Cynulliad Cenedlaethol Cymru

Yn ôl i Chwilio

Y Pwyllgor Cyfrifon Cyhoeddus

Public Accounts Committee

04/02/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Adam Price AC
Jenny Rathbone AC
Mohammad Asghar (Oscar) AC
Neil Hamilton AC
Nick Ramsay AC Cadeirydd y Pwyllgor
Committee Chair
Rhianon Passmore AC
Vikki Howells AC

Y rhai eraill a oedd yn bresennol

Others in Attendance

Adrian Crompton Archwilydd Cyffredinol Cymru
Auditor General for Wales
Garth Higginbotham Is-gadeirydd Cyngor Iechyd Cymuned Gogledd Cymru
Vice-chair, North Wales Community Health Council
Geoff Ryall-Harvey Prif Swyddog Cyngor Iechyd Cymuned Gogledd Cymru
Chief Officer, North Wales Community Health Council
Mark Thornton Cadeirydd Cyngor Iechyd Cymuned Gogledd Cymru
Chair, North Wales Community Health Council
Matthew Mortlock Swyddfa Archwilio Cymru
Wales Audit Office
Mike Usher Swyddfa Archwilio Cymru
Wales Audit Office

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Claire Griffiths Dirprwy Glerc
Deputy Clerk
Fay Bowen Clerc
Clerk
Meriel Singleton Ail Glerc
Second Clerk
Stephen Boyce Ymchwilydd
Researcher

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

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

Dechreuodd y cyfarfod am 13:30.

The meeting began at 13:30.

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

Can I welcome Members to this afternoon's meeting of the Public Accounts Committee? We've received no apologies—full attendance today. As usual, headsets are available for amplification or for translation. In an emergency, please follow the ushers. Do Members have any declarations of interest they'd like to make? No.

2. Papurau i'w nodi
2. Papers to note

Okay. Item 2 and papers to note. First of all, the Welsh Government have provided a final update on their response to our medicines management report. The response demonstrates that implementation of our recommendations is progressing, but a number are only due to be completed between now and September 2019, with one—recommendation 3—being funded until March 2020. So, I propose to write to Dr Goodall asking for an update in the autumn term on the recommendations scheduled to be completed by September. Happy with that course of action? Happy to note the letter? Good, okay.

3. Trefniadau Llywodraethu Bwrdd Iechyd Prifysgol Betsi Cadwaladr: Sesiwn Dystiolaeth gyda Chyngor Iechyd Cymuned Gogledd Cymru
3. Governance Arrangements at Betsi Cadwaladr University Health Board: Evidence Session with North Wales Community Health Council

Moving on to our substantive issue, and the governance review of Betsi Cadwaladr University Local Health Board and lessons learnt. We've got an evidence session today with North Wales Community Health Council. Can I welcome you to today's meeting? I think it's worth saying at the start that the community council have been very involved with the Tawel Fan families, but are aware that this inquiry will not be focusing specifically on those issues.

Okay. Before we go into questions, I understand that you wanted to make a brief statement.

If possible, Chair. I'd like to make a brief statement describing what we do and who we are in the North Wales Community Health Council. And also a very brief overview of the written evidence that we've supplied to just put it into context, if I may.

I should say, first of all, for the record, would you like to give your names and positions for the Record of Proceedings?

We'll do that too. So, we'll do that first then. I'm Mark Thornton, I'm a volunteer member of the North Wales Community Health Council and elected chair. Before retirement, I actually worked for 30 years in the nuclear power industry at Wylfa power station.

My name's Geoff Ryall-Harvey, I'm the chief officer of North Wales Community Health Council. I've been a CHC chief officer for about 35 years, and much of that was in Cheshire.

Garth Higginbotham. I am the vice-chair of the North Wales Community Health Council, and therefore, again, a volunteer. I worked as a lecturer in physics in university and in a teacher training college and also taught, and then, for the last 17 years of my paid career, I was an inspector with Estyn.

Okay, moving on—North Wales Community Health Council, who we are and what we do. The North Wales Community Health Council is one of seven statutory CHCs that are coterminus with the seven health boards. In addition, there's a board of CHCs that provides us with national standards and further support, should we need that. We're 72 unpaid lay volunteer members and there are 14.4, as it turns out, staff members, nine of which are to support the actual complaints advocacy service. 

Our statutory duties—we have four and they're written in more legal terms, actually, in the regulations, but I'll put them in the more normal terms. The first one is visiting and monitoring. We actually have a statutory right to enter places where healthcare services are being provided to listen to patients, listen to staff and to see what we see as part of a monitoring programme. We engage with the public at the places where people meet, so actually at hospitals, but also places like the Anglesey show and other places where people meet, to actually get their views on healthcare issues.

We also have a right to be statutorily involved with service change, and, if we can't come to some agreement with the health board on service changes, we have a right to actually refer the matter to the Minister. This is a right that we use rarely; we prefer to work with health boards in service change to actually reach the right conclusion that's in the best interests of the patients. 

The final thing is that we have a complaints advocacy service, which we've stated before, and this has been the area that has been so important to the Tawel Fan families, but we actually run a complaints advocacy service for anybody—any patient who is having trouble navigating their way through the 'Putting Things Right' arrangements.

All four elements work together to provide an integrated service to patients and the public. Our main focus area is the patient experience. Informally, we call it the 'mums test'. So, we're not experts in healthcare. We actually do our visiting, do our engagement, on the basis of: would you be happy for your mother, father—whoever—to be actually given healthcare in this setting? 

The other thing is our role with the health board is that of critical friend, so that means we actually try and give help where we can, we criticise where we must, but we try not to surprise the health board with anything we do, and we hope that they will do the same for us as well. 

Moving very quickly on to the overview of the written evidence, we've drawn the information from a number of areas—patients, public, staff, members of the advocacy service, and our members, from the presence in the community that they have, as well as the published information. It's not comprehensive. It's drawn together really to illustrate the point that the health board now has been in special measures for three and a half years, and we think that the rate of progress in that time has been much too slow. Having said that, there are some areas where things have moved on. It would be wrong to say there's been no progress. Women's services, maternity services in particular, was one of the early ones that was taken out of special measures. They significantly improved their public engagement with the use of social media. They've used a programme called Safe Clean Care to improve performance in infection prevention and control. End-of-life pathway for dementia patients, dementia-friendly emergency departments across north Wales—all of those things deserve credit, and they're a credit to the staff that have actually implemented that, and we know there are others in the pipeline. However, it remains the fact that, three-and-a-half years after entering special measures, the health board is still in special measures, and it also remains the fact that, in that time, there are still many areas of health board service delivery that would fall below the standard that the public in north Wales could reasonably expect. 

The final thing I just want to say is that, if there's any question that a member of the committee has today that we cannot answer here and now, we will do our very best to actually find the right answer for you and get that back to you, and then we'll say we don't know this answer here and now, and get the answer back to you. Thanks very much, Chair. 

13:35

Thank you for that. We've got a number of questions, so I'll kick off with the first couple. Could you outline the type of work that you've been doing since the health board was taken into special measures in June 2015, and how effective do you believe the escalation and intervention framework has been?

We've been doing our visiting monitoring much the same as we've always done. When the health board was put into special measures we actually were very pleased about that because special measures we felt would actually bring help, focus and scrutiny to the health board to help them come out of special measures. In terms of the effectiveness—. Well, the fact that the health board is still in special measures three and a half years afterwards—I think perhaps it's not been as effective as anyone would like. In England—across the border in England, it's very rare for a health board or trust to be in special measures for longer than two years. They seem to have a slightly different approach in that they actually bring much more resource, expertise, whatever's needed to actually set a health board onto an even keel and provide a stable platform for a health board to make the improvements required to come out of special measures. As far as we're aware, the health board was provided with some expertise in terms of the special advisers, but certainly initially at least we didn't see a lot else. So, in that regard, we think that—shall we say, the implementation of special measures could have been better.

I note from the evidence that Dr Goodall gave last week that he also recognised the fact that now they do things differently, that Betsi Cadwaladr university health board was indeed the first health board in Wales to be put into special measures, and that perhaps things could have been done better.

13:40

Do you have anything to add to that, Geoff, or—? 

Not really, other than the level of intervention I don't think has been sufficient. I don't think it's sufficient to tell Betsi Cadwaladr that they're not progressing and point out where they're going wrong; they clearly need help on that, and I don't think that has been forthcoming at the level that has been required. As Mark said, we welcomed special measures. We thought it was the right thing to do, for all the reasons that were explained by the Cabinet Secretary at the time, but there doesn't seem to have been the intensity of follow-up that we were hoping for. 

Basically, on that particular point in terms of what could have been done better—and, obviously, in a sense this was the prototype, and that has been discussed at the previous committee, but, from your perspective, what does 'good' look like in terms of that follow-up? What should have occurred?  

As I mentioned earlier, I've worked in the north-west of England for a long time and seen trusts go into special measures. And, in those circumstances, they got teams of people to help them. They had very intensive help. I think here we saw single special advisers come, and they came weekly for the first six months or so, but then it seemed to tail off from there. From our perspective, we weren't sighted on anything else that was happening other than that. We wrote a letter in March 2018—I think we've included it in the pack—called 'failure to progress', and we touch on those issues there. I think it would have been good to see more assistance, more specialist assistance, and we just didn't see that; we felt that it—certainly, for a period after the first year, it just seemed to drift. 

We'll be coming on to questions around governance and leadership later, so I don't want to stray into that, but that—we will pick that up later on. Okay. Thank you. 

In terms of the health board themselves, how well do you believe they've engaged with the community across the north in making the improvements that were intended as a result of the special measures? 

We've commended them for efforts they've made around engagement and communication with the public. I think we said—I said to the healthcare summit on two successive occasions that their use of social media has been absolutely exemplary. They are much better at that. That's one of the areas I would say that they've improved; they've gone and sought external expertise, and they've really taken that whole need to engage on board. They do that much better, and they feed in that engagement into their policy-making process much better than they ever did, but we still have an issue with what happens after that, and there are other questions that are being asked where we can go—. But in terms of, 'Have they improved?' Absolutely. 

If I may, I'll just quickly add that there are two examples of that, I would say. I think the engagement done for the 'Living healthier, staying well' strategy—there was a great deal of stakeholder engagement for it and, in addition, the new mental health strategy, there's been a great deal of stakeholder engagement for it. As Geoff says, I believe they've improved a lot there. It's just the delivery often isn't at the pace and urgency that we would like of the actual—.

Yes, let's go on to that, because you've already said that you believe progress has been much slower than you would have hoped since they were placed into special measures, despite progress in some areas that you've already mentioned. What would you have expected at which point that hasn't happened? What was the benchmark in your mind in terms of the progress that you would have liked to have seen?

I think when Betsi was initially put into special measures, it was said that it wouldn't be fixed overnight, that it might take two years. So, in fact, that expectation was set at that point. So, by now, I think we would expect the board to be out of special measures and we would be expecting them to be delivering excellent services across the whole range of functions to actually warrant that withdrawal from special measures.

13:45

In a sense, I suppose, the clue is in the term 'special' measures, isn't it? The longer it continues, would you say, it starts to kind of undermine the fact that it is meant to be short, sharp, focused, urgent intervention.

Indeed, and in our letter that we sent last March we alluded to the fact that, after a period, our members were starting to feel that special measures was becoming the new normal. I do know that the board has a new chair and new independent members and there's been a change, and I can see there is a determination to actually change all that, but the proof is in the delivery.

Thank you very much, Chair. Thank you, Mark. Geoff, you mentioned you were very happy to have special measures, or at least you were—. Special measures is a last resort to put things right. So, things are still not right after many years, which is totally unacceptable. We know things are still not right, and Mr Goodall would agree with that. He is doing his best to do these things. There must be complaints and there must be some other areas where it very easily could be detected at a very early stage why it has gone on so long. The performance in Betsi Cadwaladr in relation to concerns and complaints improvement—have these been improved since those complaints and other concerns? Have you improved now or are things still the same as in the beginning?

I think the way we look at it is the complaints used to be managed by corporate services. I think actually moving the complaints management to the director of nursing and midwifery was a good move, because it actually gets the clinical staff more engaged. I attend the quality, safety and experience committee as an observer with speaking rights, as a member of the CHC, and there's no doubt that the raw data has actually improved as we've gone forward in recent times. We do have a concern that some of that raw data improvement might be due to an increased use of holding letters to actually hold the system going forward, and we do have a bit of a concern as well because they've brought into place what they call an 'on the spot' resolution, and that should also reduce the number of formal complaints moving into the system. In principle, that should be a very good thing, because it means there's early resolution that happens within a few days at the most. But we have some concerns about the implementation of that, that it might be being used as an alternative to the 'Putting Things Right' system instead of it being in addition to the 'Putting Things Right' system. 

You're just missing my point there. The complaints system then and the complaints system now—what are the improvements that have been made?

Given everything Mark said, which is accurate and factually correct, there has been, on the face of it, an improvement. If you look at what the patient experience is, there has been very little improvement. Part of that, I think, is a national issue and how you decide on whether a complaint has been solved. The target relates to the first response, the first full response. There's a four-day target for acknowledgement, which is neither here nor there. There's a 30-day target for the first response. All the Assembly Members here will have dealt with complaints departments in various health boards, and you will know that very often the first response does not settle the matter, and then you go on to correct misunderstandings, you might have meetings and so on. Our experience is that far too many complaints take a year to settle, and far too many complaints take much longer than that. So, in terms of how the patients feel about whether the concerns system has improved from when they were taken into special measures, because, of course, it was one of the reasons they were taken into special measures, and how it has improved to now, I don't think for most people they would feel differently about that, and, of course, we have people who made complaints back in 2015 who have still got complaints going now.

So, I think there is—. I would not deny that there have been efforts, and the on-the-spot resolution, the PAL scheme that they've got going—the patients advice and liaison system they've got going—all good things, but there are still a lot of complaints, and it's still very difficult to navigate your way through that as an individual patient. It's difficult when you come to the CHC, or when you go to your AM—as an individual it must be very, very difficult. 

13:50

There are six other health boards apart from yourselves. The thing is—what about your learning and sharing of the complaints procedure? 

That comes back to Mark's point. He said that previously complaints in Betsi were dealt with by corporate services. I think that's unique in the UK. Complaints are a learning exercise. There is a value to complaints beyond the value to the individual. 

I don't know why they did that. 

Where is the problem, then? That's what I'm asking about. You worked 13-odd years as a volunteer, before you became the chair—or many years—so you must have experience of the local community? Where was it failing?

Historically, the failing has been in the timeliness of the responses, the quality of the responses, and really that's it. The responses in the past have often been of poor quality— 

But the move back to the director of nursing, which is the normal way it's done right throughout the NHS, that's much better, because it offers the opportunity for clinical learning, which was missing when it was with corporate services. And I think that happened when Gill Harris came. She'd be able to tell you more about that, if she comes next month. But that's an improvement for the positive, and we hope to see more. 

Okay. We need to make some progress, Oscar. Did you have any further questions? 

Just finally, to what extent do the complaints help to influence service improvements in Betsi now?  
 

It's very early days. I think they call it a PAS system— 

It's the same as the English PAL system—they call it PAS.  

Yes, a patient advisory and support system, I think it is. I think it's very early days yet. In fact, I actually don't believe it's been incorporated fully at all the sites yet. 

No, it's been at Glan Clwyd, and I heard on Friday that they're taking it to Wrexham Maelor now. 

So, in terms of the patient experience, the impact across the whole health board is actually currently quite low. 

I just wanted to move on to mental health services, and I wondered if you could tell us what progress has been made since our report in February 2016. I note that you've made three visits to Bryn Hesketh ward, the last one being, according to this, on 8 May 2017, where you were quite critical of obviously the staffing levels in particular. Could you just explain whether you think things have improved since then, because that's quite a long time ago, and whether no further visits have been made since then? 

We visit a great deal right across the spectrum of services. So, yes, there have been visits to other mental health services since then—plenty. We can provide you with a programme. 

13:55

I think there have— 

We pulled those out specifically because they illustrated a point, not because they were the last ones we did.

There was a good response to that. We had a positive answer. We heard about what they were going to do to improve it. Staffing levels were a bit of a moving target for them. It's difficult for them to recruit staff. I don't know whether that's because it's difficult for them to retain staff. Staffing levels are an issue right across mental health services in north Wales and any other service you care to speak of.

Okay. Your report in May 2017 is saying the unit is staffed by a number of bank and agency staff. As far as you're aware, has that changed?

It could have changed there. As I say, it's a moving target—they plug one gap and another appears somewhere else. 

We can find out for you.

I think that's one of those ones where, if you want that detail, we'll find out and send it back to you.

Since special measures, we've had a better quality of response when we express concerns. We don't have a big backlog of reports that we've sent into to them and not got—.

They are responding to queries. They're responding to adverse reports.

Okay, thank you very much. Obviously, there's been correspondence between Donna Ockenden and the health Minister, and she reports that she continues to be contacted by service users and their representatives and staff about the little progress being made. What correspondence have you had from any of these stakeholders?

We hear things when we go on visits. We have complaints and I've included some of those complaints in the document, or alluded to those complaints in the document pack. We often have conversations with staff on all sorts of wards about their concerns. And we take those forward on an anonymous basis. So, staff will talk to us about staffing levels, about quality of estates issues, and we will take those up as part of the report. Very often, we have success on that, and then staff want to talk to us more. 

Okay. Donna Ockenden's highlighting concerns about the rate of improvement and the capability and capacity of the board. But we've had more positive indications from the Minister for health, both in July and November. So, as you're on the ground in north Wales, could you just tell us whether noticeable improvements are being made?

We share many of the views of Donna Ockenden and the reason we're here is because of the slow progress. We believe progress has not been quick enough. There's been a great deal of work done around policies, but that needs to be translated onto the ground. I've included issues of complaints we've had around mental health and, clearly, for those patients, they're not seeing the improvement.

There are degrees of improvement. There has certainly been improvement. I wouldn't support anybody who said there had been no improvement whatsoever. But sometimes things fall back, sometimes new issues come up. We're not where we need to be with mental health. I don't think even Betsi Cadwaladr would disagree with that.

Okay. But from your perspective, would you say that the Minister for health's reports of improvement, and indeed the Welsh Governments officials who we saw last week, I think, who are saying that there had been substantive improvements in mental health—? Do you think those are accurate?

I don't know if I'd go as far as to say substantive improvements. There are improvements in lots of areas, but, equally, there are other issues that come up, that have come up in the last three and a half years, that weren't there at special measures. So, there's a variety of issues.

14:00

Okay, but I'm focusing on mental health here. Have there been improvements?

There have been some improvement. There have been some improvements, yes.

If I may, Chair, from my perspective, I think an awful lot of effort has gone into planning and strategy, and that's to be commended—I spoke about that earlier. I think the problem is: actually translating that into action on the ground, as it were, has been very slow, so it's actually been very slow to be reflected in the patient experience. I spoke at the start here of the patient experience, and I think in many cases that hasn't been the case. We had a services planning committee meeting last week, and in that the health board were keen to mention some of the things that have been mentioned here today in terms of service improvement. But one of our members was keen to point out that a person who lives in their community, if they have some difficulty with their mental health, they still feel as if they're, to some degree, bounced around the system. And he was also keen to mention that young people who are suspected of having autism—

We're drifting into different areas. Okay. I wondered if you could just send us any reports of visits you've done since May 2017, because I think those observations will be fresh.

We can send you reports that are very positive, and we can send you reports that show problems, and we'll send you—

If you could organise for that to be sent to the committee, that would be good. Rhianon Passmore, do you have a brief supplementary?

Yes. In that regard, then, you mentioned that there's not a large backlog of reports—

—that were adverse, from your behalf, to the health board. So, is there still an issue in regard to their response to you as a community health council, in terms of your reportage, in terms of your visits? Or is that not an issue? Would you like it improved?

We'd always like it improved. Our reports are dealt with in a timely way. They are taken seriously. Now, sometimes, the problem is resolved in that particular ward, but we see it still in other wards, and sometimes we go back to the ward a year later and we find the same problem.

So how much, endemically, then, is this down to the fact that you've underscored—and it's our understanding as well—that there are issues around capacity of the workforce in this regard? Because, if the operational plans are in place, it's about embedding that, and if you don't have a consistent workforce and if that is a major issue in this very large organisation, then how much is that down to—?

I think staffing is a major issue. That's not unique to Betsi Cadwaladr. Staffing in all sorts of areas is fragile. Recruitment is difficult. I think in these particular specialties, mental health particularly, turnover is higher than anywhere else. As far as we're concerned, efforts are being made to improve the service, but we seem to get stuck, as Mark has mentioned, at the policy creation side. So, we see a policy created, it's done very well in terms of engagement, and the policies are all well thought through, and then there seems to be just this impasse of getting it from policy stage to being embedded in the culture of the organisation, and to making changes for the benefit of patients. It's not just us making that criticism; it's widely held within north Wales—within the third sector, for example—that Betsi Cadwaladr create a good policy, but then, do they go on and deliver it?

Could I just add that one of the best indicators of this, perhaps, is staff satisfaction? At your meeting last week, it was pointed out that staff satisfaction has improved. 'Would you recommend to somebody else to work in this institution?'—that has improved, but it is still not terribly good. There are still 40 per cent—I think it is—of responses that are not positive. So, it's getting better, but it's not there, and the link between board and ward—there's a lot being done to try to improve it. That is a clear policy, which we welcome, and we're seeing that, but it hasn't got there yet. 

14:05

Diolch. The Ockenden report concluded in 2015 that Tawel Fan patients had been subjected to a lack of professional, dignified and compassionate care in an environment that led them to being restrained and possibly breached their human rights. There was a rather startling difference of view with HASCAS—the Health and Social Care Advisory Service. In their report in May 2018, they concluded there was

'No evidence to support prior allegations that patients suffered from deliberate abuse or wilful neglect or that the system failed to deliver care and treatment in a manner that could be determined to meet the thresholds for institutional abuse.'

Do you think that this difference of opinion has got in the way of making improvements in Betsi Cadwaladr?

I'm not sure it's quite in the way of making improvements. Certainly, the 'no institutional abuse' from the HASCAS report we feel very strongly was a mistake. It's made life very difficult for the Tawel Fan families. I don't know if I may, Chair—. Myself and Garth were actually at the launch of that at a hotel in St Asaph when that was actually launched up there, and it was very wrong—very wrong. And we actually released a press report after that—a press release—saying that the whole report was very critical of the health board, in a similar way to the Ockenden one, and then just came to some quite different conclusions, and we welcomed the parts that were critical and we actually welcomed the recommendations, because the recommendations are very similar to those in the Ockenden report, but the 'no institutional abuse' was very poor, and we commented at the time that we were really concerned about the lack of empathy with those affected, the patients and families. And I'm also quoted as saying that there seemed to be a, sort of, methodology that would actually take evidence of good care to be in some way mitigating or offsetting evidence of poor or very poor care. Well, the CHC view is that good care is the absolute minimum that anyone should expect, and to try and use that to offset the poor or very poor care is simply wrong. 

About three months after the overarching report came out, we'd started to get the individual reports coming out, and I attended almost all of those—. When a report was delivered, there was a meeting between the family concerned, the HASCAS team, and the Betsi Cadwaladr team. I attended most of those. What I can tell you is that the vast majority of those reports detailed poor care, harm, and, through the redress bit of 'Putting Things Right', there were a number of families who received very large settlements because of the harm caused to their relatives. Now, I don't know where the line between poor care and neglect comes or where the line between harm and abuse comes and what the relevance of it being an institution is, but the individual reports were very, very different from the overarching report in the claim that I think the overarching report made, 'Overall, there was a good standard of care'. Well, you don't settle £20,000 on somebody if there was good care. 

Of course, this committee meeting today isn't about a rerun of Tawel Fan, but what we're interested in is the impact of the investigations that have taken place and the policy formulations that have evolved from that with a view to improving mental health provision in north Wales. I'm keen to know, therefore—and you've, I think, answered the question in a sense by what you've said—which of the two approaches has been preferred. 

Just to add, I mean, there's no doubt, on that day, it was very distressing, you could see that it was very distressing for the families of the Tawel Fan patients. In terms of what's been done, we welcome the action plan, the fact that they've merged both and that they've actually instigated two groups—a stakeholder group and an implementation group. But again, we hear from members of the stakeholder group that they're frustrated about the rate of progress about implementing the action plan. Just going briefly back to the Tawel Fan families, Garth was also present that day and I just wonder if Garth has anything to add about the—

14:10

Yes, it was a very, very unfortunate day. The issue about institutional abuse is that the term is not defined, and therefore, you can say—. I mean, it's pretty clear, I think, that there were not nurses sitting down and saying, 'How can we abuse these patients today?' That is way, way off any truth at all. The fact is, however, that there were shortages of staff; there was difficulty in getting consultant psychiatrists; there were very limited activities for people; there were shortages of nurses; and there was a big deficit in training, both statutory training and developmental training. In a sense, the disaster was a matter of when it would happen, not if it would happen. Now, if that constitutes the institution getting us into that situation where it did happen, then you could look at it differently. But, on that day, the fact that there was not institutional abuse in the judgment of HASCAS was presented very early and very strongly. Had they said, 'This was a weakness, that was a problem, this happened, that happened, all these things happened, nevertheless, we cannot, with our hands on our hearts, say that that was institutional abuse', the families could've listened to that, heard it and had some closure. As it was, they heard, 'No, it wasn't.' Apparently, what they heard was, 'We believe the health board; we don't believe you.' That wasn't said, that wasn't intended, but that was what was heard.

As well as that, there was a separate event timetabled that day where the report was given to the press. And that meeting got ahead of this meeting by about 10 minutes, and the families, on their phones, were looking at the reports coming from that. It was just badly stage managed. And the families went to that meeting hoping for closure, and because of the way it was presented, really could not get that closure and were further agitated. When you've been going at it for five years, it's not easy to walk away from.

I think the main point from this is that the conclusion completely undermined the investigative process, and I think, in a way, it can't be overstated how much that has happened.

I think the other thing to draw from the HASCAS and the Ockenden review is that the conclusions were very much the same, and in fact, the way the health board responded to those, they merged the reports and had the joint conclusions. Now, HASCAS said that all of those recommendations needed to be acted on, implemented and resolved by March 2019.

May—sorry. May 2019. We're now in February and we're not seeing a great deal of work towards that, or a great deal of on-the-ground evidence that those have been resolved. I think the timetable now is very, very challenging.

That's very interesting. The reason for my question was that in the HASCAS report, they say that what happened at Tawel Fan was a catalogue of fundamental system failures in relation to oversight and governance. And the Minister has tended to concentrate upon those factors as well. On 6 November, he made a statement on Betsi Cadwaladr, saying that he was 

'content that the plans the health board has put in place to implement the recommendations, both with mental health and more widely, are comprehensive and robust, with operational leads identified and being held to account.'

This is all to do with process rather than results on the ground, which you've just been mentioning. So, your overall impression is that, whilst the processes that have been put in place might have effectively answered criticisms that were in those two reports, nevertheless the progress on the ground has not been sufficient so far as you can tell. 

14:15

I think that puts it in a nutshell, to be honest. I think they have plans and processes, they have strategies, all of which are very important—let's not underestimate that—but planning is a means to an end, and not an end in itself. If you like, in the foothills they've done a lot of the preparatory work, dug the ground and all of that, but we really do need to see some pace and urgency in getting it to have an impact in the patient experience in a consistent fashion across north Wales. 

A moment ago you referred to problems with recruitment being partly, or to a great extent, responsible for many of the problems that occurred. To what extent do you think that recruitment of a senior management team helping to drive forward improvements to the mental health service is happening now? Is the recruitment problem being effectively addressed?

We're primarily focused on the patient experience. Having said that, there's no doubt that the new chair's appointment has brought quite a different tone and expectation than there has been previously. The focus now is much sharper on delivery on the ground. There have been other changes as well. There have been changes to the independent members and there have been changes in terms of executive directors, all of which is good. It's early days and time will tell. The only thing I will say is that we're three and a half years in from special measures, so there really does have to be a sense of urgency and focus, I think, to actually make those impacts that do positively affect the patient experience. 

I think, in terms of executive management, it's probably easier to recruit an executive manager than it is to recruit a psychiatric senior registrar. Those staff—. And this is not Betsi Cadwaladr's; they're not responsible for that. That is a national issue. The drivers for that are probably way outside the control of Betsi Cadwaladr. 

Obviously, the health board has to work harder to recruit people given the background, the appalling publicity that they've had. People think it's going to be a massive challenge to turn things round, but that could be an invitation to some people with the right attitude towards making a difference, but, on the other hand, others may take a different view.

It is north Wales, and it's a beautiful place to live and work. That will be attractive to some people. We should be very clear that the staff—the doctors, the nurses, the support staff—at Betsi Cadwaladr are not in special measures. We see every day fantastic examples of staff going above and beyond. If you look at the Betsi Cadwaladr staff awards, you'll see in there some tremendous examples of initiatives where staff have, in their own time, and in many cases with their own money, brought about improvements for patients. We did a report on this called 'Lonely in Hospital' and it looked at what staff were doing to socialise older people in hospital. We see that all the time, and it's not the staff in special measures. What we often see is a consultant will come over and with him, because he's there, he will bring people. There are certain services at Betsi Cadwaladr—pathology, for instance—that are world class, and they have no issue whatsoever in recruiting.

So, that's where they need to be heading, but the senior management is vitally important in that. 

Thank you very much indeed. Thank you very much to all three of you for joining us. A couple of points that concern me are that, you have done whatever you can and effort's been made, but it's slow progress. How long will it take to put things right because in the light of actually some reviews being done—Donna Ockenden and the Health and Social Care Advisory Service and all the rest of it—. Patient and family support is needed in mental health—I'm talking about mental health and not other areas. So, basically, what have been the key messages from the public engagement work in Betsi?

14:20

I would say, right across the board and also in mental health, that once people get into a service, they're generally very satisfied with it. Access is a huge issue. So, access to community and mental health services is something that we deal with all the time. People—they're not making complaints about it. They come to us—. It would be inappropriate to put it through as a complaint, because what it really is is a call to action. In individual cases, I can, for want of a better expression, rattle some cages and get something done, and I'm sure that you as AMs have the same experience, but then you wonder, 'What about those people who haven't come to me? What's it like for them?' And we have heard some—. Pain management is something that we've always been very, very interested in, and the waiting times for that go from 36 weeks, and I think we're currently at about 76 weeks, which is a dreadful time to wait for something like pain management. We can generally get results, as you can, for individual patients, but you worry about those people who don't come to you who haven't got a voice.

I don't know how long it's going to take to get that right, really. I think we need to move beyond this phase of creating policy into a real phase of hard work on implementing those policies. HASCAS quite rightly called for their recommendations to be implemented within 12 months, and back on 3 May 2018 that seemed like quite a long time, and it doesn't seem like that now, and whilst a lot of work has been done around writing policies, we are still seeing people with difficulties of access, we're still seeing people not being able to get beds when they're in distress. I'm sure you've seen the press releases of the north Wales coroner around suicide of young men. There is a lot of work to do.

And I'd just like to support that. I mentioned earlier briefly the services planning clinic [correction: services planning committee] and that the wait for young people suspected on autism runs into years. When you're a young person—. When you're my age a year is much shorter; when you're 16 instead of 60, it's actually much longer. These are unacceptable waits. You can look at orthopaedics as well, and waits of two years are not uncommon and people are living in pain and some disability in that period. So, it is access and waiting times that really are the problem, because, as has been said, once people actually get to the point of being seen and being treated, they're generally quite happy. So, that really is the problem.

I'd just like to add, in terms of how long it will take, really that is a question that's better directed towards the board, because, as a patient-facing service, we don't necessarily get involved in the detail of the planning and delivery, because that is what the board should be doing. But we do actually care deeply about what the patients experience.

Thank you, Chair. Just apart from the mental health issue and patient care, have you got any system in place to observe the service that Betsi is providing—video and visual observation by the service provider? I'm not saying nurses and doctors, but to check them, you know—observation for them to look at and measure how they are going to be treated and how they are looked after.

Indeed, we do, and that's part of the visiting and monitoring programme that I mentioned earlier. North Wales is one of the most active community health councils in their visiting and monitoring programme. We've had things like bug watch, care watch, food watch, all of these things, which, whilst—. As I said before, what we do is what we informally call 'the mum's test'; we are not specialists in healthcare. As I said earlier, my specialism lies quite a bit outside of that. These are the sorts of things that laypeople can do, and they're all recorded and they're all reported, and they're all reported back to the health board for their action.

14:25

We've led on a number of national reports, and one that we did, which I've not included in this pack but I can send along, is one called 'Our lives on Hold', and it looks at what waiting times mean for individual patients. And quite a lot of the time you'll hear about 76-week waiters and 52-week waiters. Well, what does that actually mean? We spoke to people about it and we found out that grandparents couldn't look after their grandchildren because they were waiting for a hip replacement, and then that has a knock-on effect on the whole family because childcare is very expensive now. We found people who'd lost jobs, relationships destroyed, marriages come apart because people are living in pain, and, for us, that's the test. We can hear about how waiting times have been reduced and fewer people on the list, but what does it mean to the individuals? And that's the way we look at it. Now, we provide that to the health board, to say, 'When you're looking at these numbers, this is what this really means; this is what it means to a 70-year-old man who can't work any more because of his hip replacement, or to somebody who needs a knee replacement'—joint replacements being the ones that are often the longest. And they make what they will of it, but we think it's important for us to feed in the patient experience.

We've moved away a bit from looking at numbers and we look more now at what people tell us because I think that's what—. Anybody can get the numbers; finding out what it means to people is different. As Mark said, the key thing is that when people get their treatment, they're very pleased with it. It's access to that treatment that's our big issue, really, at the moment.

As Geoff says, I always try and remind the health board that, behind every number that they show us, there are real people who sit behind that.

I'm just dealing with a call to action from a patient who has a very, very aggressive and life-threatening cancer, and that patient needs pain management. They also need psychological support to come to terms with a very early death, and the times I've been quoted for waiting for those services are beyond their life expectancy.

Thanks, Oscar. Briefly, Rhianon Passmore, before I bring in Vikki Howells.

In that regard, regarding the longevity of the situation, the seriousness of this situation, how do you react to the scenario that you could be deemed impotent as a community health council, or, indeed, others could think that you have failed as a community health council with regard to this wider situation. How do you react to that?

We work to the limit of our powers. In terms of Tawel Fan, I believe we've engaged very effectively and have provided all the support we possibly can to those families, and I think there's a document in the pack that describes that. I would certainly like more powers.

That would be my next question. In terms of the tools in the toolkit—.

I think my view goes like this: we clearly have value to the people of Wales. I think I would draw your attention to the letter from John and Ann Stewart, one of the Tawel Fan families, that's in the pack. I would also draw your attention to the consultation on services fit for the future that has about 1,300 responses, very many of which were very supportive of the CHC. I would also draw your attention to the Francis report from the public inquiry on the tragic events that happened in the Mid Staffordshire hospital.

I think in terms of the toolkit, which is where you really want me to talk, if we had more powers, we would obviously be very pleased to exercise those. Currently, we have a statutory power to refer matters to the Minister, and you can see from the letter that we wrote last March that we have done that. We try to do that sparingly, because we try and resolve matters with the health board and, indeed, that letter was actually written with the health board, so we can do that. We also work very closely with Healthcare Inspectorate Wales, so if matters are not right, we can actuallly report what we see and what we hear to Healthcare Inspectorate Wales—

14:30

I believe that we have. We can refer matters to the people who have powers of enforcement and sanction, and I believe that we have been—

And that's a two-way street—[Interruption.]—in that HIW—. Sorry.

I just said we need to make some progress, so if you can be succinct with your answer.

HIW will come to us and say, 'We're hearing such-and-such about a particular ward.' We'll send somebody in, often that day, possibly the next day, and we'll report back to them and they can decide whether to put that in their programme. The recommendations from this committee of 2016 about increased co-operation and information sharing between HIW and CHCs was taken very much to heart. Shortly after that, there was a memorandum of understanding, and, in fact, tomorrow, I'm attending a review with HIW about how things have been working and what we can do better. 

I think that CHCs can always do better in terms of holding the NHS to account. I can think back and think how I would've done things differently with the benefit of hindsight in relation to Tawel Fan and to many other matters. I've been involved in similar things at Alder Hey, in the Shipman inquiry—we supported families there. By and large, I'm satisfied with what we did around Tawel Fan, but the CHC's role is not to stop these things. Nurses and doctors are professionals who should govern their own conduct, so it's not acceptable to say, 'Well, we did that because the CHC didn't stop us.' I've been involved with CHCs for nearly 35 years now and in that time, I've only seen one abuse of a patient as it took place; that was somebody being restrained. The fact is that people temper their behaviour. When we visit, we visit unannounced, but, usually, we visit two or three wards on that day and it goes around—they know we're coming. We visited Tawel Fan a number of times before it was closed in December 2013, and I've been turning this over and over in my mind, 'Could we have done better? Could we have found it out?' Mark's experience in the nuclear industry and safety in the nuclear industry was helpful, because we did a 'five whys' on why we didn't pick it up.

Okay, I think we'll move on at that point, because you've given some very full answers to that supplementary question. We'll bring in Vikki Howells.

Thank you, Chair. Primary care is clearly the interface through which most patients access health services, and I know that Betsi Cadwaladr has not been without its problems in that area historically. However, we've taken evidence that suggests that improvements have been made, so I just wanted to test that against your opinion. Firstly, what improvements, if any, do you think there have been to GP out-of-hours services in north Wales?

There has been some improvement, but it remains incredibly fragile, and the recruitment of GPs is the big problem there. Again, it's a national issue, but I think there has been some improvement. Geoff.

14:35

I would agree. There has been some—certainly in how it's organised, But, however well it's organised, if you haven't got enough GPs, then it's difficult. Attempts have been made to use specialist nurses to fill the gaps, but those people are difficult to recruit as well. I think it's probably time we saw some more joined-up, pan-Wales out-of-hours arrangements. I think that would be useful.

The difficulty in recruitment can't be laid at the door of Betsi Cadwaladr. Not only is it national—it's UK-wide, and I think it's beyond their issue to fix it. What I would like to see is some change in the performers list arrangements in Wales, and there was a consultation on that last summer that we organised a very large number of responses to. We've yet to see the outcome. But the performers list is sort of a checklist. It's a back-up, it's a backstop to check that a GP is safe to work. It's not the only one, because individual employers will do their own background checks, and you have to be on the performers list to act as a GP in Wales. If you're a GP who, say, trained in Cardiff, went to work in England, say Chester, and fancied working, after a couple of years, in Wrexham, you cannot do that. It's not allowed. You have to get on the Welsh performers list. That takes about three months. It has been fast-tracked, but it still takes about three months, and there's a degree of uncertainty. I would say 99.9 per cent of all GPs who are currently on the English list could be on the Welsh list and vice versa, but it's still a hoop you've got to jump through that takes about 12 weeks. If you can work anywhere you like, then why bother? Why not just go down the road and get—? It would be really helpful—. It's not the solution to the problem, certainly not for GP recruitment of practice-based GPs, but particularly for the sort of GP who likes to do out-of-hours and a few other things, and this portfolio career that they all seem very keen on now, it would be useful that they could pop over the border. One of the worst hotspots for problems in GP appointments is Wrexham. Now, I live in Chester. Wrexham is 11 miles from Chester, and you would think that there would be no problem there; there's a major problem there. It's as bad there as it is in Ffestiniog. So, I'd like to see that.

There needs to be some national initiative about this. I think there are things you can do to mitigate it, but they are getting increasingly difficult, because if Betsi Cadwaladr are thinking about filling the gaps with specialist nurses, then so is everybody else.

Thank you. Moving on to primary care estates, this committee's report in 2016 recommended that all health boards should review and improve their primary care estates. In your opinion, has the primary care estate in north Wales improved since that time?

Some of it has improved. The big health centres—three new big ones in Ffestiniog, in—

—Llangollen, and in Flint. Some people might argue that was not the model to go with, but in terms of estate they are excellent. There are inevitable snagging problems with new estate, but other than that, they are excellent.

By contrast, that shows up the rest of the estate, but, of course, a lot of that is not in the control of the health board. Some of it may be owned by individual GP practices, who are independent contractors, small businesses, and they decide what they do with their estate. We have seen an estates plan. There is now an estates strategy as of last month.

Indeed. I think that's the first one, but it's a step forward. But that does show that the estate across the health board—that very nearly half of it is in need of some substantial refurbishment or work. But just coming back round to mental health, I know your question's primarily about primary care, but we were pleased to see that the health board is pushing forward with the redevelopment of the Ablett site, for instance. So, again, there are signs that things are being done but, in some cases, the improvements in one area highlight perhaps the deficiencies in others. 

14:40

The Royal Alex has just got its business case approved—I'm sure you know; I saw a film with Ann Jones and Vaughan Gething—and that provides primary care-based initiatives on the site. One of the things we're seeing as well is as GP practices reorganise themselves for new challenges, they are, in great part, giving up branch surgeries, and branch surgeries are some of the most problematical in estates terms. And that's good and it's bad. It's good because people are then—. It allows more investment in main practices, but it's bad because in north Wales where distances are long and transport is poor, then it denies people an opportunity to be treated closer to home. 

Thank you, and that leads me on to a question about patient experience, which might tie into that, actually. What does patient experience tell us about the improvements needed to primary care services in north Wales, and what lessons do you think can be learned from what patients are saying? 

I think the patient experience, like much with the health board, is mixed. In many cases, people are very satisfied with the care they receive, but in some cases, they're not. Travel is one of them, which Geoff has just mentioned, and also what services are provided. 

I think that's correct. I think also patients are very loyal to their GP, and they'd rather be treated by their GP in a branch surgery that's perhaps not got good heating or it's a bit damp, or whatever, than see that go. So, they're sort of reluctant to complain about that. And the travel costs are not to be neglected, I think. When a branch surgery closes—I was talking to a mum in Penmaenmawr whose branch surgery was closing. She had to go about three miles down the road with a pram and three kids; the bus fare was about £5, and so that was worrying for her. 

In terms of out of hours, I think the service in north Wales is very good because they take social need into consideration. If a mum says, 'I've got no transport and I've got kids here', they will come out. So, I think that's to be commended. 

I think one of the concerns, though, going forward, is the number of surgeries that are handing in their general medical services contracts. That is of concern, and if you actually look at the age profile of GPs, that really doesn't help the cause. There really needs to be a concerted national effort, I think, in training younger GPs, and actually making the career very attractive. 

There's a difficulty with that, in that younger GPs now tend to marry each other rather than marry nurses, and you have a household with quite a considerable income. And many people are taking a decision about quality of life, and saying, 'We really only need three days each', and that reduces the amount. Also, as you go—. One of the significant things we're seeing is this phenomenon of entire practices giving notice together. Then, they want to come back and work in the directly managed practice that's taken over, and they generally just want to work half time. So, you lose 10 GP principals and then, effectively, all you've got is five. 

Fundamentally, we think what that's about is that many younger GPs want to be GPs; they don't want to be business managers. 

We, a few years ago, repeated the—. We did a cut-down version of the GP work-life balance study that the University of Manchester does for NHS England every year, and we found a number of very interesting things in that about what people's intentions were, and what was important to them. I believe that NHS Wales should be doing that, because this is a much more complex problem and it's not particularly about salary levels, it's not particularly about responsibility; it's about lifestyle and it's about what these professionals want out of life. And given that they're highly sought-after professionals, I think that needs to be listened to and thought about. 

14:45

Thank you. That leads me on to my final question, which is: are primary care services on a secure and stable footing in north Wales now, and, if not, how and when do you think this will be achieved? I think your answer is basically going to be around GP recruitment, so feel free not to repeat what you've already said. 

I think they are not, and when you speak to the Betsi Cadwaladr people, they have an at-risk, fragility list, and they'll tell you all about that. But I think we come back to the issue that many of the problems are not about money. When we hear about service development and improvement, for us, what we hear more and more is that the problem is not money and the problem is not being £30 million, or £40 adrift; it's about can we get these very important, very hard to find NHS professionals? Can we find a vascular surgeon? Can we find a urological surgeon?

We have a continuing and deteriorating financial situation at Betsi Cadwaladr. What do you think the role of the CHC is in supporting changes that are going to be required to balance its budget?

I think, as a patient-facing, patient-focused organisation, the detail of the financial position isn't something that we are overly engaged with. Our main concern, as Geoff just said, is in recruitment and being able to get the services and equipment and the people that the patients need. One of our concerns is that, with the deteriorating and difficult position that the finances are in, if that becomes an all-consuming problem, that might take the board's eye off the patient services. 

No change is not an option though, because, at the moment, obviously, the taxpayer is subsidising Betsi Cadwladr's poor financial situation. So, I appreciate that your predecessor, Jackie Allen, was arguing that the funding formula was not appropriate to the needs of north Wales, but Vaughan Gething said quite clearly that the allocation that Betsi Cadwaladr is getting is higher than it would be if it was on a needs-based formula. And he also mentioned that, in terms of the performance fund, Betsi Cadwaladr got the highest award. So, it's about what you think is not happening to enable these funds to be used to get that change. 

I think one of the big drains on finances has been the use of locum and bank staff, and I have seen an improvement in that. That's been much reduced.

Because one of the worst problems here is that it's not just for staff who call in sick, who obviously have to be replaced very speedily, but that they're using them to plug vacancies. 

That's because they can't recruit. And for the people who—

This is not really our area of expertise, and they will tell you more, but I know that they've made efforts to drive down the bank and locum costs. They are trying to get—. On the consultant level, they're making great efforts to persuade people who are on locum to come over and be in the permanent establishment. And that's difficult for reasons that I don't need to explain to you. 

There are two divisions that haven't delivered on the financial targets that they were set. One is the mental health and learning disability division—we've already talked quite a lot about mental health services—and the other is the secondary care division, mainly at Ysbyty Glan Clwyd and Wrexham, due to unscheduled care pressures, combined with medical and nurse agency costs. We've talked about costs, but I'm also interested in your observations that the board talks a good game when it comes to strategic plans, but they aren't then implemented. What role does the CHC play in your visits and observations around, say, unscheduled care or, indeed, planned care?

14:50

Our visits do actually note unscheduled care, or the consequences of unscheduled care. It used to be the case that you'd frequently have ambulances stacked up outside hospitals. In our visits as laypeople, we would note that and report that back. And, again, we visit emergency departments and actually talk to people who are waiting there to find out what their patient experience is. And, again, we report that back to the health board.

No, not in any great detail.

That isn't included in our terms of reference. We've got an interest in that, in that, clearly, it impinges on patient experience. In the past, when we've complained about, say, the length of waiting time for pain management, we've appealed directly to the board, and they've gone and bought sessions, say, in Clatterbridge or in Manchester. And that's been brought down to an acceptable level. That happens less often now. Now, I don't know exactly why that is, but the suspicion is that it's to do with financial stringency. So, it's at that point we'd be worried about finances. But we don't have a formal remit about that; it's something that we would urge the board to perform better on, and the new chairman, as Mark has mentioned, is much more sighted on that.

Okay. I heard earlier you say that the new chair, and the new independent members, and the new executive leads, obviously, have promising prospects. How much do you think—? Would you agree with me that the deteriorating financial situation is primarily down to failure to implement change that's required to improve this?

Okay. So, given the focus on finance and performance within the board, do you think the board now has the right leadership to take the health board forward and out of special measures?

I think time will tell. Garth was there for a presentation by Mark Polin, and our members were very impressed with that. But then again, you can't make a reputation on what you're going to do. So, he's coming back in 12 months. It was his 100 days, and so we wanted his reflections on that. We will ask him to come back again, and we would hope to be seeing how he's implemented those intentions. And if he has, then we will certainly be very grateful for that.

Thank you. You've mentioned a number of times, collectively, the new appointments in terms of both the executive directors and the non-executive directors within the board, and the importance of rolling out and implementing the new policies, new systems that are part of that mandate. So, in regard to the effectiveness of the board, in terms of recruitment and retention of independent members, and their former issues around attendance, especially, at board meetings, what is your current overview of the state and the status of the new 'board'? And what is your prognosis for the future?

Certainly, I know there were questions around the attendance of independent members at the board previously. These days, we see no problems in that area. The independent members do attend the board meetings, and, as far as I can see, the other meetings as well. We don't attend many board meetings. I go to the quality, safety and experience one, and I see independent members there regularly. So, we don't see a problem there.

In terms of prognosis, I think that we're hearing all the right things. Certainly, the three priorities that have been put forward by the new chair do resonate with us, especially with access and waiting times being one of the lead ones. Clearly, that is a very important part of the patient experience. So, it is early days. It's early days.

14:55

And we've been saying for a long time that these changes have not actually embedded as they should have and we are in a very serious scenario here. So, in regard to your organisational role in terms of challenge and scrutiny and the pace of change that we have seen, do you feel that what you're hearing when you attend the board meetings as, I presume, observers, do you feel that there is enough systemic cultural change within this very large organisation to be able to implement some of the changes that we would expect?

I actually think there is. The fact that there's recognition that the board, with the exception about the IMTP, largely has all the plans that it needs to move forward—it's got 'Living healthier, staying well', and it's got a three-year plan that isn't yet quite an IMTP—going forward, there's a clear focus now on delivering those plans. In other words, the effort should shift from continually planning to actually delivering. That's the sense that I feel. Again, it's only a sense that I get from attending board meetings, talking to the chair, talking to IMs. I think we've said before that the proof will be in the delivery, and that will be in the future.

Okay. So, in that regard, the governance arrangements Betsi Cadwaladr report from 2013 included a recommendation that concerned renewing and reuniting the executive and non-executive teams and closing the gap, as you've already referenced, between board and ward, very early on in this session today. That was from 2013. So, in regard to the challenge and pace and, yes, your very specific mandate as a community health council, I go back to my earlier point: do you feel you have enough tools in your toolkit as a community health council to be able to instruct that figure from what you can see and have evidenced in terms of your prior reportage to the health board, because that is a massive challenge, isn't it?

It is. Clearly, the board has to be the leaders in this. We report back to the board what the public and patients tell us. Do we have the right arrangements to actually do that reporting—because we have no enforcement or sanction, apart from referring matter to the Minister, not formally anyway—and do we have the right tools to do that? Well, we have a particular statutory meeting called the services planning committee, which is a bit dry, but that is very important because that's where the health board gets a chance to inform us at an early stage of the service changes that they're planning to make, or indeed ones that have been forced on them by shortages of staff, and we do have a good discussion at that meeting. We have a chair-to-chair meeting—and I'm meeting the chair again in the middle of this month—where we can actually convey those concerns or any concerns that we do have to him.

To interrupt you, because time is running short and I'm conscious of that, do you feel that your communications to the health board are aggressive enough, in a non-aggressive way? Are they direct enough? Are you able to make the points that you need to make in a satisfactory way to them that you belive is being understood and digested?

I think we do fulfil the role of critical friend. There are a number of ways that CHCs can work, varying from very aggressive and outside the arena of discussion to right inside but less challenging. I believe that we have the tools to do the influencing that we have. I think we've got those. We don't need any less than that. That's the minimum we can deal with. Every CHC has a different style. We are a critical friend. I think Mark does the friendly and I do the critical, and I think we have that balance right. I believe that, since special measures, we've been taken increasingly seriously and they listen to us. The letter of March 2018, that was actually written after having sat down with the senior management team and the chairman, and they signed up to that letter. Everything that's in that letter they agree with and it's quite critical. 

15:00

I think the term that I would use is that we're not shy of being assertive when the need is required. 

Finally, from me then, in that regard, do you believe that the improvements that were highlighted in recommendation 19 from the December 2013 report—governance arrangements—that concerned renewing and reuniting ward and board—? How far advanced have they got since then? Are you on that journey? 

We certainly support reuniting ward and board, and we do encourage that. The actual delivery of that is for the board to deliver. But it's something that we historically have seen the lack of, and, to this day, it probably isn't as good as it should be. 

In terms of where we go forward from here, I was just wondering—. One of the issues that came up in the last evidence session, and indeed I think the outgoing First Minister, Carwyn Jones, raised this as a prospect before the last election: do you simply think that the patients and service users that engage with you—? Is there, potentially, a view that Betsi Cadwaladr, as a region, is simply too big, too mixed, too heterogeneous, and that actually splitting service provision and governance of that in the north to the north-west, north-east would be one potential way forward? 

Certainly, at this moment, we wouldn't support that. We think it would probably throw the north Wales health service into two years of organisational change. 

Why do you think the former First Minister said that then? It was one of the potential solutions that could be looked at during this five-year term. 

I think it is one of the potentials to look at if things continue not to work out. Having said that, our view at the moment is that it would just add more disruption to an already difficult situation. We think that large organisations can be well run and managed. There are plenty in the public and private sectors that are well run and managed. So, it's not, in principle, an impediment to good performance. However, if the pace of change doesn't improve and the health board is still in special measures in a year's time, two years' time, whatever, then clearly other options will have to be looked at. 

It wouldn't be the first option that you should look at, I think. I'm not sure what the former First Minister was thinking of when he said, 'Split it into two or split it into north-east, north-west', because there are actually six local authorities that work in pairs. So, it would probably be more appropriate to split it in three along with the three major hospitals. It needs to be sorted out first. These issues need to be addressed first.

One of the issues that you have in north Wales is you've got a very large area and a population of about 760,000, and elsewhere in the country that would really warrant a single district general hospital. But, clearly, that would be impossible and inappropriate in an area like north Wales, and you run into the issue then that some of the services just don't work. Some of the very specialised services don't work with populations of that size. So, very complex vascular surgery—really, you can't do that very complex stuff at three different hospitals where you're getting a handful of patients every time. And it probably needs an overarching management system or health board to look at that and to decide how that's going to be done.

And, as Mark says, it would be a distraction that would go on for two or three years, and you'd replicate boards, you'd replicate senior management structures. You'd then have all sorts of difficulties about everybody wanting to do the specialist service and nobody qualifying to do that under royal college rules. So, by all means, look at it, but it's not going to be the panacea.

15:05

One of the things that struck me, in looking at the unscheduled care service, particularly accident and emergency, was a very, very different pattern between Ysbyty Gwynedd, Glan Clwyd and Wrexham Maelor. They're poles apart. Why do you think that's the case? Within the same organisation, you get a couple of hospitals, clearly, right at the worst end across the whole of the UK, and Ysbyty Gwynedd are very different.

I think some of them are, potentially, geographical factors and population density factors. That aside, I think that the health board—

Can I just stop you? The reason I raise it, precisely, is that that would suggest that, possibly, there's a spatial determinant here that, actually, the very different nature of the service need and the context in north-east Wales is driving some of the poor performance, and it may well be then a board that traverses those two.

Some of those figures—I know there was one around deaths in A&E—. Some of those are driven by actually quite small numbers. And, I think, in the Glan Clwyd one, it needed closer looking at because I think some of it was related to drug users whose lifestyle and drug use meant that they came to hospital much sicker and much nearer to death. So, there are a number of issues that need more exploring. But I think that standards, the patterns of management can take into account differences in locality and so on.

I don't think it's the solution. Maybe in the future. But you also have to remember that these three hospitals were NHS trusts, separately, with separate management that weren't linked to health boards in the past, and that when Wales moved away from the purchaser-provider split—. I think that was a good thing for a lot of reasons, but, it left hospitals and organisations that were very used to acting in their own interest alone, with their own standards—

Just to summarise then, you would accept that, say if we were in the same position in another 18 months, and therefore they had been five years in special measures, then other, more radical suggestions, including redrawing the map, would have to be considered, possibly, at that point, because, otherwise, what else is—

I just wanted to pick up on your observation that dividing it up into three separate units wouldn't necessarily solve anything at all—it could create bigger problems. I just wondered how much of the current problem is about the failure to rationalise and centralise specialist services on one of the three sites, given that patients are happy to travel for quality services.

They are, and it will always be something that's very, very difficult on many levels to sort out. And I think that bullet wasn't bitten.

But, if it's not bitten, we'll never get anywhere. I'm not talking about emergency services—cottage hospitals do a lot of excellent work on that front—I'm talking about planned services where we all know that, on x day, this is what's going to happen to the individual. So, why has there not been more rationalisation or centralisation of particular services on one of the three sites, and others on one of the other three sites?

15:10

I think there are lots of answers, if you like, to that. In many cases, of course, the patients and the public—although you do say that people are willing to travel further for the best care, which is true, not everyone finds it easy, and we find that very many people would actually like everything to be provided at their nearest hospital, so—

Indeed. From the CHC point of view, there is clearly a balance to be struck between actually providing the healthcare reasonably locally and providing a good standard of care, or an excellent standard of care, preferably. So, in principle, we're supportive of very specialist care being concentrated on single sites, but more general care, I think, would be a poor option for the distributed people of north Wales.

Vascular care, for example, has been concentrated on a central site, but it has been considered that you cannot bring every vascular issue to one site. It needs to be spread out, because of how far people are spread across north Wales. So, that process is happening.

Good. All right. Thank you. We probably haven't got time for much more of that conversation.

Great. Well, thank you. If no-one else has any further questions, can I thank our witnesses for being with us today? That's been really helpful. Quite a marathon session, that, I appreciate, so thanks for bearing with us. We'll send you a transcript of today's proceedings for you to check for accuracy before it's finalised.

4. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o’r cyfarfod
4. Motion under Standing Order 17.42 to resolve to exclude the public from the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

May I propose, in accordance with Standing Order 17.42, to meet in private for items 5, 6, 7, 8 and 9? Everyone's content? Yes.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 15:12.

Motion agreed.

The public part of the meeting ended at 15:12.

Archwilio Cynulliad Cenedlaethol Cymru