National Assembly for Wales

Bore da. Croeso. Welcome, Members and witnesses, to this meeting of the Senedd's Public Accounts and Public Administration Committee. We have only one apology for absence from Rhianon Passmore. Do Members have any registrable interests they wish to declare? Thank you. For participants around the table today, headsets are available in the room for translation and sound amplification, with translation on channel 1 and amplification on channel 0. Please switch off any electronic devices or ensure that they're on silent. Note that in the event of an emergency an alarm will sound and ushers will direct everyone to the nearest safe exit and assembly point.

We have a few papers to note. Firstly, scrutiny of public administration, letter from the Welsh Local Government Association, dated 31 January. The WLGA responded to our consultation on the public administration remit of the committee. Are Members content to note the response? Thank you.

The second item, the Chair of the Equality and Social Justice Committee recently wrote to the Minister for Social Justice regarding the current review of public bodies subject to the Well-Being of Future Generations (Wales) Act 2015. The letter also refers to the commissioner's concern about comments made by the former Permanent Secretary when giving evidence to the Public Accounts Committee in the fifth Senedd on 1 February last year. When asked whether she had to challenge a Minister regarding an inconsistency between the policy or approach that a Minister wanted to take and the Act, the Permanent Secretary replied that she could not think of any examples. The Minister has been asked if she can confirm if she agrees with this assessment and if she can outline what systems the Welsh Government has in place to ensure that its business and conduct are compliant with the Act. Are Members content to note the letter and that we consider the response when it's received? Thank you.

The third item relates to correspondence on the use of the term BAME, which of course we've discussed previously. We've had a comprehensive and positive response, I think, from the Commission regarding use of the term. The Chair's Forum, which I attended, also discussed this issue at its meeting on 17 February. Do Members have any comments, and would you like to take the Commission's offer to discuss the use of the term? If so, we can advise the clerks to make the arrangements. 

I know I've spoken about this previously in a meeting that we've had, and I'd very happily like to see the term 'ethnic minority' used, as opposed to BAME. I find BAME is rather obtuse as a term for people who are not from the black ethnic minority background, because minority ethnic is rather vague. I know a lot of people don't quite understand what it means. And personally, as someone from that background, it doesn't apply to me.

Thank you. I think, if I remember, the letter we've received suggests, depending on the context, either 'ethnic minorities' or 'ethnic minority communities'. Thank you.

Yes, happy with that.

Right, we move then to item 3, for which our witnesses are with us, focused on governance issues at Betsi Cadwaladr University Health Board, an evidence session following on from the committee's legacy work from the work done by our predecessor committee in relation to the health board. So, I welcome all the witnesses to the meeting. I'd be grateful if you could now formally state your names and roles for the record, perhaps starting with, I don't know, the chief executive.

Diolch, and croeso. Mark Polin.

[Inaudible.]

We'll come back to Mark then. We have Sue Hill.

Cadeirydd, do you want me to—

Oh, you're here. Right. Just so we confirm for the record your name and title, job description. 

Sorry, we were having problems with the sound a moment ago.

Thank you. And Sue Hill.

Thank you. And I believe Gill Harris has had to give her apologies because she's unwell, but she's being represented instead by—

Teresa Owen.

Teresa Owen. So, could you introduce yourself and your role please?

Thank you very much indeed. Well, as you'd expect, we have a number of questions, and I'm asking, if I may, Members and yourselves to be as succinct as possible to enable us to cover a wide range of issues generated by the topic.

So, if I begin by asking the first question, and then I'll bring in my colleagues, and this is focused very much on de-escalation from special measures. In your view, was the Welsh Government's decision to de-escalate the health board from special measures in November 2020 the right one, and how confident is the health board that they can sustain the improvements that contributed to the decision to de-escalate, both in general—and I'm sure we'll get into this further a bit later on—and in the context of recent reports?

If I may, I'll start with the response to that question, Cadeirydd. Firstly, I'd like to note that, of course, the decision to de-escalate does not rest with the health board; it rests with the tripartite, which is comprised of Welsh Government, Audit Wales and the inspectorate, Healthcare Inspectorate Wales, and it's our responsibility to provide information and any evidence that they wish to consider in any de-escalation or escalation decision. So, that is a decision taken outwith of us.

In terms of sustained improvement under the targeted intervention framework, which we now find ourselves the subject of, certainly as a board we are more confident in our ability to demonstrate improvement under the TI approach than previous special measures arrangements. And there are a number of reasons for that, but, principally, the targeted intervention framework has afforded the board the opportunity to set a clear trajectory for improvement, which can be evidenced and assessed, both by us and by that tripartite, and overseen by the Minister of course. 

The areas for improvement are those set by the Welsh Government, however, the detailed improvement journey and the content of the maturity matrices that we use are owned by the board. And we're very clear about that responsibility. As a board, we've set the expectation for the organisation, and we have implemented arrangements to provide evidence of action, and importantly, impact. The delivery framework that underpins the maturity matrix approach, or matrices, is robust and involves executive directors as leads for improvement domains, complemented, importantly, by independent members who are there to bring insight and experience in the role of critical friends, for want of a better description. This has the ability to harness the wider knowledge of the board and the skills that it possesses. 

Our focus is not only on evidence of action, but more importantly on the impact of that action for patients, staff and partners. And, as an aside, I held a meeting with the independent members yesterday, and we discussed that particular aspect of the targeted intervention framework and what we expect to see by way of outcomes at some length. Adopting this approach also enhances our confidence in that what we are doing will make a positive difference. 

So, in summary, I would suggest that the board feels it now has greater ownership and responsibility for improvement, and that it is more able to describe the areas that it will focus upon to secure that improvement whilst operating within the framework and the expectations set by the Minister and the tripartite.

Thank you. Does anybody else wish to comment on that, or shall we move on? Members, thank you.

Sorry, Chair, I have a question in relation to de-escalation before we move on to the second section. Do you want me to ask that now, or shall I just start with that?

Well, yes, if you could pick that up and then run into your questions around the targeted intervention framework.

Thank you, I will. Good morning, everybody. Just a quick one, coming on from our Chair's question to you. In relation to de-escalation arrangements, from my understanding, the TIF sets out that, under the joint escalation intervention arrangements, the Welsh Government meets with Audit Wales and the healthcare inspectorate twice a year to discuss the health board in respect of quality service performance and financial management. Under the current situation, and the current state of how the health board is, do you think that's enough, or should more sessions be held in relation to this?

I think, importantly, those sessions provide an opportunity for the board to demonstrate progress to the tripartite through our executive team. And there are regular meetings between the executive team here and the officials in Welsh Government. So, those more regular meetings with officials will be informing the twice yearly tripartite meetings. And I feel sure that, if the tripartite wanted to call further meetings, they certainly would. So, we feel it is sufficient, because there are other avenues of reporting that are taking place. And moreover, I'm sure you would have noticed that the board, in public session, receives regularly an assessment of progress against the TI framework—in fact, it's at every board meeting. And in terms of the staged assessments—and the next one is due in May—that will be considered in full at a public board meeting too. So, I think it is sufficient, bearing in mind there is flexibility in that arrangement, and there are other processes that inform that tripartite meeting, from our perspective.

Thank you very much for that. Can you please provide me, and the committee, with an update as to the progress of the TI framework that you have at the moment? What are some of the key challenges that you're experiencing at the moment? Are there any hurdles, worries, concerns that you want to bring to our attention at the moment?

I think Jo will come in on that.

Thank you. Our priorities are associated with the four areas of targeted intervention improvement: mental health; leadership; strategy, planning and performance; and engagement. And with regard to the strategy, planning and performance priority, as a health board, we're due to submit a balanced integrated medium-term plan, an integrated operational plan, for the next year, which seeks to balance our performance targets and our financial duties.

We are on track to present for approval by the board a balanced plan. However, within that balanced plan, there are undoubtedly challenges for us, as there are for other health boards. And they are, predominantly, managing the uncertainties that are ongoing with regard to our COVID situation. Typically at the moment, we still have around 70 to 80 COVID-positive patients in hospital at any one time, and although we are, thankfully, moving into a situation of reduced community transmission, we're obviously always aware that a further wave of COVID may befall us up here in north Wales. We're also somewhat affected by inflationary pressures, particularly with regard to the costs of energy. So, within those uncertainties or challenges, it is our intention to develop a balanced IMTP, and that will be a real achievement for us as a health board, and I think will help us consider our position around the maturity matrix domain for strategy, planning and performance.

As an organisation, with regard to leadership, we have entered a period of relative stability, with additional senior appointments being made, in order to enable us to make the most of digital opportunities for our staff and our patients up here in north Wales. And in order to strengthen our response to one of our other areas of targeted intervention, that of engagement, we have strengthened the capacity and capability within the organisation to be able to respond more fully, and develop our approach to partnership and co-design more fully. Those aspects of co-design and partnership and engagement are in play, as evidenced by the approach we've taken to developing our clinical services plan in partnership with clinicians, and our approach, through the RPB, to winter pressures, which has seen us ensure that the additional resources available for winter pressures of just over £2 million were indeed allocated to our local authority and third sector partners in their entirety in order to enable us to respond as appropriately as possible to those winter pressures.

It's very important to us that we continue to develop a clinically led organisation, but, of course, the capacity of our clinicians to engage in our clinical strategy work may be impacted by COVID or the impact of COVID. Thank you very much.

Thank you very much for that. The report from the previous Public Accounts Committee identified issues around leadership at senior levels at the health board. So, I'd like to now ask you all whether the health board is now in a position, and has the capacity, to undertake its role effectively, as it should have previously.

I will start with the response, if I may. It wasn't just the committee that had concerns about leadership; the board did have concerns about leadership at the time. I'm pleased, as is the board, that we were successful in appointing Jo at the start of last year as our chief executive and leader of the organisation. That was an important appointment, as I'm sure you'll imagine and recognise. And the board has supported Jo in making some adjustments to her executive team, both in terms of responsibilities that sit within that team and how they're divided, but also some additional capability. And in that regard, the support funding from Welsh Government has proved helpful in ensuring that we've boosted the leadership capacity, or we are in the process of doing so, particularly in terms of digital and IT capability and development within the organisation, partnerships and engagement work, and, finally, in terms of some other aspects of performance improvement and transformation. And we're currently boosting our capability in that regard, which I'm sure we'll come on to later in this meeting. I'll now hand over to Jo, if I may.

Diolch yn fawr, Mark. So, just to build on the chair's response, one of the pieces of work that we've been very keen to do as an organisation is to think about how it feels for our staff, for our patients, to work in and be looked after by Betsi Cadwaladr. And one of the first things we sought to do on my recent appointment was to create an engagement opportunity with all of our staff, which we entitled our Stronger Together programme. This has enabled us to have wider-ranging conversations with staff and has resulted in the co-creation of a development programme, which will support the organisation at all levels to enhance the talent across the organisation as a whole, thereby increasing our ability to respond to our challenges.

The programme that we developed in response to over 1,000 conversations with individual staff and in groups does have five broad areas. One is to really think about the culture and behaviours associated with the provision of care for the people we're here to serve and within our teams: what we value and how we support and treat each other.

The second programme of work is around strategic deployment, making sure that all of our staff—and there are many thousands of them—understand how each are doing in their role and how their role connects to the health board's purpose and goals. We've also considered how we organise ourselves. Betsi Cadwaladr is a big and complex organisation, and so one of the things that we have in progress at the moment is working on how we can simplify the way we work, or our operational model, to make it easier to get things done, to make us more able to be able to respond as an integrated organisation, focusing and understanding the differences of places across north Wales. Llŷn is very different to my home town, Wrexham, and we need to be able to be in a position to respond accordingly, whilst maintaining consistency of practice. And one of the key opportunities for Mark and me, as chair and chief executive, is to make sure that we are able to make the most of the abilities of all our staff. 

And finally, the final area of the Stronger Together programme is how we improve and transform our services. We know—and COVID has shown us—that there are different and more effective ways of providing healthcare services into the future. We and our staff are keen to make sure that we work with patients in order to adopt those aspects of transformational change, which works for all of us. Diolch yn fawr.

If I could just wrap up that response, if I may, of course it's important that the board, and particularly Jo and I, demonstrate what we're expecting of the staff, and we are demonstrating our support with that Stronger Together programme. As you might imagine, Jo and I have done a lot around that, but also with the board, and we continue to run a board development programme with the King's Fund, which we are finding, I think, as a collective, extremely helpful. But also we have work ongoing with the Good Governance Institute to assist us in ensuring that other aspects of what we do as a board, particularly around governance and assurance, are as effective as they can be, because whilst we want to unleash the organisation in a more fundamental way than we have done in the past, we want to ensure that we get it right strategically and as a corporate body too. So, there is a lot of work wrapped in and around what we've just said to you.

Thank you very much for that. You actually answered a lot of the questions that I had pre-planned, but I'm going to ask two more questions and I'll pass it on to my colleague, if that's okay. You mentioned previously—. When I asked you what were some of the challenges, you mentioned COVID uncertainty was one of those, but I really appreciate in your previous answer you touched upon how staffing was really important, and that's something that I'm a huge advocate of. One thing that we've all seen from all of our regions across the board is that we've had a lot of staffing issues within health boards of people wanting to leave who are in the profession themselves. So, you've mentioned the development programme. What are you specifically yourselves doing to ensure that you have that staff retention in your health board, because it's so vital at the moment to ensure that staff are happy, and, if you're falling short, what are some of the provisions that you're doing to ensure that your staffing levels are always kept to that level where your patients receive the best possible care?

Thank you. I can't tell you how proud I am of our staff up here in north Wales, and I'm sure the same would be said across the NHS in Wales. We are nothing without our people, and, goodness me, they have given and given again during the COVID pandemic.

Recruitment is very important to us here in Betsi Cadwaladr, as is retention. I'll start first by talking about recruitment, then I'll talk about retention, and then I'll touch on some of the strategic opportunities that are available to us up here in north Wales.

The chair and I visited one of the emergency departments in north Wales 10 days ago, and, in that conversation with the matron, we discussed recruitment challenges for nursing staff within emergency departments, and you'll be aware no doubt that recruiting to emergency departments is a challenge. To our delight, the matron there was able to confirm that they had most recently fully recruited to all of their middle grade posts, so to speak, and she was going to be spending the next couple of days, she told us, shortlisting for the next phase of applicants. We were interested to understand her success, and she spoke about the fact that, as a team, as a department, they were able to offer a structured approach to preceptorship to support nurses who were relatively newly qualified in that emergency department space, so that, as those staff came online, they were supported in their professional growth, and those individuals who had worked through the pandemic and some difficult times were ready for career progression and she was able to offer those individuals at the middle grade those posts, and so she felt more confident as a clinical leader to be able to offer opportunities to a whole range of nursing staff. And indeed her department is known now within the organisation for creating that kind of developmental opportunity. These clinically led responses are very, very important to us, not only for recruitment, but also for retention and career progression. And of course, one of the opportunities or challenges for us is to make sure that those consistent approaches are applied across each of our aspects of business.

There are some aspects of nursing that are difficult to recruit, and we of course are thankful for the support from Welsh Government in commissioning additional nursing places, particularly with regard to mental health nursing. Of course, whilst nurses are our largest single staff group, they're not the only members of our multidisciplinary team approach, and we've been particularly proud in Betsi Cadwaladr about the approach we've taken to extending the scope of practitioners, particularly allied health practitioners, and developing approaches to nurse consultants, including the appointment, for example, recently of two nurse consultants for dementia care.

We have most recently been relatively successful in the recruitment of some of our more long-standing medical vacancies, and the success of that most recently is undoubtedly part of the context whereby we're working in partnership with Bangor University on the development of the north Wales medical and health sciences school, and working with Glyndŵr to provide bilingual speech and language therapy training, which will significantly improve our ability to be able to provide opportunities for north Walians in north Wales to provide care in the language of choice.

A key to the issue, though, of staffing and staffing support is retention, and we're working hard to make sure that we're creating flexible opportunities for those staff, as you have said, who are tired and who may want to reduce their hours, but also look at rotational posts, which would enable newly qualified staff to spend time, in a structured way, across a range of departments, a little bit like a 'try before you buy'.

And strategically, of course, the partnerships that we have with our universities in the north, but also with south Wales, are very important. We have also instigated a north Wales strategic group, pulling together representatives of ourselves as one of the single largest employers in north Wales, and both of the universities and all of the colleges of higher and further education.

So, a lot of work is in play with regard to recruitment, some successes, retention feeling very important to us, but the strategic approach around thinking about developing our approaches in north Wales will be the way that we resolve our challenges in the longer term. Thank you.

I think it's right to highlight how important a subject workforce is, of course, and it's one of our two biggest constraints in terms of improvement. I would say the other is the estate. But whilst there's a lot of activity going on around recruitment, which Jo has described, we ought to recognise that key to moving the organisation forward is the medical and health sciences school, from our perspective, and it is the primary care academy that we're working on, because the workforce challenges extend across the whole NHS and services in the region. And there have been, on a more practical, tactical level, some key pieces of work undertaken, including a review of our recruitment process, which is due to report to the board in due course. So, I think we're trying to ensure that we, in the eyes of our population and those beyond it, demonstrate ambition and the wish to push forward, including with things like robotic surgery, so that we draw in some highly qualified clinicians. There are signs of positivity in terms of recruitment, but there is still much to do, and ensuring that our staff are able to progress in our organisation, as Jo's just identified, is key too. Because if we just look at nursing vacancies, there are considerable amounts that we have and we've got to do all that we can to encourage people to come into Wales and into the region.

Thank you very much. I have one final question, and then I'll pass over to my colleague and the Chair. You've received Welsh Government funding for three and a half years. What happens if the board can't deliver a sustainable and robust return to financial recovery within that time?

Thank you. I'll start off and then hand over to Sue Hill. Key, I think, to our success is our ability to unlock the transformational savings that we feel do exist in north Wales. Why do we have that sense? Well, when we look at our benchmarked data, it does show us that there are some opportunities for us to use the resources that we have at the moment in slightly different ways. And by 'resources', I do mean the money that we have, the beds that we have, the equipment that we have and, of course, the staff that are at the heart of delivery.

I'll just give you a couple of examples that we are determined to work on. We know, for example, that when we compare ourselves with the absolutely best in class across the UK, in line with many, many other organisations, there are things that we can do, for example around our orthopaedics care, that would enable us to treat more patients through out-patients and our theatres without detriment to quality. So, we know, for example, that we tend to ask patients to attend for a lot of follow-up appointments to check out that a surgery has gone well, and often those appointments are a very quick assessment from a clinician to confirm that, 'Yes, everything is absolutely fine with your mobility, or with your wound'. And, of course, in north Wales, people may have travelled a long way at some inconvenience to attend those appointments. One of the evidence-based ideas that we are seeking to develop is the idea where individual patients are asked to self-identify whether they themselves feel a follow-up check would be appropriate. Using guidelines that we provide for patients, they're able to take much more control of their care, and all of the evidence from the trials of this do suggest that that does reduce the number of follow-ups, and, of course, that creates more capacity for new patients to be seen within our existing resource. These sorts of clinical changes across the organisation do help us to deliver long-term sustainability for the organisation as a whole.

Whilst we're working on these transformational challenges, we will, obviously, continue to work on good housekeeping steps, transitional financial savings, which we tend to achieve by thinking about how we procure as effectively as possible in order to ensure best value for the public purse. I'll hand over to Sue just to talk a little bit more about our long-term financial sustainability plans. Thank you.

Thanks, Jo. In terms of the financial plan going forward, we've done an awful lot of work over the last three years and we are very grateful for the assistance that we've had from Welsh Government in terms of the funding. The funding is in three tranches: £40 million is supporting the underlying deficit of the health board, £30 million is around performance improvement, including planned care, and we've received £12 million that is around capacity and capability and supporting mental health services in north Wales. I think the reason why the funding is so important is because it recognises the need that we have to transform the services that we provide in north Wales, and we do know that we have huge opportunities to eat into that underlying deficit, because the way that we provide services at the moment is not as efficient as it could be.

As you all will be aware, we are very reliant on specialist and tertiary services from NHS England. We spend about £300 million across the border each year, so the development of a transformational programme in terms of the regional treatment centres that we are working towards at the moment will have a huge impact on the quality of the care that we deliver, the cost of it and also the fact that we're bringing it closer to the home and location of our patients in north Wales. So, that is a really critical project for us.

We've also invested a lot of support in terms of the transformation team. So, this is about working with our clinicians and our operational staff to review the way we are delivering our services, taking into account the adoption of value-based healthcare principles, and so we're thinking about patient outcomes and experience, and not just how many procedures that we're doing but the appropriateness of those procedures, and this will all help us start to reduce the underlying deficit of the health board.

Going forward, we are also keeping in line with all the controls and recommendations that we put through after the 2019-20 financial review. So, there were a number of recommendations around both the financial baseline and key expenditure controls, and we are still working through and following the procedures that we put in place at that time. Thank you.

I think I would add to that, if I may, that it is our intention, as you've heard, to submit an integrated medium-term plan in March that will look to balance the plan and the budget over the next three years. But the assistance funding from Welsh Government, which was sought by the board and was helpfully provided, did not anticipate, did it, the arrival of COVID? And whilst we've delivered significant savings this year, that has, of course, been a challenge given the operational context. And we have a limited period now from which to drive forward with the support of that funding to deliver the necessary improvements. And we will drive very hard at that.

I know, though, that other boards are concerned about emerging costs pressures, particularly linked to inflation but other aspects of what we rely on to operate our business, and also the fact that, were COVID to return in a significant fashion and place the level of demand that we saw in wave 1 and wave 2, and to a degree with omicron, then that will affect our ability to do some of those other things that we wish to do, particularly around transformation and financial improvement, in all likelihood. So, we are set to do what we're expected to do, we are working very hard at that and have brought in capability to deliver what's required, but there are risks to what we've described to you and some unknowns that we can't, at this point, predict.

Mike Hedges.

I've been impressed by your strategic view. My concern is that Betsi Cadwaladr University Health Board is a very large organisation and one of the problems with large organisations is the gap between strategic decision making and operational management. How are you going to ensure that decisions you're making at board level are actually going to be carried out at ward level and at operational management level? I'll give you two examples from the past in Betsi Cadwaladr. One was the department that, on being given its budget, said, 'That's not enough. We're not going to bother to work within it.' And another one is that you are twice as likely to have your tonsils removed, if you were 11 to 16, living in Anglesey, or Ynys Môn, than you were if you were living in Wrexham. Now, with these sorts of problems between great ideas at the top and so many layers of management and such a long route for passing information along, aren't you worried that your proposals, your decisions, lose something in translation by the time it gets down to people who are actually implementing them?

That is a risk and has been a problem in the past. What the board is pleased to see is the efforts that Jo and her executive team in particular are making to address some of those challenges that you've properly highlighted. So, the work around Stronger Together, as Jo described, is about fundamentally seeking to engage the organisation in a better fashion than previously in terms of describing the direction that we are taking, the service changes that we want to make, and so on and so forth. And secondly, Jo is, with her team and the support of the board, implementing a new operating model, which I'm sure she'll speak about, which should provide a clearer sense of where responsibilities and decisions can be taken outwith the need to refer up to board. And that has been a problem in the past, in terms of the escalation of many things upwards, which has been driven by some culture in the organisation.

The other thing I would say is that we are working very hard to ensure that our clinicians are informing the service changes that are required. The new medical director, Nick Lyons, has impressed the board, and I know he's impressed Jo, with his determination to work with and engage clinicians—there's been a particular example this week—to ensure that they feel part of the service improvement change journey and do not feel, as they have on occasion in the past, that it is being done to them rather than with them. Because, ultimately, as you recognise, we need to ensure that they are with us in what's required and also focused on the improvement that they need to make themselves, which might require some commitment to change in terms of their behaviour and manner of working. We won't secure that unless we work with them to do just that.

Are you happy with that?

Yes.

Yes. Thank you, Chair.

Your question on this point, Cefin, or—?

Thank you, Mark. As Mark's outlined, our new operating model is designed to deliver a number of things. One is to simplify the complexity of Betsi, and, as a consequence, our proposal is to work more strongly with our three geographies of east, west and centre, which are coterminous each with two local authority areas. Each of those areas will have a single integrated management structure. Our intention is that those structures will be clinically led, and, for the first time, those individuals will sit directly on the executive team, precisely in order to make closer connection between the front-facing aspects of delivery of healthcare and our strategic developments.

We're trying to create a little bit of a push and a pull in the structure. So, the push is to devolve decision making, accountability and local choices to each of those three areas. I have said in the principles around the push, or the devolution, it is okay for services in Llŷn to be delivered in a slightly different way to the way they might be delivered in, for example, Deeside. But, on the outcomes for patients, the patient experience, we must aim to become much more consistent than has traditionally been the case in the past, and that's the aspect of the pull function. So, as part of the operating model, we're also creating a stronger sense of a set of consistent clinical guidelines that we expect all of our clinicians to use across the multidisciplinary team, which would, in your example of tonsillectomies, say to clinicians, 'We expect you to all work to this evidence-based guideline.' That would put some very clear parameters around the circumstances in which a child would be offered a tonsillectomy, and those circumstances aren't postcode related. So, the push is to build on the opportunities around integration, particularly including the importance of partnership working with our local authority and third sector partners, but with some strong, consistent clinical guidelines and standards to be applied across the whole of Betsi Cadwaladr.

And we would see those principles of push and pull being underpinned by our schemes of delegation, but being supported by the cultural work we spoke about earlier on, which is to say to individual clinicians, 'If you are able to identify different and better ways of working in partnership with your patients, and those approaches are evidence based, we should enable you to implement those changes and share those changes, those ideas of good practice, effectively across the organisation as a whole.' That is why we have pulled together all of the staff who have been working on improvement in Betsi Cadwalar into a single team in order that we can ensure that those improvement methodologies are consistently applied.

Now, Betsi is big and has a long history, and, of course, it will take time for the changes I've spoken of to be strongly embedded, but that golden thread from the ward to the board is absolutely vital to make sure that all feel their responsibility to their budget, but, most importantly, to the population of north Wales and, through them, to the board. Diolch yn fawr. Thank you. 

Thank you. I would remind everybody that, at the beginning, I asked if everybody could be as succinct as possible, and, given the time constraints, I'd be grateful if you could perhaps have one person answer each question. If others want to intervene, they can indicate through the Chair and, time permitting, I will call them.

Now, given that you've been in an escalation/intervention process for a number of years, I've written down today comments such as 'seeking to develop,' 'work in progress,' 'much still to do,' 'we're trying to,' 'we're thinking about.' This is a public accounts and public administration committee. We need firm numbers, action plans, focused priorities. We've heard reference to change management by Mr Polin, but that's about cultural and systemic change, doing things with people, rather than to them, agreed action plans that are monitored, evaluated, reviewed and then changed as appropriate. So, can you now or subsequently provide us with firm numbers, action plans and focused priorities that will enable us to do our job and the job of this committee in terms of audit and administration?

So, I'll respond. Yes, we can. The starting point for that would be the integrated medium-term plan, which is due to be approved by the board on 30 September [Correction: 30 March], in which I hope you would see, because it has been the focus of the board and the executive team, a clear description of priorities, a clear description of how those priorities can be delivered through a range of activities, actions and so on and so forth, but, most importantly, the outcomes we expect to see delivered as a consequence of those activities and that plan.

Too often in the past, I think, the plans have been plans, but we've not seen the dials turn sufficiently, and some of that which you'll see described can be supported by other plans that we have, Chair, in place too and that we have shared with Welsh Government—for example, in terms of unscheduled care and the challenges that we have in emergency departments, around the work we're doing to respond to the backlogs in planned care, and, again, there is a paper going to board on 30 September [Correction: 30 March], and so on and so forth.

So, there is a lot that we can share with you, as you say, and as you request. We'll forward those to the clerk, and, of course, if there are any gaps in that evidence that we provide, then we will respond to those gaps. But I seek to assure you, we are not sat here in a world of fluffiness and we are keen to ensure, Jo and I in particular, that the patients in our area are receiving the services that they should be receiving. And if they're not receiving them now, we've got a plan to ensure they do as we move forward. And that is a clear focus for the board and the organisation.

Thank you. Cefin Campbell.

Diolch yn fawr iawn. Bore da ichi. I'll be asking some of my questions in Welsh, but I'll start off with a few questions in English, if that's okay. I looked over my notes yesterday, over the troubled history of the health board, including numerous reports showing concerns in key services, investigations, critical reports around mental health, being put in special measures, and now in a de-escalation process. Now, I'm, obviously, more concerned about the future, but, given the troubled past of your organisation, can you reassure us this morning that you know what 'good' looks like?

Thank you. Yes, we do know what 'good' looks like, and our staff, our clinicians constantly strive to provide good-quality services for our patients. We're an organisation that is committed to improvement, and we'll seek to take as much benefit from the commissioning of external reviews, or indeed internal reviews of our services, because it's by being open to the concepts of improvement and being willing to seek advice from elsewhere that we should constantly seek to improve and never be complacent.

There will be occasions, as has been the case in the past and will be the case in the future, where the board seeks, for its own reasons of improvement and assurance, to undertake independent external reviews of the service, and that is because we are determined to seek and drive improvement, going forward. All good organisations who want to improve are open minded about those opportunities.

We are in receipt of a large volume of data and information that we're increasingly using to discuss with our clinical colleagues how they may seek to change and improve their clinical practice in order to deliver great-quality outcomes. I used an example earlier on with regard to orthopaedics where, by the active use of comparison data, we can see what 'good' looks like, and we will strive to implement those evidence-based changes. In Welsh Government, we are blessed to be supported by Improvement Cymru, an organisation whose sole focus is on improvement and the delivery not just of good, but great, and I'm pleased to confirm that we have a strong partnership with Improvement Cymru to support us in our improvement work. Thank you very much.

Can I just follow up on that? Referring to a point the Chair made, in your lengthy and detailed responses to our questions this morning, there are a lot of good intentions there, but what we want reassurance from you about is whether you take the need for change seriously enough and, more importantly perhaps, at the pace required.

So, I would say we do. You might expect me to say that, but I do think there's ample evidence to suggest, actually, that the organisation's moving forward. I think the response of the organisation to COVID and the many challenges that were presented as a consequence of the pandemic was tremendous, be that in terms of how we worked as front-line teams with partners on the ground to care for patients, be that in terms of the work that was done with partners around the vaccination programme, for example, and so on and so forth. I think that, when you look at our track record of delivery during that period, too, we were one of the few organisations in Wales to still deliver significant financial savings. So, I do think there are signs of improvement. The ambition and the sense of ambition is heartfelt by Jo and me and the rest of the board. We don't deny, nor do we fail to recognise, the challenges, as you've heard us say, but what is important is that we demonstrate ambition and positivity, because our staff, our patients, rely on that. So, I do think there are signs of improvement. Jo and I have been in partnership meetings quite recently where two of the chief executives from local authorities said they'd never felt the relationship between the board and their local authorities had been better. So, we are working hard, too, with our partners to ensure that they feel we are changing and working with them differently, which is important and will be ever more important as we move forward as an organisation.

In that regard, the medical school was not on the table a few months back. That has taken some significantly hard work and determination, and we appreciate the support that the Minister has expressed in that regard. Likewise, there are other things that are going on now that weren't going on months ago. As I say, we will maintain the focus. We understand the challenges, and I can assure you that every time Jo or I receive a letter from a patient, it strikes us really emotionally, for want of a better description. But we are determined, the pair of us, with the support of the board and the organisation, to move forward, and we are, as I say, doing, I think, all that we can to do that. But there are challenges. It would be wrong to deny that, and we are keen to ensure that we overcome them where we can.

For change to happen successfully, it needs to change across the whole of the organisation. Now, clearly we've heard from you as senior managers this morning, but change needs to be owned and implemented by clinical leaders and middle management as well. Can you tell us this morning that that middle level of management, which is critical to implementing change, are on board with your views? And could you tell us how that has happened?

Thank you. Part of the work that we did with regard to our Stronger Together engagement approach has enabled us to work directly with the engine house, as you say, of change in the organisation—clinical leaders and middle managers. It is in response to their feedback to us as an organisation to simplify, to make it clearer what decisions they can make locally and what decisions they have to refer back up the line. That engagement and the design of our operating model around their advice does make me feel that we are on the right track from the point of view of those clinical leaders and those individual managers, because it's those individuals who make the day-to-day decisions around clinical care that have the day-to-day communications with patients and their relatives. So, because of the engagement work we've done, we are responding to the feedback that we've had, and therefore we are confident that we have borne their commitment in mind as we develop our model, going forward.

And we are also involving our co-workers, our clinical leaders and our managers in helping us support the development of our clinical services strategy, and in the prioritisation associated with our national integrated medium-term plan, both of which will help in terms of that engagement, involvement and commitment. When I speak to staff, as I very often do, I talk about—. One of my personal priorities is around patient experience and good-quality patient outcomes. It doesn't matter who I speak to—whether it's nursing staff, housekeeping staff, as I did in Ysbyty Glan Clwyd just a few days ago—everybody is up for that and that gives me joy, because with those staff we can make progress. 

Diolch yn fawr. The targeted intervention and maturity matrices approach has been incredibly helpful for us here in Betsi Cadwaladr. We have worked with individual clinicians and with groups of managers in order to not only undertake our self-assessment, but also to design the steps of improvement that would take us from a level 0 to a level 5. And in the conversations that we've had by way of involvement engagement, colleagues have said that whilst initially they felt disappointed to be in targeted intervention, they have found the process incredibly helpful for them in thinking through their own priorities.

Using the example of all-ages mental health for a moment, we have a targeted intervention approach that has a particular focus on adults, a particular focus on children, as you would expect, but also a particular focus on transition for those individuals for whom that is important, because we often had feedback from staff, from families and from young people themselves that the process of transition was something that we could do better. Through the auspices of the maturity matrix approach, we have been really able to much more strongly pull together both aspects of adult and child mental health services, which our clinicians tell us, and indeed our patients have told us in terms of their individual feedback to us, has been effective and has enabled us to provide patient-centred care at a moment of change. 

So, we have some strong structures and a strong framework and process of assessment and independent review, which help us at a board level feel that the scores that we are giving ourselves are evidence based and robust. And we have evidence at an individual patient level and with groups of staff and individual staff that the maturity matrix approach has been helpful and thoughtful. That is why I believe the chair earlier on in his response said that, as a board, we're feeling more confident about our ability to progress through the levels of the maturity matrix to ultimately achieve de-escalation. Thank you. 

Okay, thank you very much, Cefin. We can now move on to mental health services. It's 13 years since I first raised concerns about care and support on the Hergest unit, raised with me by bereaved families. And, of course, a few years later, the 40 staff whistleblew on the record in relation to similar concerns. It's almost 10 years on from the instance in Tawel Fan, after which we know the Ockenden report was published. And yet we know from recent reports that many of the concerns and recommendations noted in the Ockenden and Holden reports are still there in mental health services. So, what issues are yet to be addressed and why?

Diolch yn fawr iawn, Gadeirydd. Thank you. I'll start. I lead on mental health services and have been working with a new team for the last 18 months or so. I acknowledge that there are a number of areas of work that we are still addressing and those reports have been key reports for the health board. Certainly, the Tawel Fan report and the recent report around the very tragic deaths are areas that we are addressing.

I feel we have a strong plan going forward. So, if I start with the targeted intervention and maturity matrix, that is allowing us to look at some of those fundamentals. And as our chief executive just mentioned, those are clinically owned by the teams going forward. Embedded by the teams, we have evidence of activities to show progress. And, again, as the chief executive mentioned, we started at a low level—that was a difficult score for the teams, but an acknowledgement that we needed to build those foundations through.

More recently, we held an internal summit within the health board, thanks to the chief executive, chairman and to colleagues, and that was a really key area of work for us in terms of thinking through how we can demonstrate to all that progress is being made. And progress is being made on the ground, but we need to demonstrate that, make it more visible, and we acknowledge that and we acknowledge some of the challenges.

The summit has led to a number of areas of work, and we're working on an improvement plan. That was discussed at the quality and safety experience committee recently. It is our first attempt to take a very different look at our progress. So, we've developed action plans. We're working through those. We're on track with the recommendations, but we wanted to take a helicopter view of our challenges and look to that new transformation approach. So, we're very grateful for the investment that we've received in mental health to make a difference, and we'll now be able to show the impact that that is making.

But if I go back to the summit in terms of some of those actual pieces of work that we need to progress on, I'm sure many Members will be aware of some of the challenges we've had with mixed cohorting over in the Hergest unit. We are now making progress with that. We have a phased plan going forward. We clearly need to engage with our partners and undertake further work. We will do that. But we have started and commenced that work recently, at the end of February.

We're also very keen on the work we're doing on ward accreditation. This is owned by the team. This is owned by our staff. And, again, it's showcasing how small steps can make a big difference and actually that taking, maybe, some of the braver, bigger steps will also move us forward. The ward accreditation is key for us; it links well with our COVID programme of work, and just in terms of the general elements of work that we need to do on quality. I'm pleased to report, while I haven't got a gold in that ward accreditation space just now, we are trying to move every ward up a level. So, we've got a number of silvers—I think it's seven silvers—we've got 11 bronzes, and I've got two whites. For those on the committee, white is where we haven't yet made progress but we will. So, we're aiming to bring all levels up, and especially from the silver to the gold. I thank all the teams for their hard work on that. 

Going forward, we are looking to a new approach and to using an Oxford model of learning, and I think that is key and is a fundamental change for us. That brings in the professional voice, that clinically led element of professional change that's needed when there are incidents and learning that we need to take forward. But it doesn't end there—there's also the working from a bottom-up approach of what the teams can do and how they work differently. We've learnt from other areas, we're bringing that forward here to Betsi, and so we're now taking that forward with our teams, and that feels like a real new step forward. And, again, working with a very key team, we need to make that work.

And maybe just a couple of last mentions on mental health. The Stronger Together work, again thanks to the funding we've received for the transformation work—we're really engaged in that. And we are looking at some of the cultural work, because, again, the report mentioned recently—and if you look back over history—the need for us to address some of those cultural issues. So, we're working hard with colleagues right across the health board to make sure that we use Stronger Together to develop a bespoke piece of work for our teams, and to support the change processes while the teams are also working hard day to day. I'm very grateful for all the work they've done through COVID to keep our patients safe. So, maybe I'll stop there just for now. 

Okay, thank you. You referred to a phased plan going ahead. I have a letter from the health board's acting chief executive in 2013 to the head of regulation at Healthcare Inspectorate Wales, detailing the phased plan going ahead to cease mixed cohorting nine years ago. We have a letter that was sent by the acting chief executive in 2015 to the Chair of this committee at the time—the Public Accounts Committee—Darren Millar, which states:

'In summary, this is a historical report'—

this is the Holden report—

'about the Hergest Unit from more than two years ago. It was commissioned by the Health Board to get an independent view after staff working on the front line raised concerns...It recognised some of the issues that had contributed to this and the report made valuable recommendations, all of which we have taken action on or addressed.'

In 2015 the health board made a brief summary of the Holden report available to the Public Accounts Committee. The publication of the full report now reveals just how much detail was concealed from the Public Accounts Committee at the time. It was a very brief summary report, and it didn't even describe the 31 concerns that had been listed by staff. In 2020 the acting chief executive again referred to the issues raised as perceived historic and resolved. In 2020 the chief officer of the community health council wrote to Mr Polin, the then acting chief executive, to Gill Harris and David Fearnley, and in his letter it said: 'It's understood that the full Holden report is brief, only 14 pages, but backed up with 700 pages of testimony from staff. We have accessed the redacted copy provided to the Public Accounts Committee and that alone is damning. The report notes serious concerns regarding low staffing levels, lack of training, low morale, poor management and the toxic mix of patients. Six years on, the concerns set out in the redacted copy of the report are still evident.'

And then jumping to the present, you'll be aware that on 18 February, the health board wrote to Members of the Senedd and MPs in north Wales, stating that you would publish on your website on 22 February external reports into the deaths of two patients on your mental health units. Now, I'm aware that the coroner has asked for those reports to be removed from the public for now so that they don't influence the inquest. So, without identifying patients or circumstances, I'll just include one quote, with reference to the death on the Hergest unit: 'It should note that there are long-standing and largely unresolved concerns that remain regarding the design of the Hergest unit and environment, use of paper-based clinical records, and mixed cohorting of working-age and older-age adults on Aneurin ward.'

And, finally, if I may refer to the two HIW reports in September and December, which made a series of recommendations, almost all of which replicated—I think it's over 40 of them—recommendations made eight, nine years previously in the Holden report. So, how can we be assured that the significant changes required to deliver on the recommendations made all those years ago, which we now know from very fresh new reports have not been acted on, will now be properly and fully addressed? 

So, again, if I go first, Chairman. Thank you. From my perspective, and working with the team—and we have a new team working with new colleagues across the health board on this agenda—we are making progress. My heart goes out to the families in terms of the recent deaths on our unit. I probably can't comment more, given the papers. But I'm grateful for the support we've received from right across the health board.

I would like to say that the health board is working differently. The division of mental health is working very differently. We're working closely with all divisions of the health board, and while there are challenges, such as some of the environmental elements that you've referenced, I do feel we are making changes. We're working hard on the ligature work, not only the high-level ligatures, but also our lower level ligatures, and that work has moved forward. Also in terms of the work, we are being more transparent, and that came through the recent report. And while reports have come down, we are being transparent and clear with our teams, we are taking a clinically focused approach to our work, and we are making a difference. So, for now, I feel we're on track.

We have been asked and we are committed as a mental health team to ensuring pace within our progress of work. I mentioned in a previous answer in relation to our summit—that has been a key focus. So, we are very clear on those pieces of work that will take us forward, and, through the IMTP, we'll see that focus on mental health and the areas of work that we need to take. The investment that we've received has also moved us forward in terms of a number of areas where we probably haven't had enough focus in the past. But, again, that's now moving forward. In terms of transparency, I can't comment too much on the past, but we are being open, we are being transparent, we're working differently, and we're working differently within the health board and with our partners, and that is key. The 'Together for Mental Health' partnership board in north Wales is also taking a new approach. Maybe I should stop there. Thank you.

I'll finish the questions on this. When will the issues you referred to regarding ligatures, and of course mixed cohorting, be addressed? Can we have a date that we can revisit this upon to engage with you and achieve a progress report?

We're working through the first phase. As I confirmed earlier, we have started the process of stopping mixed cohorting; I think that went in place on 21 February. So, that process is in place. We've now got four phases to work through, but given that the decision was taken on the grounds of patient safety, because we needed to make a change, the team are now working closely with governance colleagues, but also with our partners, and there are key discussions with partners such as the CHC to make sure that we are following our obligations as a health board, but ensuring that the focus is on patient safety. Meanwhile, there is work on estates being undertaken in Cefni, to ensure that we will be able to look after and care for our patients in an appropriate environment, and stop this mixed cohorting, which isn't usual practice in this modern age of mental health. So, certainly, I'm looking at a programme that will be successful over a period of months, not years. I would refer to the brave decisions of the team to move that forward, and to put the patients at the centre of their decisions.

You say months; would this process be completed by the end of this year, by December? Should we be reconsidering it and revisiting it then? What date do you anticipate completing the process you describe?

It's to be completed within months. I'm certainly looking within a six-month programme. For me now, some of the communications that we need for the second, third and fourth phases of the programme will be an engagement piece. And again, as we've discussed through the targeted interventions framework and the maturity matrices, we are keen to ensure that we bring our partners with us through this and provide the best care. So, certainly, I'm looking at a successful programme of stopping that mixed cohorting within months. And we've started it—the programme has stopped, but it's a phase now as we undertake the estates work.

Okay. So, we can contact you again about this in September, at the start of the autumn term. And in terms of work on ligatures, moving forward, how and what timescale?

I can confirm that the work on the high ligatures has been completed. Our more recent focus has been on the lower level ligatures, which are equally a high-risk area for our patients, but of course they are lower risk—it's difficult terminology. That work is in place for mental health, we're on track. We are working with all-Wales colleagues to ensure that work is in place. So, we will continue to learn, and I think this is a programme of learning. While the focus a few years back was on those high ligatures, the world has moved on and mental health divisions right across the UK, England and Wales, are now focusing on that low ligature piece. So, our work will be complete. We are now supporting other areas of the health board to undertake the lower ligature work in those areas.

Perhaps we can revisit that at the start of the autumn term as well in terms of those lower level ligatures and seek a progress report from you. If we can move on to Cefin. 

Firstly, I'd like to say 'thank you' to all the staff for their dedication and hard work day in, day out on our unit. We've got some very committed staff, I have to say, and I thank them. That's actually been noted in recent reports. Of course, I can't comment on workforce issues. I don't think that would be appropriate in a committee such as this. What I can say is that we're working on stability within our teams, training within our teams, learning within our teams and also ensuring the staff voice in the work that we do. Again, I refer to Stronger Together as a programme of work in the health board. That investment is supporting us in mental health now and making a difference. Actually, I've got a couple of e-mails this week from staff about how positive the changes are.

But I appreciate that that work needs to continue. We will work with our staff, work with their commitment and passion on the ward, and learn from them. As I mentioned, the Oxford model of work will probably take us forward in a slightly different direction, ensuring that we have the professional, clinically led voice, but also have that bottom-up approach, where people own their areas of improvement. Our improvement plan does feel different and I hope it feels different to our teams. I would go back again to that foundational work that we're undertaking through the targeted interventions framework. That was owned by the teams. The work continues with the teams. The evidence collection works through the teams, and our focus is on improved patient outcomes.

I understand that—some say 43, some say over 40—originally 40 staff whistleblew in relation to three or four managers. I fully appreciate that employment law means that you can't discuss what may or may not have happened with those individuals since then, but can you assure us that there is now an effective performance management system in place so that all staff at all levels have an opportunity to agree with you what they've done well, agree with you the areas where they need to change and that an action plan is monitored with them to achieve that?

I can say on behalf of the board, Chair, that I do feel confident in that regard. The board feels confident too in the leadership being exhibited by Teresa, as the new executive lead on mental health and the leaders that we've brought into that division. I'm also confident in terms of the last question, whilst not going into detail, that where performance issues have been identified with individuals or a team, those concerns have been addressed. That is within the remit of the chief executive, of course, but there is oversight by the board. 

Going back to your earlier point, if I may, Chair, about accountability, you'd know, I hope, because you have been in meetings with Jo and me, that we are truly committed to ensuring that reports, wherever possible, are written for publication so that we can be held to account through greater levels of openness and transparency, which have been lacking in the past. I hope you feel too that, in the meetings that we've called with Members of Parliament and Members of the Senedd, we've sought to do just that. Those meetings, understandably, have been rather uncomfortable for Jo and me on occasion, but we expect to feel uncomfortable, because we feel uncomfortable about some of the issues that have arisen.

The other thing I wanted to say too, and I touched upon this earlier on, is that there is a concern about the fitness of Hergest in terms of its ability to provide modern, clinical services in a safe fashion. You know, I hope, that we previously did work on Heddfan in the east. There's a business case in for Ablett with Welsh Government at the moment, but there is a shortage of capital nationally, and that is a significant constraint for us as a health board and for other health boards as well. We would dearly love to be able to submit a business case in terms of the Hergest, because it is not fit for purpose. So, at the moment, we are working with a sub-optimal clinical facility that we're seeking to do our best with, in trying circumstances. And I'm sure that we will together minimise the risks for patients still further, but it remains a challenge in that regard.

Thank you. Of course, I have been part of those meetings but nobody else on the committee has, so my function as Chair is to detach myself from the local role and focus on the function of this committee. I'm sure you—. I can see you nodding your head. Natasha.

No, it's okay—thank you so much, Chair.

In that case, if we can move on to finances and recovery. Mike Hedges.

Can I do vascular services first and then come back to finances?

By all means, Mike, yes.

I wouldn't like vascular services to drop off the end of the agenda. On vascular services, the Royal College of Surgeons review raised serious concerns on delivering safe patient care. How are you going to resolve it, and when are you going to resolve it?

If I may start, could I just express, as I did at the last public meeting, my disappointment, frustration and anger in terms of our finding ourselves in the position that we currently are? There were concerns that had been identified by the board in terms of vascular services, and those concerns have continued to be registered, which is the why the board instructed the RCS to carry out an independent review of the service, and you've seen the product of that review in two reports. I can assure you, having convened an extraordinary meeting to consider the vascular report from the Royal College of Surgeons, that there is much focus on ensuring that the issues and recommendations they've described in those reports are being progressed at pace. And indeed, you will know, I suspect, that the Minister has indicated her expectation of me, in terms of reporting monthly to her on progress against the issues highlighted by the review. The first such report on progress went to the Minister on Monday, which I'm sure we would be able to share with you as a committee. There will be a follow-up meeting between the Minister and me on Friday morning, when I expect vascular to be the centre of our discussion. But no doubt we'll be discussing other things as well. So, I and the board are concerned to find ourselves in this position. There are many underlying reasons as to why the centralisation of vascular and its implementation has not gone smoothly, but we are keen to ensure that the model now adopted, which remains the right one in our view, is implemented fully, and also that we learn from the experience of vascular, so that we don't repeat the same mistakes that we've heard here in terms of the implementation of service change. 

Coming back from that answer, if we're going to have a further report in September, will vascular services be in the same state as mental health services, and be able to come and tell us some very positive things?

I would expect us to be able to demonstrate significant improvement, in keeping with the Minister's expectation, within three months. The first report, as I say, went on Monday; two further reports are due from me over the next two months. I can assure you that Jo and I, and her team, are focused on delivering the improvements required. There are some challenges in this, of course, as ever, around recruitment of vascular surgeons and so on and so forth, but we are doing our very best to secure those improvements, and there are already signs of progress, as I've described in my update report—for example, in terms of entering into a bilateral relationship with the Royal Liverpool and Broadgreen trust, who are a recognised centre of expertise, and also drawing in a new clinical lead from outside the organisation to oversee the service improvements that are required.

Without trying to put words in your mouth, do you believe that the vascular service model is deliverable and sustainable in the long term?

Yes.

That was easy. Can I move now, Chair, on to finance? Given the issues the health board has previously faced over very many years—I have served on and off this committee for 11 years, and Betsi Cadwaladr has probably been the thing we've talked about the most, mainly about its financial position—how would you describe your current state of financial health?

Thank you. So, we are in a much better position than we have been previously. I think the turnaround year was 2019-20, when, after the chair had commissioned an independent financial review, we had a very thorough and interactive conversation with Welsh Government about the underlying deficit, which was recognised at that stage, and we are really grateful for the funding that we have received on a transitional basis from Welsh Government. So, we're now in year 2 of that funding and, obviously, we are in receipt of about £40 million that is supporting the underlying deficit. We understand the challenges a lot better than we did previously. We've worked through the calculation of the underlying deficit with Welsh Government, and what we need to do now is to be able to use the transformational support that we're receiving from Welsh Government in order to start to reduce the underlying deficit. Unfortunately, and obviously, the pandemic over the last two years has delayed that progress, but we are really clear about what we need to do; we have some really robust benchmarking information from the national benchmarking network, from CHKS, and from work that the delivery unit does centrally in Welsh Government. So, that is something that we need to move ahead with now.

I think the challenge is going to be meeting those sorts of transformation targets at the same time as being able to work through the other issues around other resources that are not financial within the health board, which obviously are around our estate and our workforce and the challenges that we have there that we need to move forward on. We have the transformation team all together, as Jo has already described, and that is going to be really key in allowing us to work to the clinical services strategy, because that is going to tell us where we need to provide services and therefore what efficiencies we can make. But we understand there is a lot we can do around reducing clinical variation and the impact that will have both on the quality of the care that we provide, but also on the overall cost of it.

So, it's just understanding how we can do that. I think we are really grateful for the funding that Welsh Government has recently announced for value-based healthcare, and we are really clear about the benefit we need to derive from that, both in terms of patient outcomes and in terms of the underlying deficit.

Thank you. What progress are you making at using the hospital-at-home model in order to provide a better provision of service to patients and to reduce costs?

[Inaudible.]—your question.

All I got was, 'your question'. If you want me to repeat it, I will again: what progress are you making using the hospital-at-home model in order to improve patient outcomes and to reduce costs?

If I may answer that question, we're really pleased with the impact that we're seeing with our hospital-at-home models across north Wales. We do have some different input models. For example, the hospital-at-home model in Ynys Môn is different to the hospital-at-home model in Flintshire, and we think that that is appropriate, given the different circumstances of those geographies.

Using some of the resources provided to us by Welsh Government for the development of integrated capital solutions, for example, in Buckley, we have seen the recent opening of step-down, step-up facilities in order to allow patients to be discharged earlier as part of the assess-to-discharge model, and, within Ynys Môn, the model is to see the early transfer of patients into hospital at home, supported by advanced care practitioners—in one example, an advanced care paramedic.

The evidence associated with both of those developments is that they have significantly reduced the number of bed days and the number of admissions to both community hospitals and to our main hospital sites. And generally speaking, the cost per bed day of these approaches offers more value for money, but, most importantly to me, the patient experience across each of those services is undoubtedly positive. And if any of you ever were up north and visited the facility in Buckley, it's a million-dollar view. It's a really beautiful spot, with views over the Vale of Clwyd and the Clwydian hills. People are uplifted by the view and very well supported by the integrated approach. Thank you.

When will the health board be in a position to achieve financial balance and have an approved three-year plan?

[Inaudible.] The chairman spoke about receiving and approving an integrated medium-term plan, a balanced IMTP. He actually mentioned a date of September; he did mean the end of March. We will achieve financial balance this year, the second year, and the intention through our balanced IMTP for the next financial year is to be in a balanced financial position, noting the strategic support from Welsh Government.

I mentioned at the start of the meeting the risks to delivery associated with uncertainties around inflation, particularly driven by fuel costs, but also the COVID situation. Thank you.

And a final question from me: you've talked about the need for having different provision in different parts of Betsi Cadwaladr University Health Board. I agree with that. Why do you think BCUHB actually works, and why would it not be better to be split up into the areas where you're providing different types of services?

Betsi Cadwaladr is very interesting. It's a big organisation, and yet, at the same time, it's a small organisation. Why would I be saying that? Well, typically speaking in healthcare terms, it's for the provision of highly specialised services that typically provide services to a population of around 1 million, and Betsi Cadwaladr is slightly short of that. That's why it makes it particularly important for us to be working not only in partnership with Liverpool, as the chair has also mentioned, but with our strategic partners in Stoke, in Manchester and in Oswestry or Gobowen. Because it is by working across those networks that we're able to be certain to provide not only the day-to-day general hospital services in north Wales, but to be able to maintain some of the clinically appropriate specialist services to be provided in north Wales, with support from our networks. 

Hospital services at the acute end of things do rely on principles of ensuring that our clinicians are very familiar with some of our more specialist procedures, and so, generally speaking, our clinicians will sub-specialise in order to make sure that they are able to provide good quality outcomes. And so it's important to us that we take a once-for-north-Wales approach by asking in certain circumstances those specialist clinical colleagues to provide their services across each of our sites. Most healthcare is provided in community settings in primary care and as part of self-care. And those very local arrangements, local pharmacies in towns and villages up and down north Wales, the same for primary care, midwives in people's homes—for all of those reasons, it's very, very important that we keep our local connections. And the operating model allows us to have the benefit of the small Betsi, the very individual relationships between the GP, practice nurse, midwife and individuals, as well as the big Betsi, the ability to operate the first robot in Wales for very specialist services, which we wouldn't be able to offer if we were very separate organisations. The trick is to try and be good at the big and be good at the small. Thank you.

Cefin.

I don't believe so. My most recent appointment, prior to coming back home to north Wales, was in Australia, where geography is, like it is in north Wales and across rural areas, a real challenge. Just as, in Australia, we've found ways to work through the dilemmas of geography, so we have done so in north Wales. And, of course, one of the benefits of COVID—there were many sadnesses—is the opportunity that that has given to us to bring care right into people's homes. A really lovely example of that is the joint school that is run out of Bangor. Patients who are due to undergo a joint replacement would previously come and have some group sessions with doctors, nurses, physiotherapists and occupational therapists to talk about what to expect when you have your joint surgery and how to prepare and make sure that you're as fit as you can be. Those required patients to come a long way. Those joint schools are now run successfully digitally, in partnership with a third sector provider, who has aimed to ensure that for those individuals for whom going online is a challenge, equipment is provided and boosters to signals are provided so that they can access that virtual care. And patient feedback from that digital option has been incredibly positive. Thank you.

I just have two final questions and then we can conclude. You only achieved financial balance because of the additional Welsh Government funding. When will you be financially independent of that funding?

Thank you. So, it's difficult to put a date on that, to be frank. What we need to do is work through the transformation schemes that we have in progress over the next two years so that we can understand the gap in funding effectively. We know that we have opportunities that are between £70 million and £110 million, but to actually deliver those is going to be difficult and will require a change in practice both from an operational and a clinical perspective. We don't anticipate it in the life of the current IMTP, i.e. in the next three years, and we are starting conversations with Welsh Government about what will be the next steps to us delivering that financial balance. But I think the point to make is that it's not just about financial balance, it's about the sustainability of clinical services across north Wales, and that has to be our primary objective.

Thank you. Finally, again to Ms Hill, you referred earlier to the £300 million spent across the border. And, of course, north Wales, because of health economics, because of critical mass of population, has always relied upon some services delivered across the border, but, periodically, there have been publicised issues around a breakdown over financial arrangements between the two sides of that border, with Walton, for example, providing neurological conditions support as the centre of excellence for north Wales; the Countess of Chester Hospital, which used to be effectively the fourth general hospital for north Wales, certainly Flintshire, which has periodically raised concerns over the funding arrangements now in place, especially given that they've reconfigured their services away from provision for north Wales, because they have to put in place sustainable funding models after services were repatriated to hospitals in Wales. So, what is the current state of play in terms of the financial arrangements, the financing arrangements, for patients referred from Wales into specialist or general services in England, and how sustainable is that?

Thank you. So, we have very good relationships with our providers in NHS England. Obviously, there has been the impact of COVID-19 on planned care in north Wales and across Wales, and it has been similar in England, but we have very good relationships with our commissioners. But this probably explains why the RTC—the regional treatment centre—is so critical to the transformation activity for the health board, because it will allow us to bring some of that elective surgery back into north Wales. So, care closer to home for our patients, but also it will help with our recruitment and retention of more specialist staff.

The current financial arrangements are a continuation of a block arrangement that we've had in place for the two years of COVID, and we are working with colleagues across Wales, and with Welsh Government, around those arrangements going forward. But we are continuing to have ongoing conversations with all our providers in NHS England, and we welcome the specialist clinical care that they provide to the population of north Wales.

Finally, you mentioned the new centre—what was the name of the centre again that you mentioned, sorry? The new centre you're developing.

Sorry, I just missed the question. We're having a bit of difficulty.

Sorry. In your previous response, you referred to a new centre that you're developing. What was its title, sorry?

Sorry. Regional treatment centres.

Okay. Will those incorporate, for example, pain management? Because I know a lot of patients, when services were first repatriated, who used to get treatment within a fortnight at the Countess of Chester who were then told they had 18-month waiting lists, for example. And the Walton model for north Wales, following the Steers report in 2007, was originally supposed to be configured on a hub-and-spoke model, and initially it was, very effectively. So, how will this model incorporate those services, both in terms of meeting the need promptly, where people are in pain, but also where there are relationships with centres in England, and perhaps developing or redeveloping the hub-and-spoke model?

So, Jo's going to answer this question.

Thank you. So, the partnership arrangements that we have with the Countess of Chester and a range of NHS England providers are, as you say, very well established. And, in partnership with our specialist commissioning colleagues across Welsh Government, we have, most recently, established good partnership arrangements that allow any issues that are arising between ourselves and English providers to be resolved. In some cases, those examples are as simple as some of the English providers wanting additional out-patient space in one of our facilities.

The issue of waiting times, not just for pain management services but more generally across north Wales, and, indeed, across all of Wales, have been significantly impacted by the impact of COVID-19, although I am pleased to say that we are increasingly seeing additional services being brought back online for not only in-patient diagnostics, but out-patient care.

I mentioned earlier on the approach that we're seeking to develop for self-initiated follow-up. Early indications of the assessment of the impact of that approach in specialties where it would be appropriate suggest that there would be an increase in freed capacity of possibly between 10 and 15 per cent. That would then allow us to redirect the clinical time that that frees up into the provision of a range of clinical services, including a more active focus on prehabilitation, including pain management, in order to work with patients to enable them to manage their pain better or to improve their health and well-being, so much so that they no longer need an intervention.

Those changes will take a little time to work through, and I am conscious that our pain management service across north Wales is one of those services where we do have waiting times. The service has embraced fully the opportunity to maintain services by the provision of digital care, where that's appropriate, and we would seek to continue to provide services, both face to face and digitally, where that seems to be the best way forward. Thank you.

Okay. Members, do you have any final questions? No. Well, thank you, then, very much, all of you, for spending nearly two hours with us and for answering our questions. A transcript of today's meeting will be published in draft form and sent to you for you to check for accuracy before publication of the final version. So, again, thank you, session over, and I hope the rest of the day goes well for you, and good luck for the future.

May I just say, as a patient of Betsi Cadwaladr University Health Board, I've recently had some excellent experiences in audiology and some other departments? So, just to balance this out, I know that there are many very serious issues and problems, and we've highlighted many of those today, but, as a patient, just to put a positive conclusion that there's some good news too.

Okay. Well, as you know, the next session was cancelled.

So, I propose that, in accordance with Standing Order 17.42(ix), the committee resolves to meet in private for item 6 of today's meeting and the meeting on 23 March. Are Members content? Thank you. In that case, if no Member objects, if we could bring the public meeting to a close, thank you.