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Y Pwyllgor Cyfrifon Cyhoeddus

Public Accounts Committee

28/01/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Adam Price AM
Jenny Rathbone AM
Mohammad Asghar AM
Neil Hamilton AM
Nick Ramsay AM Cadeirydd y Pwyllgor
Committee Chair
Rhianon Passmore AM
Vikki Howells AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Adrian Crompton Archwilydd Cyffredinol Cymru
Auditor General for Wales
Alan Brace Cyfarwyddwr Cyllid, Llywodraeth Cymru
Director of Finance, Welsh Government
Dave Thomas Swyddfa Archwilio Cymru
Wales Audit Office
Dr Andrew Goodall Cyfarwyddwr Cyffredinol Iechyd a Gwasanaethau Cymdeithasol, Llywodraeth Cymru/Prif Weithredwr GIG Cymru
Director General of Health and Social Services, Welsh Government/Chief Executive of NHS Wales
Jo Jordan Cyfarwyddwr Iechyd Meddwl, Llywodraethiant a Gwasanaethau Corfforaethol y GIG, Llywodraeth Cymru
Director of Mental Health, NHS Governance and Corporate Services, Welsh Government
Matthew Mortlock Swyddfa Archwilio Cymru
Wales Audit Office
Mike Usher Swyddfa Archwilio Cymru
Wales Audit Office
Simon Dean Dirprwy Brif Weithredwr GIG Cymru
Deputy Chief Executive of NHS Wales

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Claire Griffiths Dirprwy Glerc
Deputy Clerk
Fay Bowen Clerc
Clerk
Meriel Singleton Ail Glerc
Second Clerk
Stephen Boyce Ymchwilydd
Researcher

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 13:18.

The meeting began at 13:18.

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

Can I welcome Members to this afternoon's meeting of the Public Accounts Committee, and also welcome Vikki Howells back to the committee? Good to have you back with us, Vikki, to replace Jack Sargeant. And can I extend thanks to Jack for his work on the committee? As usual, headsets are available for translation, same for amplification. Please turn off any electronic devices, as I check my phone. In an emergency, follow the ushers. We have received no apologies today, so a full complement. Do Members have any declarations of interest they'd—? I should also say as well, Adam wasn't here when I last chaired, so thank you for chairing in my absence during my paternity leave. I know that you were empathetic about what paternity leave entails. 

Thank you, Adam.

Item 2, papers to note—. Any declarations of interest? No. Okay.

2. Papurau i'w nodi
2. Papers to note

Papers to note, and first of all, Welsh Government have provided further clarification on a number of issues relating to the review of the funding formula for NHS finances. Can we note that letter?

Before we note it, when is the first stage of this review work to be completed? Because this doesn't actually state it from what I can gather. It was just the early part. Can we get an answer to that?

We can get you that clarification.

The Permanent Secretary has written to me following the questions regarding guarantees. This relates to our scrutiny of accounts 2017-18 on headlease arrangements and other contingent liabilities during the evidence session that we held on 18 October 2018. The Permanent Secretary has offered that officials can expand on the information received during a private briefing. The clerks will liaise with the Government to find a suitable date. Happy to note that letter? Yes.

Moving on, the Supporting People programme—a letter from the Welsh Government. Following the evidence session on 3 December, the Welsh Government have provided a comprehensive response to the action points identified in the meeting and the subsequent letter sent from Adam Price in my absence. Happy to note that? Okay.

13:20
3. Adolygiad Llywodraethu Bwrdd Iechyd Lleol Prifysgol Betsi Cadwaladr: Yr Hyn a Ddysgwyd - Sesiwn dystiolaeth gyda Llywodraeth Cymru
3. Governance Review of Betsi Cadwaladr University Local Health Board: Lessons learnt - Evidence session with the Welsh Government

Moving on to our substantive item today, and the governance review of Betsi Cadwaladr University Local Health Board and the lessons learnt, so, we have an evidence session with the Welsh Government. Can I welcome our witnesses to today's meeting? Thanks for being with us today. As usual, would you like to give your name and position for the Record of Proceedings?

I'm Andrew Goodall. I'm the director general for health and social services and the NHS Wales chief executive.

Alan Brace, director of finance for the health and social services group.

Simon Dean, deputy chief executive of NHS Wales. May I just mention for the record, Chair, that I was the interim chief executive of the health board, seconded for the first nine months of the period that it was in special measures?

I'm Joanna Jordan, and I'm the director of mental health, NHS governance and corporate services.

Okay, thank you. Before we get into questions, I'd like to say at the start that following the fourth committee's work into this area, the committee agreed to undertake a short inquiry to consider and evaluate the lessons learnt from the fourth Assembly Public Accounts Committee. This inquiry was also prompted on receipt of private correspondence requesting that the committee undertake an inquiry specifically into the Tawel Fan ward at Ysbyty Glan Clwyd, and a similar article was also reported in the press. The inquiry will return to the governance issue at BCUHB, as a number of the previous committee's recommendations were still to be implemented at the end of the fourth Assembly.

Members also wish to ascertain what improvements have been made to the health board's mental health management following the series of reviews undertaken, but will not be focusing directly on the Tawel Fan ward issues. The committee's remit does not enable it to engage directly with families, so we're looking at the broader issues rather than specific family issues. I think it's important that we set that out there. The inquiry will examine the wider Welsh Government targeted support and intervention. 

The older people's commissioner has written to us, which is paper 2 of the pack, with an overview of her ongoing concerns in relation to the progress being made by the health board—that wasn't prompted by the committee, by the way; that's come off the back of the older people's commissioner—in relation to improving mental health services for older people.

Okay, I'll ask the first question. Could you briefly update the committee on the current situation as you see it in Betsi, in terms of the special measures arrangements that are in place? 

Chair, perhaps, just as it's the initial question, with your agreement, if I could talk about some of the changes over recent years, and where we stand right at the moment, firstly, to say to the committee that, whilst the initial decision to move to special measures was significant and difficult, I think it's really important to recognise that we have an escalation framework in place in Wales, and it is there to be used. It is to highlight challenges for any individual organisations, and we have obviously utilised it in terms of Betsi Cadwaladr's particular position.

Also to say that we will only de-escalate Betsi Cadwaladr when we feel that we have seen the relevant progress that certainly satisfies us about the milestones that have been set out. We need to have an organisation that doesn't just achieve outcomes at a moment; we need to see that there has been sustainable progress that allows us to step away from the organsiation. 

Having said that, I am disappointed that the organisation hasn't been able to address our requirement for sustainable progress, but I do think it'd be wrong to reflect that there haven't been some changes over the course of the special measures time.

I think my underlying comment, Chair, would be that the focus of the special measures areas has actually shifted during that time, in respect of the issues that were highlighted. These were initially driven predominantly by quality concerns within the organisation, triggered by areas such as maternity and the concerns around out-of-hours services. But, we have focused on this in respect of the need to ensure there was progress around other areas, like leadership and governance within the organisation. So, areas of quality, as that initial concern, in my view have transferred into areas more about our, perhaps, planning system in place for north Wales, and certainly some key areas of performance that we'll be happy to take any questions on at this stage. It was, however, important that maternity, as a very significant trigger, was de-escalated—that was a specific quality concern about the viability of services up there and, through a variety of actions and measures, that was improved. We've seen areas like infection rates improve. We've seen progress on out-of-hours, where we feel now that we are dealing with Betsi Cadwaladr on a more normal basis, but, obviously there's been quite a lot of change around the board itself in terms of executive members and also independent members. So, whilst that changes some of the individuals leading the organisation, there was a real focus at the time around the make-up of committees and the way in which the board was discharging its scrutiny.

I think the underlying challenge for the organisation is whatever improvements it's putting in place for the machinery within Betsi Cadwaladr. We have to track it and measure it by the progress it's making on its outcomes. Where we stand at the moment—and you'll be aware from your own packs and our written evidence that has been provided that we needed to, unfortunately, extend special measures criteria for a number of other areas that were causing concern. So, at a moment where we were just seeing some progress within the organisation, we had to extend into areas around performance and financial concerns in the organisation, and there still has remained a lack of a signed-off, approved three-year plan at this stage.

Just to perhaps finish in opening, Betsi Cadwaladr was the first organisation in Wales that we have escalated to special measures, and whilst that has proved difficult, it's also had to be a process that we've had to learn in terms of the interventions that are put in place, and we do feel that whilst we've been supporting Betsi Cadwaladr as an individual organisation, it has been possible to ensure that actions around other organisations in Wales have at least had some of that learning while we've tried to stabilise it and allow it to recover their own situation. I think the intention of any intervention is to stabilise and then improve against the specific escalation criteria, and certainly it's true that Betsi Cadwaladr have had the widest range of criteria, and we've probably been struggling more to see the sustainable progress on a number of areas, particularly around finance and performance. I'm very happy to answer any more detailed questions, but I thought maybe it was just worth trying to describe the shift of our attention over that period of time.

13:25

And there were three partners involved in implementing the special measures: the audit office, Health Inspectorate Wales and the Welsh Government. How are those three, as you see it, working in tandem? 

Well, first of all, a reminder to Members that, actually, the establishment of the escalation framework was in response to a recommendation from your predecessor Public Accounts Committee, and I do think it has introduced a significant degree of discipline and information sharing across Welsh Government, the Wales Audit Office and HIW. I would say that, clearly, out of all of those arrangements, Welsh Government has to call the decision in respect of escalation, and certainly has the responsibility to be putting in place the actions that are necessary to support any organisation that is placed in a higher level of escalation. The Wales Audit Office and HIW have to protect their own responsibilities and interests, but I think the basis of the committee meeting that takes place around this is a very open sharing of information and concerns from all parties. So, from a Welsh Government perspective, we're very open about the nature of concerns that we have about organisations and their status and progress, and that is reciprocated by HIW and the Wales Audit Office, who will have their own insights. As an example, the Wales Audit Office will give evidence to us in those settings, not just on local contacts, but the structured assessment work they do, which is very useful in terms of leadership and governance.

I think, judging by some of the correspondence that we've received, some people think that we've not just recommended it as a committee but we're actually implementing the special measures ourselves, so—.

Indeed, but I would say it's been very effective, and whilst I know today's lens is, 'Where are we with Betsi Cadwaladr?', it is there as a facility to be used to be open about the status of organisations, and whether they are individual triggers on the quality side, whether it's about finance and delivery, that we have a responsibility to support and make the appropriate interventions.

Members of the public watching this will be—. We've been talking about this now for a long time, the problems surrounding Betsi; are we getting anywhere near a—? I know it's a complex area, but are we getting anywhere near a resolution of this, overall?

I think it is a complex area, as you've outlined. In my opening comments, I was trying to describe the shift of our attention from those initial quality triggers that were driving some of the immediate concerns, the need to ensure that the scrutiny and challenge process is working. And I do think that on some of the original measures: the public engagement aspect; the maternity that was de-escalated; progress on out-of-hours, explicitly; progress on committee structures—they have definitely made progress on those areas. But we've had to move our attention on to concerns around ongoing finance and performance concerns. Even some of those areas are starting to show that, even over recent months, there's some improvement compared with last year, but the two most significant areas on performance from my perspective are unscheduled care, performance for the north Wales system, and also finances. And I have to say that the mental health arena, which obviously has had some very serious reports that have had to be handled in a very sensitive manner—it would have been very difficult to see Betsi Cadwaladr making progress on mental health concerns without the publication of those reports, and, obviously, handling a move on. And, again, we'll be able, through the course of this hearing today, to give some evidence of progress we have seen on mental health. 

13:30

Very briefly, then, because, obviously, this is a long-standing affair and, obviously, this is an action that Welsh Government has taken in determination because of the very seriousness of the nature of this particular issue. So, you've mentioned some of the areas in terms of what you're currently looking at around financial management, the sign-off of the plans and the de-escalation around some of the issues around maternity et cetera, what are—? We'll be coming on to scrutiny in a second, but what are the main underlying issues in terms of management, then? Because they seem to be a movable feast. 

So, I think we have had issues about leadership across the organisation. So, there's been quite a lot of change around independent members in the board, around executive members, and there has been a need to ensure that there is leadership in place that can take forward some of our concerns in the organisations. If I'm looking at where we are now in contrast to where we were three years or so ago, I think the inability to set out a strategy that could be followed through with delivery—

If I could just interrupt, I accept that fully, and that always seems to be the case. It's taken quite a long time, hasn't it, to get to this particular scale of intervention, and, obviously, that has to be evidenced, but at what cost? So, in terms of an ability to intervene at the very highest level, have we got enough tools in the toolkit to be able to do that effectively? 

When we first pressed the button on this, and, obviously, it was a very serious recommendation that was made to the Minister at the time, we were having to learn about the nature of what a special measures arrangement would mean—the kind of intervention that we'd have to put in place. We put in support particularly around external reviews that needed to give us a feel for the underlying issues within the organisation and some of the work that was done at the time under escalation was about trying to diagnose the issues. As a team, firstly, we're much more experienced now in terms of what we've had to learn through that process. We are applying those lessons, certainly to other organisations that are in other escalation categories, and, hopefully, that prevents them from deteriorating in terms of some of the concerns on those, and we've had to deploy certain levels of expertise in Wales to build up our capacity as a team. So, there are external commissions that we've done through the process, for example, including financial governance reviews that were done. We needed that to be done through an external lens. So, I think we're more experienced and that we have greater knowledge of the kind of support that is helpful for individual organisations.

Yes. Unscheduled care: that presumably covers A&E admissions? 

Indeed. 

The record there—I mean, in Wrexham Maelor and Glan Clwyd—is appalling, isn't it? Fifty—. The target of four hours for being seen at A&E, I think, there is at about 50 per cent or 54 per cent respectively— 

Indeed—

Indeed. So, the performance is not acceptable at all there and we've had to focus attention both with outside support but also trying to improve the capacity of the organisation to make a difference there internally, particularly to ensure clinical leadership is in place there. So, as an example, at the moment, we have the organisation going through 90-day improvement cycles. We do think, at this stage, that they are focusing on the right kinds of areas. We would have concerns that the organisation was probably trying to do too much at one time rather than working its way through the areas that would have impact at the moment. We've also tried to get them to look at the overall unscheduled care system as a whole rather than only target the A&E aspect, which becomes a high-profile area of concern, because at least that would give us some confidence that they are starting to put in place the alternative services that would be needed, for example. So, I can point to some areas of improvement in the system more generally, because ambulance response rates are better, handover delays are better, delayed tranfers of care have been very materially reduced, but they have to resolve the underlying concern about, 'What does that mean at the front door?' and 'How can they support that?' And they also have variation in north Wales across the three sites. Now, we tend to see Ysbyty Gwynedd producing much better performance overall. I was at one of our patient safety huddles just a couple of weeks or so ago and it did feel that there was good grip on that site in order to work through the issues. So, we have to ensure that that learning is spread across the whole of that patch as well, but the performance on unscheduled care is not acceptable, and that is a clear area of focus under the special measures framework. 

The targets that I referred to, they're reflected right throughout, aren't they? So, if you look at people waiting over 12 hours, those two hospitals are also responsible for a very high number of the figure overall in Wales. Has performance improved over the period that you've been engaged with them? Or has it—? It seems to have actually consistently reduced, going back now over a decade, so have we seen any improvement over the period that they've been in special measures in this specific area of A&E?

13:35

No, in this specific area, the unscheduled care performance has deteriorated. And whilst the organisation had focused its time and attention on the initial special measures areas, unscheduled care wasn't one of those. And it has seen improvement, and maternity improved, for example. Potentially, that took the organisation's eyes off some of the broader system measures in place. So, on unscheduled care, there has been a deterioration. As I said, when we look at the broader system measures beyond just the four and 12-hour performance, we can at least see some broader improvements that show that alternative services are having some impact, but that is the clear outstanding test, I think, for performance within the organisation.

They have improved on other areas that are part of that same equation. On elective waiting times, for example—and, at least over these recent months, it's in a better position than last year, so we expect to see further improvement there but it's about 30 per cent better. And we can see some improvement on other measures. Occasionally, Betsi Cadwaladr can really demonstrate—not even being in the pack, it's actually leading on some areas of performance. But, absolutely, unscheduled care is an area of focus and attention.

But I think you'd accept that, where a national target is 95 per cent, a major hospital actually recording a figure that is almost just half of that—I mean that's beyond outlier status. I mean, that's pretty phenomenally bad, isn't it?

The performance on those two sites is not acceptable, and the performance of north Wales on unscheduled care on the current measures is not acceptable.

Thank you very much, Chair. And thank you, Andrew. The problem in this hospital in Betsi was well before your time, and you were given this task, and this is a last resort by the Government to put it in special measures. My question to you is just on the current position: how effective do you believe the tripartite arrangement to have been, and has the introduction of the escalation and intervention framework been a positive development in identifying concerns and agreeing the necessary responses to them?

Over time, the NHS has always had to identify support for organisations that have been struggling, but I think the advantage about the framework is that it makes us very specific about what those concerns are and puts it properly in the public domain. I think that the first starting point with escalation frameworks is to identify that there is a problem that needs to be sorted. I've already reflected on the benefit of having that other intelligence around the table from colleagues in the Wales Audit Office and in Healthcare Inspectorate Wales, but, of course, it's Welsh Government that needs to determine the outcomes of those. Certainly, I do feel that that underlying sharing of information and our need to really be open with ourselves has been quite an important part of our process. So, I came in just as the escalation framework was being introduced in response to the Public Accounts Committee recommendation. And whilst I guess that we've had to make sure that the commitment around the table is very open, I do think it's made a difference. And I would argue that that is beyond Betsi Cadwaladr, the fact that we've had to apply it. It would be easy for us to avoid, I think, some of these areas, but we've tried to adopt more discipline in our system over the last three or four years. So, whether that is about calling out concerns on finances or being really clear where there are quality issues that need to be addressed, I think the escalation framework has absolutely underpinned that.

Thank you. In your reply to Adam's question you mentioned a 30 per cent improvement—just now, in the last few minutes. So, how long will it take to get it more than 75 per cent better? How long will it take?

We've been pushing the health board to look at the areas that will affect the reputation around its service and give us confidence about delivery. I think that, to be fair to the health board, on its current annual plan mechanisms, it describes three areas of focus: access and waiting times; reputation and confidence; and finance and resources. I think that the step of trying to see, at this stage, a 30 per cent improvement on last year's waiting times—we would hope that that could get higher and further. We are expecting to see further improvement by March, but it's really important that those elective waiting times are improved for the north Wales population. Whilst, on the one hand, a typical wait will be just under about nine weeks or so, those excess waits really do need to be addressed by that organisation. So, an improvement certainly by March 2019, based on the plans from the health board, and we should see further improvement through 2019-20, as long as the organisation maintains that momentum.

Thank you. And now my question relates to the leadership and governance of Betsi. The committee report identified issues around leadership at senior levels in the health board. Do you believe the health board now has the right leadership to take it forward and out of special measures? And also, what has the Welsh Government done to support that leadership through its escalation process?

13:40

In terms of the current position, there's been a change of individuals who sit as board members around the table. We have a new chair and vice-chair and we have six new independent members. Eight out of the nine members of the executive team, if we go back to 2015, have actually changed in terms of new individuals who've joined that team. A couple of posts in there have been posts that we have required to be introduced as part of the special measures regime, notably around primary care focus and also on mental health services. So, there has been a real change around in terms of the team.

In terms of progress on leadership, we have our own views on what more needs to be done moving forward. We have the chance to triangulate that with other information. I do think that the structured assessment process is useful, about demonstrating whether there is any support. I mean, certainly, looking back in 2017, the follow-up review at that time that was done by HIW and the Wales Audit Office was demonstrating, at least, that there was some progress, and some of that was connected with some of the leadership that was now in place within the organisation. But, ultimately, I don't think it's about the individuals who've changed around the table, we're going to be tracking progress as to whether the outcomes and the measures and the milestones that we're expecting are actually delivered or not.

I think if I was to look back with some hindsight, a lot of the focus has been at the top of the organisation and the leadership there, and I've described how much change has happened there. The need for more support in capacity and individuals to be in place right through the structures is an area that I think I wished that we could have acted quicker on at that time. There were probably some difficulties, even prior to some of the decisions that we took, that weren't, really, as visible to us other than through this process, and that's why, even recently, over this last 12 months or so, we've invested some funding to actually underpin the support for operational managers within the structure. So, it's a board that needs to be clear on its future direction, but, actually, operational systems in place to make sure, atually, it does convert into some of the performance and the patient experienced on the ground.

Thank you. And finally, have the arrangements for appointing senior health board staff and for monitoring their departure changed since the publication of the committee’s report in February 2016? And do you believe that they are robust and fit for purpose in the NHS?

I've been in my own post for four and a half years, which means I've overseen nine out of 11 chief executive appointments now in Wales. I've been through the process myself, and although it was a predecessor Public Accounts Committee, the two recommendations at the time—one we didn't accept and another one we partially accepted in the language at that time—I think there was concern from the predecessor committee that chief executive appointments were being made on the back of personal references rather than a process, and that has not at all been my experience. Obviously, I've had my opportunity to make sure that the governance is discharged through my own perspective, and I can confirm that every chief executive appointment that has taken place has been through an external process, has had a range of support mechanisms, feedback from headhunters, and, where they're involved, stakeholder discussions. We've even done media interviews just to test people's ability to be able to comment in a public arena.

I'm involved personally on any appointment panel. Whilst it's done via the chair of any of our health boards and organisations in Wales, I have a role in there, not least that I have an accountable officer duty to pass on. And all of the other director processes that happen in Wales go through similar processes, where that machinery's there and there's stakeholder/staff feedback, and my equivalent colleagues within my own team will actually sit on those respective panels as well. So, I do think that we have made sure that we're able to have panels that are properly constituted with good governance, and, of course, there's a reference aspect, but that's kind of the last thing that is dealt with as part of the process.

In respect of your second point and how—I'm sorry, I've missed the point, I'm afraid. Could you just repeat that?

So, beyond, actually, board members' appointments?

Yes. Since the report in February 2016, do you believe—?

Yes, I do think that they are now fit for purpose, and the process that we've been through—outside of Betsi Cadwaladr, as well as including it—. Obviously, from our perspective, as appointments are made, we have a closer set of expectations, I would say, for Betsi Cadwaladr, perhaps, than other organisations, but we're absolutely involved in all of those. Sorry for forgetting that.

I'm going to ask a little bit more around the board, but we've talked a little bit about leadership. So, bearing in mind the embedding of the special measures process—and you've mentioned already that it's embedding and you're getting everything fit for purpose and the tools in the toolkit from Welsh Government's perspective and you've talked about the flux in terms of board membership, leadership issues, and you think that you're getting that into the correct place now in terms of the health board. In terms of the support and capacity that you are actually able to offer around middle management and the operational systems that need to be effectively in place, what sort of support are you able to offer, bearing in mind that we're now in that driving seat?

13:45

I think the support can go through various stages, but, certainly, as we went into special measures initially, there was a need for particular areas of external support to come in. Some of that was recognising that individuals had to sit alongside the board and give advice to the board as well as give assurance to ourselves—so, appointments of people like Ann Lloyd, for example, and Emrys Elias, who had a particular focus on mental health, were to both ensure that the board had some expertise available to it, but was also to give us some assurance back.

There are mechanisms that we can introduce through our own functions in Wales; we have delivery units in place—so, there is a financial delivery unit and there is a delivery support unit in place. Currently, around a third of the delivery support unit's focus, which, typically, is in areas of planned and emergency care, is targeted at Betsi Cadwaladr, and that would show that they are an organisation, clearly, of concern at this stage. But we can also commission external support as part of the process. We were able to bring in external experience in respect of the financial governance review that's happened, but we've been quite interested to make sure that these aren't just external partners coming in to give a view and to move out; we've moved into, 'How do we make sure that the learning is stable and carries on within the organisation?' and that's why we've more turned our attention, over the last 15 months or so, to supporting the operational capacity within the organisation and the local planning experience as well. But there are choices that we have that can sometimes be about individuals or can be about organisations.

I'm going to move on, then, and you've partially answered this. In terms of the current scale of effectiveness of the current board, are you in the frame of mind that that is now fit for purpose?

There have been quite recent changes there—so, a new chair, obviously, of a health board is a very significant issue, and I think that, whilst a lot of the committee machinery has been put in place over recent years, it feels to me, over these recent months, with the chair, that there is a greater focus on the outcomes that we expect, on the delivery. I've already described that that has allowed the organisation to shape its three objectives, which include delivering on these areas for this year, because they are about confidence and reputation.

I think that we have to be really clear with the organisation about the areas that we have expectations on. So, the current phase of the special measures framework, which was updated back in January 2018, is quite clear on a set of arrangements that we do need to track through on leadership and governance, on outstanding mental health issues, and also particularly clearly around finance and on performance areas. So, we need a focus and attention from the board, which I think is happening locally, but we need to turn that into the delivery, which is the key test. But I'm content that the chair is very clear about that, and I have seen a change with the executive team representation, particularly when we have some of our ongoing contacts with them. We meet with them monthly and we have mid and end-of-year reviews. We partly assess the organisation's progress through those mechanisms, and there is an influence from recent appointments to the board.

Okay. In regard to the committee's report around the quality and safety committee— recommendations around that—have those recommendations now been addressed since this committee's report in 2016? They were identified by the chief executive of Healthcare Inspectorate Wales and the auditor general.

Yes. It's part of the original trigger for the work. As I said, when we placed the organisation in special measures, quality concerns were at the root of driving some of our decisions at that time, and it was quite clear that there were concerns expressed by HIW and Wales Audit Office about the nature of the quality committee machinery, its effectiveness in tracking concerns and problems. I guess that I would use some of the external validation of this at this stage. The follow-up review by HIW and Wales Audit Office mid 2017 indicated, at that time at least, a confidence that there was a change around those mechanisms.

The recent structured assessment by Wales Audit Office, which has been shared with us by Betsi Cadwaladr, also demonstrates that the committee mechanism seems more robust; there seems to be good leadership from the chair. I think, importantly, it can also show that there is a methodology being adopted around quality improvement and I think this has led, actually, to some material improvements in areas like infection control, and that was certainly a worry five or six years or so ago. So, even over the last 12 months, there's been about a 30 per cent increase in C. difficile rates and MRSA [correction: a 20 per cent decrease in C. difficile rates and MRSA]. And that does show an organisation that is focused on quality.

The final thing I would say as an outcome is that it does look as though there have been improvements around some of the complaints and concerns process that have happened—so, removing some of the longstanding complaints and starting to show a better focus about how lessons are being learnt within that organisation. So, I feel more reassured on that myself, but I also feel more reassured by what the Wales Audit Office and HIW have said too. 

13:50

Okay. In regard to recommendation 9 of the governance arrangements report from 2013—from quite a while ago—which addressed some issues around executive and non-executive teams leadership, there was a mention of renewing and reuniting the executive and non-executive teams, closing the gap between the board and the wards. Bearing in mind the wholescale state of change within the organisation, has there been any progress made on that? Because, obviously, in terms of staff morale, in terms of staff tension around all of these wholescale changes, it must be very profound for the workforce within Betsi Cadwaladar, and I would have thought that, again, would be another focus that's very important to centre upon amongst the whole plethora of other issues that are being focused upon.

I think you're absolutely right to say—and we've been mindful of this—that, when an organisation has the label of special measures and it's associated with a number of specific items, obviously it remains an organisation that's delivering a whole range of services in all sorts of different settings. Betsi Cadwaladr is actually our largest health board in Wales. It's got over 16,000 staff and employees, and it does raise a challenge about how you communicate with all of those staff, particularly in the most difficult and challenging of circumstances. So, I would perhaps suggest three areas that would allow us to see is there progress being made on this and the feel of the organisation. Firstly, is there visibility around the board? And I do think that the board has, over that period of time, genuinely tried to ensure that it has different ways of engaging and working with its staff. Are there outcomes that allow us to indicate whether we feel that there is progress? Certainly, if we track the NHS staff surveys that have been done for Betsi Cadwaladr over the last three years, there's a very significant improvement in the Betsi Cadwaladr scores on a range of different measures about whether they would recommend care and treatment, about visibility of senior management across the organisation, and I think it would be worth us perhaps even showing a note to show you the level of that improvement that's happened—so, more to go at, but something very material has happened there.

Certainly, staff representatives locally feel more involved and engaged in the mechanisms. So, there's been quite a lot of recent commentary about people feeling that they are listened to, that they are content with the partnership arrangements in there, and, in fact, one of the unions had excluded itself from some of the original arrangements and they have now decided to opt back into the partnership arrangements—that's Unison—which I think is a positive sign. 

And I guess the final trick is: in difficult circumstances, and with a label of special measures, is the organisation able to recruit? And I think it is significant that, despite special measures, and, clearly, a profile around that, there are 600 more members of staff in post now than there were back in 2015. There's been progress around doctors being recruited, around nursing staff as well. So, despite these concerns, the organisation has been able to recruit. So, I feel all three of those are examples of why we should have some expectation for further change. 

Okay. Finally, in regard to the machinery around special measures, and the importance of that being fit for purpose, do you feel that you have enough tools in your toolkit to be able to do this job in regard to Betsi Cadwaladr and the whole process of special measures effectively? You've mentioned support and capacity previously. Because this is a massive area to be good at. Do you feel that you have what you need in terms of being able to carry out that job?

We've clearly had to build up more experience by using it and we've had more choices. We certainly need flexibility to put in place local capacity, get in external perspectives and expertise when we require. We're developing plans as part of 'A Healthier Wales' that are about an executive function overseeing the NHS that is more distinctive and would include increasing some of the intervention capacity. And I do feel that, if it's not just Betsi Cadwaladr on its own and we also have to manage other organisations, we will probably need to continue to expand some of our intervention capacity, but I also feel that, over the course of the months to come, we will see some organisations in other categories reduce and demonstrate that it is possible to come out of the escalation framework. Interestingly, the Welsh Ambulance Services NHS Trust came out around a year and a half ago—out of their special measures or, sorry, escalation arrangements—and it does show that there can be some progress, and I would expect that for other organisations in Wales. 

Just about a year ago, this committee published its report called 'Wider issues emanating from the governance review of Betsi Cadwaladr University Health Board', and one of the things that we were concerned about there was information on serious issues identified within the health board not being shared with the Welsh Government, and, indeed, ministerial correspondence—the issues that were raised in such correspondence—also not systemically being shared. So, can you tell us what the current arrangements are, in the light of those criticisms, for sharing information on serious issues that have been identified either within correspondence or within health boards or indeed by Welsh Government?

13:55

First of all, our starting point is that there is a serious incident reporting process in place that is there for all of our health organisations in Wales. And, whilst we have to track back those mechanisms, receive reports on it regularly, if there is any individual incident that is of that level of seriousness, it needs to be reported in to Welsh Government, it has to demonstrate the actions in place. But it's correct that predecessor Public Accounts Committees were concerned that some of the intelligence that was contained within ministerial correspondence perhaps was outside of that loop. And we have tried, therefore—over these last couple of years in particular—to ensure that, where those serious concerns are highlighted in that way, that is thrown into our serious incident process. There is an expectation that, should somebody write to any of our Ministers, that will be picked up with the individual organisations to ensure that that is properly investigated locally. But also it allows us to ensure that, if there are any themes that are emerging, we're able to actually track those and make sure that we can follow those through—firstly, in respect of the individual organisation, but more importantly, actually, what does it mean for the remainder of the health system in Wales. And I think we have got examples, both in process and in correspondence, where we've had to pick up on those areas. So, as an example, Members will be aware of recent statements that we've had to discharge around maternity services in Cwm Taf. Irrespective of our focus around Cwm Taf and the need to have assurances around the local quality of those services and progress, we have actually gone out to all of the organisations delivering those services to look for assurance that they can be confident about their local position as well. So, it's not to look at things in isolation, but to ensure the system has an oversight.

So, what's the internal mechanism for ensuring this happens, then? Do you have some discrete unit that's responsible for this, and does Betsi have reciprocally such a unit internally?

Jo, it may be worth you just commenting on this, on the ministerial correspondence side.

Yes, certainly. So, on ministerial correspondence, that all comes into a central place within Andrew's department. So, there is central oversight and recording. Then that is shared with the relevant policy teams, which are a relatively smaller number of officials, so they would be seeing all the correspondence and would easily identify themes and issues that were emerging in a particular area. There's a similar arrangement with the serious incident reporting—that comes into a central team within the chief medical officer's part of the group. But, also, those serious incidents are themed—so those relating to mental health, for example, would be shared with me and my team, so the join-up can happen there between correspondents, and also the follow through on what actually the response, via the health board, or the response back then would be. So, that's joined up within the group.

The first responsibility for handling the nature of the complaint has to revert to the organisation; it has its own local duties to require. It's just about trying to share that information.

Well, what you've just described seems a very sensible approach. What is the health board itself doing to replicate this structure?

It's a particular area of concern with Betsi Cadwaladr, as in amongst some of the original areas, particularly around governance. The extent to which it was picking up quality triggers within the organisation were a worry, but it has dealt with its complaints and concerns process in a very different way. That's now led by the director of nursing in place in there; it's why I highlighted that there had been progress. So, the organisation itself is able to track through those issues, and has been giving us some assurance about progress, as well, as part of the process. Simon.

Just to add, if I may, I chair a monthly quality and delivery meeting with each of the health boards at which we start with the quality agenda, which includes the reporting and handling of serious incidents and complaints. That's attended by the director of nursing and her assistant director of quality. They've developed a good dashboard, so that they understand where they are. They're addressing the backlog—a little way to go, but they are addressing the backlog. Andrew mentioned the delivery unit and its focus on performance; it also has a team within it that focuses on quality, and they engage with all of the health boards on the quality aspects of their work. We also have a quality team, as Jo mentioned, sitting within the CMO's department, who quality assure the sufficiency of the responses that come back to serious incidents, and either accept them as being an appropriate response, or will ask for further information and questions. Then, that's all brought together through the quality and delivery mechanism that I've mentioned. So, there are a number of different routes through, and BCU has certainly sharpened up its own internal processes significantly under the leadership of the executive director of nursing. 

14:00

There are other bodies, of course, as well that are concerned with complaints about service quality: community health councils, Healthcare Inspectorate Wales, health boards themselves, and the public services ombudsman. Are you satisfied that information sharing generally has improved between all these bodies, the health board and ultimately, of course, you in Welsh Government? 

We have our own arrangements on sitting down with some of these organisations ourselves—more bilateral arrangements—whether that's with the public services ombudsman or we have regular contact with CHC officers who can raise their own concerns on here. But a lot of that happens outside, without the involvement of Welsh Government. So, there are summit processes in place, not least that tie in a number of the organisations that have a more regulatory function—they could describe the nature of some of those conversations, but do allow discussions to take place.

I know that HIW and CHCs have tried to strengthen some of their own arrangements in terms of the interface that they have had. Previous committees were highlighting a need for some improvement there. Again, it's not that we oversee that as Welsh Government; that's a responsibility of Healthcare Inspectorate Wales itself. So, I do feel that there are mechanisms in place, but many of them are owned by the individual organisations.

The public services ombudsman has a panel that he draws in to again make sure that he's able to rehearse some of those concerns and issues. I would always hope that any of those organisations know that they can advise Welsh Government, and there are mechanisms to do so. We can do some of that through our tripartite arrangement, with at least the regulator and the auditor, but equally we have to allow some of those concerns to be reflected amongst the bodies that are responsible themselves. 

Many of the concerns that have afflicted Betsi Cadwaladr, and indeed other health boards for that matter, have been developing over many years and could have been nipped in the bud or at least alleviated in the extent to which they developed if there had been proper information sharing at an earlier stage. So, are you sure that the arrangements you've now got in place are sufficiently robust, given the labyrinthine nature of the NHS as a vast and complex organisation, to address serious issues in a timely way? After all, what we heard earlier on in Adam Price's questions is that, in relation to unscheduled care, things are getting worse not better.

It's right that we have very large organisations overseeing these areas, and the extent to which you're filtering different information through those organisations is quite critical. So, we have to try and focus on the areas where we are triangulating some of those concerns, rather than always go for individual issues. I think our interventions in using the escalation framework for other organisations would be part of me saying, 'Yes, of course, we are ensuring that we are having to learn from our decisions about that first decision with Betsi Cadwaladr, but we are genuinely trying to make sure that we are escalating and responding as appropriate with other organisations.' Even our recent actions around Cwm Taf in respect of some areas of quality concern demonstrate us trying to pull that into a process to make sure that we're calling it earlier. But, equally, I would emphasise and suggest there's a lot more confidence that, when those concerns are outlined, we now have a mechanism in place to respond to it, including the escalation framework itself.

If we could turn to the area of mental health services in Betsi Cadwaladr, I was wondering if you could begin by addressing the developments as you see them in relation to these services since the time of the committee's report in 2016 and how you've monitored progress, and particularly if you could refer to the three sets of indicators that you introduced earlier in terms of visibility of senior leadership figures, staff surveys, and also recruitment in this particular area.

Chair, perhaps I could give a brief personal view, but I'll ask Jo to step in with some of the detail as the lead director on mental health in Welsh Government.

Firstly, I would say, in respect of our original issues, mental health was always the greatest concern—that it would be the longest to probably see progress. It was inevitable that, with the very serious reviews taking place, and reviews that have required an enormous amount of sensitivity to be progressed, that was going to potentially affect and compromise some of the decisions needed to be taken to improve services. They are now in the public domain, and I do think it allows the organisation to at least make some progress on the back of some of the recommendations that have come through those reviews.

I think that the development of a mental health strategy, signed off outside of the organisation by stakeholders and partners—so, done as a collective—has been quite important for north Wales. So, beyond some of the individual measures, actually trying to find a way of doing something very different that has the ownership of organisations that can support the whole mental health pathway experience. But there have certainly been a number of issues around needing to change the leadership and direction and the oversight of mental health services in that local area, which have been important. It would always have been, I think, the most significant and difficult area to see improvement within the special measures areas, and that has been declared a number of times, not least through the statements of Ministers. But, Jo, it may be worth you just giving some of the detail on a range of the areas that have been highlighted.  

14:05

Yes. Fine. So, it might help, actually, in terms of the developments, if I cover those first. I'll give those in a couple of different areas, around the strategic and leadership areas, perhaps some stuff around service and performance, partnership working and then possibly something that I'd call grip and responsiveness, so how we engage with BCU and what we see from that.

In terms of the leadership of mental health services, I think there was a big step forward, really, when they appointed the director of mental health in 2016. With our intervention, the director was made an associate member of the board, so that ensured there was board visibility at the board to be able to present the views of the mental health division as well as answer for the improvement. So, that was a step forward.

They've also appointed, quite recently, a new mental health nurse director who's quite inspirational and is having a positive effect up there. So, they've got the triumvirate in place now: a strong clinical director that's been in place all along, a strong mental health director and the strong mental health nurse director. Together, they've put in place the more regional management teams on the same model. That's all been recruited to and is in place now. That gives them a really strong platform to drive forward on. 

We've seen much improved quality and governance monitoring arrangements. That work was started a couple of years ago by Jenny French, a mental health director that we helped place in the health board. That's now been really embedded across the system. They've more recently introduced a new engagement and improvement methodology called the interactive CAMHS assessment network, and that's really starting to galvanise staff and make them feel that they're seeing [Inaudible.] And that is being felt in the staff survey feedback. So, since 2013, for example, 7 per cent increase—they'd recommend it as a place to work. 'Friend or relative, would you recommend—happy with the care provided?', it's gone up by 8 per cent. 'Proud to tell people I'm part of the organisation'—that's gone up by 12 per cent in the mental health division. So, that is beginning to feed through.

The ability of the organisation to manage and respond to both the Health and Social Care Advisory Service and Donna Ockenden reports—. That was a big development and took a huge amount of attention for the organisation in the middle of last year. But they have developed quite detailed plans on the back of that and systems and processes to drive those improvements through. 

Andrew's already mentioned the mental health strategy. The mental health strategy was published back in 2017. What we see now is that they've got quite embedded local implementation plans in place that engage with other partner agencies and they're starting to move forward on that. They've also published a dementia strategy, and actually we've seen a few hospitals gain accreditation from the Alzheimer's Society, and they've received some commendation on some of their memory clinics as well from the Royal College of Psychiatrists. So, that was a really important step forward given the nature of the HASCAS and Tawel Fan issues.

We're also seeing at the board much greater visibility of mental health and the issues there—so, coverage at the quality and safety committee of the board but also at the main board itself with regular update reports, and their mental health committee is functioning well.  

In terms of service improvements, one of the key things that we wanted the health board to address was their in-patient services—quality, safety and safety of the environment. So, those were the things that were constantly coming up in HIW reports. Over the last 18 months or so, they've begun a whole programme of work around that and that is receiving positive feedback in recent HIW and CHC reports. They've still got quite a way to go on that. Last week, the board agreed the outline business case for a major redevelopment of the Ablett unit, because some of these safety issues within the units need major capital build and redesign, but they have a plan to take that forward now, and that's been submitted to Welsh Government in the last few days. So, at least they're getting to a point where they're planning on that.

They have made strides towards the recruitment of more nurses and consultants to reduce the reliance on locum staff, but I'd have to check the precise detail of that for you, and there's quite a way to go. In terms of performance itself, one of the big safety issues that we were worried about were the number of adults being sent out of area for treatment in the health board. So, emergency admissions, they weren't able to deal with them, and patients were sent out of area. They've had a huge focus on this, actually, in the health board, and if you were to compare and contrast, in July 2017, there were 27 adults placed out of area. I think, in the last 12 months, there have been only two nights where adult patients have needed to be placed out of area. So, they've had a huge focus there in terms of protocols, procedures, escalation around that, which seems to be paying off.

Performance and the mental health Measure: we do still have concerns around some of the headline performance figures, particularly the primary care measures, but what we do see now is that they've done the demand and capacity modelling and they understand the issue. We've seen some improvement in performance, but they still have a way to go on that. Care and treatment planning: they're back at, or neat to target. Specialist CAHMS is something we still have concerns on.

We've mentioned some of the partnership working around the strategy, but also, in terms of the work with regional partnership boards in the area, they have put together some really quite substantial bids into the transformation fund around mental health services and services for children and young people that I just don't think could have happened a few years ago. That really does show the improvement in partnership working there, and also with the police in relation to how they deal with section 136 arrests for mental health patients. So, there's quite a lot there.

14:10

It's probably worth just pausing there, Chair.

Thank you for that very comprehensive update. One quick question. You mentioned the improvement in some aspects of the staff survey. Specifically, we've covered the mental health team. Could you just return to those figures for a second and give us a sense of how low a base we are talking about, because that gives us a sense of how we can judge those improvements?

Yes. So, 'recommend the organisation as a place to work', it was at 44 per cent in 2013, so that was probably just before Tawel Fan. It's at 58 per cent now. 'Would I be happy with the standard of care provided by this organisation if a friend or relative was asking?', it was 45 per cent. It's now at 63 per cent'. Proud to tell people I work as part of the organisation', it's gone from 38 per cent to 64 per cent. 

Right, so, in general, we're still talking about a non-positive response of around 40 per cent—there or thereabouts—for those three indicators, which I would just tend to immediately react in feeling that that is still considerably worrying, given that we're talking about NHS staff in this area.

It brings me on to really a key question, then, for you. You said that this is a complex area of all of the areas under special measures and it's one that's going to take, possibly, the greatest amount of time. But how long is it going to take, do you think, in your assessment? Progress in delivering the mental health strategy and, indeed, continued improvements against the mental health Act and the mental health Measure are two of the five criteria that you set out as the benchmarks for de-escalating. Well, can you give us a more concrete sense of how long you think that will take and how you will know when you've got there? 

Just on the staff survey issue, I just wonder, Chair, whether if we could give a sense of the NHS Wales position against those three measures? Because you're right to say that, although that, on the one hand, is demonstrating some progress, it may help to know where that would stand against some of the broader—. And it's not that far away from some of the other measures at this stage, but we need to see broader progress. On the 'how long' question, I said at the outset that mental health was always going to be the most difficult area to emerge. We've tried to adopt an approach whereby the list of the concerns that were there at the outset—that we could target them and reduce them alongside the organisation. Disappointingly, we've had to extend, but mental health did need to receive in public the very serious reviews, I think, in order to move on.

Actually, with the strategy that's been outlined, although that is for the next three-to-five years, I do think that mental health services in north Wales have a real opportunity to actually show some leading examples of care and treatments, even comparing and contrasting with other areas. But, we have still got some quite significant milestones in place, as part of our special measures framework, that would need to be addressed under mental health.

We need to ensure that it's sustainable, equally, before we declare it. So, a couple of the areas that Jo has mentioned—those need to be maintained, I think, going forward, but, Jo, you have a closer sense of this.

14:15

Yes, so, some of the things that we really feel further improvement is needed—they do need to ensure that they have nearer a full complement of consultants—consultant psychiatrists—particularly in the west of the region. We've already mentioned the meeting of performance targets on a sustainable basis and DU are in there working with them now. 

There's certainly work to do around their CAMHS services, and access to specialist CAMHS, and the ability of the in-patient unit to take urgent referrals. We would want to see the redesigned Ablett unit, which will really act as a catalyst for the modernisation of some of their services, taken through and delivered.

So, there is quite a bit of work still to do, but what we've seen, particularly in the last 12 months or so, is a grip by the organisation—full understanding of what needs to be done and effective plans in place to deliver against those expectations. We are getting feedback, both from HIW and from Emrys Elias, who's the expert in there on the ground for us, that they are making progress and things are happening.

How do you explain the contrast between the evidence of progress as you see it that you've just presented against the account set out in Donna Ockenden's letter to the health Minister in the summer, referred to in the older people's commissioner's letter that the Chair referenced at the beginning of his remarks? She says that, based on the representations made to her, staffing is 'worse now' and staff are 'exhausted'—'on their knees'.

On the question of visibility of senior leadership, which you said is a key issue overall, they rarely, if ever, see senior managers or board members. If they do, they see them on flying visits only. The complaints system is also going backwards, although the outward-facing image is one of progress. In summary, those using and working within mental services on the ground tell me they do not feel the service is better or yet on an improvement journey. 

It's partly why the staff survey results, which allow us to track over time and happened after that as well, have been quite important to try and get the broader opinion, as well, of areas. Jo, do you want to respond to those issues? 

I think you mentioned there that Donna Ockenden's correspondence was back in last summer, just after she'd published her report. I think she recognises in her letter that she'd completed her own fieldwork the previous November for her report. It is true—she shared the information with the Minister—that she had taken some phone calls and concerns from individuals within the health board.

She said that a large number of people had contacted her, and they'd contacted her of their own volition—they'd sought her out, even though she had no ongoing role in the situation.

She also mentioned a letter that was being sent by a number of staff, which was sent to HIW and the health board. What I can tell you is that the health board responded very promptly on the receipt of that letter—met with the staff in the Ablett unit to address their concerns, most of which were around the physical estate and improvements that needed to be made there, and a lot of those issues were dealt with.

What I can also say is that HIW very recently visited the Ablett unit—as recently as last week—and clearly their report will be published in time, but the initial feedback from that report is that many of the concerns that the staff were raising have been addressed. So, I think that the view is that there may still have been staff at a point in time last summer who still had concerns, but hopefully, now, a further six months since that, the progress, particularly over the last 12 months, that I've been able to allude to, will be borne through [correction: fed through] and that the staff will be feeling that.

14:20

So, you're fairly confident, for instance, if the committee were to contact Donna Ockenden and to ask her if she's had any subsequent representations from members of staff, that now there would be a different picture.

I don't think we could be confident that she wouldn't have had any members of staff contacting her, and there may still be some difference of views among staff there, particularly as changes are made to services, stronger leadership, more leadership is put in place—sometimes that can be uncomfortable. Obviously, I couldn't give that guarantee, but what I'm saying is the evidence that we have and we're seeing, which is tested both by Emrys Elias on our behalf and HIW, is pointing to the improvements I've outlined.

Just finally, in terms of commissioning the reports, do you think it would have been better if the Welsh Government had commissioned the reports, rather than the health board itself, in terms of public trust and confidence in governance arrangements and in the reports themselves?

Yes. I think we'd say that we've learnt from the Tawel Fan situation, including the importance of making sure that the initial investigation is done with the right scope and the right expertise right from the start. More recently, where there's been a need to commission wider reports, Welsh Government have done that. We've already mentioned the one in Cwm Taf around maternity services, where the Minister himself took the decision that the Welsh Government would commission the report. But also, in relation to HASCAS and the second Donna Ockenden governance review, we did step in and put in an independent oversight panel to try and ensure that there was independence and scrutiny of that report, and to give separation from the health board in terms of its governance and, in a sense, from Welsh Government.

It did work in the sense that the independent oversight panel were able to come in, they looked at the scope and the terms of reference and the timing. There was some blockage in some of the partnership working and sharing of information they were able to sort. I think if they hadn't, those reports may still not have been published. And the really important thing is that they were able to bring in a QC to advise that the HASCAS methodology was robust and appropriate for that formal investigation to give us further assurance.

Great, okay. I'm aware that time is moving on. Adam, then I'll bring Vikki Howells in.

Just finally, you did stress the creation of this; I think it was a triumvirate that you referred to—these three key senior positions that are going to be critical in terms of moving things forward. I know hindsight is a wonderful thing, and we trade in it in this committee more than most, possibly, but just, I'd like to—. It's a genuine question: why was the importance of that missed, up until the point where the decision was made to put that senior management in? Why do you think it wasn't identified earlier?

Firstly, one of our interventions was to require that a director of mental health services was put in place, and, equally, that they were made an associate member. Our structures across Wales don't necessarily have that as explicit as we would wish at this stage, so organisations have a post that typically will deal with primary care, mental health and acute hospital-based operational measures. When health boards were established, there was a wish to particularly focus on the development around primary care and mental health, and I think, given the range of challenges and pressures that were happening within Betsi Cadwaladr, the hospital side of the equation probably outweighed the concerns on that particular side, and I think that's why we put in the individual and made it a requirement, and we have definitely seen an impact from that arrangement. And, of course, as I said earlier, it's never just about a single individual, you have to then make sure that that follows through the structures and that teams feel supported, and you can make connections with those who are operating in clinical environments, but it was certainly something we had to learn. For another health board, if it was on different areas, you might not want to highlight mental health specifically in that way; you might go down a route of wanting other services to be a bit more visible around that table as well. But it was certainly necessary for mental health.

14:25

And it did take them a while to recruit the right person, so they needed to go out to advertise a couple of times to make sure they got someone with sufficient experience to undertake the role.

Thank you very much indeed. The fact is that, since Betsi went into special measures, out of nine, eight executive directors have been replaced or changed. Recruitment of the new officials or new directors is very important in the mental health area. I'm concerned how—. Have you got enough tools at your disposal to make sure that mental health services are fully catered for in Wales?

Well, there are perhaps two points from that. One is: are we able to discharge that for Betsi Cadwaladr? And the other one is: what does that tell us about the arrangements that we need more broadly? We do track a number of areas of measurement across Wales on mental health performance measures—how we're doing on primary care; obviously, children's and adolescent mental health services are tracked through; and we do have some examples across Wales of leading an excellent performance in terms of what's happened—

Well, in part, the individuals that we have put into Betsi Cadwaladr along the way are individuals who had some of that expertise themselves. So, Emrys Elias had a background in mental health services himself and had overseen performance. Some of the clinical individuals who actually chose to move up to Betsi Cadwaladr were those who were leading excellent units elsewhere in Wales. Obviously, they had to make their own decisions about going to work for the organisation, but the experience of mental health is an area where we can collaborate across Wales. I do think that there is a set of further service changes that need to happen. That's why the delivery of the mental health strategy is so important, because there's been some quite traditional focus on services, and there is a way of improving that, I think, in line with our experience in Wales but also elsewhere in the UK.

Thanks, Chair. Moving on to primary care, could you give us an update as to the situation with GP out-of-hours provision at Betsi?

If I could start briefly, but I'll hand over to Simon. So, one of the initial areas of concern was in primary care as one of our areas of development, but whilst we wanted to see general progress in primary care, you're quite right that it was the out-of-hours services that were a particular concern. I said in my introductory comments that it felt as though we were now handling those arrangements on a more normal basis in line with other areas, but, Simon, you might want to demonstrate why we would have that kind of confidence and assurance about progress over the last three years.

Thank you. We've seen a significant focus from the health board on improving out-of-hours services, and there was a peer-reviewed process of all of our out-of-hours services in Wales that looked at the provision in BCU at the end of October last year. Just a quote from the letter from the chair of the review, it says that overall, the panel was impressed by the ongoing dedication and commitment that was demonstrated by all staff and the continued focus on delivering high-quality care to patients within out of hours. It was clear that there was a passion to deliver long-term sustainable change and that your proposed service vision aligns with the wider 111 transformation agenda too.

So, the team has really come together to improve out-of-hours services. We've seen that tracked through into performance metrics, where BCU has gone from perhaps being an outlier in performance terms to being, I think as Dr Goodall described it, more normal in its arrangements. On some of the key metrics that the health boards that are measured against, in November 2018, it was third on three of them and first in Wales on two of them. So, we're seeing improvements in fill rates, in shift filling, in telephone triage times and in face-to-face contacts as well. They've introduced a single integrated clinical assessment and triage service, which is better linking out-of-hours provision into WAST's services, so it's a precursor to the 111 model that we'd expect to see in place, where BCU clinicians are engaging with WAST earlier in the process when patients dial for an ambulance response. That helps to signpost patients to alternative pathways and alternative professionals, which is a key part of the strategy. We're seeing improvements in recruitment and they're continuing to work to staff a multidisciplinary team approach, again, to broaden that focus away from being a GP-only provided service into a team-based approach.

The service in north Wales has been three separate services, and they're currently consulting on proposals to bring those together into a single service, which will increase both flexibility and resilience, and it will also allow them to streamline the triage and call-handling processes. So, there's more work to be done, but, as Dr Goodall said, they are not at the outlier in Wales now, they are more in the normal range compared with other health boards, where there do continue to be challenges in fully staffing the service. But we have seen some quite significant and pleasing improvements. 

14:30

Thank you. That's very encouraging. It seems to be a mixture of both efficiencies within the system and also staffing, as you said there, which brings me on to the wider primary care service issues. What are the current challenges, still, around securing stable and effective primary care services in north Wales? How much do they actually hinder attracting GPs to that area?

That's a key feature, as is common with primary care across the rest of Wales and the wider UK. There are currently a number of managed practices in BCU—14 at the moment out of about 110. The health board is working with a potential provider who would take back three of those contracts into arrangements, and we know that there are another two practices that are going to be handing back the contract at the end of March. So, there are pressures in north Wales. They are a version of the pressures that we see elsewhere in the system in Wales.

We're seeing things like Healthy Prestatyn, which is an exciting model that is very much in tune with the primary care model for Wales, with a focus on multidisciplinary working on health and social care, working together in co-located and collaborative arrangements, on team-based working, and that's entirely in tune with the developments that we wish to see through the primary care model.

We've also seen some innovative capital developments in north Wales over the last couple of years, which provide the facilities within which primary and social care and the voluntary sector can co-locate and work together on a broader well-being agenda as opposed to only an illness-treating service. There are pressures in the system, there's no doubt about that, but we are seeing some very positive signs, some strength in leadership within the health board with the appointment of a director of primary care, who's a GP by background. As Dr Goodall mentioned, the director of primary, community and mental health care post in health board was a combined post, that's been separated off in BCU, which allows, as we've just heard, a greater focus on mental health from having a director of mental health and a greater focus on primary and community care by having someone who can build a team to focus on those services themselves. So, positive steps, more work to be done, but some very encouraging signs.

Thank you. You referred there to the new primary healthcare model in Prestatyn, which certainly makes for interesting reading. Do you think that could offer lessons for development across Wales then?

I think it certainly informed the development of the primary care model for Wales. We have a strategy that has a broad model and it's entirely consistent with that model, as I mentioned, bringing together multidisciplinary team working, allowing people to work within their particular skill set. So, a very important role of GPs, but supported by other health and social care and third sector skills combined. That is certainly a part of our primary care model for Wales, and we're seeing that development across Wales. I know a number of colleagues from other health boards have visited Prestatyn to learn from their experiences and then take that learning back to their own sectors.

Importantly, the model—it happens to be run by the health board on this occasion—applies and works, if that's general medical services, which is our extant model for GPs in Wales. So, it doesn't really matter who's got the responsibility; it's about drawing together the clinical teams in the most appropriate manner.

Yes, certainly. I've seen examples of that in my own health board area of Cwm Taf as well. Just one final question, then, to sum up: would you say, Dr Goodall and Simon Dean, that primary care services in Betsi are now on a secure and sustainable footing? And if not, how and when do you think that this will be achieved?

To start, I personally feel that we can see progress, particularly on the quality concerns, and I would hope that we would be in a position, even with other areas of criteria on special measures, to feel that we can de-escalate on out-of-hours as a particular concern. I think the more we are measuring Betsi, as we would any other health board in Wales, I think that demonstrates a level of normality around it. I think it would be wrong to commit that we feel that all of the solutions are there at this stage because, as Simon outlined, there are still a range of recruitment challenges and practices that are under severe pressure, and I think that if Betsi Cadwaladr health board are able to grab those, work with their GPs who are cluster leads, and make sure that's more resilient, then I do think that they have a chance of improving that for the population.

We're also hoping, through other measures, however, that we can have some influence on this. So, last year, we actually saw a higher proportion of trainee GPs join north Wales as part of our ‘Train. Work. Live.’ campaign, and, again, looking to the year ahead of us, I hope we'll be quite confident that there should be, again, a further improvement of GPs who want to actually train in north Wales at this stage. But we're not quite there with the final numbers at the moment.

14:35

I think I'd echo that. Certainly, it's on the right direction, we can see signs of progress, and there is more to do but they're on track.

I'm aware that this is quite a marathon session and you're covering a lot of information. We've got a few more questions, from Jenny Rathbone and Neil. Are you happy to plough on, or would you like a short break now—a comfort break?

We're happy to plough on, Chair. I think, normally, we're in here for about two hours before you let us out, so we're happy to carry on [Laughter.]

Yes. Literally, we have just got two more sets of questions, so we'll try and be succinct for you. Jenny Rathbone.

Thank you. How would you categorise the current financial health of Betsi Cadwaladr?

Finance has become a greater concern under the special measures arrangements. So, in January 2018, as we had to extend some of the criteria even though there had been progress, we had to be much more explicit about its delivery within its financial budget.

If I can just go back a little bit to the history, Betsi Cadwaladr was an organisation that was balancing its budget up until 2013-14, so it had a history and a strong financial track record, which we believe can happen again for this organisation, and it sets, in part, our expectations to see financial improvement. We've gone through stages of seeing some progress, and then, I would say, we have been disappointed by a reversal of some of that trend over the last year and a half in particular, and we've had to spend a lot of attention on trying to understand and underpin our expectations for this area. But, Alan is probably the best person to outline this, including some of the external support that we had to put in to identify the underlying issues. Alan.

Yes. Just by way of context, with all of the organisations that we've got in intervention, particularly with financial difficulties, I think we start that process by trying to understand whether they have a clear idea of what they're trying to achieve, whether we call that a financial strategy or a strong sense, in two areas, really. The first area is: do they understand their opportunities for improvement in what we would call the normal efficiency and productivity areas? The second area, which I think is a little bit more strategic, is: do they understand the needs of their population and are they starting to realign resources through different service models, through different workforce models, to make sure that they can plan and deliver services into the medium term within the available resources?

As Andrew said, if you look at Betsi up until the financial year 2014-15, they were in balance. They started to hit difficulties in that year and they partly recovered that the year after, so there were signs that they were actually back on a trajectory of getting back into financial balance. They then drifted again and I think, going into 2017-18, they started to produce plans that looked like they could recover that position, and I guess that's when we were escalating some of our interventions. They drifted off that halfway through the year and that's when we begin the more formal interventions with the Deloitte governance review.

If you look at Betsi Cadwaladr, though, through that process of, 'Do they understand where their opportunities are?', through some earlier work of Deloitte and through some earlier work that they had produced themselves using traditional benchmarking information, they'd identified that they had opportunities for improvement in normal efficiency and productivity areas of somewhere between £100 million and £180 million. So, what we were testing is, 'Have they got the ability to develop those into programmes of work? Could they get that implemented and can they increase the pace and scale of that implementation?'. I think what we found was that they weren't successful in that. That led—

Why not? What were the reasons why they weren't successful?

Well, that's what led to the first intervention by Deloitte in terms of the financial governance and I think they found a couple of things. I think they found the approach to financial planning was simplistic and underdeveloped and too isolated from service and workforce planning. They found the approach to financial management to be simplistic; budgets were rolled over and targets were issued out to the operating divisions with an expectation that the operating divisions could build plans without a lot of central support and translating some of where their opportunities are into much more practical programmes of delivery in their operational units. And then, finally, I think they found the approach to financial forecasting and risk management to also be simplistic and underdeveloped.

They developed an action plan to respond to that and, through our intervention process, we gave them until the start of this financial year to see if we could see that progress coming through in much more of a tangible way. That didn't come through in the first quarter. We then escalated. The financial delivery unit was then established. They have been working alongside the LHB executive and finance team around delivery of the plan. Unfortunately, we found they haven't made the progress that we had anticipated, and we are now not seeing the improvement coming through that we would have expected.

On the governance side, Dr Goodall had pointed to some strengthening of the board and the committee arrangements. Through the intervention process, the board and the committee have also identified now that they don't believe the team is capable of addressing those at the pace they require, and we're in discussion with them now about what further external intervention and support is required to achieve that.

14:40

Local authorities watch all this with considerable frustration. Councillors would be sent to prison if they weren't able to set a balanced budget. So, do you think we ought to be introducing such a methodology to health boards, to ensure that they do only spend the money they've been allocated?

Yes, I think we've been—. Particularly those who have struggled to deliver, and—. If you take the three organisations who are in intervention, who have put these frameworks and methodologies in place that we've both developed nationally, but also advocated locally, Cardiff and ABM health boards will probably have stepped down to a £10 million deficit by the end of this financial year and are now producing balanced plans for the next financial year that they've submitted to us for scrutiny. Hywel Dda health board will have stabilised this financial year and are now producing plans to step down further. So, Betsi Cadwaladr at the moment remains an outlier within the Welsh context, but we have got the frameworks and methodologies. Betsi Cadwaladr have identified themselves the opportunity for improvement. We've put actually quite significant funding in place this year to support them, without the deficit support that we've held within the MEG. They have had about £60 million-worth of further allocations above their core allocation—so, that's about 6.2 per cent—which should be more than enough for them to have made a much more substantial improvement than they had this year. Because, I guess, of previous public accounts recommendations, we deliberately have not put deficit funding support in place. We've held that back so we have got enough cover within our MEG to cover the deficit within Betsi Cadwaladr, and now I think we've arrived at a situation where they're not going to be capable of either developing those frameworks successfully and making sure they're implemented at pace.

It's important that we approach this with some balance, so part of our approach with those organisations where finance has been one of the triggers for escalation levels has been that we also want to ensure the organisations make the right decisions on behalf of their population. Financial decisions in the health service don't come without consequence, whether that's capacity, service implications, the staffing arrangements that you have in place. There's a danger that when we use the phrase 'efficiency', which I'll offer, that doesn't seem to really translate to the fact that it's something about having to change something. Having said that, I think the way in which we've approached some of the deficits, and that includes Betsi—. Betsi's situation has meant that we've taken some of that responsibility to protect the quality judgments of the organisation, and we felt that if we simply asked them to break even, it would have had a potential detrimental effect on the north Wales population. So, that was a point of protection.

Okay. Obviously, they're not going to get back into financial balance unless they change the way they do things. Instead of the deficit being reduced, it's growing, so the Welsh Government doesn't seem to be effective in the oversight that you're giving—well, the tripartite arrangement that you've got—because the deficit continues to grow. So, at the moment, I understand that the health board has reported a £20.3 million overspend on the already approved deficit at the end of September. What is the situation at the moment?

The last set of monitoring returns we had for the board was their position to the end of December, or month 9 of the financial year, and they were reporting an overspend then of just under £31 million.

Than the September position that you just quoted, yes.

So, how is this going to be managed? You don't have a printing machine for money upstairs. All this is money that is not available to spend on other things.

14:45

As Dr Goodall said, because we've probably been intervening quite heavily with the board at the moment, we set them some clear trajectories of improvement that they haven't met. We understood the risk with that, so what we've done is make sure that we can cover that within the MEG. And I think the board have also arrived at their own conclusion that they will now need further escalation and intervention to make sure that they recover that trajectory as much as they can before the end of the financial year, but certainly going into the first quarter of the next financial year. 

There is accountability about this. It does start with the organisation being accountable for its own plans. I think they're learning from us on this, because there were some signs of them starting to improve their financial position two years ago. The reason we've had to elevate this as a special measures issue was we could not see that they were translating their financial performance into sustainable plans for the future. And I think your point is exactly right: they have to reflect on the way in which they are organising their services, the nature of the response that they're providing to look at areas of duplication, to look at the skill set of their staff in a very different way—all of which is to captured in a three-year plan. And we have not been able to approve that plan at this stage, which would include us having confidence that they were in a position to break even. Our experience with other health boards in Wales is that we are looking for people to have to step down. It's probably impossible for any organisation to recover that position in a single year, but we are seeing an impact from interventions occuring with the other organisations in Wales who are in escalation, and that would be Hywel Dda, ABMU and Cardiff. So, our approach has been able to stabilise those and see a recovery, and we have to ensure that Betsi Cadwaladr can deliver the same.

Okay. Well, let's just look at some specifics at the moment. Of the £6.8 million that was given by the Welsh Government about six months ago to improve planned unscheduled care across all acute specialities, £0.5 million was for extending a pilot in mental health for the right care and repatriation programme. It sounds as if, if that hasn't been implemented, that people are staying in hospital who don't need to be in hospital and who need to be reintegrated into the community, and that obviously costs money. 

When Jo was highlighting earlier that the health board had really improved the number of people staying out of area, it was the repatriation programme she was describing. So, that example of 27 back in July 2017 and only seeing two in the last 12 months shows, actually, an impact from that, which helps. It's better for patient experience but, of course, it has a financial benefit as well.  

Good. Okay, well, that's one positive. There was £4.6 million—£2.3 million a year—to strengthen delivery, planning and service improvement capacity. What's your assessment of where we're at in terms of understanding—? You know, things need to change; staying the same isn't going to be an option, surely. 

Indeed, I agree. Simon. 

That resource was provided, from memory, to fund 37 additional operational management posts across the hospital system, and they're in the process of recruiting to those posts now. So, some of those staff are in post, others are to be recruited. So, it's about strengthening our operational management capacity.  

So, it's a bit too soon to judge whether that's going to actually improve the financial situation.  

Yes, it will certainly improve that interface between operational delivery and service planning, which, as Alan was saying, is critical to helping to drive a sustainable financial position. But the important thing about that spend is that that is a need that the health board identified for itself, and the crucial thing is that it was them identifying what they needed to be put in place in order to strengthen their ability to deliver and plan.  

How much is this deteriorating financial situation down to clinicians not wanting to change the way they deliver services?

There are examples of services that have changed. If I go back to the structured assessments that have just been done for Betsi Cadwaladr, I think the WAO's reflections on this is still right to say that there is still not the full comprehensive plan of clinical service change in Wales that is able to cover at a level of detail what that means for individual settings, whether that's at the hospital site side or whether it's in primary and community services. So, the general direction of travel on their strategy feels right, but it needs to be coloured in, which I guess is the best way of describing it. 

Certainly, there are service changes that have occurred in north Wales, and they have been material. The development of the Prestatyn model in primary care has been very significant. The sub-regional neonatal intensive care centre, the SuRNICC, which was commissioned up there, has been a really significant change, and it was nice to meet staff up there who'd been recruited to that, who saw it as a very positive aspect. The vascular service changes have been necessary up there, and we've invested funding to support new theatre arrangements to underpin that as well. But I think we need to not just have the individual examples of service change, which will give confidence about working with clinical teams; we actually need to have that comprehensive overview, which is why we don't have the approved three-year plan at the moment. 

14:50

Okay. And we seem to be talking about the capacity and capability of both planned and unscheduled care. The changes aren't happening fast enough, and that's why we're in the financial situation we're in. Is that right?

I certainly think the health board has got a significant challenge to start from assessing the needs of its population and then blending a service delivery pattern across all sectors of care, from out of hospital through to secondary care and tertiary care, and to align that with a workforce plan that is deliverable within core capacity and doesn't rely excessively on expensive locum and agency staff, and then to make that work within a key financial strategy. And it has to be driven hard by identification and implementation of best practice, and it's going to have to balance those to an age-old equation of access, quality and cost, and that's where the health board needs to be. It's got to work through its service portfolio from that position. 

Dr Goodall, you mentioned that there are some areas of excellence in Betsi Cadwaladr, and I would agree with that. The Bevan Commission was here on Thursday, and I was speaking to a consultant orthopaedic surgeon who said that, by doing day-care surgery for knee replacements, he could save £1,600 per patient. Well, he's done the training, he's been to look at how it works in other parts of Europe—why is that not something that they aren't instantly thinking would be a good way of reducing waiting lists for planned surgery?

That's why we need to underpin these issues. We have a planned care programme for Wales. We look to that to distribute examples of good practice. That's our local initiative with Betsi Cadwaladr. Actually, coincidentally, they're providing us with their orthopaedic plan for the whole of north Wales shortly, and we will be challenging them to make sure that their own local best practice is included in that, because we can provide better patient experience, as well as deal with the finances. And, Alan, our experience for health boards generally, but it's certainly true of health systems, is that you can ensure that you can deliver better quality services and deal with the finances at the same time. 

Okay. So, how confident are you that you'll be able to encourage Betsi Cadwaladr to implement those transformational changes, so that it will be in a position to be able to be allowed to implement a three-year plan? At the moment, I don't think there's the confidence there that they would be able to keep to it. 

Alan—on the financial side. 

On the financial side, by now, we would have expected, this financial year, in line with the other health boards, to see a fairly significant step down, in terms of their deficit, with a further step down in the next financial year, and then entering financial balance the year after. I guess, because of the problems that we've experienced, we're at least 12 to 18 months behind now on the financial side in getting the health board to where they need to be. And that's a combination, as we've just described, of more ambitious service change and spread across the whole organisation, and also picking up the pace of implementation in just the normal areas of efficiency and productivity, where significant opportunities still remain for them to actually get much closer to financial balance just through the normal efficiency productivity mechanisms that other health boards have been deploying more successfully. 

Okay. They seem to be the third largest spender on agencies for filling vacant posts. Is that something that they're actually addressing?

They are going at that, and there are some examples of them having made progress this year, but that absolutely is an opportunity. Some of that requires a focus around their ability to recruit substantive staff. So, if you actually track back to the maternity experience, one of the problems that they did have in that service was that they were spending too much, actually, on locum individuals within that service. And I'm pleased to report, through very significant recruitment, that they were able to attract in. So, maternity itself has been able to demonstrate that reduced spend. And as Alan says, we are looking at an organisation that has still got a lot more opportunity to do better within its resources at this stage, and we have to keep holding them to account for that and making progress. And, of course, you as committee members will have a chance to also ask those questions of Betsi Cadwaladr about their current methodology and expectations for the finance too. 

Okay, because at the moment it seems to be that two divisions are letting down the rest of the organisation in terms of delivering on the financial plan. 

In their current position, and we've been debating this in our special measures meetings, I worry a little that some of the focus is on mental health services, because out of all of the areas that have felt most fragile, mental health services, because out of all the areas that have felt the most fragile, mental health certainly is an area that we've wanted to make sure that there was progress in delivery. So, in terms of an overview of their—

14:55

And as we're aware through our special measures meetings, that's one of the areas they're highlighting. I think it's absolutely true that all services should have the same discipline applied to them, but certainly we have had to start from a lower baseline on mental health services, and it's important to have initiatives like the repatriation of out of area mental health placements, because I think that's something in the interest of patients. But the assessment of mental health being the reason why the organisation has overspent—that, for me, is not the reason why the organisation is overspending. 

If I could just add—? If you look at the work that Deloitte did, I think that's part of their problem. They've got a very simplistic approach to rolling over budgets and then issuing cost-improvement targets against that, and that's probably true of mental health. If you look at the analysis that they have now benchmarked their service model against, what they need to do is change their service model, change their workforce model and make that deliverable within existing resources. And, again, both Wales Audit Office and Deloitte have said that that's really where they need to spend far more attention.

So, rather than describing a budget overspend, which is the wrong mechanism and the wrong approach, they need to think about what a sustainable service model is. As Jo said, they are making progress, they are retaining a lot more patients within their health board rather than putting them out of county, but they've got a long way to go to change the service model. 

Rhianon Passmore, do you have a short supplementary?  

Very briefly, then. I think I'm understanding the main issues here. We've mentioned culture and skill set—so, bearing in mind the clear direction of travel and advice that Welsh Government and the audit office is giving to the health board around service modelling, workforce modelling, efficiency productivity, measures that every health board is introducing, and the scale of ambitious service change involved, and bearing in mind that that seems to be coming out of everybody's ears, and that's being translated to the health board and its leadership, are you still then satisfied that that board make-up and that leadership arrangement is satisfactory, because otherwise why is the deficit still growing? Why has this not been acted upon? And, therefore, I go back to my earlier question—in terms of the tools that you have to be able to instruct when there are clear messages that are not being taken effectively on board in this really important area—what is still going wrong?

I think there's a leadership question for the organisation. So, that significant change around independent members and executives—  

Obviously with accountability, but Betsi Cadwaladr is the largest health board in Wales, it's got over 16,000 staff, and the trick for delivering this change is the ability to reach through the organisations to connect from front line right through to that oversight from the board. I think we've been very clear in our special measures improvement framework about how we will be measuring the organisation. I worry that at various points the organisation has set out too many different objectives to go at.

If you look at their annual plan that they're pursuing at the moment, I think they're focused on three areas that would represent confidence for us, and they've actually clarified that for the organisation. But the trick for them is to absolutely convert this into operational support through their structures to get to the performance that we're expecting in the organisation. Some of that performance has a knock-on effect on finance and vice versa, but we need to allow that accountability for the team that is there to deliver. A new chair has spelt out his expectations for the organisation and we do see a pick up in terms of some of the scrutiny and challenge, but, as I said earlier, it won't be about good intentions—we will be tracking this organisation on whether it hits the milestones. 

Okay. We're entering the last few minutes, so if Members can be succinct. [Interruption.] Can Neil ask his question, and then I'll bring you in, Oscar? 

To be honest, the evidence that we've received this afternoon is profoundly depressing, because we all recognise what the problem is with Betsi Cadwaladr. And when Mr Brace spoke about the failure of Betsi Cadwaladr to respond adequately to Deloitte's criticisms and proposals to improve performance, he made it sound as though, 'Well, there's nothing that can be done, because we're pushing on a piece of string.' We've heard the points that Adam Price started out with earlier on about how, in terms of unscheduled care, things are still way, way suboptimal. If we look at the overall financial performance of the health board, as Jenny Rathbone spoke of a moment ago, in 2016-17, on the rolling three-year financial result, the deficit was £75.9 million. In 2017-18 that had risen to £88.1 million. For 2018-19, it's forecast to be £103 million. With all the best efforts that you have made through the interventions that you've been responsible for, although there are success stories—Mr Goodall mentioned about the maternity service, the neonatal service, and so on—there are other areas that are going backwards and, overall, in financial terms they're gobbling up more and more of the scarce resources that the Welsh Government has at its disposal, and that's going to have an impact on health boards in other parts of Wales. So, what is to be done here? Either Betsi Cadwaladr does not have the resources that it requires in order to provide the people of north Wales with the health services they deserve—and the Minister is frequently saying to us that he believes they do have the resources, so, therefore, we still have a problem with management in Betsi Cadwaladr—. With all the revolving doors of changes that we've had in recent years, we're still not making adequate progress.

15:00

And I think that's why I've focused on describing the need to move through structures, rather than it wholly being at the board level. Because while the accountability, absolutely, is held by the board, we need to ensure that there is a proper level of resource, and I do think that, unfortunately, there are some legacy issues that have affected some of that operational experience and understanding in the organisation. And, certainly, there are areas under special measures—as I described earlier—that have shifted. So, we know that, when the board is able to focus its attention on the small set of issues, it can make progress, not least on some highly significant areas. And I think the fact that we are describing an organisation that has moved away from an environment of concerns about quality to ones that are more about the planning and operational systems—I think that is at least a shift in terms of the concerns. But it's also partly why we do call out the finances. We are saying that there is a deficit here, which we do think can be handled, and we think it would be wrong to allocate differently for that organisation, because that would be detrimental to other organisations in Wales. And part of the escalation framework is making sure that that is visible and called out on behalf of the organisation. So, we do expect progress on finance, and we do think that there are areas that can be improved on there, starting on the control side, but more about the future plans for the north Wales population. And I absolutely feel that should be a focus of attention for the organisation.

But Mr Brace still says that they have a simplistic approach to rolling over budgets from year to year. No organisation can operate indefinitely on a basis of not being able to control the cash that it has available to it. If they don't, even after all this time—given that they've been in special measures for three and a half years, the problems that led to the decision to take them into special measures had been developing over many years before that. We're talking about 10 years since this organisation was constructed, and we seem to be—I won't say no further forward, but we've not made enough progress by any means to deal with the systemic problems, which fundamentally go back to a lack of management control.

If we look at audit assurances around their controls mechanism, they all say that there are appropriate controls that are expected in the NHS in place. I think the challenge for the organisation is absolutely to move its attention away from annual, in-year savings targets to something that is about setting out what the service provision should be for the population of north Wales. And I think that they have an opportunity to do that. I would say that I think they should take some confidence from some of the examples of service change that they've delivered, but they need to scale it up, and they do need to do it with pace and urgency, given the current situation, and they do need to do it in line with the special measures framework that we've outlined, which is really clear on our expectations to October 2019.

Well, on the basis of what you've said this afternoon, I personally have got no confidence they're capable of doing that, unless you put in somebody to the organisation to sit there and direct them in what needs to be done.

The health board will be able to account for itself, and there are areas where we have had to put in additional support at this stage. But we have set clear expectations, particularly on the financial arrangement, because we do expect to see improvement from that organisation, as we have with other health boards in Wales.

Well, if we don't see the kinds of improvements that you want to see and we can reasonably expect, what further measures can you take to ensure that you bring this about? We'll have to conclude, I think, that the individuals who have been charged with the responsibility of achieving what you want to achieve are not up to the job, but we can't keep on changing the heads of organisations without incurring other costs and administrative deficiencies. You are in overall charge now, because they are under special measures, so what further measures will you take to ensure that they do actually respond to what you suggested they do?

15:05

Any team in Wales for any of our organisations will be measured on their collective ability to deliver and achieve outcomes. I think we've tried to ensure that that is very explicit and visible for this organisation. It's why there has been a series of ministerial statements and why we've made sure that the special measures framework is in place. We are having to make constant decisions about areas to move forward with and intervene with, some of which is investing in their local capacity, as I've said. At times when that's required, that's about bringing in expertise as well at this stage, but I agree that to some extent this is a challenge about the nature in which the organisation works right across all of its settings and services.

I think, whatever they are also discharging internally, we also believe that the organisation—and it has some examples of really excellent partnership working in place—can really work really closely with the other support organisations in the area, local government, third sector, et cetera. So, there are other choices that we can make about support under the special measures label. But, at the moment, we're continuing to make sure that that accountability is held by the organisation. It has its own board, it has a chair and a chief executive, and it has a team who need to step up to our expectations.

Okay, we've got loads of supplementaries on this; you've spurred interest. If Members can be succinct, that'd be helpful. So, Oscar first.

Thank you very much indeed. Thank you very much, Andrew. My concern is it's not only Betsi, it's the whole of Wales. What is happening is we're producing around about 300 doctors—qualified—in Wales every year, and leaving and retiring more than 400. That was given to me by one of—you know, a reasonable official from your health service. So, this gap is widening. So, how—? Are you prepared to make sure—? Because without doctors and consultants and clinicians out there, we cannot give a service to the public. So, I'm pretty sure you might have something on this side to make sure that the public of Wales should have proper, qualified doctors and clinicians and nurses available in the future. 

Our long term plan, 'A Healthier Wales', has an absolute focus on workforce, as you would expect, because it's what makes the NHS successful in terms of the services that it offers. We have taken steps over recent years to expand medical student places. We've taken steps to expand nursing places. We've had nearly a 70 per cent increase in those nursing placements over the last three years. We've expanded it around some of our community areas and we've expanded it in respect of doctors also. So, there has been an agreement to expand the number of training places that are in place, for example, and how they are supported. There are currently more doctors in post in Wales, but there is a need for us to continue to develop those alongside other practitioners. So, the workforce plan that we'll produce in 2019 will show how we do that, not just for doctors but for the range of staff that support our settings across Wales. 

The skylight has just opened, so I was wondering if you could shed some light on—[Laughter.] It's divine intervention, maybe. But I suppose what was at the heart of Neil Hamilton's question, and I think Jenny Rathbone touched on it earlier—what we're struggling to work out, I guess, in this case—is a serial inability at the senior management level laid out clearly in terms of the financial deficit.

Five years ago, the chair and the chief executive, I believe, resigned. Six years on, we're still kind of in the same position, aren't we? So, what is in your armoury in terms of actually moving things on? You have an intervention system that hasn't achieved here. What else is there: the wholesale replacement of the entire board and the entire senior management team, rather than—you know, the chief operating officer retired early last summer, et cetera? Or is it the case that possibly Betsi Cadwaladr as a region is too large and too heterogeneous? It's deep rural and, actually, fairly urban post industrial. Is the abolition of the board an option that you've looked at on a contingency basis, and replacing it with something else entirely—a different model, a different structure?

We undertook an engagement exercise back at the outset of special measures, just asking for some of those underlying views, and, certainly in terms of stakeholder feedback in some broader areas, the concerns were to ensure that the underlying issues were addressed at that time, rather than revisit the organisation. I've had experience myself of running large organisations in Wales, large health boards. I accept the geographical distribution in north Wales is different, but I do believe that large organisations, even with significant members of staff, can be led and that they can be managed and they can deliver outcomes. I think the spread of the issues for Betsi Cadwaladr has been significant—so, the range of areas that they've had to tackle at any one time. I think, to be fair to any of the organisations in Wales, any organisation would have found dominating the need for the serious reviews that were undertaken just on mental health, just as a single issue. So, I think there have been factors.

I would say that, in terms of change over recent years, certainly through 2016 and 2017, both on measures from some of the external reports that were coming in, we were seeing some signs of more progress generally. It's unfortunately the end of 2017 into 2018 that demonstrated that we were going to add on these extra areas. But I do think that large organisations can be led and managed. We have turned over the whole board in reality, in terms of the individuals that are coming on. I do think that that means that we have to look at some of the structures, the geographical areas and the operational structures in place to underpin any future changes as well. Because I think you're right that any connection from the board to the front line is where we need to take the next improvement in services.

15:10

That's exactly what I was going to ask you, actually, in regard—but as a nuance to that. In regard to the tools in your toolkit—we keep asking this, 'Do you need further tools in your toolkit to be able to instruct?', and I wonder about that. But, in the other question, you keep mentioning it's the largest organisation that we've got in Wales, and I take your point on board that absolutely we can manage large organisations, but, in regard to the holistic stresses and strains despite Welsh Government uplift in terms of health spend, in terms of the rurality, in terms of clinician recruitment, is then that system change just too much and therefore is, in terms of the original analysis, the fact that it may be, potentially, once you've got to the end of this process and there are still not the changes that we want to see—all of us, collectively—it then the time to perhaps look at how large that area is? 

Ultimately, the organisation will be measured on if it delivers the outcomes. The special measures framework sets out what we expect. If the organisation falls short on those—

And can you just outline that to me, in terms of, if it does not get to the end of that process and have the adequate outcomes, what is the ultimate sanction? 

The Minister will be looking for us to make recommendations about the way forward for that organisation. We have not been—

We have not been operating or running this organisation and in fact that would be impractical given that it’s obviously going to have a north Wales presence at this stage. But there are other arrangements that are available. Certainly, at the moment, from a board perspective, given that there has been a turnaround of the board, one would expect them to be very focused on the outcomes that we’re expecting.

One would, but, in terms of pace and in terms of what’s been stated, that doesn’t clearly come across. Okay.

Okay. So, finally from me, with hindsight—always easy to talk about in hindsight—would stronger intervention have produced greater and more rapid improvements in the health board and have lessons been learned?

It was the first organisation that we placed into special measures and it was the first real use of the escalation framework. I don’t think we had necessarily been expecting to have an organisation in the most difficult category at that stage. I think the fact that we did so, however, and that happened pretty quickly was a sign that the escalation framework was there to be used. That would still be my underlying message as we track other organisations in Wales: the escalation framework is not to be avoided; it’s there to be used to call out the issues and concerns that we have.

But, of course, we’ve learnt lessons: it’s been really important to have co-ordination and liaison in respect of Betsi Cadwaladr, to have some local presence that’s been able to support; the importance of the availability of intelligence and information and really using relationships with other stakeholders and partners, appropriately so, which would include colleagues in Health Inspectorate Wales and the Wales Audit Office. We have adapted aspects of the escalation framework based on learning and reflections from other colleagues. We don't see it as only for Welsh Government to learn. I think the deployment of skills and experience externally has been important to us, so we have had individuals that have gone in. But I think—. Knowing the organisation now, I think that an earlier step that we should have taken was to have recognised that there had been a removal of some of the operational experience in the organisation and for us to have put that back in place earlier in negotiation with the organisation. It’s pretty clear that, having failed to deliver some of these services and outcomes as we would wish, they were missing a range of experienced individuals to do so down the structures.

But, whatever we need to do going forward, it’s really important to make sure that special measures remain on the issues that we identify. As much as possible, we have to try and deal with organisations also on normal business. I would say to finish that there are normal areas of delivery within Betsi Cadwaladr, even despite us having had to run through some special measures area. I would also say that there are actually some excellent examples of service delivery and staff in north Wales who are doing the right thing for the population of north Wales.

15:15

Great. Thank you. That’s been a marathon session. Your voice held out. You are now allowed to go and have that break, as Members are as well. I propose that we reconvene in 10 minutes or so—3.25 p.m.

Okay. Diolch yn fawr, Chair.

Gohiriwyd y cyfarfod rhwng 15:15 a 15:26.

The meeting adjourned between 15:15 and 15:26.

15:25
4. Plant a phobl ifanc sydd wedi bod mewn gofal: Ymateb Llywodraeth Cymru i adroddiad y pwyllgor
4. Care-experienced children and young people: Welsh Government response to the committee's report

Welcome back. Item 4 is our look at care-experienced children and young people. We've received the Welsh Government response to the committee's report. The auditor general has provided advice on the response. There are some observations, as well, which the research service would like to make. Auditor general, would the audit office like to elaborate—

I'll try to say something, Nick—forgive me.

Through the medium of mime. [Laughter.] It's a very full response from the Government, and a very full advice note from us as well. It's obviously for the committee to consider the degree to which you are comfortable with the position and how far you want to go in following things up, but I think you'll want to consider whether it's worth pursuing this just through further correspondence or having a short further evidence session to pick up some of those points. But there are a couple of additional things that Matt will talk you through that might be relevant to your discussion as well.

Thanks. Last week, there were three developments in this area. Unfortunately, we'd already drafted our advice letter at that point, so I'll just flag those up: one is that, as you may have seen, the Welsh Government published its final evaluation of the pupil development grant last week. Obviously, the committee made a commentary on that issue in its report, drawing as well on the work of the Children, Young People and Education Committee. 

You can read the report in different ways, I guess, but it does raise a number of concerns around some fairly basic weaknesses in the arrangements for delivery of the grant previously. I think the Welsh Government's response to your own recommendations tries to provide some assurance that it was already sighted on those issues and was trying to address them in putting in place new PDG arrangements going forward. Nevertheless, if you are following up with the Welsh Government in correspondence or, indeed, in a further evidence session, it's probably worth picking up on the evaluation, possibly seeking an update and a response to the specific recommendations in the evaluation report as well.

So, that was one area. The other was also, I think, published last week—new statistics on children in care in Wales, based on the census from last March. They show that the number of children in care increased, I think, by about 8 per cent in 2018 compared to 2017. So, again, it's a bit of wider context in terms of what's going on in this area and some of the issues that are still driving growth in the number of children in care.

Thirdly, the National Audit Office also published a report last week on local authority expenditure on care. It had within it some useful analysis of some of the drivers of social services expenditure in England on children in care, but I think there were probably some messages and lessons arising from that report that are relevant in a Welsh context, and particularly relevant, actually, is some of the work and modelling they've done that's relevant to the analysis that the Welsh Government has pointed to that it's commissioned in response to your own recommendations. So, again, it's probably for the committee to flag up that work in England and encourage the Welsh Government to take account of it as it takes forward its own research and analysis. That would be helpful.

So, I think, regardless of which direction you go in—whether you want to have a short follow-up evidence session or write back to the Welsh Government—I'd encourage you, and we can work with the clerking team, to make reference to those three other developments as well. 

Great. In terms of the minutes, we've received the verbatim discussions, of the minutes. I think our intention, when we asked as a committee, was to have the outcomes and the decisions, which we haven't really been given.

15:30

That's in relation to recommendation 3.

Yes, so that's recommendation 3, and it's an advisory group, so, ultimately, it's up to the Welsh Government what decision they make, which wouldn't be recorded in the minutes anyway.

Recommendation 4—the timescale for completing the research is unclear, so we can seek clarification on that. That's quite straightforward.

Recommendation 5—the first sentence of the response is pretty weak, so we could seek clarification on that point in our correspondence with the Government. 

And on recommendation 7—

Yes. In terms of the new arrangements coming into force 2021-22, I'm slightly concerned about that being pushed into the long grass in terms of being able to put the recommendations around placement costs and outcomes with the national approach and on commissioning. So, I'm a bit concerned around that issue. I'm wanting to strengthen that, basically, in terms of what that effectively means.

I think we made the point in our advice that the Welsh Government set out that there are a number of things flowing in linear sequence, if you like—there's the research, the analysis and then the strategy beyond that. But they've only really set out an indicative timeline—'Well, if this happened then, then something else could potentially happen.'

Yes, and I think we agree, but what I'm saying is that I don't see why that can't happen in parallel, in terms of being able to be in place in a more appropriate timeline.

Okay, and recommendation 7—it's reasonable to expect the Government to at least attempt to take forward this recommendation or at the very least scope it out as a one-off. However, they've stated they cannot implement it. So, there are challenges with time and expertise, but Members may wish to have a bit more of a positive response from the Welsh Government on that one. Happy to press the Government on that?

Yes, but in regard to Welsh Government overview and oversight on local authority responsibility around that, I think, from my perspective—.

So, being clear that they can only be expected to do what they're—

Okay, then recommendation 9—the Welsh Government could seek assurance on the level of ongoing spending on these services. Happy with that?

Recommendation 10—there's an additional allocation from the Government. Prevention is better than trying to deal with the outcome of children being removed. So, we can keep a watching brief on that.

Yes, I think we flagged it, Chair, in our letter, on our own work on the integrated care fund, and while we haven't looked at the extra £15 million of funding that's come in, or coming in next year for that, obviously, if the committee does, in due course, look at the integrated care fund, there will be an opportunity to look at the use of that additional money as well.   

Okay. Any other points on the response? Research, did you want to—?  No. Happy. Okay, so we'll follow up those issues with correspondence, then, with the Welsh Government.

5. Cyfoeth Naturiol Cymru: Ymatebion i adroddiad y pwyllgor
5. Natural Resources Wales: Responses to the committee's report

Great. Item 5 and back to our old favourite—Natural Resources Wales and responses to the committee's report. Auditor general, did you want to comment?

Nothing specific. I think these are helpful to receive now, but, obviously, you've got NRW coming in in a couple of weeks' time, so these are helpful to receive in advance of that session. But nothing specific from us at the moment.

They're coming in on 11 February, so any issues arising from that, we can raise with them then.

The Grant Thornton report was supposed to be out before the end of January. So, is that happening?

Sorry, I missed that.

I understand it was being considered by the NRW board last week and we've been promised it for the end of this week, so it will be in the papers for 11 February. I haven't got a firm date, but I have been promised it.

And we've got a Plenary debate on 13 February, the day before Valentine's Day.

15:35
6. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o’r cyfarfod
6. Motion under Standing Order 17.42 to resolve to exclude the public from the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Okay. I propose to move Standing Order 17.42 to meet in private for the remaining items—7, 8 and 9—and nothing for the next meeting. Content? The ayes have it.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 15:35.

Motion agreed.

The public part of the meeting ended at 15:35.

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