The proceedings are
reported in the language in which they were spoken in the
committee. In addition, a transcription of the simultaneous
interpretation is included. Where contributors have supplied
corrections to their evidence, these are noted in the
transcript.
Dechreuodd y cyfarfod am 09:30.
The meeting began at 09:30.
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Cyflwyniad,
Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
Introduction, Apologies, Substitutions and Declarations of
Interest
|
[1]
Dai Lloyd: Croeso i gyfarfod diweddaraf y Pwyllgor Iechyd,
Gofal Cymdeithasol a Chwaraeon yma yn y Cynulliad. A allaf i estyn
croeso i fy nghyd-Aelodau i’r cyfarfod diweddaraf yma? Ac, yn
naturiol, a allaf hefyd bellach egluro bod y cyfarfod yma yn
ddwyieithog? Gellir defnyddio’r clustffonau i glywed
cyfieithu ar y pryd o’r Gymraeg i’r Saesneg ar sianel
1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel
2. A allaf atgoffa pobl i ddiffodd eu ffonau symudol ac unrhyw
offer electronig arall a allai ymyrryd ag offer darlledu? A hefyd a
allaf hysbysu pobl y dylid dilyn cyfarwyddiadau’r tywyswyr os
bydd larwm tân yn canu, ac os bydd mwg yn
ymddangos?
|
Dai Lloyd: Welcome to this most recent
meeting of the Health, Social Care and Sport Committee here at the
Assembly. May I extend a very warm welcome to my fellow Members to
this meeting? And may I also explain that this meeting is a
bilingual one? You may use the headsets to use interpretation from
Welsh to English on channel 1, or to hear amplified sound of the
verbatim feed on channel 2. May I remind people to switch off their
mobile phones and any other electronic equipment that could affect
the broadcasting equipment? May I also let you know that you should
follow the instructions of the ushers if there should be a fire
drill, and if smoke should appear?
|
Ymchwiliad i Gynaliadwyedd y Gweithlu Iechyd a
Gofal Cymdeithasol—Sesiwn Dystiolaeth gyda'r Sefydliad
Iechyd
Inquiry into the Sustainability of the Health and Social Care
Workforce—Evidence Session with the Health Foundation
|
[2]
Dai Lloyd: Felly, gwnawn ni symud ymlaen i eitem
2—ymchwiliad i gynaliadwyedd y gweithlu a thystiolaeth gan y
Sefydliad Iechyd. Nawr, bydd Aelodau wedi derbyn, unwaith
eto—. Roedd rhai ohonom yn lansiad yr adroddiad yma fis
diwethaf yma yn ystafell y cyfryngau, ond byddwch hefyd wedi derbyn
copïau ychwanegol o adroddiad y Sefydliad Iechyd fel cefndir.
Felly, beth sy’n mynd i ddigwydd rŵan ydy ein bod
ni’n mynd i gael tystiolaeth ar lafar ger bron, ac wedyn
cwestiynu o’r llawr. Rydym ni yn ymwybodol fod yn rhaid
i’r tystion fod o flaen y Pwyllgor Cyllid am 10.30 a.m.,
wedyn mi fyddwn ni’n gorffen yn brydlon yn fan hyn er mwyn i
chi gael digon o amser i fynd i’r pwyllgor nesaf.
|
Dai Lloyd: With that, we’ll move
on to item 2, which is our inquiry into the sustainability of the
health and social care workforce, and we’re hearing evidence
from the Health Foundation. Now, Members will have received—.
Some of us were present at the launch of this report in the media
briefing room last month, but you will have also have received
additional copies of the Health Foundation’s report as
background information. So, what’s going to happen now is
that we’re going to hear oral evidence, and then we’ll
ask questions. We are aware that our witnesses do have to appear
before the Finance Committee at 10.30 a.m., so we’ll be
finishing promptly on time so that you can have enough time to go
to that other committee.
|
[3]
Felly, gyda hynny o ragymadrodd, a
allaf groesawu Anita Charlesworth, cyfarwyddwr ymchwil ac economeg,
a hefyd Adam Roberts, pennaeth economeg y Sefydliad Iechyd? Gyda
hynny o gyflwyniad, a allaf roi y llawr i chi i ddweud beth sydd
angen ei ddweud, ac wedyn fe gewch chi gwestiynau oddi wrth
Aelodau. Nid wyf yn gwybod pwy sydd eisiau cychwyn.
|
So, with those words of introduction, may I
welcome Anita Charlesworth, director of research and economics, and
Adam Roberts, head of economics at the Health Foundation? With
those words of introduction, I pass over to you to say what you
have to say, and then we’ll ask our questions. I don’t
know who wants to start.
|
[4]
Mr Roberts: I will start. I will give a very brief summary
of the key results of the report that we published last month at
the Health Foundation, looking at projections on pressures for the
NHS and social care, then a couple of words on what’s
happened since the announcement of the draft budget and the
additional funding for this year for the NHS.
|
[5]
So, it was predominantly a modelling projection exercise from the
Health Foundation, looking at pressures for, crucially, the NHS in
Wales over the next 15 years. We also take a look over the period
to 2019-20 for which the UK budget was set in the comprehensive
spending review. The pressures that we examine come with the
growing and the ageing population—crucially, the ageing of
the population—where, while the total population is expected
to rise by around 6 per cent over the next 15 years, those aged 65
and over are expected to grow by over 25 per cent. So, ageing of
the population seems to be one of the major pressures within
this.
|
[6]
We also look at pressures from hospital activity related to growing
chronic conditions, some of which come from the fact that
we’ve got more people living longer, and therefore more
likely to develop chronic conditions, but also the likelihood of,
for example, an 85 year-old living with one or two or multiple
chronic conditions is also rising as well. So, you’ve got
that multiplicative effect there.
|
[7]
Crucially, within that, if you compare the growth of single
conditions to multiple conditions, the rate of growth for
admissions for people with more than one condition is rising around
three times faster than that for single conditions. So, an approach
where we continue to look at single conditions in their own right
looks more and more difficult.
|
[8]
And then, finally, we look at the rising cost of healthcare
predominantly from pay, which, historically, rises by around 2 per
cent a year above inflation per head for public services, which is
our initial assumption.
|
[9]
If we look at the long-term period first, over the next 15 years
we’d see pressures rising by around 3.2 per cent a year just
to keep pace with those demands. That’s not assuming that the
NHS makes any savings within that, which, historically, has not
been the case. Historically, the NHS across the UK—we
don’t have Wales-specific numbers—but across the UK
over the last 30 years or so, the NHS has achieved around 1 per
cent efficiency growth a year. If it maintains that, that obviously
brings pressures down to around 2.2 per cent, which is actually the
current projection from the Office for Budget Responsibility for
economic growth beyond 2020. Actually, the long-term picture is,
just to keep pace with pressures, that the NHS will need additional
funding, but if it rises in line with economic growth and continues
the rate at which it achieves efficiency growth, there is a real
cause for optimism of the long-term sustainability. That
doesn’t fund any dramatic improvements in care, but at least
keeps pace with demand, so then you’ve got a political
decision on whether to spend more to improve care.
|
[10]
There are some major challenges for that. Predominantly, it’s
the short-term period up to 2019 where actually, instead of
maintaining a share of economic growth, we actually expect NHS
funding across the UK to fall as a share of economic growth. So,
although we expect it to rise above inflation, it will fall as a
share of GDP and therefore, crucially, fall in comparison relative
to the pressures that we’re expecting.
|
[11]
In the report, by 2019-20, making assumptions on what might happen
to the NHS budget in Wales relative to what’s happening in
England, we estimated a shortfall of around £700 million.
With the recent announcements of the £50 million within year
and the additional around 2 per cent increase for the budget next
year, that’s going to bring it down to just over £600
million, but it’s still a sizeable gap to close.
|
[12]
We looked at options for closing that. We assumed that the 1 per
cent efficiency growth would continue, and we also look at the UK
national pay deal. They would go some way towards closing it. The
fact that pay across public sector is capped at 1 per cent in cash
terms would have a big implication, but that wouldn’t be
enough to close it.
|
[13]
In the report, we look at the need, therefore, to increase it to
1.5 per cent efficiency growth every year. With the new budget, it
has fallen to around 1.2, but that’s still above the
long-term trends. So, there’s real need to act now around how
we improve efficiency within the NHS. Obviously, if you need
additional funding for transformation within that, that either
needs to come on top or through greater efficiency elsewhere.
|
[14]
Alongside the financial pressures, and obviously relevant today, we
identify real risk around staffing within the NHS, with a large
proportion of the savings coming from the UK pay deal. That follows
five years of broadly flat growth going back. So, you’re
looking at almost a decade of broadly flat pay for NHS workers.
|
[15]
Over the last five years, although not great by historic terms,
public sector pay has fared broadly better than private sector.
That’s not likely to be the case going forward. So, we may
have some increase in pressures there. We are already seeing a rise
in difficulties in recruitment and retention of staff, with many
posts going unfilled across the NHS and an increasing reliance on
agency staff, with a 60 per cent increase in agency spend in the
last financial year. So, workforce issues are at least, I would
say, as pressing as the financial issues.
|
[16]
Some of the other risks that we identify—. Obviously, you
can’t look at the NHS on its own; you have to look at the
impact of other public services and, crucially, social care, which
we project—using modelling from the London School of
Economics—to actually rise faster than healthcare at about 4
per cent a year with potentially less scope. There was money in the
budget for social care for next year, which accounts for around
half of the pressures, we would estimate.
|
[17]
Finally, there are two other risks to the sustainability. One is
around realistic assumptions and what you can do with a set budget.
So, what we model is actually the pressure of just keeping pace
with pressures, as I say. If you want to improve dramatically the
services, as we did in the period of the Blair Government, you
would need funding on top of that to help build capacity and
workforce. And then finally, anything that happens around the
long-term budget would obviously have implications for the
sustainability and the funding challenge long term. So, if the
budget is actually lower than we’ve projected, either because
it falls as a share of GDP over a 15-year period or because GDP
would fall, then that would have implications for the
sustainability of the NHS.
|
[18]
One of the biggest risks potentially at the moment around economic
growth not being greater is, obviously, the recent decision to
leave the EU. The majority of economic experts across the UK
estimate that that will actually have a negative impact on economic
growth. So, if that then feeds into less money being available for
the Government and, therefore, less money for the NHS, that could
increase the scale of the financial challenge over the longer
term.
|
[19]
Dai Lloyd: Diolch yn fawr iawn i chi am hynny. A oes gyda
chi rywbeth i’w ychwanegu at hynny, Anita?
|
Dai Lloyd: Thank you very much for
that. Do you have anything to add to that, Anita?
|
[20]
Ms Charlesworth: Yes, just to draw out a little bit
more about the workforce. Obviously, as Adam has very clearly set
out, the ability to close the gap is very dependent on what happens
to pay. But I also want to emphasise that I think the workforce
challenges have big implications for the ability to achieve the
efficiency target as well. If you are not able to recruit and
retain staff, not only do you get a direct additional cost from the
agency, but most of the efficiency savings come from teams in the
NHS being able to work differently, and where you don’t have
a stable, permanent staff who are well engaged and well motivated,
it is incredibly difficult to realise those efficiency savings. So,
actually, workforce issues are at the heart and core of all of the
sustainability agenda. Equally, then, the ability of the system to
meet the changing needs of an ageing population and all that work
on new models of care, again, requires staffing change at its
heart, and the willingness and ability of people to engage with new
ways of doing things. So, this really is, at its heart, a workforce
challenge.
|
[21]
Dai Lloyd: Diolch yn fawr am yr ateb hwnnw, sy’n dod
â ni yn ôl at bwynt ein hymchwiliad ni. Dyna beth yr
ydym yn edrych i mewn iddo yn yr ymchwiliad arbennig yma, sef
cynaliadwyedd y gweithlu. Felly, diolch yn fawr am y cyflwyniad
hwnnw. Cwestiynau o’r llawr—Rhun.
|
Dai Lloyd: Thank you for bringing us
back to the point of our inquiry. That’s what we are looking
at in this particular inquiry, namely the sustainability of the
workforce. So, thank you very much for those introductions.
Questions from the floor—Rhun.
|
[22]
Rhun ap Iorwerth:
Bore da i’r ddau ohonoch chi. A
yw’n deg inni edrych yn ôl ychydig wrth inni edrych
ymlaen? Ym mhle wnaeth dwyster problemau’r gweithlu ddechrau?
A ydym yn gallu trasio hynny yn ôl i ryw bwynt mewn amser er
mwyn trio gweld beth aeth o le bryd hynny, er mwyn chwilio am
atebion?
|
Rhun ap
Iorwerth: Good morning to you both. Is it fair for us to look
backwards slightly as we look forward? Where did the intense
workforce problems begin? Can we trace it back to some point in
time in order to see exactly what went wrong at that point, to seek
solutions?
|
[23]
Ms Charlesworth: So, I think there’s a mixture
of, obviously, some very long-term issues that are not unique to
Wales or unique to the UK, about profound changes in the demands on
our healthcare system with an ageing population with chronic
conditions, which mean that you need different sorts of skills. So,
the World Health Organization has done a big piece of work looking
at shortages of skills. Equally, the Centre for Workforce
Intelligence, which is doing some of the analysis on an England
basis in its Horizon 2035 programme, has been looking at this and
identifying that, with the ageing population and rising chronic
conditions, you need many more people at the lower skilled end of
healthcare, and you need much more integrated care, obviously,
which requires people to work together. Those things have been
running along for quite some time and have proved quite difficult,
in workforce planning, to address—not just here, but
generally speaking—with quite siloed structures of working.
So, there are multiple reports talking about trying to equip people
with more team-based skills and with more generic skills, and it is
still the case that workforce training programmes are struggling to
keep pace with that.
|
[24]
Because it takes so long to train healthcare workers, obviously,
most of your staff, even in 10 years’ time, are people you
still employ. I think one of the criticisms that one can make of
healthcare systems across the piece is that they put a lot of
resource into the new staff and have under-resourced the
development of existing staff. Actually, if you want to transform,
that is primarily a task for your existing workforce. I don’t
have access to a breakdown of this, but certainly, if you look
elsewhere, the balance of funding for training and development that
goes into new staff compared to existing staff is completely out of
kilter with what you would spend if you were looking at this from a
service transformation point of view. So, I think that focus on the
development of existing staff is a really important thing.
|
[25]
There were obviously some cuts to training places at the beginning
of the decade that seemed sensible at the time as a way of cost
saving. They were a real example of where cost saving can actually
undermine your drive for efficiency in the longer term and that is
coming back to bite us. I think that decision is looking like one
of the worst decisions that was made in response to the economic
slowdown.
|
09:45
|
[26]
Rhun ap Iorwerth: If I could just stop you there. In any
particular areas? Are we talking nursing mainly?
|
[27]
Ms Charlesworth: So, the big reductions were in nursing and,
obviously, they’re the big budget and where we’re
seeing a lot of the agency pressure at the moment. I guess the
other thing is that part of the policy for social care has been to
try to be very aggressive in driving down cost with private
providers and that, for quite a long period, has left social care
on a minimum-wage economy with very poor working conditions, which
lead to incredibly high turnover rates in social care and make it
incredibly difficult to do skill development in social care. So,
again, that workforce is looking very fragile and in a very
difficult place to do the kind of integrated care partnership that
all health boards would talk about as being fundamental to their
vision for the future.
|
[28]
Rhun ap Iorweth: That’s useful. Thank you.
|
[29]
Dai Lloyd: Lynne nesaf, wedyn
Caroline.
|
Dai Lloyd: Lynne next, then
Caroline.
|
[30]
Lynne Neagle: It was just on the point that you made there.
Obviously, the Welsh Government has got a number of things in the
pipeline to improve things for the social care work to
professionalise it but also to look at things like ending
zero-hours contracts. Have you got any comments on what
that’s likely to mean in terms of the sustainability
we’re looking at?
|
[31]
Mr Roberts: I can’t say anything on zero-hours
contracts. I just wanted to come in on the point generally around
workforce, in that when we’re looking at training, it’s
absolutely crucial, and part of the reason we look over a 15-year
period is that you can do planning for what the health service
should be in 15 years’ time. Part of the issue around
training at the moment is that I think there is still too much of a
focus on moving training—hospital staff, effectively, and
clinicians. So, part of prudent healthcare and transformation
across the world is moving care out of hospital and caring for
people with multiple chronic conditions out of hospital, and yet we
think we still have a bit too much focus within education services
around training staff for hospital care, so not necessarily for the
positions. I don’t know if you want to come in on zero
hours.
|
[32]
Ms Charlesworth: We’ve done no specific work on zero
hours, but I think it is clearly the case that trying to stabilise
the social care workforce, so that people are able, means that you
get much less churn in the social care workforce—providing
people with the ability to invest in their own career development,
because there is a sense of a career that you can develop. All
those things are really important and much of the current
employment offer, clearly, for social care staff doesn’t
provide that sort of route through. Equally, most of the work on
integrating care points to the fact that the most important thing
in integrated care is not combining budgets or anything
administrative, but it’s about the skills and relationships
and cultures of the people who are delivering front-line services
and bringing those and aligning those more together. You just
cannot do that with levels of churn and without more
professionalisation in social care.
|
[33]
One of the issues that you see across the board is that there are,
with varying degrees of success, bodies that look at and oversee
and plan the workforce for healthcare. There is much less structure
in social care and, even where it exists, it’s disconnected
from healthcare. How, if we’re trying to design a workforce
for 2030 and the world that Adam is describing, can we do that
without bringing together thinking across the whole of the care
workforce?
|
[34]
Also, I guess the other thing to think about is the vital role of
informal carers. All of the work that’s being done by the WHO
and others highlights that, with an ageing population, the role of
informal carers is absolutely vital, and you need to think about
the workforce both in the formalised workforce and also worry about
how that links in and supports the informal workforce and the
support they need to be able to manage.
|
[35]
Dai Lloyd: Ocê. Caroline
nesaf.
|
Dai Lloyd: Okay. Caroline next.
|
[36]
Caroline Jones: Thank you, Chair. Good morning. The British
Medical Association survey conducted found that over 60 per cent of
the respondents did not have a good work-life balance, and
that’s a lot of people to be sort of dissatisfied with that
aspect. I wonder if you could elaborate on that.
|
[37]
Mr Roberts: I mean, we looked specifically at the Welsh NHS
survey as well to try and get—which is from 2013; I think the
next one is coming out this year, isn’t it—an update,
and we see very similar things. We see the majority of people
feeling stressed. But I think if we go back to Anita’s point
around how important it is to actually achieve transformation in
services, you’d need a very engaged workforce who feel
supported. Actually, the level of engagement was very low. They use
a composite measure across a number of things and, in some areas,
it’s quite high, and in some areas, it’s very low. And
actually, overall, they create a composite measure. So, it’s
the engagement as well as the morale and the stress that I think is
particularly an issue within the workforce.
|
[38]
Ms Charlesworth: The other thing I would just mention is
work that has been done by a number of the trade unions on why
people choose to work for agencies. It has identified that pay is a
factor, but the biggest factor actually is the flexibility, and the
ability to manage your work. With an aging workforce, obviously a
lot of the healthcare workers are the informal carers that I was
just talking about, caring for their own elderly relatives, and
with the retirement age rising, the ability—. I mean, if you
think about things like nursing that are highly physically
demanding jobs, I’m just about to have my fiftieth birthday
and the idea of doing full-time 12-hour nursing shifts at the age
of 63 and being able to cope with that.
|
[39]
So, there’s a clearly need for NHS employers to think about
how they can offer much more imaginative and flexible packages to
their workforce, recognising the demands on their lives and what
they want to be doing in the later stages of their career.
Flexibility, I think, increasingly will be seen, as a key issue in
the later stages of our career. We’ve traditionally thought
about it more in relation to women with children, but you can see
the pattern of work and our caring responsibilities changing, and
it does feel like the healthcare system is behind the curve of many
other private sector employers in thinking about this. One of the
things that the health service should be doing, as such an
important part of the economic social fabric of our society, is to
think about how it can role model some of these good
behaviours.
|
[40]
Caroline Jones: Yes, definitely. Thank you very much.
|
[41]
Dai Lloyd: Dawn nesaf.
|
Dai Lloyd: Dawn next.
|
[42]
Dawn Bowden: Thank you, Chair. I’m very interested in
your analysis around social care workers in particular. I know
we’re going to be dealing with that a bit later on. Can I
just say, in terms of the health service and the lowest paid staff
in the health service, the healthcare support workers, the Welsh
Government has introduced something that is unique to the NHS in
the UK, which is a career development framework for healthcare
support workers, to give them an opportunity? But, it still
doesn’t get away from the fact that they are the lowest paid
group of staff in the NHS— they are still paid better than
the social care workers, which are in local government. I just want
to flag up this contradiction between the forecasts that
you’re making about efficiency savings and the need to
recruit and retain staff and so on, and the contradiction between
that and what the Nuffield report was saying—I don’t
know if you read the Nuffield report into austerity and beyond in
the NHS in Wales, which talks about pay restraint beyond three
years really being unstainable—and where that leaves your
forecasts, if that is unsustainable, because that’s the
contradiction, isn’t it? It needs to happen, but it’s
unsustainable. And actually, it impacts on our recruitment and
retention. So, have you got any kind of thoughts about that?
|
[43]
Mr Roberts: Yes. I would say, within particularly the
short-term projections that we did, the biggest risk to achieving
those saving would be being able to hold that 1 per cent. As I
said, you’re not talking about three years, you’re
actually talking about nearly a decade when you add on what’s
happened.
|
[44]
Dawn Bowden: It’s never happened beyond three years
before.
|
[45]
Mr Roberts: No. And that becomes even more of a concern if
private sector earnings start to rise relatively, so it’s
harder to encourage people into the public sector, particularly the
NHS. That’s possibly a big concern for non-clinical staff as
well. I think it’s really important to acknowledge that some
of the agency spend is actually on non-clinical support staff as
well, who, in some cases, might have more transferable skills. So,
it’s not just the training of the clinical staff within this;
it’s the support given to managerial and back-room support
staff as well. We do estimate that—. So, we have modelled
through the impact of the pay deal, and estimated the savings that
would create. Without that, it makes the efficiency challenge much,
much harder. You can’t get away from the scale of that. I
think another risk for that around relative earning power is that
we’ve assumed the current estimates for inflation and there
are some suggestions that, in the light of the EU referendum and
other issues, we might actually see higher inflation across the
economy, and also potentially slightly higher healthcare-specific
inflation, which, if that’s going to have a further impact on
the cost of living and therefore the real terms wage, could add
further pressures on recruitment and retention within staff.
|
[46]
Ms Charlesworth: So, from 2020 onwards we do assume 2 per
cent a year real terms increase for healthcare workers. We can, I
think, envisage no plausible scenario where you could continue to
hold down a pay restraint beyond this decade. There are two things
I would say that the pay outlook really points to as an imperative
for the NHS in the short term. One is that pay is one reason why
people change jobs, but it’s not the only one, and most
people work in the health service because they’re passionate
about healthcare. As you were alluding to with some of the surveys,
they often don’t feel valued, and they often don’t feel
that they can do a good job. But in this regard, I think, the
efficiency agenda actually is helpful because a lot of what is
inefficient are actually practices that are deeply frustrating to
staff. You know, we’ve done a lot of work on flow through
hospitals. If you’ve got patients who you can’t get to
their scan or to be seen by the consultant, you’re spending
large parts of your day running around administratively, trying to
work out how to get something done, apologising to patients why
what you thought was going to happen is not going to happen, and
then working out what you’re going to do about the fact that
this patient who should have been moved on wasn’t moved on,
as a working environment, as a professional, that must be deeply
demoralising when you’re there wanting to do a really good
job. So, being able to make sure that we are working with staff to
help them to do a good job, to feel really valued, engaged,
offering them some of the flexibility.
|
[47]
The other thing that is a real opportunity is the apprenticeship
levy. The opportunity, particularly for staff at lower levels, to
see beginnings of possibilities for career progression and using
that training and development, and that apprenticeship levy, to
support people. Those sorts of things would be really important to
manage through a very difficult pay environment.
|
[48]
The other thing, obviously, is looking creatively around skill mix.
So, primary care, in particular, is looking very difficult to
continue to sustain on the historic model, even if we had more
money for pay. So, we will have to look, in some cases, at new and
different ways of delivering care. You can see some of that in the
NHS. Given that almost everybody in social care will be on the
national living wage, it’s very difficult to see any sort of
similar opportunities there. So, we’re much more pessimistic
about some of the efficiency opportunities in social care, but do
think again that the apprenticeship levy is a very important
opportunity to seize for social care.
|
[49]
Dai Lloyd: Okay.
|
[50]
Mr Roberts: Can I just make two points on that? Sorry. One,
if we weren’t able to hold the pay deal in the NHS and it
went back to 2 per cent historic, you’d be looking at
efficiency growth of around 2.5 per cent to keep up with pressures,
which is over double what the NHS has achieved historically.
Secondly, although we had the data to be able to model in some of
the impacts of the new minimum wage and the apprenticeship levy for
the NHS, we haven’t been able to because of the data
available for social care. So, it’s really important to say
that the pressures, which are high already for social care,
don’t include the potential impact of, crucially, the new
minimum wage, which would add pressures on that. I would say that,
actually, at least some work understanding what those pressures are
likely to be would be quite important.
|
[51]
Dai Lloyd: Ocê. Julie
nesaf.
|
Dai Lloyd: Okay. Julie next.
|
[52]
Julie Morgan: Diolch. You say in the report—you said
when you were speaking to us—that you didn’t include
any projections of new technologies or any increases in abilities
to provide care and, I think, certain qualitative sorts of issues,
and obviously those are going to be there, aren’t they?
|
10:00
|
[53]
Because we’ve seen such transformation of people’s
lives by what has happened, in terms of new developments. So, are
you able to make any projections about the sort of resources that
might be needed to follow on from what’s been happening
already?
|
[54]
Mr Roberts: Yes, so the way that we’ve done
that—. There are a number of ways that you can do this
modelling. This is very much a bottom-up, delivering the pressures
we have now, to get a real understanding of what the baseline
pressure is, and then you can add on top of that; it becomes more
of a political decision. So, I think that’s a sensible
approach for the medium term, which is our suggestion. If you look
at the Office of Budget Responsibility approach, they take a much
longer view up to 2060, where they make assumptions around health
spending rising above economic growth, which we know is not
happening at the moment. They’ve just published a series of
scenarios where they look at different options. Through working
with them to understand the difference between our model and
theirs, we would estimate that, actually, the cost of new
technologies, if they continue to be adopted as they have been in
the past, will actually add about an extra 0.7 per cent. It’s
quite a crude estimate, but in terms of taking our 3.2 per cent
base, you’re looking at around 4 per cent, or maybe 3 per
cent with 1 per cent efficiency, if that makes sense. That’s
the best estimate we’ve got for new technology: about 0.7 per
cent a year in real terms.
|
[55]
Ms Charlesworth: It is worth saying that one of the things
that has probably been unusual over the first half of this decade
has been the comparatively low number of new and innovative drugs
brought to market, and a lot of the big blockbuster drugs, like
statins, coming off patent and becoming generic, and that has been
quite a big saving. The indications are that probably the rate of
medical advances is picking up again and, certainly, all of the
challenges around hepatitis C are a real example of what can
happen. You may well be aware that, at the moment, NHS England and
NICE are consulting on a slightly new framework for the
introduction of new technologies that will, more explicitly,
recognise affordability, alongside cost-effectiveness. They are
proposing that if any new drug, even if it’s cost-effective,
has the potential cost to the English NHS, I think it’s,
£20 million a year, then, actually, there’ll be a
further additional stage to plan and assess how to introduce that.
It will not be subject to the traditional requirement that drugs
are then implemented, if cost-effective, within 90 days. So, those
are some of the choices that would obviously present themselves, if
you don’t want to increase spending above what we’ve
said. But we treat them slightly differently, in that we feel they
are choices.
|
[56]
Julie Morgan: Are they choices then?
|
[57]
Ms Charlesworth:
Well, in the end you could spend any
amount of money on a healthcare system; there is no right sum of
money. It’s a question of how far you value healthcare
spending versus the other things you could be doing, in terms of
things like—in the public sector—education, social
care, et cetera—those are the trade-offs—or individuals
determining what they want to do with their own spending. So,
ultimately, you can’t get away from the fact that how much
you spend on healthcare can be informed by this sort of analysis,
but it is ultimately a political choice. It’s a societal
choice.
|
[58]
Dai Lloyd: Ocê, ar y mater yma, Rhun.
|
Dai
Lloyd: On this matter,
Rhun.
|
[59]
Rhun ap Iorwerth:
Pushing a little bit more on the options,
if you like, for making the savings, we mentioned changes in
technology and we talk about efficiency savings—good
old-fashioned efficiency savings of up to 2.5 per cent, possibly,
depending on what happens to pay. I’m a little bit concerned
that we’re talking a little bit too much about keeping up the
pounds and pence going into the NHS to keep the kind of NHS that we
have now, going as it is now. What, hopefully, we’d all like
to do, is move towards a new kind of NHS that is more adaptive to
changing contexts. What is the scope to really transform the
NHS, the way it’s managed, its very existence, as an
alternative to just those efficiency savings? Or is the firefight
just going to be too overwhelming to follow that kind of
agenda?
|
[60]
Mr Roberts: One of the ways in which we looked at the
opportunity for transformation was using the initial results from a
project we’re funding with the Welsh Institute for Health and
Social Care, looking at the pace of change that you can get from
prudent healthcare. We’ve done some scenario modelling within
the report, based on—they’ve been out and talked to a
lot of clinical experts about what the likely impact of prudent
healthcare might be over the next five years. The aim is, as I was
talking about, not reducing the amount of hospital care we have
now, but reducing the rate at which it increases and replacing that
with quite large increases in community spending. So, what we find
from that is that level of transformation wouldn’t
necessarily have an impact on the scale of the financial challenge,
but it wouldn’t increase it further.
|
[61]
With the investment that they believe you would need in
out-of-hospital services, if that could be—and it’s a
big ‘if’—if that could be translated into
reducing the trend for hospital services, you’d end up with a
scenario that’s cost-neutral. You may need some front-loading
of investment and some capital investment within that. It’s
worth noting that, actually, the budget for next year has quite a
large decrease in the capital budget—10 per cent in real
terms, I think. So, you might need some investment and
front-loading in that. You will need staff engagement, but one of
the key messages that’s coming out from that work is:
actually, the principles of prudent healthcare and what’s
trying to be implemented gets a lot of positive reaction from
staff. So, there is a willingness to work towards that kind of
change. The estimates that we have suggest it wouldn’t have a
major impact on the financial challenge and that, additionally, it
could be done within the funding envelope without dramatically
increasing the pressure within the budget.
|
[62]
Ms Charlesworth: We do think that transformation is really
important for sustainability, because without lots and lots of
extra money, sustainability is economically affordable, but
it’s also a service that meets needs. It’s not actually
that complicated, in a sense, to design a cheap NHS; you can just
cut the budget if you don’t care what happens to the quality
of care and the range of care. The challenge—and I think this
is a huge challenge—for the NHS in Wales is to live with a
budget in the next decade that is growing but growing modestly, and
transforming itself underneath that to better reflect the changing
needs of an ageing population with multimorbidity. An ageing
population with multimorbidity does require a very, very different
provision of care.
|
[63]
Also, when we talk about efficiency savings, over the long term, we
are much more interested—. Most of those come, actually, not
from what you do to your back office or how you procure services.
They are actually about how you deliver clinical care. So, if you
look at the last 20 years, where have the big efficiency savings
come from? The change in anaesthetics that has meant that we can do
much more by day case has been one of the biggest transformations
and contributors to efficiency, but then you actually need to
change your health service, don’t you, to enable people to be
seen on a day- case basis. Similarly, there is probably a lot of
scope to move from day case to outpatient, but you’d have to
provide outpatients in a very different way.
|
[64]
Rhun ap Iorwerth: We’re talking about workforce in
particular. Do the challenges that we face in terms of developing a
more adaptable workforce make that transformation agenda more
difficult? Are we, because of the acuteness of the problem that
we’re facing, just having to plan the workforce for the kind
of NHS that we have now?
|
[65]
Ms Charlesworth: I think you raise a really important point.
We did some work for England with the King’s Fund, looking at
a transformation fund and talking about—actually,
there’s huge agreement across healthcare systems about how
they need to be different to meet these sorts of challenges, to be
adaptive and, as you describe, more fleet of foot. There are some
capital issues associated with that, and having buildings that are
fit for purpose. But overwhelmingly, what we identified in the work
that we did is that the big change is people—are the staff
being equipped to work differently, to have time and space to
define what that different service is, and to try that service,
which often takes a while to get right. People talked over and over
again about headspace and time. We looked at a range of other
transformation programmes in other healthcare systems
internationally and in other sectors, like a lot of what’s
been done in education elsewhere. Everything that came back said
that this is about people changing, it’s about all of the
people changing. It’s not done in a chief executive’s
office; it is done on the ward, in the clinic, day in, day out. You
have to engage everybody in that, and it takes time. So, resourcing
that, giving people the time, providing the formal skills in terms
of training and development—all these things are
fundamental.
|
[66]
So, I would say, with the new budget, one of the key questions over
the bit of extra money that has been put in this year is getting
that balance right between supporting immediate needs, which are
real and pressing—and I in no way want to suggest that
they’re not—and trying to carve out some money to allow
people in the system to be focusing on that adaptive change. I
think that’s really important for the service, but also for
their morale and engagement—the sense in which you’re
not just running around trying desperately to keep the show on the
road, but also able to begin to think and move towards a better
place. Everybody needs some hope, don’t they?
|
[67]
Dai Lloyd: Angela.
|
[68]
Angela Burns: Thank you. I’ve got two areas of
questioning, Chair, but the first is on workforce, again. It seems
to me that the human resource element of the NHS transformation
agenda is very finite. There are only so many people in our
country, and we have a balance of population. So, given that, have
you done any modelling at all about what possible effects there
could be if we could return stressed-out, exhausted and ill staff
back to the front line more quickly? I certainly took on board your
comments about the balance of training and that we don’t give
the training and the space to the existing staff—it’s
all about the new people, without capitalising on that. But, we are
using so much of our money on agency nurses. They’re there
not just because we haven't got enough nurses, but they’re
there because so many nurses, doctors, GPs, healthcare assistants
and physiotherapists are on long-term sick leave with issues. Have
you done any modelling at all about what would happen if we were to
be utterly brave and say, ‘Actually, we’re going to
prioritise healing our own workforce first, because without them
back at the front line, we can’t heal everyone
else’?
|
[69]
Mr Roberts: One of the things that have become quite
apparent in this project is actually the lack of information around
what you refer to, which is the productivity of your
workforce—so the lack of information around NHS productivity
specifically for Wales. We talk a lot about the UK numbers and the
work that’s done by ourselves and other organisations in
England, but, actually, a good understanding of the level of
productivity currently and in the past, both across the NHS, but
also labour productivity within that, was really hard to find. So,
we haven’t to date, and we’re not aware of any
high-quality productivity measure for Wales, specifically.
|
[70]
Ms Charlesworth: There are two pieces of work that are not
Wales specific that have tried to look at some of the issues about
the health of the workforce and sickness absence. We see that Lord
Carter, in his review for the English NHS, looked a lot at sickness
absence and the variations in sickness absence, the variation in
the quality of management of sickness absence and support. He also
looked in there, obviously, at, again, how often that was not very
well known to managers and not very proactively managed, and was a
big advocate of e-rostering systems and much more real-time data
for hospital leaders on what’s going on.
|
[71]
The other thing is that Dame Carol Black has done an awful lot of
work on the real value of workplace health. This is one of those
‘Physician, heal thyself’—surely, the NHS should
be an exemplar of workplace health. One of the things we obviously
see a lot, generally speaking, is the critical impact that mental
health issues have, both on absence from work in their own right,
but also, as people are getting more chronic conditions, the very
high prevalence of mental health problems when you have a chronic
condition, and how far the mental health problem can become the
tipping point, and access to support and psychological therapies
early to enable people to live with that—all of those things
would be a fundamental part of being a healthy employer and a
healthy workforce, and it’s still very patchy across the
NHS.
|
10:15
|
[72]
Angela Burns: It might go some way towards making being
employed by the NHS a more attractive prospect, if you know that
you’re being taken care of.
|
[73]
Ms Charlesworth: Indeed, and it also points to the
efficiency challenge and the pay challenge and all of that. You can
do it in very different ways. You can do it in a big
stick—kind of ‘Just work harder, just turn up to work
regardless’. But actually that doesn’t work and that
doesn’t sustain. Actually, if you want to tackle sickness
absence, there are positive ways of doing it that help staff, and
given that this is not a one or two year little challenge and then
everything’s back to normal, and we don’t have to worry
about it again, this is how we need to work, and we need to worry
about these things for the long term. That much more fundamentally
positive approach to actually trying to improve your workers’
health to support them in their wider lives so that they are able
to contribute is a much more sustainable way of tackling something
like sickness absence.
|
[74]
Angela Burns: Also, I’d like to add on that particular
point, before I go on to my next one, that people think of sickness
as a big thing, but actually, it’s somebody with a chronic
back condition who’s lifting up elderly people out of beds,
or whatever, and taking the odd day, but the odd day is every week
or every 10 days, which puts enormous pressure on their team, but
then brings other on-costs. So, if we can help people like
that.
|
[75]
My second question—I’m terribly conscious of the
time—
|
[76]
Dai Lloyd: Yes, so am I.
|
[77]
Angela Burns: It’s about something you mentioned much
earlier on in your presentation—it was about silo working.
So, for example, if you look at the implementation plans for the 10
key conditions, it’s a great idea because it brings the focus
onto each of those conditions, but when you look at the fact that
the causes of at least four or five or six of them are all
absolutely identical, then I wondered if you have a view
about—I mean, that’s just a very top-level example of
silo mentality, and I think it must drive, from what I’ve
seen, all the way through the NHS, in much bigger silos. So, I just
wondered if you could expand on that. If we could end that silo
mentality through the integration, would there be cost
savings—but not just financial cost savings, but actually
time? You’re looking after people with that co-morbidity
problem that people tend to develop as they get older.
|
[78]
Mr Roberts: I think, to get towards it, it comes back again
to what we were talking about—transformation. The only way
you break down silos is the staff time, and the protected time for
staff to work together. I think when you look at where staff can
see waste within the health system, nobody in that situation is
making the wrong decision for that set of circumstances. The waste
isn’t there because they’re making the wrong
decision—it’s because they aren’t able to step
back and work with people to look at the system as a whole. So, I
think it comes back to a lot of what we said about allowing,
somehow, the ability for staff to design those pathways together. I
think the complexity is how you find a pathway that works across
lots of different conditions at the same time. It’s very easy
to find a diabetes pathway—well, not easy—but
it’s more straightforward to find a diabetes or a chronic
obstructive pulmonary disease pathway. We look at 12 conditions in
the report. Finding pathways that work across those 12 conditions
altogether is going to be growingly complex. The only way it is
going to happen is getting staff talking to each other and
identifying those savings themselves, and being supported to do
so.
|
[79]
Angela Burns: Would you say that a barrier to that is also
the super-specialisation of the consultants? So, we don’t
look at people in a holistic manner, so we get that revolving door
syndrome all the time.
|
[80]
Ms Charlesworth: Indeed. I think one of the
challenges—there are a couple of things around the more
integrated care. At the moment, the evidence base is that more
integrated care tends be associated with better outcomes, but not
yet much evidence that it reduces cost. But better outcomes are
what we need, so the value of that remains vitally important. Most
of the work on integrated care at the moment is looking at care
co-ordination. It’s looking at someone, isn’t it, in
the system who holds the ring between all of those silos. And I
guess one of the profound workforce challenges is to say, ‘Is
that enough?’, or, actually, do we need fundamentally to
re-examine some of the roles here, the balance of the specialist
and the generalist? Almost, in primary care, we have the
uber-generalist. We need slightly fewer generalists—the
geriatric specialist and one in child health in a primary care team
who are more skilled in that. And in the secondary care sector, do
we need fewer specialists? The other point I would highlight is the
boundary between community nursing and social care workers, where
very many people now have got large numbers of people coming into
their home, all to do individual tasks.
|
[81]
Angela Burns: Yes.
|
[82]
Ms Charlesworth: Yes. That cannot be a good use of
resources. And, as an individual on the receiving end of that, that
must be just so upsetting and unsatisfactory, and where people have
had personal budgets, one of the main things that they do is reduce
the number of people who are interacting with them and get people
who can do more. So, if I was looking at areas where changing some
of the skills and multitasking might deliver a quality benefit and,
potentially, an efficiency improvement—I won’t say a
cost saving, because I think social care may be underskilled, and
some of the people coming into the home may be overskilled, and I
think where that would land out in cost is different. I certainly
think it’d be fundamentally better.
|
[83]
Dai Lloyd: Ocê. Y cwestiwn olaf gan Jayne
Bryant.
|
Dai Lloyd: Okay. The final question
from Jayne Bryant.
|
[84]
Jayne Bryant: Thank you, Chair. I think Anita has answered
my question—from Angela—on the absences and supporting
staff in work, but considering how much data we do have on health
and social care in terms of waiting times and things like that,
it’s quite extraordinary that we have very little information
on our own workforce, making it very difficult to plan, which seems
evident here. But I just wonder if you could say a bit more about a
move to unpaid carers, because of the profound pressures in terms
of caring for loved ones on people who aren’t necessarily
trained to care, but also the extra pressures on their health,
because people who are caring for loved ones are actually putting
themselves last, often, and I just wonder if you could say a bit
more about that.
|
[85]
Ms Charlesworth: One of the things that we’re seeing
through this period is a change in who cares informally, a little
bit. So, as men’s life expectancy has increased, which is a
good thing, there are going to be fewer women living alone, but,
obviously, middle-aged women are more likely to be in the labour
market. So, there appears to be a shift from, if you like,
daughters caring to partners caring. What that means is, very
often, you’ve got an elderly person with their own health
needs caring for another elderly person just with more health
needs. Obviously, by and large, people desperately want to care for
each other, stay together and support each other—it’s a
fundamental part of loving someone, isn’t it, to want to do
that? But if you provide no support to those people, then obviously
what you often end up with is people tipping over and they
can’t cope at all. So, one of the things that worries me
about what’s happening in social care is, for understandable
reasons, we’re concentrating care at the highest end of need,
and I completely get why we’re doing that, but a little bit
of investment in supporting lower-level need in couple households
where both have health issues, and they are caring for each other,
could actually enable them to be able to sustain their life at home
for much longer. So, I think trying to understand that unit, rather
than just dealing with them individually as a health need and a
social care need, and getting much more sense of them as a unit,
and the balance of support that they need to be able to be
sustained in their home for longer, which, even if you didn’t
care about them, which I think we should do, must be better value
for the system in the long run.
|
[86]
Dai Lloyd: Diolch yn fawr. Mae’r cloc wedi ein curo
ni, felly a gaf i eich llongyfarch chi ar eich cyflwyniadau a hefyd
am ateb y cwestiynau i gyd mewn ffordd mor raenus ac mor aeddfed?
Diolch yn fawr iawn i chi’ch dau. A allaf hefyd gyhoeddi y
byddwch chi’n derbyn trawsgrifiad o’r cyfarfod yma i
gadarnhau bod y cyfarfod wedi bod yn ffeithiol gywir, o leiaf?
Felly, diolch yn fawr iawn i chi, a dyna ddiwedd y sesiwn yma.
Diolch yn fawr.
|
Dai
Lloyd: Thank you very much. The clock has beaten us, so
may I congratulate you for your presentations and also for
answering all of the questions in such a comprehensive and mature
manner? Thank you very much to you both. May I also let you know
that you will receive a transcript of this committee’s
proceedings to check for factual accuracy? Thank you very much to
you both. That’s the end of this session. Thank
you.
|
10:25
|
Cynnig o dan Reol Sefydlog 17.42 i
Benderfynu Gwahardd y Cyhoedd o Weddill y Cyfarfod
Motion under Standing Order 17.42 to Resolve to Exclude the
Public from the Remainder of the Meeting
|
Cynnig:
|
Motion:
|
bod y pwyllgor yn penderfynu gwahardd y cyhoedd o
weddill y cyfarfod yn unol â Rheol Sefydlog
17.42(vi).
|
that the committee
resolves to exclude the public from the remainder of the meeting in
accordance with Standing Order 17.42(vi).
|