It is really helpful to have you in front of us today, Petra. Thank you for giving us your time, including in the private session beforehand. My name is Ruth Jones, and I am Chair of the Welsh Affairs Committee. We have Committee members here today who are really interested in the digitisation of healthcare records. What were the main reasons that Estonia moved to digital health records, and when did it do so?

Estonia started digitalising pretty much as soon as we regained independence, so in the 1990s. I am not going to go into the history of that, but before you digitalise you have to digitise, so if we are talking about the digitalisation of health records, the beginning would have been 2007 or 2008—that is when we launched the first interfaces. At that point, citizens’ data was not quite usable or user-friendly; it took us a while to learn how to design user-friendly interfaces, but by 2008 all the supporting infrastructure that is required to build digital platforms for transportation, public housing—whatever you can imagine, healthcare included—was already in place. The e-health system can exist because we have the underlying backbone supporting all the processes in Estonia. We have a unique digital identifier, which is actually just an ID card with a personal code and a chip at the back, and different ways of authenticating ourselves—proving our identity—when we log into any service, digital or not, so you can also identify yourself when you go to a hospital in person. We also have X-Road, an information exchange layer. It sounds fancy but it is a very simple technology. It is a way for Estonia to connect all the decentralised servers and databases where citizens’ data is stored, on premises where it is generated. It is stored there, in ministries and in offices, but it can still be connected and exchanged. That data exchange process is fully controllable, fully transparent and fully automated. There is no human in the loop—no one who can tamper with the data. We trust in technology. Estonians actually have a full overview of who has been accessing and using their data, when, how and for what reason. In the e-health portal I can look at the logs section and see which doctors have been accessing my file. That may raise some concerns; maybe I do not recognise a name or a hospital. In that case, our Data Protection Inspectorate will look into it. Historically, back in the day, when not everyone was very clear on how transparent these processes are and how sacred people’s data is, we had some very public cases in which people abused their power of data access. You are not allowed to look at patient data or any other citizen data unless you are providing a service to them at that very moment. Doing so out of curiosity or for any other reason will land you in jail.

We understand that. Thank you, Petra. That is really helpful. Let me bring in Gerald Jones.

Petra, could you give us some thoughts on the benefits of the digital healthcare system, primarily to patients but also to healthcare professionals and the Government?

The digital tools in Estonia give us additional freedom to use and access our data, and to act upon it—or not. Digital services exist in parallel to offline services—no one has to use them—but with a digital programme like I showed you, with all my health records, I can make an appointment to see a doctor anywhere in the country for any reason, and I have a full overview of all my conditions and prescriptions. I am the owner of that data that belongs to me. I do not have to keep records on paper. I can fully trust in the system, because we have been doing this for so long in Estonia that we have full clarity that it works and is safe. I can log in at any time and revisit anything that I need to know, such as my blood type or some condition that I might have forgotten the name of. It is very convenient and user-friendly. Everything can be done pretty much in three steps, with no prior training required. They are truly user-centric and user-friendly interfaces that give us more clarity and flexibility on how we would like to deal with our healthcare and health.

I am going to move on to Andrew Ranger, for probably our final question before we have to go and vote.

You obviously have a different culture in Estonia around digital technology and the public approach to it. How has that changed since the introduction of digital health systems? Has the perception changed? Was there an eagerness for it anyway—was it being called for desperately—or has it developed and evolved as it has gone along?

I now realise the difference in cultures. I grew up with digital healthcare. We expect everything to be digital; if it is not digital, we are frustrated. Everything has been digital always, forever, and everything has always worked. If the healthcare system was not digital, it would be really bizarre, because it is what you expect. We digitalised incrementally and not everything became available online immediately, but it was obvious that we needed to start early with healthcare records. We started that in 2008, which was relatively early, considering that the last service that we digitalised was divorce in 2025. It was a pretty high priority, and it took a while to digitise everything and digitalise and make it all user-friendly. Our frustration has only been that it is not user-friendly enough, or that I might not have enough of an overview, or that it might take me 15 clicks when I know it should take me three. We got here over time—over decades of training people how to use computers, how to stay safe, and on cyber-hygiene. A lot of things went into generating the culture that you are now talking about, considering that Estonia started as a digitally illiterate post-Soviet country in the 1990s. This is a process that we went through over 30 years.

That is really interesting. Does that mean that there is not a high level of digital exclusion—of elderly people, perhaps, or people who do not have access to broadband or mobile internet—in Estonia? From what you are saying, I am guessing that that is not a major issue.

You just saw the speed of my connection—it is not usually that bad! Let me explain: the digital tools are an additional benefit. We did not cancel offline services; we still go to hospitals to get blood drawn and get other stuff done to us. You do not need any digital skills whatsoever. All you need is a digital identity, which is actually a very physical identity—everyone has it everywhere; we are used to it. A person with no digital skills and no internet access can still go to the hospital, present this and get everything done. It is going to be more efficient and friendly because people are not overwhelmed with paper. The people serving you are going to be using digital tools, but thanks to the processes being more efficient, they have more time to focus on you as a person. In Estonia, you draw your prescriptions digitally in 100% of cases, meaning that you go to the pharmacy and insert your chip in the payment terminal. That requires absolutely no digital skills. If you struggle to put it in, which sometimes is the case for the elderly, the people in the pharmacy will help you, so it is not an issue whatsoever. Not everyone uses digital tools, and that is okay. [Interruption.]

Sorry to cut you off, but that is our Division bell ringing. That is really interesting; thank you very much.

Thank you so much for your time this afternoon, Petra. I appreciate that it was a whistlestop tour, but thank you so much; it was really interesting. I am sure that we will come back to Estonia’s model of digital healthcare. Witnesses: Alyson Thomas, Gemma Lelliott and Stacey Keegan.

Good afternoon and welcome to this second session of the Welsh Affairs Committee this afternoon. My name is Ruth Jones, and I am the Chair of the Committee. As it is quite warm in here today, if Members or anyone else would like to remove their jackets, they would be more than welcome to do so. I do not want anyone passing out in the heat. Thank you to the witnesses for appearing before us in person this afternoon; it is really helpful to have you here face to face. Would you briefly introduce yourselves and your organisations, and say what the biggest challenges are when it comes to cross-border healthcare arrangements?

Diolch, Chair. I am Gemma Lelliott, Wales director and head of advice and support at the Community Transport Association. The CTA is the membership body for community-led transport across the whole of the UK. We work alongside about 1,400 member organisations, including around 100 in Wales. There is a wide variety of styles of operation. We have some operators with quite big fleets that run bus services that take people here and there; smaller schemes where volunteers provide transport to their neighbours in their own cars; moped-based and e-bike-based wheels to work schemes, where people can access support to get to college or to their first job; and everything in between. We work with a wide network of groups, organisations and communities to support them to set up where transport needs are not being met. There are multiple challenges around health transport that crosses the border between Wales and England, as I am sure you have already seen in the evidence that the Committee has received. The vast majority of these kinds of journeys are arranged by patients themselves. There is very little by way of commissioned or contracted services, so it is very much reliant on patients getting the information they need in a timely manner, so that operators—who are all independent, hyper-local charities—can look to see whether they can meet that need. It is very much driven by volunteers, particularly in this space; volunteering is a hugely important part of community transport, but especially so for cross-border health services, as, generally, people are looking for the support because other forms of transport have failed. What if, for example, they are not eligible for non-emergency patient transport, for whatever reason? That means that they are looking for support if they cannot ask a family member or a friend to take them on the journey or drive themselves. On challenges, the approved mileage allowance payment for volunteers is very much a hot topic for our members. We have just done a survey of our members in England specifically, and 86% of them are already very worried about potential fuel shortages and are already seeing costs increasing across the board. That is having a knock-on impact on volunteer availability, and we are seeing people leaving the community transport workforce; we are worried about how far that is going to extend. Generally, investment in the sector in Wales and England is quite patchy. I can talk more about that later, if the Committee is interested.

Thank you, Gemma. That is really helpful.

I am chief executive of Llais, which means “voice” in Welsh. We are the citizen advice body for health and social care in Wales. We were set up to provide three main functions. The first is to engage with people and communities across Wales, to give them an opportunity to share their views and experiences of health and social care services. The second is to use what we hear to work with NHS bodies and local authorities to drive improvement in health and care services. The third element of our role is to provide an independent complaints advocacy service for those who wish to raise concerns about their health or social care services. At the moment, a number of key areas prove challenging for people accessing cross-border services. The first relates to clarity around their rights and entitlements in relation to NHS care cross-border. That differs according to the individual. Some people don’t necessarily recognise that there is a distinction in relation to policy and practice in Wales versus England. Others are unclear about the differences in policy and what that means for them. It is not always easy for people to find that out through things like websites, social media and so on. It is not always easy to identify in NHS messaging whether it is specific to England or to Wales and England. It is really difficult for individuals to find out about those rights and expectations. That is compounded by the fact that it is really hard for NHS staff to know that as well. If NHS staff who are working in that environment day in, day out don’t know that, they can’t help those individuals who might be accessing health services for the first time in a particular area to get that understanding. That is the first aspect. The second aspect for us is systems that feel fragmented. It is often very difficult for people to see that they have a seamless service across their whole care pathway. A large element of that relates to the lack of talking together between different digital systems across England and Wales. It is an issue in Wales itself because some of those digital systems don’t talk to each other within Wales either, but it is compounded when we are talking about Wales and England. People don’t understand why that is. Naturally, they think that in the NHS that information should be shared safely and securely to support somebody’s care, and they find it difficult to understand why there are problems that prevent that from happening. That causes significant challenges around delays and duplication—they often find that they have to repeat themselves in providing information over and over again. Sometimes it means that people have to have tests or X-rays done more than once. They will have it done in Wales, but it doesn’t get to England, so they will have it done again in England. Not only is all of that inefficient, but it has a fundamental impact on them in terms of delays and the potential for patient safety issues, particularly when key information is not shared between the different parts of the system around things like individual communication needs, safeguarding issues and so on. One of the biggest areas of concern that we have been listening to over the last year is waiting times and inequity in waiting times, stemming from the decision by Powys Teaching Health Board to ask NHS organisations in England to slow down waiting times for people in Wales. People cannot understand the logic of that decision, for a number of reasons. The first is that bringing down waiting times has been identified consistently as one of the biggest needs for people across Wales. For an organisation to take a decision that lengthens waiting times does not seem logical to them.

We are going to come back to that shortly.

The two final things relate to travel and transport, and the cost of that, and to being able to access services and engage with systems in your first language.

Thank you, Alyson. We will move on to Stacey, please.

Good afternoon, everyone. I am Stacey Keegan. I am the chief exec at the Robert Jones and Agnes Hunt Orthopaedic specialist trust. We are based in Gobowen, Shropshire, just on the border with Wales. As a specialist trust, we deliver routine and complex specialist work. A large proportion of that work is from Wales, and probably about 30% of the work that we undertake is from across the border. The first thing to say is that we care for patients in Wales and England. Although our clinical standards, outcomes, patient experience and aspirations are the same, policy, funding and performance frameworks that govern English and Welsh healthcare differ. That is what creates the challenges for us as an English provider—Alyson has articulated some of them. Probably the one that is the most challenging is the performance standards and the differences from a waiting time perspective. That is challenging for our staff, a lot of whom live in Wales. It brings complexity when we are booking and scheduling pre-op assessments and scheduling for theatre. There is a disparity—an inequity—between English and Welsh, which our board really struggles with. It is very transparent with that data from an English and Welsh perspective, although waiting lists are managed collectively, so individual surgeons do not have separate waiting lists. Another challenge, which has already been articulated, is data transfer, data sharing and digital maturity. There is a lot of work around the differences we have to put in place within the organisation to manage some of that, and to try to reduce the impact on patients, clinicians, GPs and so on. The third challenge is inconsistencies in care pathways—that is additional services that are available to support patients. Some of those are on discharge, and some are before patients come to us. Some are alternatives to surgery, for example, pain services and weight loss management. It seems more difficult for us as an organisation to obtain some of them; it is not clear what else is available. This is not a challenge, but from a clinical perspective, there are a lot of clinicians collaborating, which is really positive and will help with some of the differences in care pathways. We have some clinical leadership working in Powys looking at the spinal pathway to try to mirror the work that we have done in Shropshire to help with demand, but there are also other alternatives to surgery.

Thank you for that really helpful outline. I am sure that we will come back to these issues.

I am the MP for Caerfyrddin, which is in west Wales and wholly within the Hywel Dda health board. It is not always on the border, but people are transferred to England for specialist services. In one case I had—and I could mention several where things went wrong after they reached England—a gentleman from Nantgaredig went for specialist eye care in Bristol. His eye blew while on the operating table. He came round, and he was just told to go to the hotel. He did not want to go to a hotel, so he went home to Carmarthen and came back the following morning, whereas he should really have gone into a hospital situation straightaway. He has lost his eye. Alyson, what changes or improvements do patients most want to see in relation to cross-border healthcare arrangements? It is not working very often when Hywel Dda sends people over the border.

I think they want to know what accessing care across the border is going to look and feel like. They want support to navigate that and play a full part in their healthcare, and they want the system not to be so confusing. As I mentioned earlier, they do not want to have to repeat themselves time and time again, and they want the service to feel seamless. They do not want there to be gaps. They do not want to have to remind and chase all the time to find out what is happening with their care. One of the biggest challenges that causes the most distress, either when people are waiting for care in the first instance or when they are on the pathway and waiting for the next stage of care, is not knowing when they will be seen next or what that looks like. They want to be kept in touch in a way that is easy for them, without having to do lots of navigating themselves. They want and expect the different parts of the system to work together to deliver the care they need, rather than having to fit in with what the services have determined. The services need to work for them. That is their biggest challenge, I think.

I represent Pembrokeshire, so we are also within Hywel Dda. I have had constituents contact me about cancer treatment not being available in Wales, about having to be referred to England, and about the difficulties in accessing that treatment in England. I had a constituent who died, unfortunately, as a result of the difficulty in transferring to the nearest stroke unit in Bristol. There are also issues with lupus treatment not being available in Wales, and the difficulties in accessing those services in England. Those are individual cases, and Ann has just set out cases in Caerfyrddin. Alyson, do you think that those individual cases represent systemic failings in cross-border healthcare?

I think there is a distinction between the individuals who live in border areas—sometimes accessing care across the border is the closest thing for them, so it is the easiest way for them to access care—and people travelling from areas like Hywel Dda. For them, travel and transport are fundamental to how they access healthcare, whether within Wales or on a cross-border basis. We see two main things that would prevent travel and transport from being an integral part of their healthcare experiences. Too often, when services are being designed or developed, thinking about transport comes too late in the day. It is not part of the discussion from the very first conversation about services that need to change. Discussions about travel, transport and accommodation are fundamental to people. They are fundamental to those receiving care and treatment, and absolutely fundamental to their families who can be so instrumental in supporting recovery, particularly for older people, children and young people and so on. When services are being designed, it is absolutely essential that transport and travel is a fundamental part of that conversation and is baked in from the start. The second thing is that some of those transport options are under significant challenges at the minute. We are hearing lots of concerns about the non-emergency patient transport service operating in Wales, and the limitations of that service in terms of last-minute cancellations because of lack of capacity, as well as challenges in people accessing those services because they might not qualify. They might not qualify for that service, and if they cannot afford to pay for the transport themselves, that has a fundamental impact on people in the most vulnerable situations. It can mean that people who might have an opportunity to be seen earlier across the border—as part of a waiting time initiative, for example—have to turn it down because they cannot get there themselves, or because they cannot afford the time. There needs to be a strategic solution.

So in your view, it is a matter of accommodation and travel. And you do not think there are systemic failings in the processes involved in how patients, such as those in Pembrokeshire or Carmarthenshire, access those specialist services in England.

Patients who live in those areas recognise that, for some specialist services, they need to travel to get that quality of service. However, they expect that travel to be kept to a minimum.

My question is not about travel; it is about the process to access those services. I take your point about travel and accommodation, but do you think that is solely the reason why we are seeing these cases? Are there processes involved in accessing services, which have been flagged to you as chief executive of the organisation, that you are concerned about?

I am really sorry, but I do not quite understand the question.

No, you are fine, Alyson—don’t worry. We will probably cover those questions further down the line.

Thank you for coming. The decision to lengthen waiting times for patients in Powys is clearly having a devastating impact on lots of local residents. That has had to happen because the health board has such a huge budget deficit of £50 million. How many patients at the orthopaedic hospital are from Wales?

Around 30%, and the contracts we have are with Powys and Betsi. Those are the areas that we cover, and that is around 30%. For a number, I would have to come back to you on exactly what that equates to.

Thank you. Can you talk about how the process looks for English patients versus Welsh patients?

As I said earlier, there is a disparity because of performance standards, although conversations continue with both health boards on what we can do to mitigate some of that. From an England perspective, we all know that 18 weeks RTT is the standard that we aspire to, and we have a long way to go in England. We are just starting to clear 52 weeks and improve our 18-week RTT position. For Powys, the ask was 104 weeks as a standard, which you can imagine is difficult, hence the conversations that took place. With some of that, we are not able to see patients earlier. For example, the spinal disorder service is facing challenges, as we have had a 50% increase in referrals in Wales since covid. That is a challenge, and the capacity is not keeping up with the demand coming through. From a patient perspective, communication could be improved. Again, between us and the Powys health board, there are lots of conversations about how this is communicated. We rightly get a lot of complaints from patients about their waiting time, or their expectations of it, as well as media inquiries. I think that communication should be better, but it is bad news whichever way we try to articulate it.

I have heard directly from clinicians at your hospital who are concerned about the long-term welfare of Powys patients affected by delayed treatment decisions. They have concerns about safety, long-term prognoses and the increased cost of treatment, as they continue to deteriorate. Is that concern shared by your leadership team? If so, can you please outline how you have expressed that to the Welsh Government and the UK Government?

Yes, it is a concern for us as a board. As I say, we have had meetings, and we have followed up in writing with Powys health board. Collectively, our medical directors and the medical directors of the other border trusts wrote a letter to raise their concerns about safety and clinical risk. There has been a lot of communication, both formally in writing and in conversation. There was an ask around leaving first out-patient appointments for a year. Again, we challenged that and have negotiated with Powys health board. We have been able to talk clinicians through some of the associated risks and opportunities. Looking at alternatives and improving what else is available is also important. Rather than just focusing on the problem, we have to look at some solutions.

Staying with Stacey, I will apologise in advance: I tend to say “Gobowen Orthopaedic” rather than Robert Jones and Agnes Hunt Orthopaedic hospital. Like many of the constituents I represent, I have been a patient with you guys. I would like to dig deeper into the relationship and how it is working. I really feel it is not working as well as it could for my constituents. In our evidence session in January 2025, on the topic of cross-border healthcare, Gobowen Orthopaedic was described as having “good, strong long-term agreements” between itself and the NHS health boards. How would you describe the relationship between Gobowen Orthopaedic and NHS Wales?

From a relationship perspective, it is good. We communicate regularly. We have members of the health board over to the trust, where we show them the services that we provide, again to try to build on those relationships. Relationships are good: we talk, we collaborate. Do we agree? That is a different issue. But rather than just disagree, the purpose is to come together to look at alternatives or how we can mitigate some of the asks from Powys health board.

The Committee heard about the frustration felt by Welsh GPs regarding individual patient funding requests and commissioning processes. What is the experience of receiving referrals from Welsh clinicians, and how would you like to see the process changed for the better?

Specialist services are the area that probably has most impact on us as a trust. As we know, specialised commissioning is not part of the health boards. In defence of specialist commissioners, some of the issue is that what they commission cross-border is small compared with what they manage in Wales, but if I think of the relationships that we have in England with our specialist commissioners, it is very different in Wales. That is one area where change would certainly help. We have some significant specialist services that Welsh residents access, such as for spinal injuries. It would be helpful if specialised commissioning was improved.

We all know about the delays—we have heard about them already. Are patients ever severely delayed due to the patient funding issue for cross-border referrals?

Yes. Patients are waiting longer than 104 weeks. I could name them; there are a handful and some of the delays are due to complexities and so on. There are other services that we could deliver quicker for patients, but the funding restraints on Powys are preventing us from doing that. From a trust perspective we undertake harms reviews, as we call them. For any patients on our books who are waiting, we make regular checks to make sure that harm does not occur. If their condition changes to an extent where they become a priority, their surgery would be brought forward.

To stick to the individual patient funding requests topic, Ms Thomas, what are patients in Wales telling Llias about the way the commissioning process works through the IPFR?

Complicated and frustrating. Again, it goes back to the sense that people feel powerless around processes that they do not feel are designed to respond to their needs, so it feels difficult and challenging for them.

In terms of the broad range of specialist care that patients in Wales have to go to England to receive, would you say that at present Welsh patients are getting a fair crack of the whip when it comes to some of these specialist treatments because of the IPFR?

Generally speaking, we do not get a huge number of formal complaints in relation to IPFR. We often get feedback from people that they recognise that, to access very specialised care and get the best quality care, it is important to access it further away, although what they look for in those circumstances is that that episode of care is kept to a minimum—so the care and treatment they have before and after it are as close to home as possible—and that access to that very specialised service allows them to achieve it with their families. If you have children and young people or older people getting very specialised services a long distance away, it is really important to people that they can be supported to do that with their families and not alone. Those are the kinds of things that we hear most in relation to specialised services.

Briefly, do you think that at present the experience of a patient from Wales accessing specialist care or treatment in one of the hospitals in England is in any way comparable to that of an English patient?

I think they ask the question of whether it is or not. We hear it an awful lot, particularly since, as I said, the decision about Powys, we often get people asking whether they are treated as second-class citizens, in that they have to wait longer than patients in England. By and large, when people are accessing care, whether in Wales or England, when they receive that care, they are really complimentary about the quality of care and they highly value the staff who are providing them with that care, and that is consistent across Wales and England.

My final question on this: when a referral has been made for a specialist treatment elsewhere, what is the experience of those who have been in touch with Llias regarding how they are looked after in terms of the totality of their care, both after the specialist treatment and beforehand? Is there anything that has been brought to your attention about whether the home health board—if I can put it like that—is very good at ensuring any relevant aftercare? Or is there a sense that sometimes they say, “Well, you’ve been referred to the specialist treatment centre. That’s it now. We wash our hands of you.”?

It is a little bit of the latter. The different parts of the system do not always work as well together as they should. There is not as much understanding from those providing care in different parts of the system about how it all fits in and works together. There is an increasing risk around that with the changes that are taking place both in England and potentially in Wales. We have shared examples of people who have had particular equipment provided to them in England that they need to use when they come home in Wales that is not supported or used in Wales, so they have to learn all over again. There is not always knowledge of what is available in terms of advice, support and community care back in your home area from those being discharged from England. That lack of knowledge as to what is available means that sometimes things fall through the gap, and people might be told that they are not entitled to something that is actually there; it is just that, because the system is not working together, and there is not that common knowledge across the whole pathway, people do not get what they need quickly enough.

On that point, if I again take spinal injuries as an example, it is a life-changing condition, and there are complexities that lead to a lot of things needing to be in place on discharge. That often results in delayed discharges as the teams try to navigate cross-border packages of care and equipment. We see it from a discharge perspective. If I look at the Welsh and English, I see more delayed discharges on patients back into Wales because we want to ensure that everything is in place for a safe discharge.

Thank you. That is very interesting and useful.

Can I quickly ask Alyson a question? In respect of the evidence you have just given to Ben, how have you been able to feed into the Welsh joint commissioning committee? Have you been able to feed those patient experiences of delays, frustrations and gaps into the committee?

We have a representative who sits on the joint commissioning committee’s quality and safety committee. We bring to that table for the consideration of that committee where things are working well and not working well. There is an established relationship between us and the joint commissioning committee.

They have given evidence to the Committee about how the majority of cases are considered individually—there is an individual nature, is what I think they suggested to the Committee. Do you think that hinders looking at the system as a whole and thinking about the systemic issues that are going on in respect of IPFR?

While individual decisions might need to be made individually in relation to the specific circumstances of that patient, it is vital that those commissioning specialised services stand back and look across the board and do not simply look at individuals’ circumstances. They have to look at that in terms of that decision for that patient, but they have to pull that information together to understand how things are working overall and to identify any systemic issues.

Do you think they are doing that?

The joint commissioning committee is still relatively new as a joint commissioning committee. It came into being after merging from a number of different parts of the Welsh NHS and it is finding its feet. There is more work to be done on that joint commissioning committee works, I think.

Finally, moving forward, what would you like to see from the joint committee? What would you like to see them improve?

The important thing for us at Llais is to continue to make sure that the joint commissioning committee hears, and builds into its thinking, the views and experiences of people accessing services, the real lived experiences of people accessing services, and uses that information routinely to determine its commissioning decisions. There needs to be more work between us and them to make sure that is done routinely.

The statement of values and principles that governs cross-border healthcare states that no patient should face delayed treatment due to disputes over funding, or due to differing rules about the level of service available in both countries. Stacey, do you feel that the current approach aligns with that principle, and would putting those principles on a legal footing instead help to prevent situations like the one we are experiencing at the moment?

I think, because there is disparity in performance standards, no. And yes, I think a legal footing would help support that. Obviously, that would mean capacity constraints, and so on, that would need to be worked through, but at the moment, as it stands, there is a disparity because there are different performance standards, and there always have been—I think 18 weeks and 26 weeks, even if I think back to covid.

How do your staff respond to being asked to implement such policies?

They are concerned. It is based on postcode from a treatment perspective. As I articulated, there are complexities within that, which are not for us as an organisation. If I think of funding regimes, the funding regime that we get from Welsh health boards does not cover the complexities or additional process systems that we need to put in place to be able to manage.

On that point, what practical problems does it create when you have to manage two distinct waiting lists for Welsh and English patients?

As I said, we do not distinguish from a waiting list perspective. For a consultant, his list is his list—that will include both English and Welsh patients. When our bookings and scheduling teams are running through that—for example, when they are booking pre-op assessments—if they do not look at the postcode, we may pre-assess patients earlier than necessary for surgery. There are lots of different systems making sure things are flagged. It does create complexities.

Different trusts have done it in different ways. It sounds like you have not separated the two waiting lists, but in Herefordshire, for example, they have. Why would that be? Why do you think health trusts in England have responded in different ways?

I suppose because it is what works for those organisations. For us, as I say, we are uncomfortable with the disparity as it is without starting to separate waiting lists. Eventually, it would be nice to have the capacity so that we do not have to look at the postcode to determine, but can go on waiting list order and priority.

Thank you all for coming today. I will move on to a section about patient records and digital records. I think you were in the room during the previous session about that. We have just heard that briefing from Estonia and how they seem to have revolutionary stuff compared with what we have, as well as a vast healthcare digital infrastructure. Stacey, as someone with experience running and working in a hospital, what level of digital implementation do you think would be feasible in the UK?

As an organisation, we have just implemented an electronic patient record. It is early days and it is still painful as we implement it, but we can already start to envisage the benefits that we will get out of that. Those are benefits for patients, GPs in England and other secondary care providers that need to understand relevant patient information. It is an expectation in the world that we now live in that we can access information such as appointments and letters via apps and other digital means. As I say, even within England there are systems that do not talk to each other, which is challenging. Maybe it is because I am in England, but every conversation that I am in at the moment, whether it be with NHS England or others, is about digital and innovation and driving that agenda forward. I am aware of the conversations in Wales, but it does not seem as at the forefront as it is within England. Again, that will create inequities for patients.

Basically, you are saying that that digital cross-border interoperability does not really happen at the moment? It does not exist.

From a GP referral perspective, it is still an email that is then printed off and input into our system. Again, discharge letters are very similar—they are emailed. As part of our EPR, we have launched a patient portal that Welsh patients can access. They can get information, whether that is a letter or an appointment, via digital means such as text reminders. There is also the myrecovery app, which will map a patient’s journey from referral through post-operative care. Again, that is accessed by and available for our Welsh residents as well.

That is something from your establishment in particular?

Yes.

I will talk about a couple of the very practical examples from a patient point of view. Obviously, I am here to talk about transport and the challenges that people experience around transport. It is a very analogue system. From a patient perspective, that does not seem to change whether you are in an England or Wales health board. We have had examples. One of our member organisations in Hay recently transported a patient to Hereford hospital for an appointment to see a cancer specialist, but a letter had been sent to that patient to say, “This appointment has been cancelled because the consultant is on holiday.” That letter never got to the patient, so they went to Hereford and then had to pay for their transport, because that is not covered under the non-emergency patient transport service. That is one of multiple examples that I have heard from operators just in the last week, when I asked for specific examples that they could share. Another is from Llandrindod Wells, in Powys. A couple in their mid-90s were carers for each other; one had mobility issues and one had visual impairment. The lady ended up having to go to a hospital in England and was stuck in that hospital for more than 18 months because of poor communication between the two health boards and the social care team in Powys county council. The Powys county council adult services team were trying everything they could, in partnership with the transport provider, to enable this patient to come home, because all she wanted to do was come home and die in dignity. The limitations and the analogue nature of the communication between the two health boards were so restrictive that it was almost as if they were not talking to each other at all. We are talking about, from a transport point of view, a very small part of the system, but what is very indicative to me is what we are hearing about the challenges more generally about health boards having the ability to talk to each other in a way that enables better patient outcomes.

From our perspective at Llais, there is an awful lot of focus on digital development and digital transformation, but it still does not feel joined up, because those transformation projects are being done at different places, at different times and in different ways. It doesn’t feel to us that there is a common standard across them. From a public point of view, why on earth can you not have a system where any NHS digital development has to meet the standard that enables systems to talk to each other? Why can’t that be directed: “Whatever you are developing or designing, you need to meet that minimum standard to enable those systems to talk together”? This conversation has gone on for quite a considerable number of years, and people are not seeing it moving forward in relation to either the technical design and development of digital systems or the agreements in place to share and protect personal data. The law and people’s expectations on personal data are very consistent, actually. They expect their data to be looked after—kept secure. They also expect it to be shared with those who are providing care, so that they do not have to repeat things over and over again. They do not understand why the challenges in relation to information governance frameworks and data sharing agreements cannot be overcome. It is a real frustration.

Very quickly on that, we heard about and I was exploring the different cultural approaches to digital that people in Estonia are experiencing compared with us. But I think you are saying that people would be open to that and are expecting it to be in place here.

They absolutely expect their NHS to work in a modern way and the systems behind the scenes to work in a joined-up way. They are keen on being able to access services digitally, but they are also really concerned that it should not be digital only. There are large parts of Wales where accessing services in a digital way is not as easy, because of issues with the ability to access those services. Also, there are some people and some circumstances that mean it is not appropriate to do that. As long as digital developments are done alongside a real recognition that you cannot exclude people—there can be digital first, but not digital only—they are happy for that to progress.

Henry Tufnell is going to come in very briefly.

Alyson, can I check that you have been feeding all the concerns that you have raised, and the frustrations that you have heard in feedback from your patients, into the health boards and the commissioning committee, and are you satisfied that those concerns are being heard and action is being taken?

We do feed those things in. It sometimes does feel as if we are saying the same things. Progress in responding to some of that is slow on a system-wide basis. We sometimes see progress in some areas; we do not always see sustained progress on some of the fundamental aspects. Some of the things that we are talking about today, which are frustrations in relation to cross-border healthcare, have been frustrations for a number of years.

I will declare an interest: I was a physiotherapist for 32 years in the Welsh NHS. We talked about electronic patient records—I left 10 years ago, and we were talking about them 20 years ago, so I understand the frustration there. I am conscious that we will have votes again in a minute. Are the three witnesses able to stay for a quarter of an hour if we go for votes? It is up to you. Alyson Thomas indicated assent. Gemma Lelliott indicated assent. Stacey Keegan indicated assent.

We will run, I promise you. Stacey, very briefly, there have been some teething issues with your electronic patient records. Given that we have just heard from Estonia about 100% digitalisation and we know that it is slow in the UK, do you have any concerns about the digital shift, and how is any risk being minimised as we move towards digital?

From a risk perspective, we wrap governance, policy and procedure around any system that we are implementing. There are obviously societal concerns around AI and everything that is coming in. The key thing for us as an organisation is clinical engagement with systems—we do a lot of that—and getting our patients and public involved with that. We need to ensure that we have the right governance wrapped around to minimise risk, but we cannot not move forward with the digital agenda. It is just about ensuring we are doing it safely.

Thank you very much; that is helpful.

I would like to speak about the distance that some of my constituents have to travel for healthcare. Some of the round trips I hear about are frankly obscene—horrific stories about people who have had procedures and then had to travel huge, huge distances. What impact does distance have on patients accessing healthcare?

I would say it is quite significant. There is a perception that cross-border health transport only affects border communities, which is definitely not the case. We have had responses from operators as far flung as Ceredigion, Ynys Môn, Powys and Neath Port Talbot, all of which are transporting patients either regularly or semi-regularly into English hospitals. Community transport has historically delivered an awful lot of transport to health, but in Wales specifically it has been very focused on primary care because there is no provision for that—for non-emergency patient transport, for example. However, in terms of secondary care, the rise in requests to community transport providers to meet need that is not being met now by the Wales ambulance service trust or non-emergency patient transport services in England has been significant since we have come out of pandemic restrictions. We have a project that we deliver in partnership with the Aneurin Bevan health board and patients in Gwent. We have mapped the distances that people are travelling there. The average journey is 18.3 miles for a single journey to a destination, and the same coming back. For a patient in Monmouthshire, for example, that would cost £67 by taxi one way. It costs money to get a community transport journey, but it is done on a not-for-profit basis, so it is a lot more affordable for patients. However, it is still money out of pocket that you have to find. That is also true on public transport. There is not a great deal of information out there for patients who might be able to reclaim some of the cost of their travel from the health board that they are visiting, and every hospital has a different system for that. That is something that a lot of patients report to us as a practical challenge. If they have been able to cover the cost of their journey, getting that returned to them by the health board that they are visiting can be really difficult. Sometimes the staff involved are not particularly helpful in that. As I mentioned in my introduction, a lot of the time it is volunteers who deliver community transport journeys. For us as a sector, that creates an additional challenge because those volunteers are then taken out of the system. If someone is taking a patient from Wrexham to Liverpool, for example, it is a fully accessible, supported journey where that patient will be picked up from home, taken to their appointment, supported if needed while they are in the hospital and then returned to their door. That probably means an entire day is taken out of the equation for that volunteer, which limits the community transport sector’s ability to deliver journeys locally. For Welsh Border Community Transport, which is on the outskirts of Wrexham, 30% of the services are focused on cross-border transport into England. It is a significant challenge for the sector as well as for individual patients.

Another thing that comes into this is that it will not necessarily be just one day if there are repeated treatments. One thing that is of great concern to me is the impact on families. It is not just the individual and the organisations; it is the families as well. Could you elaborate on the impact on families and those visiting patients when health facilities are such a massive distance away from a patient’s home?

It is a real difficulty. Say you are a patient who is travelling and needs a carer or support from a family member—[Interruption.] Shall I pause there because you need to go and vote?

I will suspend the session. Sitting suspended for a Division in the House. On resuming—

I thank the witnesses for their patience. Steve, do you want to re-ask the question?

Thank you, Chair. I am grateful for the answer, but I would like to place a little more emphasis on what families face. Obviously, it is not just the patient; it is their family. It is not always one big trip; there are the trips before. Could you outline your view on the impact on families and those visiting patients when the health facilities are such a vast distance away from the patient’s or the family’s home?

Absolutely. Something that we hear often when patients are having to travel longer distances is that it can be a real challenge. For non-emergency patient transport, for example, the eligibility is restricted. Say you are a person who needs support from a carer or a family member in order to make a journey. That can restrict your ability to access non-emergency patient transport that is free of charge, which then would mean that you have to pay for that transport yourself, so there is a direct financial cost to patients who are in that position. One of the things that I do in my role at the CTA is lead our advice and support team. We provide a national advice service to community transport organisations and members of the public, as well as partners and stakeholders. I remember a conversation with a lady whose son had been referred to Alder Hey hospital. She was in north Powys, just on the border with Gwynedd, I think. She was trying to find support because she had been refused non-emergency patient transport to access Alder Hey by both the Welsh and the English non-emergency patient transport services. Because her child was under the age of 18, he needed to have her with him. As a result, she had been referred to a taxi provider—she was just told that she had to make her own way there. She did not have any other family around or any other support, and that is not taken into account in the eligibility criteria. She was looking at a weekly journey from her home to Alder Hey, for an unknown amount of time, for her son to access the support that he needed. Having to find the funding for that, at a time when her ability to work was heavily restricted, was a huge challenge. We were lucky that we were able to link her up with a community transport provider that was able to do that at cost, and it was subsidised in the end, because it took quite a long time for her son to be well enough to not need to go to Alder Hey any longer. From a patient and family member point of view, there is a direct challenge around how much it is going to cost to be able to access the care. It is right that people take their child, or the person they love and care for, to the best place for their care, but it does create an inequitable system. The fact that 19% of the population in Wales does not have access to a private car really restricts what options are available. I mentioned the average taxi cost in Monmouthshire. The average taxi cost across the whole of Wales for an 18.3 mile journey is about £47. That is a huge financial burden, as well as the length of time it takes. What we hear from some patients, though, is quite interesting. Some patients do not have family or carers to call on. The non-emergency patient transport eligibility criteria tells you, as your first course of action, that you should be looking for someone else to take you before you even contact NEPTS, WAST or whoever it is that you need to contact. Some people do not have that option available to them. For a lot of patients, though, especially the older passengers who access community transport, it is a question of independence. They do not want to be calling on their children, who have their own responsibilities and their own lives, to be their taxi because they cannot access hospital transport through the health board. We hear from patients and family members how difficult that is, and it is not a problem that has an easy solution. Unfortunately, I cannot say to the Committee, “You should do this. Wave this magic wand and it will fix it,” but it is important to recognise, at a structural and strategic level, how important accessible transport is to patient experiences, and to their families and carers alongside them. If the system were better planned, better commissioned and better designed, and if there were better communication between the health boards, the non-emergency patient transport services and the transport providers that are picking up the slack in the system, that would go a long way towards improving the patient and family experience.

Thank you, Gemma, for highlighting the importance of volunteers for community transport. Obviously, fuel prices at the moment are soaring. You alluded in your intro to the importance of the fuel allowance, which has been frozen since 2011, so I thought it would be handy for you to make sure it is on the record just how important that is, and that volunteers are signing up to help.

It is a really important issue. I would say it is very much in the public eye at the moment because of the fuel crisis that we are experiencing. As you mentioned, the approved mileage allowance payment limit is set at 45p by the UK Government. It has been set at that level since 2011, but figures from the RAC Foundation show that the cost of motoring has increased by more than 58% over the last decade. The reality for a volunteer driver—and cross-border health transport is extremely reliant on volunteer drivers transporting neighbours in their own cars—is that the actual cost of delivering that vital public service has increased astronomically. We are losing volunteers already, and that is a very real concern. The survey that we have just done with members in England shows that we are already seeing a significant drop-off. That is particularly prevalent in rural communities, which is where we see a lot of this demand coming from. The CTA has been leading a campaign to ask for a fully funded increase to the limit since 2022, because there are more than 1.7 million volunteers across the UK who are involved in transport. It is a really important issue. As a result of the current fuel crisis, the UK Government have committed to review the approved mileage allowance payment limit, but they have said that it will be a worker-first review. We would appreciate some clarity around that, and we would push for it to include volunteers at the same level, because it is really important that we retain that volunteer workforce so they can continue to support people in the way they have done in the past.

I want to say a huge thank you to Green Dragon transport and Dolen Teifi, which operate in my patch. To be honest, they are phenomenal. The work they do is amazing. I want to touch on the air ambulance service, because in south Wales, in my patch, the helicopter based in Llanelli covers Pembrokeshire, Ceredigion and areas of Powys, and of course we have the trauma hospitals in Swansea and Cardiff. It is very different in north Wales, where the ambulance has been moved closer to the border to service the trauma units in England. Of course, that leaves a huge swathe of north Wales and the Wyddfa and the national park, which has millions of visitors over the year, climbing the mountain and the mountain ranges there. With that move, staff are probably moving from Bangor into the specialist units, which are over the border. What is the end result for patients in north-west Wales—in Ynys Môn, Pen Llŷn and Gwynedd —when that shift is going towards England? Where is that leaving patient care in north-west Wales? I do not know who fancies answering that. You are all looking a bit “Errr”, but who fancies answering it? It is a huge issue, because it is moving east and the patients in north-west Wales will be left in limbo. Lives will be lost; there is no doubt about that.

Unfortunately, I cannot comment on the air ambulance because it is not an area that we specialise in, but I can say that we already see a significant number of patients who have to make those longer-distance journeys across the north of the country. We had responses in Flintshire and Rhyl, for example, from operators that regularly do that kind of cross-border work, but as I mentioned in my introduction, we are also seeing that demand coming from the Llŷn peninsula and Ynys Môn, because there are no options closer to them to access the kind of care they need. We see journeys coming right the way from the top of the island over to Liverpool, Chester and sometimes further afield. That places a burden on patients and their families and carers. There is a fear from patients. Certainly when they report to our members, we hear examples of patients having been told what will happen if they do not agree to an appointment at whichever hospital it is. Green Dragon is actually one I can refer to. We had a cataract patient who has been waiting five years from the point of referral to get an appointment for the treatment she needed. It had been exacerbated by covid, unfortunately, and the waiting list had got really long. She was offered an appointment in Bristol, but the only way they would support her to access that appointment was if she could get to Carmarthen, because that is where the hospital bus would be running from. She was told in no uncertain terms that, if she did not take the appointment, she would go back to the bottom of the list and would have to wait at least another five years before she could be seen. That is a very real worry, and we hear regularly from passengers on community transport, “If I say no, what does that mean for me?” From talking to the other witnesses before the session, I think that is a real fear. People feel that they almost have their hand behind their back. “You have to do this—you have to make this decision and accept this appointment.” The reality of having to put those systems in place in order to access that care can be really difficult. We have seen some patients dying, as one member of the Committee mentioned. We have seen that, and it is unforgiveable that we should be in that position. People are afraid. They do not get enough information, they do not get it at the right time or in the right way, and the system is not there to support them to access the care that they need.

Stacey, you run the hospital in Gobowen. Do you, on a clinical level, have concerns about the air ambulance moving, bearing in mind that so many people fall on Yr Wyddfa and on the mountain ranges there. Do you have major concerns about that?

We have a helipad, so we receive patients via air ambulance, but very few come to us because we are not a trauma centre. For specialist input—for example, spinal injuries—that is predominantly what we see. But from what you have just articulated, that will be a challenge.

Have you got any feedback on this, Alyson?

Yes, there has been quite a lot of concern, as you know, around the emergency medical retrieval and transfer service and the impact of the Wales air ambulance looking to close the air ambulance base in Welshpool and move the one in north Wales. There was a judicial review done in relation to that decision, and the joint commissioning committee is about to go back out to engage with the public on one of the aspects that was proposed by the NHS in recognition of the concerns that people had raised, particularly in rural areas, about quick and effective access to transport. The joint commissioning committee is going to do further engagement in relation to what that additional service was proposed by the NHS looks and feels like. It is about to go back out to the public in the affected areas so the public will have an opportunity to find out more about what the joint commissioning committee and WAA’s thinking is around strengthening the arrangements and to give their views and experiences in relation to that.

I am very glad to hear about that opportunity. Can I go on to the Welsh language, Chair?

Please do.

Does Gobowen have a provision for Welsh language patients, and how effective is it?

Yes. As with any language, we have an interpretation service and so on. Our signage in the hospital is bilingual. A lot of our staff are Welsh speaking. We also offer a Welsh-speaking chaplaincy service, which is well publicised across the trust.

Do you ever feel that there is a delay in patient care or patient services because of the lack of Welsh language, or do you feel that you have done as much as you can within Gobowen?

I would say that we have done as much as we can. It is not something that we hear feedback from patients about; it is not something that ever crops up. We do ask, so I expect that we would hear if patients did not feel it was enough.

Alyson, do you have a lot of feedback from patients all over Wales now who are going into hospitals in England or on the border that there is not provision of Welsh language, especially if you are elderly or vulnerable? If you have severe dementia, for example, you go back to your first language—that is where your brain goes. I had an aunt who had a bleed on the brain, and for six months she could only speak Welsh; her mind went there. Do you have concerns, or do concerns come to Llias, about this provision?

We see pockets of really good practice and strong efforts from trusts across the border to accommodate Welsh language, but it is not consistent; there is no minimum standard. Local health boards as commissioning bodies in discussing their long-term agreements can absolutely put in place and have some discussions about what Welsh language provision looks like, but there is no requirement for them to do so. They have to consider the impact on Welsh language, but we do not see a single minimum standard across Wales, and neither do we see a huge amount of information in terms of feedback. It is great to see that you are proactively gathering feedback, Stacey, rather than purely relying on complaints, because lots of Welsh speakers do not complain about not being able to naturally speak the language that they want to, yet it has a significant impact on them. As you know, it is much more than having an interpretation service or a sign; it is about their whole sense of self and their whole being. It is about their ability to engage with and be an active participant in their healthcare journey, rather than them being a passive recipient of healthcare. It can make that much difference to how they feel, to the relationship that they build with those who care for them and to their ability to express themselves in a way that is easier for them. It is significant, but we absolutely cannot rely on the number of complaints to judge whether people are satisfied, because people just do not complain about it.

We are a non-complaining breed really, aren’t we? As my final question, would you like to see a minimum standard in hospitals along the border?

There is absolutely an opportunity in Wales to define a minimum standard we can ask for, but there is also a responsibility in Wales to work with English NHS organisations to help them to achieve that. That should build understanding of the fundamental importance of it, in terms of not just communication but how people feel about accessing that care. There needs to be some real, strategic work from Once for Wales to understand how we can strengthen Welsh language provision across the border.

Diolch—thank you.

We are coming to the end now. Moving on to policy more generally, I would be interested to hear from all of you—we can start with Gemma and work down the panel—what you think will be the impact of abolishing NHS England and reducing the number of ICBs in England on cross-border healthcare.

That is really unclear to us at the moment. Similarly, the abolition of Healthwatch is quite a concern. It is a real worry that Welsh patients will have access to Llais, but English patients will not have the same access to an independent body that acts as their voice and provides a constructive challenge to health boards in Wales and England. At the moment, it is not clear what the impact of that will be. I can speak more widely on other policy changes if it would be helpful, and if the Committee has time and would like me to, or I can send that in my follow-up evidence.

I am just conscious of time.

Thank you. Alyson?

From the public’s perspective, at the moment there is not a great deal of awareness about what changes in England might mean for them. In Wales at the moment, there is an awful lot of discussion about what a potential change in the Welsh Government might mean for the NHS in Wales; that is at the forefront of people’s minds at the moment. There are both opportunities and challenges in the significant, transformational changes happening across England and Wales. There is an opportunity to bake in the importance of cross-border arrangements and to ensure that when decisions are made on how things change, cross-border is a consideration and a core element of how services think about the way the transformation needs to work. There is the opportunity to bake in a fundamental focus on that when designing and delivering services. However, the risk is that organisations or sectors will lock in on the bigger changes and cross-border healthcare will be forgotten, and that all the issues and frustrations that we have spoken about today, which have existed for years, will actually seem further away or even get worse. That is particularly the case when we talk about moving services out of hospitals and into communities. That is absolutely the direction of travel that the public want, but what does it look like in relation to cross-border? Does that mean that NHS trusts in England might come into Welsh communities to deliver the services that were once provided in hospital, and what would that look like? It needs some real, joined-up thinking, and the involvement of people and communities, to find what that looks and feels like, and what would work for everybody.

Do you see already—or can you envisage—who should be driving that thinking? I know that it is happening all at once, but based on what you have said, do you have something in your mind where you are thinking, “Right, we need this to happen in Wales and this to happen in England,” to make sure that that will be driven?

It is really important that the two Governments talk to each other at the strategic policy level about what those changes are. There is an awful lot of common direction. In both England and Wales, the direction of travel is to focus on prevention and promotion, and to move services to bring them closer to home. Those directions are not described in the same way, so it is easy for the public to be confused as to whether we are talking about the same thing. There needs to be a commitment, at the level of the Welsh and UK Governments, to understand and collaborate. It is important that where there is a need for distinctiveness, that is also understood. That needs to be translated down to the level of health boards and NHS trusts. One frustration that the public have is that when things do not work in a joined-up way, it is difficult for them to know who is responsible or accountable. It is important that it is clear who is responsible and accountable: who has ownership of designing and delivering services in a joined-up way and how are they held to account for doing that? There are lots of opportunities there.

What you are asking for is good, strategic thinking at the level of the UK and Welsh Governments, and to drive it down from there?

Yes.

I agree. I think that it is unclear at the moment. As an organisation, we do not think that the 10-year plan just applies to English patients. That is the work that we are doing, with Powys more than Betsi, because our work from Betsi is more specialist and this is about our more routine work. We have consultants who run clinics to try to make care closer to home. But the digital bit is significant to enable care closer to home. As a specialist trust, we are used to dealing with multiple commissioners. Yes, we sit in Shropshire, Telford and Wrekin but we have our own individual contracts with other commissioners. We are a bit more used to the collaboration and working through pathways with multiple providers, but it is still unclear.

Chair, may I ask one very quick question?

One final one.

This is a very quick question, to which I need just a yes or no answer. There is no such thing as an average person, but do you think that the ordinary person on the street in Wales knows that there is an NHS Wales and an NHS England, or do they think that the NHS is just the NHS?

Mixed.

I would say that the answer you would get depends on which bit of Wales you were in.

From where I sit, I would probably say they think it is just one NHS.

Great, thank you.

That is a helpful way to end the session. I thank all three witnesses for coming along and appearing in person before us. Am I right that this is the first time you have given evidence to a Select Committee? Alyson Thomas indicated assent. Gemma Lelliott indicated assent. Stacey Keegan indicated assent.

Your honest real-life examples and the way you have given the evidence have really helped us to understand the issues. Thanks so much to all three of you. It has been really helpful. I also thank everyone who submitted evidence into the inquiry and completed the survey because that is also helpful and will inform our work from here. I declare the session closed.