Cynulliad Cenedlaethol Cymru

Diolch, Cadeirydd. Good morning. I suppose I want to ask, before I go into some of the questions: can you explain as to why a senior member of the board is not with you this morning? 

So, an independent member?

A senior independent member of the board, yes—the chair, vice-chair. Somebody in a senior role should be also here, I would have thought? 

So, we had a discussion about that. We thought that this would be better served by the officers of the health board, and so, what we've brought together, the finance— [Inaudible.] Just looking at some of the topic areas that were described, we've constructed the team in the way we have to try and be as helpful as we could. 

I appreciate that but—

So, apologies if there was an expectation of an independent member. We weren't aware of that, and we've constructed the team. So, I made the decision around the people who would be here. 

I'm very surprised that neither the chair nor the vice-chair is here, to be honest, because they are also accountable and they are ministerial appointments. So, I would have expected them to have been here.

So, my apologies for that. If we can note that. But I did make the decision on the team that would be here, so it's me at fault. 

Which would have been sanctioned by the chair or vice-chair. 

Pardon?

Which would have been sanctioned by the chair or vice-chair. 

[Inaudible.] I think that's inappropriate—my personal view. But let's go on to some of the questions, and I'm sure one of my colleagues will want to ask questions about the report that's come out this week, so I might not preempt them—looking at Angela—but let's go to primary care, and in your written submission you've talked about a new primary care multidisciplinary model. I suppose what I want to ask is: has that been rolled out across the whole of the health board, and if not, when will it be rolled out across the whole of the health board? That's an easy one to start with.

Okay. So, if I hand over to Steve, who's been—[Inaudible.]

Yes, thank you very much. That model is a new model we've put in place just at the end of last year. It's as a result of primary care difficulties in terms of resilience in primary care, and what we'd seen was a number of pilot schemes that we'd seen across primary care, which we're trying to scale up capacity within the primary care team. We know that, from our GP colleagues, about 30 per cent of our primary care work at GP level is mental health or musculoskeletal work. So, what we're trying to do is scale that up across the health board so that we can provide extra capacity for GPs and patients in those two areas across all nine clusters. We're about a third of the way into that at the moment and we expect to complete that by the end of this year. 

Okay. Obviously, this model, I'm assuming, is one of the mechanisms we're using to look at the workforce issues, and in particular GP numbers, to try and address—. Because I noticed that, in fact, you were talking about 252 full-time equivalent GPs and you might need 280 to 290-odd. So, there's going to be a shortage at the moment.

Yes. If we run with the existing model, that will be the case. I think what we're recognising through the primary care plan is that we have to change the model for delivering services to deliver care and treatment at the appropriate level of need.

What is going to be the whole-time equivalent of this model's needs?

So, I don't have that exact number now, but that will be wholly dependent on delivering that, as you say, in a multidisciplinary way. So, what we'll be using is community psychiatric nurses, primarily, some social workers, and certainly physiotherapists for the MSK element of the model to deliver that in its entirety. At this point, we have already provided about 1,500 contacts in mental health and just over 500 contacts in musculoskeletal, and only 5 per cent of those contacts have progressed to a secondary care requirement in the mental health element and 1 per cent has progressed to a secondary care need in the other element. So, they are giving really good access to patients at the point they present in primary care, without having to go a multi-assessment route to try and get their needs met.

I understand that, and what I want to try and work out is the resourcing for this model. Clearly, if we are looking at the existing model and we're going to be short of GPs with the existing model, will you be short of GPs in the new model, considering also the possible retirement group brackets as well? But also you are increasing, as you said, mental health therapies, physiotherapists, and you're increasing a number of other resources if you go out in the community. So, are you confident that there are sufficient resources out there to actually meet the needs of the model?

Yes, so I think we can recruit to those resources. It won't always be in the traditional way that we have. We will deliver the service differently as well as increase our recruitment to it. Last year, the board took a decision to invest £2 million in this area, which was over half of our entire investment for the year, but we felt it was appropriate that that investment should go to the out-of-hospital services to support primary care needs at that level, and it's in keeping with our overall approach and strategy. But we will always have a recruitment issue to some extent, but there'll be two things that will influence that. One is the degree to which we can recruit into those short-skilled posts, but the other will be the degree to which we change the model of care to allow patients to access what they need at the level they need in a way that hasn't been traditional, and this is one element of that.

Is this being funded through the transformation fund?

No, that's not transformation fund; that was the health board's own investment that supported that.

Okay. Now, again, the model—I understand the model, because, obviously, we've talked about this in many cases elsewhere. It's about making sure that both patients understand the model and the nine clusters you have are fully behind it, and the out-of-hours services link into this, because, again, in your report, in your written evidence, there was some concern about that. You've improved the out-of-hours, I appreciate that, but 75 per cent means that 25 per cent are not being seen. So, how is this model going to work with out-of-hours as well?

When we look at our primary care resilience—I think that's a really good point—we don't look at it separately, and general medical services resilience in particular, we see that the in-hours service has a very strong impact on the out-of-hours service, and vice versa. So, you rightly point to some progress we're making in the out-of-hours service in terms of additional investment with extra GP cover overnight and some other multidisciplinary models that are in there as well, including pharmacists et cetera. But we're very aware that, what happens in hours has a direct impact on what happens out of hours. So, making our core GMS service resilient and, in this case, providing the capacity to become more resilient is key to each element of the system being able to become sustainable.

Okay. Can I ask, because again in your figures you say that the number of hours covered in out of hours was almost 44,000 compared to 40,000, so it's actually up 4,000—what you don't tell us is actually how many hours should've been covered, and I would like to have known that, because as an example, in my own area, I'm aware fully that, on occasions, some of the out-of-hours services are not available because they haven't got the GPs to cover them, and I would like to have known how many hours were not covered?

So, last year, there were two occasions, and each of them lasting about one hour, where we had to ask the people who were calling the out-of-hours service to delay or to go to A&E, for one hour on two occasions. So, there has been an out-of-hours cover practically all of the year, but that was the winter before last when we had a particularly difficult winter, if you recall, and we had a reversal of pattern of presentation, which was not in keeping with what we plan for every year. So, every year, we plan for a build-up of GP out-of-hours capacity over the four-day weekend, usually four days, and it gets busier and busier and busier towards the fourth day. We plan on that basis. On that year, the exact opposite happened, we were absolutely inundated on Christmas Eve and the pattern of presentations tailed off over the four days following that, and on those days, on those two hours, we had to take a break for one hour to allow the service to recover.

Can I just clarify for my own purposes, this break of one hour—? Again, in my area, Neath Port Talbot has an out-of-hours service and Morriston has an out-of-hours service, and so there are different locations.

Of course.

Are you talking about all locations—[Inaudible.]—or just one location not being able to? Because I could have out of hours not being delivered in Neath Port Talbot, but it is being delivered in Morriston, and is that going to be argued as, 'We've got an out-of-hours service', because it means that a lot of my constituents have to travel a lot further just to get there. So, are you saying that, when you had these two slots of one hour, that was only on one site, or was that across the whole health board?

No, that's where, as a health board, we had to pause for one hour to allow the system to catch up. There are occasions where we will default from three primary care centres to two, where cover is difficult in those, to keep the core service going.

Well, I would be grateful if you could provide the committee with the details of how many times that occurred—

Okay, yes.

—because I think it's important to understand that position.

Yes, we do record that.

I suppose the question we're focusing on clearly is: everyone talks about secondary care, because everyone knows about the hospitals, and everyone sees the hospital as the main centre of healthcare, but we all know that primary care is the biggest recipient of patients. In your reporting, are you making sure that there is sufficient report data on the quality of care in primary services so that, in a sense, your board would have been able to check whether you are doing sufficient work in that area? Because I've got some data in front of me, but there's always more time being spent on data from secondary care than primary care. So, are you comfortable that you have sufficient data to actually produce sufficiently detailed quality reports so the health board can actually say, 'Yes, we are comfortable with the care of the service in the primary sector'?

There is very good visibility of primary care activity and reporting within the board, so, for example, the out-of-hours snapshot that you have there—there's a much more comprehensive table of out-of-hours measures across the measures that is presented to our board in every board performance report. That's not on an exceptional basis, that is in every performance report that that is received. There is a comprehensive narrative on the challenges facing the system, the successes that it has achieved in the period between boards. That is replicated in our sub-committees of the board, so our quality and safety committee and our quality and delivery committee are very, very sighted on primary care. I personally report and the executive nurse director reports on both quality and performance at those committees as well.

And then, in our general governance terms, I and the finance director and the executive nurse meet each of our component parts of our clinical boards, once a month, to go through, in detail, the issues, the activity, the risks against finance, against quality and against activity. There is a particular meeting with the primary, intermediate and community care board once a month, which is minuted and recorded. So, I think there is very good sight to that. That's reflected in our overall strategy, but it is operationalised and is very much embedded in our governance.

Okay. And the final question from me in that sense then is: are you confident, again, that you have—the challenges that are facing you in transferring from the model you have, the current model, and that does mean change, and people don't like change—overcome, or you will be able to overcome any barriers that may arise in that process?

That is a challenge. It is a challenge that is firmly fixed in our strategy and very firmly fixed in our integrated medium-term plans, our three-year plans and our 10-year plans in terms of doing that. I think there are real examples of where we are making progress on that, but there is a lot more work to do. So, if you take diabetes or international normalised ratio clinics, a year or two ago, they were wholly being driven by the health board and people came to a hospital, to a clinic, and waited and were reviewed by a consultant. They're now being delivered at a cluster level and at a practice level. Every practice is involved in the INR work. We've taken those clinics down, that work is done at primary care level. Patients have the convenience of going more locally to have their bloods reviewed and their medications adjusted accordingly with that. So, there are real examples of where we're making progress with that.

One that we're now currently working on, to connect more intricately the pathways for patients between primary and secondary care, but emphasising the need for it to move to primary care, is our health pathways approach, where we are rolling out working with secondary care clinicians and primary care clinicians together to design pathways for patients, to design triggers for patients progressing through the pathway, and where those patients can be seen, treated and managed in a community setting, that is taken as a first step before people progress through. So, that mechanism itself is bringing our clinicians together across the health system to encourage a different approach to delivering care in a different way going forward.

Thank you very much, Chair. Although I do want to come to nursing, I'd like to come to it in a slightly roundabout way, if I may, because I just wanted to ask you your views on the Healthcare Inspectorate Wales report on the emergency unit and assessment unit, primarily because we were just taking about care, and of course one of their comments on the delivery of safe and effective care was that:

'Overall, we were not assured that all the processes and systems in place, were sufficient to ensure that patients consistently received an acceptable standard of safe and effective care.

'We had a number of immediate concerns relating to the safe care of patients, and these were dealt with under our immediate assurance process. The AU staff told us that in their opinion, patient safety was frequently compromised by day and particularly so by night.'

And why this is so important is because one of the questions I would like to ask you is: throughout the rest of your hospital estate, how confident are you that you meet the safe standards of nursing care that we've set out in legislation? So, perhaps you'd like to comment on your reaction to the HIW report, and then perhaps move into general nursing care.

So, if Steve comments on the report itself, and then we can pick up between us around the standards throughout the whole of the hospital.

The report was extremely concerning to us, as you would expect, and we were very worried and disappointed to have received the report. The nurse director and I met directly with the HIW team directly after the report to have a person-to-person conversation, or a face-to-face conversation, on that, to be able to provide assurances that we were obviously taking it seriously and doing what we needed to do.

The report is set in a context—which is not an excuse; it is just the context that we're working in, and we're working in the context of an unscheduled care system that is unstable, and, at various points in that system, there are pressure points that come into the system—in this case, in the assessment unit, which was unacceptable. But that can appear anywhere in the system. It can appear in ambulance waits, it can appear in waits for people waiting for an ambulance at home, it can appear in patients waiting to leave hospital to an appropriate setting of care. That is one context. As I say, it is not an excuse in any way, shape or form, but it is a context.

The second one is the context of the estate we're working in, and it's just a reality that we are delivering services that are high volume—huge numbers of patients going through an estate that is over 50 years old. We have clear plans now moving forward to deal with that in the future, but, for the moment, the environment isn't necessarily what we would choose to have to deliver modern healthcare.

When we met with the HIW inspectorate, we set out, as you rightly say, some immediate actions that we have taken. I'm happy to go through those, but they are on the record of what we have taken. That included putting extra nurses in, that included reviewing the availability of meals, it included the ability to recline patients to make them more comfortable, and it included some dignity measures, further dignity measures, to ensure that patients could be screened off and given privacy where there is a prolonged wait, which isn't what we'd want.

In terms of the intermediate plan, we as an executive have just this week discussed plans to decongest that area—the assessment unit—by streaming more patients directly to the services they need. This is, in particular, surgical patients, and there are three groups of surgical patients that we can look at, but a high-volume group are ambulatory trauma patients, and our first look at that suggests that we can move something in the order of 200 to 250 patients a month from having to go through that by providing an alternative route in the hospital, which would be more direct care and less congested. So, that intermediate work is happening immediately.

We will also look at whether there are some structural things we can do to the environment. It may be displacing it slightly, it may be doing some work around it. That's something we couldn't do immediately, but we are looking at what the options are on that. That takes us then to the long-term view of how we move forward with this. I've mentioned the estates and the planning that's coming forward, and I'm sure my colleague Abi will refer to developments on that, but, in terms of an unscheduled care plan, we have made significant progress this year, and this report demonstrates that, despite some real, material progress in our unscheduled care performance, and measures, there are still points in the system where we become very, very pressurised and congested. Notwithstanding that, we have a lot of work now working through an unscheduled care plan that will improve flow through the hospital. Last winter, we were able to free up 47 beds by improving the way patients moved through the hospital. Forty of those beds happened to be in respiratory, so that respiratory stream of patients is a focus for us this year to improve pathways for patients, and that includes working in primary care as well as working in secondary care to improve the whole system pathway. So, the respiratory pathway will be important.

Another pathway will be frail elderly patients and, in particular, trauma patients. So, I've mentioned the ambulatory trauma moving through more quickly and not having to go into that area any more. The other area that we need to focus on, and we've engaged some partners to work with us to help us with the information around this, is to improve the pathway for frail elderly patients and the trauma pathway. So, by focusing in on some of these larger streams and on a whole-system approach to unscheduled care, the way out of this is to avoid the pressures in the first place and improve the entire system. 

What we didn't want to do—

Can I—

Sorry, if I may, what we want didn't want to do is take immediate action in this area and displace the risk to another area. So, we needed to address the whole pathway to avoid the risk being moved around, as opposed to addressing the underlying causes. Sorry for interrupting. 

No, no. I don't underestimate the complexity and difficulty of the jobs that you have, and I really understand that—unscheduled care, by its very nature, you cannot do the predicted element. But I think the areas I have concerns about are—you know, crumbling buildings are one thing, not being able to access medication is another, treatments, you know, the poor old NHS cannot afford absolutely everything. But, when it comes to patient safety, the one thing that we should be able to get right—. This report is absolutely damning, and one of the comments here, and I'm going to read it because I think it just struck me so strongly:

'The biggest failing of this health board is the practice of nursing patients in inappropriate areas for long periods of time. It is not uncommon or is increasingly common to nurse patients in chairs for 20-30 hours and more. These patients are unwell, septic, requiring intravenous treatment and sit in
chairs throughout their treatment, in areas where there is only one nurse to 10-20 patients.'

Now, coming back to the nurse element for a second, we've got the staffing levels legislation in place. The Government is looking to extend that, rightly so. I appreciate it doesn't include this area as yet, but it will eventually. Hopefully, we're going to be able to set a standard throughout all hospitals in Wales about how many people should be on the floor, should be nursing, what numbers of patients. And so, I just think to myself, 'Wow, if it's that kind of difficulty there, the difficulties elsewhere—are you meeting those safe levels?' 

But I suppose my other question to you is—. I remember meeting—and I'm not going to name names, but a couple of your real top A&E people a couple of years ago, who were talking to me about the changes that were going to be made about the frail and elderly pathways, about diverting people from the front door so they could go in different directions to have less pressure on the medical assessment unit. That was a couple of years ago. I don't see the changes and, to be frank, why did you need HIW to tell you this, because why weren't your staff—and Helen's going to talk, I think, about candour and stuff, so I'm not going to go into this—but, you know, does nobody walk the floors to look at this stuff and think, 'My goodness, this is going on'? Why did it have to take them to tell you? And now you've leapt around and you want to something about it, but this seems to have been going on for quite some time, and that's what I have a concern about.

In the old days, it was a very different business, I admit, but one of the jobs I did was I walked the floors, and I went with my own eyes to see what was going on. Do you have senior members who do that and who come back to you and say, 'Guys, do you realise this is what's happening here? We have to do something about it.'

So, that's part of the disappointment in this, in that HIW found this and we didn't find it, although we were aware that, at pressure points within the floor of emergencies, there were blockages and there were pathway blockages within the organisation—

It's going to happen from time to time.

—and that it happens. So, we were aware of that. 

We do have safety walkarounds. Each independent member is buddied with an executive member of the board, and we go out and about across the whole of Cardiff and Vale once per month into a different area, and we engage with the staff around safety concerns that they may have, and it's an opportunity for them to raise them. And we act on them—there's a proper process to feed those into our quality team, and then to pick up actions as a result of that, and to feed back to staff. We have a very active concerns process. So, if patients raise concerns, or if staff members raise concerns, we've got a 'speaking up for safety' approach, whereby, if anyone in the organisation thinks they're not being listened to, they have a route through to our chairman to raise issues, and we then deal with it through a whistleblowing-type arena, whereby we can preserve anonymity, but we can deal with the issue that is raised.

My sense of this is that unscheduled care can be challenging, and it can be challenging through winter periods. And, over the years, we've seen an increase in the number of attendances in accident and emergency; that just goes up relentlessly on a year-by-year basis. This isn't an excuse, and it's something we have to blow open, but people get used to what they see in front of them—and that's executives, as well as staff in the organisation—

We've got Helen Mary with a supplementary here. I'll come back to you, then, Angela.

—but we've got to get beyond that.

I want to pick up on what Angela said. I need to understand why you didn't know. You talk about being disappointed, and you imply that you're surprised, but this must raise systems issues for you, because, if you haven't seen this, what else have you not seen? Because this isn't minor and this isn't a one-off, this isn't a bad day, and winter happens every year—and, actually, this was spring, I think, when they did this inspection. So, for example, are the walkabouts that you do, are they unannounced, do people know you're coming? Because, if they know you're coming, there may be things that will be done that you wouldn't—. Part of the reason I suspect why this is so candid was because this was unannounced. So, I want to understand, because it's our duty to hold you to account for this, why didn't you know, what are you doing to look at your systems across the board—and we'll come back a bit later on to some of the concerns-raising processes—and what are you doing to assure your board that they're not going to face this again, that your patients are not going to face this again? Because this is—. It's not as if you're managing dozens of accident and emergency units all over a huge geographical area. As I understand it, this is the main one, isn't it?

Yes, it is, yes.

It's the only one that deals with serious trauma. So, I think you—. I hope you'd agree that you've got some serious questions, as an executive, to answer about why you didn't know. And I'd argue—and, of course, we haven't got the board here, as David has said—the board has got some questions to answer about why they haven't been holding you to account for this.

So, as I said, we are aware, and we were aware, that there are times at which the emergency floor in the organisation gets congested—we are aware of that.

Can I just stop you there a minute, Mr Richards? Because the report says that the staff are saying to HIW that this not a one-off, this is not, 'There are times when it is like this'. The staff are saying that people are often sat. This is not a one-off, this is not, 'There are times'.

I'm not saying it's a one-off; I'm saying we are aware that that happens, we are aware that it gets congested, and it gets congested quite regularly through periods of high demand. And the winter, and the months of the winter, are periods of high demand. It's not on a Tuesday morning; it can last for quite some time. There is a very active management of the flow of patients through the organisation. And my sense of this is that we didn't see the gravity of the situation. We knew that there were patients waiting a long time in there. We knew there were patients in there for longer than 12 hours. We work very hard to make sure that patients don't wait that length of time, but we knew that that was happening. It had been raised with us by our independent members, prior to the report, that patients shouldn't be waiting that length of time throughout our whole process. So, I don't think it was—we were aware of it. I think HIW—and a previous community health council visit as well—raised these issues, and we were in the process of thinking how we were going to deal with some of that. So, it wasn't a question of awareness, it was a question of—. I think they brought an acute sort of view of the situation to our attention, which we—

So, you knew what was happening, and you didn't realise it wasn't all right—is that what you're telling us?

No, no, I'm not saying that. And please don't put words into my mouth, because I'm not saying that—

Well, I can only tell you what I'm hearing.

What I'm saying is that hospitals get congested. We do our best to manage them. In this situation, we haven't managed them as well as we should have done. That’s been recognised by the board; that’s been recognised by the executive team. As a result of that report, and I think it is a very helpful report to us—it has shone the light more brightly into that particular area—there are now plans and proposals to take forward what will improve that particular area by streamlining patients, as Steve said, into different areas or directly to the wards. So, we have those proposals. We've made some immediate changes in the area as well and we must not take our eye of this ball—it is an important area.

Okay, I've got a supplementary from David and then back to Andrew.

I’m just concerned, because you run the health board with one of the biggest hospitals in Wales with, probably, the biggest A&E department, and you're going to be the major trauma centre. Let’s not hide that fact: that’s going to be critical and will add more workload to you. I'm disappointed to hear you say that you weren't aware and you weren't focusing on that unit, which we know has been the major unit of concern for a long time in the media. If you've got a community health council report highlighting this, you know. First of all, when they turned up with just one member of staff, one nurse for 20 patients, why weren't more nurses there to start with? I know that it's challenging—I understand that—but this is a critical area of care for people who come in to the unit, to the hospital, for their healthcare.

Now, I'm not going to talk about out-of-hours and how that may feed into that, but I'm just so surprised that you're saying that this is something where we know there are pressures, 'but'—there are not 'buts' here, as far as I'm concerned. You know there are pressures and you have to deal with those pressures. Why weren't they dealt with, particularly if you've got a CHC report, telling you the same thing?

So, I never said we weren't aware and I never said that we weren't dealing with it. What I think I said was, or what I hoped to have said was, that we are always working on the unscheduled care pathway. It is probably the biggest pressure in any hospital organisation with a significant accident and emergency department. So, we're always working with the teams, with the management teams and the clinicians in the area on how we make improvements to that. Because there is a relentless pressure in a hospital environment with an A&E the size of ours. So, we were working on it.

What I think the report did was shine the light more brightly on that and raise that as a more acute issue that we needed to be working on much more quickly or much more directly. So, that’s what we are now doing. That’s what we did as soon as we got the report. We have done some soul searching as a team around the points that you're making, but it’s not that we weren't doing any work in those areas.

The staff in those areas are engaged all the time. We put in safety huddles throughout our assessment areas, and safety huddles in our A&E department, to ensure that any member of staff can raise a concern in that huddle and that huddle is run every two or three hours during the day and any member of staff can raise a concern about a particular patient that they are concerned about and, at that point, a doctor or a more senior nurse would then attend to say, 'Well what do we need to do about that patient?' So, there is a safety net that exists during these periods so that we can manage the risks of individual patients on an ongoing basis. We find ways of enabling staff to raise concerns so that they're not stuck with 20 patients on their own, or through the safety huddle they would be able to bring other staff into that, if required.

Okay. Jayne Bryant.

Just on that, you mentioned the safety nets and then we've got the report, but was there any time between when you say you recognised that there was a problem to the time of the report when you felt that you weren't doing enough? Was it the report that told you that you weren't doing enough?

Do you want to come in?

There were a range of actions that the nurse director, in particular, led in those reports, mainly around the dignity, privacy, hydration and nutrition of patients, which were all being progressed over those areas, recognising that we couldn't actually move the area in terms of that itself.

The other thing that we reinforced at that time was the system in the hospital for moving patients through the system. So, we've worked with the Welsh Government delivery unit to establish a risk-based system to identify which patients in the various points of entry to the hospital, whether it's A&E, an assessment unit or elsewhere, may be at a greater clinical risk. There are four to six meetings a day—it depends what time they happen, but there are four meetings a day—where all of those teams come together, and they are clinical teams, not managers, and decide what the priority is in terms of moving patients through the system. So there is, in that sense, a system and a safety net for that.

Having said that, it's still left patients on this occasion waiting way too long in circumstances that were wrong, and we completely accept that and that's why we need to work even faster than we have before on finding ways to relieve this. 

Time to move on now, then. Angela.

Yes, but I just want to ask one follow-up question on the pathways. Because if we step away from your front door for a minute and you talk about the fact you've got pathways, and we know that the Government has spoken about, 'We're having a stroke pathway, we're going to have frailty pathways.' I think if there was a real problem at the front door, but we knew that pathways were at least drifting some of those people around and were working, you could think, 'Well, at least there's some ability', but even that gets clogged up.

A patient who was suffering with a stroke was on the ambulance so long they did not receive timely treatment for the stroke. I dread to think about the personal consequences for that individual. But then, I think to myself, 'Well, hang on a minute, why weren't they on the stroke pathway? Why did they have to wait there? Why weren't they at a CT scanner? What is the blockage?' Because if the blockage is at the front door, this report also implies that there are blockages further, further back. You talk about trying to put in place the frail and elderly pathway, which as I say your colleagues have talked about for some years, why isn't it happening? What is that pathway?

I note that you talk about nurses being a key issue. I come from west Wales where there's three of us, you know. You're in Cardiff. You must be able to get more staff. If you can't get more staff, then to be frank the rest of us have got absolutely no chance of getting qualified or training up good calibre people. So, is it that there really are no nurses available in Cardiff that you could employ, or is it because you don't have the money, or because you're not prioritising that because you're putting your resources elsewhere? What is the issue? Because to have one nurse for 20 patients seems to me to be incredible. 

And if you think we're being a bit tough on this, yes, you're right, we are. Why? Cwm Taf. Do I need to say anything else. Maternity services. What is happening in our hospitals? What do we not know about? Where's the next crisis going to be? That's why we're giving you a hard time, because we don't want to uncover the next crisis in another hospital. Because for no other reason, not only does it devastate other people's lives, but acually it just brings our health service into a really—

Into disrepute.

Into disrepute, yes. It's a really difficult position. We're trying to get to why you didn't know what you didn't know—what are the blockages, what are the blockages beyond your front door, and how confident are you that there isn't a Cwm Taf maternity services issue that's somewhere brewing?

Steve, if you answer the pathways, then I'll talk about nursing.

You're right, there have been well-established pathways for some time. When we look at the assessment unit report, the AU report was looking at ambulant pathways, so through an AU lounge.

The stroke pathways and the frail and elderly are usually non-ambulant pathways, in that those are patients who will need to lie down on a stretcher or a bed, in terms of those things. The latter is wholly dependent on the availability of beds and the availability of beds is wholly dependent, you're absolutely right, on our ability to discharge patients to a place. The challenge really, if I may say so, isn't necessarily at the front door. The challenge is at the back door, if you like, to use a term, where we would work better with our partners in social care, in housing, in third sector to help patients to get home in a timely way and avoid the harm of them staying in hospital. So, that is still a key element of our ability to move non-ambulant patients through the pathway in terms of that.

The ambulant pathway is a pathway, obviously, that is different, which would have affected the lounge area. So, the stroke and the ambulant pathway may not have been interdependent in this case. It may have been, but it is a measure, you're right, of general congestion at the front end of the hospital. So, really, our work is focused on avoiding patients needing to come to hospital in the first place, where possible, and we have seen a reduction in ambulance conveyances in the last year. We haven't seen a reduction in attendances, but we have seen a reduction in ambulance conveyances working closely with Welsh Ambulance Services NHS Trust partners, and we've focused on working with our system partners at the discharge point of the hospital to improve flows through the pathway. That is where it's at. That's our opportunity to improve both pathways, in fact. 

So, coming to the point of nursing, we're confident that we comply with the safe staffing nursing standards, as they're set out, and they don't cover the whole of the nursing areas—they cover the acute wards. But we have to do that through the use of bank and agency staff. There is still a challenge to recruitment of nursing staff within Cardiff. It's not as big a challenge as it is in some other parts of Wales, but we still, just as an example in medicine, have over 50 vacancies of nursing staff in our medicine clinical board, and that's where care of the elderly, the unscheduled care areas are. So, we have to then backfill those positions with bank and agency staff.

So, there's a significant amount of work going on around recruitment. It's a continuous process, recruitment within the organisation. We are getting success around recruitment. We're holding recruitment fairs, in a sense, whereby we invite people to the organisation for a Saturday afternoon to come and talk to the many different nursing staff in the different areas, so that they can see what's on offer in Cardiff and Vale, and then, if they're qualified, they've got their CV, they're suitable, then we hold an interview there and then with people so that we can actually fast track that whole process. And we're seeing some significant gains. We just recently had a recruitment fair, and we recruited 47 nursing staff over the course of that Saturday. They'll be coming in at different times, as they work their notice in different areas, but recruitment is a challenge, and will, I suspect, continue to be a challenge going forward. 

Can I ask you about the other side of the coin? I get the recruitment side, but, of course, the vision for health was very clear about making sure that the health and well-being of staff is paramount. 

Yes, absolutely. 

What programmes do you run to try to bring staff back into work who are off with stress or physical illnesses? Because the last time I looked, across the whole of Wales, I think it was something like 900 man years or person years are lost every year because of ill staff in the NHS.  

So, we've got quite an active well-being at work programme, led through our occupational health department. There are initiatives like Itchy Feet, which is if someone's thinking of leaving, raise that with us, let's have a discussion about why you might want to leave, are there things that we can do in Cardiff and Vale, because we've got a broad range— 

One person looking after 20 patients has got to be a pretty good reason for wanting to leave. I mean, that must be so stressful. 

And we do have to resolve those things. But we have a mechanism available within the organisation where staff can raise their concerns about their own employment or about how they're feeling. We run a thing called CAV a Coffee—'CAV' for 'Cardiff and Vale'—whereby people can go and meet with occupational health independently and just talk about the pressure at work, how it's making them feel, if they need support—any additional support—and what can be done about that.

So, we're continuously working at trying to provide the facility for staff to talk about the issues that they believe are important that need to be resolved, so that we can then feed that back through. Just as an example of that, we just did our last charitable funds board meeting. We approved two extra clinical psychologists to work within our occupational health department so that we could reduce the waiting time for staff to get occupational or psychology support, as a way of just increasing access, so that staff can have that conversation with us, and then we can act on it. We do believe it's not just about recruitment, it's about retention. We've put as much effort into that as we have into the recruitment side.  

Okay, we need to move on. 

Chair, I know, my last question, which should have a very short answer, I hope, but I have to ask it. Are your maternity services safe? 

So, we've reviewed the report from Cwm Taf, and that was a sobering read, but we’ve also reviewed the report and do routinely review reports wherever they emanate from—so, the Shrewsbury report and the Morecambe Bay report before that. There’s a process within Cardiff and Vale at which these reports are considered. They then go through our quality and safety committee, which is a sub-committee of the board, which would be, ‘These were the issues highlighted in the report—this is where we sit against them’, as a way of giving the board assurance of our position. And in the Cwm Taf report, there was an area we’ve rated ourselves as amber on. We’re green on all of the other issues.

As the Cwm Taf report came out, myself, the director of nursing, the clinical director for obstetrics and Suzanne Hardacre the lead midwife actually spent the weekend in the maternity service talking to staff, going around asking them what it was like to be a midwife in Cardiff and Vale. We got very positive messages back, and we got messages back from midwives who had worked in Cwm Taf and who were now working in Cardiff and Vale, who set out the differences for us. So, it wasn’t just a midwife saying, ‘Yes, it’s fine here’ to the chief exec—we got good accounts of what the differences were in the different areas. We’re Birthrate Plus, so we comply with those standards in midwifery.

Recruitment is a challenge in midwifery as well, and we have a number of vacancies in midwifery, which we are looking to resolve as well. But the feel and the perspective given by the staff was a very positive one. We also invited Suzanne Hardacre, our head midwife, and Meriel Jenney, our clinical board director for women and children, to the board as well for them to give an account of where they felt their services sat against the Cwm Taf report. And we did that through a patient story and then an account of where we were against the recommendations. Again, that was just all a part of trying to give the board some assurance that we aren’t in the same place as Cwm Taf.

Thank you.

Okay. Next section, Helen Mary.

Thank you. This will take us back to some of the points that you’ve raised about how you deal with staff raising concerns and how you deal with patients doing that. So, first of all, can you tell us how confident are you—? And I think you have to put it back in the context of that report where you’ve got staff reporting themselves tearful in shifts because they’re so distressed. And this is obviously only one part of the service; I appreciate that. How confident are you that the culture is there where staff would feel genuinely supported to raise concerns? And how would you evidence that?

I think, on the whole, we are confident that staff can raise concerns, and I’ve just talked about some of the occupational health-type approaches to create the space for staff to raise concerns with us. We’ve got a high level of reporting of incidents through our Datix system, which is the national system. That sounds paradoxical—a high number of reports is a good thing, because what we find is, of the percentage of those reports, very few of them are very serious incidents, but there’s a lot of low-level incidents or near misses, and those sorts of things. So, we feel confident that people can notify us through that formal mechanism. We believe we’ve got informal mechanisms. We’ve also got some board-level mechanisms through Speaking Up for Safety, through Maria Battle as the chair. So, that can be dealt with independently and anonymously. And there are a number of issues that are going through that reporting as well.

So, whilst we’ve got these mechanisms, we also have people using them. And if you go out into the organisation, people are aware we relaunched the speaking up safely initiative and we do that routinely. So, about every six months, we launch that to make people aware that they can do it. But we’ve got people using those systems. The difficult question to answer is, ‘Is every member of staff aware and is every member of staff comfortable?’ and I don’t think we can give you an answer to that. I think what we can give you at a higher level is that people use the systems, we’ve got good reporting. When we talk to staff—and this was the point that was coming through in maternity—they felt they could raise concerns, and that was one of things that they set as a difference: that when they raise concerns they're listened to.' That's credit to the local team within the maternity service as well as the organisation as a whole.

That's really encouraging. I'm sorry to go back to the report again, Chair, but I think we have to. Obviously something that wasn't in that particular situation—. If I'm a nurse and I'm looking after 20 patients and I'm tearful as a result, obviously they weren't using, in that case, that system effectively. Have you looked at, or are you in the process of looking at, why that might be? You've reassured us; I'm very encouraged to hear that in maternity services the midwives would feel able to raise concerns. Clearly, in A&E, there were staff who didn't. So, what have you done to look at that and to try and make sure that that's addressed? Because obviously, that's your most high-pressure—. That's probably the place where people are most likely to end up, as staff members, worried and distressed, and obviously they didn't successfully raise those concerns, because if they had, presumably you'd have dealt with them.

So, again, our nurse director, on receipt of the report, and previous to this, following the CHC report, had specific meetings with those teams and with the wider team in, as you say, that sort of pressure area at the front of the hospital—A&E and assessment unit et cetera. So, they've had specific discussions about that. They explored some of the issues within there, and there was a good conversation on a number of occasions.

Without breaching anybody's confidentiality, what were those issues?

So, the issues are broadly reflected in some of the comments that you see in the report, but the issues were the volume of patients being moved through from A&E to the assessment unit; as you can appreciate, we need to keep A&E with some capacity to receive patients. And of course, as we move patients through with a sense of urgency, that puts pressure on the system and that has resulted, on this occasion, in pressure on staff—undue pressure on staff—and in a poor patient experience.

But that doesn't explain why they didn't speak up, does it?

No, and as I say, the nurse director had a conversation with them about the importance of using the mechanisms that Len has referred to. Those mechanisms are there for us to improve the service, not for us to act in any punitive way or anything like that there. They help us to understand what we need to do to improve the service.

Okay. Thank you. So, if we can move, then, to—. I think you'll understand I'm still a bit worried about that, but let's move on from there for now. Let's look at patients raising concerns. So, how do you support patients who raise concerns with you? What's the process and do you feel that that works effectively? How are you performing against the 30-day target for responding to patient concerns?

So, we have a concerns team, and they operate independently from the services, in a sense. So, if you're concerned about accident and emergency, you don't have to go through the accident and emergency department if you don't want to. You can go directly to the concerns team, and they provide support to the complainant, and then they will lead an investigation into that complaint, and get an understanding from the individual about what their expectation is as a result of making that complaint. As you'll imagine, complaints range in seriousness. Sometimes it's an apology. Sometimes it's a recognition. Sometimes there are serious issues and therefore much more serious root-cause analysis would be done around that particular issue where we get clinicians together. My experience of the concerns team is that they're very empathetic as a team and they encourage people, and they'll bring people in if they want a face-to-face. It's not always written. They'll take any comments and then treat them as a comment, a negative comment, or a complaint, and then act upon them. In terms of our responses, 78 per cent are dealt with within the 30 days. We just had our recent joint executive team meeting, and I can't remember the number—maybe Steve or Abi or Bob can—but a significant proportion of our complaints get dealt with by the concerns team to the satisfaction of the complainant. That, in a sense, gives me some assurance that they're dealing with things properly, because the complainant has then agreed that what they expected as a result of their complaint has been dealt with.

Just to add to that, again, I keep referencing the nurse director here, but she leads on producing an annual quality statement, which you may see us referring to here, which is a really good snapshot of some of the key metrics that you're interested in in terms of doing that. And that ranges from the formal to the informal. It gives the volume of formal, the volume of informal et cetera et cetera in there. One of the informal mechanisms is the simple touch screen—happy or not happy with the service that you received. Some 140,000 people used that last year and there was an 82 per cent positive response. But there are a range of ways that people can raise their concerns and I'll just re-emphasise what Len said about the independence of the way we deal with them so that individuals don't feel, even if someone was kind and supportive to them but they felt that the service was not good—they have somewhere to go where they don't have to face that individual and say, 'Look, this was good about what happened to me, but this wasn't good'. It depersonalises it from that point of view.

It's probably just worth adding that we also work very closely with the Community Health Council and, obviously, their complaints advocacy service is very good and if individuals feel that that's a better mechanism, we do try and ensure that the information about the CHC is well publicised throughout the hospital. Certainly we have regular dialogues and Steve Allen, the chief officer there, meets with Ruth and talks through those cases and will support an individual making a complaint and following through the process too.

That's helpful. So, just very briefly, then, can you tell is what level of board-level scrutiny there is around handling of concerns from patients and from staff and what the mechanisms are?

It's included in our quality, safety and patient expericence report that comes to the board every two months. So, just like the performance report that Steve was alluding to, Ruth and the medical director bring a comprehensive report on patient experience and quality issues and our performance in relation to managing complaints is included as part of that report.

And there's an open discussion at the board around anything that's serious. That is an open discussion at the board, and, again, the nurse director leads on those. And one other thing just in terms of that is that each of our clinical boards in the organisation in rotation come to the quality and patient safety committee to talk about safety concerns in their board. It's a specific conversation directly from the service to the independent members—not from the executive—to hear at first line what their top three or four concerns about patient safety et cetera are in their part of the organisation.

Thank you.

Thanks, Chair. I'd like to ask about children's services, first of all. Can you just tell us where you are at the moment in terms of how effectively you're meeting the target for CAMHS referrals, both for urgent and routine assessments, please? And then I would like to ask whether you've got any data you'd like to share with the committee on how long young people are waiting for interventions following the initial assessment.

So, our CAMHS service—. We have two elements to our CAMHS service: the primary care service, which has always been delivered from Cardiff and the Vale, and we have now repatriated the specialist service that was delivered through a network solution through Cwm Taf Morgannwg health board. But that's just come over to us in the last eight to 10 weeks, so that's in its infancy of us moving it forward.

Over the last year, overall, in terms of the 28-day access against a minimum of 80 per cent, we performed at 79.1 per cent over the year. Now, that was 22 per cent up on the previous year, but it's still below where it needs to be, and we are still, unlike the adult mental health services where we have demand issues—fluctuating demand—we have a demand and capacity issue in our CAMHS service. So, it is a relatively small service. I know you'll appreciate it's not a huge service and it is quite valuable skills. But in the last quarter of last year, we saw a 69 per cent increase in referrals to that service in three months. It was phenomenal. It sometimes happens after exam period, sometimes after holiday periods, but sometimes because of high-profile issues in the media et cetera et cetera that are driving that. So, it is difficult for us to plan to that.

Halfway through last year, we resized our service because of continuing increases in demand. For example, we resized it to 155 referrals a month and that was significantly higher than before. In January, February and March, we were receiving referrals at over 200 a month. So, within months, having resized the service and thinking that we could make it sustainable, we're already responding to increased demand. So, fundamentally, going forward we need to find a way through this that changes the model as well as provides the correct capacity in that. We're already working at an educational cluster level in terms of putting primary mental health support at school level in. That's already happened. We've already introduced a single point of access, although that is an administrative single point of access to stream patients and their families to the appropriate service. But our next step is actually to make that a clinical single point of access, so that, actually, some advice at the point of referral could be given and signposting to help there as well.

Finally, one of the things we're looking at, going forward, is to look for digital solutions. We have a really good engagement mechanism with young people in the community around this particular issue, and we asked that group what would make a difference to them in terms of accessing services. They specifically said that finding alternatives to having to face someone face to face, or attend a building or whatever, would be really, really helpful to them. And we've looked at some digital systems that are being used elsewhere in the UK that may help with both assessments and with cognitive behavioural therapy, going forward. So, we're expecting that to be procured and in place by the autumn, and through that changing model, resizing the service, continuing to recruit, but streaming patients to the appropriate level of need, we would hope to make the service sustainable going forward.

Okay. Thank you. I have followed the work that you're doing around children and young people's mental health; I know that you've got a panel, which is really good to think that you are actually talking to young people. You didn't tell me what the waiting time is for the 48-hour urgent CAMHS access target.

Let me just check if I have that stat with me. I don't have that one here, I'm sorry. I'm sorry; I'll have to get that to you.

Maybe you could write to us on that.

And have you got any data—I know that it's not measured by Welsh Government, which is in itself a problem—about what happens to young people once they've had that first assessment? How long are they waiting for any therapeutic interventions? I know that Welsh Government don't measure it, but it is important.

That brings us back to the single—. They're waiting too long in our health board; there's no question about that. We have 73 people in a backlog at the moment, waiting for interventions, so I'll get the committee the timelines for those. But the same resource is being used to assess patients as it is to provide interventions. And what we see is that the service is trying to stay ahead of both measures, but sometimes, the other measure, if you like, starts to suffer when they get ahead of the assessments or vice versa. So, that's why we needed to change pathways on this, where there is more direct access and more options for people to see. Because if we just wait to try to recruit to these posts, those skills and people simply aren't there. One of the things we're doing at the moment is working with school nurses to see whether we can do some lower-level training with school nurses to help provide some direct support to young people and children who may not need to progress to a more intense service, if you like. So, it's through those alternative methods that I think we will be able to meet the demand.

I know that you've been doing some work with Aneurin Bevan University Health Board around their attachment and trauma team. Is that something that you're looking to actively take forward—taking the best practice from elsewhere?

Yes. We've just commenced—and this was more driven by the repatriation of the specialist service—a review that will report at the end of July, an independent review from an expert that we've sourced to look at our services on the whole to understand where there are opportunities. For example, the choice model, the choice and partnership approach model, is something that we want to look a little bit further into. It is correct that individuals have a say in how they're seen and treated in that co-production way, but, actually, there can be inefficiencies there that affect a wider group of patients when we get it right for one patient, if you know what I mean. So, we need to understand how that balances.

We're working with AB; we're also working with Hywel Dda, who have put their intervention teams together from primary and specialist, and are getting a scale of benefit from that by having both teams together. So, we have a group going to Hywel Dda—well, actually, Hywel Dda couldn't make it last week; we're going down in a few weeks' time to learn from them as well. So, we will absolutely be susceptible to any learning from other services.

Okay. Thank you. Can I just ask, then, about the mental health Measure standards more generally? Your paper highlights a significant increase in referrals to primary mental health support services, which did have a negative effect on your performance against the measure. What assurances can you give the committee that the service is sustainable for adults, which is mainly what's measured? But I know the NHS delivery unit has been doing some work around children's access, because we don't actually have much data in that area. Is there anything you can share with the committee about how well you feel the service is delivering for children and young people?

So, the overall measure, then—over last year, we performed at 80 per cent for the 28-day assessment against the measure. We performed at 80.9 per cent, which is just in line with what the requirement is, but, again, we would want that to improve further. That was 8.9 per cent up on the previous year, so it is some improvement, but there were three months in the last year where we didn't meet that 80 per cent marker. There were four in CAMHS last year, and in the previous year, there were eight months. So, there is some improvement, but the improvement is not in keeping with the growth, and that's why change is part of that. On part B, we did drop back on that at one point in the year in terms of meeting the treatment in a further 28 days, but we're fully compliant with that now. Parts 3 and 4 are fully compliant in the overall thing.

In terms of right-sizing it going forward, emphasis again is on innovation, change and transformation as the way forward. In adult mental health, I'd point to two key things that will help us going forward: the first is we've made a big step this year bringing together our CMHTs—our community mental health teams—into a locality footprint, joining it up to social services, joining it up to local authority services, housing, the third sector, and seeing those patients all in one place coming through. We're using a trusted assessor model, where, before, patients had to graduate through the system to get to the right service, often recounting again and again an assessment that they'd done many times. We're now putting our trusted assessors, our senior clinicians, right at the front of the pathway, streaming them on to where they need to go and providing a better service for service users, but also getting some scale of benefit and access.

The second is: I refer to an earlier comment about how we are rolling out first contact primary mental health services at cluster level, and already, as I say, there are over 1,500 contacts that have been provided through that. If that works at the pace our best cluster is working, and that's because we invested in it first, we could provide up to 60,000 contacts—not patients, contacts—for mental health at a primary care level a year. So, what we want to do is work at that best cluster practice level.

Just one final question. I think I would argue, really, that you're probably never going to meet the demand for CAMHS unless you actually do have that transformation, because what we know is that a lot of the kids who are fighting to get into CAMHS really need to have been helped much, much earlier on. So, can I just ask whether you feel, as a regional partnership board as well, you're getting to grips fully with those issues in terms of putting that early help in place?

I was just going to pick up on that, actually, because, obviously, prevention is absolutely critical as part of the pathway, so both the regional partnership board and our two public services boards have all got a focus on children and young people in terms of giving all young people a good start in life and really trying to make sure that people have the resilience they need going into adulthood. So, we're really actively involved in the Child Friendly Cities and Communities work that Cardiff public services board is overseeing, and one of our community paediatricians is really leading a lot of the work on the adverse childhood incidents, so really looking at how we can identify children and young people at risk much earlier, and how we can provide much more targeted intervention at earlier points in that pathway.

It goes back to something Steve was saying about working with things like the school nurses and education more broadly. One of the things that was fed back from all the professionals was no-one really knowing when they're concerned about someone actually where to go—not wanting to overmedicalise, but needing to find the right kind of level. So, we're doing a piece of work that is really trying to map out where people can go; more broadly speaking, the well-being services that we've got and, actually, the fact that that's a self-referral service, so teachers can refer in, but young people themselves or their family members can refer in. So, we're just trying to make sure that we can piece together all the bits of the jigsaw puzzle so people can see across the pathway how can we identify children who might be at risk much earlier on, how can we ensure that whichever professional is working with them can find the right pathway until they get the support they need earlier on. And we're certainly not there yet in having all of that knitted together, but the public services board partners are certainly committed to doing that.

Okay. Thank you.

Thank you, Chair. In the evidence that you've provided, the paper you've provided, you highlighted that the performance against the 62-day urgent suspected cancer target is not at the required level, and the integrated medium-term plan describes cancer outcomes as not good enough, with a need to accelerate the rate of improvement. What specific action are you taking to improve outcomes for cancer patients?

Yes, absolutely. We felt it important to point out that where we are with our cancer performance is clearly not at the required standard and not, obviously, where we want it to be. Cardiff and the Vale has been on a bit of a journey in terms of its cancer delivery over the last few years. It started on the 62-day target at about 60 per cent, and we have progressed to the mid to high 80s and, at times, gone into the 90s and met the target on a number of occasions.

I think, over the last year, one of the real challenges for us, which is in some ways similar to the mental health discussion, has been the extraordinary rise in demand for cancer services. What I would point out is that our cancer treatments are probably no greater in volume than previous years, but our cancer referrals are extraordinarily higher. So, we're seeing, I think the paper points out, a 25 per cent increase in gastrointestinal referrals and about 16 per cent increase in neurological referrals. Again, many related back to some high-profile media things, and these are legitimate but worried well people who are coming through the system. All of those have to go through a significant pathway, particularly in GI, of multiple diagnostics, potentially, to get to a point of deciding whether they do or don't have cancer. So, those areas—and there are more; dermatology is another area of significant growth—are where we've seen extraordinary demand increases this year.

There are a number of ways that we need to move forward on this. We still need to right-size our capacity, because waiting for design solutions while cancer patients are waiting isn't good enough. So, we need to put some capacity options in in the short term to try and improve the capacity for seeing patients in a timely way. We're employing another neurologist this year, we're doing more work and increasing significantly our capacity in our endoscopy units in GI this year. So, those plans are in train.

But the focus is moving now to the new single cancer pathway approach that is coming in; we're shadow reporting on that already. We're doing a lot of work with Welsh Government colleagues, and we have been given some financial support to get ready for the single cancer pathway, which works on a principle that is different to the current pathway. Rather than referral, it works on the point of suspicion, and that is good for patients, it's the right thing to do, but it does provide significant technological, diagnostics, pathway management and capacity challenges for us to align ourselves to that. But we are actively involved in the national work on this, and my deputy and our deputy medical director for cancer services are on the national group influencing how that pathway work can be taken forward.

Okay. Thank you. Just moving on to winter preparedness—or to go back a little bit—but in your paper you also say,

'Our overall experience of this winter is that we have been more resilient following implementation of our Integrated Winter Plan.'

We've talked about the challenges in the winter period and the pressure. How do you feel you coped during the winter of 2018-19? What was it—? You've said in the paper that you feel that you've gone up. Can you expand on that a little bit?

Yes. There is no doubt that last winter was not as difficult as the previous winter, and the example is one we've discussed today; there are times where we have been under significant pressure, and that's been manifest. The winter context was better: the flu circulation was down, the adverse weather events were fewer. So, in that context, it was a better circumstance for us. But demand wasn't down to—. Our emergency department attendances over the winter were up by 5 per cent, and that did translate into further admissions for us. So, in medicine, for example, one key area, a 5 per cent increase in admissions over the winter period, in surgery a 7 per cent increase. So, we weren't less busy but, actually, the circumstances were more beneficial. Our headline performance was all improved on the previous year. So, right through from our waits in A&E to our ambulance delays, which were down 23 per cent on the previous year, all of that was better than the previous year. It showed a system change.

I referred earlier to some of the extensive work we did last summer to try and prepare ourselves for winter and to get sustainable change. We used 47 fewer beds this winter than we did last winter, and that has been independently verified in terms of how we've worked with partners to try and understand that.

We've already debriefed our board on how last winter went. That's included lessons learned, but also included some of the things that worked well. Our first cut of our winter plans are already under way. We've done a piece of modelling to understand what our bed base or bed-equivalent base will need to be next year. We've been commended by peer review and by the delivery unit on the work we're doing on out-of-hours demand and capacity modelling to understand how we can right-size the service going through for winter as well. And we will be concentrating, as I said earlier, on two key streams of patients: respiratory patients and frail older trauma patients to improve our pathways going forward.

So, all of that work will come together. We expect to be in a position to bring it back to the board for approval in the late summer, and then it will be peer reviewed across Wales and submitted to Welsh Government accordingly.

Can I just add to that? What was different this winter—I've only experienced two winters here—but what was different about this winter compared to the other was the level of clinical engagement in those plans, and, under the good offices of Steve, who leads our winter planning and then delivery, I think we had clinicians fundamentally engaged in what those plans were, and invested then in the delivery of that through the winter, so more responsiveness on the ground. We had better information for clinicians, so we were able to tell them what was happening at that time, rather than tell them what happened last week, because of our much more real-time reporting of information. But I think the key ingredient was much more active engagement of clinicians at the front line in the planning and then in the delivery. That's something that we are trying to take across the whole of the organisation. So, whilst it applies in winter planning, it applies in all of the work that we do. The culture change we're trying to develop is one of clinically led service development, service change and service management, which is really starting to engage and change some of the participation within the organisation. So, I just wanted to highlight the good work that Steve did in preparation for the winter as well. 

Thank you. I think, in the evidence that you gave on winter preparedness in July 2018, it was highlighted about the domiciliary discharge-to-assess service in Cardiff. Perhaps you could give us a bit of an update on that.  

In previous years, we had some real issues around the domiciliary care market generally, and, in a previous year, we had a significant reduction in that market that affected flow out of the hospital. Over the last year, as you rightly said—I've fed this back before—we moved more into a discharge-to-assess model. Now, we can do that through residential nursing care homes, if you like, but what we did was take that a step further to get people back to their own homes where they can be assessed for ongoing need and care in their own environment. And that has been rolled out significantly over the last year. We worked closely with local authority colleagues in putting our community resource teams together to support that model, and we moved over the last year to delivering it on a seven-day-a-week basis as opposed to a five-day-a-week basis. It's actually becoming the norm now for us to do that.

The rate limiter is the domiciliary care capacity. That market is still somewhat fragile, and I know our local authority colleagues are working hard on that, but, at a rate at which we can secure that, we will continue to move people into their own homes and then make an assessment of where they need to go after that. But what it also does is contribute to better outcomes, because a model that through urgency may default to institutionalised care, for example, is now working on a reablement model and on the principle that the starting point is that we try to get everybody to be as independent as possible, with the right support, living in their own communities, in their own homes. So, that’s continuing to roll out.

So, you've seen some real positive results from there.

Absolutely.

Yes, thank you. My understanding is that there's a Welsh Government commitment to developing a gender identity clinic here in Wales and that that's going to be hosted—there'll be a national clinic—by yourselves. I've got some concerns about the length of time that this seems to be taking to establish. There's some recent press coverage about that, and I appreciate the need to get it right and to get the skill mix right and the right people in the right jobs, but obviously it's not a very satisfactory situation when we have trans people having to travel very, very long distances for services and they're actually then having to travel very, very long distances for back-up to that. 

I've got a particular individual concern about people's ability to receive psychological services in that area through the medium of Welsh, because people have brought issues to me where they're having to have—they have their assessment in their home health board in their own language, but then they're having to go elsewhere in other parts of the UK and they have to repeat that assessment not in their own language. So, can you tell us a little bit more about where you are on the work to establish a gender identity service, and what sort of skill mix of staff you're looking to have and what extent of services will be able to be provided, because, as I understand it, there will be some services that people may still need to travel for? I think, particularly, we're still talking about children and young people going to London, aren't we?

So, if I talk about where we are with the process and the establishment of it and I don’t know whether, Steve, you can maybe comment on the breadth of the service that would be there. It has been challenging—it’s been challenging to get the right people in the team, to actually source the expertise into the team, but we believe that we’ve done that now and we have appointed a gender specialist who will come, who will take up a leadership position within that team. And therefore we believe that towards the end of August/beginning of September, we will be in a position to then start taking specialist referrals into that service.

We’ve got a solution to the locality of the clinic, which will be out of St David’s Hospital and I know that the team are very pleased with the facilities that are being provided for them. So, it will be off an acute site, which I think is the right thing for it to be. It’s St David’s—we all know where St David’s is, so it’s quite convenient. And we will—as I say, we hope to have that established toward the end of August/the beginning of September. Expertise in this area is quite rare and therefore sourcing the right people—. And there are some challenges in the model of care as well that are being worked through.

So, that just gives you, I guess, some of the reasons why it has taken so long. But we were always keen that, when we set it up, it was sustainable, because the worst thing that we could do for that population was to set something up and then for it to fall over and then to have to re-engage in a different clinic. So, we probably have been more cautious around this than maybe we would have with more mainstream-type services, because we could use bank, or agency or temporary staff in those areas; I don’t think we can in this particular area. So, that’s where we are, but we feel as if we’ve now made those appointments and are ready to go with it.

Yes, and just to add that I think the point's well made—we've been very cognisant of the need for engagement in setting up these services to ensure that stakeholders are fully engaged in that. We had a really good board development day last week, where the Stonewall group came to talk to us about this and this featured in our conversations quite heavily.

The other conversation about getting the right mix of a multidisciplinary team was really, really important—not starting from the point of psychiatry to avoid stigmatisation was really made a strong feature of the conversations. So, it is a true multidisciplinary team in terms of we have GP specialists, we have psychologists, we have psychiatrists, we have good back-up from our endocrinologist services in the hospital, and, of course, we’ve got very good pharmacy support. So, it is a holistic approach that’s been taken, but it’s also been a very engaged approach to ensure that the stakeholders and users of the service have a say in how that service will be developed. I would emphasise that it will not be at full capacity and fully functional on day one, but it is a good start in terms of developing the service, and I think the theme of engagement and development, going forward, will be really important for us.

That's really helpful. Chair, perhaps we could ask for a written response around what services will be provided and what services people will still need to travel for. I don't want to engage us now, but I think that's quite—in terms of keeping the community, the potential patients, engaged, I think it's quite important that people know that, so we'll—.

Thank you very much indeed for that, Helen Mary, in terms of agility in terms of timing, because we've come towards the last few minutes now and so—. We need some questions on financial performance, and obviously our specialist on agility questioning is Jayne. Some agility in terms of answering would be good as well, although keeping it factually based. Jayne, queen of agility.

Thank you, Chair. The board continues to report a significant deficit and there was a marginal improvement in 2017-18. What is the reported outturn for 2018-19 and are you on course to break even in 2019-20?

In 2018-19, we delivered just under the £9.9 million deficit target, and that's been subject to audit, so that's now confirmed. That's on the record. The plan that we've got for this year is to break even, and that's part of an approved plan with Welsh Government. It's not without its challenges, but it's something we think that we can set our stall out to do this year.

And you're still on—you're on target.

Broadly on target; we've had some early pressures this year, some early costs have emerged, but we've got the remainder of the year to resolve those, so we remain quietly confident that'll be the case.

Great. And what are the implications for the health board of its move away from targeted intervention to enhanced monitoring status?

We await and see the exact detail of that. We would expect less scrutiny, fewer meetings to go through our figures. We have a strong relationship with Welsh Government through the finance delivery unit, which helps with that process, but our initial understanding is that there will just be less scrutiny and less detail required on a regular basis. 

So, how will you ensure that you receive from Welsh Government the support you need? Is that the—?

The support that we need—. We will engage in our conversation with them. There are lots of opportunities for investment from Welsh Government. We intend to make sure that we're there alongside them looking to maximise any opportunity for us.

Okay. And the IMTP 2019-22 assumes an increase in the health board's net income of £56.6 million for 2019-20. That's considerably higher than the sum set out for the subsequent two years. How does the figure compare with the actual uplift received from 2018-19?

I'm not sure, actually, if I'm honest. I do know that this year was quite a substantial settlement, and it is expected to reduce in the next two years. But this year, 2019-20, was a very good settlement for the NHS. 

Okay. In his structured assessment report of 2018, the Auditor General for Wales reported the health board's plans to change the base of the saving target it sets for its services from 2019-20. Have you as a health board implemented these changes and what difference have they made?

I think what the auditor general was talking about was, instead of offering a 2 per cent reduction in cost across all budgets, to look for specific areas where we could target savings. And we have done that. We've looked at procurement, we've looked at agency use and other variable cost bases that cut across all the budgets. That's been well received within the organisation, but we're still working through that and we're hoping to enhance that as we go through the future years. 

Okay. And the Auditor General for Wales noted that, at the time of preparing his structured assessment report, the board had not received a briefing or update on the all-Wales costing system implementation project. Can you provide an update in respect of this and explain how the costing project will contribute to improving the health board's financial management position?

So, we've done that now. We've updated our finance committee, which reports to the board. We did already have a costing system; this just enhances the old system with the new one to make it more agile. Those costs are shared with our clinical teams and they can review any variation to see if that variation is reflected in their clinical practice. Working together, they'll try to streamline and take out unwarranted variation, and ultimately that could reduce the cost.

Angela—some financial agility on your behalf, I think. 

I just wanted to ask a quick question about—[Inaudible.]—because I think you alluded earlier to the fact that you have very old buildings, et cetera, and I've got a degree of concern, because, as David mentioned, UHW's going to become a trauma centre—where are you going to squash it in? At Llandough, you're going to have the 10-bedded long-term ventilation programme, from the critical care report that Vaughan published yesterday. I understand Rookwood's closing, being moved into Llandough. Having been to Llandough quite a lot just recently, the pair of us—not together, I have to say—we can see the enormous space constraints there. What are your plans for ensuring that the buildings keep up with the future, and that you have the funds to do it in a timely manner? 

So, two things—firstly, last year, the board received and approved quite a comprehensive long-term plan around our estate. So, it took information on the condition of our buildings and the utilisation of our buildings, and it worked through and indicated where there were priorities in terms of coming out of buildings that were obsolete. And its overarching aim was to ensure that, over the course of that 10-year period, we were delivering all our services in buildings that were of a decent condition, but also functionally fit for the service that we are providing. You'll be very aware that we're providing a lot of services in buildings that were built a very long time ago. 

That is coupled with our clinical services plan, because, clearly, what we need in our infrastructure is absolutely dependent on what kind of service we want to deliver, and we're doing a lot of work on—as Steve and Len have already alluded to around the pathways—shifting the balance of care in line with the aspirations of 'A Healthier Wales', so that we're delivering more care out of hospital into the community, and we are just finalising a more detailed primary and community asset and infrastructure plan that looks at primary care as well, because we know that some of the GPs are not in the environments that they need to be providing. We've got a plan for developing our health and well-being hubs in the community, and the programme business case has been endorsed by Welsh Government, which is very helpful, which will mean we'll have a hub in each of our three localities. And, working our way back up to the hospital, in both of our hospitals we've got plans about the changes that we expect to happen over the next period—next five, 10 years.

In terms of major trauma very specifically, we are working very hard to work through, at the moment—and we've got the business case—how we will deliver that for 1 April. That does require us to do a few workarounds that—in an ideal situation we would organise things slightly differently, but we are working through how we would best organise with the infrastructure that we've got. And there are four components to that—there's needing to provide an additional resus bay in the A&E department, and we've got a solution to that by moving things around; there's a need to ensure we've got good access to a theatre close by—our theatres are not directly behind and so we've got a plan and business case coming through, in terms of building that theatre. It won't be in place for April, but we've got to a workaround model of how we can free up another theatre. And two further bits—(1) about expanding our critical care capacity, and we've been part of the task and finish group that Welsh Government's been looking at. So, we've had some investment already, and we've got a footprint and a plan for how we could increase by another six beds in the short term. And, then, finally, the introduction of a polytrauma unit, where people who've got multiple injuries wouldn't just go and sit in neurosurgery or orthopaedics, they'd sit in a ward, where all the clinicians and specialists that need to come together are in one place, and that's regarded as being best practice. So, we have a plan, by rejigging some of the wards and actually taking down some of our bed capacity as a result of improving our discharge to assess process and getting people home sooner. We know that benchmarking indicates that we still have unacceptably long lengths of stay in getting people home when they're medically fit for a discharge, and we are doing a lot more work on that. 

In the longer term, we do know that there is a conversation to be had about replacement of UHW, and we're in the very early stages of starting a conversation around that. But, looking at all of the hospital replacements across Europe, we know that's a 10-year business case time frame, but we've indicated that we'd like to start those conversations more formally with Welsh Government. For us, an important component of that is our relationship with Cardiff University in terms of teaching, research, innovation, because they are co-located on our site. So, it's not just a case of the hospital; it is a case of the co-location with the services that they provide too, and, again, they're key partners in terms of that longer term planning. So, there's a recognition that sometimes we're having to do a bit of make do and mend with the site that we've got at the moment.

We have submitted a business case to put an extension at the back of UHW, because there are new things that we are also being required to do. You'll be aware of the conversations about chimeric antigen receptor T-cell therapy and cell and gene therapy. We're linked to the unit in Birmingham, and that requires a bit more critical care and some more specific space for patients around things like proper isolation rooms that have got proper air flow and those kinds of things. And we know that’s a constraint at the moment, so we are seeking capital funding to enable us to put an extension on the back, and doing it in a way that will be as cheap as possible, knowing that, actually, we need, in the long term—. So, looking at things like modular build that would enable the infrastructure cost—not the quality of what’s inside, but the infrastructure cost—to be kept to a limit. And I have to say, I had a capital review meeting with Welsh Government on Monday, and then the capital colleagues from the team came to talk to us again yesterday about positioning of the UHW conversation. So, we have very regular dialogue and are getting good support in terms of those conversations. 

And, just very quickly, when you—. Because you're centralising a lot, particularly in Llandough, you seem to be putting in—all the non-critical stuff seems to be going there. So, what are you doing with all the buildings that I assume you're emptying out?

So, a place like Rookwood—

Are you going to sell them or—?

Rookwood's actually owned by the charity, and the charity—. So, it's a slightly different governance around it, but the charity approved, at the charity meeting last week, to dispose of the site. Clearly, we’re interested in our relationship with Cardiff council in terms of housing opportunities, so we’re exploring those kinds of things. And, as part of the public services board, we are engaged in very good dialogue with all of the public sector partners about how can we share resources more effectively—so, co-locating.

So, we’ve got business cases in for two of health and well-being hubs—one for Cogan that will link to the Maelfa—. No, the Maelfa development, which will link into the hub in Maelfa, and then one for Cogan, where we’ll be reproviding core primary care provision. It’s still going through the engagement process at the moment. So, we’re trying to make sure that we can share, where we can, with public sector and make it easier for citizens to access a fuller range of services. And where we’re coming out of old estate that we really don’t think we’ve got a use for, we are selling those. And, clearly, they give us a pipeline of funding, subject to Welsh Government approval, to come back into the capital programme.

Where's the patient voice in this?

Well, we're doing a lot of it. So, the engagement, particularly, is around the clinical services plan, about what the future model of our services is. Our strategy when we first started on the journey of our strategy started with the conversations about the citizens and people who used our services—so, really hearing what is important to people. We know that things like access are really important, so we’re just introducing, this month, a park and ride for Llandough too, so that people don’t have to rely on finding a parking space at Llandough. We’ll have a—

There are only 319 parking spaces for the general public in Llandough.

Yes, and so we will have a bus now providing a park and ride up to Llandough, because we do know that's problematic, and the site's tricky as well, if you're parking at the bottom. The other thing that—. It's tricky in terms of because you're trying to also understand how technology's going to change, and, again, looking at some of the best practice around clinical provision, but also the technology that will enable us to deliver services very differently. We've got pockets of really good practice in terms of things like virtual clinics. So, our cystic fibrosis clinic—if you are resident in Pembrokeshire, you can do that through a Skype-type model. But we don’t do that anywhere near as much as we could be doing, even for citizens—we still drag a lot of people in for things like patient appointments and follow-ups. And, just as Steve was saying, young people are telling us, 'We'd like a different solution—a more digital solution.' We are aware that, in some healthcare systems, 50 per cent plus of out-patients plus are delivered through a digital solution. Of course, for some people, that technology is not accessible yet for individuals, and, for some clinicians, that's quite a journey to change their practice. But we're just making sure that our thinking around those things—and talking to citizens as part of that engagement process that we will be starting in earnest in the autumn, so that we're listening.

And also, Steve talked about how we have a lot of mechanisms for listening to patient experience. We will want to, when we’re doing the design of new facilities, make sure that we’re listening to the experience of patients and, again, understanding how other places have learnt from patients around things like how do you keep it dark at night? How do you keep the noise down at night? How do you protect dignity for people so that they can have their conversations with clinicians without everybody else hearing, knowing that, actually, a single-room model isn’t the perfect solution either? So, our longer term programme, for both the clinical services plan and the UHW reprovision, and, actually, all of our estate changes, enables us to have those engagement conversations with people.

Thank you.

Okay. A final few questions from David, and then Helen Mary.

I just want to go back to the point of finances, in a sense; I just want to get my head around it and have clarity in my own mind. You mentioned the £9.9 million deficit, but, actually, that's because you had £10 million extra from Welsh Government to reduce that deficit. And you've got a projected zero deficit—from what I understand, it's actually a £31.3 million cost savings target for next year. You've not hit that level in the last five years, so are you confident you'll actually hit £31.3 million? Things are getting tighter: (a) costs are increasing, (b) services have been reduced already as a consequence of savings. You've not hit that level before. Are you confident you're going to hit £31.3 million to actually come net zero?

I think at this point in time, yes, we are. We've set ourselves out with quite a number of initiatives; I think we've made savings consistently. We're now looking at the more wider savings, looking at changing service models, we're looking at transformational opportunities. We built up to that; we've always used tactical opportunities. They still exist, there'll still be—always opportunities in procurement. We are going into areas that are much more difficult and harder to do, but we do remain confident at this stage that we can do that.

Because some of the models you talk about, actually more resources will be required, so it might cost a little bit more.

And they could cost a bit less. Unwanted variation, duplication, these things within clinical models and within pathways are where we need to go now, and that's where we're setting our stall out to look to make significant reductions in costs.

Okay. Final question, Helen Mary.

Yes. Just very briefly, Chair; I know we're over time. This is a question that arises out of concerns that have specifically been raised with me. Can you tell me what systems the board has, both at executive level and board level, to monitor and report on the implementation of the continuing healthcare framework and assessment process? And, as a result of that monitoring, what have you been able to do to improve the experience of people being assessed for continuing healthcare?

I can touch upon it from a strategic level, and Steve might want to talk about some of the operational arrangements. This is very much part of the joined-up work we're doing under the regional partnership board with the two local authorities. We know that we are monitoring how many patients are coming through the system and how quickly they are being assessed, and the outcome of those assessments and where there are differences of opinion going through the assessment process. What we're trying to do through the conversations about pooled budgets is actually have a much broader conversation about joint commissioning. So, in a sense, from a citizen's point of view, the assessment process, as described in social services and well-being legislation, is a system that, from a citizen's point of view, should feel the same and a joined-up system. We are not there yet with all of the parts of that, and I know that we still get feedback that people find that they're getting caught in the different bits of the system. But our joint commissioning arrangements are trying to ensure that we're bringing together a single pathway for individuals.

Last week, I think it was, we published a joint commissioning strategy for people with learning disabilities, really reflecting on their experience of going through individual care planning and continuing healthcare assessment and experience, trying to make sure that we can make that process as citizen-focused as possible in terms of individuals. And then our sharing of resources and pooling of budgets enable us to make the right decisions and support people for the outcomes that they want in terms of their life. And we do know that, actually, one of the outcomes of our process is that we've probably got too many people ending up in the institutional care I think you touched upon, Len, or Steve, and we want to—we're looking at how we can use some of that investment to invest in services that bring services much closer to home.

So, mental health would be an example where with low secure services, developing more support in the community, we've actually been able to disinvest in some of our continuing healthcare funding and expenditure to invest in some of our more local service, and appropriately manage to transition and bring patients back to a more local provision. So, we haven't got it all right, but we are working very hard with the two local authorities to bring this commissioning approach, joint commissioning approach, together.

Just to add that, at an operational level, as Abi said, our panels are meeting frequently to ensure that there are no delays in the process. The change in emphasis and the outcome is apparent in the work that they're doing. I'll just point to one specific piece of work that our mental health team are working with colleagues in Swansea on in terms of joint guidance for support for people moving out of mental health care, where the balance between local authority funding and health funding can be quite different across the system. Swansea colleagues have produced excellent guidance in that, which our local authorities are fully engaged in, and it has produced a much slicker process in terms of the panels being able to meet and come to a decision.