Cynulliad Cenedlaethol Cymru

Yn ôl i Chwilio

Y Pwyllgor Cyfrifon Cyhoeddus

Public Accounts Committee

04/03/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Jenny Rathbone AC
Llyr Gruffydd AC Yn dirprwyo ar ran Adam Price
Substitute for Adam Price
Mohammad Asghar (Oscar) AC
Nick Ramsay AC Cadeirydd y Pwyllgor
Committee Chair

Y rhai eraill a oedd yn bresennol

Others in Attendance

Adrian Crompton Archwilydd Cyffredinol Cymru
Auditor General for Wales
Andrew Doughton Swyddfa Archwilio Cymru
Wales Audit Office
Andy Roach Cyfarwyddwr Iechyd Meddwl, Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
Director of Mental Health, Betsi Cadwaladr University Local Health Board
Dave Thomas Swyddfa Archwilio Cymru
Wales Audit Office
Deborah Carter Cyfarwyddwr Cyswllt Sicrhau Ansawdd, Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
Associate Director of Quality Assurance, Betsi Cadwaladr University Local Health Board
Gary Doherty Prif Weithredwr Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
Chief Executive, Betsi Cadwaladr University Local Health Board
Mark Polin Cadeirydd Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
Chair, Betsi Cadwaladr University Local Health Board

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

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.

Cynhaliwyd y cyfarfod ym Mhrifysgol Glyndŵr Wrecsam.

The meeting was held in Wrexham Glyndŵr University.

Dechreuodd y cyfarfod am 11:00.

The meeting began at 11:00.

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

Can I welcome members of the committee to this meeting today in Wrexham in north Wales? I'm delighted to be chairing a meeting in north Wales and to be out and about. It's good to reach different corners of Wales. Headsets are available in the room for translation and sound amplification, as usual. Can I remind Members to ensure that, rather than electronic devices being on silent, as I normally say, because of the internet system within the university, if those devices could be switched off, that will enable—

Airplane mode, yes, so it's not interfering with the internet signal. We've already had, apparently, at the university, a fire alarm this morning—a drill—so we're not expecting any others. So, if you do hear the alarms go, then follow directions from the ushers.

We've received apologies from Adam Price, and can I welcome Llyr Gruffydd who has agreed to sub for Adam? That's really helpful. Also apologies from Vikki Howells, Rhianon Passmore and Neil Hamilton as well.

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: before we get to the substantive item with our witnesses, we've got a couple of papers to note. First of all, I've received a letter from the Welsh Government dated 13 February. That was following the public accounts session on 28 January, when Dr Andrew Goodall agreed to share further details on the Betsi Cadwaladr staff survey results. We've also received some additional information from the North Wales Community Health Council regarding their visits to mental health facilities within the health board area during the October 2016 to December 2018 period. They've also provided a copy of their report, 'Our lives on hold…Impact of NHS waiting time on patients’ quality of life', which was produced by the Board of Community Health Councils in Wales on behalf of the seven CHCs in Wales. Finally, we've received additional information from the health board on agency staff spend in the mental health and learning disability division. The CHC were asked to send these details, but, on reflection, the health board held the information, which they provided on behalf of the CHC. So, are Members happy to note that correspondence? Good.

3. Adolygiad Llywodraethu Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr – Yr Hyn a Ddysgwyd: Sesiwn Dystiolaeth gyda Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr
3. Governance Review of Betsi Cadwaladr University Local Health Board - Lessons Learnt: Evidence Session with Betsi Cadwaladr University Local Health Board

Okay. Item 3, then, and our governance review of Betsi Cadwaladr University Local Health Board and lessons learnt. Can I welcome our witnesses to today's meeting? Good to have you with us. Would you like to give your names and positions for the Record of Proceedings?

Mark Polin, chair of the health board.

Andy Roach, director of mental health and learning disability.

Hello. I'm Gary Doherty. I'm chief executive of the health board.

Hello. I'm Deborah Carter. I'm associate director of quality assurance, and I'm here on behalf of Gill Harris, executive director of nursing.

Good. I think the mikes should operate independently, so it should come on when—I'll keep an eye on that, though.

Great, thanks for being with us. We've got a number of questions for you, but I know that you wanted to make a short opening statement first.

I do. Thank you. Bore da. Thank you for coming to north Wales and for the invitation to be with you today. I would like to say at the outset that, whilst progress has been made in some key areas during the period in which the health board has been in special measures, there's an absolute recognition that not enough improvement has been achieved, and particularly in terms of planning and setting out a clear direction, in terms of financial control, and also in a number of aspects of performance, most notably in terms of planned care and unscheduled care.

There's also an absolute recognition that the responsibility for improvement rests with the board and the organisation, and we are determined to discharge that responsibility fully. This session with you provides us with an opportunity to demonstrate how we propose to do just that and, in short, we've already taken or are proposing to take action in a number of respects. First of all, to describe more clearly the direction of the health board, in particular what will be delivered during the coming year and to support this with a clear sense of what we plan to do as regards our biggest asset—our workforce—but also in terms of the estate and optimising our information technology; to introduce much more rigour into our approaches to financial management, savings delivery and pursuing change, informed by an external review, which is being commissioned with the support of Welsh Government; to strengthen governance, scrutiny, accountability and leadership by the board and across the organisation; to ensure that the board and the organisation are equipped with skills and the opportunity to achieve this; and also to improve performance in key areas, for example by commissioning a taskforce to get to the heart of the obstacles we face and improving waiting times for treatment and by adopting a far more structured approach to driving improvement in unscheduled care.

These actions, to name but a few, coupled with the determination and relentlessness by the board, and with the support and scrutiny of Welsh Government, are the key ingredients to its success in our view, and we are, I assure you, determined to succeed. Diolch yn fawr.

11:05

Diolch yn fawr. Okay, I'll kick off with the first questions. With regard to leadership and governance, which you've just touched on, the health board's been in special measures since June 2015 and, despite some improvements, fundamental challenges remain around finances and performance. Why is it proving so difficult to turn the health board around, and are the size and geography of the organisation particularly problematic in this area?

Chair, I'll start, if I may. I think the first thing to recognise—and I'm sure you do—is the scale and breadth of the subjects for which the health board was put in special measures in the first place, albeit some time ago, and, therefore, the need for comprehensive address to that variety of issues and circumstances. I think—and I'm, of course, relatively new to this role—that there is absolutely nothing to stop this organisation moving forward and out of special measures. I don't underestimate the challenge, of course, but I think there are a number of key ingredients. The first is, as you have referred to, Chair, leadership. Most high-performing organisations have stability in terms of the leadership team. We've recruited new members to the executive team and to the independent element of the board. We've not reached stability yet, but what I'm absolutely convinced of is that those new appointments are bringing something new to the table that is helpful, and they will provide a basis from which to move forward. The second thing, from a chair of a board perspective, is to ensure that the expectations in terms of the board and the functioning of the committees have been reset in terms of being clear about how those meetings will operate and also in terms of the level and nature of the scrutiny that will occur within those environments. And I believe that those two things, amongst many others, are key to moving forward.

If I could just follow on, Chair, one of the key points you mentioned there in your question was around the size and scale and scope of the organisation. I think it is clearly a very large organisation—one of the biggest in the NHS—covering a very large geographical area, with many different and substantial health challenges, in terms of the population, that we face. But I guess I would equally emphasise that some of the challenges that we face, were the organisation to somehow change its size or its scale or scope—in and of itself, that wouldn't give us any extra doctors, it wouldn't give us any extra nurses. Fundamentally, I think there are many organisations in the NHS that are as big as Betsi Cadwaladr that are successful organisations. I think it is an opportunity for the health board to try and build on some of that size and scale, and some of the things that we've been able to do over recent years, particularly areas like the SuRNIC, the sub regional neonatal intensive care centre, particularly areas like our cancer developments and our cardiac developments—I think if we were a smaller organisation, they would have been more difficult.

Having said that, I am alive to the challenge of the size of Betsi Cadwaladr, simply because, if nothing else, getting around it for the senior management team and all of the leaders within the organisation is a challenge, and that's one that I don't think you should underestimate, but, nevertheless, I think, in terms of that size and scale and scope, the challenge for us is to turn that into strength. I think there are opportunities to do that, and I think we've perhaps not taken them as much as we might have done, and those, I guess, as the chairman's outlined, going forward are the kind of opportunities we want to take.

In terms of dealing with an area of this scale, what sort of opportunities can be taken? And what specific changes are in place with the current leadership and governance to try and deal with the issues that couldn't be dealt with in the past?

Well, I think in terms of the opportunities in terms of the size and scale, today we are at Glyndŵr University—I think an organisation that is large has advantages in terms of its ability to undertake research, development and innovation. I think the bigger you are the more opportunities there are in terms of those economies of scale in terms of some of those studies, for example. Obviously, that can give opportunities for staff to be attracted in who have got particular interests. Again, smaller organisations might struggle around that. I think, in terms of investment in equipment, some of the cases we're currently looking at—for example, in robotic surgery—I think an investment like that is more difficult to consider. And if you were a very small organisation in the NHS, I think you really would struggle to justify the expense of robotic surgery. So, I think those are just some of the areas where there are some opportunities.

Equally, as I've emphasised, in terms of our governance structures and our ways of working, the fact that we need a coherent, consistent model of governance that works across a very large and complex and diverse area I think is a challenge, but, equally, I think that's our opportunity to try and turn that into a strength.

11:10

You have read, Chair, the most recent structures and assessment by the Wales Audit Office, which refers, albeit at an early stage, to changes in the manner of governance that's taking place in terms of the organisation and the board. And I think that's important, because the changes, for example in terms of moving board meetings to bimonthly, are facilitating the opportunity in-between to hold very detailed workshops to get to the heart of some of the greater challenges that the board and organisation face, and afford a far greater opportunity to get beneath the surface of those topics to work out how, as a board and an executive team, we can seek to address them more forcefully and more successfully moving forward.

I think, too, that is a recognition of the fact that there is a high level of expectation now that the scrutiny and accountability for the board and committees will be different, to a degree, than it has been before. And there is much closer liaison now between the independent member who chairs a committee and the lead executive to ensure that we are clear as to what those expectations are, what subjects are going to be addressed and how, and that there is a clear level of assurance being provided to the board through the committees in a way that may not have existed before.

I just wanted to follow up on Mr Doherty's remarks about the size of the area you serve, because, for me, given the size of the population that you serve, how on earth would you deliver the critical mass of clinical governance in secondary care unless you were one organisation?

I would agree. I think having—[Inaudible.]—across the NHS, there are small organisations that do a very good job—

Well, there are small acute hospitals across the NHS that do a very good job, so I don't think you have to be large. Equally, I think the advantages of being large are there, and I think if you look at north Wales, I think it would be difficult to see another organisational structure that would have inherent strengths over and above what we've got, because what you've got is a population size there that I think gives you a good opportunity to do some of the things I talked about. If you were to start looking at a different alternative, I think the downsides would far outweigh the upsides—that's my personal view.

I don't want us to get bogged down with the geography, but I'd just like to make the point: you mentioned SuRNICC, for example—you referenced it earlier—and I'm just thinking, well, the decision was made for that to move to England, wasn't it, and then it was brought back? And we were told that the capacity wasn't in north Wales to justify having it, but it is happening now. I'm just wondering, if we're not tinkering with the footprint of the board, then, clearly, there is a dynamic to-ing and fro-ing of patients across the border, isn't there? Now, the feeling I get is that, too often, or more often than not, it's all one-way traffic, where Betsi Cadwaladr pays for patients to have treatment across the border. To what extent are you looking at options to develop some specialisms in north Wales so that, actually, we could be bringing patients from England in to access services in north Wales, which would mean, of course, that we have that provision here in north Wales, and potentially as well some element of income generation, I'd imagine?

Yes, I think you're absolutely right. I think that's an opportunity that we need to look to make the most of, clearly bearing in mind that that's a challenge, because in terms of attracting people in in terms of travel, you need to be offering them very, very good services. I think we may have to do some of that this year in terms of some areas such as in Chester, where we have invested in and made real improvements in our maternity service, for example, and I think we've seen some changes in what were previous flows of patients around there. We've got activity that currently takes place in Liverpool in areas like urology, where we're looking at how we can develop locally and pull that back in, which I think would be a better service there and also would allow us, then, to attract staff. There are some areas around mental health, and I know that Andy is discussing with the specialist commissioning team that covers Wales how we might be able to develop some services and potentially attract in some work there by, currently, patients who reside and get their services in England. So, I think there is an opportunity there. I think it is a chance for us to exploit equally. What we would need to do is make sure we've got a robust plan and that we can offer something that would be attractive there, and that, clearly, in attracting something in and bringing more patients in, we're not disadvantaging the patients that we've got. And that, obviously, would be a key risk that we want to be assured on. But I think we've been doing that and I'd like to see us do it more, certainly, going forward.

I think the important thing is that those elements fit within a coherent whole. So, you'll see shortly in our plan the reference to establishing a clear and comprehensive clinical strategy before we get to September, because we ought to be able to present that. Clearly, change is needed, because the status quo, given where we are with our performance and funding position, is not an option, but what will be important is that we set out what it is we plan to do, that we engage effectively with our communities, patient groups, and so on and so forth, and that we listen to what's being said to us, too. But I think we're also very clear that, if we can offer services of a high order, moving forward, it will help us address other problems. So, in terms of our staffing, if you can offer an excellent place from which to work, with the best technology and equipment, and so on and so forth, you're more likely to attract good people into this area. And we are seeing signs of that already.

Can I just, Chair, if I may, on the first question—? I think what's important, too, though, from a regional perspective, is that we are not too big to engage effectively with our partners, because a lot of the solutions that we will want to deliver, moving forward, particularly in response to 'A Healthier Wales', will need to be done in partnership. And we have invested heavily over the last few months in ensuring that our relationships with partners, particularly at the regional partnership board, are as effective as they can be. Indeed, we're due to take over the chair of that board fairly shortly—an opportunity that we're looking forward to. So, whilst we may be regional, we're very clear we need to operate locally, too, as you've already referred to, but not just in terms of our patient services, but with our partners, too. 

11:15

Thank you very much, Chair. Mark, I heard your initial remarks very keenly and you mentioned a couple of areas—leadership, finances, skill and performance. You mentioned these words very clearly, and Betsi is one of the black spots on NHS Wales, really, according to the performance and different areas. Tell me why the leadership—. Where is the problem of leadership? Why can't they have a business plan and delivery and why can't they sustain the best performance in Betsi Cadwaladr's hospitals, rather than learning from other hospitals, which I think we're all concerned about? The last few years—. Still, you just mentioned that you're investing now; how long will it take to get performance in the right order?

Shall I go first? First of all, in terms of moving forward, I think the absolute requirement to start with is to have a clear plan. The health board has been criticised in the past for not being able to describe a clear direction, and therefore, unsurprisingly, a lot of work is being undertaken at this very moment to ensure that, before we enter the new performance year, the plan is as solid as it can be. And, as I referred to earlier on, it's underpinned by work around the estate, IT and our workforce. What we need to demonstrate, as we move into the new performance year, is that we're on a track record to improvement. And we're very clear around that, both in terms of finance, in terms of unscheduled care and also, of course, a number of other areas, too. So we need to be hitting the ground running when we get into the new performance year. 

I'm absolutely set on the fact that, by the time we get to the next year, one, we should have that clear sense of direction, supported by our clinical strategy; we should be able to demonstrate improvement in those key areas; and we should be building confidence. What I can't commit to from my perspective at this point is some wholesale transformation that's going to occur in the next year, because I just do not think the board or the organisation is in the right place yet for that to occur. So there's a sense of realism required here, and from my perspective—and I state that, because I truly believe that's where we are as an organisation. I think what will go with that, too—and you heard it from Mr Goodall—. Welsh Government have supported the organisation, it's put in additional operational capacity on the ground. That is already providing very visible leadership that I'm sure Gary will comment on better than me, but moreover, what I find truly impressive is that some of those people who are coming into the organisation, one, are extremely good—some of those promoted within are extremely good, but they're also offering very fresh perspectives, and you might have got a sense of some of that last night when you visited GP out of hours. So, they are getting to the heart of some of the problems we face and the intractable problems on the ground. So, it's important that, on the one level, the board is responding and seeking to address the concerns and doing what's required. On the other hand, there needs to be a bottom-up approach, for want of a better description, and I'm convinced now that it's occurring more than it was previously. 

11:20

Beyond this year, you say that next year, medium term, you hope that the new governance arrangements will deliver improvements. 

I would expect the improvements to be seen in the next year. What I'm not saying, Chair, is that we will be on a truly transformational journey in the next year, because I think there are still some bedrock issues that we are tackling and they're important to moving forward. 

Thank you, Chair. If I may come in there, I start from the absolute recognition that, as the chairman has already pointed out, in terms of the health board's performance, it is not where it should be, and I expect us, obviously, to have an opportunity this morning to get into some of the detail of areas, particularly around referral-to-treatment waiting times and accident and emergency waiting times and, obviously, we'll come to those. But I think, nevertheless, you would perhaps expect me to just put some context to say that there are areas where we are highest performing health board, so in terms of us being a performance black spot, if you like, in cancer, 31 days—we're the only health board that's meeting that target right now. I think it is fair to say that the health board has had quite a decent track record in terms of cancer services. In an area like C. difficile, for example, we haven't always been in a good position, and we're one of only two health boards right now that's meeting our target in that area.

So, I think there are elements there where we have consistently performed well, amongst the best in Wales. There are areas where we weren't, where we were perhaps towards the bottom in our performance in Wales, and now we're at the top. What we do know is that that's not—. We can't say that for all of our services, and we'll pick those things up later, I'm sure, Chair, but I just think it's important to start from some of that context, because it just puts that balance in. As I say, good performance in one area in no way, shape or form excuses poor performance in another.  

I'd like to move on to finance, if I may, and I suppose we start with the deficit, don't we, and the overspend? And I'm just wondering if you could tell us a little bit about what the main issues are that are driving that, really. 

Thank you. There are a range, I think, of areas where you can see some very clear financial pressures in the organisation but, equally, I'll hopefully come on to what I think are some underlying issues that might not be as clear. So, areas such as staffing recruitment and retention I think are a major issue for us. If you compare ourselves to other health boards, and some of them in particular, we have a much higher spend in terms of temporary and agency staff and, obviously, that gives us—. There are many, many fantastic staff—you may have met some in some of the out-of-hours work last night—in that area who work as locum and temporary staff, but, clearly, that costs more than what you will pay in terms of NHS rates and, clearly, it means you don't have the continuity and you don't have the consistency that you would ideally want. So, that, I think, is a major challenge for us, and our vacancy rates, depending where you look, are running at between 10 per cent and 20 per cent, and we'll no doubt come on to some of those areas and how they might challenge us.

Equally, we've had some success in reducing that, particularly in terms of that spend. If you look back a couple of years ago, then our spend on agency has gone down by about 30 per cent. So, I think we are doing something about that, but that is a major challenge for us. Other areas such as continuing healthcare, other areas such as unplanned care—we, generally speaking, have a number of additional beds open at any point in time that are not within our established budgets and, obviously, if those extra beds then need to be staffed by temporary staff, then you've got a double whammy there in terms of costs.

But I think then, fundamentally, I would get into the heart of some of the issues, because they're some of the headline rates. I think our models of care, the way we do things, the extent—if you look at the benchmarking data—to which other health economies have managed to intervene earlier on in a situation, so you don't get to a point of escalation and higher cost, I think there are opportunities within areas such as mental health, in particular, I think within unscheduled care. If you look again at our models of care compared to other areas, if you can have that community resilience and keep people well, clearly, alongside a more longer term population health focus around people's eating, around staying active, but right here, right now, if you can avoid some of those situations escalating, then you avoid some very expensive care. 

So, I think our models of care, our estates, the way we work are—. And that's where I think it comes back to the heart of what the chairman was saying. We make savings every year, so this year we're on track to deliver something like £39 million-worth of savings. Now, all of those savings need to be delivered carefully with a consideration to equity, quality and safety. But what we do know and what we can see, I believe, are opportunities to go further than that, and that's what we need to do to really eat into that deficit.  

Are you content with the level of savings, because it was hoped that it would be higher? 

Yes, we're aiming for £45 million for this year, so that's fundamentally one of the reasons why our performance in year has deteriorated. So, we set that £45 million target with an eye to those opportunities that I've just referred to. We've not delivered to the level that we would want to deliver. We need to go well beyond that if we're going to really start eating into that deficit.

11:25

I was just wondering then, in terms of scrutiny of the process of establishing that target, in terms of savings, how realistic and how credible was that, really, and what does that say about maybe coming back to some of the governance issues? Does that again highlight maybe that things aren't as robust as maybe they should have been?

I think the financial plan was not robust enough, nor clear enough. And both Gary and I, we've acknowledged that. I've taken over the chair of the finance and performance committee myself, and we're at a point whereby we're commissioning an external review of the approach to financial savings and change management for the coming periods. And then we'd expect to interview bidders for that work on 18 March. Because I'm still not convinced—nor is Gary, I know—that we are sufficiently robust around our financial planning, and that needs to shift, and shift quickly.

I think there was a good deal of thought put into the financial plan, but it got off to a bad start, when some of the more cross-cutting-type savings programmes just simply did not get off the ground. And we can't repeat that, because, as Gary has already said, a substantial amount of savings were delivered. Unfortunately, the proportion of those savings that were of a recurring nature was not sufficiently high enough to bring the base down. And that's the challenge. So, we need to improve the focus on recurring savings, but that will have to be in light of the clinical strategy, moving forward. So, I think we need to be realistic for next year—we need to ensure that we deliver savings, but they need to be at a realistic level, agreed with Welsh Government, recognising that there will be more substantive change coming, after we get through the next year.

Okay, thank you. You mentioned that there had been a reduction in the cost of agency staff, although I think it's still around £90,000 a day—that's the equivalent. But there has been an increase in nursing agency staff. So, could you explain a little bit about why that's the case, and what's driving that, and how maybe you're hoping to address that as well?

If I may. I think Gary alluded to some of that in terms of our additional capacity that we've increased. And I think the work that we've been doing to adhere to the Nurse Staffing Levels (Wales) Act 2016 has certainly impacted, in terms of ensuring that we can get our recruitment right, which we're working really hard to do with the new recruitment strategy. But instead of that, as we get to where we need to do with our nurse staffing levels, we do need to drive safe staffing, which enables us to provide safe care. So that definitely is having an impact. One of the things we know that we are getting as a result of that is that we're seeing a reduction in the amount of harm that patients are experiencing. Whilst we see that as an impact, and very positive, what that also means is it impacts on our ability to be more efficient. Because patients who come to us who can get through our services without being harmed—so not having a pressure ulcer, or a fall, or getting an infection—will be able to leave our services much more quickly, and that enables us to be much more efficient.

So, you're definitively saying that more nurses means more savings, in effect.

Absolutely, absolutely.

There's a real draw on value for money by having highly staffed wards, with highly skilled staff.

If I may just come in there, Chair, obviously it's important to emphasise that the dynamics that Deborah has identified there are absolutely spot on. But, fundamentally, we've put an awful lot of effort over the last few years to improving the way that we recruit all ranges of staff, but nursing in particular. Now, whether that's using social media, whether that's using word of mouth, whether it is going out to various recruitment fairs, whether it's trying to reduce some of the delays around, when you go from getting your staff into post, when you've got them, because, obviously, the sooner they start the sooner they'll have that impact—. Equally, in terms of retention of staff—I've no doubt we'll touch later on, as the discussion progresses—but in terms of morale, in terms of teamwork, in terms of people feeling valued and respected in the organisation, clearly, the more we retain our staff, the more it helps that equation. And we're on track this year to recruit—we recruit about 300 or so nurses a year; we're on track to do that again this year. I'd like to see that step up a bit, but, fundamentally, the kinds of vacancies that we've got, and people retiring, and other levers mean that we're always kind of trying to run to stay still. But, clearly, we have had improvements in our recruitment. I believe we have also been able to retain and improve morale in that regard, and those are two key parts of that staffing equation that, hopefully, will then help us in terms of that cost at the end of the day.

And Brexit, potentially, is going to have an impact on some of that.

Well, I think, for us as an organisation, clearly there are some numbers that I would imagine the committee have seen, in terms of the numbers of staff coming into the UK economy from the EU. Clearly, for us, we're in a competitive market. Whichever way you look at it, anything that reduces that supply, I think, is a greater challenge to us. The numbers of staff that will be working at BCU in terms of an EU origin is relatively small, but every little helps in that regard and obviously that's something that we try to plan for as best we can, and, obviously, it's a pretty good reason to up our game in terms of a whole range of areas where we can try and mitigate that problem as best we can.

11:30

The board has appointed a director of turnaround or a turnaround director—I'm not sure how it's phrased. Maybe you could give me an update on what's been achieved so far and where the focus of that work is taking us.

Yes, certainly. So, the turnaround director is, effectively, working with our clinical teams to look for opportunities to turn it around, I guess—

Indeed. It's not just around finances. Clearly, as I mentioned earlier, I think, to impact on the resources that you're spending, you need to impact on what you're doing. I guess, whether it's the turnaround director or the finance director, generally, they're not spending the money; we spend our money on our staff and treating people. But they're working with those teams to try and come up with those ideas to turn them from ideas into action, to deliver them safely, to deliver them consistently and fairly, and to involve staff in putting them together, because obviously that's the best way to do it. So, some of the key focuses that the turnaround director has been working on, where we've seen real success, have been around some of our use of drugs and our non-pay, around some of our agency work, where, as I say, we've been able to get people into post—we've driven a harder bargain with some of the locum agencies, and we've seen material savings there—some of the work that we've done around, for example, our mental health service, which we'll pick up a bit later on, I'm sure, in terms of the number of very expensive out-of-area treatments that we had—. So, there are things that range from £50 up to £50,000 and beyond and things that run into the millions. As I've said, that £39 million is made up of a very wide range of schemes. Responsibility for that, obviously, is throughout the organisation, but having a central team—a relatively small team—that can help with that, can help in terms of the plans, can make sure that we do some of the planning and the risk assessment that we need to do consistently across the health board is—. And I guess, if you look around other parts of the NHS that have got some of the financial issues that we've got, they would generally have somebody doing that kind of role.

Can I, chair, make a couple of comments? Before I come to the turnaround, of course, in terms of recruitment, one of the other new appointments was an executive director of workforce, and I'm absolutely convinced that she and her team are bringing a new vigour to and spotlight on our recruitment challenges and also how we manage our establishment, which is really important, moving forward.

In terms of the turnaround director, I do think that something's been lost in the term 'turnaround'. We've got to ensure that, fundamentally as a board, what we say we are going to do in our plan is going to be delivered: what we say is going to change is going to change, and what we're going to save, we're going to save. And what will be required, moving forward, is a coherent sense of where the responsibilities sit in that regard, and with whom, and with which team, to ensure that we are able to demonstrate improvement. And that review that I referred to, together with other work going on, I think, will bring clarity to that.

So, we're 12 months away from really being confident that, actually, some of the aspirations that you have are being realised, do you think? Or is that too crude?

No, I wouldn't say that. I wouldn't say it as starkly as that. I think I did indicate that what's important is that we get on the road to improvement soon, and Gary will talk about some of the performance in that regard if you wish that demonstrates that we're on the road to improvement. You'll also know that some areas have come out of special measures and they were pretty significant and big areas to come out. I would hope that, during the course of this year, we'll be able to demonstrate further progress in terms of mental health services, with a view to seeking to exit from special measures in respect of mental health services. What I am saying is that some of the more substantive change that might be required, for example, in terms of transformation of services, will take a bit longer.

So, if I can pick that up, obviously, the new financial year starts very soon. We have a plan that increases our ambition in terms of savings, particularly in some of the recurring savings that the chairman referred to earlier. So, we're upping our ambition there, but, equally, we have put a great deal of time and energy in this year and whether it be workforce, whether it be in terms of our new team there, whether it be our turnaround, whether it be the additional capacity that we've put into some of the middle management tiers within the organisation, whether it be building on some of what we've already done to take it forward, whether it be that clinical engagement, we've got a much stronger clinical leadership.

When I arrived at the health board three years ago, we had 14 GP clusters but we didn't have 14 GPs to lead them because people didn't want to do it. So, we've got that in place. That, alongside, as the chairman has said, some of the clarity of plan and direction, I think puts us in a better position to learn some lessons from last year. But I think it will—. Clearly, you'd expect me to point out the challenge of saving whilst running a high-quality, safe public service, but that's what we're here to do. As I say, I think we have areas where we've been doing that well. We've made some progress there, but we've not done as much as we wanted and we've not delivered on our targets. It's for us, next year, to prove that we can do that.

11:35

Finally, if I may, on this, it's inevitable, though, is it not, to realise the level of savings that you need to realise, that there will be an adverse impact on services somewhere. You will have to not provide something that you previously provided or do it in a way that isn't maybe as comprehensive. It's inevitable.

Well, I think at this point the issue is that, until we can demonstrate more improvement than we are already, and particularly grip around the finances, it's difficult to seek to have a different conversation, be that with Welsh Government or other stakeholders, about what's required to run this organisation effectively and provide safe services. There is still a lot to go at in terms of financial savings; I'm convinced of that. The scale will emerge as we move forward. So, no, I do not think it's right to say there will be a compromise on service delivery at this point, because I still think there's a lot to go at, and of course what we'll be seeking to ensure, as you would expect of us, is quality and safety at the forefront of our considerations, not money. But the two have to go together.

Clearly, I'm sure committee members will have read the HASCAS report into Tawel Fan, and they will know that, certainly from the evidence in that report, the organisation had challenges at that time in balancing quality and safety and cost and planning accordingly. I think that the system of governance that we've got in place around that now is very strong. I'm sure we will strengthen it further. I believe there are substantial opportunities for us to have a set of actions in place that would improve quality and reduce costs. I've already mentioned C. difficile. Every time a patient gets C. difficile, they stay in hospital for longer, they need antibiotics, they have a much more—that is a very, very unpleasant experience for them, but it's actually quite a costly one. So, there is an area where you can balance the two.

Some of the areas, particularly in areas such as mental health—. Again, the committee may be aware—I'm sure they'll have seen some of it in other health boards—of some of the groups we've got around running clubs, where some of our community psychiatric nurses are now out running with patients every day. By definition, whilst there is a cost to that—and we have had some of our clients struggle to get the basic kit, but we can help them with that—it's a damn sight cheaper than an admission to an acute mental health bed, particularly if we were sending people out into England and paying those kind of rates.

So, I think there is, as the chairman's indicated there, an awful lot to go at that would say, 'Right, we can do a better job here; it can reduce costs.' Equally, there is a challenge, and it will not be easy for us as a health board. That's what we've got to tackle, but I think we've got the governance systems in place to do it. It's about then delivering on it and obviously engaging our staff to make sure that the plans we come up with are the ones that they would want for themselves, their family and the community of north Wales. I think we've got a good opportunity to do that. 

Thank you. My first question is to the chair. I understand you want to commission an external review of existing arrangements, on top of the already pretty comprehensive review we've all read that's come from Deloitte. I just wondered what you think this new review is going to give you over and above what Deloitte has already unpeeled.

What it will provide, amongst other things, is a far greater sense of what the capacity and capability is in the organisation to deliver improvement, change and savings, and whether that capacity, amongst other things, is being used effectively. I think there is scope on the face of it to use it more effectively. It also will assist us to ensure that the financial plan for this coming year—a point that Mr Gruffydd raised—is as robust as it ought to be and can be. That is a pretty significant requirement at this stage, because there are lessons that have been learnt from this current performance year and financial year, but I need to be assured, the board needs to be assured, that those lessons have been learnt and have been effectively acted upon, and that will help.

This is pretty fundamental to our concerns, really, this issue of capacity to deliver change, given that you've been in special measures for over three years. I appreciate that you're new to the board, but, if the board wasn't able to come up with a strategy for delivering the change needed, that is a major cause for concern, and, indeed, expense for the Welsh Government's budget. So, I just wondered what this—. I appreciate that this is a key question, but what do you think this additional report is going to give you if it merely exposes the fact that you simply haven't had the capacity amongst your senior managers to implement change?

11:40

Well, I'm not saying we haven't had the capacity. This will tell the board whether it has the necessary capacity to do what's required. And that's important, because we don't want to start running with a new financial savings programme to realise part way through the year that the capacity either wasn't there or wasn't being used effectively. Now, at this moment in time, I've got no reason to believe the necessary capacity doesn't exist, broadly, but this will help confirm that.

Moreover, there is still further work to be done around the financial planning for next year. In fact, we've got a meeting after this session to talk about that. So, it's important that the early feedback from the review confirms that the plan that we are arriving at is sufficiently robust. And it will also help us to understand, from an objective perspective, the scale of those things that we can go at that I've already referred to, and how quickly we can go at them.

Just looking at where the failings in savings targets have occurred, it seems to me that some areas are just resistant to change, whereas others, like—medicines management has obviously made very good progress on avoiding unnecessary spend on medicines. But the—. I wonder if you can just talk about the transactional savings, which were short by £1.7 million, and the workforce savings of £1.5 million, as to why you think they were unable to achieve what they'd been asked to do? 

Well, I think reducing costs in the NHS is difficult. I think we got progress across the health board, but there are areas where, as you said, we've not been able to deliver. I think, particularly on some of those workforce ones, there are areas where we can show real improvement, particularly around agency and other areas. We were hoping to drive that down a bit more, because that 30 per cent I've talked about has been over the last couple of years.

Where we get into challenges there, I guess, is, if we are going to reduce our workforce costs, then we either have to—as Deborah mentioned earlier on, if we got additional beds open, then what you need to do is look at that whole pathway right from the community up to people being discharged into their own home or back into a nursing residential home, and you need to make improvements right the way along there. Now, we have not been able to make the level of improvements that we wanted to make there, but we have made improvements.

So, I think, in all of these areas, what you will see will be that people have been able to make improvements, they have been able to deliver savings—it's about the level. So, it's not, I guess—. I'm not sure I would say—. It's not about resistance to change in areas, it's that areas have been able to change more than others, and, if you take those areas that I've outlined, particularly around areas such as mental health, around areas like our emergency services, around the whole pathway that you need for those—because, bear in mind that that, as I say, is about everything from primary care right up to what they sometimes call the back door, so to speak—you've got to make improvements there every day, you've got to work with partners, as Mark mentioned earlier, you've got work with the third sector. There's a very complex set of actions that you've got to deliver to get to the level that we want to get to. We have to drive that and be ambitious, but, equally, we, obviously, have to be realistic.

So, I think that's where I would say—and, as Mark has said, just to re-emphasis that point, in terms of what the review would give us, there are things that we've done over the last six months or so that would not have been reflected in the Deloitte areas. Some of the areas around workforce in particular—we've put some substantial changes in place. So, clearly, what a review now would give us is a reflection on how successful those have been: do we need to change them more going forward? So, I think it will genuinely deliver information and knowledge and actionable information that we didn't get—because, obviously, things have moved on—from that Deloitte review.

Clearly, staff have got to own the change, and you talk about joint working with clinicians as well as other partners to deliver improvements. When do you think you'll be in a position to get all the staff behind the changes needed, so that you are in a position to come up with a three-year financial plan?

11:45

I think it's not easy to give a definitive answer to that, but I think the message I would give you today is that I think that that's moving in the right direction. So, I know you addressed in one of your sessions—you've had some more information from Dr Goodall around the staff survey. If you look at that—people's commitment to the organisation and recommending it to friends—within that as well there are measures of, 'Do you think the organisation needs to change?', and that has been increasing as well. We've seen some really substantial improvements there.

If you think about what's happened in the health board since 2013, I think you could actually put forward a case that would say that if those had gone down then that would be understandable. The fact that they've gone up, despite all of that happening, by about 20 percentage points, I think shows that we have been working hard to involve our staff, to improve morale and to make people feel respected and listened to. So, I think what we've got there is that in terms of our general staffing, but then, obviously, with some of the extra leadership that we've put in place in terms of our clinicians, we're in a better position than ever in terms of staff involvement and staff engagement. But, clearly, again—I know this came up in your previous session—even though we made those 20 percentage point jumps, we're still just below the Welsh average, and you'd want that to be much higher still, wouldn't you? I suspect I will never feel that we've got the level of engagement and involvement that I would like. Equally, as I mentioned earlier on, when you've got levels of 10 or 20 per cent vacancies, then, you know, to get our staff involved and engaged, and have the time, energy and space to do the work you need to have around those transactional savings, and to do the work you need around the transformational savings, when, obviously, we have to focus on the right here and right now, in terms of patients coming through the door—that is a difficult ask. In some parts of our organisation, they are very well—[Inaudible.]—establishments. So, those numbers that I've quoted are averages as a whole. If you take our emergency department service at the moment, we've got 22 middle and junior-grade doctor gaps. Now, if every time you come into work you're meant to have 10 people and you've got nine people, then that's a challenge, and in some areas it'll be worse than that.

So, I think that package is a really important one. I think there is progress in the right direction. I'd like to be definitive with you in terms of exactly when we'll get there, but I think we are certainly going in the right direction, despite a very difficult, challenging circumstance that I hope you'd recognise.

Okay. I think you're absolutely right in the fact that your numbers have all been going in the right direction in terms of the staff survey, but I think that the one that concerns me most is the one where staff are asked, 'Senior managers lead by example'. It's improved, but, still, there's only 42 per cent of your staff who think that senior managers lead by example. That is quite disturbing, because senior managers are paid a lot more money and they should be leading by example. So, it seems to me that that is absolutely critical to your ability to lead on delivering the change that's needed.

I agree, absolutely. We do see some messages that would come through, whether it's in Health Inspectorate Wales reports or whether it's work with other partners, so we get a range of feedback on senior leadership. It does range from very, very positive feedback to less positive, and a figure down at that level is not a positive figure. Equally, obviously, all of those senior leaders are there to do a job, and, as you say, they are paid to do it. Those are difficult jobs, and, as I outlined earlier, one of our challenges has been to get people into those roles, particularly when you've got some of the everyday challenges that people have got. But I expect people to lead by example—I'd like to think that that's what I do myself—whatever the difficult circumstances that people might face, morning, noon and night, in Betsi Cadwaladr. People are there to lead, and the job is to lead by example, to roll up your sleeves and to get stuck in, and to listen and to engage. I will be certainly looking at that, and I know our new director of workforce, as Mark has identified there—we are looking at how we have better training and better development, but, clearly, equally, obviously, what we need to make sure is that people are held to account. If, even having had some of that support, people aren't delivering what they need to deliver, then, fundamentally, we need to address that too.

Okay. So, just moving on to some of the specific areas of challenge—first of all, on elective care, obviously the board is performing poorly on waiting times for elective care. You yourselves have highlighted orthopaedics, urology and ophthalmology as particular areas of challenge. There are clearly lots of good examples of good practice—the Bevan Commission exemplars, for example, highlight several areas where Betsi Cadwaladr's doing very well and are pointing to good practice that could be adopted by others. I just wondered if you could just tell us, then, why orthopaedics is still struggling, given that one of the exemplars was a wonderful orthopaedic surgeon who is now doing hip replacements as day surgery, because there's better preparation, engaging with families to act as buddies, and better outcomes. So, why is that not being celebrated and implemented with pace?

11:50

Well, I think it is, and if you look at Betsi Cadwaladr, we've got the second-best day care surgery rates in Wales. We've got the best admission on the day of surgery rates in Wales. We've got, already, some of the lowest orthopaedic lengths of stay, so the most effective pathway in Wales there. If you look at some of our emergency orthopaedic work as well, and if you look at our fractured hip data there, we have a really good position compared to other health boards. So, I think in terms of where we're at, you're absolutely right to point out that our services aren't where they should be. If you look at the averages, our median average is 8.4 weeks to be treated on an RTT pathway—that's just better than the Welsh position—but then what we've got are some very, very long waiting times in the specialties that you've just identified.

We have made some progress. We've made some progress overall in terms of RTT. So, if you look at all our waiting lists—I've got the figures up to the end of January; I've not got them up to February yet—they're about 30 per cent better than they were this time last January. If you look at orthopaedics, that's 15 per cent better. If you look at ophthalmology, that's 49 per cent better. And, obviously, that has been done with support and additional funding to do additional activity, because I guess, then, that speaks to that, 'What is the issue here?' The issue is that the demand and capacity in those specialties is out of line.

So, there are two key things that obviously we want to do in that circumstance. One is to make sure we're using what we've got to the best of its ability—and I think, in areas like orthopaedics, actually, as I've hopefully outlined, I think we do a pretty good job of that. What I would say, in orthopaedics, is we've looked at the whole of the pathway and alternatives to surgery, because, clearly, where alternatives to surgery are there, that's exactly what we should be doing, and, indeed, avoiding the need, through tackling anything from obesity to activity to a range of areas there, which, as I said earlier on, also helps us in our mental health challenges. So, that whole pathway's been looked at. We've developed a plan that says we want to maximise all those opportunities, but even then, having done that—and, as I say, what I belive is a pretty efficient and effective orthopaedic service now—we need some additional capacity. We need more, not just using what we've got better. So, that's a case that we've put together.

We've obviously engaged our clinical teams and partners outside the health board, in terms of: if you're going to put some additional theatres and additional capacity in in north Wales, where do you do it? Because, we've got some options there. So, we have a plan there that's quite a complex plan that's taken a bit of putting together. Clearly, where we're at now with Welsh Government—who have supported us in the meantime, with additional non-recurring money, to do extras, if you like, with our existing staff—is that what we're working through now is: is that good value for money for the public purse? Is it effective and is it the best plan? I believe that we'll reach a conclusion on that very soon.

As I've said and outlined in terms of the figures, we're making progress now to get waiting times down, but they're not where we want them to be at all. What we want is that kind of permanent solution that isn't about doing extras, so in all those areas that we've outlined—ophthalmology, orthopaedics, urology—. The urology example is around the robotic surgery and potentially bringing back and attracting some work from England as well. So, I think we've put together plans there that are about the whole pathway, that aren't just about doing more of the same, although in some of them there are elements of that. Those are significant investments that would need some careful work. As I've said, those improvements that we've made are not where we want to be, but I do think there are signs there that we're moving in the right direction and that those cases are the right ones.

Okay. So, you've centralised vascular services. Are you planning to centralise planned orthopaedic services? 

Well, we're planning to make some changes in terms of the number of sites where we provide it from at the moment, because—

Because this is production-line stuff, really, isn't it, in terms of—? People who do actually need surgery—they will travel.

Yes, and as I outlined, our current production line, if we use that analogy, is pretty effective, but I think there are some opportunities and there are some diseconomies of scale at the moment. So, part of our plan would be to reduce the number of places where we'd be doing that surgery, not—

Well, as I've said, fundamentally, what we need to do is work through with colleagues in Welsh Government who are quite rightly scrutinising that this is a good way to spend the public's money. I wouldn't want to pre-judge that, because, clearly, from my perspective, I'm hoping and I expect that to be a relatively quick decision, but, equally, if I had the public's money in my hand and I was sat where they're sat, I'd want to make sure I'm sufficiently assured. So, that's a case that I'd be expecting us to be sorting out and starting on in the next financial year, in terms of putting the additional theatre capacity in and appointing the additional staff. 

11:55

Okay. So, mainly, you've got to take your orthopaedic surgeons with you, so that's—.

Yes, and I believe that the work that we've done and the clinical engagement that we've had I think has been very effective. We had orthopaedic surgeons presenting the case to the board when we agreed that. It's clinically owned and I think it will be clinically driven. It's about having orthopaedic surgery across Wales, but, equally, having consistent pathways, consistent audit, making sure that we purchase prostheses and use that non-pay budget well over the whole of north Wales. So, I think there's a good package there that's got substantial clinical buy-in.

Okay. Just briefly on ophthalmology—I think you said that you'd had a 49 per cent improvement in ophthalmology, which is excellent. A problem we've had in my area of Cardiff and the Vale is ophthalmologists simply refusing, in secondary care, to refer patients back to ophthalmologists in primary care once the cataract operation has been completed. Clearly, people need follow-up but they don't need to come back to hospital. So, have you managed to achieve that, what is in line with Welsh Government's evidence-based practice? 

I wouldn't say that we've achieved it, but we've made some progress on it. What we have done recently with Welsh Government support is put in some more dedicated project management and expertise to drive that change through. I'd have to say that our ophthalmology team—. One of the challenges in all the areas that we've looked at, without wanting to state the obvious, is that people are challenged to make sure that they are doing today's work, and, as I've said, the improvement in waiting times that I just mentioned is primarily because our own staff, but with some additional outside staff, have been working really hard. They want to make some of those changes but if they're going to make them, they want to make them safely, and make sure that what we get is a better pathway. So, I think we've made some progress there in terms of clinical engagement and using high-street optometrists and other people to be able to do work to the top of their expertise, which I think is absolutely an opportunity. So, again, when we've had the ophthalmology plan presented to the board, we had optometrist expertise in the room to explain that opportunity for us. I don't think we've got to where we need to get to on that. And, on that one, obviously that's around follow-up patients but also around those patients who are waiting for treatment. So, that's a particular focus, I think, for this year in terms of taking that forward, and, as you said, other health board colleagues I'm sure will have some good practice to spread, because I'm sure some people have made some more progress there than others. 

But it's clearly an area where you can make substantial savings, as well as providing a more patient-focused—

Yes, and a local service. 

Chair, can I just make a comment, just coming back to orthopaedics? I'm a bit concerned about the description of a production line, particularly given there's still a lot of concern out there about the centralisation of vascular services. Of course it's important to highlight that the geography and the needs of our communities are at the forefront of our consideration around the orthopaedic plan, and that will be reflected in the model, we hope, and we have got a session planned with Dr Goodall and his team, being arranged in March, with a view to seeking to resolve any outstanding issues, because the Minister is keen that we should move forward with an orthopaedic plan that provides sustainable services moving forward, and not least because it's at the heart of our planned care challenge, as you've rightly identified. And also, we're being propped up with money at the moment, and this will, we would hope, offer a sustainable solution and value for money.

Okay. Thank you for clarifying that. I don't think we can spend any further time on that. 

Could you just tell us what your plan is for improving the waiting times for unscheduled care. Now, I appreciate that this is now an area that's been taken out of special measures, but the latest figure we had for Wrexham Maelor was that only 49 per cent of patients were being seen within four hours. 

So, that—. I mean, Deborah will come in on some of the detail around that, but, obviously, this is a really important area of focus for us. The figure for February for Wrexham was 57 per cent, so that, again—. And I think what we've got here is improvement, but a long way off where you'd want it to be. So, if you take the February figure for four hours, it'll be the best that we've achieved since June. It will be better than it was last February. Obviously, there are a number of key metrics that we look at around four hours—so, it's patients seen, treated, discharged within four hours—and it's then 12-hour waits. So, if you compare February this year to February last year, that's about 21 per cent better. Then it's delayed ambulances, which, again, I'm sure the committee will be aware, have been a real challenge for us. That, for February, is an  improvement of 71 per cent. That's the lowest that we've had all year, and I think, therefore, to achieve that in February, in the winter month, is obviously very good progress for us. But, equally, I think on all those points you'd want to see further improvement. Again, we've started March well, so we'll be on track to be better in March than we've been in February. Obviously, it's relatively early days, so I would just bear that in mind. There are areas of progress and improvement here that hopefully the committee will recognise.

Making a change to unscheduled care, bearing in mind, as I've said, it starts, effectively, in the community and it goes right along the pathway, is one of the more complex tasks that we've got, but if Deborah picks up a little bit about the way we've approached that, and some of the things that we've been doing, our work with partners, that will hopefully give you a feel for some of the ways we've been trying to tackle it. 

12:00

You rightly comment that we're effecting a culture change across our organisation, and to get sustainable change so that the right things happen every day for all of our patients needs our whole workforce to be engaged with that, and that's something we've been doing through lots of different work programmes. 

With our unscheduled care pathway, we've done a number of real focused events with our emergency department colleagues and other partners who can actually help us to impact on that. And they've helped us to build a plan, which we know that, based on outcomes in other organisations, if we can get that right—so, if we get the mixture of the cake right—that will  deliver real change. What's really important to that is that our staff believe that we're there to make that change and it will be sustainable and we will support it. I think that's one thing that we would accept that probably, as a senior team, we've perhaps not necessarily been brilliant at—being really clear that we set the clear line of direction and we support staff to get to where they need and then we help them hold the line, because some of these changes are really difficult, particularly when you're affecting culture. And a lot of our staff have been around a long time. So, bringing people with us is really important, and being really clear that we hear the voices of those people, who perhaps don't want to change in the way that we know they need to do, has been really important. So, in building our 90-day plan, there's a real theme through that, which is about culture change and is about engaging with the hearts and minds of our staff to say to them, 'Most of our staff live and work in north Wales, most of our services treat them and their families and in order to get to where we need to be, we want to make sure that we provide the highest standard of care.' And what we've seen is a shift in language and a change in behaviour as a result of that, and that's helped us to build a 90-day plan that's got us the improvements we've got so far. We start our second 90-day plan for unscheduled care today, and that, we know now, will get us the traction that we need to actually get those harder targets delivered, which ultimately will impact on improved patient care and outcomes. 

What we've been really clear about is that, as part of this, whilst we know it will help us to be more efficient, it will also help us to reduce harm. One of the things that we've seen is a really huge reduction in the number of serious incidents across our emergency pathway, and we're very proud about that. Engagement with staff about that—. No-one comes to work to see harm occur to patients, and what's been really clear is the power of that with staff, and understanding themes and trends of our incidents and engaging with them to understand that has been very powerful in effecting real change. We've got to keep going with that to enable it to become sustained. 

Okay, because key to all this is appropriate triage of need so that people aren't turning up in A&E for a plaster. 

Absolutely, and that happens pre-hospital, where we can, and using some of our minor injury units wherever possible, being able to deflect patients away from ED so that really only the sickest patients are being cared for there. We've been doing some of that work through really effective triage, so making sure that the standard for triage is the universally accepted one, being really clear that we do that pre and at arrival at hospital, and we can divert patients so that they can be seen more quickly in a more suitable setting. All of that is incredibly important in getting that patient pathway right and underpinning all of this with patient experience, so that we're gathering patient experience data and information at the point of their experience with us through that ED journey, wherever it happens to be, because that will really help us to drive change more effectively for what patients in north Wales want from us.  

Okay, well you've got excellent hospitals. I've been to several of them and you need to build on that, obviously. 

12:05

Okay, we've got a lot of interest in supplementaries. Llyr, then Oscar.

I was listening to this three years ago, so why has it taken so long? Because it's the same that we were told—you know, this cultural change and taking the staff with us, and we're still there. Okay, there has been some improvement, but I spent 12 hours myself in the emergency department at Wrexham Maelor at the end of January, and it was complete chaos. So, when and where you hope to collect this data, I've no idea, because we had triage nurses coming out and actually having a roll call to see who was left there who was still waiting for treatment. It's not a great experience, as a lot of people know.

I'm sorry that that was your experience—

No, no I don't expect you to comment on my personal experience, but I just wanted to—

But you've brought it to us and it's important to acknowledge it.

But equally—so, the apology is obviously to you and all of the patients who wait and are waiting right now too long, whether that's over this weekend or, indeed, over the period. It is a very fair question to say, 'Why hasn't it happened? You've been trying to do this.' And I think, fundamentally, that there are many factors that would come into that. So, whilst, obviously, this January the weather was better than last January and flu was not as big an issue for us as it was last January, we still had 5 per cent more people come to our emergency departments. If you look at the most poorly patients, the majors patients, that was a 10 per cent increase. So, demand's going up, that is driven by a whole range of areas where we, obviously, as a health board wanted to do something about it. I'm not suggesting that we're kind of passive in this situation, but whether it's issues around demographics and age, whether it's issues around a range of other areas that lead to drive that emergency demand, I think that demand is certainly a challenge for us.

If we were saying this three years ago, the demand is a lot higher today than it was back then, as I mentioned earlier on, in terms of some of those staffing issues—so, within that department where you were there will have been gaps on rotas, there will have been gaps throughout that whole pathway. So, our challenge is how we can change those workforce models, whether it's back to primary care, where we've had some good success around a more multidisciplinary team approach, how we can support patients with mental health and other challenges, how we can work with partners, how we can get people out running in the park, how we can help people with substance issues.

Fundamentally, the reason why this takes so long, if you like, is the range of things you have to do, the challenge that we've got, the fact that, when we make changes, working with partners—. So, we've seen some real improvements in terms of delayed transfers of care; those are lower than they were before, getting patients through, out of beds, into the right bed. But they're still higher than I want them to be. Just because we've made improvements, doesn't mean that we've got them. Now, obviously, when you talk to the rest of the health and social care system, there are real challenges for them in terms of recruitment. When you talk to people who own nursing and residential homes, they've got real issues around staffing, they've got issues around patient safety and other things—

Yes, indeed they are. Having said that, as I mentioned earlier—. In a sense, I try to avoid talking about other health boards, because, at the end of the day, I don't know their business, but—

We can. So, we can see that there are health boards that have very, very low, if any, expenditure on medical agency locums; we can see there are people like us. So, there are differences there, but, equally, these challenges of increased need are there everywhere across the whole of the NHS. I'm not suggesting that they're not. For us, that's the reason why we have to say we can do something about it. So, I'm not suggesting that we are a special case that can't do this. As I said, if you look at where we are right now today in terms of the February position in particular and some of the changes that we've made that Deborah's been alluding to, I think we are seeing progress there. As I said, the start of March would make us then on track to be better still. But, until we get to the point where we think we're offering the services to our patients and the experience to our staff that we'd want for ourselves, then, I appreciate that our population expect better and they deserve better.

I think I would say too, as chair of the board, that there's been a notable change in the few months that I've been here. There is a clear sense that the executive team, supported by the additional capacity on the ground, are getting to the heart of this topic internally and with partners. And the planned approach that Deborah's referred to is helping in that regard, because it's bringing some coherence to the planning around unscheduled care that may not have existed in that way previously. And that's, of course, been helped too by the appointment of the director of primary care, which provides that early focus too in terms of delayed transfers of care and so on and so forth.

As I said to the Minister quite recently, I'm particularly confident around the approach being adopted by the executive team and the organisation around unscheduled care that there should be improvement coming, and that's starting to emerge now. And the same attention is now being paid to planned care.  I get a sense for that because they are subject to specific monthly reporting to the finance and performance committee, which, as you've heard already, I chair. So, I'm more confident now than I was five months ago that we are on the journey that we need to be in terms of improvement. It's early days, they're early statistics, but we did predict, and we had our fingers crossed, if you don't mind me saying, at one point, that we would start to see this emerge, and it is emerging. The important thing is we build on that.

12:10

Okay. We are a little more than halfway through our session. We've still got a fair number of questions. There's still some time to go, but if Members could be succinct, that would be helpful. Mohammad Asghar.

Thank you, Chair. Thank you very much to the panel here. Actually, after listening to you all, the more questions I am writing on the other side rather than what we prepared before. Because, in 2016, I think it was a special measures improvement framework was set up—three years ago. And, actually, in seven areas, from leadership to primary care and healthcare, they're all inclusive there. I heard Mr Goodall—he's trusting you to deliver the best possible way in all these areas in national health. And don't forget, the biggest budget is spent on national health. Out of £15 billion, more than £7 billion goes on health, and you still can't perform and you're still in special measures after three years.

Now, you just said, Mark, that—it was your words—the financial plan was 'not robust enough'. That was only one aspect of lower performance in the area. There are other areas that we haven't achieved here. That's why we are concerned—seriously concerned. Mr Goodall trusts you to perform the best for the public in this area. His name has been mentioned a few times. How long will it take for you to, at least—? You know, the four years, five years—.

You're being trusted to deliver, so, to respond to one of Oscar's questions—.

I'm sure the chairman will want to come in, but, obviously, in terms of the time that I've been in the organisation, I think it gives me some perspective in terms of' back to that', having now been here three years. I think where I would start from is that I don't think there is, to my knowledge, another area of the NHS where primary care, mental health and secondary care have been in special measures all together at the same time. And I think, again, as Dr Goodall recognised, if you look at the scale of issues that was there, then, fundamentally, that is a lot to deal with. Fundamentally, I believe that progress has been made, but not enough progress, and if I were satisfied with the progress, I think that would be the wrong place to be, and we cannot be satisfied with that progress.

If you look at when I immediately arrived in the health board, then, what we had to do was a number of things: we had to reconstruct our leadership teams, as I mentioned earlier on, whether that be in primary care leadership, whether that be the exec team, whether that be across the organisation. We substantially changed and invested in our leadership teams in primary care and community care. We did the same thing in mental health. Fundamentally, I believe that those have had a really fantastic and material impact, and then, what we've said to ourselves is, 'Well, having fixed, if you like, the roof there, as that's sorted out the problem in the room below, well, then, what we do is then we look at the next problem that we've got, and we've been focusing particularly around acute care, whether it be the plan—. Again, when we arrived, we were completing still—and we're pretty much there now—the outputs from the 2013 'Healthcare in North Wales is Changing'. What we did immediately then is put in place plans and strategies for maternity services, for GP out-of-hours, for mental health, for some of those immediate safety, sustainability issues that the health board faced. And obviously, as we've already mentioned, two of those areas have come out of special measures, which, I think, is a mark of the improvements there—not that those areas are perfect, by any means—and I think, in mental health, we've mentioned some of the progress that we've made there.

In terms of our overall plan and the clarity that we need there, I think we are making progress. We've set ourselves that objective of getting everything sorted by September, but, again, in terms of areas like orthopaedics, ophthalmology, stroke, urology, I think we've put a lot of effort in there as well. In terms of that change in culture, in terms of that change in morale, if you look at what you would need to have to respond to a challenge of that scale and to climb that mountain, then, I think we've put in place some of the things that we would need. Nobody says we've got where we want to get to. I would have wanted to have made quicker progress. That has not been for lack of effort or hard work, I think, in terms of the people who I'm certainly working with. Again, if you go back to this time last year, I think some of the steps that we've put in place have really moved us on. So, I appreciate, obviously, the very fair criticism that says, 'Well, look at where you are right now; is that where you want to be?', the answer is 'no', but, as you would expect, I would emphasise to the committee that in terms of the things that we've had to do and deal with, they've been major. I think, again, the foundations have been laid, the proof will be in the pudding and I'd expect to be coming back to you, I'd expect us to be building on what we've done and I'd expect more things to be out of special measures, I'd expect more progress to be made. But, clearly, if I was sat here with no progress being made, then I'd be expecting the conversation to be much more different than it is.

12:15

Thank you very much indeed, but the fact is—. Performances and the rest, leave that, I'm talking about finances. Continuously over the last five years, the deficit has increased from £26 million to £42 million expected this year. So, that is another area that is a strain on this already strained NHS. So, how far are you going to go with the financial affairs in the NHS Betsi area?

Well, as I said, we're looking for improvement, so we're looking to deliver more savings next year. More importantly, we're looking to make more of the changes that will help us to safely change the way we work, change our workforce models, change our services and improve the quality of what we do. And as I used the example earlier on, whether it be running clubs, whether it be people not getting C. difficile, there is a whole range of things there where I think we can change our service models, change our workforce and get those savings delivered. Fundamentally, we need to stop overspending and putting pressure on the public purse. We're very, very clear on that. We're clear that we need to do it well and we need to do it properly. I think people are committed to doing that. Again, I'd expect us to be back here answering questions on the progress that we've made on that in future.

Yes. I absolutely would not have left my last role voluntarily to come here if I didn't think we could get this organisation out of special measures. I think some of the fundamentals are in place, but they're just not fundamental enough and that's what our attention is on, as you've heard already. There has to be an absolutely clear sense of direction and a clear sense of what we're going to deliver and then we've got to deliver, including with the financial plan, which is why that additional work that we're commissioning is really important to provide confidence to the board that those things are in place.

Ultimately, of course, it's for us to get this organisation out of special measures with our teams, and I'm convinced that Gary now has some of the members of his team, whom he didn't have before, to help with that. Some of the new appointments are particularly key to bringing focus to some of the areas that are undermining both our performance and our financial delivery. And together, through the board, it's about us stepping up, ensuring that we do what we say we're going to do, and that has to be the focus.

Thank you very much indeed, Mark. The thing is, you also mentioned turnaround directors, I hope it's to turn around the whole system in the right direction, rather than—[Inaudible.]—turnaround. Thank you very much.

Now, the question is: what is the health board doing to tackle the growing number of patients whose follow-up appointments are delayed in Betsi?

Thank you for the question. This is an area the health board clearly wants to look at as part of the overall plan that Mark mentioned earlier. There are three or four key specialties that are driving, or that have got the biggest numbers of follow-ups that are not being seen on time. Orthopaedics, ophthalmology and urology are three of the key ones, so, we've developed plans there. The kind of improvement levels that I talked about earlier on in terms of 15 per cent improvements and 49 per cent improvements, we've not been able to see those improvement levels in the follow-up patients as much as we have in some other parts of the system. The plans we've put together are about putting in place the right service models using high street optometrists, as I've said, using physiotherapists and other people as alternatives to orthopaedic surgery. So, the plans we've put in place will give us then the capacity that, if you like, is balanced across, whether it be the operations or the follow-up appointments.

Equally, we're also looking at some areas whereby we can change the way that we follow people up, so making more of a move towards patient-initiated follow-up, because some work that the committee may be aware of around patient-reporting outcome measures does tend to suggest that, in terms of some of the follow-ups that we have, some of them potentially are patients who could actually need to be followed up earlier than we're planning or indeed actually not be followed up, and could opt in and opt out of that system. Also, we're looking at how we could maybe utilise e-mail conversations; we could have Skype consultations, so that we don't have people—. Because, obviously, a follow-up appointment can be a very brief appointment, clearly, people travelling long ways across north Wales to do that is not the most effective. We've got some good examples there. So, there is a plan for those major capacity in those three or four ones that are really driving those numbers, and what we've also done as well is set up a more clinically led group to help us drive that through. But those plans that I believe we need to drive through in ophthalmology, urology and orthopaedics would resolve, I think, in the region of 80 per cent of the problem that we've got.

12:20

Thank you. And how many patients come to harm as a result of a long wait for a follow-up appointment?

What we find is, we've got systems in place to monitor harm across our service. Now, whether that's a pressure ulcer that somebody gets; every time somebody gets an avoidable infection then fundamentally that is harm. Where people are waiting for an elective operation they can sometimes end up being admitted as an emergency, and that I would define as harm. So, when patients come back for their follow-up out-patient appointments, what we do find is that, for the vast majority of them, they're on track, their rehabilitation is going to plan, but there are some that we will find that we should have brought in earlier, and that there is a level of harm that we now need to respond to. So, that's the system that we have to manage across, but what we have got are good reporting mechanisms. We encourage our staff to report those. Incident reports are done. Clearly, then, they feed into clinical audit and into our range of plans. Obviously, depending on the seriousness of that issue, it would reach a certain point in the organisation in terms of where it gets reported to. So, yes, at any point in time where a patient is not getting the service that they should be getting, we need to be vigilant in terms of patient harm, and we are. As I've said earlier on, in particular, I think an area where we have done a lot of work, certainly in the time that I've been at the health board, is a culture of reporting, and I think the most important thing is that we are encouraging people to say when these things happen.

I think those have been covered, Oscar. I think the next couple have been pretty much covered earlier, and I'd like to move us on now to the important area of mental health, which I know Llyr Gruffydd has a few questions on. 

Thank you, Chair. Can I just ask initially what timescale the board is now working to in terms of fully implementing all recommendations from the Ockenden and HASCAS reports?

Andy and I—[Inaudible.]—so if I may: some of the recommendations were very short term, so, appointing another dementia consultant nurse, we've done that. Some were much longer, obviously. To effect a full culture change across our mental health services we accept is going to take us a period of time. But the programme of work that we've described to do that is in train and is very comprehensive. So, I think it will take varying measures, varying amounts of time, but we've got that mapped really clearly into a very comprehensive work programme. So, some are quick, some are not so quick, but there are plans behind all of them, and we are delivering measurable change each month when we meet to monitor our actions against each of the recommendations.

Because you will understand there's a great deal of frustration—

—the feeling that there's a slow pace of change and we've had the Commissioner for Older People in Wales express as much, as well as Ockenden herself, of course. The perception out there certainly is that things are pretty slow in developing. So, what assurances can you give to people that we will see the significant changes that we want to see? Because currently, I think people are still very sceptical.

Yes, and we met with the older person's commissioner recently, Mark, myself and Gill, to talk through the view that she had formed from reading the report. I think what we were able to do was to give her some assurance about the improvements that were being made, and we've had a very positive response back from her, and a real commitment from her to work with us so that she can see those changes in real time. What we need to be really careful about is that we don't get caught up in living in the past, that we are seeing ourselves changing quite effectively, and actually those changes are being embedded well.

What we've been doing with working through our stakeholder groups is making sure that they can see those changes in as much real time as possible. So, we've got a stakeholder reference group that sits alongside our work programme of change for the HASCAS and Ockenden recommendations, and they are acting as our eyes and ears and critical friend to test those changes and to actually tell us if they believe that they'll make the difference that they expect us to see. They have been very positive in the way that they're feeding back, so they're getting involved in our recruitment of staff across our organisation, be it psychiatrists or other members of staff, and we've had real positive feedback from that. They're sitting alongside some of our mental health nurses whilst they're doing restraint training. That was the real key point that came out from the Ockenden report, and they're very positive with the way that that restraint training now is being embedded across our mental health services. And they're also really positive about some of the cultural changes they're seeing. The enduring issues that were really washed out through Ockenden and HASCAS, they've been able to positively say that they're not seeing those anymore. So, I think the best critical friend for us and the best people who will help us to get better will come from those groups, and also through the work we're doing to engage in the wider mental health community, so that we can demonstrate the changes that we're making are tangible and are sustainable, because that is really important to us. 

12:25

I think on that assurance point, I think it might be worth Andy mentioning some of the Healthcare Inspectorate Wales unannounced visits that we've had recently, obviously as a—. One of the points Deborah's already made is that the work of HASCAS and Ockenden is about the total older person's pathway, so there is a very large range of services in there. But, obviously, Andy can just give us some brief feedback in terms of some of those external mental health inspections.

Thank you, Gary. We've had three recent reports from HIW on the Hergest unit over in the west, on a community mental health team in Conwy and, more recently, on the Ablett unit itself. What we're able to demonstrate through all of those reports is a significant improvement across all areas of patient safety, quality and experience from previous reports, which, again, provides assurance and evidence that we are starting to embed some of the cultural changes. Particularly pleasing from the most recent report from the Ablett was around the level of staff engagement, the morale and the governance of the unit, and the report reflects also the leadership from the board to ward, and clear evidence that there's good reporting of incidents and support for managing difficult situations on the unit.

So, I think from my perspective as the director of mental health, we are starting to get that external assurance of changes and improvements. It has been an improvement journey, and we are very much keen to drive up the quality of services across mental health, and these reports are starting to give us that external evidence base and assurance that these changes are being embedded, and that continuous improvement is being made.

That also reflects and ties into our special measures framework, and how that supports the special measures framework where, clearly, we're working with Welsh Government and Emrys Elias around our quality improvement plan as part of our special measures, and there's a real read across now in terms of the outcomes from the HIW report that, again, gives that external evidence and assurance around service improvements.

There are still more improvements to be made—I'm very clear about that, and we're very clear as a health board—but with the continued support from the health board and from Welsh Government around us driving our special measures improvement framework, we really want to try and push to get mental health out of special measures, but there is a way to go on that journey. 

So, how is staff recruitment and retention affecting this particular agenda, and what's happening particularly in mental health to address some of those challenges? 

Staff recruitment, again, is another good sign of improvement. Year on year for the last two years we've had an improved ability to appoint. We've recently just appointed 21 qualified nursing staff that will commence this year. In particular, for me, a sign of good recruitment is that we're getting students who are coming on placements who are deciding to stay within the division, which is really, really positive. Our retention is good, particularly across central and east. We do struggle in the west because of the geography, particularly around medical staff but, again, positively over the last two years, we've recruited to 16 substantive medical posts that were previously—and they're key and critical posts—covered by expensive locums. 

So, again, I think we're demonstrating a positive trajectory around recruitment and, more importantly, retention. Again, reflected within the HIW report and our improved staff survey is a general improvement in staff morale across the division. I visit services on a regular basis, and I can evidence that myself in terms of starting to see a shift change around staff's views, and staff feeling much more open that they can talk. I think, for me, the impact of that has been around the ability to put in a clinical leadership model supported by a senior leadership model across the division that wasn't in place previously. Staff talk to me now regularly about knowing who their local clinical leaders are in terms of the clinical director. We've got a head of operations and a head nurse. They are senior posts across each of the areas that weren't previously there, strengthening the governance and leadership that, again, has been reflected in all of the HIW reports. 

12:30

Let's just talk a little bit about Bryn Hesketh, specifically, because it was the subject of a CHC report back in 2017 and it was quite critical in terms of staffing levels and dependence on bank and agency staff as well. Where are we in terms of Bryn Hesketh these days? Can we use that as a bit of a temperature gauge?

Yes, I'm very pleased to announce that Bryn Hesketh—I visited there about two or three weeks ago. We've got sustained leadership in there now. We've got a new matron who's been in post for over a year. She reported that pretty much by the end of the spring, they'll have all their qualified vacancies filled. They've got a couple of students who've said that they were going to come.

We've also increased the establishment of Bryn Hesketh in relation to the statutory review and our own internal reviews of Bryn Hesketh. It is a stand-alone unit. It is a dementia assessment facility. It does have quite challenging patients on that unit and that's reflected now within the increased establishment. We do tend to have a turnover of healthcare assistants and support workers, but that is fairly natural, but we are really pleased around the recruitment to Bryn Hesketh as it stands at the moment.

Okay, and generally, in terms of agency staff working in mental health specifically, I think I saw a figure of around a £6 million cost in 2017-18, which is 20 per cent of all agency costs across the board. So, has that picture improved?

It has in some senses in terms of our qualified—. We still have problems with our locums; we've still got consultant vacancies, and I think quite a significant amount of that figure will be around locum consultants, who are expensive and obviously do drive up the costs.

Again, around the agency, across all the areas of division, we're working very much around, obviously, filling the vacancies, but also around vacancy management, being much more proactive about recruitment and also sickness management, where, again, we've seen an improvement—it's not where it needs to be, but it's a continued improvement, because, obviously, particularly our in-patient facilities, when people are off sick, we often have to fill that with either bank or agency staff.

Did you want to mention out-of-area replacement—[Inaudible.]

Yes, the other area of significant improvement has been out of area. Last year, in 2017-18, we spent nearly £2.5 million sending people out of area. Fundamentally, whilst it's not sustainable financially, for me personally, there's a real quality issue around people having to go out of area to receive acute care. We've absolutely driven that down, with very low numbers this year. I think that fewer than 20 patients this year will have gone out of area and when they have gone out of area, we've brought them back very, very quickly, and that's obviously when we've been having high demand for acute beds.

I think the clinical leadership model, in terms of the ownership locally, and that clinical and management accountability locally. Obviously, as part of our strategy, we're reviewing our care pathways, in particular the acute care model, ensuring that patients are assessed regularly and that they are not left for long periods before there are ward rounds.

The whole pathway around working with our community mental health teams to pull people out back into the community—all the evidence is that people get better closer to home and in the community, and what we're seeing—as Gary alluded to earlier—is a decrease in delayed transfers of care in mental health and a real robustness around how we manage that acute activity across our in-patient facilities. We are still running at high occupancy levels. The optimal level is 85 per cent; on average, we are using leave beds so, we're predominantly, across the board, working around 100 per cent occupancy. But, again, if that prevents people from going out of area, and we are managing that safely, then that is the right thing to do.

You've mentioned a couple of times that morale is improving—how do you evidence that other than through your own anecdotal experience?

It's not just anecdotal. I think, it's through the HIW report; I think it's through—we have the 'listening leads', they are front-line staff, who meet with me and my senior team on a regular basis. It's also through engaging with our third sector partners and service users and carer groups, and, more importantly, it's also feedback from patients and their families that they are receiving much improved care.

I think, the staff survey results—one of the things we're moving to, which I maybe should have mentioned earlier, is that, obviously, within Wales, the staff survey is a periodic thing. We're working across some systems in place whereby we can run our own surveys effectively and get some of that information in and then obviously, we can run it on a very frequent basis. But, as Andy says, there is a range. Equally, Andy, I'm sure, would be the first to say that we want to see it improved more, because, fundamentally, the higher morale is, the more we can achieve together what we want to achieve as a team. But, there is a level of external evidence, as well as what Andy sees and what I see when I visit units, that can back up what we think when we talk to people.

12:35

From a board assurance perspective as well, it's worth saying that in terms of HASCAS and Ockenden, for example, while speed is not as clear on occasion as it perhaps ought to be, what's important is that the changes are embedded. The board is, as you might expect, all over the response to HASCAS and Ockenden. It's the subject of monthly reporting to the quality and safety committee and to the board. In fact, the board, at the next meeting, have asked for feedback to be gathered from the stakeholder group and be presented to the board in public so we get a feel for how happy the stakeholder group are with the current arrangements.

In terms of the unit, I and the vice-chair, who particularly leads on mental health, have been to the unit ourselves, and I have to say you do get a sense of a positive change in mood. You do get a sense of the management team being there to lead and support their colleagues, and particularly the new head of nursing has been received very well in terms of demonstrating and wishing to engage with the nursing staff in particular to help them overcome obstacles to improvement. That is writ large in terms of every visit that we undertake.

So, does all of that give you sufficient confidence that if, heaven forbid, there was another failing similar to Tawel Fan, let's say, that that would be identified early on because of these new processes and would be addressed before it became a big issue?

I think, to use your example of Bryn Hesketh, that would be an example for me of early reporting of some issues from Bryn Hesketh and the response that we undertook as a health board and as a division to ensure that the unit was supported. We took on board some of the issues, it was a proportionate response to some of the issues that were happening at the time. I think what we have demonstrated is we've followed that through with a continuous improvement plan, and Bryn Hesketh does feel very different. Again, that's down to the local leadership and the local team in terms of how they're managing that service. 

But did not the impetus for that come from the CHC, not internally from the board?

I think there was a mixture. There was the CHC and there were some issues that people had escalated. But, again, the response, I feel, was a rapid response and a proportionate response. 

So, you'd still see an important role for CHC in terms of being that sort of critical friend. 

Absolutely. We welcome CHC. CHC are regular visitors. We work well with them. We always work with them in terms of that additional external scrutiny. But, again, from the CHC report, they go in and they will raise issues, they will talk to staff, but I think you can see a trajectory of improvement in their reports and what they're experiencing themselves when they're visiting our units and our services. 

Okay, great. Last night, myself, Mohammad Asghar and the clerks visited the Wrexham Maelor to look at the out-of-hours service. That's an inquiry the committee has also been following through with. Can you give us an update on the current position of out-of-hours within the health board? And how do you respond to the auditor general's concerns regarding reduction in real-terms expenditure on the service?

Thank you, Chair. I think that we have done, but still have, a great deal of work to do around our overall—the label we use is 'unscheduled care', but the system that meets people's needs 24/7, 365, when they need some assistance that isn't planned. Whether that's around the high street pharmacy, whether that's around our minor injuries units—obviously, our GP out-of-hours service is a really key and important part of that.

The challenge that we've got there, as I mentioned earlier on in response to an earlier question, is fundamentally a situation of rising demand and a situation of challenges around staffing and capacity and ways of working. Obviously, we're trying to tackle both those fundamentally. We have seen an increase in terms of expenditure in the service. We've seen different staffing models come in. We believe we've got some way to go in terms of the potential of those to see more multidisciplinary team working. I think there's some more potentially around technology and the way that that team is supported by that. There are some issues around where people are located.

I didn't mention it earlier, because we were moving on, but whether it's our mental health service or whether it's our out-of-hours services—we may touch at some point on our estates and our buildings, but there are some real issues for us there, I think. As the committee will be aware, through a combination of performance data that's been validated through peer review where we've had external inspections, there is a progress and a momentum in our out-of-hours services. I think, as the chairman's already alluded to, our decision to appoint a local GP who has transformed part of our system in north Wales to be that director of primary and community services at a board level, was a very good appointment and that is working very well.

We're out of special measures for GP out-of-hours. That does not mean that, as I say, we're where we want to be on it, but, looking at that from an across-Wales perspective, then I think that we've gone from a situation that was very concerning to being where we need to be in terms of compared to others, but we want to get that service improved further still and we want more resilience both within our daytime services and our out-of-hours services. And, as I've said, that's a complex picture, because every time somebody feels unwell and accesses a service somewhere, and, as I've said, there's a mixture of mental health and physical health that people need assistance with, there is a preventative agenda there. There is then responding in different and better ways and people getting the support they need so they don't have to end up in part of that service, and I think there's a long way to go.

12:40

You mention an increase in the funding for out-of-hours. Is that a real-terms increase or is that a cash-terms increase? 

In terms of inflation, real terms, I think it might be keeping up with inflation, but, for us, fundamentally, our issue is being able—for want of a better term—to spend the money because, fundamentally, it's around getting the staff and those gaps around that, and, from our perspective, we know that although we've made substantial progress in our shift rates and, obviously, we monitor that, and from that perspective we've made—. And that's one of the reasons why we've come out of special measures, because you can see that improvement. We have occasions where we're not able to fill those shifts. Now, obviously, what we want to see are those shifts filled and that money expended because, clearly, that would give us the service that we want to have and that's our fundamental challenge around it from a financial perspective. The health board has set itself an objective that would say it wants to invest in community resilience. As I mentioned earlier, one of our challenges is having acute beds open that are very expensive. It is a financial and a quality plan to make sure that we don't get to that situation by having the money out there where we want it to be. 

Yes. Just to say that there's clear recognition on the part of the board that we need to better balance the focus on health improvement and addressing health inequalities with care closer to home and unscheduled care pressures, which is a difficult challenge to pull off, but, of course, those three things help each other, and, in that regard, the health board, with partners, have been very successful in applying to the national transformation fund and have just been allocated £6 million over two years to assist with improvement in care closer to home, and I'm sure, under the leadership of the executive director, who is bringing a greater sense of equality and balance across the organisation in terms of the focus on primary care, those moneys will be used with partners to good effect to deliver better care closer to home.

How many GP practices are directly managed by the health board currently? 

I'll confirm the exact number, but it's in the region of 13 or 14.

Clearly, for us, fundamentally, what we want to see is a successful primary care service, and as the chairman's just said, we want to see that and we want to invest further in that. What we are looking at right now is we're working through returning three of those practices into—without wanting to get into jargon, it's called a general medical services practice. From my perspective, some of the examples of real innovation and some of the Bevan exemplars that we've seen have been in directly managed practices. Equally, we've seen some real innovation, some new service models, some new ways of working in what are the more traditional GMS practices. So, from my perspective, I can see fantastic examples that are both directly managed and not directly managed of practices within north Wales that are doing a great job.

Obviously, from our perspective as a health board, the situations that have led to some of those practices being taken into, kind of, directly being ran by the health board have been difficult—have been situations you'd want to avoid. We have a proactive programme of working and a way of assessing where we might see challenges and stresses and strains within the system and we try and work with practices to support them. Clearly, from our perspective, the more proactive that support is the better. Where we need to step in and make sure that we can provide a service to people, we have to do that. Obviously, all the health boards in Wales have had to do that to a greater or lesser extent. But, like I say, we are working with people and I'm pretty confident that soon we'll see some of those practices going back into GMS, giving a good service to patients, and from that perspective, then, we're intending to work as proactive as we can. But from my perspective, as I say, I see innovation in both, and I see strength in both, and obviously what I just want is the best care for patients. I don't want them to have to think about what these labels are that we tend to apply in the NHS. There are different ways of achieving things, and for us that's the most important thing—the outcome for patients.

12:45

Okay. A couple of supplementaries on the back of that. First of all Oscar, then Llyr.

Thank you very much to the panel. Gary, to you first—I know the public services your health board is doing. How often do you meet with clinicians and nurses and doctors, leaders, in your health board?

Generally, I try and do it once a week—

In terms of well-being. 

Right. So, assuming in terms of getting out and about and going to talk to people and saying, 'How's it going?', and one-on-one—?

Right, okay. Well, I generally try to do that once a week. I don't always achieve that. I think the last time I was out and about and just spending time in a service talking to patients, to doctors and nurses, was in the mental health unit on the Wrexham site a couple of weeks ago. What I have is then—. I also then go out and give staff achievement recognition kind of things out, which is obviously an opportunity to talk to people, but it is around that. I think it's really important that people's senior leaders are visible. I like to come in on Christmas Day. I think that's a really good opportunity just to get out and about and see people equally. Fundamentally, that isn't always—. As I say, I wasn't able to do it last week. There are other means that I try and engage with people that have been proven to be successful, both in my last chief exec job and in this one. So, whether that's my 'My week' that goes out to the organisation, where I just say what I've been up to and add a little bit on the end of it, which is 'My opinion', where I give my opinion on all sorts of things. Then people e-mail me on a regular basis. So, I think that it is a challenge to get out and about as much as I would like—certainly, covering the whole patch. In terms of Christmas Day, I've been around three places so far. It will take me a few Christmases to get around the, I think, 147 properties that we've got in Betsi, but I think that visibility is really important. The whole of the health board, the whole of the board, we have more structured walkabouts, but equally, then, we have just calling into places to see people. And obviously, in that, then, it's important not just that you go, but that you go to listen and you go with the right attitude. And that, I believe, is something that I and the team do as well.

And I'd just endorse the fact that planned as well as impromptu is important. There is a planned structure in place between health board members—the independent members and the executives—which has been reinvigorated over the last month. I'm out on visits for the full day on Thursday, in the west, both in the acute site and a number of primary care sites too. That is being mirrored by colleague members on the board.

I'd imagine there is an acceptance that, you know, there will be more directly managed GP surgeries in years to come, because of the age profile of GPs and the issues in that particular sector. But do you have a preference? Because, I think anecdotally there was a suggestion that the board were accepting of the fact that they would need to manage. In fact, maybe, some people suggested that you thought you could do it more efficiently financially. But then, of course, the reality hit, and people realised that, actually, we need to get these back out into GP management ASAP. So, is that still your position, really, that your preference would be that others do it? But, of course, you're the ones that have to pick up the pieces.

Well, my preference is that we give people the services that we need and that, in a sense, how we do it is not something patients should worry about. I think, from the point of view of the health board, there is a position whereby if you're directly running something and I'm in a committee like this and you ask me a question about it, there is a strength to having a direct line of accountability for something. Equally, the health board has got a pretty big challenge and our leadership team has got a pretty big challenge as it is. So, where people are, if you like, running themselves, as part of, if you like, their own organisation, I see innovation and I see good practice in both. I can give you some really good examples of people doing really good stuff in both. So, from that perspective, I don't have an ideological position on it, and as I've said, we're working at the moment to return some practices to GMS. So, in a sense, things will potentially go in and out again.

But in a practical sense, there will be more coming your way, and that will have an impact on GP numbers, on finances and—.

Well, I think if you look at some of the—. What we are working on, obviously, with Dr Stockport taking the lead on it, is that there are things that make it—there are challenges in primary care and, as you say, as people are retiring, some of the issues around property, some of the issues around recruiting new people in, some of the issues around the sheer challenge of the job mean that that potentially does drive there being more directly managed practices. But I don't see any of those as insurmountable. There are some things that we've done over the last couple of years that have helped us to address all of those issues. So, in a sense, I'm not sure I'd want to say for sure it would be the case. I think it's certainly a potential, and it's one we need to be prepared for, but the more we can work with people to fix those things—which we should want to do anyway—the more, potentially, it means that they will carry on in what is perhaps, if I can call it the more traditional model, but I would want to emphasise again that the traditional model can have innovation and change just as well as, if you like, the new model can.

12:50

You've all given us good examples of how you're leading from the front, but, at the same time, you acknowledge in your conclusions that there's still some work to be done on delivering a more robust plan with rigorous resource allocations and planning and a stronger clinical strategy. What are the three things you need to change to achieve the direction of travel that you all want to go in and we want to see you go in?

First of all, it starts with the plan. The plan has to be in place, robust, clear about deliverables and expectations, and we need to be assured that the right capacity is in the right place to deliver. That's been part of the problem in the past. Alongside that, there needs to be a clear alignment of finance and investment to what's in the plan. That's been a difficulty in the past. So, if we want to provide confidence to you, to our communities and to Welsh Government that we are going to deliver, the two things need to be lined up more effectively than they have been in the past. And what's also important is that we are clear about what our trajectories are going to be, in terms of both performance and financial savings moving forward over the next year, and we will be.

The board has until 28 March—or on 28 March—to approve the plan. What's absolutely paramount, of course, is that all those things come with that plan for approval on 28 March. That's why there is still much work going on to ensure that those things will be in place before the board can sign off what's required.

Okay. The most concerning thing you've said is that, at the moment, you don't have the capacity to change the service model and the workforce model that the Government expects you to do.

What I said—I think—was that I don't believe we are ready to embark on significant transformation moving into next year, because the first thing is we need a clear clinical strategy that pulls the various threads together to ensure there is a coherence to the whole and that we've engaged effectively. That is not to say that there will not be service transformation taking place in the meantime. Vascular will go live in April—you've referred to that. What's fundamental to the board and around planned care in particular is that we clear the orthopaedic business case with Welsh Government and we clear it soon. I've mentioned already that there's a meeting in March intended to do that, because that is also fundamental in terms of our service model moving forward, for the reasons you've described.

There is already work going on around urology, there's already work going on around ophthalmology, but it's the coherence of the whole that's important and also to ensure that, given our financial challenges, the estate, IT, workforce programmes are aligned too, because, in my view, an estate of 130 premises or thereabouts is currently unsustainable in our own financial envelope. And it's currently not properly aligned to our service delivery as we might see it moving forward. So, those things have got to come together with some coherence to ensure that everybody is clear, including all our stakeholders, about what our direction is and what we're going to move to.

I was on the Public Accounts Committee when we wrote the 2013 report, where it was absolutely clear that the governance arrangements were completely inadequate, with service papers being submitted at the last minute in order to avoid proper scrutiny and all manner of other things that were really considerable cause for concern. With the benefit of hindsight, do you think that the Welsh Government, Healthcare Inspectorate Wales and the Wales Audit Office underestimated the scale of the changes needed, or do you think that it was just a failure of leadership to do what was necessary to implement the change?

12:55

I think probably everybody underestimated the scale of areas that the organsiation was in special measures for, which is, as Gary has referred to, unique across the UK. Of course, would we want to be out of special measures by now? Of course we would be; all of us would be. I do think the special measures framework, from what I've seen, has brought a degree of focus. It's brought scrutiny, it's brought support and it's brought additional capacity. The onus must be on us to ensure that, particularly the last, is used most effectively to deliver moving forward. Now, you've heard of examples of where that is the case, particularly around our organisational capacity to deliver and that leadership that we've referred to. It's really, really important to our improvement journey that that is kicking in and kicking in really well. And I'm convinced from what I'm seeing already that it is, but there is more to be done.

So, I'm convinced, with the things that we are putting in place now as a board and also the independent member element team that I've got, working with the executive, of course, that the level of scrutiny and expectation is changing and has changed, that we are clearer about where the areas of focus need to be and that we're driving up those areas. There is more to do before we get to the new performance year, as I've already said, and the clock is ticking, I realise that, but we are on it.

Now, I know you would've said that or heard that back in 2016. I fully recognise that point. I can't say anything else, then—I wasn't here, we weren't working together, the new executive directors weren't in place and the chair at the time didn't have the IM contingent that I've got. I think there is every reason to be optimistic, but to not underestimate the challenge that we still face. And I think what's fundamental is that during the next year, we demonstrate more stability than we have done in the past and we demonstrate that we are sticking with those areas of improvement that we've referred to, and that, in terms of finance and also key aspects of performance, we're starting to demonstrate a positive trajectory. Because we've got to build confidence amongst your good selves, our stakeholders and our staff that we can drive ourselves out of special measures. And I actually think, from the staff I've spoken to, to a degree, they're more confident about our ability to do it than, on occasions, the board has been. So, if we can only grab that positivity that exists out there, and particularly some of those new members of staff that I've met and Gary has met, those who are now working in our mental health units—if we can harness that in a more effective way than we've done previously, and I do think there's an element of empowerment required in that regard, then we have got something really to go at and something to really be positive about.

Good. Any other questions from Members? No. Thank you. Can I thank our witnesses for being with us this afternoon? It's been really helpful. I thank the Betsi Cadwaladr health board for answering our questions. I should also thank Glyndŵr University, of course, for providing the venue for today. It was remiss of me not to do that at the start, but thank you for welcoming us here to Wrexham. Thank you.

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.

Item 4: I move Standing Order 17.42 to meet in private for item 5 to discuss today's evidence session. 

We will also provide you with a transcript of today's proceedings for you to check before it's finalised. Thank you. Diolch yn fawr.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 12:58.

Motion agreed.

The public part of the meeting ended at 12:58.

Archwilio Cynulliad Cenedlaethol Cymru