, that's where we actually instigate prevention, which will, ultimately, be cost-effective for society. So, what we need is that big-picture view of not always focusing on access. Okay, it's important, we’ve got to work out how to deliver the essentials, but we need to ensure there's enough investment resource going into continuity, which is quality and prevention. So, we've got to keep that view, I think, really front and central. Thank you.

Thank you.

Please carry on.

One final question from me, therefore, and very briefly: I've been very fortunate to go to Belfast, Edinburgh and London to speak to different people on this, and they're all talking about the shift left, this left shift, as you've been mentioning today, of resources away from hospitals towards primary and community care. How can you do that in that careful way that you were talking about? Do you have any ideas about that?

Sorry, could you just explain that in a bit more depth?

Yes. So, what we've heard from many people is that we need to draw resources away from secondary care and just place them in primary care; it's this idea of a left shift. We've heard that we need to do that, but that we need to do it carefully. We need to do it slowly and with caution. So, how can we do so? How will we, essentially, take millions of pounds from the hospital and give them to the community services in primary care?

Well, it's a very difficult question to answer, really. Unfortunately, secondary care does have an expectation, and the expectation has been developed over 50 years. So, it's difficult to have—. Well, one thing is to have the conversation, because I'm not sure that—. We realise the issues in terms of deprivation in the Deep End, but I'm not sure if secondary care is as aware of the points. So, to have a voice that goes into secondary care, perhaps, that can start the conversation—.

I don't want to put Adrian on the spot.

I don't want to put Adrian on the spot, but how do you think we could deal with the redistribution, if you like, in a rising tide?

That's a very good way of describing it. So, I think actually what it comes down to is, when there is new resource, that needs to be targeted to these areas of challenge. We can't be taking away from those who are currently using resource, but if we actually have some money—and it might even be, for example, around investment, let's call it that—in managing waiting lists, now, the immediate understanding is, 'Oh right. Waiting lists. Well, that clearly means that we need more people doing things in hospitals.' Now, I'm aware, from discussions with the strategic programme for primary care, that they feel that that conversation is developing and it's not only about chucking money at hospitals to deal with waiting lists—actually, some of that money, when committed, needs to be spent in primary care on the prevention. But maybe, actually, we need to really swing it even more considerably; perhaps, as well as waiting lists, there'll be numerous other examples. If we're talking about, say, a shift from a focus on access to continuity, then we will need resource to do that. When we're developing new areas of resource commitment, let's put it into these areas of prevention, rather than patching up the existing underperforming system.

Mabon, do you want one final question?

Thank you. So, the final question from me is: when you look at the role of GP practices with a pharmaceutical or dispensing element to them, in terms of mitigating those inequalities that we have in the health service, what reforms do you think might be needed to ensure their sustainability within the Welsh general practice model? Is it sustainable as it currently stands, and is there a role for more dispensing practices?

Dispensing practice is primarily used in rural areas. From my experience, which was a few years ago, the downside with a dispensing practice is it doesn't have the pharmacist element. So, at the moment, when you ring a GP surgery, you will be care navigated. If you have something that can be dealt with by a pharmacist or a pharmacy, you will be directed to them. Unless dispensing practice has changed dramatically, there isn't that element, so, actually, what you're going to end up doing is pushing that element of work into the GP practice.

I don't think—. Perhaps I speak for myself here. I don't think we would find it particularly helpful to absorb a pharmacy into our practice. We have a pharmacy on our site, but it's not managed by us. I think pharmacies are a whole other bag of worms that I wouldn't really want to dip my toe into, if I'm completely honest, because we all know that they have had more than their fair share of problems with recruitment and retention. So, for me, I don't actually see that it would be helpful to have a pharmacy coming into general practice per se, but I may have completely misunderstood your question.

Diolch.

Sorry, I'll answer this in English.

To me, there seems an inequity about dispensing practice, because it's a means of generating income in a practice, but why should one practice have that availability and another practice not meet the requirements, just by geographical quirk? I guess that's an issue of Deep End as well, that lots of practices have—. They're independent businesses, they have opportunities to make money in other—. They may own their own building, they may rent out rooms to pharmacists or to homeopathists or whatever. As much as that's the prerogative of the business, it does seem difficult, because, if you're in Rhymney, for example, where I am, those are not options for us. There's no additional business development that we can look at, so we rely solely on the contract. So, I don't know about dispensing practice. We applied once and we got knocked back in our patch. It always seemed to me rather inequitable the way things have been worked out.

I think we've just about—. Well, we're smack on 11 o'clock, and we've exhausted our time, even though we had a few more areas we would have liked to have covered. But thank you so much for your input today—invaluable and great to have an insight into the Deep End practices, as well. Some fantastic work and it's challenging for you, we recognise.

So, thank you for your evidence. There will be a transcript available for you to check anything you said. Can I just thank you once again for taking the time to come in today?

Thank you for having us.

Diolch yn fawr.

Diolch yn fawr.

Members, we will be taking a short break now for 10 minutes.