National Assembly for Wales

Can I welcome members of the committee to this morning's meeting of the Public Accounts Committee? No apologies have been received. Do any Members have any declarations of interest they'd like to make at the start of the meeting? No. Okay. Usual housekeeping rules apply.

So, item 2 and papers to note, and we've got a couple of papers to note. Dr Goodall has provided an update on the progress being made on implementing recommendations from our report on the national health service informatics service in November 2018, and a response to the issues highlighted in my letter of 26 November. He's also provided commentary on the Welsh community care information system, and there are some aspects in there responding to the COVID-19 pandemic. Auditor general, did you want to make any comments on this?

Very briefly, Nick; thank you. Like you say, a very wide-ranging update—far too much ground for us to unpick now—one or two issues that we'll follow up in our exchanges with the Welsh Government in due course. I think, given the breadth of the update, it may be something worth flagging either in the committee's legacy report, or for an incoming PAC or health committee, as a starting point for some of their work. 

And just a couple of specific points for the committee to note, in respect of the new digital special health authority, I'll be the external auditor of that new body, and, in addition to our usual audit of accounts work, we're anticipating that we'll also do some performance audit work in that space as well in due course. 

And just a reminder to the committee that in my letter to you following our appearance in response of the Well-being of Future Generations (Wales) Act 2015, the new SHA was one of those bodies that I flagged as possibly needing designation under the Act, if that were to be possible in the future. Thank you.

Good. So, I suggest that we recommend to our successor committee in the sixth Senedd that they keep the digital transformation roll-out under review. Okay. And the second paper to note—Dr Goodall's provided an update on progress against recommendations made in both our and the Wales Audit Office reports on out-of-hours service. The pandemic has had a profound effect on the delivery of NHS services and the behaviour of the general public in the way that they choose to access healthcare. I think this is quite a positive paper. There's been a sharp reduction in attendance at emergency departments, which has been looked at. Auditor general, did you want to come in on this paper? It seems to be broadly positive.

Nothing from me. Thank you, Nick.

Okay. Are Members happy to note that letter? Darren.

Just one comment, Chair. Obviously, the 111 service for NHS Direct is still not available in all parts of Wales. There are two health board areas where 111 hasn't been rolled out. That means that there's a great deal of confusion in those areas, where they see 111 being promoted on a national level across Wales, yet it's not accessible in their local areas. I think that this is something that a successor committee should keep an eye on in the future to make sure that 111 is accessible in every part of the country. There are significant charges for many people when they dial the 0845 service at the moment for NHS Direct, for example in north Wales, especially if they dial in on a mobile device. That cannot be acceptable; it's a barrier to people being able to access that service, and I think we ought to keep a focus on this.

Yes, some good points there, Darren. Dr Goodall's response does refer to an increase in 111 calls. That ties in with the reduction in terms of the COVID-19 symptom checker; it ties in with a reduction in emergency departments. But I take your point. If it's a sporadic service across Wales, then that needs to be looked at. So, are we happy to take Darren's point on there, and recommend to our successor committee that they continue to monitor this? Yes. Okay.

Right, on to item 3, then, and the substantive issue today, our reflections on the fifth Assembly/Senedd, and our evidence session with Dr Andrew Goodall, the director general for the health and social services group and chief executive of NHS Wales. I can see that Andrew has joined us. Welcome, Dr Goodall. Would you like to give your name and position for the Record of Proceedings?

Bore da. Good morning. Yes, I'm Andrew Goodall, I'm the NHS Wales chief executive and I'm the director general of the health and social services group. 

Great. Thanks for being with us today. I appreciate there are a lot of demands on your time at the moment. As usual, we've got a lot of questions for you, so if Members can be succinct in questions, and feel free to be succinct in your answers. Did you want to make a brief opening statement?

Chair, if it's okay with you and colleagues, yes, it may just be helpful to get some reflections from me, not least of course that I've attended many committees over the course of the last five years and, obviously, we have had a need to have attendance as well in respect of the pandemic response. I was just going to reflect on three areas, if that is okay, briefly for you, just at the outset, just to try to help your reflections: firstly, perhaps, just to reflect on just normal NHS and group activities, not least some of the Public Accounts Committee reports; secondly, just to acknowledge the impact of the pandemic response; and thirdly, just maybe briefly to allow some sense of some of the governance and oversight issues that I've had to focus on within the group. But, as always, I'm really mindful that, within my role and responsibilities—. I'm now seven years into my role, coming up in June, and trying always to balance the director general role and responsibilities alongside the NHS Wales chief executive role and its oversight. And of course whilst the Government response has been critical in respect of the pandemic, I've obviously had to act in a more visible way as the NHS Wales chief executive, and with more time allocated to the system response and resilience. And I just want to share with colleagues, obviously, a more unusual role of needing to speak publicly. So, of course, there's always the usual committee accountability, but also a need for me to respond in respect of public assurance on actions and responses. 

Just on the first part, inevitably, despite a pandemic response, the five years—and even over the last 12 months, we've continued to need to focus on some of the normal activities of group business and, obviously, the NHS. What I've tried to do over the last five years in my approach generally, and this would be particularly true of the NHS, is to look at three approaches: one about stabilising the position—that was certainly true as I was arriving into role and entering the start of this Government term—secondly, to look at improvement and how we have an ability to move the system and activities and actions on. And the third challenge has been to allow a longer term view and to allow some strategic reflections. And I would say that that applies whether I'm looking at planning or finance or performance in particular. It's really been important to set accountability and expectations for the system, but also to follow through on those. And of course, as you know from your reviews, there is a statutory basis to areas like planning and finance. We are also developing further legal proposals for quality here, but inevitably there are improvements and changes we'd want to introduce into the system, with the escalation framework, for example, being a very significant, I think, development during the course of this particular Welsh Government term.

What I've tried to do is to maintain a personal approach to plans, but to make sure that we are pushing on delivery. It's been really important to make sure that there has been system accountability, which I do think has been supported and endorsed by the escalation framework, for a system that is about improving and expecting there to be changes around organisations, but it is—and I would emphasise this—a supportive mechanism for the system, and I've wanted to try to make sure that those values and principles were applied. 

I do think that we've made progress on planning and around the financial system. I recall some of the original committee sessions that we had at the outset, about some of the areas of financial resilience and planning, and I do think that we have approached that in a different way and had a response back from the NHS. But I'm particularly pleased about the more strategic shift, by introducing 'A Healthier Wales' two years ago, which allowed us to start thinking much more strongly about the longer term, and a challenge, actually, to some of the traditional ways of working for the NHS, and making sure that we take advantage of the integrated structures that we have in Wales. But, inevitably, as part of that normal business, it has been necessary also, of course, to respond to individual areas of detail from different subject committees, including the Public Accounts Committee, and I hope that, in our responses, which have been quite comprehensive and detailed on a range of areas—. I was just reflecting on the detail of the digital correspondence that I sent in to you—genuine progress on the 13 actions that were highlighted by the Public Accounts Committee to make sure that they could be moved on and closed, but obviously many others, no doubt, that you may want to pick up during this session. 

So, there is a lot of normal business that has been necessary to discharge and, whilst masked by coronavirus and the pandemic response of the last 12 months, none of those have really gone away. And I think the fact that we've been able to maintain delivery of a range of areas from the programme of government, as well as some of the new expectations for the system around 'A Healthier Wales', and also maintain the pandemic response—I'm very grateful to both the system, the NHS and the care system, but of course also to the civil servants who are part of that role.

Just quickly, secondly, Chair, just on the pandemic response, I've obviously had a chance to speak both informally and formally to the committee, and it's very difficult in this very short session to convey the unprecedented nature of the response and all of the challenges on here, and I just wanted to say for the record that I am very proud of what the NHS and the care system has done to respond to something that is a once-in-a-century event. And obviously, we're still very much in the middle of it, seeing very visible pressures at the moment. But it has required a level of thinking and response beyond anything that we thought the system would have been able to manage before, whether that is through the Welsh Government lens, or actually through the NHS lens. And if you think about the fact that we have had to instigate rapid decision making to make sure that governance and value for money are still applied, and start a range of different services from scratch, ranging from field hospitals, rebalancing NHS activities, the vaccination programme, personal protective equipment supplies, the roll-out of digital, and a test, trace protect system based on local arrangements, testing capacity and the shift to new patterns and services—. I think, whilst they have all been under the guise of the pandemic response and absolutely essential, I do think that the process and the learning that we have got from that about the ability to understand how we can make more rapid decisions for systems, it is possible to roll out more quickly, we can have a more universal approach across Wales by working with the structures—. But I think the real advantage in discharging my role has actually been being able to take advantage of the intimacy of our system, with the relationships and the structures that we do have in place, and, whether virtually or not, the ability to have 12 organisations sat around my table to link out to them to ensure that there has been an appropriate and a resilient and a learning response from within the pandemic. There are areas and actions that we've had to put in place over recent months that are different from the outset, because what we've obviously had to do is to learn and adapt to that kind of system. But I would just want to make the point that actions that maybe would have taken us many years in some respects, and almost negotiating professionally and around organisational structures, we've been able to put in place in matters of days and weeks, and an appropriate governance mechanism around it.

So, I think that where we stand at the moment with the pandemic response—still in a very difficult position for the NHS. Our numbers even over this weekend remain that we have more coronavirus patients in hospital beds than we did at the peak in April, but it is an improving position and rapidly improving. It does mean—

Thanks. I'm just mindful we've got quite a few questions for you. You've covered quite a lot of areas there. Can I ask you, in terms of this committee, and, as you say, you've been in front of us quite a few times over the last few years, in terms of the way that the committee has influenced Government policy, how helpful have you found the sessions with us, and do you think that the recommendations of the committee have led to real change and transformation in the NHS?

Well, Chair, I think I've attended the committee over time probably well in excess of 50 times, and in different roles. So, I've obviously had to attend in previous roles as a chief executive of a health board as well as the lead chief executive co-ordinating out in the NHS in my current role. I think that governance and scrutiny is really important to make sure that we're able to improve our public services, and I think it is a rather unique arrangement about the way in which that occurs in Wales, given how frequently not just myself but NHS colleagues will be in various committees, including the Public Accounts Committee. I do think that that is a strength to have to be accountable, and to ensure that we respond.

Inevitably, the committee will be taking a measured view of a range of different issues, but, obviously, it will be putting its attention on areas where there were often concerns, and I think it's really important to be open to the scrutiny and to make sure that we are able to respond and give assurance. I've had to attend on a range of difficult areas over the years, and, clearly, where I know Members would have expected further improvements, I'm very mindful, and colleagues will recall, that the ministerial direction that was necessary was the first occasion that that had had to be introduced during devolution—that happened to be in my area—and that we had spotted the need for needing to work in the area of ministerial direction, given the issues that had affected the NHS pension arrangements for doctors.

But I hope that committee members who listened to the evidence, and certainly that when I was sat alongside the Permanent Secretary, would, I hope, have received a very open and transparent description of the environment that was taking place and the need for those decisions. Hopefully there was some assurance about the process that we've followed, despite the uniqueness of that, as well. I've always welcomed the challenge. Obviously, there is a relationship with some of the Audit Wales work, and I hope that we're also able to build on some constructive relationships with Audit Wales in terms of our general day-to-day contact. The committee discharges an important function of governance, and governance makes it a better system.

Thanks. I'm going to bring in other Members now. Vikki Howells.

Thank you, Chair, and good morning, Dr Goodall. I've got some questions around finance. Since the implementation of the National Health Service Finance (Wales) Act 2014 it's been the same four health boards, hasn't it, that have not met the first statutory financial duty to break even over a rolling three-year period. How successful do you think the legislation has been in allowing for better decision making and implementation of optimal solutions in local health boards? How would you assess the financial position of local health boards at the end of this Senedd term when compared to the start of it?

I recall attending committees where we had some very significant numbers in respect of potential deficits for the system and, whatever an end-of-year position was, needing to outline some very serious pressures for the NHS in terms of its ability to balance its budgets. Where we're heading for the end of this financial year is that we probably will have an underlying NHS deficit, linked to two organisations, below £50 million. That will be the lowest level of deficit that the NHS itself has reported. I think it's been important to us, however, to recognise the balance of needing to see progress on finances alongside the impact that it has for the system, and whilst technically it may be easy for us to be frustrated about some of the progress over the years, I've always been really mindful to make sure that finance has consequences for organisations. In respect of the approach that we've taken for a number of the organisations in Wales, wanting to see progress does need to be countered by making sure that what we don't see is an unacceptable drop in access to services or the standard and quality of services that are available. So, I've wanted to take, really, a progressive approach, starting with organisations demonstrating that they can stabilise their finances and then they can recover and improve. 

You're right; the three-year duty, which I do think has helped us, alongside planning, to introduce much more discipline and set clear expectations for the system, has meant, however, also that even when we have organisations that are improving their in-year financial position, it can take them time to actually work through. So, in Cardiff's example, on the back of a couple of years now of breaking even, it's going to take until the end of the 2021-22 financial year for them finally to come to demonstrate that they have actually shown that they've broken even over the three-year statutory period of time. But what they have done over the last two years is demonstrated that they have made progress on their financial report. So, there's much more resilience, but that has also helped us with our overall management of the main expenditure group, and I have to say has put us in a really good position. Even in a pandemic response year, the NHS actually will have managed to improve its financial position, despite all of the stretching of its responsibilities. 

Thank you very much. Turning to Betsi Cadwaladr health board in particular, on 3 November last year the health Minister announced strategic assistance for the Betsi board, later the same month announcing that they'd been taken out of special measures and moved into targeted intervention. What improvements across the health board triggered the decision to move it out of special measures, and what will the board need to do to move out of targeted intervention?

What we have had to do with Betsi Cadwaladr is to make sure that we have been able to stand back and think about the progress it had made from its very inception, where it was really a series of significant quality concerns, notably in areas like out-of-hours and maternity, which were real concerns about the level of service that was offered to patients up in north Wales. During the special measures period there has been a change in respect of some of the underlying concerns for the organisation. We have had an opportunity to just think back and reflect on the starting point for the special measures alongside the escalation framework that was in place, and actually judge the progress that has been taken in Betsi Cadwaladr, and also to make sure that what we're doing there is allowing a level of understanding about the performance and broader resilience of the NHS across the whole of Wales as well.

I think that if we stand back and look at the organisation over a five-year period, it has been able to demonstrate some significant improvements and changes on a range of different areas. There's a danger of describing that as meaning that they don't have issues to go at. I just want to say for the record that the targeted intervention part of the framework remains a very significant trigger for the need for further assurance and actions as well. But actually, the organisation itself was able to demonstrate to us genuine progress over a number of years, which we can triangulate in a number of different areas, even seeing some of the improvements in the staff surveys that we've seen, and actually, despite still an underlying financial set of issues, at least seeing stabilisation and improvement in its financial position that has allowed us to start to make some different decisions about strategic assistance. 

I think this was an organisation that was starting to show us a different level of confidence in some of the ways in which it was dealing, but I think what really has changed our outlook for the organisation has been the way in which we see an organisation respond to such a unique event in respect of the pandemic response, and actually seeing that as an opportunity to really, I think, consolidate some of the progress that we've seen and demonstrate a good response on a range of different areas, which was even tracked through recently in respect of seeing the level of vaccination activity that's been happening in north Wales as well. North Wales has remained resilient in its response in respect of its ability to respond to coronavirus. But we still need to keep that organisation under review; as I've indicated, targeted intervention remains a very significant label for us to continue to work through. 

Just before you go on, Vikki, Darren Millar, did you have a supplementary question briefly? 

Yes, I did, if that's okay, Chair. I'm a little surprised, Dr Goodall, that you haven't referred to some of the big challenges that still remain in the Betsi Cadwaladr University Health Board. I can appreciate you will want to focus on some of the positives as to why the organisation was lifted out of special measures, but mental health was the big issue that tipped the organisation into special measures after the Tawel Fan scandal, and many people do not feel as though the mental health services are of sufficient quality in north Wales as they should be. Can you tell me what progress has been made there? Because they haven't even got a mental health strategy at the moment, as you will know. They've had a revolving door of leadership around the table over the five years during special measures, and leadership and governance, of course, was one of the big issues again as to why the organisation was put into special measures. Its strategic and service planning still hasn't been sorted, another thing that it was put into special measures for as well. I can appreciate that the maternity services side of things has been nailed, and I'm very pleased about that. I can appreciate also that there have been some significant improvements in the delivery of GP out-of-hours services, and there has been a stabilisation—although I would still say there are some significant risks still—around some of the primary care services, particularly dentistry, for example. But what's the situation with leadership and governance, and mental health in particular? I'm very surprised you didn't mention mental health in your opening remarks there. 

Well, the Chair interrupted me as I was just moving to the targeted intervention areas, and I was going to just clarify that mental health was one of the outstanding areas where we still wanted to have progress. What we have seen within mental health is a shift and a change, including in the culture of the organisation over recent years from the starting point. There remain some significant areas for improvement as well. We also do track and oversee the performance of mental health services in north Wales alongside other organisations in Wales as well. There were some significant examples, for example, of patients who were being treated out of area, and actually seeing the level to which the organisation has been able to repatriate those and build up some of the local services to access does give us some confidence about the progress that's in there. But I do think that, under the targeted intervention mechanisms, mental health will remain being one of the key areas where we do need to see further improvement going forward. 

In respect of the leadership and governance, I do think that that is one of the areas that has come through very strongly within the pandemic response itself, because one of the tests there was about the ability to work in partnership and in collaboration across the different areas, to ensure that there was resilience with some of the relationships with clinical teams across the organisations as well. But I was really mindful that in terms of trying to move on with some of the planning expectations that we had for the system, what we do need to make sure is that the financial outlook for the organisation doesn't prevent, actually, some of the necessary thinking I think needs to happen in north Wales, not least around ensuring that we improve some of the quality of services.

As an example, the strategic assistance that we've put in place for now will be an intervention to break the cycle in north Wales, having seen at least some of the financial stability return for the organisation. But what we want to do is to make sure that there can be a development of services now, rather than something that is overdominated by the financial perspective. In fact, in that respect, there is actually some particular and dedicated resource that has been put in place, actually, for mental health in itself to improve some of that. And you'll be aware also of some of the proposals that have been more confidently brought through by the organisation for improving some of its mental health infrastructure. Obviously, they will be areas that Welsh Government will want to address. But I really wouldn't want to leave the impression that there aren't outstanding areas that we need to see further progress on. We will continue to review this organisation within the escalation framework, as with other organisations in Wales, but we will want to also make sure that we approach it in a fair and equitable manner in terms of its ongoing performance.

I do think that one general concern to share with Members this morning will be the level to which the NHS and its performance we will need to set in a different context about reset and recovery. So, whilst there may be performance areas in any single individual organisation, I do think we're going to have to lift some of those performance expectations to the national level, and actually make sure that we're able to make progress on those, obviously very significantly, assuming that we come though the back of this as well. But this will remain an organisation with appropriate contact with us to ensure that the confidence that we've seen of some of those changes coming through continue to be sustainable and will actually lead to a plan that can be endorsed and signed off for the north Wales population.

Okay. I'm mindful, Dr Goodall, that I also interrupted Vikki Howells. Did you have some further questions, Vikki?

That's fine, thank you, Chair. Dr Goodall's last answer covered off my last question.

There we are. That's good. Okay. Moving on, then, to Delyth Jewell.

Diolch. Good morning. The committee has been interested in the informatics systems in NHS Wales, and we've raised issues with you before about our concerns about outages at the Blaenavon data centre and the resilience of the cancer network information system Cymru, or CaNISC as it's referred to. In your most recent letter, you described CaNISC as a complex and fragile system that continues to be managed as a major risk. Could you explain what you mean by that, what the potential implications could be for delays in cancer care if there are issues with CaNISC, and how those are being managed, please?

Yes, indeed. I think my intent, as I said earlier, was to be open in my response about the situation. We have had scrutiny in respect of the development on this. We have the CaNISC replacement mechanisms in place, and are really pleased to report about the really strong clinical endorsement that we do have for the measures and the actions that are taking place, including the replacements that will lead to the replacement Velindre system, and of course then tie into that national system as well, at this stage. But it remains a dated system in need of replacement. What we have been able to do, certainly since the evidence sessions that we gave in respect of digital, is to underpin more strongly some of the contingency arrangements, actually, for the system. I think whilst clearly the arrangements around the data centre may seem to be almost the more fundamental issue, actually it's been more about ensuring that we have an ability to provide more specialist support for the system, to actually have resilience in our response.

I think one of the changes has been that whilst we were reliant on individual clinicians accessing CaNISC as an individual system, we actually do now have the ability within the Wales clinical portal to have all of the CaNISC case note summaries now available. What that means is, irrespective of any underlying issues for the system, once they are recorded on that, then they are actually available to clinicians wherever they sit in Wales, in terms of being able to have those available. We have had to put in some investment in terms of some of the infrastructure, and that has included some of the data centre mechanisms, and we've taken on that responsibility on behalf of Wales for that sort of resilience, but we'll also be shifting in overall terms. This isn't just about CaNISC as a system itself, but the data centre arrangement changes will happen, shifting away from Blaenavon data centre. We do have some extended dates for that, which, for me, is actually a way in which we can ensure that we have sufficient time to work through the significance of shifting all of the Welsh systems over from the two data systems, including the contingency arrangements in place.

I really want to make sure that the progress on CaNISC, though, does remain with this very strong clinical leadership in place. There's a whole series of different expectations to make sure that this can track patients and their experience right across our whole system in here. Unfortunately, what we don't easily have is where you can simply go to the market and have a system that is just available to almost plug in overnight, which is why this needs to be more of a developmental process that is available in respect of the cancer patient needs, as well, of course, as the clinicians who are overseeing that care as well. But I've wanted to make sure that all of the funding is available. That's not come from the system. We've actually provided that centrally, again just to make sure that we're able to progress, but on the current timetable, which will mean that some significant developments will occur in September of this year, which is linked to the Velindre centre developments and the use of the patient management system there. It will be November 2022 when we look to implement the proper CaNISC replacement. That in itself is a very tight timescale, but as you would expect, we are trying to keep it under review. At this stage, particularly on the back of the pandemic response, we've not slipped at all on the timetable, but I do really think it's going to be impossible for us to try and bring that forward very materially at this stage.

Thank you for that. Just a couple of follow-up questions from what you've said. Firstly, could you explain to us, if the CaNISC system were out of operation for an extended period, would that mean, practically, that health professionals would have to return to using paper notes? What impact do you think that would have on their workload and the impacts on cancer care?

Any of our systems in Wales, at any point—and this will be true of the NHS generally if you think of the wide variety of operational systems that are in place—always have some minor outages at times, where they'll have some contingency arrangements in place. Ultimately, if needed, the NHS can revert temporarily to any of these sorts of paper-based systems if needed. Some of the outages that occur sometimes are behind the scenes and don't really affect any of the front-line access. Some of them can be more significant and they just add a little bit of a backlog that needs to be added within the system.

But, as I said, in terms of patients who are moving into the system, one of the significant changes that we've introduced over the last couple of years has simply been the ability to access the broader range of cancer summaries, which have been populated on the Welsh clinical portal. And I think, if I go back to some of my original evidence sessions, that was a gap and that was not available as a function beforehand. So, I do think that that is a very material improvement. But, obviously, our cancer clinicians across Wales want to make sure that they have a progressive system available that is in line with current specifications and expectations for patient care, and we will be able to deliver that over the course of the next 18 months in particular.

Okay, thank you. Looking at the dates that you've just quoted, we've seen the papers for the meeting of the Velindre NHS trust board in September of last year, and they noted that the agreement for an on-premises replacement would be—. Well, the on-premises infrastructure at Blaenavon, at least, was due to conclude on 31 October last year, but there as an agreement to extend that to 31 March this year. I just note that you've said that there's not going to be a full replacement until November 2022. Could you just talk us through what the interim period between the end of March this year and November will look like, because that seems like quite a lag? Are you confident that there will be a fully resilient CaNISC system in between those times?

Yes. Just to clarify, there is a danger of us bringing together two issues. The Blaenavon data centre and other data centre arrangements represent the way in which we host all of our data and all of our systems across the whole of Wales, which happens to include CaNISC. And then, there is the procurement and development perspective, which is the development of CaNISC itself, so the data I gave earlier was the data that we expect the CaNISC system to be implemented with in the system.

The summer date that you have for the Blaenavon data centre change is on the physical infrastructure for our hosting arrangements when we switch it across. And when the Velindre board was reviewing those arrangements, I have to say, from my perspective, particularly given everything that we were going through in respect of the pandemic response and how we've been so reliant on digital as a way of changing our services and giving us resilience, I am actually much happier that we've got an extension around those arrangements in agreement and with governance of the Blaenavon data centre arrangements, because it just simply gives us more time to ensure that that very significant infrastructure can swap across. But what we have done in the interim is invest in a whole series of resilience arrangements that at least give us better contingency arrangements and also better communication flow with the system as well. So, I just need to separate out those two different issues. Often, they are brought together, but the data centre is a completely separate issue from CaNISC, if that makes sense.

Yes, it does. Thank you very much for clarifying that. We really appreciate that. So, just finally, just to confirm, with regard specifically to the Blaenavon data centre and the issues there've been with outages, and until there is a new place where all that infrastructure can be housed, then, do you feel confident that the CaNISC system will remain resilient?

Well, as a dated system, which doesn't have all of the normal support available, and even if we've developed the specialist side, you can't give a 100 per cent guarantee on it at this stage and, obviously, that's why we're developing the alternative system. But as I said earlier, I do think that the contingencies that we've put in place, ensuring that the records are translated across to other systems where they can be accessed, means that we do have available access to the records for our cancer patients across Wales, and there are alternative ways for people to build up that. 

I think, also, some of the developments of the patient management system within Velindre in September 2021 also will provide some added resilience in respect of the pathway for many of the patients at least who were accommodated and treated within south Wales, but, of course, we continue to focus on that national infrastructure. So, I do think at least our ability to support—. But, as a dated system, it will have some limitations in terms of if there were some major problem at this stage. So, we will be doing our best to maintain it, but we incrementally are making sure that there are alternatives available that mean that the broad breadth of the data is actually going to be available for us.

Okay, thank you. 

Thanks, Delyth. Jenny Rathbone. 

Thank you. Dr Goodall, you mentioned in your opening remarks the strategic importance of 'A Healthier Wales'. Now, in the middle of a pandemic, nobody would be expecting you to be pushing money and resources down the line back into prevention and primary care, but, nevertheless, COVID has exposed in plain sight those vulnerabilities of health inequalities, which is where COVID has attacked most vehemently. So, I wondered if you could explain to us how you think we are going to really start to drill down deep into the underlying problems that we have in our communities and our collective failure to deal with these over many, many years. So, how are you going to turn that corner, while we're still in the middle of a pandemic? 

If I rewind myself to March/April, last year, in particular, I probably thought that having issued a longer term plan for the NHS and a vision for what the next 10 years could look like following the parliamentary review, whilst it may not have been foremost in my mind, I have to say that I would have been thinking that maybe we had lost the ability to think about strategic issues in the longer term. Having said that, having gone through the pandemic response and the range of areas that we have had to handle and deal with—and you're quite right, in terms of the highlighting of the underlying health characteristics of our population in Wales as well—actually, I've been pleased to see the resilience and the relevance of 'A Healthier Wales', particularly as we've moved from the immediate crisis points, when we've been at the peaks, and rather thinking a little more about what reset and recovery should look like. 

So, the feedback that we have from within the system for a document that was issued two years or so ago is that it still remains as a relevant framework, even more so, interestingly, in the context of a pandemic response. It was focused on underlying characteristics of population and on well-being. It was focused on shifting the system, and it needed to ensure that there was going to be a better co-ordination of activities and services across health and social care, and all of those, I think, have been at the front of our recent response as well.

So, it's been really important to make sure that we have been able to track through, and, in fact, some of the alternative service models that we've actually introduced, as part of the 'A Healthier Wales' transformation fund have actually been really critical in maintaining patients outside of the hospital environment during the pandemic response itself and have been there. In fact, we've extended the transformation fund arrangements for another year, just to make sure that it wasn't just about an evaluation process, but rather to make sure that some of those that are almost transferred now into core services could be kept in place, because they do represent a better future than just reverting that everybody needs to go into a hospital environment. 

But a couple of the biggest things that we've seen through this response have been the ability to have change delivered quickly and with urgency and on the right principles, and the learning that we've had around innovation and transformation. We're actually just completing a study that we've done with all of the health organisations across Wales. We were doing it through the autumn, but we've just brought in Swansea University to help us and we look to publish it in March. We're just really capturing the level of innovation and transformation that has happened, much of which is endorsed by the framework that we introduced in 'A Healthier Wales'.

But I do think that one of the biggest examples of change and improvement that has happened is the way in which, given some of the criticisms and recommendations that we had from the PAC about digital, digital has absolutely come to the fore, ranging from teams' abilities, change of systems, virtual consultations happening, and introducing systems in four weeks basically that have allowed us a national platform on a range of areas, even tying into the NHS app, for example. And I think it's really emphasised to me that digital is not a budget just to be spent; digital is an enabler for the way in which we're going to offer our future services to patients. 

Right, I agree that we've made huge improvements in digital. We've cut through a lot of the bureaucracy to a much improved situation. But that's not going to resolve the fact that we spend 10 per cent of our budget on treating people with diabetes, mainly type 2 diabetes, which is preventable. So, how are we actually going to tackle the prevention agenda, which means that more people are living healthy lives and less likely to need the services of ill health? 

Well, firstly, because we have a plan and a vision that actually says that and sets that expectation. Secondly, we need to take the momentum and the experience, sadly, from the pandemic response that has exposed some of the health inequities across our system, but also the impact of underlying health characteristics, and as much as we—

We can agree on that. How are we going to do it, though? You're the man in charge.

By focusing on prevention activities and by having the confidence that we can switch services to different settings, which is not about how we take people to experts and specialists only within the hospital environment, but that we ensure that there are opportunities to handle those requirements within a primary, community care set-up. 

I think there is an opportunity to co-ordinate differently with patients. One of the areas in 'A Healthier Wales' that I think we need to make some more progress on is the level to which we work alongside citizens, the public and the population. Whilst I know the pandemic has opened up a different, I think, conversation with the public, because it's given them an awareness of the nature of the response that the NHS has had to deliver, I think there is still a need for us to come alongside individuals to provide personalised care for what they can do for their own well-being in different ways.

What we have to do, I think, and we have got mechanisms in place to do this, is to shift some of the measures that we use within our system. So, we've been developing a different outcomes framework that is more reflective of 'A Healthier Wales'. Whilst, of course, there are areas of good service and quality service that we want in place for hospitals, it's to shift our focus in respect of measures that are actually about the community care setting and, also, about the prevention and the well-being agenda as well, and, actually, to introduce those as well. So, they are part of it.

Clearly, we can give some of those signals ourselves, with some of the investment that we want to put into the system. You know, we've maintained a focus around 'Healthy Weight: Healthy Wales', irrespective of the pandemic. I just think that the pandemic response has elevated some of those expectations for the system and the way that we're going to co-ordinate ourselves going forward, and now we need to follow through on it if we're wanting to achieve the aspiration for a wellness system, even though people will still need to access specialist services in the hospital environment.

Okay, so, in five years' time, when this committee is asking the same questions of you or your successor, how much of the finite resources we spend in the NHS do you think is going to be more dedicated to prevention and primary care than secondary and tertiary care?

Well, we need to shift with the resources that are within our gift. So, where we are putting in additional funding nationally, then we have the opportunity to make sure that they are in line with the resource allocations that demonstrate that we want to have that more geared to 'A Healthier Wales' criteria. We have to allow organisations to redesign and shift some of the service models that have been in place. Some of those have been positive experiences through the pandemic response, but we need to allow them to deliver those outcomes for services as well.

What we need to make sure that we don't do is that, by artificially forcing a shift of services, we leave patients exposed where they need to have access within the system. So, I think one of the approaches that we tried to take with the transformation fund, as an example, was to allow the opportunity to pump prime and have the services in parallel, rather than force an overnight shift on these areas.

One of my worries would be that if we simply tried to lift our system up and push it into acting only on prevention overnight, we would have people—patients—who are not able to actually access appropriate services in the system for their current needs at this stage. We still need to allow that to be progressive, but I do think that's why, taking some of the evidence that we've given previously to the Public Accounts Committee—framing the strategic intentions, changing the resource allocation process, giving the triggers like the outcomes framework in Wales acting differently, setting out the planning principles about 'A Healthier Wales' rather than the traditional services—this shows a system that is being co-ordinated in a different direction of travel.

I'd love to go on, but this is going to have to be for another day. 

Yes, thanks, Jenny. We are halfway through our session, so I'm grateful for that. Rhianon Passmore.

Thank you very much, that's really interesting. I do recognise and agree with your comments in regard to the once-in-a-century response to this crisis, and I'd also like to express gratitude this morning to our health and social care workers and civil servants. I note your comments in that regard and, also, that there has been a swift and agile response to this health pandemic. However, in regard to legacy—obviously, we're still in the middle of that—you do note in your letter to the committee in December 2020 that fewer patients were on the overall follow-up waiting list at the end of October when compared with March 2020, and there's been an increase in the number of patients who were 100 per cent delayed over that period. So, in that regard, are you able to provide an update to this committee and explain what the new data shows on our current positioning at a regional and national level, Dr Goodall?

Yes. Members will recall that, despite the December update, I'd also written back in August 2020 on the follow-ups. And, again, this was an area that we had been able to show progress in, despite the fact it felt like it was quite a long-standing concern within the system, our ability to improve the outlook for out-patients. If my letter of August 2020 is recorded, that was where, for the end of the financial year, even with some of the early impact of the pandemic, we had actually managed to meet all of the individual measures that we had set for the system, bar one where we were just 0.5 per cent short. So, I do think that that was significant in the sense that rather than just set an expectation for the system on out-patients and follow-ups, we were actually to ensure that that was actually deployed within the system. And, obviously, the measures that we were setting were about access and quality, so I think was really important to demonstrate that.

I think, having had that confidence that the systems had been able to report, we've obviously wanted to maintain the systems that were put in place to achieve that. But, obviously, the pandemic response has affected all aspects of out-patients, and at various times it's been necessary for us to, obviously, focus on the essential services aspect and the urgency of patients within our system, recognising that all of our activities have been affected. So, I think that over the recent months, our performance will have been affected by the pandemic response and the inability to deploy the normal level of services in that kind of—[Inaudible.]—way. So, there has been some deterioration in some of those levels. Having said that, I'm confident that the changes that we have put in within the system to track and monitor these areas are still in place, and that the system continues to focus on it where possible, and to make sure that there is progress.

But I do think that there is a bigger ask around the way in which we organise out-patients for the future. Again, I think this is sponsored by 'A Healthier Wales', but really what we've demonstrated to ourselves is the traditional pattern of an out-patient service, which is very much still in the light of a 1948 model, has changed very significantly already: the balance of remote and virtual consultations to physical contact, the deployment of other professionals, not everything needs to be a review or a specialist consultation with a consultant. There is a range of experience through the pandemic that has demonstrated that this is going to be very different. I believe that this is quite a trigger moment for the system, including the way in which we oversee our follow-ups, to say that there is just a different way of organising our out-patients. We've always wanted to achieve that, but this has been the most significant kind of change in the way in which we've delivered out-patients across Wales.

In that regard, in regard to the deterioration in that baseline due to the pandemic, balanced with the new systems that we have in place and the legacy around that, how do you ensure that no-one is going to fall through the gaps whilst we take the foot off one accelerator and move it to the other, because that momentum is absolutely critical in terms of Jenny Rathbone's point in terms of the health prevention agenda for the future? Can you just quickly comment on that?

Well, we have a responsibility to two sets of patients, the patients who are with us now and—if I can put it this way—on our books, and those patients who will be with us for the future, and we have to continue to balance the way in which we develop services and responses to those types of areas.

I do need to make sure that our reset and recovery process for the NHS is looking at all aspects of patient experiences, right through from first referral and primary care contact, right through to the way in which we're delivering these in our clinic environments, for example. We do need to make sure that there is some consistency about some of the patterns of services that have changed across Wales. And, as always, there is a trick to how we share good practice and develop it. But I've been pleased in terms of the collective response of the NHS system over the last 12 months for the way in which we've ensured that services haven't just been there to share for future reflection—we've been sharing a whole series of changes on a very regular basis for more immediate impact within the system, and where something is working really well, that we've set an expectation for the system to roll it out.

But I think on the quality aspect, whilst we can use our overall systems, including the digital approaches to this, we will continue to be very reliant on the clinical oversight of our patients, to make sure that those in greatest need continue to access the system, as well as to make sure that those that still want to have access to the system for their broader treatment can still be supported in the pathway as well. So, I think the ongoing relationship with our clinical teams and making sure that they have the infrastructure and the technology available to oversee that is really important.

Thanks.

Great. Thanks, Rhianon. So, Gareth Bennett.

Thanks, Chair. Thanks, Andrew, and I would just echo Rhianon's comments about the NHS in Wales's response to the pandemic. So, thanks to all of the staff for their sterling efforts during the crisis.

Obviously, the pandemic has had an effect on waiting lists. You've got stats from StatsWales showing that, as of last December, there were over 225,000 patients in Wales waiting over 36 weeks to start their treatment, which compares with 28,000 in March last year, which is an eightfold increase. Obviously, we know that there are very challenging times and we know what that's all about, but how will the NHS manage the competing demands of phasing back normal services during the recovery phase while also maintaining COVID provision within the existing resources?

Well, both around the health committee and also around the Public Accounts Committee, I've spoken about progress that we were, in the past, seeing around our waiting times. So, again, part of my preparation over this weekend was just reminding myself that, when we had got to March 2019, we actually were, at that time, reporting the best waiting times on a range of different areas—from the general waiting lists through to diagnostics and therapies—that we'd seen for many, many years. We'd got down to around 9,000 patients waiting over 36 weeks, and in the year ahead, we were actually quite confident that we were going to see further progress again. And I'm afraid that, subsequently, two quite significant issues—one more significant than the other, and the change of the UK pension arrangements that affected access for doctors in particular to run some of our waiting list approaches—caused a real problem after March 2019 that meant that there was some deterioration during last year, although it was limited, it still meant that we had lost some of the gains that had been in place.

And, obviously, unfortunately, because of the pandemic response, the ability of the NHS to be able to discharge the routine activities in order to make sure that there is a focus on the wider range of waiting times has been a problem for us as well. And I've been very open about that in previous evidence sessions and also in my own public comments. So, there are concerns about the deterioration of the waiting lists that's happened, and I know, speaking to my colleagues across the UK, that is a shared concern about what we need to do. However, what we have to focus on is: what does the recovery of the NHS look like? And what we need to ensure, referring back to the 'A Healthier Wales' context that I outlined earlier, is to make sure that we are not simply reverting to the NHS as was; we have to make sure that the changes that have been introduced are maintained, these different technologies and approaches, including the ability to transform out-patients to use digital remote working, remains in place, and we have to make sure that we discharge responsibilities for patients who are on our waiting lists. So, whilst we inevitably are having to focus on those who are most urgent within our system, we have to have mechanisms to work our way through all patients who will wish to have access, who are both on the list now but who will also be referred too.

I've also been worried about some of the experience during the pandemic response, to different degrees, where, of course, some of the level of activity going on in the system has been lower, but also the level of referrals in has changed as well. I think that has improved from where we were back in March, April and May, notably in respect of areas like cancer, for example, where the cancer referrals have at least recovered to more what we would expect to be normal levels, based on, say, last year's performance. But we do need the reset and the recovery process for the NHS to have a clear plan forward on this, but it will take us some time to work that through. And, as I said, talking with my colleagues across the UK, all of us feel that this will be a really significant challenge for the NHS going forward. It will require investment on the one hand, but I do think that we have a responsibility to offer a changed service to the population of Wales that can handle that, which is why I think 'A Healthier Wales' gives us momentum to make those changes as well.

Darren Millar, I think you had a supplementary.

Thank you, Chair. Yes, I just wanted to ask: to what extent is the picture different now? Obviously, we're a few months ahead, or a couple of months ahead, of the situation in December, and what's the distribution across health boards? Are some health boards particularly worse than others? I know, for example, my local health board was the worst performer on this prior to the pandemic, but what's the situation currently, Mr Goodall?

Yes. As I reported at the outset, we remain in the middle of the pandemic response. Patients in hospital beds is higher than the April peak, but I'm hopeful that we are now seeing a more rapid change in the number of patients in our hospital beds. Certainly, over the last couple of weeks I've seen a real change in the speed of reducing numbers of patients in hospital beds.

What we tried to do having come out of the original first wave was to allow ourselves to restore a level of the NHS activities across Wales. Now, some of those have been able to retain, and rather than take just a national position over recent months, we actually had endorsed a choices framework for the NHS in Wales that has actually allowed that, where organisations feel that they are in a position to restore their elective work, for example, that they are able to make that as a local decision for themselves, rather than wait for national permission. So, 'It varies across Wales' is probably the answer.

Every organisation will have a starting point for themselves, and will have been affected by the pandemic to different levels, so any deterioration would be from their starting point. So, Hywel Dda, as an example, had almost cleared their number of patients waiting over 36 weeks just as we were coming into the pandemic response. They've obviously seen an enormous increase in patients, not least because the good progress that they had made over recent years has actually, obviously, deteriorated. As you say, with north Wales, they will have deteriorated from the position that they had at this stage. 

It's also been interesting watching the north Wales experience because we've some evidence that the pandemic, whilst having a very material response, it's interestingly, in the second wave, seen, in Betsi Cadwaladr, patients in beds for coronavirus reasons hasn't exceeded what they had in the first wave. And I think that has allowed them to retain a level of elective activity that has continued, and also some flexibility, as you might well have seen in north Wales, for them to flex across their sites. So, where Wrexham was particularly struggling at one point, they were able to switch some of those elective activities over to Ysbyty Glan Clwyd and Ysbyty Gwynedd, which I think was an opportunity, and perhaps demonstrated some underlying resilience up there at this stage.

But, looking forward, clearly, this is a very big ask for the system, and one of my worries is that, as we all, collectively, in the population, see some of the improvements in what the health system has and the patients we have within the system, I just need to emphasise that even when there is minimal prevalence of coronavirus in our communities, we still have to deploy the same protection mechanisms. So, we still have to screen patients, we still have to have the physical changes to the environment, we still have to test, we still have to allow for PPE to be worn in those areas—all of which actually slow down some of the activities.

The one area I worry about from a service perspective is that we also need to ensure that we have access to critical care, obviously, for the most urgent patients. Many of our areas have been under very sustained pressure, but I'm very mindful of the particular sustained pressure that critical care has been under. And whilst things have improved there enormously from a coronavirus perspective, they still remain much fuller than our capacity, and that's going to be difficult for us to provide some resilience, I think, for those staff working in there, even though I think all staff are going to need to be supported for some time to come.

And current picture, Dr Goodall—you didn't tell us where things were at in terms of 36 plus weeks.

So, the figures that were reported in the question to me earlier, where we had numbers that were higher than 220,000, that still remains the case. Interestingly, at the end of December, figures that were reported, there was a small drop of 5,000 patients. And what that showed me was that, from a position that had really been deteriorating each month, at least before the end of December, we actually had not just the stabilisation for some improvement, but, I think, given the scale of the numbers that we've outlined, it would be remiss of me to sort of say that suddenly that is part of a recovery process. So, those numbers still remain very difficult, and obviously that will take us some time to work through that list. But I do think that—. If I could share with you that two thirds of the waiting list in Wales reflects patients who are on the out-patient waiting lists. I do think that gives us some opportunity to say that not all of this is about people who are waiting for operations in the system, and it should be possible, I think, to bring some changes around out-patients that would allow us to tackle that, perhaps, more in the shorter to medium term, rather than leaving this as a problem that probably will exist for some time.

Okay. Gareth.

Thanks, Chair. Yes.

So, moving on, and Jenny Rathbone. You have some questions on transformation.

Thank you very much. In the daily COVID briefing on 10 February, you said that 8 per cent of NHS staff were absent from work, compared to 5 per cent the same time last year. And meanwhile, the nine unions who are operating the health services are highlighting the fact that the staff are completely exhausted. So, even when they're not absent, they are on the verge of collapse. So, I wondered if you could tell me what your strategy is for reinforcing the workforce, and giving people who've given 150 per cent over the last 12 months some measure of respite.

Well, again, and if I could just remark again, I do think it's just been simply an extraordinary effort and response from health and care staff right across the system, and one of my worries, genuinely, has been at the time that we went into the first wave and that first pandemic response, with the real concerns that there were about maintaining the resilience of the NHS system, we had actually, and were still in at the time, just come off the back of probably the most difficult winter that I recall even in my 30 years in the NHS. And I think we are right to place on record our concern for staff who are really tired and exhausted and have been on a constant treadmill. Even as we come out of pandemic responses and the very immediate pressures that they represent, obviously, we're asking staff to point in different directions, because then what we want to do is to recover activities in a different way.

On the sickness and absence side, the figures still remain high, but they are at least improving a little. So, the latest figures over the last couple of weeks are 7.2 per cent, that's compared with 5.2 per cent at the same time last year. About half of that sickness and absence, 3.5 per cent, relates to COVID-19, so that means around 2 per cent for self-isolation and about 1.5 per cent in respect of people who are actually off for reasons of being treated and concerns about symptoms at this stage. I do think we have to try to work this through short term, to give resilience, but really this is about having a broader plan. So, I hope, as we look forward, the investment and the commitment that we have given to the system to have a pipeline of increased numbers coming through in a range of professions, including very significant numbers on nursing and seeing GP numbers recover, will give us a bit of hope for the future resilience because we have people in. We do have 5 per cent more staff within the system. Inevitably, that will have been affected by us needing to expand out, including in clinical roles during the pandemic response, but that will be insufficient.

I do think we have a responsibility to support people on their own emotional needs, coming through this crisis. We have some very immediate support in place about professional access, particularly some infrastructure that we have in place that we've extended through Cardiff University, and we wanted to make sure that although I oversee directly and line manage the NHS there is a level of support available for the social care system as well. But I think that because of some of the experiences that some of our staff have had, as well as being tired, there will be concerns about the emotional health and well-being of staff for some time to come. You may have seen a study that came out last week, going as far as post-traumatic stress disorder support, saying that you can actually see these consequences coming through for anywhere up to seven years or so. I'm really pleased that, at a softer side in respect of our approaches, given that we've had such good military liaison support with us in our response across Wales, and they are embedded with my team here nationally, we've been able to access some of the support that they themselves use for their own staff and military colleagues, and I do think, unfortunately, there is some read across from that at this stage. And I think we are going to have to push forward by looking to invest and balance in our services at this stage, continuing to make sure that we can expand out on areas like critical care, which I know are the more traditional areas, but, I hope, having good pathways in place for services that support, so it's not just that everything runs in one direction to individual members of staff.

The final thing I'd say is just that, however, there's been a tremendous amount of camaraderie about the way in which the NHS has responded alongside the care system. So, the collaborative working and the way in which teams have worked with each other, but also across organisations, I think that is here to stay, and I hope that will also give us some hope for the future for the support. The workforce plan that you may recall us launching back in November, which was always a commitment of 'A Healthier Wales', gives us a lot of the hooks, I think, for the way in which we're going to support and endorse that resilience and well-being of our staff in the future.

Okay, but I just want to probe you on one further point. I agree with everything you say, but the vaccination programme, hugely successful, strategically, absolutely very, very important, but a lot of the retired doctors and nurses who've come forward say, 'We'll help here', you know, there's been quite a bureaucratic response to that: (a) obviously, they need to be vaccinated themselves so they're not becoming sick as a result of that activity, but (b) practice nurses in primary care have been told they'd have to do the full induction programme to join the mass vaccination centres, as if they'd never worked for the NHS. It seems to me that there needs to be a way in which we can bring in more people to do something that is clinically quite a basic job, to relieve some of the people in some of the more complex areas in our hospitals. I just wondered how you think you've been doing on just developing the new ways of working to this particular aspect of our strategy.

Well, firstly, even beyond everything that staff have been through, staff have equally wanted to make sure that they've been part of this unique opportunity to protect the Welsh population with the vaccination approach, with the number of extra hours that people have offered, and out of hours, in order to maintain our progress on this. Obviously, from an outcome perspective, you'll have seen over the weekend that we hit the 1 million vaccination mark, and I keep having to remind myself as well as others that it was only on 4 January, for example, that we actually issued the first Oxford-AstraZeneca vaccinations here and we have completely set up this vaccination system from scratch across the system, on top of the fact that this is still right in the middle of the pandemic response as well, and indeed discharging other duties as well.

So, I think the exceptional arrangements that we've had to put in place recently, and having the advantage of mass vaccination centres right through to primary care, is probably different from how we would continue to discharge this in the future. So, an effort to get everything as quickly as possible through the system now provides that protection to avoid hospitalisation and, in a very salutary and sad way, to avoid deaths in our system, and if we can get that done as quickly as possible, I think we can then look at the longer term in a different way. So, we are looking to the long term on vaccinations. We obviously need to have a minimum probably annual cycle in place; the extent to which that can happen alongside other vaccinations like the flu will be something for us to consider. But we will also be recruiting a more flexible workforce who can discharge vaccination, but we have needed to have the expertise available now, because—

Okay. But all these—

—it's the best way in which we can reduce the hospitalisations.

So, why is it that all the retired clinicians I know who say they've offered their services since November still are not putting jabs into people's arms?

At the moment, we are able to keep up with the supply that we have, so there will be moments when we need different people at different levels, and I would suggest, going into the summer and into the autumn, particularly when we have the annual cycle, we'll need to continue to expand outwards. I agree with you that as we were setting the system up through January, the system, I think, was overly bureaucratic on some of its expectations. If I could just say that these were standardised approaches across the UK, not anything that we were exceptionally doing in Wales, but using some good rule work that Aneurin Bevan had put in place about just a more pragmatic approach, allowing for that accreditation of existing experience, we were actually able to break into that through February to make sure that there was a different offer available. And perhaps offline, if I could ask if you still feel that there are some individuals who want to help and are having a concern and problem, I'm very happy to facilitate that with their local respective organisation as necessary. But we have removed some of those initial obstacles, because obviously we still have a duty to safety in respect of what's happening. But I do think that the vaccination programme needed to more reflect some of the exceptional arrangements to get through patients really quickly and, of course, we've been doing that over these recent weeks. I'm really proud of literally in weeks how well the vaccination programme has delivered that, both in Wales, but I have to say across the UK as well.

Thank you.

And just building on from what Jenny Rathbone raised there, lessons were learned on that front, because I know a lot of us as Senedd Members got queries from people who wanted to be able to volunteer, but felt that there was over-bureaucracy in the system at that time.

Yes, we dealt with the bureaucracy issues. I think there is a separate issue about given the supplies that we have available, how many staff we need to continue to maintain that level, and as supplies increase, then we are able to expand out at that stage. But I would also agree with the comments that were made here that if there are opportunities for us to withdraw individuals who've been appropriately supporting the vaccination programme because they want to revert to their other activities, or even the extent to which it just gives them some respite from some of the expectations in Wales, then that is a genuine opportunity for doing that. So, I've already had conversations with two chief executives through last week, where they were emphasising how they were shifting to a different staffing model moving forward, and I'm sure that'll be part of the answer and solution for that.

Diolch. Darren Millar.

Thank you, Chair. I just wanted to ask, if I can, Andrew Goodall, obviously it's one day over 12 months since the first COVID case was identified in Wales, and the health Minister very candidly said in interviews yesterday that he would have done things differently, given the picture that he now knows was the case and hindsight. Can you tell us what you would have done differently, with hindsight, over the past 12 months?

Yes, I think that the pandemic response has clearly stretched us beyond any previous experience, either working at an organisational level, at a front-line level, but certainly working at a national level as well. And I think that we have had to be guided by the understanding, the data and the science, but there were just so many unknowns about the way in which the virus was going to spread in the first instance, back in February and March. I do still recall the way in which the NHS needed to step up its arrangements from a general sort of winter-resilience-type response or even a major incident response to something that was much more significant, and I do feel that we responded quickly to that, establishing things like the field hospital arrangements so quickly, but they were very much influenced by some of the international experience at that time. So, I do think that stepping away from the system in March, as much as that had an impact, I felt that that was the right thing to have done, and I still believe that was the right thing. I know subsequently clinicians have really strongly argued for the need for them to be more prepared to get that training in place, and some of the numbers that we were potentially dealing with, you may recall that, at one point, we thought that we could have anywhere in excess of 1,500 ventilated patients across Wales. That would be in comparison with a normal number of beds for critical care of 150.

But I think there are a couple of things to sort of learn from this. Firstly, previous emergency planning and pandemic planning absolutely helped, and not least it gave us access to a supply store for PPE in the first instance. Without that, we would have been in even more difficult territory there. But I think that what was different on this virus was that it wasn't a pandemic flu virus, so there were some differences, and I think maybe to think more broadly about the pandemic arrangements in that sense, that whilst there was a very specific issue that was listed on the risk register, thinking more broadly about the kind of viruses that can emerge would have been quite important.

I think the second thing that it has brought home for me is actually perhaps, more broadly, the resilience of the NHS more generally, so this ability to have access to beds exceptionally if needed, including access to the field hospitals. I'm pleased that we've not had to deploy them to their full extent, because that would have shown a system that was really in a very, very difficult position, to have had to have used all of those beds across Wales, but I think it does raise some questions about our balance of activity and capacity for the future, particularly as we go through some of the winter arrangements.

And I think the third bit, although we've been able to rely on this obviously through both Welsh Government reserves and also from consequentials, is having some flexibility in the system for some of the financial decisions that we're making. I was really mindful that, in governance terms, whilst we were on the one hand committing to capacity like the field hospitals and securing PPE supplies in the first instance, we didn't necessarily have the initial flexibility within the budget to probably handle some of those. So, probably we were making the right decisions with governance, but at risk initially, and perhaps having a level of understanding that sometimes what we need to have is some underlying financial flexibility to handle those issues as well.

But I think there's going to be a whole range of reflections that we'll learn along the way. Having said that, some of the very significant asks of us in the pandemic—starting things from scratch, as I said earlier, PPE supplies, TTP, the field hospital arrangements, the digital arrangements—I do think that we have been able to execute those very, very quickly, but I've always been mindful of the probity and the value-for-money issues associated with those types of decisions as well.

I would absolutely applaud the way that the NHS responded, particularly in those early days, just to get things up and running and to increase the capacity and focus its energy and resources on preparing for the worst. It was a very difficult time, obviously. But I think there were times when some of the fragility of the NHS was exposed, too, weren't there? I remember the whole issue in terms of the shielding letters, for example. That seemed to suggest that we had some weaknesses in the data that was available to the NHS. Do you want to expand on how you've managed to overcome those now in terms of making sure we've got systems that do talk to one another? I know you talked at length earlier about some of the digital work that's been going on, but how does the NHS identify those who are very vulnerable and make sure that we can focus resources on them in times like these?

I think, firstly, we have had to not just draw a lot of our operational and scientific data together on behalf of both the system and on Government, but we've had to use it to inform the basis of decision making right through. One of the reasons on field hospitals, for example, when I originally called out that there was a need for up to 450 critical care beds in Wales, and perhaps up to 10,000 extra bed capacity based on the modelling that was done at that stage, we were actually using data not just behind the scenes, but actually to frame the resilience of the system that was needed. But also, it demonstrated that, whilst we have access to levels of data, what the pandemic response required us to do was to revisit a number of the definitions and categories, and one of the issues with the shielding approach was that there wasn't simply just a list of shielded patients that we could press the button on overnight—we had to reconcile a whole series of systems. And whilst there were advantages for us in Wales, not least using our national infrastructure and the fact that we did have NWIS available to oversee it, it was more in the definition and the interpretation of some of the data categories where we needed to ensure that we were developing and focusing on the right kinds of patients. I think the particular challenge for Wales, though, as well was it was another example, with shielding, where it exposed the underlying health characteristics of the population. What I mean by that is that, pro rata, we probably expected there to be, say, no more than 90,000 shielding patients in Wales, based on the analysis in England, but, obviously, given our underlying health characteristics—age of population, et cetera—we ended up more in excess of 130,000 that we needed to address.

So, I think that, if you think of test, trace, protect and the Welsh immunisation system, the way we've had to bring together a range of our different data systems, the way that that influences some of the modelling, we now have much more of a collective sense of data that is actually available for use, rather than just interesting retrospective analysis. And I've been able to draw that quite strongly, I think, into the operational performance of the system, of course, as well as ensure that it's available actually for Ministers to make their range of decisions as well. 

But it has exposed this weakness for outdated data being collected by some parts of the NHS in Wales versus GP records and the centralised record keeping, hasn't it? You referred to the cancer records earlier, for example, and those not always being aligned with data in other parts of the NHS. So, this inability, if you like, of data systems to talk to other data systems has really been a feature that I think has been perhaps one of the more challenging aspects of the NHS response. I know that work is going on to try and address those, and to try and have a more centralised data system that everybody can access, which is live and up to date at any one time, but it is, of course, at the moment resulting in duplication of effort in many respects, with GPs recording vaccinations in their GP surgeries and then having to upload them later, for example, onto the immunisation service database.

When do you expect those changes in terms of the data systems to be implemented to an extent that we can overcome this unnecessary duplication and bureaucracy within our national health service, so that we can have one truly national health service system that everybody can rely on for being accurate and up to date? 

Firstly, because I would agree with your reflections that we've obviously had to challenge some quite challenging asks of our data and our systems by the fact that we have actually been making that good, and improving it and progressing it at this stage—. So, we are going through a risk stratification exercise ourselves in respect of what the data means at this stage. With the Welsh immunisation system, actually, whilst it was a system that was enhanced and created within four weeks or so, we have been continuing to upgrade and enhance that to make sure that it is an available system. And one of the advantages of the Welsh immunisation system is, once the data is on there, it reconciles to a whole range of other systems, including the pathology systems, for example. So, the records are then available for the GP. So, there are, actually, a number of advantages from the systems that we've done, but we have had to put in progressive changes as well.

So, I think that, again, coming through the pandemic response and recognising how we've used technology and data, our commitment to wanting to make sure that that data is available routinely for system planning right through to operational and front-line use by clinicians, that will absolutely be an area of focus for us to work through. And I think a lot of the digital focus has been on what systems and technology infrastructure. I do think that we need to pause and allow ourselves to reflect on how data has been a driver of the pandemic response in terms of the individual decision making.

Just as a personal example, I'm able to access a system that tells me how many patients are in any area of Wales, or field hospital or whatever across there for all sorts of different reasons in order for me to maintain my daily focus. So, I know at the moment that we've seen our figures over the weekend drop down to below 1,500, for example, of patients who are in for COVID-related reasons across Wales, and I'm tracking that on a daily basis. So, even in my own operational oversight of the system, there is data that I would not have had available to hand 12 months ago that is now simply ingrained and part of my own day-to-day interest and oversight. 

So, lots of things to build on. Maybe I could find a way of committing—and whether this is for a successor committee—to a way of just describing some of those changes around the data, because I do think we have learnt an awful lot about trusting it, making it more accurate. And I have to say some of the background modelling that's been done around the potential for future waves, not least of coronavirus, we've been able to track a very accurate forecast of the position going forward. So, the systems themselves have actually learnt as we've gone along over the weeks and months, as well as us as officials obviously having to learn about what they mean in practice.  

That's very encouraging to hear. Just one final question, if I may, Chair, and that is around the transformation of services. You've already alluded to the fact that the NHS has had to find new ways of working and the benefits of technology have really come to the fore in terms of digital consultations. We know it's not possible for everybody, but digital consultations have certainly been something that has really, frankly, nudged us into the twenty-first century in terms of the way that this technology is being used, and particularly, if I may say so, for mental health patients, many of whom might suffer from anxiety and other disorders that make it difficult for them to leave home, or plan to leave home, even, because of the nature of their illnesses. What are you doing to make sure that we can absolutely lock these gains in, going forward, and can you tell us who is leading on that work from a Welsh Government point of view?

Yes. So, obviously, change of practice, services, even behaviour, is something that we'll oversee in overall terms, but I've wanted to use the 'A Healthier Wales' framework and team for the way in which we capture that. We have just been updating the actions for 'A Healthier Wales' so that we can recast them for the future, which will include some of these service transformation changes. I think the exercise that the committee may welcome, once that's in the public domain shortly, will just be bringing this exercise of the work we've co-ordinated with health organisations across Wales about innovation and transformation, and just the extent to which the pandemic response has led that change. And, as I said, that work that Swansea University has facilitated with us I hope will be out in the public domain during March, and I think that will give you a lot of the evidence and examples.

I do think—. As I started off this session, I did talk about how I have wanted to use my own time to set different expectations for the system, and one thing that I'm very focused on at the moment is, whilst I think the NHS has responded in a really agile way and moved away from perhaps some of the slower decision making that maybe we could revert to, you can see, as we come out of the pandemic response, if you're not careful, the elastic will go back, and I think we simply can't tolerate that. We have to ensure that we're setting a different level of expectation and compliance for the system about the change of services that have happened across Wales. So, whilst sharing what's worked well and making sure that that's endorsed by clinicians is a really valuable thing, I think making sure that the system is clear that we will not want that to revert is also important. I can personalise that to some extent. Just last week, I was speaking to the lead clinician for Wales who'd led on the Technology Enabled Care Cymru work around the video consultations that have led to 120,000 video consultations to take place across here, and her energy to want to continue to ensure that is used across Wales, across different specialties, in all sorts of different settings, was absolutely still there, but we did agree that we didn't want the NHS to revert to its traditional mode of operation. So, I will keep a focus on that personally, and I'm sure the committee will continue to scrutinise that in the future.

Great, okay. Diolch, Darren. That brings us, well, back where we started with my initial question to you, Andrew. How do you feel that you've worked with the committee? In terms of our legacy, are there any recommendations that you would make in terms of how we can do things differently in the next Senedd?

So, a few reflections from me. I'm always mindful, coming into the Public Accounts Committee, not least attending other committees in detail, that I'm coming through to focus on my oversight and accountable officer role, and that inevitably there will be issues about system progress but also governance that will become the particular default of the committee at this stage. I think it probably continues to be important in the way that you have taken a complementary review with other committees to make sure that I am able to come in to discharge and respond in those environments. I would like to feel that I can maintain my ability to come and simply answer the questions of the committee. I've always approached these—you know, 50 plus on at this stage—wanting to make sure that I can give you answers that actually help with your own reflections and response, whether I'm on my own, as today, or with the team more generally.

I would give a little bit of feedback that I've been really pleased about some of the liaison that we've had with clerks of the committee over this recent period of time, because obviously—. And I'm really mindful, even of a session like today, I mean, really, you could be asking me anything at all on any area of oversight I have or responsibility, and on any of the reports that you've issued over recent time. It takes many hours to prepare for these committees and prepare, but the more that clerks can give us a feel for the types of areas that you're going to highlight, the more I feel I can prepare to be able to turn up and answer the questions that you're looking for at this stage. I'm really grateful that you've allowed, over the course of these last few years, for the clerks to just give us a bit of a steer for some of the areas under consideration. 

Just as a single point, I would—. I offer this as a genuine reflection. There are some recommendations, perhaps, that the committee has made, that for me have probably gone into operational territory, and rather than perhaps focus on the governance and the outcomes, have sort of given an operational requirement to implement something that means that I'm then responsible for it. I think you probably just need to think sometimes about maybe the wording of—. Maybe, a couple of the recommendations, these are not the core ones, because, really, you should leave it to me to work out how the system will operationally respond and then challenge me about whether I've got there or not. And just some of the language on some of the recommendations along the way—there were one or two on the digital side that I felt that they were probably more telling the system what it precisely needed to do, rather than perhaps setting the outcomes and governance.

But that would just be, for me, a peripheral comment. I'm just grateful that I've had the chance to turn up, alongside colleagues, and I hope, generally, speaking, to be able to respond to some of your questioning, not least on some very difficult issues, including, as I said earlier, the fact that we had a particular session just on ministerial direction, because that was such an unusual issue. So, I'm very grateful for the support, and I know I'll be back here in the future, no doubt, on many subsequent occasions as well.

I can see Rhianon Passmore's eager to come in, so, Rhianon, over to you.

Thank you very much, Chair. I'd also like to express my thanks to you, Dr Goodall, for the work that you've put in, and your staff. My question, really, pertains to the many asks that have been made of the Welsh NHS over the past year and successfully mitigated for. You mentioned that you would, ideally, want more financial flexibility, and I know we've not got much time, but could you explain what you mean by that comment and what does that look like in terms of your management or future management of the Welsh NHS?

Yes. So, a couple of things I'd reflect on. Firstly, the more we've been able to focus on individual organisations meeting their financial positions means that we are able to make different central decisions about how we want to focus on areas. I think, inevitably, there is going to be, however, a post-coronavirus reflection on what the needs of the NHS are, both on a temporary basis, but, I have to say, more on a long-term infrastructure basis as well. You'll have seen some of the reflections across the UK, and it will be no different in Wales: there will be a need to just think about flexibility to allow the system to not just deal with examples of backlog, but actually to secure the longer term wishes. So, what I don't want is 'A Healthier Wales' to be taken over by the fact that we simply need to focus only the lengths of waiting lists, for example; I think we have a responsibility to do both. So, some of the financial flexibility and whether some of this comes from opportunities around, initially, coronavirus reserves or whatever reflections are—there will just need to be some reflection from Welsh Government. But the more I can continue the discipline financially of the NHS in general terms, the more I have some choices as to where I can set aside some budgets for particular purposes through my own choices under the ministerial budget.

Good. Diolch, Rhianon, and thank you, Dr Goodall, for being with us today—your last appearance before the Public Accounts Committee in the fifth Senedd. The last of many appearances, as you mentioned earlier. So, thank you for taking time with the committee, not just over the last five years, but also particularly during the pandemic period, when I know you've been busy. So, we will send you a transcript of today's proceedings for you to check for accuracy before that's finalised. But thank you for assisting the committee.

Okay. Thank you very much. Diolch yn fawr iawn.

Diolch.

Okay, item 4. I will move the motion under Standing Order 17.42 to exclude the public from the meeting for items 5 and 6 of today's meeting and the meetings on 8, 15 and 22 March. Happy with that? Okay.