Cynulliad Cenedlaethol Cymru

Diolch, Cadeirydd, and bore da—good morning, everybody. First of all, can I say I'll just make some general points that I'd like your views on, and I think we'll then drill down a little bit more beyond that? But, first of all, can I thank both Allison and Marcus for taking the time out to spend some considerable time with me on a one-to-one basis, and with some of the other AMs in the Cwm Taf board area? I think that was helpful and we appreciate the time that you gave us to do that. 

I wanted to cover four key areas that I see from my point of view at this stage: one is around governance, the other is around what the report refers to as 'false assurances', the third would be around culture, and the fourth, which in some ways could be the starting point, but it's really how these failings—these what we now consider to be quite obvious failings—could have been allowed to continue for so long unchecked.

So, firstly, if we can deal with governance, in particular, I was—. I attended a meeting with families, with the health Minister, Vaughan Gething, Friday before last at the Welsh Government offices in Merthyr. It was probably the most sobering and distressing meeting that I can ever remember having with constituents. Yes—it was a very difficult meeting. Interestingly, in that meeting, there was no-one there who was actually critical of the health Minister. The people there were very critical of the management in the health board, and were very critical of people within the health board who had dismissed their complaints, who hadn't listened, who had told them that things could not have been any different, regardless of what had happened, and that nobody—but nobody—appeared to be taking responsibility for what appears now to be a catalogue of errors that are actually fairly consistent in their reporting. So, my starting point would be for your views and comments on that, please.

Perhaps I can begin, Dawn, and the first thing to say is, of course, to apologise to the families for those failings that you've described. I think that there is a need for us to review, amongst many things that we need to review, how we handle people who raise issues with us—patients, women, who've been in the service, because, clearly, on all those occasions, we haven't done that any way appropriately. So, we need to have a good look at how we handle those issues. 

In terms of taking responsibility, I think the board is absolutely cognisant of the fact that its responsibility is unequivocal for all of this, going back many years, and the board takes that responsibility very seriously, and most importantly of all is making sure that everything is now being done to address the issues that have been raised.

Perhaps if I could add, I would agree that probably this is the most difficult thing that I’ve ever come across in my career. The patient experience report that was produced alongside the royal college report—some of the accounts of the families are nothing short of heartbreaking. We can’t make any excuses for that. Their experiences were unacceptable at a whole range of levels. When we consider the failings, they go right the way through the organisation. I think we’ve got lessons to learn about how people are actively listening to women when they’re in labour, right through to when they raise concerns higher up in the organisation, and right through to the whole ‘Putting Things Right’ process.

I have had the privilege—and it has been a privilege—to speak to some of the families myself and to listen to their stories first-hand. Clearly, there were missed opportunities to address things with them at the time when they were in receipt of their care, which we have to work with the staff to address, so that people are actively listened to and heard when they’re raising concerns. Particularly, women know what’s going on in their own body during labour, so they have to be listened to. That goes right through to the top of the organisation in terms of what I as the leader of the organisation and the management of the organisation can and should do when these issues are escalated to us.

Where they have been escalated to me, we have met with families and we have done what they’ve asked of us. After the meeting today, we are spending the afternoon with Cath Broderick, who was the engagement lead on the review with the royal college. She is going to be helping us work with these families going forward, and also working with others to ensure that the engagement processes are the best they possibly can be. We need to learn from the best and take that advice to help us for the future.

I think the issues that you’ve outlined in terms of going forward are what we would want to hear—that you are seeking to address those issues of concern and you have the experience from that. What I’m interested to know is if there has been a review and reflection on what has happened. Because the voices that I heard in the meeting in Merthyr just recently were that there did not appear to be any kind of learning from previous experiences, in terms of the number of people that recounted complaints that they had made and meetings that they had had with senior managers in the health board, and they were consistently getting the same responses, so their concerns appeared not to be taken seriously. So, what I need to be assured of is that that process has been—you know, that you have looked back and there has been reflection on the way in which those complaints were dealt with, and that going forward we will have those patients’ voices listened to and taken seriously. That would be my No. 1 concern.

The second point I wanted to raise with you was what the report talks about in relation to false assurance. I’d like to know what you understand by false assurance in terms of what the report set out. Because I have to say to you that, on reflecting over the discussions that we have had, I now feel that there was some false assurance given to me as well. That may not have been deliberate, but when we talked about this report when it was published in October time and we had conversations—we had private conversations with Marcus and Allison—I was left with the distinct impression that what we were talking about here was some procedural difficulties. Clearly, we were not talking about procedural difficulties, we were talking about long-standing, systematic, cultural and procedural problems. So, I’d welcome your views on that as well.

Shall I start? I think there are probably two things, really, to say. One is that a number of the issues identified in the report, as you look back over the deliberations of the board over the years, were there. There are issues about staffing, some of the issues are about clinical practice, and there was awareness of some of the cultural issues. So, I think, retrospectively, the board probably was aware of many of the issues, which we're talking about now, and some action was taken on those. Clearly, what didn't happen was that the problems were resolved, because they've continued.

I think the second thing to say is that when we heard from the royal college reviewers in the middle of January—their verbal feedback immediately at the end of their visit—certainly, I and those there were shocked at what was revealed. So, we simply didn't appreciate the full extent of the issues, particularly accounts from the women who had experienced the service, and a number of the other issues were a shock to us at that point. And since that time, a lot of action was immediately taken to put right those things that had to be put right immediately and the rest of it is in the maternity improvement plan.

So, to come to your question, 'Did the board take false assurance?' I think the board was aware of most of the issues. What it didn't succeed in doing was putting those properly right. If that's false assurance, then it took false assurance. 

So, the false assurance that I'm talking about, I guess, is the—. There was the false assurance to the board and you've explained that. But how many other people had assurances that I felt that I'd had around the extent of the problems? Now, was that because—and this is what I don't know—you didn't know the extent of the problems, or was that because you were intent on making sure that it was resolved quickly and so, 'We could give some assurances that we've resolved it quickly and we paint a slightly better picture than actually existed'? That's what I don't know.  

Perhaps I can answer that. If we look back in September, October, when we had initially raised the concerns ourselves around the instant reporting, which was the trigger for the whole of this review process, we were very clear at that point in time. We put this in the public domain through our board papers and we had the briefing sessions with you and others—fully cognisant of the fact that we clearly had a problem in the way that incidents were being reported. At that time, we didn't know exactly the extent of the challenges that were underpinning that. We knew we had some very significant procedural issues and we immediately put in some measures that would address that. But it was only when we were going back to really look at what was underpinning that that the full scale of some of the challenges started to emerge.

To be absolutely frank, the extent of the feedback from the families, which has been the most distressing element of this, was a complete shock, even to me, and I sign off complaints in the organisation. And when we went back and had a look, the complaints that were coming through were not giving us that strength of failure in the care that people were receiving. So, I think some of the deep-rooted cultural issues amongst the staff, some of the patient experiences, were a real shock to us.

Some of the challenges around staffing, some of the challenges around some of the clinical practices—as in having high inductions of labour rate, a very medicalised model—were known to us and were known to the board, and those had underpinned the original south Wales programme work where we had identified the need that the service model needed to change. With the benefit of hindsight, the time that it has taken to actually effect some of those changes that were decided upon back in 2014-15 has only served to make the position even more challenging. Those were known. I think the issue that was not known was the extent of the cultural and of the patient experience failings.

And certainly in the conversations that we’ve had previously, you did talk about some of the previous failings and what was known historically, particularly about some of the cultural issues. Why is it, then, that those issues were not effectively dealt with at that time, and what gives you the confidence that they can now be effectively dealt with?

If I go back over a period of four or five years, we have had challenges with staffing and we’ve had challenges with staff engagement. Our previous director of nursing led an extensive piece of work with the support, initially, of trade union colleagues as well—had a programme of engagement with staff, they developed a maternity voices forum, she held weekly listening clinics with the midwives—and after a period of time, the staff didn't engage with that process anymore because they were happy with some of the arrangements that were put in place. The issue was they were not sustainable.

What I think we have to recognise and what is different now is that we can't do this for ourselves; we have to bring in expert advice and help to deal with some of the more deep-rooted cultural issues. We're working with Welsh Government colleagues, identifying the expertise that we need. We've already brought some of that in. In fact, we've had some of that in since the turn of the calendar year, with a whole range of training and team building with the clinicians that, perhaps, Ruth might want to comment on. But it's bringing that external expertise in. 

The other thing that we are looking at is how we work with our trade union colleagues to have a different system of freedom to speak up, because people have been given routes—they've been given routes directly to the director of nursing, directly to the trade unions and, actually, directly to me—but, for whatever reason, the report tells us that people have still not spoken up when they've felt that things were not right. So, we have to have a different way of doing that and getting that external expertise to help us.  

And that was something, of course, that we raised with you—Vikki Howells and I flagged with you an anonymous letter that was produced by a number of staff highlighting those very points, wasn't it—that people were afraid? This is really quite shocking, isn't it, following how long after the Mid Staffs scandal, when a duty of candour was brought in after that for that very point, so that people could feel that they had the ability—? Certainly, from my experience as a trade union official before I came into this place, to actually blow the whistle and make complaints could often be the finish of your career. So, that is something that clearly has to be addressed. 

My final points on that, then, really, would be around the medical staff and the fact that what we have established is that there was not robust medical cover in that unit despite the fact that there were sufficient numbers in place to enable that to happen. So, what I want to know is, again, was that known, and if that was known, how was that allowed to continue? 

The answer is, yes, it was known. If you look back through some of our previous reports, particularly reports from what is now Health Education and Improvement Wales, but deanery visits, it had been brought up previously, and we had had a number of conversations with people and addressed those issues—as in we had sat down, we had looked at everyone's job plans and we had ensured that there was sufficient cover. The cover at consultant level, however, is not the only critical factor. And so, one of the issues that we've found when we're running two separate units—it's not the issue now—is that, if you've got a consultant on call for the labour ward, which was what they were looking at—the royal college came in to look at just the labour ward—that same consultant was covering gynaecology intake during the day, and if there wasn't a middle grade available then the consultant would often be on the gynaecology wards.

And I think part of the issue again is that cultural issue, because if a midwife knows that the consultant is around, but has to go to the gynae ward, and if the consultant has communicated that that's where they are, then they're not seen as being unavailable. But I think because of the cultural issues, they were seen as being unavailable. In fact, they were available, but just not present. And so, what we've done is, now that we've amalgamated into a single unit, it's actually much easier, and we've got much better labour ward cover. And we've got someone who is allocated to labour ward and isn't even going off doing elective caesarean sections, which, because of our high section rate, that was another place where the consultant who was dedicated to the labour ward, supposedly, could be doing elective sections. Whereas now, it's all in one place—we've got a consultant who's dedicated to the labour ward, and we've got another consultant who is dedicated to doing the elective sections. And we've got a more robust middle-grade rota to cover the gynaecology.

So, I think we had at times put things in place to try and mitigate the fact that, actually, the consultants were covering a lot of different areas, but I think, because of the cultural issues, it still never really embedded properly. And so when you challenged it, it went back in for a while, but it was never sustained in the way that we would want.

So, that is going to be a major challenge—changing that cultural thing is going to be huge. I'll leave it there, Chair, because I understand that other people want to come in.

Yes, indeed. Helen Mary Jones next, then Lynne.

Thank you. You've mentioned the cultural issues on a number of occasions, and, obviously, I'm sure we will want to question you about your plans to move things forward. But I don't think we can satisfactorily do that until we have some better understanding about how things got to the state that they're in. So, can you outline for us what you're understanding is about how this culture developed? And can you explain, picking up a little bit on what Professor Longley has said, that there were issues that the board might have been concerned about, but that this toxic culture was something that you didn't know about. So, what understanding have you got of how it came to this, I think is—. Because a lot of the practical issues, as you've just said, fall out of the cultural ones. 

Perhaps I can start. We know that cultures build up over a long period of time, and, in the same way, they can take a very long time to change. We had two very different and separate maternity units—one in the Royal Glamorgan Hospital and one in Prince Charles Hospital. We had never had any cultural challenges in the Royal Glamorgan Hospital historically. One of the bigger challenges in the Royal Glamorgan Hospital was knowing that the changes were coming, and that inevitably has a very big impact on staff. They were going through a period of very significant change, but also recognised that this was the right thing to do in the long term for patients. The challenges in the Royal Glamorgan were exemplified through staff changes that happened through the middle of last year as we were approaching the time of the move of the service to Prince Charles Hospital.

Some of the challenges, culturally, in Prince Charles Hospital were much more deep-rooted, and if you look at the royal college report, it reflects challenges in inter-professional relationships. And what we know is that maternity services rely very heavily on effective teamwork between the midwives, anaesthetists, support workers, obstetricians. And as the chair has referred earlier, we had repeatedly put interventions in over the recent years, but, clearly, after that happened, things were slipping back, and that was not a sustainable solution. And in my response to Dawn Bowden's question just now, this is where, to be perfectly honest, the shock factor of the report has had a major ripple through the service. 

Can I just briefly interject? I'm sure you've got more to say. I think 'shocked' is the right word. You have presided over this, and I really want to try and understand how it is that you didn't know, because this is not new. I've talked to families who’ve been raising concerns for some time—one particular case going back as far as 16 years. How could it be that you had such a dangerous, difficult culture going on there? You’ve just described, Ms Williams, putting in interventions that were not successful because of that culture, so, clearly, you knew something was going on. I’m just slightly at a loss. I mean, it’s only two maternity units—the cultural concerns, as you’ve rightly said, were only in one of them.

I think that, in many ways, it’s a very difficult question to answer—

I’m sure it is, but, given that you’re now supposed to be presiding over dealing with it, I think we need to understand your understanding.

Absolutely. If we look back over the years—as you know, I’ve been a chief executive in this organisation since 2011, and I’m also a chief executive who is, actually, very visible and in touch with the service. If people ask to speak with me, I will speak with them. I have spent time myself in the maternity unit many times over the years and continue to do so.

I think the issue with deep-rooted cultural issues is that sometimes you see what people want you to see and you track the information. We have been very clear that, in terms of the serious incident reporting, we hadn’t appreciated that that was not being undertaken correctly, and we absolutely put our hands up to that. We raised that, as soon as that became clear, ourselves.

But when we look at our complaints information, it wasn’t giving us those indications, which tells us that the metrics that we need to be using to really understand what’s going on in a service—we can’t just rely on the data on what we were doing and we have to do better to capture patient experience in a very consistent and proactive way to help us to understand, from their perspective, what is happening.

Since you mention patient experience—if I can come back and follow up on some of the points that, I think, Dawn Bowden has very correctly raised—would you accept that where concerns were raised there was more of a focus on dealing with the potential reputational damage to the organisation than there was on making sure that the individuals received justice?

Without any evidence of individual cases, it would be very difficult for me to comment on individual cases—

I'm not asking you to comment on individual cases.

As an absolute rule of thumb, my answer to that would be 'absolutely not'. The whole purpose of accepting patient feedback and dealing with their concerns is about putting things right. It's not about the organisation's reputation—it's about dealing with the issues for that individual patient, but also about learning the lessons more fundamentally for the service. So, I would not accept that.

It's certainly what it looks like from where I'm sitting. Can I give you one specific example, and I need to ask Ms Hopkins about this? Would it be accurate to say, Ms Hopkins, that you appeared on Radio Wales on 4 October last year and reassured the public that there was no need for them to be concerned about the state of maternity services in Prince Charles?

I think at that time I stated that we were aware that we had staffing issues and that we had concerns within the service, but that we had taken significant steps to improve not only the staffing levels but the safety within the service. As much as we have done since the Royal College of Obstetricians and Gynaecologists came in, the changes that we've made are always focused on maintaining safe services.

So, there is a balance between, obviously, being clear about the challenges that we knew that we had at that time, but also giving assurance to the patients that we're doing everything that we can to make the services safe and keep the services safe.

So, coming back to this, 'Whether we're worried about reputation or whether we're worried about being honest with the public', is it true that at that time the board was in possession of an internal review by a senior midwife setting out how serious the situation actually was?

There was a report received in October from a consultant midwife who was working in the organisation at that time. The actions from that report were taken and put into the improvement plan, because, as Allison has already said, we were aware already, and had developed an improvement plan to make further improvements in the services. So, clearly, when that report was received, we looked immediately—. Whilst we were working with the author on points within that report, we acted immediately to make sure that issues that were identified within the report were cross-referenced and included in the improvement plan overall.

While at the same time reassuring the public that they didn't have anything to worry about. Let’s move on from that, if we may, Chair.

The culture, of course, in an organisation, is dependent on people, isn't it? And you have spoken and in some of your other public statements you've talked about the need to change that. Yet, what some families have said to me is that they find it very difficult to understand how that culture is going to change while the same people who presided over the development of that culture remain in place, and while, as far as they are aware, there’s been no disciplinary action as a result of some of the very serious concerns. And, again, Chair, I wouldn't expect either Professor Longley or Ms Williams to talk about individual cases, but how would you respond to that concern from families? The same people who allowed this to happen are now telling me that they are going to put it right. Can you understand that there's a certain level of scepticism around that?

I can completely understand that, yes, and I think there are probably two things to say that hopefully will start to give people some reassurance as we go forward. One is that the oversight regime for the health board now has changed completely. So, as you’re aware, the independent oversight panel is now starting its work, and that will scrutinise very closely our response to all the challenges laid out in the royal college report. So, I hope that will give people some reassurance that there can be no slipping on the changes that need to take place.

I think the second point to make is about the need for us as a health board to get on effectively, quickly and determinedly to make the changes happen. It would be very unfortunate, I think, if we dithered, if we didn’t take action effectively now, because that would let down, I think, those who’ve raised these issues with us. That would be a complete dereliction of our duty. So, it’s very important, I think, that the team who understand these problems and who know intimately now what needs to be done about them are those charged with the responsibility of getting on with it now. To have a change of leadership at this point, I think, will only result in hesitation and in delay, and that, I’m sure, is what nobody wants.

I can see that point. You talk in your report about the—. There’s a phrase about the board needing to work differently to provide strong leadership. Could you tell us a little bit about how you propose to do that?

So, we have already changed a number of the fundamental ways in which we work, essentially. So, we have arrangements for ensuring that the quality and safety of all of our services are always at a level that we would expect. Clearly, those arrangements did not work in this instance, and that has obviously triggered questions for us about, ‘Well, if in maternity, why not elsewhere?’ So, we’ve looked very carefully at that. At our board meeting next week, we will be setting out some immediate changes that we’re going to make that will ensure that those processes work exactly as they should do, and I fully expect more changes during the course of the year as others come in and look at the arrangements. So, that is a fundamental way in which the board can be assured properly and reliably that the picture is as it appears to be.

I think, secondly, there will be a lot of external input to the health board to make these changes happen, not just in terms of oversight, but in terms, actually, of working to make the change happen. We've already benefited from some of that, and we can already see the benefits of people from outside with expertise in particular areas coming in and working alongside us. The board is very receptive to that. There is absolutely no suggestion that we think we can do this by ourselves, and we are very welcoming of that input, and I fully expect there to be a lot more of that in the coming weeks.

That’s helpful. I’m really conscious of time, so there are just one or two other points I want to raise. Ms Williams, in your response to the question about culture, you said—and this is, I think, understandable—that when one goes into those kinds of places with those kinds of cultures, one tends to see what people wants one to see, and I do accept that. What steps have been taken to deal with the front-line managers who must have been responsible for covering up that kind of—for making sure that, when you were there, as you tell us you were, that you saw what they wanted you to see? Because this does come back to my point, and, while I take Professor Longley's point that perhaps this isn't the time to be cleansing the Augean stables at this particular point, but, again—[Inaudible.] So, the people who understand the mess may be best placed to clear it up. But some of those front-line managers who were hiding things from you, because that's what I can take from what you've said, Ms Williams, are they all still there? Are they still running those maternity wards where the midwives are sitting looking at their phones instead of dealing with their patients?

I don't think that I would necessarily say that people were hiding things from us, but clearly things were not—

Well, you said you could only see what people wanted you to see. If this was going on and you couldn't see it, then was it that you weren't able to see it or was it that somebody was making sure you didn't see it? I can't understand how both those things would be true.

Either which way, I fully accept that things were not being escalated in the way, necessarily, that they should have been. What might be helpful to understand is that some of this—. Well, the original under-reporting of the incidents, which triggered us raising these issues and wanting to do all of these reviews, was because we had a change in personnel. We had a new head of midwifery come into the organisation, which was instrumental in actually putting fresh eyes into the service. And we've also, in the period, had the appointment of a number of other new key staff. We've brought in a support head of midwifery alongside our head of midwifery from another health board.

That's all encouraging to hear, and, of course, that's in the information you've provided for us, but are those front-line managers still in charge of those wards?

No.

That is, to some extent, reassuring. Last question from me, Chair. There are other things, but I'm sure other Members will want to explore. How would you characterise your relationship as a board now with those families who have been wronged? And how can you—? You said a little bit about this in response to Dawn Bowden, but how do you intend to deal with their distress, rage, outrage, profound disappointment? Because that isn't going to go away. And we're not talking about one or two individuals here, are we? We're talking about quite substantial numbers of people. 

May I start, chair? We are absolutely clear that it is our duty to work with these families, nobody else's; it's our duty to work with these families to ensure that they have the redress that they deserve and also that, where they feel that they are able to, and would want to, they can help us to be part of creating a better future for our services.

The engagement lead for the RCOG review, Cath Broderick, has been appointed to the ministerial oversight group. We had discussions with her last week, and she's meeting with us this afternoon. We've already had the conversations about, through them, contacting the families to ensure that the right people who want to be engaged with us [Correction: to ensure that the people who want to engage with us are engaged in the right way]—because we recognise that, for some people, they may not want to and we wouldn't want to force that on them if it wasn't their choice—that those who want to and are willing to engage with us, that, with the support of the community health council and their independent advocacy service, and the expertise of the independent person on the oversight panel, we will do whatever those families want in terms of the engagement.

That's good to hear. Just finally, can I have assurance from the chair that none of the families will be threatened again with legal action because of the complaints that they've raised?

As far as I'm aware, nobody has been so threatened.

Well, that has happened on at least one occasion.

And if it has then we would absolutely want to investigate that, because that's—that would be appalling. That would be appalling. But my guarantee, absolutely, there will and must never be any suggestion that—

No more threats.

Well, if there have been any threats, then we need to have a look at that, but, certainly, there will be no threats. Absolutely.

Good. Thank you.

Okay. Lynne Neagle.

Thanks, Chair. Obviously I don't represent Cwm Taf, but I did have my first baby in Prince Charles Hospital 16 years ago, and I've always considered myself really lucky to come out of there with a live child, so—. But I had assumed that my experience was unusual, and obviously, since then, all this has come out. And I must say that I do struggle to understand that people at all levels of the organisation didn't actually know what was happening within the health board.

I've got some specific questions. Allison, you referred to complaints and the fact that the strength of feeling of some of the families didn't come through the complaints system. So, I'd like you to elaborate on that, please. I made a complaint; I took it all the way to having a meeting with all the senior clinicians. But, for me, it reached the point where the lies that were told—outright lies—in response to my complaint made me think that I needed to leave this for the sake of my own well-being and move on. So, I'd like to ask you how you have reviewed the complaints process to ensure that—. You know, we had a report a few years ago, didn't we, to the Welsh Government: 'Using the Gift of Complaints' it was called, and it was all about how complaints can be really, really valuable in flagging up things that are just like this. So, I'd like you to explain the whole approach now to complaints.

And I'd also like to ask about timescale. As I said, my experience was 16 years ago. A lot of the focus has been on the last 10 years and it's absolutely right that those families have the justice that they need, who've experienced these things in the last 10 years. But I know that—. I personally believe that this has gone back a lot further than the last 10 years. I know that Dawn has spoken to people who have said that this has gone back some 25 years. I think everybody who's had a poor experience has the right to know that it's being properly investigated as far back as is needed, really. So, I'd like you to comment on the timescale, please.

Okay. On the issue of complaints, just to clarify, the strength of feeling through individual complaints is indisputable, and the distress through individual complaints is clear and is fully acknowledged. What we hadn't been able to ascertain, looking across all of the complaints that we have, was the extent of the deep-rooted sense of failure that came through the report and through the patient engagement. It was that that I'm sorry if I didn't reflect clearly enough in my response to the earlier question. We do have a complaints review panel in the health board, which is chaired by an independent member of the board. The CHC sit on that and they review complaints and our responses to complaints. I think the question for me is more fundamentally why more people were not raising their complaints, because there are people who have come through this engagement process with very distressing experiences and very distressing stories—some of them we knew about because of a complaint, but some of them we didn't. So, we've got to find different and better ways of enabling people to give us their feedback. Because not everybody, and particularly when you've had a new baby, has the wherewithal—as in, you know, you've got other priorities in your life—to pursue a complaint. So, this is what we've got to do, with the help of Cath Broderick and the oversight panel, going forward—look at where's best practice anywhere that allows us to capture that experience without people necessarily having to go through what can be quite a challenging complaints procedure at a very important time in their lives.

On the timescales, we initially identified the timescale going back to January 2010, because we wanted a sufficiently large cohort of people to be able to understand what the scale of the challenge was, and that was 10,500 births, so we thought, well, that would give us enough of an idea about the scale of the challenge that we've got. The recommendation of the RCOG report, which the oversight panel is going to be overseeing, goes back probably to 2010, but we, in all of our communication with the public and in the setting up of our dedicated contact line, have said very openly that we would talk to any woman or any member of their family if they've had a poor experience, because we would want to help them. And different people need different things—it's very individual—but we haven't set any timescale on helping anybody who comes forward and has an experience they want to share with us, or has a particular question or any help that they want.

So, on the issue of complaints, you've clarified that, actually, there were women who were complaining. You've said yourself that you sign off the complaints. I certainly wrote my complaint to the chief executive. How is it, then, that somebody in the chief executive's office wasn't thinking, 'Oh, well, I'm getting a lot of complaints from women about maternity care in the area. There's something going on here. What do we need to be doing?' How can this have gone on for so long?

We weren't getting a large number of complaints. I think that is the real difficulty here. The number of complaints, formal complaints, coming through the maternity service was not reflective of the scale of the problem that has been identified. So, what is very clear is that—. And I think in my answer to your question earlier—. We look at claims information, we look at complaints information, for all of our services to look at whether or not that's giving us any indication of underlying problems. That wasn't giving us the indication of the scale of the challenge that the report has identified. So, there have to be other, better ways of capturing patient experience, and that is what we have absolutely committed to and are getting the expert help on, because just relying on complaints and claims doesn't give you enough information to actually be able to draw the conclusions that this report has clearly drawn.

Okay. Just finally from me, then, I believe that this whole debacle is an example of the inverse care law writ large, really. I don't believe that if this was a hospital in Surrey or somewhere very prosperous that it would have taken so long for these issues to come to light. I think there are particular challenges, then, for you going forward in how you do make sure that you capture that information from a community that perhaps doesn't always expect to have things that they would in more prosperous areas. It shouldn't be like that, absolutely it shouldn't, but how are you going to make sure then that everybody understands that it's their right to have a good experience in your hospitals, and that it's their right to raise concerns about things and that they will be listened to?

I chose to come and work in this community, and I've stayed working in this community for exactly the reasons that you say. A community like ours deserves the very best, for all the reasons that you say, and we have failed them. There's no disputing that. I think what we've got to do is take the experiences and, hopefully, the help of the very brave women who have come forward who can help us to understand how best we capture that information in the future. I think we have to do a whole range of things, from making it simple through technology—. We've already put in place a system that we picked up from Northumbria, where we take iPads into the unit and we get people to give real-time feedback, which is giving us rich information. But there will be ways that the expertise of the people who are going to be supporting us through the oversight panel will help us to do that. What, clearly, we can't do is rely just on people making complaints, because that's not giving us enough of an indication of some of the challenges that we face.

Okay. David Rees.

Diolch, Cadeirydd. I'm very distressed at the reports we saw, I'm sure you are as well, and to be blunt I wouldn't expect you to be sitting there if you weren't taking action to make sure that, moving forward, there were actually going to be improvements on what we've seen. So, the real question that comes here is why did it happen in the first place. I've heard your comments about complaints, and, to an extent, I understand that, because the reason, sometimes, you don't get more complaints is because people are very wary about making complaints. It's a very difficult process. Sometimes they hear others who have made complaints and don't get the responses and they think, 'Why am I bothering, because the system is closing in on itself to protect itself?' So, when a single complaint comes forward, that should start raising concerns, because, if someone is prepared to come forward with a complaint, there's something that needs to be looked at very, very carefully. So, I suppose the first question I'll ask is—. You had very few complaints, you've said—did you actually meet any of those complainants at any point in time?

When there is any complaint that is made then there is an investigation and people are offered the opportunity to meet with whoever they want to meet with. Often, the person they want to meet with is the clinician that was responsible for their care. It may be the consultant, it may be the senior midwife, it might be the head of midwifery. So, we are guided by the patients. They're always offered a meeting to discuss their complaint, and we're guided by them about who they want to meet with. So, if patients say that they want to meet with me, from any specialty—they might want to meet with the medical director, they might want to meet with the director of nursing—then they will be offered that opportunity. I have met with some of the families myself who have made complaints into our maternity service. I'm seeing one family in a couple of weeks' time. We are guided by them as to what's going to be most helpful.

I'm not talking about seeing them following the report. I'm more concerned about when someone makes a complaint, as you highlighted. To me, it's an extent of—. Allowing someone who perhaps is managing the system to actually deal with a complaint in that system isn't necessarily an appropriate mechanism. Now, Keith Evans, back in 2014, came before the committee of the fourth Assembly with the investigation into complaints, and highlighted very clearly how important complaints were. It just seems that the health board hasn't taken Keith Evans's recommendations into effect and actually acted upon them to ensure that anybody can raise a point at a point in the hospital beyond that and those complaints are taken seriously. By that I mean to say there is something acted on as a consequence of that complaint. And, clearly, in this case there are examples where action hasn't been taken.

We do take complaints very seriously. Complaints are properly investigated and responded to. I think my major issue in this whole sad situation is not so much the people who made the complaints, it's the people who didn't make complaints, and what do we do to ensure that those people's voices are heard. I think that's a massive lesson for us, and is a lesson for us that we need to consider across the whole of our services. Some people want their voice to be heard, but don't want to pursue the complaints process. That's been a really salutary lesson for me, personally, in all of this. We've got to find a better way to listen to those people.

Well, Keith Evans highlighted both of those points, so you may want to go back and look at it. But, as I said, the one way you get people to make a complaint, if they feel that strongly about it, is to ensure that those that you do receive are acted upon and therefore people see a value in a complaint. That's a crucial element.

But, Professor Longley, you also highlight the fact that the south Wales programme, which again was about four or five years ago—. There were reasons as to why you put the two—you know, had challenges identified for the south Wales programme. I suppose my concern is that, if there were points on that programme discussion that caused you to think that, 'Actually, we need to change the model of delivery within Cwm Taf' at that point in time, did you take action to ensure that there were safe levels at both sites because you knew that there were challenges at both sites?

Could I answer that, because Professor Longley wasn't in Cwm Taf at that time? I was. The south Wales programme was triggered by staffing challenges, as you probably remember, and the decision was made that we had to reduce the number of consultant-led obstetric units and paediatric services in the region by one, and the one that was to change was the Royal Glamorgan. Having made that decision, there was then a significant process that needed to be gone through to ensure that the other units were big enough and sustainable enough to be able to take the activity. Some of that was about changes in staffing, but a big amount of that was changes in buildings, and particularly neonatal care, to be able to accommodate the additional neonatal activity.

So, what is clear is that the length of time that it took for all of that to be done put significant strain on the unit in the Royal Glamorgan, because, when a service knows that it's not going to be there for a long time, it's very difficult for people to stick with that, and people made choices about taking jobs elsewhere, which put further pressure on the staffing levels. So, that was a contributing factor, but we did everything we could to ensure that there were sufficient staff in each unit. What you will reflect on in the royal college report is that we were heavily reliant on locum doctors, and we all know that locum doctors, as good as they may be, don't provide the continuity of care that doctors who are directly employed by an employer do. And so that was a big challenge that we have been grappling with in sustaining those services on two sites until it was ready to move. 

So, therefore, can we assume that you were aware that there were challenges to the safety of patients as a consequence of those challenges?

We were very aware of the challenges of staffing levels and what that does in terms of the ratios of midwives and doctors to the number of births. 

So, that's a 'yes', then. 

Yes. 

Thank you. Just a final question from me, in a sense: you've also highlighted, Professor Longley, that there were some actions taken by the board following some issues raised. I suppose my question is: how did you monitor those actions—not what's happening in the future, how did you monitor those actions? What follow-up was made by the board on the actions it took, and who assessed those actions? In other words, you knew something was wrong, you took some actions; who assessed whether those actions were effective and delivering what you expected and you were now in a position where you didn't need any follow-up? Where was the board at that stage? Who was assessing your actions? You've identified now you've got an oversight, basically, over you. That won't happen all the time. So, we have to be confident that you're able to actually now monitor yourself, effectively. So, who monitored those actions and why did that fail?

I'm not really in a position to comment on that in relation to most of this period, really, but certainly, in the last 18 months, a number of things have changed that I think answer your point. So, the immediate issue last year was about the reporting of serious incidents. There is now a completely different way of handling that, with checks and balances built in that would make it impossible, now, for the problems that have been going on to continue. So, I can say with great confidence that we've completely changed that system. But that is only a relatively small part of the issues highlighted by the royal college.

I think, by their nature, some of these cultural issues are much harder to monitor, just by their nature, and we need to think of different ways of doing that. We've put in place a number of new— particularly senior midwives now, who have come in, as Allison has already mentioned, who are making changes happen in that group of the workforce, a crucial group of the workforce. And the feedback from that will be very carefully monitored, and there are new ways of doing that and new people in place in order to do that.

I think, as I mentioned before, our routine methods that are in place day in, day out, in every department of the health board, which can give us assurance that the whole system is working as it should do, we're in the process of changing completely, and that will provide much greater assurance. I think one of the challenges that we've seen in the royal college report is that, in the maternity unit, those standard processes were simply not being followed, and we didn't detect that. The new arrangements will make sure that that can never happen again. 

So, those are just some of the things that we've done already and we're by no means finished yet. There will have to be a lot more, I think, particularly during the course of the rest of this year, and probably beyond, where we continue to tighten up our systems. 

Chair, may I add just one quick point to that, which is that, in November of last year, we established a maternity improvement board? We brought in an external chair for that, and our vice-chair of the board sits on that maternity improvement board, which reports directly to the quality, safety and risk sub-committee of the board. So, we've put in an infrastructure that also concentrates specifically so that the maternity improvements can't get lost in the overall quality governance arrangements in the organisation, because at least for the next 12 to 18 months they're going to need a particular and concentrated focus that is properly plugged into the governance arrangements of the organisation. 

And can I ask, because, obviously, the report also highlighted that you—and, in a sense, I suppose this happens, and very much so here—that people were operating in silos, effectively, and different departments were not talking to other departments and not listening to other departments. Have you put in place rules now to make sure that that silo concept is abandoned so that paediatricians will work clearly, that anesthetists will be there, and they will be involved in all the processes? 

Yes. Absolutely, and Ruth may want to comment on this, but this was something that we put in at the turn of this year. It's been made an awful lot easier now that everybody's working on one site, because you don't have that split site challenge. From the multidisciplinary debrief meetings, multiple-professional safety handovers at the beginning of every shift, dedicated staff with dedicated leads—so, the system has completely changed. But I will say that the move to one site has made that much, much more effective because of the co-location of people.   

We've obviously talked about maternity in this case, but have you ensured that those procedures are in place for all your services, because there will be therefore some of the other services that still operate across split sites?

Yes. And one of the big opportunities that we have is the shared learning from the maternity experience across the whole of our system. So, there are a number of key lessons coming out of the maternity reports that we are working through with all of our services, where there is transferable risk and transferable learning. And multi-professional working, clinical leadership and extending clinical leadership, the whole gathering of patient experience, which is wider than complaints, and this ability and, working with the trade unions, real clarity of staff feeling safe to speak up—these are not lessons that we should just look at within the maternity service, and also we need to be sharing that experience with our colleagues across the rest of Wales, because there is learning here for everywhere. 

Okay? 

I'll stop there for the moment. 

Jayne Bryant. 

Thank you, Chair. You've touched on how you intend to do the most important thing, about building trust with patients and the public, and how you—that must be monitored. It's just following on from a point that Dai has just made as well, but the consultant midwives report identified inadequate staffing levels, and it described a fragile workforce and high levels of stress and anxiety amongst staff. You've said it's important that staff feel confident to come forward with complaints, but how are you ensuring that staff are engaged with and feel part of that improvement process, and that morale is built up as well, because I think it's really important that staff are involved in that? 

It's been incredibly challenging for our staff, and I have to commend them that, whilst all of this has been going on, they have very diligently continued to provide care to women. There are a number of ways in which we have to look at this differently. Some of it is about the training that has been brought into the service, and yesterday I was in Keir Hardie Health Park, where there was prompt training going on. This is a particular skills and drills training that is done for people for how they work together in emergency situations—multi-professional all engaged in that. That's really important.

The second is how we've put in a new system of debriefing when things haven't gone the way that you would expect it, because one of the lessons, or one of the messages coming out, was this fear from staff when things go wrong. And things do go wrong; in the best of hands, with nobody making mistakes, things go wrong. So, it's how that is done and facilitated, and we've brought people from outside the maternity service with expertise to help us with that.

But, in the same way as it is really incumbent on us to listen to the women and what they want, we're working very hard with our staff so that they're telling us how they want that to work. And that's why we're bringing external organisational development support in help to us, so that they will work with our staff so that they come up from the ground level with the solutions about how they want to be better engaged and involved going forward.   

Okay, Jayne? 

Yes. 

Nick Ramsay. 

I must admit, I'm struggling to get my head around this, as a father of a six-month old baby boy, so, someone who has, in relatively recent times, had experience of the—well, my wife obviously—midwifery and maternity services in the Aneurin Bevan area, where I've got to say, our treatment was exemplary at all points, from what I could see, anyway. I can't speak for everyone who goes to that service, but I can for myself. I'm trying to get my head around the gravity of what you're telling us and what exactly is going on here and has been since this report was published.

You said earlier—and I made a couple of notes, so forgive me if this is paraphrasing—but in one sentence, you said that—and this is Marcus Longley—there were cultural issues to blame here, which are very difficult to deal with. Then, a few moments later, you said that because of decisions and procedures you put in place, you're confident that these sort of issues can never happen again. Are you saying that these issues can definitely never happen again? And in that case, have you definitely resolved these 'cultural issues'?

The short answer is 'no'. We have not resolved the cultural issues and—

So, therefore, this could happen again.

Well, the cultural issues will take a long time. They'll take as long as they take to resolve, and many of them will take a long time, because we're talking about behaviours that have been embedded and have grown over the years and so on. So, there is a lot of work still to be done. And 'cultural issues' is a broad term, but it means people's behaviours, their attitudes, their assumptions about what is acceptable and what isn't, the norms of behaviour and all of that and more. So, that is about human relationships and that's going to be a really difficult one to root out, but we must root it out, because in the past those problems have not been rooted out. So, that will take as long as it takes. I make no apology for that and I wouldn't put an artificial deadline on that.

So, can we be sure, therefore, that if those cultural problems have not yet been resolved, there are no safety risks associated with that? I think we've done everything we possibly can to make sure that that service is as safe as it possibly can be. And there are a lot of things that we've put in place, starting with the immediate response to what the royal college told us back in the middle of January, and a lot more since then, and the merger of two units and so on. So, the question is then: what is the level of safety that is threatened by those cultural issues? I think we have put in place every conceivable mitigation and remedy to ensure that the system is as safe as it is and we will do more as time goes by. So, I think that would be my answer to the question, if that's helpful.

I think we all realise and accept that the NHS is a very large organisation, and with my other hat of public accounts, which I'll park for now, we see issues across the public sector in terms of efficiencies and 'value for money', which is an awful term—but in terms of people getting the service that they deserve. So, things do happen. I think what's most shocking in this situation is, of course, that we are dealing with some of the most vulnerable people or people who are at the most vulnerable point in their lives, where they look to the NHS and they look to expert advice to make sure that everything's going fine. So, I think that's the issue here.

Earlier—I can't remember; it might have been Dawn Bowden or Dave Rees actually who mentioned the unwillingness of staff to report serious incidents. I think that the suggestion there was that that was due to fear, but the report says that this can also be attributed to a blame culture where people just weren't taking responsibility and that lack of responsibility and accountability, according to this report, goes right up the chain. So, if that is the case, I understand why you're saying you've got a cultural issue there—you've got a massive problem, haven't you, if you've got a problem at all of these levels of accountability? So, are you sure that the mechanisms that you put in place to try and deal with this to make things as safe as possible are going to work, if you haven't even got that chain of accountability? 

Well, I think in terms of people's understanding about what they should do when issues are raised and how to escalate problems and so on, we've looked again at all of that to make sure that if a situation develops this afternoon, when, because of peaks in demand, the system rapidly becomes under pressure—because these things do happen from time to time—that everybody is absolutely clear on how they should respond to that and that mitigating factors are brought into place immediately—extra staff are brought in or whatever else is needed. So, in terms of addressing those immediate challenges to patient safety and the quality of experience, the processes in place there, I think, are robust, and will work, and there are plenty of resources that can be brought in to bear if that's what's required.

So, just to be clear there, if a complaint happened this afternoon, for instance, and that was made to somebody, that complaint would not be brushed off. Would you be aware of that complaint, and it wouldn't just stay at one level within the system? Would that go to the top of the organisation immediately?

Perhaps if I can answer that. If I'm in a clinical situation this afternoon, and I complain about my care in the moment, the really important thing is that the clinician who is attending at the moment deals with that complaint. And this is about, at all levels through the organisation, that on-the-spot resolution of issues. If issues are not resolved, and they're escalated, the minute a complaint is made formal, then that goes in to our complaints procedure, and that information is tracked. So, we would be aware of that. I wouldn't be necessarily immediately aware, because, as you can imagine, in a very big organisation, I wouldn't be aware immediately of complaints as they're made, but, certainly, complaints that are in the complaints process, I would.

I should have been clearer there. Because, obviously, complaints can be made all the time about all sorts of things, and some of those might not be of a serious nature, or might be vexatious or whatever. I should have been clearer that, what I mean is that, if there's a complaint that reaches a formal level, then that would not just stay at one level and one clinician, that that would go—that you would be aware and could make sure that the resolution process is effective.

Yes. And just to be clear, there are very clear systems and processes in the organisation where a complaint will be formally logged, will be formally acknowledged. There'll be contact with the patient to clarify exactly what the questions are they want us to answer, because sometimes you'll interpret a complaint in one way, and then the complainant will say, 'Actually, that's not what I wanted you to look at'. So, we do that upfront. We then do a proper investigation, with the clinicians who are involved in the care, if it's a clinical matter. And then that's all drawn into a response. I personally sign off all the responses, so that I know what the complaints are. And then the trends and themes coming out of complaints are tracked through our complaints review panel, which is chaired by an independent member of the board. And the overview information then is scrutinised by the quality, safety and risk committee of the board. So there is a very clear process. And to be honest, I'm less anxious about a complaint once it gets into the complaints process. I think the learning for me in this whole process is the experiences of people who don't make a complaint.

That's very interesting.

Okay. Final sweep of questions now. Helen Mary first, then Dawn to wrap things up. Helen Mary.

Thank you. I appreciate your previous answers—some of the points I wanted to raise were things that have arisen in your response to others. When I asked a direct question of Ms Williams about whether the front-line staff were still in place, I'm very reassured to hear that they're not. And you also mentioned, of course, that locums had to be brought in, and it's difficult to know—. One of my concerns when things like this happen is that people—whether they are clinicians or whether they're members of managerial staff—are responsible for issues, they disappear, and then they pop up elsewhere. Do you as a board know where all the people who we ought to—? Let's focus this, perhaps, on people against whom there have been formal complaints that have been upheld. Do you know where all of them are, and have steps been taken, if necessary, to ensure that they don't continue in clinical practice, if it's not appropriate for them to do so?

Yes.

You do know where they all are.

The people who have been involved in the formal complaints, if they've left our organisation, as we've gone through this process, we have notified their current employer, and we've notified them. And as we go through the individual case reviews, and as they will also be looked at again through the oversight panel, if there are specific either personal conduct or professional conduct issues with individuals, then they would be picked up with the regulator, as appropriate. There are very clear guidelines for doing that—

And you're confident that those guidelines are now being followed.

Absolutely, yes. And we have proactively been in conversation with the GMC, we have been in discussion with the NMC, through the university for midwife trainees, and if there are any issues that arise that require onward referral to the regulator, there are very clear criteria that the nurse director or the medical director would apply in making that onward referral.

Thank you. If I can take us back, then, to the complaints procedures. Many of us will have heard directly from families involved in this situation. Lynne Neagle's mentioned it today, but actually the formal complaints procedure is pretty difficult. I hear what you say and I agree with what you say—that formal complaints are not the only way that you should pick up concerns—but have you done anything to look at that formal complaints procedure and to make sure that it is easier? Bearing in mind the points that have also been raised about some of the people in these communities are not necessarily people who are very articulate, not necessarily people who find it easy to navigate these procedures, and wouldn't necessarily know, for example, to perhaps go and see their AM for help. Have you looked at those procedures?

And in terms of the people who are dealing with those procedures, have they had the appropriate training, for example, to enable them to respond to how angry some people will be in those circumstances? I've certainly spoken to people—and I know you will have done yourself—who have felt that they've been stigmatised for being distressed and angry and perhaps raising their voices, rather than having their complaints properly addressed. That was a bit rambling, I apologise. There are two points. Have you reviewed the procedure? Are you going to review the procedure to make it easier? And thinking about that cultural change, what sort of training and support are the staff dealing with those complaints getting to make sure that they don't stigmatise and dismiss people because they're angry and upset?

There are a couple of things that are really significant in this. Some of the patients that have been involved and given you the feedback, I hope these are the people that will engage with us directly and help us to understand their experiences. Because I think what we can do—. There are two things that have already been raised directly with us. One is the complexity of language in responses, and I think that is a really fair point, because having had that raised with us I've gone back and read through some of the complaints responses—I'm a clinician, so it's easy for me to understand—but I think there is more we can do to make some of this simpler for people. I think that the procedures themselves follow the national 'Putting Things Right' procedures, so the procedures themselves are robust. I think there is an issue about the pace that people move through those procedures. We need to do better so that these things don't take so long. I think the final thing is on the point of the training. There is training for staff in the handling of complaints. I think it is a very difficult situation when you're dealing with somebody very distressed over the phone—

Well, face to face—people being thrown out of rooms because they're crying and distressed.

If you've got somebody who has an example of that, I would really—

You know of it, and more than one, but we can discuss that outside this forum.

I would be grateful if we could have that feedback, because that is unacceptable. The most powerful way, in my experience, of people learning is when a patient, after the event, is strong enough to sit and tell them exactly how they were made to feel.

I appreciate that, but I'm sure that you will also appreciate that some families have frankly had enough and don't feel responsible for cleaning up messes that they haven't made.

My last question, if I can, Chair. There are some other things that I think we might want to come back to, and I'd be particularly interested—. You referred in your paper to the maternity improvement plan, and it might be useful for us—. I don't know whether that's a document that we could see or that we could—. I'm not qualified to understand the clinical detail, but I think it might be useful.

My last question is—. Professor Longley said in response to Nick Ramsay that cultures take a long time to change, that none of us would expect those to turn around overnight, and that some of the really serious safety issues arose out of those cultural issues. Can I just ask the witnesses how confident they are that those issues have been sufficiently addressed for the service to be safe, and whether they would be happy for somebody they cared about to be going into that service this afternoon to give birth? I ask that because I'm actually in a situation where not a family member but a close friend may be in that situation.

Perhaps the most significant way I can answer that question is that the board invited the head of midwifery, the support head of midwifery and the clinical director in to meet with the board four or five weeks ago and asked exactly the same question of the head of midwifery [Correction: the support head of midwifery]. Her answer was that, yes, she would be willing for a member of her family to give birth in that unit, and I think that's a very powerful reassurance. I think that we recognise that the cultural issues will take time. I think what Marcus has said through this morning's session is that there are checks and balances in the system now that were not in the system before that give us the assurance that the level of scrutiny on a day-to-day basis—. For example, I get a daily report on the staffing levels, the pressure on the unit and what's happening in the unit. That level of scrutiny gives much greater assurance than we would ever have had before. 

Maybe colleagues would comment as well.

I would certainly agree that the changes that have been made, the improvements that have been made—. I only joined the health board in September and I've seen significant movements in that time, with the maternity improvement plan, as you outlined as well. I think that's why we have made the changes that needed to be made at that time. Further improvements needed to be made again following the receipt of the Royal College of Obstetricians and Gynaecologists report, all of which were put in place—those that needed to be immediately made were put in place straight away. We do have excellent staff working in the unit, and they're absolutely committed to the service. I would have no hesitation in agreeing with what our head of midwifery [Correction: support head of midwifery] said at the recent board meeting—that she would be happy for a member of her family to have their baby there. 

Again, I would reassure you that since the first discovery that we were under-reporting, which was, as you know, the trigger for all of this, we've put things in place incrementally. At the time of the royal college actual review, before we had the report, with the immediate feedback they gave us a list of things that they felt were needed to improve safety, which were all implemented very, very rapidly, some the same day as they had suggested it was necessary. And then yet further improvements were made when we were able to co-locate on one site. The sobering effect, I think, of having read the report, for everybody involved in those services, has meant that they are much more committed, I think. As Angela has said, we've got some excellent staff who have really redoubled efforts to ensure that the services they are providing are safe for women, but not just safe but give a good experience, which is the other thing. In some ways they are different things, because you can have a safe experience that still isn't good. And so, that's one of the things: that I think we've really seen people taking much more ownership of that, and that is part of the start of the cultural change that we need to see. The fact that we've got all of those people co-located so they can work better as a team, I think, has definitely improved safety.

That is encouraging, and I think we'd probably all want to echo what you've said about there being lots of very good people working in those services who are absolutely doing their best, and indeed the reports reflect that and reflect how difficult it is for them. But what you've just said is not entirely consistent with what Professor Longley says about the culture persisting. Because you can have the best systems in the world, but systems are only delivered by people and if those people are still saturated in a culture that doesn't treat their patients with respect, that doesn't take their concerns seriously—do you see what I'm saying? I mean, I'm hearing you say that if you had daughters and daughters-in-law in that situation, you'd be happy for them to give birth there, and that's really encouraging, but yet at the same time, Professor Longley, you've just said to Nick Ramsay that the culture persists. 

I think the cultural problems are not resolved and that is absolutely the case. I think what we have done is put in place the checks and the balances to make sure that those cultural issues, as they persist, cannot ever endanger people's safety, and I think I can say on behalf of the board that safety is completely non-negotiable. So, we have made it absolutely clear that if there's ever a situation where we say, 'Can we afford to make this service safe?', that isn't even a question, because of course we can. So, as far as the board is concerned, that is competently non-negotiable.

Okay. I'll leave it there, Chair.

Dawn, to round things off. And if we can't get to all the questions, we will write with additional questions. Dawn.

Just a couple of points, Chair. Thank you. From my understanding of the meeting I attended with the health Minister—Mick Giannasi was at that meeting, who's chairing the oversight panel, and he was saying that, obviously, they're going to be monitoring very closely the improvements that the board are putting in place, and he's required to report quarterly to the Minister on that, and, obviously, will be making recommendations along the way if he's not satisfied with those changes. But you've also said that you have instigated some changes already, and you've outlined some of those.

One that I was particularly concerned to get a little bit more detail about—and if we haven't got time for you to provide it now, then perhaps we can hear about it—was the serious incident reporting. Now, this whole thing started because you had a new head of midwifery who noticed that serious incidents weren't being reported in the correct way, or some serious incidents weren't being reported in the correct way. And I think, Marcus, you were saying that you've now got a system in place that will ensure that that can't happen in future. I think it would be helpful for us to know what that system is and how that is now foolproof in terms of dealing with serious incident reviews.

If I could give you a very quick overview, and if it will be helpful to put a note into the committee, we'll be very happy to do that. We have a maternity information system that captures all information about everything in an individual's pregnancy and labour. And we now have an agreed trigger list, which has been agreed by all of the heads of midwifery in Wales, and those are the trigger lists that would trigger, automatically, a serious incident report, even if an initial assessment identifies that with that unexpected outcome there wasn't anything that could have been done to prevent it. So, we've got that trigger list. We've got the maternity information system. The expectation in the system—. Before you can log out when a baby's born, you have to identify now—we've put a technological solution in that asks, 'Has any of these things happened?', and if it has, they automatically trigger a serious incident report. But we also now have weekly check with the head of midwifery and the risk management midwife who looks at what serious incidents have been reported, and they reconcile that to the information systems. They can immediately see if there is something that's on the trigger list that hasn't been reported, and there they can go back to the attending midwife and make sure that that report is in place. So, there are a number of checks and balances that the chair referred to earlier in the system that now mean that it would be really, really difficult for that incident not to be reported. But I'm happy to put a note into the committee to explain how that works. 

Okay. That's fine. Thank you, Chair.

David, briefly.

A very brief one. It's going back to my earlier questions on the complaints process and the response from Allison Williams indicating if she checks everything off. I've just been to revisit the report, and the conclusion is: lack of comprehensive investigation resulting in incomplete responses to concerns; lack of access to all appropriate information; notes being unavailable; missing elements from the record or inaccuracies; missing reports about the conditions involved. I don't see that as a thorough investigation. So, perhaps you might want to revisit the actions. Because if you're signing things off and the report is saying that, there is an issue on the complaints process.

Perhaps if I could just explain. I believe that part of the report was referring to the root-cause analysis reviews of incidents. That is we've had the delivery unit working with us over the last couple of months with the retrospective case reviews, completely reviewing the process for undertaking the root-cause analysis reviews of serious incidents. So that was clearly an issue and a weakness that we've now already strengthened. But we'll certainly go back and have a look at that in the context of the complaints procedure as well. 

It does come under the heading of serious issues about the way that the concerns and complaints were investigated and responded to. 

Okay. We're out of time. There are some remaining issues. Also, we take our responsibilities to the people of Wales seriously in this committee—in this particular case, the people of Cwm Taf—and we will be discussing the way forward as regards how we continue our scrutiny of the performance of maternity services. Because, at the moment, it's still a live scrutiny for us as a health committee here. But we're grateful for your attendance this morning. We're grateful for your written report beforehand. You will receive a transcript of the deliberations this morning for you to make sure they're factually correct. But we will be in touch as well further. Thank you very much indeed.

And to my fellow Assembly Members, we'll now break before the next witnesses for 10 minutes—11:10. Okay? 

Diolch yn fawr, Gadeirydd. Good morning to you all. Picking up, really, on our previous session, following the revelations about the situation in Cwm Taf, the health Minister has written, as we understand it, to all local health boards to ask you to assure yourselves that your maternity services are safe and fit for purpose, and are services in which women and their families are treated with respect. So, I'd like to start by asking you how you've responded to the Minister's letter and how confident you are, in the light of some of the issues that have arisen in the Cwm Taf situation, that there's nothing like that for us to worry about in the services that you're providing.

The microphones work automatically.

Thanks very much. Obviously, the report was difficult reading, I think, for us all in the NHS in Wales and more broadly, and I think it would be fair to say there's learning for everyone from it. We considered the recommendations and the detail of the report in the context of our own services within Swansea Bay. Our conclusion, overall, was that we felt our services were generally of a high quality and safe. There are a number of reasons why we felt that—our own patient feedback, for example. We do a friends and family test in Swansea Bay University Health Board, which is a regular test,= in terms of whether you would recommend your friends and your family to receive services. Of 9,000 patients in our services—in maternity services—98 per cent would recommend our services, so we took some, obviously, assurance from that.

The all-Wales patient experience survey—we looked at that again, and, again, there was a 98 per cent positive response in terms of our communication, 96 per cent in terms of privacy and 97 per cent in terms of dignity. We also checked our training records just to make absolutely sure in terms of our different professions and groups involved in services around maternity-specific compliance, which was showing 90 per cent compliance. We looked at our staffing—so, our midwifery staffing. We looked at our consultant staffing and our medical staffing in terms of rotas and cover within the labour ward, and at the Birthrate Plus staffing levels for midwifery, and we were compliant with those. And, of course, we're part of the Welsh Government monitoring as well.

We've also revisited the culture. How open are we? How confident are people to say what they think? We have weekly safety huddles, as we call them, where any issues of the previous week are considered with all members of the team. That's well attended by different members of our maternity services, and it's facilitated by midwives and consultant medical staff working together. So, we took some assurance from that. There's clarity of roles in leadership, and from our human resources people indicators, there are not high levels of disciplinaries or grievances.

Having said all of that, as I started my answer to your question, there are lessons in it for us too. So, whilst we took some assurance from that deep dive into those issues, there are a number of things that we need to do as a consequence of it. One thing that we specifically are changing is we're streamlining our leadership and governance arrangements. We have maternity services in two of our different units. We're bringing them together, with one single leadership and one single governance system, because we have Neath Port Talbot Hospital and we have Singleton. They will now be managed, in terms of maternity services, together.

Fetal surveillance is an area where we are looking to increase training, and we're also looking to bring in a specific post of a fetal surveillance midwife, on a pilot initially, to bring that in so that we can, I guess, improve our surveillance in that area. And we will be more regularly reporting through to our board governance in terms of quality and safety indicators. So, there are definitely things we will do differently as a consequence, and of course we're also in conversation with the board, looking at the impact across other services, because there's broader learning.

Thank you. That's very helpful. If I can take you back to get a little bit more detail about the culture around how comfortable staff are in raising concerns. I quite like the idea of a safety huddle, I must say, but then I'm a soppy person who comes from the third sector, so I like that kind of thing. Are you confident that across the health board, and not only in maternity services, staff would feel able to raise concerns if they had them? How easy is it for staff to access senior managers—the board, if necessary—with concerns that they've got?

Our leadership approach is one of visibility. So, since I joined a year ago, my colleagues and I, we spend a lot of time out and about. We don't like sitting in our ivory tower in Baglan. No disrespect to our wonderful offices in Baglan, but we like to be out an about. It is a contact sport, leadership, and I think people need to see us, listen to us, see that we're human and talk to us. So, we work really hard to do that in terms of being accessible to our people. We get lots—. I mean, we use social media as well, in terms of our communication. I personally use social media a lot. We get lots of feedback from our staff on our intranet, lots of anonymous comments on the intranet, and I've been trying to find a way of people—. So, there's something about people who are raising concerns; they're not always putting their name to their concern. So, what we—

So, there's something going on there, perhaps.

So, what we've done as a consequence of that—. We can communicate. I can communicate with people anonymously—it's really interesting—and they communicate back. They just don't say what their name is. So, I've been saying, 'Talk to us—come to us directly.' We need to get underneath some of the comments. So, we've just set up in the last two weeks a guardian service, which is a confidential service for our staff. It's run 24/7. It's not run by us, and it gives anyone the opportunity to raise any concern, whether it's about patient safety or staffing. This is the first health board, I think, in Wales to do that.

Who does run that service for you? That's a really interesting initiative.

So, we tendered for that service in terms of looking for outside companies to provide it. It's a non-NHS service, and we'll see how it goes, but it's in response to people saying that sometimes people don't want to say who they are. We don't want to lose those people. We still need to know. That wasn't as a consequence of this report. We were putting that in place anyway from feedback from our staff survey, and from our walkabouts and our social media interactions. So, it's just an added avenue for people. It is totally confidential. The people who take the calls have nothing to do with the health board, in that sense. And then they have a direct line into the vice-chairman of the board, and in terms of, you know, out of the executive sphere. So, we're just trying to make it as easy as possible for people to be able to raise their concerns.

That's really interesting. As that service rolls out, it would be really interesting to see how that works.

The other important thing is that, when we do get one, even if it is an anonymous suggestion on the intranet, we try and get into that area very quickly, and then from a leadership perspective it's pointless us saying 'We're open and transparent' from the HQ. We've got to actually live what we're actually saying from a leadership point of view. And some of those senior managers have a bit of a moment, when we walk into an area—sometimes unannounced, sometimes announced, sometimes with independent members, sometimes not—but also then ask the senior manager of that area to go away, so that we can actually talk to the people that are delivering care, because in the capacity that we operate, we deliver care in the umbrella sense, but it's important that we get a feeling from the people on the ground. Some of that can be very small, but it can improve what we're giving to our patients and the population we serve. So, it's then very important, and we hold ourselves in this space regularly as an executive team, around coming out of that area and doing what we said we were going to do, so that we can actually go back and move the organisation on. And we believe that we will move the organisation forward with that style of leadership.

Thank you. How is the board performing against the 30-day target for responding to patient concerns? Can you tell us a bit about what you do to make sure that patients are adequately supported to raise concerns and that they're supported once they have raised a concern?

In ABMU as was, and now Swansea Bay, we've significantly improved our response time in relation to concerns. So, 12 to 18 months ago, around 50 per cent of our concerns were responded to within 30 days. That's now 83 per cent. So, there's been a lot of effort, a lot of commitment, a lot of focus to make sure that we—. Well, we're exceeding now the Welsh Government target, which is 75 per cent, but we've also set our own target, which is 80 per cent. So, we are exceeding that. We're still pushing to get that even further. So, there's been a lot of progress in relation to that. I think the other focus for us is that it's not just about a timely response, it's about an appropriate response and a compassionate and caring response, and the approach that we are instilling in anyone in our organisation who's working either in concerns teams or locally is that we need to welcome concerns, welcome complaints, because it's free research and its free feedback and it's something that's really important for us in terms of our culture. So, that's something else that we're trying to do. So, timeliness is much, much better. We're working with our teams in terms of the style of response, and we continue our focus on that. And, obviously, we meet people who raise concerns—give people an opportunity to meet. I meet people personally as the chief exec, colleagues do, and certainly locally, everybody's given that opportunity.

That's really helpful again, thank you. So, just finally from me, could you tell us a bit about the board's scrutiny of this process, all of which sounds pretty healthy to me, to be honest? How do they assure themselves that you as an executive team are delivering what you should be delivering, and that when there are things to learn, if there are things to learn from patterns of complaints, that they've got a handle on that as well?

So, just a couple of reflections on that. Obviously, there are formal board meetings. We have a formal quality and safety committee, which is a formal sub-committee of our board. We've recently changed our leadership of that committee, actually, which gives an opportunity for a fresh look. There are always opportunities when somebody comes in with new eyes. So, we've done that. There are sub-groups, then, below that quality and safety committee that focus on particular areas. So, whether it's concerns, risks—different areas of quality. So, there's that formal mechanism, and what this new chair of the committee has just introduced is he is actually inviting all of our unit quality and safety groups to come and assure the committee of what they're doing in a way that we weren't doing before. So, we're looking to improve that, and then we will triangulate that by the visits. We've just re-established independent member board visits out and about, sometimes with us, sometimes not, so they can see it, feel it, and touch it as well as read about it. But we are reviewing that and we're reviewing that again in light of the recent events. How do we know? How can we be assured? They're very big, complex organisations. What else can we be doing to make sure we're as assured as we can be at the board? So, we're having a consideration about how we do that now. Part of it will be like the world cafe dating events where quality committees from each part of the organisation will come and talk to board members about what they're doing and how they're doing it in a bit more of an informal way, but a deeper way, to get underneath what's happening.

Thank you. That's very helpful.

David Rees.

Diolch, Gadeirydd. Good morning, everyone. I will, for the record, thank you for the briefing last Friday as well, because, obviously, as one of the AMs in the area, I did attend that briefing. But I did ask the question last Friday and I'll ask it again—on your financial position. Obviously, one of the targeted intervention aspects was the financial performance of the board and you're in a one-year approved programme at this point in time, not the three years. So, I suppose, how is financial outturn being addressed? When do you think you'll be in a position where you'll be having a three-year plan approved next?

Thank you. Hopefully you will have seen from the briefing—and our financial position is pretty public anyway—that over the last three years we've reduced our deficit. So, in 2016-17 we were running at £39 million overspend at the year end. In 2017-18 that was down to £32 million, and last year, 2018-19, that was down to £10 million.

It is fair to say that the £10 million was because of—

That's what I was going to say. We did get a gift of £10 million, so that would have been £20 million in terms of comparing like for like. So, £39 million to £32 million to £20 million. So, that's steady progress, obviously, in the right direction. We are working very hard to get the organisation in a place where it's de-escalated from targeted intervention and in a place where we can agree a three-year plan. Our ambition is to be able to do that during this year. So, we would like to be, in a year's time—we won't be in no escalation, but at least de-escalated to enhanced monitoring, and hopefully with the three-year approved integrated medium-term plan.

What's happened since last year to this year? We've now got an organisational strategy we didn't have, so we know where we're trying to go. We have a detailed clinical services plan approved by the board, so our planning has really taken off in the last year. Our performance has improved around a range of measures. We still have financial pressures, we still have unscheduled care pressures, but we are moving in the right direction. So, that's the ambition at the moment. I couldn't tell you today I guarantee that's going to happen. There's still work to be done. We've got to deliver our promises this year as well, but that's where we're hoping to take the organisation.

Your paper identifies that in fact you have a sort of underlying deficit position for next year—or this current financial year, now we're in it—of £30 million. Seeing as some of your reductions were non-recurring costs last time, do you now believe—? You know, where do you think you'll be at the end of the financial year as a consequence of that £30 million underlying deficit?

That's right in terms of the end of last year—£30 million deficit. So we've worked through how we need—. Obviously there are additional costs, but there are also additional investments in terms of the settlement we've had—we've had more money. So, we've worked through all of that to determine how much we need to reduce our costs by to enable us to balance, and we've got a £21.3 million savings programme that we need to deliver within the context of that brought-forward deficit to enable us to get to a position, hopefully, in 2020-21, of going into that year in a balanced position.

The non-recurrent/recurrent point you make is a really valid one, and every time you make non-recurrent savings, you've got to find them again. There's definitely more work for us to do to change that balance. There will always be non-recurrent opportunities and there will always be non-recurrent savings, but in terms of the proportion, last year a quarter of our savings were non-recurrent, which means you've got to find that again. So there's still work to do on that, and what we are also trying to do is be a bit more strategic in terms of looking at how we spend our money, making sure we spend our money in the best way, with value-based healthcare as an approach to where we spend our money, so that it's a lot more in terms of value and opportunity rather than cost-cutting. So, we're trying to change that balance as well. I think now we've got the clinical service plan, we know what we need to do, we know what we need to do over the next three years, we know the changes that we need to bring in, and we just need to marry the money to the plans, and that's what we're trying to do.

On that basis, your non-recurrent savings have been taking a large proportion the last few years, and you just mentioned what you'll have to have saved, what you're planned savings are. What percentage do you anticipate, of those planned savings, to be non-recurrent?

In the year that we're going into?

Yes.

We're looking to—. Of the £21.3 million, we are expecting on top of that some non-recurrent benefits as you get every year, probably in the region of £4 million to £5 million. In a £1 billion organisation, that's okay. But in terms of our main savings plans, we need to change that balance. It's not going to be where we want it to be this year, David. It's not going to be the right proportion. But we have three work streams. We have one that is called unit cost reduction, so unit plans within the different parts of our service. Some of those are strategic, some of them are service changes and sustainable, some of them will be taking opportunities to reduce costs. Then there's a range of programmes—high-value opportunities we call them—which are health board-wide approaches to change. Where we were a couple of years ago, you'd just put out a cost reduction target and expect a service to tell you how they're going to save it. So, we are trying to blend that with strategic change and change that mix. 

That's interesting, because obviously your approach has been identified in your paper—that you're going taking more of a strategic approach, rather than the top-down arbitrary approach there has been in the past. So, how do you see that working? Because it's very easy to talk about a strategic approach, but things happen that upset that approach. Circumstances arise, winter pressures come in, events occur. So, in your strategic approach, how are you looking at that and how are you working with, perhaps, the local authorities in that agenda for your strategic approach? Because I have many colleagues in local government who are deeply concerned about their finances and then they look at the health boards and they ask the question why they are continually in deficit.

If I start, and then I'll ask my colleagues to support the conversation, particularly in terms of local authorities and the work we're doing there. When I talk about a strategic approach within the health board, what we're trying to do is have a lot more consistency about what we do. We know there are opportunities and what I don't want are six different answers, or five different answers to an opportunity, depending on which part of the organisation we're in. So, for example, we know there are opportunities to become more efficient and there are national Welsh opportunities that are being given to us on a plate in terms of national benchmarking and efficiency that Welsh Government's finance delivery unit—. There are opportunities we know we can gain from. So our strategic approach to that is a health board-wide programme of change to deliver those savings, as opposed to 'Let's see what each unit can do.'

In terms of the broader approach with local authorities, the commitment that we've given in the last—it's not just local authorities, but particularly local authorities. We need to partner like we've never partnered before. None of us can deliver unless we really work together in a truly integrated way, because they're the same people. They are the same population. And there's a lot of work ongoing in terms of working with local authorities around our unscheduled care pressures and some changes that we're making. But if I ask Sian to share some of that with you, and I'm sure Chris would want to come in, and possibly Richard. It's a major plank of our change. 

Okay. So, specifically on the joint working with the local authorities, we've got really strong partnership arrangements through the now West Glamorgan regional partnership board—it was the Western Bay RPB previously, which we had in place from 2012, so before it was made a statutory requirement. And last year, we undertook a significant governance review of the West Glamorgan arrangements, just to make sure it was fit for purpose, if it needed to be more strategic in terms of the work that it was doing, and supporting a lot of long-term service change across the region. So, we've re-looked at that in terms of three key work areas. One of those is around adult services, the second is around children, and then the third one is around integrated services. 

So, just a couple of specifics on each of those. If we look at the adult services transformation board, one of the key areas that we clearly work really closely on together is around older people's services. We've got integrated services and integrated teams across the region, but we jointly, with the two local authorities and third sector colleagues, in the autumn of last year, did a survey of people who were in our beds across the system—so, across our three acute hospitals, and Gorseinon Hospital as well, and local authority residential care and local authority beds as well. And we've developed a model that is called Hospital to Home, which is really focused on a whole-system approach, but really very focused on strengthening our reablement services. And that's been jointly developed with the local authorities and working with the Institute of Public Care in Oxford Brookes University—John Bolton. We have actually submitted a proposal to Welsh Government for transformation funding for that proposal, and we were using that as a way of seeing service change this year, but we were also going to be able to see that as a way of delivering some financial savings within this financial year. We haven't had a response in terms of the transformation fund, but because it’s so important to us as a region, as a system, we’ve identified integrated care funding to be able to take that work forward this year as well. So, that’s an area where we’re looking at seeing strategic change across the whole system, including local authorities, third sector partners—and clearly see savings coming out of that as well.
 
And then, I suppose, a couple of other areas just to focus on in terms of the transformation fund—and this is longer term in terms of service change, remodelling services, but in terms of really focusing on the well-being of future generations, focusing on our communities. Within West Glamorgan, or primary care clusters have received funding through the transformation fund, so that we’re able to roll out the cluster approach and the integrated cluster approach across all eight of our GP clusters, and we'll be the first health board in Wales that is actively rolling out the whole of the primary care model. So, we’ve had a significant amount of funding for the transformation fund through that process. And as well as that, through the regional partnership board, we’ve had funding to develop what we’re calling ‘our neighbourhood approach’. Services are in two of the neighbourhoods at the moment, which are aligned with the GP clusters, and that’s very much focused on a neighbourhood and community asset approach, working with local communities, people within communities, to try to develop community resilience, and that would then be more of a wraparound service with the cluster work that’s going on to really help communities as they develop their own resilience, so to reduce reliance on some of the statutory services. So, we’ve had funding from Welsh Government for two of those neighbourhoods, and again, we’ve submitted proposals to roll that out across the whole of West Glamorgan. We actually had a presentation on that at our board development session yesterday with Neath Port Talbot local authority, with the future generations commissioner there as well. So, we're using some of that in terms of some of our longer-term approach to delivering changed models of care with local authorities and with communities as well.

Thank you, Sian. 

I’m just wondering whether you wanted to add anything.

Chris?

I’m happy to add to this perspective, but I’m sure we’ll be talking unscheduled care in a moment.

Oh, I'm sure. 

And I’m mindful of how much detail I can go into.

I’ll move on then, because we are looking at the financial position this year, and we’re looking at the financial position last year, which ended April 2019. Of course, last year was ABMU and the footprint was different. We now have Swansea Bay, and the footprint, again, is smaller. So, are the figures you’ve now produced based upon the ABMU footprint so that we can do comparisons? Are they based on the Swansea Bay footprint, which will make comparisons a little bit difficult, because they aren’t the same groupings necessarily, because they’re not actually the same services?

The figures that I quoted to you in terms of the current plans and the savings plans, they’re based on the Swansea Bay footprint. There’s a due diligence exercise going on at the moment in terms of finalising the move and the change from 1 April. End-of-year accounts aren’t final yet, so there’s still some discussion to be had, and to finalise the exact agreement between Government and us and Cwm Taf Morgannwg. But in terms of our plan for Swansea Bay, that’s what I talked to you about earlier. So, we know what we need to do within the new footprint of Swansea Bay.

So, those figures are for the smaller footprint.

They are, yes.

And when you come to the end of the financial year, will you have comparative figures for that footprint this year? Are you in a position to be able—? So we can do comparisons, in other words. If you look back and do a comparison, will you be able to do that by the end of this financial year so that that comparison can be made?

We’ve been working hard to disaggregate the finances in terms of commissioning budgets and provider budgets, so we should be able to—. There’s been so much work put into that. We should be able to show ABMU, and ABMU without the Bridgend part of it, but also in terms of other areas of work—so, our performance. We would report unscheduled care for ABMU, referral to treatment times—we’ve done quite a bit of work to disaggregate that, because we want to know that we’re comparing like with like. As we move forward, it’s really important that—. It’s a different organisation now, so we are working on that. We should be able—

And you’re still in discussions on the disaggregation of the deficit, for example, with Cwm Taf? Because, clearly, an element of this is going to be that, if you're in deficit and Cwm Taf weren't, an element has gone over, and it technically carries through with it some deficit aspects. So you're still in discussion as to how that is disaggregated.

We've obviously worked through that, and we've been working with Cwm Taf on that. The Bridgend part of ABMU is in deficit, as is all of ABMU—it would be a bit weird to think that Bridgend isn't and the rest of it is. That's part of the due diligence exercise, to test those assumptions, to test whether our assessment of that is appropriate. So, that's going on at the moment.

And since I'm on the budget, just one last question, Chair. In your paper, you say that, in practice, this is an administrative change and not a service change. I've always said I'd challenge that, because, hopefully, in the first year, there will be no service change, but you are actually handing over services to another health board, they will prioritise their needs—and we've just had them in, and, clearly, they've got some serious priorities to address. But there is going to be a service change down the line—there has to be, because that is the way in which it will work. So, I don't think it's appropriate to say it's only an administrative change—there is more than that. So, I suppose I'm asking the question: how are you preparing for those changes? Because, as you know, many of my constituents will actually be still going to Princess of Wales—partly because it's actually the closest hospital to them, but also because they are already under consultants there. Now, they, I assume, will not see any difference or change, because that's going to continue, but, at some point, they're going to be asked to move out of Neath Port Talbot Hospital for some of their services, and you'll be looking to put more of your services in Neath Port Talbot. What schedule, and what type of timescales, are we talking about to actually start seeing these changes happening, so that people in our area are aware of that fact they may no longer be going to Bridgend to see their consultant—they may be going to Morriston, they may be going to Singleton? So, have you got a timescale in your mind as to when these types of proposals will come into effect?

There is no schedule of changes in the way that you've described. And, as you say, it is an administrative boundary change in that sense, so there'll be no planned changes from 1 April as a consequence of this change. And we've worked really hard with Cwm Taf to make sure our patients don't see or feel any difference from 1 April. That means we've got about 50 service level agreements between us, where we continue to provide some services now for the Bridgend population, and vice versa. What we've agreed with Cwm Taf Morgannwg is that we will continue a monthly executive-to-executive meeting with them, so we keep close, that it's not over, in the sense there are still some services we've agree will transfer that we need to work through—mortuary is one, our ICT services are still joined. So, there's a schedule of changes like that. But it's also really important that, as exec teams, we keep close to one another.

There will, inevitably, be change in service—there are always changes in the way we deliver NHS services. So, from our point of view, it is very important that we are very tight on that. But there isn't—. I haven't got—I don't know if our planning director's got one—I haven't got a plan that says, 'This is going to change then, and this is going to change, and Cwm Taf are going to change the way they do that, and we're going to bring this service back.' That's absolutely not been the focus, in terms of the work. It's been transferring the staff—as I say, not impacting on patients—and we spent quite a bit of time reassuring the public of that—Allison and me personally, together. But, as I said, the NHS will change, it does change, and we just need to make sure that we work close with them.

And the only thing I would add to that is that, if there were to be any change, then we would work with the CHCs, in the same way that we do any engagement and discussion with the public around service change at the moment. So, if there was to be a suggestion that patients might need to go from Neath Port Talbot to Princess of Wales for any services, or vice versa, or from Neath Port Talbot to Morriston for any services they currently receive in Neath Port Talbot at the moment, we would go through the same sorts of engagement, discussions, working with the public, working with patients, about what the impact of that was, to take it through our board, and the Cwm Taf Morgannwg board, if that was appropriate, as we do for all other service change. So, that would be the same as we currently do for all service changes.

Because, obviously, sometimes, change can happen by creep, not necessarily by plan as well, so it's important that you keep an eye on that process.

Yes, and we have, as Tracy said, a schedule of all of those services, which we currently have those SLAs with, between the two organisations, and we will be having ongoing discussions with Cwm Taf about those SLAs, to make sure that that creep doesn't happen.

And I think, as Tracy said, we have the joint executive team meetings coming up. We had one of our 'meet the exec team' sessions in Neath Port Talbot Hospital a couple of weeks ago and were asking whether there had been any suggestion of any of these changes happening, which people hadn't picked up, and we asked anybody, if there were any of those examples, to bring them up directly to members of the exec team.

Can you give us an example of one—[Inaudible.]—that staff might know, but the public wouldn't know, and I only sussed this when I asked the question, and you mentioned maternity. Neath Port Talbot came under Bridgend for many, many years. And, in fact, four of my grandchildren were born in Bridgend as a consequence of this. Now they're under Singleton. I bet you that a large proportion of the public don't know that.

So, they're not under Singleton at the moment, but that is—

In terms of the leadership changes that I talked about earlier.

And where they may end up going as a consequence of—if there needs to be an emergency.

This is not about service change; this is about one unified governance system and one unified leadership system within Swansea Bay health board. So, that's what that's about. It's not about shifting or changing services—we're one organisation. I just think when you've got five—. We've now got five units, we used to have six. To have maternity services in two units, coming up with parallel reporting systems—they come together at the top of the organisation. It's more about that.

But patients—I can tell you now, patients used to be taken to Bridgend or sent to Bridgend if there were complications with births. They are now sent to Singleton. So, there is a change, and people don't understand that difference. I think it is important that perhaps the message gets out to people as to where you now may be having some of your care. It still needs to get out there. I'll leave it with you.

Absolutely. Yes, we'll look at that outside.

[Inaudible.]

Diolch, Cadeirydd. Good morning, everybody. How are you? Just a couple of questions around winter preparedness—the perennial—. How did it go last year, basically, in the key areas, I suppose: elective surgery, out-of-hours GPs, ambulance response times, A&E waiting and discharge planning? How did it go last year and how are the plans progressing for this year?

So, I am going to give my colleagues a chance to speak, otherwise you'll be fed up with my voice. It was better this year than the year before—

Good.

—but there's still more to do. But I'm sure Chris will fill you in on a bit more of that detail.

Yes. Please tell me when to stop, though, if I say too much. [Laughter.]

Oh, we will, it's all right. [Laughter.]

When you look back, I think we had a far better winter this winter than we had the winter before. I think the plans  we put in place were more resilient. I think we had better bed equivalence in the system to underpin our bed base. Clearly, there was less flu floating around this winter and there was less norovirus in the system as well, which, obviously, helps to provide an unscheduled care system. 

We've already taken those reflections out of this winter, looking at what else we could do into next winter. So, to underpin the financial plan that Tracy was talking about, we are now looking at what is our bed plan for the organisation for Swansea Bay, moving forward, because what we were having was that each unit had their own bed plan and that wasn't encouraging the units to have an overarching view of how that fits.

I think, in last year's winter reflections, we were talking about, 'What does our system offer?' So, we're now talking about more detail with Welsh ambulance colleagues around pre-front door—how we can stop people coming in—and we are having success: if you look at our ambulance emergency department conveyances, they're going down. 

We're also having some good success with our integrated care of the older person at Singleton. That's been held up as an exemplar in the ambulatory emergency care audit that the delivery unit has undertaken and that's mirrored now at the front door of Morriston, where it's called something slightly different. We will get the names unified over the next few months. It's called 'the older person's assessment service' at Morriston, and they are slightly different, but, fundamentally, they have the same output in so much as being medically-led, but with therapy and nursing support to make sure that they can pull back into the home before people start experiencing muscle wastage and then they keep their independence. So, I think there's some success there.

We are seeing acuity going up, because of those two successes there—the patients actually getting into a bed are more ill. But, at the moment, the internal process that we've changed over the last 12 months—our average length of stay hasn't gone up at the moment. So, rehab teams, our nurses and our therapists on the ward are using the rehab indicators wisely.

You're getting them through the system quicker, did you say?

Our average length of stay, with the context of pre-front door and front door—as I've just said, our average length of stay has gone down, albeit only by 0.4 of a day, but, against the context of more acuity and higher acuity patients coming through the front door, I think that's good. We have worked, as Tracy and Sian alluded to, with our local authority colleagues—hospital to home is one of them, it's based around the Stay Well@home model in Cwm Taf. We've also done an analysis of the differential from our community resource teams and our acute care teams out in the community. What's the differential shortfall against—if Stay Well@home is best in practice, how can we do that? We have some of our teams that are already there. So, that's the out-of-hospital model supplemented by hospital to home that we will be delivering. 

Clearly, it would be remiss of me not to mention the ambulance problem that we have with colleagues outside the front door of Morriston, that's the ambulance handover, and we are very mindful and we have regular conversations with Welsh ambulance colleagues around that there is risk in a community setting when an ambulance is outside Morriston and how we get to those calls. We manage to stack, we've got a GP at the Singleton end who's now taking patients off our stack directly, which is a new innovation and we're trying to keep that going and reflect on that and bring that—

How does that work? Just get them off the ambulance into the—

No, they don't even come—. The ambulance stack is the pending calls that the ambulances have to go to in our area, so what the GP is able to do—

Right, this isn't a queue. Sorry.

It's in the queue to be picked up, so instead of being picked up and brought outside Morriston, they can then have a look at the clinical indication, have a conversation with the patient or the paramedic at source, and prevent that conveyance.

So, these are the alternative care pathways, which you used to talk about in the Welsh Ambulance Services NHS Trust, Tracy.

[Inaudible.]

We have a number of those. We've also, over the last 12 months, got our falls pathway up and running with far more traction. We've had a dedicated falls vehicle in Welsh ambulance so they can attend falls, so that patients are not sitting or lying on floors for lots of hours. We've also improved our fractured neck of femur pathway so that patients can come in. They don't miss A&E, because they can't miss A&E with that type of indication, but they need to get to the right ward sooner so they can be appropriately addressed, so, therefore, if they need to go to theatre urgently, they can go. We're also doing that in vascular. We're also doing that with our medical admission unit.

So, the flow out of our front door is quicker, but what you will see, and what we can't hide as an organisation, is the fact we still have our lost hours with our ambulances outside the front door going up. That's because we are clinically assessing. If a patient comes to the front door with a clinical indication that's difficult to describe, that's not okay, but that is stable, they're clinically assessed on the ambulance before coming in anyway and then they are superseded by somebody who's got a myocardial infarction heart attack or a convulsion or a respiratory arrest—that will take clinical precedent.

That isn't an excuse, what we still have to do—and we're working with the national collaborative commissioning unit under the director of unscheduled care, Stephen Harrhy. We're also working with DU colleagues, because we have to get some of those long waiters into a protected area. We have a number of areas—. I won't bore you with all the detail that we're trying to do to alleviate this, but we've got certain areas—we have been without a decontamination area in Morriston. We were upgrading it for the right reasons, because we didn't have a decontamination area that was fit for purpose with positive air flow. We now have; that's back on line. We've worked with Welsh ambulance, and we can hold three patients in that area at times of increased escalation. So, I think that will give us some options, and there are a number of areas that we are working on in the immediate and longer term.

So, the second part, if I may, is around what we are doing around the elective/unscheduled split, because we've still got a lot of our unit, our scheduled care, carried out in Morriston, and the more ring-fenced protected capacity we can give to our surgeons, then there's more guarantee that they will be operating on our population and giving them the service—

Are you trying to work towards continuation of elective surgery during that period?

We have provided continuation of elective surgery on the Morriston side through this winter by using a dedicated theatre admission unit, which brings patients in through a different way so that they can then go to theatre while the capacity is coming on line, and then they go back to the bed when they come out of theatre. So, we're doing that. That isn't ideal. So, what we're now trying to do, when we're talking about system, is work with Neath Port Talbot and work with Singleton. We've identified some theatre capacity in those parts of the organisation and some bed capacity to underpin it, so we're considering what type of specialities could go into that capacity, which would leave us with more bed capacity at Morriston. Then that would be used for medical patients that are at the front door. We don't want also the currency to be beds. More importantly that we have a currency of bed equivalents, as we were talking about—Stay Well@home. So, we don't want our older people to be in beds, but we need to provide a little bit more bed capacity at Morriston at the moment. We've had three peaks in the day at Morriston and those peaks are around about six to eight ambulances. If we can't clear the first peak of six to eight ambulances, the second peak becomes 10. So, there's something around creating that flow that you mentioned earlier. 

And I'll come on to the community care stuff in a moment. So, just to be clear, then: in terms of your priority actions, I guess with winter pressures your unscheduled care is the greatest challenge, and that is the area of priority in terms of planning for your winter preparedness. Yes? 

Absolutely our priority, but not seeing unscheduled care on its own, because we have to deliver scheduled care services.  

I understand that. Obviously, going back to a previous life, Tracy—the issue that you're all familiar is how we get people off the ambulances, because they need to be back out there on the next call, don't they? And the longer they're sat outside your A&E, the longer they take to get to anyone else. Thank you for that.

So, all of the lessons from 2018-19, which you've had some success with, you're rolling over into this year, or are you putting some new initiatives in place as well? 

We're embedding those in our unscheduled care system, because we want to move away from pilotitis, and make sure that we're actually putting the right things in for the patients that we serve, and that's underpinned by the community teams. For example, we have an ESD team—sorry, an early supported discharge team—in Neath Port Talbot, around Neath Port Talbot Hospital, working very successfully at the moment. It was initially put in to look after 10 to 12 patients—now looking after 18 patients. So, they've refined their processes and are doing a fantastic job and are up for a national award, which is lovely. But there's a slight difference in our ESDs around Morriston and Singleton. So, what does that ESD system need to look like for Swansea Bay moving forward? So, that we can get the same benefits for our patients in the other two units and, therefore, we are seeing that ambulances then should be able to get back into the community where the risks are where people are at home. 

Okay, all right. Thank you. 

Moving on. 

Moving on, yes. Moving on to the transformation budget—you touched on it earlier, Sian. Can you perhaps tell us a bit more about applications you've made to the transformation fund? I know you were talking about some of the work that you were doing with your GP clusters, building community resilience. That part of your transformation bid, was it? 

Yes. So, there have been, I suppose, four transformation bids in total. The first one was around establishing the Cwm Tawe cluster model, so really looking at how we can improve well-being across the age spectrum, and there was a particular focus within that on young people and carers. The second element was around co-ordinating services to maximise well-being and independence. I suppose that was particularly focused on older people. How we can move much more towards a social model of health—we've got some examples of social prescribing there, better using the workforce. So, that was the first bid proposal that went in, which was funded by Welsh Government, and alongside that—. So, that was Cwm Tawe, and there was one in Neath Port Talbot as well. Alongside that, through the regional partnership board, we put in equivalent proposals around developing the neighbourhood approach, which was very much based on the asset-based approach, which I mentioned earlier. So, those two were both supported. We had I think about £1.8 million for the primary care—the cluster development—and just under £6 million for the two regional partnership board proposals. We're progressing those at the moment, and that's going through our joint partnership arrangements. So, one in Neath Port Talbot, one in Swansea.

Then, we were also asked to submit a proposal to roll out the cluster proposal across the whole of the health board. We've got that. We got funding for that, just under £9 million. We're taking that forward in a phased approach. So, Cwm Tawe cluster and Neath are getting going, then by the middle of 2019-20, we will be extending that out to Loughor—Llwchwr—and the upper Valleys area, and then by the end of 2019-20 across the rest of the clusters within the health board area. And we submitted, at the same time, or slightly later, actually, in early April this year, an equivalent approach for the whole of the RPB area so we would have the equivalent of the neighbourhood approach. We haven't had a response form Welsh Government on those yet; they're still considering that. 

And then the second area was around really working up this hospital-to-home model, which is very much based on reablement, having a trusted-assessor approach—

And does this link into what Chris was just talking about? 

It would really support, absolutely support, the work that Chris was talking about. So, we've had lots of discussions with Welsh Government about that—still part of the process, going through the process. But because we as a region see that as so important to us, we've said that we will use some of our integrated care funding to progress that to enable us to have a model in place by December. 

So, you're working with other community partners, then—local authorities, social services. 

Yes. It's a joint piece of work that comes under the regional partnership board governance structure. So, it comes under the adult board, which is chaired by Dave Howes, director of social services in the City and County and Swansea, and the director of social services for Neath Port Talbot is part of that group, and the specific work programme that is about hospital to home is actually chaired by our unit director for primary and community services. So, yes, it has local authority and third sector involvement as well.  

So, taking Chris's point about how you don't want to be on a constant cycle of 'pilotitis', how are you planning to—because the transformation money, obviously, is to kind of pump prime; it's to pump prime some change, isn't it? But it's about saying that that change has to be transformational in the longer term. So, is that the objective for you?

Yes, absolutely, so the plans—. There needs to be some evaluation, clearly, to make sure that it works, but the planning, as we're doing the rolling out of these, is to make them self-funding and self-sustaining as we go through, and then that would need to go through our integrated medium-term plan or annual planning process. 

Okay, that's fine. Thank you, Chair. I'm happy with that.

Moving on—Jayne Bryant. 

Thank you, Chair. Good morning. What are the most significant workforce pressures currently and where are they? 

Thank you. One where we haven't got workforce pressures, where we had some pressures last year, is GP out-of-hours. I'm sorry to go back but we didn't pick it up, and we've had really strong GP out-of-hours this winter, which has really, really helped. So, that's positive. But we do have challenges in our emergency departments around workforce. We have challenges in our medical workforce at senior level and middle grades within emergency departments, and we have some challenges within our pathology services, radiology and some challenges in intensive care unit nursing, specifically, and in some therapies, I guess. So, those would be the hotspots. 

We've had some success in nurse recruitment. We've managed to bring hundreds of nurses into the health board over the last year or so, which has been positive. That doesn't mean that we're not still working hard to up our nursing numbers, but also our retention of nurses has gone up. So, we're keeping more people, which is really important as well, because there's no point recruiting lots more people and then losing them. So, that's a constant focus for us. 

But, I guess, in terms of the hotspots, those are the ones that we are working on and we've got programmes of work on, particularly in our emergency departments, given our earlier conversation. We've got a plan to change the way that we staff our emergency departments. We're looking at junior doctors, aren't we, Richard, and senior doctors, and Richard can tell you a bit more about the plan there? But there are a few hotspots that we need to take some action on. 

Okay. And how are you approaching the balance between filling the gaps to meet workforce pressures and supporting the development of new ways of working?

I think that's quite interesting, because in some circumstances, so some of the examples that Sian has talked about, we're pump-priming change—so, we can double-run in a way because we've got a bit of extra support to enable an investment, to test the change and then double-run two systems. In other parts of our change, we have to change as we go along. And that's okay as long as we know that that's what we're doing. So, we will look for opportunities for people to gain new skills, for people to take on broader roles in our therapies, in our support areas, where we can bring professions together. We have a workforce committee that reports to the board and our workforce director has just agreed with the board a strategic framework for the development of the workforce. So, we look at the whole in the round. How can we be more efficient? How can we be more productive? How are we skilling up people? How do we make sure it's not just the statutory and mandatory education, which is really important, but role development, personal appraisals, so we can give people opportunity to develop more skills. So, it's a much more rounded, I guess, strategic approach to workforce development moving forward. That's the approach that we're trying to take. 

And you're seeing some progress.

We are. We are seeing some progress, yes. Do you want to—?

Yes, just to add to that. So, I think in terms of the recruitment pressures—we're not unique in that. There are a number of shortages in specialties across the UK, so the challenge for us, really, is how to attract people to Swansea Bay in preference to other places. And, certainly, histopathology recently have been successful in that in using one of the agencies to source somebody for us, where we've had no applicants for a couple of rounds of recruitment, and have recently managed to secure somebody on that basis. So, I think it's looking creatively about how we advertise, how we recruit, making sure we're providing attractive job offers to people.

On the emergency department side, in emergency medicine, we've done a detailed piece of work with an external company who've provided some excellent advice to us about recruitment, not only in terms of staffing mix—senior, consultant level, middle-grade level—but also to profile that, Dawn, related to your question, on a seasonal basis, but also across the week. And we know we have peaks and troughs in the day. And, generally, particularly with medical staffing, we have shifts of hours that are the same every day of the week. So, this gives us the opportunity now to move forward with that in designing rotas for doctors and for nurses that profile the need during the day, during the week, according to seasonality, in a far more sophisticated way than rotas that run Monday to Friday in this way, Saturday/Sunday in another way. So, that offers us big opportunities.

And then, secondly, what's also come as part of that is understanding better who patents need to see. They might not always need to see a consultant. In which case, how we skill-mix our nursing staff—extended nurse practitioners versus advanced nurse practitioners—but also looking at some of the newer roles that are coming in now. So, physicians' assistants are gaining some traction. Swansea University are clearly, in the UK, one of the few centres that train people. We're taking advantage of that in terms of their graduates and their interns. So, it's a much more flexible approach to staffing, both in terms of the number of staff, the type of staff that we had during the day that match what the patients need.

Just on that, really: I don't know if it's the same with you, but with the hot summer last year, I know that my own hospital in my area had a very difficult summer—one of the busiest summers I think for 10 years—and the time it's taken them to recover—. It's a lot of pressure on staff and the hospital before you start the winter preparedness. So, did you find a similar problem? You haven't had much time to recover as you have in previous years.

Winter's getting longer.

And summer's getting hotter.

Yes. I think, generally, what you tend to find is the difference between summer and winter isn't necessarily the numbers that come through—it's the level of acuity in sickness. In winter we'll see more people who are more unwell because they've got a chest infection, whereas in the summer, we'll have loads of kids coming in who've hurt themselves, falling on harder ground in park, and elderly people with the heat. So, the numbers tend to be fairly constant—there's not much of a drop-off any more. It just means meeting the needs of the patients as they come in and present are just slightly different according to the seasons.

The other two things I'd add to that are we're having conversations with Swansea University around what an academic offer is, because a clinical fellow offer may help some of the gaps that we've got. So, myself and Richard are having meetings with colleagues there who we've known for a number of years. And the other thing is: what are we doing regionally? We're already outreaching to Hywel Dda for many services, particularly some of the specialist services, and could we make joint appointments moving forward? And I think that will give the system more resilience. And, again, we're having conversations with their medical director, Phil Kloer, around how we would do that. And we meet on a bimonthly basis. There's a senior leadership team—chair, chief executive—[Inaudible.]—director of strategy, medical director—around what opportunities we could have. And we've had some successes recently in cardiology. We we're talking around acute coronary syndrome work. That's worked really well. There used to be 35-plus patients waiting to come in from Hywel Dda. We're now down to eight to 10. Some of those are not fit to travel to Morriston. And likewise in dermatology, vascular, radiology, interventional, particularly radiology, which is a shortage nationally. So, I think we are seeing not only what we're doing in Swansea Bay, but how we are working as a region, to make sure that patients are not unfairly disadvantaged.

Okay. There have, quite rightly, been repeated calls for a greater focus on the health and well-being of the staff and workforce. What action is being taken to support this? 

We've got over 300 well-being champions in the health board. We started with 50 and we've now got 340. It has been quite a big focus for us in terms of the health and well-being not just of our population, which is a key responsibility of ours, of course, but of our staff, because if they're not well and strong then we can't look after the people we're there to serve. There's been a real push on well-being champions, who are championing well-being activities and encouraging people locally, so that's been really, really positive, with really good, positive feedback from that.

We also introduced a new service last year—a staff well-being advice and support service, from June of last year. That gives advice to our staff in a much quicker way in terms of helping people stay in work and helping people get back to work. Physiotherapy is part of that, for example, so musculoskeletal issues and advice—quick advice, or quicker advice than people had before. That's been really positive. I think there's been a reduction from 26 days to seven days to receive advice as a consequence of this service. So, there's a lot of focus on that.

The guardian service I mentioned earlier—the 'freedom to speak up' service—is also part of employee well-being, because people need to know there is an avenue if they can't address their concerns through other ways. The other focus has been on managing stress at work. So, there's quite a focus around skilling people up, and skilling our managers up, around workshops managing menopause at work—and I can champion that, as people will know. There are lots of different approaches to help our people look after themselves, and to be as resilient as they can and as strong as they can, to look after our people.

A fundamental part of that for us is the appraisal system. We are pushing and pushing to increase the numbers and the quality of that, because if you have a good appraisal system, and you get regular dialogue about your development needs and how you're doing, we know that that makes people stronger and more able to care for our people. So, we are working hard with our units to improve those rates. We have really high job planning rates with our medical staff, and 65 per cent on average for PADRs, or personal appraisals, for the rest of our staff. We are pushing that up to try to get that to 85. So, there's a bit more work to do there, but there's been quite a strong and vocal focus, I would say, on the health and well-being of our own people.

David Rees has a supplementary on this.

Actually, it fits into both—. I'm not sure whether I missed it earlier. The health and well-being of staff, in terms of stress—I fully understand the pressures they're all facing, and I totally acknowledge that—but, also, we want to help develop those staff, as you mentioned earlier. So, are you also ensuring that we train up individuals into posts that we find difficult to recruit in? I know there's a chance that those individuals then move off, but it is important that we have the training schemes in place to help them. Are you giving staff sufficient time to study? Even if you're not going for that sort of approach, to keep up to date you need time to study, and that adds to your pressure and to the stress on individuals. How are you managing those types of arrangements to ensure that we can train our own specialists in areas where we need them? Maybe, to an extent, it could even be apprenticeships, in one sense, in certain areas, because it's not all about doctors, but about other health professionals as well. Are you giving them sufficient time? Is that also an issue with nursing? Because, obviously, we see a lot of nurses going to agencies and banks now, and we want to try to ensure that they actually feel fulfilled and that they're supported in their development as well. 

Just a few comments on that. We have an apprenticeship academy in the health board, which is amazing. I've not seen that in my 35 years in the NHS in Wales. There's been a real focus on training apprenticeships and supporting apprenticeships. We brought our apprentices to the board last month to talk to the board about their experience of being an apprentice in our health board. So, there's a really positive focus there, similarly on graduate trainees and focusing on enabling people to develop.

In terms of nursing, there's been nearly a £4 million investment in nursing numbers. Part of that is, obviously, the Nurse Staffing Levels (Wales) Act 2016 and part of that is making sure that there is, built into rotas, time for development and time to cover leave so that people can be supported to develop, and that's quite important. And then we talked about agency, and part of our approach in nursing is about trying to grow our own, so we give people, some of our support workers, the opportunity to do part-time degrees, so they can work and train and study and become some of our nurses of the future. So, we are working hard to try to do that. Another focus has been on increasing the essential, mandatory and statutory training for our staff, because that's obviously important as well. So, there's a bit of a coherent, I guess, co-ordinated approach.

The other part of our focus has been on leadership development, which goes back to some of the other comments around the fact that you've got to feel well led, you need to be well led, you've got to feel supported. So, we've put a great deal of effort into award-winning leadership programmes. One is called Bridges and one is called Footprints and they're for different levels of leaders in the organisation. It's about values-based leadership and it's about treating people as individuals and caring and compassionate leadership. It doesn't mean not managing, but it's in terms of the style of leadership we're trying to bring into the organisation. So, that hopefully gives you a bit of a flavour of what we're trying to do.

I just want to come back to Jayne, to give you two great examples in terms of well-being. One of our gastroenterology consultants suggested that he'd like to undertake a session on mindfulness for staff at Morriston Hospital. They were a bit sceptical about booking it but booked a room in the education centre. In the end, they had to book a bigger room and were oversubscribed within a week, with all levels of staff attending that session—hugely successful, fantastic feedback, and obviously we've asked him whether he'd be willing to undertake that again.

And a second example: we've got some registrars in surgery who are undertaking research projects. They've looked across Wales, actually, at burn-out scores amongst junior doctors, and not surprisingly, in terms of hours worked, found that the burn-out scores were high, but particularly identifying particular indicators that might suggest that people were either at risk of burn-out or there. And also sleep deprivation scores. Using that information, particularly at Morriston, they've allowed their junior doctors in the surgical rota to redesign their own rota completely, so they've added in an extra rest day or they've reprofiled the rest day. Clearly, in terms of empowering the junior doctors to be able to design their own rotas, still clearly delivering the service, that's been very, very positive in terms of what they've done. We're yet to find out—. It's obviously interesting every August when the junior doctors change, but certainly it's been a very, very useful exercise that I'm looking now to take forward with other staff groups—other junior doctor rotas across the health board.

That's really encouraging, thank you. Just to follow on from David's point about the agency staff, have you been able to demonstrate a sustained decrease in spend on agency staff?

A sustained—?

Sustained decrease.

Unfortunately not in the last year. Certainly, before that, we started to make some inroads in terms of being able to control and reduce investment in agency, but in the last year our spend on agency has gone up.

Was there a particular reason for that?

We are analysing that, as you would expect us to, in quite some detail. Sometimes it's a double-edged sword, because we've invested in nursing—so, our £4 million investment in increasing nursing posts—and if you can't recruit to them all, it results in an increase in agency spend. It's a rock and a hard place in some ways. It's the right thing to do, but we need to get cleverer at being able—. There's no point saying we're going to add another 10 or 20 or 30 or 40 jobs if we can't fill them, because then nobody wins. So, some of it is linked to the 'grow your own' that I talked about earlier. There are also improvements we can make in the way that we plan our rotas, plan our rosters, plan for our staff. The later you know when you're working, the more chance you're going to use agency. If we can plan better, there will be less short-term trying to fill gaps. We know there's huge opportunity there. We've got a programme of work in place, led by our nurse director, in relation to that: e-rostering, using digital applications. There's LocumOnDuty that we've got for our docs, which will create an internal bank for doctors to fill gaps, which means the agency use for doctors will go down. So, there is a lot of work ongoing to make sure that we can start to see that change direction again.

And just on the staffing levels, is the health board compliant with the staffing levels? 

Yes. 

Great. And also, what are you doing to prepare for the anticipated extension of the Act into other areas? 

Luckily for us, our nurse director is the executive nurse lead on that. So, we're well in in relation to the conversations that have gone on around pediatrics, for example. Child health is one area where we are working together to see what would that mean and what would our challenges be. We've got a children's summit coming up within the health board, bringing all different groups of people working in children's services to see where we are. We've done an analysis of where we are, where our gaps might be, where might our staffing gaps be, but then part of that has to be—. We have to learn, from previous experience, where are people out there. Registered children's nurses are hard to find. So, again, there's no point in us getting to a position where we say we need another 20 nurses, but they're not there, and then we end up in a difficult place. So, we're working on it, we're thinking about it, we're considering it. We're using the advice of our people and I know that, as I say, our nurse director is involved in the national preparations as well. It's on our radar. We've got a report, I think, going to our board this month to make sure that board members know what's coming and know what we're considering. 

Okay. Lynne Neagle on mental health. 

Yes. How able are patients in the area to access mental health services? Are you able to just give us an update for children and adults on how the health board is performing against both the primary and the secondary targets?

The straight answer is that we meet or exceed all the mental health targets for the health board. It's good to be asked that question because we focus a lot on unscheduled care, referral to treatment, cancer and stroke, which are really important, but they're targeted intervention areas. Mental health is not in that place—for good reason—and we have delivered significant improvements, particularly in psychological therapies in terms of reducing our waiting lists and achieving our access targets there. The improvement was so significant that our numbers were queried in terms of being sure that that improvement was delivered. So, generally, we are in a positive position in relation to achievement against the mental health measures. If you want, Sian can give you a little bit more detail, maybe, around children. 

Okay. So, on children's services, I think what I would say is our performance is significantly better than it has been over the last few years. It was really worrying several years ago, but there have been significant improvements. We are not meeting all the targets at the moment, and I'll just explain why for those. So, in terms of primary CAMHS, we aren't hitting the target in terms routine assessments, although, again, our performance is better than it was 12 months ago. The key challenges around that and for some of the other CAMHS services is that they're really small, fragile services. So, if anybody leaves or if anybody goes off on sick leave, then automatically the performance drops. So, we're working really hard with Cwm Taf Morgannwg, who deliver more specialist CAMHS services, and our two local authorities, and we took a paper through our board in March to agree to develop a single integrated service for Swansea and Neath Port Talbot. So, that is up and running, being taken through the local authorities, taken through our board as well. So, we're on the road to have that integrated service by 2021, which is when we're going to be implementing that. So, that should then lead to a more sustainable service.

The other area where we have made significant improvements but are feeling the impact of those improvements is around neurodevelopmental services. So, we've had quite a lot of investment in that, particularly through the integrated care fund over the last year or so, and we did deliver the target for that in the summer of last year. Our performance, unfortunately, has dropped on that, but that's because the service became so popular and became so well known that, actually, our referrals from GPs skyrocketed, and that's a similar position across Wales. So, that is now starting to plateau off again, and we'll be looking to build that or to improve our performance on that. We've got a full team in place now. So, it's become a more solid and sustainable service going forward. So, I would say it is much better than it has been. We know that we need to do more on it.

The other thing I would say is that it's been a key area of focus for our internal performance and finance committee. So, our vice-chair has been really closely monitoring our performance on that. And the other thing I would say is that we've been to Swansea and Bridgend scrutiny panels within the last six months—the local authority scrutiny panels—as sort of follow-up visits, and they were both satisfied with the improvements in both the way in which we're planning services and working with the local authorities around having a much broader approach to CAMHS services, so focusing much more on the emotional health and well-being of children and young people so that they're not being inappropriately referred into the very specialist services, and also the improvements in performance. So, clearly, Bridgend is no longer part of our service, but we went there with Cwm Taf Morgannwg just before the end of March, and, in Swansea, I think we went there in January/February time.

So, you said that you're not meeting the target for routine referrals for children. How long are children waiting, then, for a routine referral, and what is the position in relation to the 48-hour target for urgent referrals?

So, in terms of urgent referrals, our latest position, which is February this year, was 97 per cent, against a target of 100 per cent. So, the reason that we didn't deliver that was because of staff vacancies.

Okay. And for the routine referrals, how far off the target are you, then, for children and young people?

We are off the target. The target is 80 per cent, and the last figure I have is 30 per cent. So, we are working through that in terms of improving the staffing levels within that but also having the integrated team. I think, until we've got the integrated team in place, it is going to be difficult to consistently hit that target. We are putting a single-point-of-access service in from the autumn of this year to help improve making sure that GPs are really clear on where referrals need to go as well. So, we've been working through that with the local medical committee and through the clusters as well, but that is an area of challenge for us and, again, that is particularly around staffing levels because it's such a small service.

My next question was about staffing. You've obviously referred to staffing issues. Are there any other issues that you wanted to flag that are contributing to that around staff recruitment and retention?

Nothing specific that I would want to flag here. The challenge has been that, when the additional moneys were made available to develop these services, because it's a small pool of staff that you're recruiting from, people go into the new service and then, actually, it's really difficult to backfill into the service that's been around for a while. So, we've been working through that, particularly with Cwm Taf Morgannwg, around how we can do that, and we have regular monthly performance monitoring and long-term agreement meetings with them to work through the specifics around services.

And what about adult crisis care mental health services? What's the position in that?

Okay. Chris, were you going to pick up the adult—?

Sure. Tracy mentioned psychological therapies earlier and what we're doing about bringing that target down. We're also working—part of it is that we don't want patients to get to crisis, and what our front door is seeing at the moment is a lot of people walking in with well-being issues and anxieties clearly driven by some social events. So, we've got liaison psychiatry at our units, which direct to the appropriate service, but under that now we've put in psychology and counselling services at our front door so that we can give patients that opportunity, and, secondly, we are working closely with the voluntary sector to redirect patients into some of those areas so that they don't escalate into a crisis position and hopefully we can support them to get back into independent living.

Okay—which is great, but obviously there are always going to be patients that do need crisis intervention. So, how long are people having to wait, if they are in a crisis, to be seen, especially if they're at risk of suicide?

I haven't got that figure, I'm sorry, but I can get hold of it and I can send it through to you after the meeting.

Okay.

We're also developing out-of-hours sanctuary services in both Neath Port Talbot and Swansea, so that's night time and weekends, so that people who are in crisis will be able to access support 24/7. So, there's lots of work ongoing in that area.

Thank you. You'll be aware that this committee has said that we think there should be parity between mental and physical health. From your perspective, what do you think the barriers are that we need to overcome to get to a position where that's a reality?

So, from an organisational point of view, in terms of how we structure and the profile that we give, coupled with the significant investment that's been put into mental health, it feels to me that there is parity. We have an associate medical director of mental health as part of Richard's team, along with associate medical directors for primary care and acute services. So, at that level, I think it feels that we are looking across the piece.

I also want to bring into the board more executive-focused leadership around primary, community and mental health. There are some developments in place there, just to make sure that at the board table, as well, that we've got that focus. It does feel to me more equal than it ever has, and it does get quite a lot of focus in terms of the way that we work. Is there anything anyone—?

Would you say it's equal, though? Because it's all very well having staff members, isn't it? But it's about delivery, isn't it? The figure of 30 per cent for children and young people is concerning. If we had a figure of that level of children and young people who are waiting for treatment for, say, a broken leg or something, that wouldn't be considered acceptable. So, in terms of the actual delivery of the services, do you think we're seeing parity as a reality?

I would say, from a children's perspective, then, over the last two or three years, there hasn't been parity. But it has significantly improved and increased over the last two or three years, both in terms of, I suppose, profile within the health board and the discussion that we have had, both at board level and at performance and finance committee levels, and then our executive team tables as well. Increasing in terms of—we have a multi-agency children and young people's emotional health and well-being group, which is chaired from the health board but which has, clearly, multi-agency representation. That has been really focused on looking at earlier intervention services, developing preventative services such as the neurodevelopmental service. So, that has enabled us to secure significant funding from the integrated care fund to develop some of those. So, I think it possibly hasn't had that level of parity; it definitely is getting that going forward.

The only other thing I would say in terms of adult mental health is that we have agreed an adult mental health strategic framework with our local authorities as well—again, through the regional partnership board—which is very much focused on changing our model of care for adult mental health services, being much more community focused, and, again, focused on early intervention and helping people to stay well. There was a significant amount of service-user engagement in developing that. We're committed to developing a business case for the reprovision of our in-patient adult services this year—the services that are currently provided at Cefn Coed Hospital—and also we're doing an awful lot of work around older people's mental health services as well.

Okay. Final question—David Rees.

I'd like to go back to the children's waiting times. You say your target was 80 and you're hitting 30 per cent. Now, I think that's more than challenging, that's a very serious situation where seven out of 10 children are not being seen within those target times. We don't want them to escalate into a crisis situation, and many, many constituents come to me and say they are waiting and they're struggling with their families whilst they're waiting. So, whereas a jump from 30 to 80 is a huge jump, what is your initial target to make sure you can see progress being made so that you are starting to improve those waiting times?

So, we are seeking to—. The gaps that we've got in the services we have, we're trying to fill with agency staff. Because the numbers are small, then, actually, if you've got an additional member of staff in, or if you're able to recruit and fill a sickness vacancy, then, actually, yes, the jump in the performance would be significant. So, that's the challenge. I haven't got with me a trajectory to get up to that 80 per cent; we could come back to you with that. But, actually, I think the issue is around the fragility of the service because it's so small. And they have been managed, and they still are at the moment, as two services for Swansea and Neath Port Talbot, which means that the—. And if you have a gap in one service, they're not currently arranged so that they can cross-cover each other, and that's why we're looking to bring it together as a single service. And the plan is to get that in place throughout this year.

So, by the end of this year, you hope to be hitting your target of 80 per cent at that point.

Well, that would be our ambition, yes.