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Y Pwyllgor Cyfrifon Cyhoeddus

Public Accounts Committee

11/03/2019

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

Caroline Bird Dirprwy Brif Swyddog Gweithredu, Bwrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Deputy Chief Operating Officer, Cardiff and Vale University Local Health Board
Claire Birchall Cyfarwyddwr Gweithredol Gweithrediadau Bwrdd Iechyd Lleol Aneurin Bevan
Executive Director of Operations, Aneurin Bevan Local Health Board
Dave Thomas Swyddfa Archwilio Cymru
Wales Audit Office
Dr Paul Buss Cyfarwyddwr Meddygol Bwrdd Iechyd Lleol Aneurin Bevan
Medical Director, Aneurin Bevan Local Health Board
Judith Paget Prif Weithredwr Bwrdd Iechyd Lleol Aneurin Bevan
Chief Executive, Aneurin Bevan Local Health Board
Len Richards Prif Weithredwr Bwrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro
Chief Executive, Cardiff and Vale University Local Health Board
Mike Usher Swyddfa Archwilio Cymru
Wales Audit Office
Steve Curry Prif Swyddog Gweithredu Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro
Chief Operating Officer, Cardiff and Vale University Local Health Board

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Claire Griffiths Dirprwy Glerc
Deputy Clerk
Meriel Singleton Ail Glerc
Second Clerk

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 13:19.

The meeting began at 13:19.

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

I welcome members of the committee to this afternoon's meeting of the Public Accounts Committee. I also welcome our witnesses. As usual, headsets are available for translation and sound amplification. Please ensure that electronic devices are on silent. In an emergency, follow the ushers. Do Members have any declarations of interest they'd like to make? No. Okay. And there are no apologies today? No apologies received, so no substitutions. 

13:20
2. Papurau i'w nodi
2. Papers to note

Item 2, and papers to note. First of all, Dr Andrew Goodall, has replied to my letter of 23 January, and advised that a 'A Healthier Wales: our Plan for Health and Social Care' clearly outlines the Welsh Government's 

'commitment to investing in new ways of digital working and to dealing with any shortcomings in delivery.'

This is in relation to our inquiry into NHS Wales informatics. To support this, he's commissioned a review of infrastructure and system design that will be informed by best practice approaches to digital healthcare delivery from across the world, which is due to report back at the end of this financial year. That's all in his letter.

I feel that progress is being made, so coupled with Dr Goodall's diary clash, which makes it difficult for him to attend when we were originally hoping to see him, but also with the commitment from the Minister for Health and Social Services to update Assembly Members on the response, I suggest we defer the proposed evidence session with him on improvements that have been implemented until the autumn term. Are we happy to do that? Good, okay. So, that letter's noted. 

3. Rheoli apwyntiadau cleifion allanol ar draws Cymru: Sesiwn Dystiolaeth gyda Bwrdd Iechyd Lleol Prifysgol Caerdydd a'r Fro
3. Management of follow-up out-patients across Wales: Evidence Session with Cardiff and Vale University Local Health Board

Item 3, and management of follow-up out-patients across Wales, and our evidence session with Cardiff and Vale University Local Health Board. Thank you for being with us this afternoon. Would you like to give your name and position for the Record of Proceedings? 

Okay. I'm Len Richards. I'm the chief executive of Cardiff and Vale. 

I'm Steve Curry. I'm chief operating officer at Cardiff and Vale, so I have day-to-day responsibility for directing operations across the health board. 

Hi, and I'm Caroline Bird. I'm deputy chief operating officer in Cardiff and Vale, and I've been working with Steve in terms of the management of out-patient follow-ups. I'm also a member on one of the national programme group—the out-patient transformation steering group. 

Thanks. We have a number of questions for you. I'll kick off with the first couple of questions. Why is the health board's performance significantly worse than other health boards', both in terms of the number of patients on the follow-up waiting list and the numbers of patients significantly delayed?  

Shall I start by answering that and then hand over, as required? This is quite a multifaceted and complex problem around out-patients. Our out-patient model is quite traditional. It's been the model that's been in place for many, many years within hospitals. We see transformation as being a fundamental part to actually addressing some of these issues. Whilst I agree that our position is the worst in Wales, and significantly different to the other health boards, we are taking quite a cautious approach to removing inappropriate follow-up out-patients off the out-patient waiting list. We're doing that with clinical engagement, working with each of the clinicians within all of the specialties, which I think gives some reasoning behind the length of time that it's taking us to address it. But it is meaning that we're taking a very safe approach to managing this particular problem. Indeed, in the 2015 auditor general's report, they did say that we were taking a comprehensive and risk-based approach to the management of the out-patient follow-up problem, and that they commended that to the other health boards.

So, we recognise that we still have a long way to go. We recognise we aren't making progress quickly enough and that we're committed to ensuring that that comes about. But the issues for me have been—there are issues with our system—our out-patient system—that we've been fixing alongside the clinicians; there are issues of capacity and demand; there are issues with the model of out-patients that we use, which is a fairly traditional one. But we are taking a very—. We're looking at that through the lens of safety for our patients so that we make sure that if anyone is inappropriately on the list, we take them off. But we do make sure that those who are appropriately on the list, we can see them quickly. 

I was just going to ask you what's been driving the increase in the delays, but, from what you've just said, you would identify the inappropriate out-patient follow-up as being the primary cause. 

Yes, absolutely. 

It sounds a simple thing to say that you'll differentiate between the appropriate and the inappropriate. How difficult will that be in practice? Because it must be quite a pressure to try and differentiate those to make sure that you don't end up with people in the wrong queue, so to speak.

13:25

That's right. If we go back to 2014, which was probably the start of the reporting of this, there were 778,000 follow-up out-patients on our waiting lists. By the time we get to the end of March 2019, the end of this month, we think that will be down to 260,000. So, we've made significant reductions in the amount of follow-up out-patients that are waiting. But the key figure, again going back to March 2015, when we started to monitor this, is there were 245,000 follow-up out-patients who didn't have a target date. So, we weren't reporting them as waiting longer than their waiting time target, because they didn't have a target date in the first place. That was the unknown problem that we had with our waiting lists. By the time we get to the end of this month, that will be down to 50,000 patients without a target date. Now, 50,000 is still 50,000 too many—

No, that was compared to 245,000 previous to that. So, we have been working with the clinical staff, looking at the requirements of individual patients and making judgments on when their target follow-up out-patient date should be, and then trying to model the system to be able to respond to that. So, we have made improvements over the course of the last few years, but clearly not significantly enough. We acknowledge that we need to do more and we need to do it more quickly. 

What sort of timescale are you looking at to see that this is all satisfactorily addressed and you really are on top of the issue?

Over the last few years, since 2014—. Len's just referred to a significant reduction in the overall follow-up out-patient cohort. That is made up, as you rightfully said, Chair, of two groups—of those with a date and those who have not a date. So, getting greater certainty of those without a date was a clear first step for us. We've seen that come down, as we said, probably to about 260,000 by the end of March. We think that we can see further reductions in that of about 30 per cent over this year, in the coming year, which will take it down significantly further than that.

That's an important figure, those two cohorts of patients, when you look at the area that the Wales Audit Office looked at, and in particular those who are delayed by more than 100 per cent, because the validation of those without a date has meant that significant numbers have been removed legitimately, after good discussion and leadership from our clinical teams, but a number of them have moved into certainty of needing a date. That's why we're seeing the 100 per cent number going up initially, before we expect to see it go down. You'll see the last reported position on that was 124,000 patients in that cohort. We're expecting that to be at about 89,000 at the end of March and we think that we can move that, as I said, further by at least 30 per cent, possibly 40 per cent over this year, which, by comparison to the previous years, will be a significant change going forward.

One other thing, if I may say, about that is that we will not take a blanket approach to reducing that in just reducing the numbers. One of the areas the Wales Audit Office did give us some credit for, and we're grateful for it, was that we have taken a risk-adjusted approach to reducing follow-up delays. So, across our organisation, we have asked our clinicians to tell us where they think the greatest risk may be, by condition or speciality. So, in reducing it further, we will reach into those areas first to reduce that going forward, to ensure that we actually continue to take a clinically risk-adjusted approach to reduction over this year. 

Okay, a couple of supplementaries. First of all, Rhianon Passmore. 

Thank you. You've mentioned the traditional model, and I'm just trying to gain a picture of the landscape that you're talking of in that regard. That's used by many other hospitals, I presume, across Wales.

Out-patients, I think, is ripe for reform, and other hospitals have reformed their out-patient models.

They have. So, the model that you have been operating up until recently, which you've stated was traditional, are other hospitals across Wales using this traditional model now?

Some are and some aren't. I think there's variation across—

I presume, consequently, from that, where you're at now—. How was yours allowed to gain such a huge number on it, without effective monitoring around that? I'm still perplexed, if it's used by others, why yours was such an anomaly.

13:30

If I can just clarify that point around the traditional model: a traditional model of out-patients is that you're seen in clinic on your first new out-patient appointment, you then may need some treatment; you would go for that treatment and then the doctor would want to see you again after that, and that would be your first follow-up. Sometimes that's done by a senior doctor, sometimes that's done by a junior doctor, and then some patients get followed up routinely every three months, every six months, every year—that sort of thing. I would identify that as a traditional model of service provision. That will be in existence in many hospitals, but in some specialties, people have reformed the way in which they provide a service. So, just as an example, in our orthopaedic service now, you'll be seen in out-patients, you'll then have your treatment, and we then do what's called a 'patient reported outcomes monitoring form', where the patient will score whether their treatment has been successful, whether they're receiving any pain or not. And if, on the basis of that, everything is fine, then you are not required to see the doctor again. So, you leave it with the patient to initiate that.

I accept all that. If I just may interject. I understand what you're saying, but in regard to my question, really, if the model that you now have has not changed and you're still operating within that model, how did it get to the state of 778,000? I know that you're in a different position now, but I'm concerned if that is still the same model that you've got, that—.

We monitor this much more actively, and have been since the 2014 position and we've been engaging fundamentally through the audit office, and when the audit office have put forward their reports, we've been putting forward our action plans to meet that. So, there is—

Okay. So, you would point that process as a driver of change.

There is much more active monitoring. We've also escalated this into our quality and safety committee, so that it is monitored on a monthly basis within—

—quality and safety. So, there's much more active monitoring as to the improvements that we're making than there was previously to that.

Just to add to that, if I may, you're right, there are two aspects to this: there is the data quality issue and there is the functionality in terms of the model we use—traditional or reformed. The number that you referred to isn't helped by the traditional model and that needs to reform going forward. The numbers rose because of our systems and data issues. For example, the figures we've just mentioned to you about the numbers we expect to be on the list over the next couple of months, we do know that up to a third of those are pathways, not patients. So, the system was reporting various elements of the pathway to increase the numbers. So, there's a data and systems issue, which we've tackled first, but also, in a sustainable solution, we will need to move forward in a transformation approach.

We need to make some progress, so can I just—? If you can keep your supplementaries quite succinct, Oscar then Jenny.

Thank you, Chair. I think I'll ask Len about that. The Aneurin Bevan area health board has 100,000 more people than your catchment area and their performance indicators in every area are better than yours. Why?

And I think that just sets out the challenges that we have. I would say we have a different system of out-patient appointments to the Aneurin Bevan system, and some of the vagaries within that system are specific to Cardiff and Vale, so I would highlight that as one of the issues with regard—

Don't you think that some lessons should be learned from that?

Absolutely, and I'm not minimising that at all. I think Aneurin Bevan are performing well in this and we should be working alongside them. Caroline attends the out-patient transformation group and Aneurin Bevn have their representatives on that out-patient transformation group as well, and so that's where the learning, on a Wales-wide basis, comes in, through that particular arena. So, yes.

So, what makes Cardiff and the Vale so different, to explain this huge difference?

The only difference I would signal is that we use a different system, and that—

Okay, well, clearly, it was a rubbish system, the one you outline in paragraph 8. I mean, how—? I appreciate that you weren't there at the time, but how is it possible that a patient management system was set up that didn't track the date on which they were due for their next appointment or intervention?

So, the system that we've got, the patient management system, is an in-house developed system. It's been there for a number of years. It does some things well, and it does some things not so well.

13:35

And nobody discovered that it was not fit for purpose.

This is an area where we have had to really examine the functionality of the system and put in place workarounds or fixes to the problems on the monitoring of follow-up out-patients, and that's been the work over the last three years, working with clinicians in the specialties and then making adjustments to the way in which the system responds to their requests, so that we can get a much more accurate position. 

When somebody has treatment, do they normally get given the follow-up out-patient appointment date before they leave the hospital?

In terms of treatment, no. The next stage should be for them to have a treatment date, and then follow-up—

No, but once they go for their treatment, whatever it is.

There are varying practices, actually, across each of the specialties. Some of the specialties will—

Why are they not simply given a date? If they were offered a date there and then, as they're discharged—'We'll see you on x, y, z day'—it would save an awful lot of money in appointment letters. 

Our booking processes are based around—. We're trying to automate those to try and make them much more efficient, to reduce some of the DNAs. What we find when we give patients appointments quite far in advance—some of those patients may be coming in at periodic intervals, it could a month later, it could be three months later, and some of them need to come back for a 12-month review, et cetera—what we find, I think, when we give patients appointments far in advance is that our DNA rates, the 'did not attend' rate, is quite high. So, we need to have a much more patient-focused booking system, where there's patient interaction about agreeing that date in line with the capacity that's available. 

But that doesn't explain why you can't give the patient a card, even if it is six months ahead, and then you ring them a month or a week before the date and say, 'Hello, Mrs. Are you still alive? We'll see you on that date.' 

I agree, and that's what the new automated system is intended to do. There are many patients who do get a date as they leave the clinic in terms of that. It's usually not an actual date, 'We'll see you in two months, six months, or whatever', but there are many who do. Where that's possible to do, we do that. But the fully automated booking system that we're starting to roll out now, which is one of the recommendations from a number of areas across the UK, and recently referred to in a Royal College of Physicians report on out-patients, is designed to do just that, exactly as you say. It's designed five weeks out of that to make contact with the patient to confirm the date: 'Is this working for you? If it's not, come back to us within two weeks, or whatever.' If the patient does come back, it's confirmed. If the patient doesn't come back, there's a second attempt to contact the patient to confirm, and at that point then the date would be given to someone else. But you're right: how we communicate with patients is fundamental to their compliance, for want of a better word, with coming to the appointment, and I think that system will give us a greater opportunity to do that. 

Thank you, Chair. Looking ahead to the next year, clearly we as a committee would like to get some assurance that patients will be seen in a timely way. So, could you tell us who is taking the lead on this issue and whether you feel that the health board has both the capability and the capacity to solve this problem?

So, as chief operating officer, that will lie with me as the executive lead for that. I report through, obviously, to the executive team and into the sub-committees and to the board itself, so they're well-briefed on that. But I don't do that on my own, and I work closely with executive and non-executive colleagues to ensure that that happens, in particular with the medical director, because clinical leadership is a key component of improving this position, because we need to challenge some traditional thinking around this, as Len has said, in terms of the out-patient appointments. 

Another key executive is our lead executive for quality and safety, our director of nursing. As Len said, we have moved this from an activity monitoring area into a quality and safety issue, into the quality, safety and experience committee for the health board, and it reports directly through to the board in terms of doing that.

I believe now that we have made some real gains in adjusting our systems, which were giving us a lot of problems. I think there's a significant opportunity for us to reduce the numbers at the rate we've been seeing in the last couple of months, and to the extent that I mentioned to the Chair earlier, over the next year I think we will do that, but that in itself will not be enough. Whilst we will see some early gains in that, we need to move quickly into the transformation agenda and we need to challenge the four principles of a traditional approach to an out-patient appointment. That is, that it is necessary, that it needs to be a one to one, face to face, that it needs to be a very senior doctor and it needs to be in an acute hospital where people have to travel to it. So, by challenging those by working with the national planned care programme and our own newly developed transformation programme with a new transformation director, where this is a key element of it, I think we will make significant progress over the next year. 

13:40

And just to add to that, in all of those areas that you've described, we have examples where out-patients are working well. So, orthopaedics: I talked about how the patient is determining whether they need a follow-up appointment. We're also, through our transformation office, looking at virtual fracture clinics, so that patients don't have to come to the hospital for their clinic appointment, but that can be done virtually through Skype, et cetera. And so we are challenging the status quo on the out-patient model. 

The challenge for us, and it is the same for all health boards, I would suggest, is then finding something that works and scaling that up to all of the specialties where it is applicable. And we're working hard through our transformation team on putting in place the capability through that transformation scheme to scale up things that are proved to work well—within a number of different areas, but out-patients is a fundamental part of that. 

Okay. Thank you. And, again, looking to the future, one of the challenges for the health services is that our population isn't static and the demands that our population makes on the health service change over time. So how confident are you that the health board can align the population's demand for treatment with the capacity for services in the longer term? What work have you done to futureproof that?

So, again, you're absolutely right: there are challenges both in the demographic of the population and in the rising number of the population itself. And in the demographic, more people are living longer, obviously, and the potential for chronic disease and follow-up management is a real challenge for us. There's no question about that. I think that's why the answer isn't simply more capacity. I think we do have to get ahead of our data and quality issues, in the first instance. We do need to match capacity and demand, but we do need to do things differently, and how we manage chronic diseases in the community, not through a follow-up process, how we move healthcare away from secondary and tertiary care centres into the community, and how we work at population health management are all really important. So this is one aspect of a much greater agenda that takes us into improving the health of the population, as well as reacting to illness when it occurs. 

Thank you, Chair. The Auditor General for Wales has stated, as you've referenced already, that you've got a comprehensive risk-based approach, but he's also identified no formal process to assess clinical risks to patients in some specialities. So, in that regard, which specialities have you, as a health board, identified that present the greatest risk of harm? And I accept that you have made a lot of progress in the overall model, but it still leaves that percentage of patients that are in that bracket. So, what have you assessed?

Yes, there are a number of specialties that we've identified with patients coming to harm. As Steve and Len have said, we work with our clinicians on not just identifying the specialty, but actually drilling down to clinical condition within that. There's probably a range of about 15 specialties, but within that, probably three or four, really, present the greatest risk in terms of patients coming to irreversible harm. Ophthalmology would be one example of that, cardiology another one. So we have a comprehensive assessment that is clinically led—

General surgery is probably in the high volumes. And so our approach is not a blanket approach. We've listened to our clinicians, have been led by what they're saying, and we're directing our efforts to those areas in the first instance to try and reduce the risk to those groups of patients. 

So, in that regard, in terms of the direction of your efforts, obviously, this is a very high-risk area. You seem to have oversight, I would hope, over that now. In regard, then, to those arrangements in terms of that direction, what have you put in place in regard to this particular cohort of those deemed most at risk? 

13:45

So, our approach is threefold. The first thing is: the large numbers that you've rightly referred to today are creating some noise for us in the system, and we need to make sure that we're getting at the patients who really do need to be seen as a follow-up. So, validating that list to narrow that down to focus in on those patients is still a very key element of that. The second one is being guided by clinicians as to which specialties we then apply our efforts to. So, that will either be through clinical validation or clerical validation under the guidance of clinicians, in terms of doing that. And then the third thing is we have to provide capacity for those patients to be seen. Now, some of our clinicians are working really well with this in terms of saying, 'Actually, that means that we're going to need more clinics', or some of them saying that that needs a virtual review of a clinician sitting down, working through the notes, possibly a telephone conversation to validate whether that patient actually needs to be seen or not.

So, the resources we have we're devoting towards those higher risk categories that Caroline's just mentioned to allow us to ensure that we work in a risk-based way.   

So, in terms of your monitoring of this important prioritised group, would you say then that that is happening across the board in terms of these particular groups of higher risk patients, or is it just better in certain pathways than others? Is it a varied mixed bag and, if so, what are you doing? 

There's a number of levels there. At a patient level, the communications with the health board, all have a communication that if there's any change in your condition that you come back to your GP, and we have systems in place where GPs expedite patients and we react to that, if there's anything around that. In terms of monitoring, as I say, we've moved that into a quality, safety and experience issue. I report to the management executive every week on risk, as does the nurse director, but also the quality, safety and experience committee then report to the board. And if there are any incidents, it is our policy to openly report those in our open board at every board meeting. So, we have a transparent process in there. We are also working very hard to perpetuate a culture in the organisation of openness to ensure that anybody who has any concerns around patients waiting, or anything else—that that is shared with us.

So, I think the level of monitoring is quite detailed now to allow us to do that, but are we monitoring every single patient on the follow-up list in that sense? No, but what we have are systems in place for those patients to be identified and expedited where there is concern, and what we have is an approach that reaches towards risk in the first instance, and is guided by clinicians.

And so, in that regard, in terms of the relevant sub-committee and the board, I would presume, then, from what you said that they receive regular updates in terms of the risks associated with delayed out-patients. 

Yes, okay. How regularly does that occur? You say you meet once a week, but how often is that—

So, the quality, safety and experience committee is once every six weeks now. It's not on every committee, but we regularly bring papers as to the follow-up in general, not just out-patient follow-up, but follow-up in the widest sense. So, we go to that committee and report back on the position and the actions we're taking, and any risks that have arisen. 

Okay, so in regard to minimising risk to patients, particularly in those three pathways, how would you evaluate the levels of risks if you don't monitor every single patient, and I accept that would be very difficult to do? But how do you therefore evaluate the risk of harm to individuals in that position? 

We don't. Our clinicians do. So, what we do is we put systems in place in response to what our clinicians are telling us. So, even within, as Caroline said, a specialty—we mentioned one specialty, ophthalmology, there—there are five sub-specialties now in ophthalmology, and the risk varies across those. So, what we will do is take the clinicians' view as to where we should be monitoring more or putting more capacity in, or doing greater validation, and we'll follow their advice 

Okay. Finally, in regard to the recent programmes of internal clinical audit work that you've referenced, do the follow-up out-patients feature in them? 

The clinical audit programmes? Yes, I believe, but I don't have that information with me at the moment. 

Okay, so perhaps that can come to us as a committee; that will be great. Thank you, Chair. 

Okay, thanks. Moving on to the modernising of out-patient services, and Mohammad Asghar.

13:50

Thank you very much, Chair. In which specialties are you prioritising future service changes to out-patient services to make them more efficient or address delays?

So, there are a number of areas where we're focusing on transformation and reforming those areas to be able to take that forward. One that was mentioned as an example is in orthopaedics, and you'll see from the report that orthopaedics is a high-volume area in this area for us. It doesn't necessarily mean it's the highest risk area according to our clinicians, but it is high volume. In that area, we're using an approach that is based on the principle of empowering patients to participate and co-produce in terms of their care, and that is a patient-reported outcome monitor for patients who have had procedures, specifically hip and knee replacements. So, what happens there is the patient makes contact prior to the event, provides us with information prior to the event, gives us a measure of their mobility and well-being prior to their operation, for example. Various tools are used to do that: the Oxford hip and knee scores is the one that we happen to use. The event takes place, the procedure takes place, and, again, the patient is asked the same questions in terms of their quality of life, et cetera. Traditionally, we would see those patients on a six-monthly then yearly basis for several years as a follow-up. In this method, the feedback that the patient gives at six months is reviewed by a physio, and the information is brought together, presented to the clinician, the clinician decides whether to see the patient or not. And of the patients we've used this with, 95 per cent of those patients have not come back for a follow-up, to the extent that, in orthopaedics, between 7,000 and 8,000 patients a year are being managed through a non-face-to-face follow-up. It is that sort of scheme that is patient-focused, outcome-focused that we need to scale up across our organisation to be able to do that. Indeed, we've now started to do that in a number of other specialties.

Other areas: in audiology, traditionally, patients having hearing aids would be brought in, and they'd be seen again at six months and thereafter to see if the hearing aid is working. We're using a system called Patients Know Best, which is a portal for the patient to access our systems and our clinicians to feed the information in as to how that's going for them after six months and, again, we put almost 2,500 hearing aids in per year; the vast majority that we've been doing so far have not needed to come back for a face-to-face appointment. So, there are a number of areas across the organisation where we have good systems in place that work on the principle of empowering patients that we now need to scale up to be able to effect this going forward.

Thank you very much for this reply, but how and why do you prioritise these specialties, and where are the gaps in there? You said there are gaps—how do you deal with—? I heard a few times you mentioning six months—the consultation with the patients and—. With every specialty, is it the same, or is the time different with different—?

No, absolutely, the times are different. There's various guidance on follow-up. NICE, the National Institute for Health and Care Excellence, is one. Royal college guidance is another. So, there are different intervals. The reason we've chosen the specialties we have—there are two reasons, really. One is that we specifically are focusing in on those of higher risk, because that's what our clinicians have told us. But the other is that, where there are examples—a colleague mentioned earlier, I think it was yourself, about learning from others—of this working elsewhere, we have, through the national planned care programme, learned about those examples and are adopting them to be able to use them and scale them up in the organisation. So, where there is the opportunity, we're doing it, but also we're doing it in accordance with the risk profile.

Thank you. And what lessons has the health board learnt from modernising services over the last two or three years?

One of the lessons for us is the importance of accurate data. It has been a difficult lesson for us in terms of that. I'm pleased to say that we are now in the right position to correct that going forward. The second lesson is related to a question from a colleague that, actually, putting more capacity and more capacity into the system isn't the answer. The system has to fundamentally change. And a number of things are coming together to necessitate that. The population growth, the demographic of the population, and the availability of digital solutions—across industries, but in particular in health—are coming together to make this the right time, as Len has said, for us to reform out-patients, going forward.

13:55

Can I just add—? One of the lessons that we've learned—and this is in existence in other organisations as well, and other health boards—is the power of the patient in making their own decisions as to their pain scores, to making their own decisions as to whether the operation or treatment that they've had has worked and has alleviated their symptoms. And if it has, then you don't need to come back; if it hasn't, then you get a quick access back to the specialist. And what we found in that is that that's the same language—we can have that conversation with clinicians very easily, because clinicians want that same thing. So, rather than it be a question around, 'Are you seeing enough patients in out-paients?', or, 'Is it an efficiency thing, or a productivity thing, or a capacity and demand issue?', if it comes down to, 'This is what the patients want'—and there's lots of evidence out there through royal college reports that, certainly for the frail elderly, the difficulties of getting to the hospital, being a part of a very busy out-patients department, and then getting back from the hospital to their home, makes them feel quite unwell once they get home, and it's a sort of insult into daily living, in a sense. And therefore, the more we can do to support people in their own homes, or the more easy we can make access to clinicians on the basis that the patient wants that access, I think the better. And it's a very positive conversation then into how we can change service provision.

Thank you very much indeed. And the last question: in November 2018, a Royal College of Physicians report identified various examples of good out-patient practice. These included flexible access to patient-initiated follow-up appointments, alternatives to face-to-face consultation, and encouraging self-management and shared decision making. To what extent can the health board demonstrate that it is adopting these types of good practices?

I'm familiar with that report, and it has definitely influenced our thinking, in terms of our transformation programme, going forward. You'll have seen from that report that 25 per cent of the Royal College of Physicians's members believe that 20 per cent of out-patients appointments aren't necessary, that 28 per cent of out-patients appointments could be done in a non-face-to-face way. And I think the principles and the learning from that report are fundamental for us. They're fundamental in two ways. One, in the methodologies—and some of the patient engagement empowerment points you make are embedded in the systems that we've just talked about—but also in terms of the clincial leadership role of changing and reforming out-patients, going forward. With the royal college acknowledging and advocating this approach, I think that's a great help to us, in terms of working with our clinicians, to move this agenda forward with a joint vision, because I believe what they're saying is absolutely right.

Let's just stick with audiology at the moment. Clearly, it's very good to know that you've had the sustainability award for Patients Know Best, for this service. Why were people ever needing to go to hospital for a hearing aid problem? They're never going to be needing surgery for something like that. Why on earth did this ever happen in hospitals?

The point you make is well made. We have a number of different services that you could—if you took a very impartial lens, forgetting the history of why they've got to where they've got to, but take a very impartial lens, there is no need for them to be done on a hospital site. There is a big question mark around whether out-patients actually has to be on a hospital site in the first place, because very few of them need the very clinical facilities that you would need for an operation or diagnostic test, et cetera. And so, new models of care are emerging all of the time. And when we think about what we require for the future, it's certainly not about audiology being on site, it's not about optometry being on site—it's about all of these things being based within the communities that they serve. So, I think we're on board exactly with the sentiment of the question.

Why did we get to where we got to? It's a difficult one to answer. I think it's about professionals. It's about, in the early days within organisations, there being relatively few audiologists who would also support an ear, nose and throat surgeon through operations and through complicated diagnostic tests as well as the issue and maintenance of hearing aids. So, in the early days, there was a scarce resource that was providing a range of services. Now we have many audiologists who specialise in hearing aids; they'll specialise in other parts of it. And so, we need to work through taking those services off the site, and we've been doing that. So, we have two major centres where audiology is provided in the community on the basis that we've described. We need most of audiology to be off-site; we need most of optometry to be off-site. There are many things that are traditionally being provided on a hospital site that don't need to be there.

14:00

Okay. Well, we can agree that the 'get on with it' time is definitely there on that one. What about something that I correspond with you regularly on: ophthalmology? We have a similar problem of resistance of professionals to doing things differently and them simply not complying with the Welsh Government guidelines. So, where are we at in terms of people systematically being seen for follow-up by optometrists in the community rather than having to go back to hospital once their eye operation has been done?

Yes, that's absolutely right. There is a significant opportunity for us to move that care into the community to optometrists. We've just agreed with the Welsh Government, through the Welsh Government eye care sustainability fund, an approach now where we will have six optometrists in Cardiff. And we expect that to be in spring, where we will be moving lower risk patients from hospital-based appointments to community-based appointments. We will have two in each locality across Cardiff to do that. The opportunity to grow that is there once it's established. We are currently in a procurement process to secure those six practices to put that in place. 

So, how many patients who've had a cataract operation are still having to traipse back to the hospital? 

They are broadly still having to go back to hospital to our ophthalmic diagnostic and treatment centres, but, as I say, as we build these services up, we will be able to—

Why hasn't this already been done? I was assured it was all going to be sorted by September?

There has been a process of us putting in place—. We have, as I say, agreed an approach with Welsh Government, which they have given us some funding for—

Well, I'm sure Welsh Government's in agreement because that's what their guidelines say.

Yes, and there is a need for us to work with our clinicians to ensure that they feel comfortable with that moving forward. The precedence is set. In principle, that has been agreed, so we believe that we can get on with it now.

So, how many of these clinicians are still feeling uncomfortable with the new ways of doing this?

Clinical opinion varies across every specialty. I'm not saying that's the predominant view in any way, shape or form, but it is something that we do have to work with colleagues on. The sorts of volumes of patients that we expect to see moving into these centres is between 5,000 and 6,000 in the first tranche. So, it's not consequential—the amount of patients who will be seen in the community from there on. But I agree—we need to progress that more quickly.

It's money going down the drain as well, because it's much cheaper for them to be seen as a follow-up in the community than it is in the hospital, and meanwhile, patients who do need to be diagnosed are not being seen, because the clinicians' clinics are clogged up with people who could be seen in the community. So, this is not a good story, and yet you're still unable to tell me that the whole problem has been sorted.

Before I move on from that, you talk about health pathways and collaborative working between primary and secondary care. Why is it not possible for the optometrist not to refer to the specialist once they've diagnosed that there is a cataract or another eye problem? Why do they have to go via the GP, who writes the 'Dear doctor' letter? It seems to me completely outdated.

So, my understanding is that the OpenEyes system, which is a system that connects those community facilities to hospital services, will facilitate that going forward. Caroline.

Yes, it will. We're not there yet. So, agreed, actually—it should be a route in.

14:05

Because it's the optometrist who's the specialist. If he's not going to be able to examine them, they won't be able to see what needs to be seen.

We're just progressing the IT infrastructure to enable that to happen, as we have with our GPs. Our GPs can refer electronically and we're progressing the IT structure now for the optometrists to do the same.

The point I was going to make comes back to the earlier point we made around traditional models of out-patients. I think in some of our specialties, and I'd put ophthalmology in there, there is a very traditional view held by our specialists as to how that service should be provided. That view, as you've described, isn't taking on board the new pathways that are being endorsed by Welsh Government. What we've been working hard on with ophthalmologists and others is to engage with them to get those practices in place. I think the new system, which will connect directly with optometrists and enable them to refer with the clinical information directly and electronically, will help in that regard. It feels as if we've made a step forward, but it doesn't feel as if we're there yet, and there's a lot more work to do.

So, what's the deadline, then, for all this soft negotiating with professionals?

In terms of the IT infrastructure, the first tranche will be bought and in place by the end of March in terms of the one model. And in terms of the model, that will go into the first quarter of next year.

Sorry, it's the financial year I'm talking about.

Sorry, you mean April to July. Okay. It felt like a long way off. [Laughter.] Okay. All right. So, I can assure all the optometrists in my community that they will be able to refer directly at least by July.

The optometrists are engaged in discussions that we have through the eye care group that we have within Cardiff and Vale. We are putting those messages out to them, that this system will enable that to happen. Will it happen in every single practice? I'm not confident enough to sit here now and tell you that, but we can come back to you with that information. I'm quite happy to set a timescale and come back to you.

Okay, great. Lastly, just on community-based diabetes—obviously, we spend 10 per cent of our health budget on diabetes. Could you just tell us how far the plans have developed that the auditor general identified in 2017 that you were working on? How far have you got?

Diabetic reviews are part of the primary care work that we're doing now. In the health pathways that Len's just mentioned, in terms of working between primary care and secondary care—this is a new set of pathways that we started to roll out this month, actually—there are between 14 and 20 specialties already on the system. They are agreeing pathways across GPs and specialists as to how best to manage patients in an agreed way. I think, through that pathway approach, we will be able to develop greater collaboration as to how and where we can manage diabetes across the system.

That all seems a bit vague to me. Once people have been diagnosed with type 2 diabetes, are they not then normally being very rigorously and actively managed within primary care, hopefully to get them out of the type 2 diabetes?

Yes, they are. And there are various outreach and inreach arrangements between the endocrinology speciality and primary care in terms of supporting that. We have a number of GP leads who lead on that as well who take an interest in that as well, so those arrangements are in place. But, you're right, some of those diagnosed as type 2, once stabilised, should be managed in primary care. 

Okay. Generally, I think there's a concern about the pace of change. What is the population of Cardiff and the Vale that you're responsible for?

It's around about 500,000.

Five hundred thousand. And yet, we have 315,000 on a waiting list. That can't be an accurate figure, can it?

No, it's not. Do you want to talk about the difference between pathways and patients?

14:10

Yes. I take the point, but, again, unfortunately, our data isn't doing us any favours here. So, of that 300,000, 100,000 of them aren't actual additional patients. So, the 300,000 represents about 200,000 patients. We do 550,000 out-patient appointments a year. So, at some point there will be, always, a number who will be on that list but not a number that should be that far past the due date.  

And also some of those patients won't necessarily be Cardiff and Vale patients. 

They're accessing the more specialist services, so—

Okay. Just for the record, could you just tell us the rough number of out-of-area referrals in, just so we've got a sense of—?

I couldn't at the moment. I will find that out for you.

You can't be expected to have every figure at your—. [Laughter.]

Well, I wouldn't want an absolutely accurate one but I think to get an idea—.

We can. We can build that into a response to the committee. 

Did you just say, in terms of the previous statistic, 200,000 is more accurate than 300,000? 

So, 200,000 patients are affected by the 300,000 follow-up pathways. That's because a patient can have more than one pathway. They can be in diabetes and renal or they can be in ophthalmology and diabetes. So, they can be in a number of different services at the same time. 

Just to go back to this issue of follow-up waiting times. The auditor general in 2015 identified two major problems: a large number of patients that didn't have a documented target date to be seen, and then it turns out, as we've been hearing, that large numbers of people who were on these lists didn't need to be there at all. Can you say at this point, because you've told us something about what you've been doing to address this problem, that you're confident that the health board's reported follow-up waiting time lists are now reliable and accurate?

I agree, the accuracy of our reporting is hugely more accurate than it was at that time. There are a couple of sense checks in that. One in particular is that the overall waiting list volume has now stabilised and the rate at which we were putting patients onto the list who shouldn't have been clearly has dropped significantly. So, we're seeing that coming down. I think, if I'm honest, the accuracy of that list is a process rather than an event. I think we've seen some real step changes over the recent years, and, indeed, this year, we're seeing a significant step change again. The reason these step changes happen at intervals is because we do a lot of work with clinicians in the meantime to make sure that the rules we're applying are clinically safe. So, I think, as we go forward, our list is becoming more and more accurate. But it's certainly markedly different than when the auditor general looked at it first.  

Because the table that you provided us with in the background note shows us that there's been a very substantial reduction in the number of patients where there is no recorded target date—71 per cent—but then there's a corollary, which is a 33 per cent increase, in the number of patients where there is a recorded target date. 

That's right. And if you look at the overall position, it shows a reduction of 20 per cent, of 80,000 patients over that period in the overall position. I think you make a really important point that what we see there is, as we validate those patients without a date, you see it came down by 144,000 over that period, but, actually, those with a date went up by 60,000. So, there was a net effect of the overall list coming down but we got greater surety on the status of those 60,000 patients in doing so. And therefore we were able to place those in categories of risk to ensure that we were seeing them. So, the rise that you saw in the 100 per cent overdue was almost expected as we validated the list. We are now seeing, through January, February and March, that starting to flatten and reduce going forward.  

So, why are we, then, in this process? I accept your description of it as—[Inaudible.]—event. Where are we at the moment? Are there issues that would still require attention? Or is this simply a process of trying to work through the numbers, simply because of the colossal size of them? And what further actions do you plan and when will these, ultimately, in your estimation be complete? 

So, I think the big changes that we needed to make to the system are now in place. I think it takes time for those to filter through the system and reflect in the numbers. I think there are a number now of smaller refinements. In any validation process, it's a rule of diminishing returns, in terms of the scale of the impact of that as it goes forward. But we do think that there are a couple of more minor adjustments that we can make, in terms of the rules of doing that.

Once we've improved the quality and kept our eye firmly on the risk profile, we then need to very quickly move to find the capacity for those who do need to be seen, and reforming the system at the same time to ensure that, when we do get the balance, we remain in balance in a sustainable way.

14:15

Informatics has been a recurring problem for the health service nationally throughout the UK, and not least in Wales, of course. IT systems can, obviously, improve patient outcomes very significantly indeed. Can you give some examples to demonstrate how this is happening in Cardiff and the Vale—how IT and informatics is improving services in acute and community settings?

There are a couple of examples, and we've touched on some of those. Patients Know Best is an IT system. It creates a portal for the patient to access their results and their information, so that they can be much more informed about what's happening and the impact of their treatment, but also so that they can have quick access and messaging to the specialist as a result of that, which enables us, as we described earlier, to have a much more patient-orientated approach to follow-ups in this instance. But actually, Patients Know Best can be used for a number of different things.

HealthPathways is another example of an IT system that can help us. That's where we are looking at high-volume conditions, and we're getting secondary care and primary care clinicians together—so, GPs and hospital specialists—to actually talk through what should be done in primary care prior to referral, at what point should there be referral to a specialist, what should the specialist do, and at what point can they refer back to primary care, with the onus being if it can be done in the community, it should be done in the community. And so HealthPathways is the start. And the value of HealthPathways, I think, is the conversations that take place between hospital specialists and GPs, and then, on the HealthPathways system, we can actually codify that so that everyone's got access to that information—on the GP desk, on the ward desk, in the consultant's out-patient clinic, in the theatre environment—so that people can always key into what is the pathway design for a particular service. So, we get consistency of practice, but we also get that agreement between hospital and the community as to where services should be provided.

I think there are lots of examples like that, but those are just two that are very contemporary, in a sense, and they're the things that we're working on with this specific—

Sorry, just before you go on, Neil, Rhianon, did you have a quick supplementary on that? Then I'll bring you back in.

Very briefly, and it may be coming next, so I apologise. In regard to the expected spike that you talked about on the 'now' list, in regard to those patients that have been given dates, it's just really a further question around the analysis of risk to those patients that have been on this never-ending, huge, long list, and are now in a different scenario. What sort of analysis is there of risk of harm to those patients? 

The biggest risk was not knowing whether they needed to be seen or not—those without a date who may have defaulted the system. So, the first call was to ensure that we had certainty about whether it was an unnecessary addition to the list or whether it was someone who genuinely needed to be seen. So, moving them into the spike, as you say, moving them into the 'known' category, where we do know the date, was at least giving us certainty of their status. So, that was the first—

But you would acknowledge that, in that never-never land, there would have been a risk of harm to some of those patients.

There would, and, to date, we haven't found anything material in that, but that isn't to say that we haven't constantly been looking for that and investigating that. But, yes, theoretically, there is. And that's the very reason we chose, rather than just managing the overdue date cohort, to go down the route of managing the entire list, so that we could ensure that the whole risk was appreciated.

As they move across to that 'known' category, they then fall into the categories of which specialty are the highest risk going forward, in the way Caroline described earlier.

14:20

When the auditor general reported on this a few years ago, he acknowledged that there had been extensive changes, or they were in progress, but he said that the validation processes had taken longer than the health board had expected and data quality issues remained. So, what assurance can you give us now that the next time the auditor general reports he'll be able to give a more optimistic assessment?

I agree, and I recognise that from the report. Ultimately, the assurance will be in the numbers. So, how we progress through those and report them through to our quality and delivery meetings with Welsh Government representatives and through to the Welsh Government—that will tell a tale as to whether we've actually made progress in terms of that.

Secondly, I think we will have seen another step change in the current period we're in, which we've seen, in May 2018 for example, and again a year or so before that. I think, as those major step changes come into place, that will give us greater confidence that we're moving in the direction that we need to.

If I can just come in on that, I think there are probably two areas, for me, where we can demonstrate to the auditor. As Steve said, one is in terms of the numbers. I think the other thing we can demonstrate is, where we have picked up systems issues, we've addressed that functionality. So, we've made changes to the system, so it now works in a way that it should be working for our patient follow-ups, whereas it previously, you know, wasn't, a year ago.

I think the other thing we can demonstrate, which would come through in the numbers, is that we've done an extensive amount of work in terms of clarifying the status of the patients on that waiting list.

We talked a little bit earlier about some of the learning at a national level. The national planned care programme—when did it start? Was it 2014?

I think it was roughly about then, yes—2014 or 2015.

So, it's been in existence for about five years. Do you see it as a permanent part of the institutional structure, or is it there for a specific purpose and, when you've achieved that, it'll be stood down?

I see it as a permanent structure. I think we probably need to review each year, in terms of where we're going with it, depending on the focus. So, as you're probably currently aware, the planned care specialty boards—. There are five of those, in terms of orthopaedics, ophthalmology, ear, nose and throat, dermatology and urology. That's something, I think, as we go forward, we will need to review, about whether it's only those specialties or whether we can pick up the programme and move it into other areas. 

I think, similarly, as well, with the out-patient steering group—I'm a member of that group—and, as a result of the Wales Audit Office report, we have reviewed our focus on that group, and we have much more of a focus now in terms of management of the out-patient follow-ups.

Just focusing on the programme board itself, it's been in existence for five years. Has it been a success, in your view?

We've fully engaged with the board. I think it has provided some areas for focus, which I think have been helpful. I was at a board meeting in recent months where the Wales Audit Office presented this report to it, and it resulted, I know, in the way forward that Caroline has just mentioned.

I think it's also helpful in terms of a sharing forum. All health boards are represented at that, and we frequently receive presentations from other health boards on the measures they are taking to improve their position. So, in terms of learning at a strategic level, I think it is very helpful in that sense as well.

Just sticking with that, can you give a specific example of a successful intervention at one board that has then been adopted throughout Wales?

There have been a number. One of the last ones we've looked at is, actually, in primary care, with planned appointments for two high-volume GP attendances—musculoskeletal problems and lower level mental health problems. We've received some presentations from colleagues who, on a small scale, have undertaken some work to provide those services at the point of primary care rather than coming into secondary care. I think there has been some good learning from that. As a health board, we now have moved into a phase where we're moving those things through our primary care services at scale, and when it is fully deployed we expect to see somewhere around 60,000 GP appointments being provided through that multidisciplinary team approach as opposed to pressures on GPs. Other systems have been shared; the Patients Know Best system has been shared. So, we've shared that personally, and another area that we have shared with the board is the development of our patient-reported outcomes measures, which has also been presented to the board for others. And we equally have learnt from other health boards.

14:25

So, it's a forum, therefore, for sharing good practice, but is it also a forum in which you're held to account by the NHS Wales national leadership? Can you say a little bit how they do that? Do you have bi-monthly assurance reports?

So, every six weeks we have what's called a quality and delivery meeting with Welsh Government representatives, including the delivery unit and the team, and they go through a range of measures with us, crossing planned care, unscheduled care, cancer, stroke, et cetera, and various other parts of that. In those meetings, our engagement with and progress against the planned care board objectives is highlighted. So, it is that meeting that probably would be the most obvious one where there is an accountability discussion around that. But also at the board itself there is a position taken from each health board in terms of their progression against the planned care board objectives since the last meeting.

Could you just say a little bit about how a problem is identified? Do you have a red flag system? Walk me through that. And how are interventions escalated? If there is a problem identified and it worsens, what happens under those circumstances?

So, in terms of general performance, there are discussions in between those meetings, with my team and with Welsh Government representatives. Caroline actually represents me in those discussions, which look at a number of process indicators, which give us an indication as to whether things are moving in the right direction or not. That feeds into the quality and delivery meeting, if there are concerns around that. If there are concerns beyond that, there are sometimes direct discussions with the performance director at Welsh Government, and there is also what's called a joint executive team meeting, between the health board and the Welsh Government executive, which will raise those issues at that joint executive team meeting as well. That's aside from the normal escalation processes for health boards in terms of enhanced monitoring, targeted intervention and special measures, et cetera.

Okay. Could you say a little bit about how the national programme board relates to other initiatives, ideas, structures, which loosely can be bundled together under the title of 'transformation'? Well, I suppose the national transformation programme that was referred to in 'A Healthier Wales', 'Prudent Healthcare', 1000 Lives—do they all interrelate?

There's an absolute link across them all. There is a link across them all, and I guess the way in which that comes together is through our integrated medium-term plan. So, every year, we have to produce a plan, which covers, then, the following three years, which actually sets out as an organisation, 'This is our response to the environment that we're in.' So, it will include issues of transformation. It will include learning from other organisations as to the improvements that we need to make. It will include programmes of work for areas where we are failing against a particular performance measure. So, it comes together within that document for a health board, and that then is submitted to the Welsh Government, and, in essence, the joint executive team meeting—and we meet twice yearly—under normal circumstances, would be the arena at which we take a high-level view, or Welsh Government takes a high-level view, as to whether the organisation is progressing in line with its IMTP. If you get escalated into a different performance level—we've been in targeted intervention, as I'm sure you know—there's a higher frequency of meetings. So, you end up in a meeting with Welsh Government on a monthly basis when you're in targeted intervention and you're setting out your plans for delivery on a month-by-month and year-by-year basis. So, there's a much more intense scrutiny of what we're doing at a health board level through that targeted intervention type approach. 

14:30

Thank you for that. One final question, if I may. We focused a lot here on the data on waiting times, but I just wanted to touch on one other aspect of the patient journey, which is more to do with patient reported experience, I suppose, because you do put an emphasis on things like self-care and also involving the patient through co-production. So, those other more qualitative aspects, I suppose, you might call them, of the patient experience: how are you seeking to measure those so we don't just measure waits, but we also measure more holistically? 

That is twofold. We've been rolling out the patient recorded outcome measures. So, we've got that in orthopaedics around hips and knees, I think, as Steve outlined, and that allows us to, both pre and post surgery, actually, get information in terms of the patient and the outcomes around pain, how they're feeling, et cetera, and there's a series of agreed questions that the patient fills in. I think Patients Know Best also gives us the functionality in being able to have feedback from patients as well. So, I think we've got some of the technology there now to get that. I think, for us, it's about picking that up now and being able to roll it across more specialities and areas. 

In addition to that, a lot of this work goes through our quality and safety community. There's a department within quality and safety and they do spot audits where they give patients the ability to tell us how it feels to be an in-patient, how it feels to be an out-patient. There is the smiley face audit at the end of every ward where people can say, 'I had a good time' or 'I had a bad time', or an intermediate time, and we monitor those things. But then there are specific audits that are done through our quality and safety group around specific issues. So, if through complaints a particular issue emerges, that we were seeing a spike in complaints around a particular speciality or around attitude or around something like that, then we will use the quality and safety department to actually get more scientific around that by sending out surveys encouraging people to comment, and then that would form part of our quality and safety agenda, which would be scrutinised by the board, but is actually a programme of work then to say, 'The patients are telling us this. What are we doing about it?', and then a programme of work to respond to those particular issues.

So, there's quite a wide range of different approaches to this. I think PROMs and PREMs—PREMs are patient reported experience measures—are the more systematic of the areas, in that every patient, when that's rolled out, will have the ability to tell us what it's like, and that will be a structured part of the care that they receive, whereas I think these others are independent audits, in a sense, that aren't—. Yes, individual patients fill them in, but we don't then go back to the individual patient. We use that as a proxy for, 'This is how our patient feels and, therefore, what are we doing within our service area?' 

Just in relation to that and how that relates—as I completely accept it does—to the out-patients and the follow-up: the report the CHC gave us last year, called 'Our lives on hold', which looks at some of the wider issues and issues of people waiting a long time for their appointment, using more painkillers, impact on employment, impact on their family lives, et cetera, all of these provide a really appropriate context for change. 

I just want to go back to the challenges you're facing in managing out-patients. I just wondered how much use you make of the Bevan Commission exemplars in terms of targeting ways in which we can improve services. I'm particularly interested in the orthopaedic surgeon up at Betsi Cadwaladr, who is doing hip replacements as day surgery, and the outcomes are miles better and it also involves a buddying system with a relative. So, is it something that you are able to contemplate doing once you've trained up people appropriately?

14:35

The answer to the more general question—the Bevan exemplars—we're very active in that process. Our clinicians are very active in going forward for the training, coming up with ideas, presenting those ideas and then getting support from the Bevan Commission to implement change on the ground. One of the challenges we have with that is that one particular clinician—and it can be a doctor, nurse, or allied health professional—develops something in their practice, how do we scale that to everywhere? I think that's a real challenge for us. I don't think we do that as well as we should, and we are really focusing, through our transformation programme, on how we achieve scale. So, a good idea, how do you roll it out to everywhere that will get the benefit? And, as I say, I think we are particularly challenged by that.

One of the other things that we're doing—and I haven't seen that example of the orthopaedic surgeon in Betsi—is we do run what we all a 'clinical senate' within Cardiff and Vale, and that's an opportunity for clinicians to come forward and tell us and tell their colleagues—it's a well-attended meeting—they can tell their colleagues the changes that they've made in practice in their particular areas, with a view to encouraging others to take part in those services. And one of the things we have thought about but haven't done yet is about how we encourage people from outside of our health board to take part in those senate-type areas, so that we can bring in good practice, whether it be in Aneurin Bevan, whether it be in Abertawe Bro Morgannwg University Local Health Board, whether it be in Betsi, to actually come and inform us around that. We haven't done that yet, but that's a conversation that's going on about how you learn from good practice elsewhere.

The Bevan Commission actually produces a number of reports as well, and we had the Bevan exemplars produce their report and had a session here to identify all of the individual projects they've got. That report has gone to our transformation team for them to identify particular subject areas that are applicable to us, prioritise them and then we'll use that through our transformation programme to try and roll that out. Whether it was invented in Cardiff and Vale or somewhere else, how do we make sure that our patients benefit from that? So, we're trying to get into those areas, but I don't think it's as implemented or as established as it should be, and we recognise that.

Okay. So, sticking with the challenges you have in trying to get all your clinicians to adopt the innovative practice developed by a particular one, how much does the board look at the outcomes for patients of your different staff?

We do. We do look at outcomes and we look at outcomes through the quality and safety meetings. I may have given the impression that we fail to roll out anything—that's not true. We do roll out some really good initiatives across our specialties and orthopaedics is one of the good examples of that, where there's good agreement around hip prosthesis, there's good agreement around the pathways of care, and they're working as a collegiate group around that. So, we do have some areas of success. The area where I think we're not as good as we should be is where you see something within orthopaedics in the surgical process that could apply within ear, nose and throat, or could apply within colorectal surgery, or could apply in specialties that would typically see themselves as, 'Well, that's orthopaedics, I'm colorectal, what have I got to learn from that?' So I think that's the area that we need to get into. Within a specific specialty, we get more traction on the positive things. 

So, in that regard, obviously cultural change within clinical fields is an issue generically across the UK. So, in that regard, is there more that you feel you could do in terms of propagating and nurturing that transformational change agenda, or is it also additionally a wider responsibility outside the health board in terms of clinicians themselves, bearing in mind this climate of harsh austerity that we all face? I don't expect a very long answer to that.

14:40

I think it is within our remit to do that. I think we've got to find ways of creating the conditions within our organisation so that best practice can flourish wherever the patient will benefit. And therefore I think we're working quite hard on identifying what organisational development techniques or approaches are required to engage clinical staff, board-level staff, managerial staff in those discussions. And I think that is a responsibility for us at a health board level. 

Great. I thank our witnesses, Len Richards, Caroline Bird, Steve Curry for being with us this afternoon. That's been really helpful. Thanks to your succinctness, we're running ahead of schedule as well. We'll send you a transcript of today's proceedings before it's finalised, just so you can check it for accuracy. Thank you for being with us. That's really helpful.

I suggest we take a short break of five minutes or 10 minutes.

Gohiriwyd y cyfarfod rhwng 14:41 a 14:55.

The meeting adjourned between 14:41 and 14:55.

14:55
4. Rheoli apwyntiadau cleifion allanol ar draws Cymru: Sesiwn Dystiolaeth gyda Bwrdd Iechyd Lleol Aneurin Bevan
4. Management of follow-up out-patients across Wales: Evidence Session with Aneurin Bevan Local Health Board

Great. Welcome back to this afternoon's meeting of the Public Accounts Committee, and item 4 is our next evidence session on the management of follow-up out-patients across Wales. Can I welcome Aneurin Bevan Local Health Board to this afternoon's meeting? Thanks for being with us. Before we launch into our questions, would you like to give your name and position for the record?

Good afternoon. I'm Judith Paget. I'm the chief executive of Aneurin Bevan university health board. 

Claire Birchall. I'm the director of operations for Aneurin Bevan. 

I'm Paul Buss. I'm the medical director for Aneurin Bevan health board. 

Great, thank you. As I say, we've got a number of questions for you, and I'll kick off with the first question. Since 2015, the health board has managed to reduce the size of its follow-up patient waiting list by over 10 per cent. How did you achieve this and what ongoing actions do you have in place to help manage demand? 

Okay. Thank you. I think the starting point on achievement is probably related to organisational focus on this as an issue for us. I think quite early on—probably much before 2015, actually—we recognised delayed follow-up out-patients as a significant issue in terms of patient experience, the potential for patient safety to be compromised, and also, clearly, it was a performance issue as well. So, the focus has been predominantly in two directions: one around a good operational approach, making sure that we are focusing on efficiency and productivity and changing the way we do things, and the other, then, on a strategic approach around the modernisation of the way in which we deliver out-patient services, working with our clinical and divisional teams to think how we might do things differently. We can probably give you some examples of the sorts of areas where we're starting to see the product of that at work. But probably organisational focus is the overarching issue that's helped us achieve some of the improvement, although we do truly believe we've still got a long way to go, and so we're not complacent at all. Even with the improvement that we have seen, there's still a lot more we can do.  

Great. And are you taking specific action to ensure follow-up appointments receive sufficient priority, given the pressure to see new patients to meet referral-to-treatment time targets? 

Yes, absolutely, and probably in relation to the 2018 calendar year, actually, we probably haven't made as much progress as we wanted to in terms of the follow-up backlog and demand. We have been focusing on RTT, but we certainly haven't switched our focus away from follow-ups towards new patients; we've maintained a focus on both. But, over the last 12 months in our health board, we've seen 805,000 out-patient attendances; 67 per cent of those were follow-up, 33 per cent new, and that's an increase on the previous year. So, clearly, as we're increasing our activity, then the demand in follow-up patients does increase, and every new out-patient—it's about 60 per cent then translate into needing a follow-up, so it's an ongoing issue for us. But, yes, we've definitely been taking action to focus both on RTT, but also on follow-ups as well, and the one hasn't affected the other. 

Thank you, Chair. I'm interested in the fact that, despite the increase in patients that you've just identified, over the last three years the number of patients waiting twice as long for a follow-up appointment has been reduced by more than a third. How did you go about achieving that? 

So, I'll bring Claire in on this point. 

So, there was a lot of conversation in the last session around validation and, clearly, we are really keen that the waiting list is accurate and that patients who are waiting on that waiting list require to be seen. So, we've done an awful lot around the validation and the accuracy of our information to make sure that we haven't got duplicate patients waiting on waiting times, that patients' clocks have been appropriately closed when they have been seen or discharged. So, there has been a real focus on validation and data quality.

But we've also really rolled out, where we can, any opportunity to transform our services, and a lot of the work we've been doing around our Clinical Futures work has been around how we transform some of our services and get them closer to home; we know it's better for patients to be seen in their local communities—it saves them travel, it saves them accessing our services in secondary care, and it means we can keep our secondary care appointments for those patients that can be only be seen by secondary care consultants.

So, there's a whole host of actions that we've been undertaking around providing care closer to home with primary care colleagues, either through shared care agreements or through providing services actually within primary care, such as community audiology. But we've also tried to transform some of the ways we've been doing services around SOS, see on symptom, services, where patients are assessed as appropriately safe in terms of their clinical condition that they can manage their own health with advice and with support, but with that reassurance that they can get support from our secondary care clinicians. And that might not be a traditional appointment with a consultant; it may be a telephone conversation with a clinical nurse specialist or a pharmacist or a therapist.

So, where we've seen those opportunities, we've tried to upscale and we've trialled them, sometimes very small scale. We've got one pilot at the moment running in Blaenau Gwent around community audiology. That's working really well, so we plan to upscale that into some of our other boroughs as well now. So, that's the kind of approach that we've taken. Where we haven't seen a great impact or where we've had concerns from patients, we've gone back and we've tested, but, where we have seen some impact, we've tried to scale those up and roll them out then to other specialties.

We've got some vehicles within our services where we're able to share that information. So, we have a local health board planned care programme, which is designing our services for the future, where we have representatives from the whole of the health board, across primary and community services and all of our specialties. So, we have that opportunity to share that good practice and to test whether we can then roll that out as well. So, we've got quite a good conversation that we're having, both clinically and managerially, around some of the service improvement that we're doing.

We also have an improvement collaborative within the health board, and that has been driving across eight specialties in improvement cycles and particularly around services like ENT, where we've actually identified clinically led ideas to transform our patient follow-up. We've tested them, we've rolled them out, and then we're able to seek those gains in other services.

15:00

What we're starting to see as a result of the out-patient transformation collaborative work is a slow move away from face-to-face out-patient consultations—although they are still the predominant method of delivery—to more services provided non-face-to-face, so through telemedicine, through telephone contact with patients and through virtual clinic reviews that are undertaken in the hospital without the patient present. And, clearly, one of our out-patient transformation collaborative objectives is to actually really focus on delayed follow-ups and give the patients the best possible experience, and using telemedicine or Skype or other things is actually becoming part of the consideration now in terms of how we're remodelling some of those care pathways. So, I'm hoping that, over time, we'll see that continuing to increase and that's certainly our intention.

How do you find that different cohorts of patients respond to that? For the older generation, do they trust in those more modern methods or is there some resistance there?

I'll bring Paul in.

Well, I think we've seen a cultural shift in our organisation in the last few years. The out-patient collaboratives that we've been describing indicate to us the absolute complexity that there is around out-patients. It's not as simple and straightforward as one might initially think. But, clinically—there's no doubt we've been surprised by some of the stuff that we've been doing, say, for example, in our Valleys-based healthcare work—not just at how adept and able some individuals in the older generation are, but how, actually, they want to be engaging in digital activity with the out-patient team. 

For example, in Parkinson's disease, this was one of our early leaders in relation to patient-related outcome measures in Parkinson's clinics. What we found was that actually engaging actively in their own patient-related outcome measures and then driving then a consultant to think about them rather than the medical model not only made them really feel engaged more with out-patients, but actually, again, when they went home and then they start to use mobile apps to regularly keep in contact with the team, that enabled them to actually maybe miss an out-patient clinic or two and not have to have the parking difficulties or other things if things were stable.

We're finding with a number of other digital mechanisms that we're using, including for inflammatory bowel disease, that the patients are saying, increasingly, 'Look, we love this; it's much better than staying in the Royal Gwent, if I'm actually parking in the Royal Gwent and waiting for hours, when we can actually have a personal conversation, in a way, with our own condition, with a clinical team and then be reassured remotely.' So, I think it's the way forward and it's part of the cultural shift that we're seeing in Aneurin Bevan health board. 

It's interesting to see how it—you might think that the older generation would see it as being removed, but actually it's delivering a much more personalised system of care.

15:05

I think it's an enabler.

It's been welcomed greatly.

It's been wonderful. Older people then came back for multiple follow-ups with multiple specialties. Now, that presents us a challenge in the future to see whether or not we can provide a system where we can see more of those appointments on the same day or at the same time. But, for some patients, the feedback they've given us through their patient experience measures has been, actually, 'It's great because I can actually take more ownership of my condition. I can manage it and I can escalate as and when.' It's given them that confidence that, if they do need to be seen, that they can be seen in a timely way.

One of the most frustrating things I find about the NHS in Wales is that you'll see pockets of really excellent practice, but then there's that barrier with rolling it out across other health board areas. What kind of mechanisms are in place for other health boards to learn from the work that you've done here?

So, I think at a health board level, clearly, it's important that we share what's going on across our health board as well, so it's not just an issue between our health board and other health boards. Clearly, we have pockets of brilliant practice in some specialties, and so our out-patient transformation programme that we've got locally, and the planned care board, is a real opportunity to make sure we're spreading that learning within our organisation as well. It's really important that we do that. But through the planned care programme board, the national board, which I heard mentioned in the earlier session—that's the place, really, to take some of that work, and, clearly, they've got a number of clinically led groups within that, and we've found that's been really helpful to take our ideas in but also to bring ideas back into our own clinical teams as well. Claire, I know you go to that, so I don't know if you want to add to that. 

Yes, and also the out-patients steering group, which is part of that work—. We all had the opportunity to submit areas where we've done some learning, where we've done some transformation, as part of a compendium of good practice. Again, that's really good to actually be able to see what's being submitted and what other people are doing, to actually see their projects and the outcomes and the measures. So, that is very helpful. That group also has specialty leads as well as clinical leads, and the specialty leads have what is called a 'man marker' group, so they actually are checking each other there, giving a bit of peer support and a bit of peer challenge around some of the work that they're doing and, where they're taking pieces of work forward, if they're struggling, if another organisation is improving. So, some of the work we've done recently around our ENT follow-up work—as part of the man marker scheme, we've done some visits to Wrexham to understand what's happening up there, to make sure we're collecting the same data in the same way, that our specialist nurses are able to do what their specialist nurses are able to do. So, that's been really quite helpful.

Thank you. It was pleasure to read your report. Could we just focus on ophthalmology at the moment? Because, although you're obviously a leader in most areas, including ophthalmology, that is the biggest blob in the graph you've provided on page 4 of your report. I just wondered if you could explain to us why there is a significantly larger waiting time—delay in being seen—even though you've done all sorts of good things like the ophthalmology diagnosis and treatment centre, and all patients are followed up by optician practices in the community—I love to read that. Could you just tell us why you've still got, obviously, quite a significant delay in some people being seen?

This is one of the areas where I think we've got more to do. So, as you mentioned, 100 per cent of our cataract patients are now followed up outside hospital by a non medic, and 71 per cent, I think it is, of our glaucoma patients. But, clearly, there's more we can do. We need some more IT kit to link our optometrists to our ophthalmologists. Fortunately, through some investment through the national programme, we'll be getting that later this year. That will allow us to maximise the number of patients who can actually be seen outside hospital and that will really help. We've calculated that we've probably got at least five clinics a week—I'm looking to Claire just so that she can nod—five clinics a week in our hospital that will be able to free up the capacity for either new or more follow-ups, once we get that new kit, IT kit, available to us. So, still more to do—it's one of the areas where we think we can make further progress and that bit of technology that will be with us, probably in September or October time, will allow us to maximie that. I don't know if there's anything else you want to add, Claire, to that.

15:10

The thing with ophthalmology is it's a constantly growing beast, really, in terms of every patient who requires follow-up requires follow-up for life for certain conditions. So, we've got to find new and innovative ways of doing that, and whilst we've started the work with the ophthalmic diagnostic treatment centres, we still need to maximise what we're putting through those areas. Patient feedback is really good in those areas, so it's making sure that whatever we can send into those facilities safely can be seen. The electronic patient record will allow us to support and train and develop our optometrists to do more diagnosis independently and prescribe independently, which, at the moment, they're a little bit limited with, because our clinicians are still seeing some paper records. So, that will certainly make an impact.

One of the areas where we've got the longer length of wait for ophthalmology is around our retina pathway, and, again, we've got some work to do around unpicking and really relooking at the whole pathway to try and bring some of those very long waits down. We have particularly had issues within our clinical body in ophthalmology, in terms of vacancies and being able to—

Clinician vacancies. There a lot of locums covering that. There is a national issue around that. So, whilst we've been able to see and develop and bring forward, maybe we haven't been able to push at the rate of pace that we potentially  would want to in that service. Having said that, they are a very forward-thinking group of clinicians, they want to support other members of the multidisciplinary team to be able to see patients, so that they can really refine what only they can see and what only they can see within secondary care.

Okay. Could you just tell us a little bit more about the new service and the first of its kind in Wales for wet macular degeneration? Are there increasing numbers of people who've got this condition? What is it that's different about the service they get from you that's different from anywhere else in Wales?

I think the difference is that this is another one of the services that we've moved out of the hospital into a local treatment centre. We've worked with a local high street optometrist in Newport and set up a service there for wet age-related macular degeneration, which involves nurse injectors, so not doctor injectors, and, again, that's been really successful. It's in a high-street location and patients have really valued the opportunity to actually go to that as a location, as opposed to a hospital. It's meant it's got a very different clinic environment and waiting times, and the whole patient experience is really positive. But also it means that we're maximising the capacity outside hospitals, so not bringing people back to hospital when it's unnecessary to do so. And, again, that's an area where we think there are probably more wet AMD patients that can be supported through that rather than bringing them to hospital, and, again, that's on our list of potential things to do in the new financial year.

You mentioned that you had a very good bunch of forward-looking clinicians, but you have got some vacancies. I think that some of the problems elsewhere is that professionals are just resistant to change. So, what is it about the air in Aneurin Bevan that makes people more forward-thinking?

I think the relationships between the hospital-based consultant ophthalmologist and the local opticians is very different. I think, as a health board, when we were established many years ago—2009—we took the decision at that time to appoint a local optometric adviser who was one of our local optometrists. And we asked him to help and work alongside our hospital-based teams to think about how we might change the pathways and look differently about how we might deliver services, and he worked really hard to build relationships, and that expanded, not just from him, but to the local opticians, and we were having regular meetings between the hospital-based clinicians and the community-based clinicians. And over time, their relationship developed, trust developed, they started thinking through how they might problem-solve together and redesign pathways together. And out of that came the ophthalmic diagnostic treatment centres, new pathways, taking direct referrals from opticians into hospital for cataracts and other procedures, and I think it was based on a really positive and constructive relationship that put the patient at the centre of what we were trying to do and, actually, galvanised both sets of clinical teams in terms of thinking about how we could do this differently.

That's very good. So, in light of all the positives that you've told us about, how confident are you that you're going to be able to align the population demand for treatment with the capacity of ophthalmology?

15:15

We've just been doing quite a lot of work on this, so I'll bring Claire in at this point.

I think one of the issues that we've got around ophthalmology follow-up demand is around sub-specialisation. So, historically, we've always seen it as ophthalmology follow-up demand, but it's very clear that the services that we're developing are for specific sub-specialisations. We haven't historically—and I don't think any health board necessarily has—counted that in a way that is meaningful. So, we've been planning our follow-up demand and capacity around the whole, rather than the sub-specific area. So, we've started to do that work now, around what capacity we need to carve out for wet AMD, what we need to carve out for cataracts, for glaucoma, and for all of the other pathways, so that we can be really clear about the follow-up demand that we're planning. On top of that, we've obviously got the R1, R2, R3 eye care measures, and we've got to feed that into—

Sorry, I do apologise. So, the eye care measures—the national improvement work that we're doing around eye care measures has been driven by the RNIB in terms of minimising reversible harm and irreversible harm. So, we've got to feed that in now, so the shadow reporting has started. Later in the year, we'll be really delivering on making sure that those patients who are at most risk of irreversible harm are prioritised within the timescale set by the Commission. That is quite a complicated piece of work. We've got to feed that into both our referral-to-treatment time and to our existing follow-up demand capacity, so that is going to be a real challenge for us. It's very complicated. There's a lot of data that needs to support us around that. And we then need to make sure that we're feeding in that capacity as the clinician describes. It will be a challenge for us. This is an area of probably our most concern around risk, but we should have the vehicle, then, to make sure that we are identifying at the earliest opportunity those patients that really do need to be reviewed. Our early reporting shows that, actually, the patients that we are seeing in clinics are the R1 patients, who are the ones who are the most at risk. So, it's telling us that the systems we've already got in place are setting us up for those patients that are most in need, but we're around 62 per cent and we need to be around 95 per cent. So, that work is really going to take pace and scale over the next couple of months.

Thank you. And you've led into my question around areas of risk that you have identified and are most concerned about. Obviously, there have been improvements around gastroenterology and urology. So, outside of what you've just described and the comprehensive piece of work that you are going to be taking forward, is there anything further that you have identified as an area of greater risk for you in terms of risk of harm to the individual patients? 

So, there are probably three areas, and I'll probably bring Paul in as well on this. There are probably three areas that we focused on in relation to risk: ophthalmology is one; cardiology is another; and rheumatology is probably the other in terms of where delays could result in harm to patients. So, I'll bring Paul in to start with, and then maybe Claire might want to comment as well.

Overall, as medical director, I'd say that given the 0.5 million follow-ups that we have every year, the numbers of patients that we know through our system may have come to harm is remarkably low. But on the other hand, that's what we know in terms of the numbers that have come through our current governance structures, Datix and reporting systems—patient complaints, serious incidents et cetera. In relation to the particular areas, what I'd say is that the previous question alluded to the systems in ophthalmology being a driver for our systems and the way we have developed our whole system in relation to risk. So, those are the three main areas where we would think that there was clinical risk—not that we have got any substantial numbers at all that suggest that there are any risks, but those—

So, how do you then instruct me and this committee in terms of how you got those—? What are the systems and processes you've alluded to?

Right. Well, if I may, because it's multilayered, and to describe it requires a sense of the whole system.

Could you give me an overview in terms of why you seem to have that overview and others may not have that overview?

We have processes of clinical active management of our lists, so our clinical directors and our divisional directors know a beat that's determined by the condition and review the lists with managers. So, by 'beat' I mean that there are certain things that we know in the organisation are a high-profile risk for us—ophthalmology, orthopaedics. So, these areas have a weekly beat or, in orthopaedics, a twice-a-week beat where clinical directors—

15:20

Well, they meet, twice a week—

We sit down and we do the list.

The regularity of the list vigilance in essence is twice a week or once a week in ophthalmology.

So, there's a vigilance in terms of analysis and regularly knowing your info.

Looking at the long waiters and identifying, 'Is there a clinical risk to move a patient more quickly into active management?' In other areas, that wouldn't be so necessary. So, in care of the elderly, for example, it's a monthly beat that they look at the list. Through those meetings, also, we learn. So, there is serious learning that takes place in that monthly meeting, which has identified the fall in a year of 1,000 long waits to 150 currently and, of that 150, nearly half are related to muscle issues. So, we've been able to adjust our service in relation to the intelligence that we've got from those monthly meetings. Across the organisation, we have a series of specialty arrangements. In cardiology, for example, it is a bimonthly meeting that takes place between the CD and managers in relation to the list, but we have devised over the years an e-mail system with primary care on a daily basis, which gets feedback and intelligence from primary care about high-risk patients. So, for example, those patients particularly with valvular disease—there are frequent daily discussions between the cardiologists and the GPs about patients on their list.

So, would you say that there is anything particularly avant-garde, particularly innovative, particularly uncopyable by others in that process, which seems extremely important to your knowledge and understanding of who is on your list and their levels of risk?

No, I think that is basic clinical vigilance in essence in terms of good relationships between managers and clinicians, trust between them and a willingness to let you talk about the fundamental issues that mean that, in this particular area—say, orthopaedics—we need to make capacity for this patient because we're particularly concerned for x and y reasons. And that's why the numbers, I think, are low.

And with regard to your systems and processes that you are currently operating within, do you feel that they themselves can be improved, or do you feel satisfied that you are moving in the right direction in this regard? And, obviously, your data is apparent to us.

I've no doubt—. On a weekly basis, the executive team meet to hear all the complaints and issues around out-patients. There is a weekly beat to the executive team. QPSC, that's our quality board, meets every three months and gets reports in relation to complaints et cetera. The directorates have their beat. And, in terms of the learning from Datix reports and SIs et cetera, that's fed right back up to the board, then, as necessary, creating the loop of learning.

Okay. And with regard to your internal and clinical audits, your results would correlate in terms of the information that you just passed on to us. You feel that your patients—and, in some of your area, my patients as well—would be able to correlate some of that patient experience.

Very much. Can I just say also that in our roles as the responsible officers for the health board—I'm responsible for revalidating all the doctors in the health board, and every single doctor has to be able to then also validate what they do in their clinical practice. Very often, they internally individually do audits in relation to out-patients. There's a lot of individual learning also that takes place. I think that, overall, we have a system both individually and team-based, where it's focused on learning and putting safety first. And ophthalmology was the original driver for this. So, in ophthalmology, five or six years ago, we actually had to start getting clinicians and managers really starting to learn, the system learning, and that is both individual and team-based.

Thank you. Finally, with regard to what the health board has done to strengthen the quality and patient safety committee's understanding of the risks and required improvements, what is your view on that?

Well, if I could say the quality and patient safety committee gets the reports of all the lists and complaints et cetera that include out-patients on a regular basis and, in fact, every time it meets, but the committee itself in this area is always focused on improvement. So, in essence, in the last year, we've talked about inflammatory bowel disease, for example, where we've got innovative mobile phone apps so that a clinician ascertains the state of illness using a mobile phone scoring system with a patient from their home, validates the score, clinically, as a clinician, and then feeds back to the patient really that all is well and that they don't need to attend. Now, in that scenario, we don't need the extra consultant that we thought we needed, and we've got emergency slots that have appeared because patients are not having to turn up for routine follow-ups. So, that's the essence of the kinds of things that teledermatology has presented, with Parkinson's disease—

15:25

We tend to focus on the positive and improvement, because there is a plethora of data saying that the numbers are going to increase, coming through the doors, of out-patients unless we transform.

Okay, and finally from me, there is obviously the issue about those who won't engage with an app and can't engage currently, and obviously, we're not going to go into that now, but it is of significance as well. But, in regard to the take-up of innovative technologies or everyday technologies now, from your perspective, do you actually feel that your engagement with your clinicians as well as your forward planning with the national programme board you talked about—? I'm very interested to know how that programme board that you are interacting with is actually rolling out some of the good practice that Aneurin Bevan is participating in across Wales, because it's all very well feeding into that. Is that mechanism enough to actually feed out to the wider health community across Wales, or is there something else that I personally don't know about or—[Inaudible.]?

In terms of the planned care programme board, I think that's the key mechanism, but clearly, there are other opportunities to share good practice between organisations, and Welsh Government do facilitate conversations at chief exec level and with the different peer groups of directors as well. I think in terms of, 'Is the planned care programme picking up good ideas and promulgating them?' my personal view on that would be, 'yes', and we've got examples in our health board of where we've developed—or I should say our clinical teams have developed and designed something, and a particularly good example would be in ENT for us, that's then become part of the national programme. And there are things that we've taken on that have been designed and developed in other health boards, that the planned care programme has developed that we've taken on as well. So, I think my answer would be, 'Yes, it does have a value', but whether it's—

—doing sufficiently at a pace, people will have different views around that. I think sometimes I get a sense of frustration from some colleagues around the pace of change that's happening, but within our health board, we have got our own replicated planned care programme; we understand the requirements from the planned care programme board; we've red-amber-green rated them; we've got a process that chases them down; some of them we can move very quickly on and some of them require new IT in order to move forward, but we've certainly got a beat and a process within our health board to drive that through.

Thank you very much indeed. Thank you, Judith. I heard you in the beginning, your statement, you said that you'd take a strategic approach to data and quality issues and all the rest of it. You're setting a benchmark of good practice, I understand, and I think it's been acknowledged by the auditor general in his 2017 report, and hats off to you. I think this should be rolled out to all of NHS Wales, rather than Nye Bevan. So, in certain areas, you have achieved good practice, like orthopaedic pathways, ENT, GP advice lines and teledermatology, and in other areas, you demonstrate good practice; it's recognised now, and I accept that. In which specialties are you prioritising future service change to out-patient services to make them more efficient or address all delays? 

We've got a list, as you might expect. I'll bring Claire in, because she's been overseeing our plans for 2019-20 both in terms of the modernisation of out-patients, but also in terms of more we can do to reduce delayed follow-ups. We've got some further opportunities to work differently across our system to do that. So, I'll bring Claire in to start that, and I'm sure Paul might want to comment as well.

15:30

So, our focus for the next year will be around the focus areas for the national work, because we know that those areas have been focused on for a reason, and for us, there are significant numbers in there, although there are also significant risks in there. So, for example, within dermatology the numbers are significant. The risks may not be as significant as for ophthalmology, but we know we've got particular workforce issues across the UK around recruiting dermatologists, so we have to do something different to be able to cope with follow-up demand in dermatology.

There are other areas where maybe the numbers aren't huge, but maybe there are other pressures. So, in new out-patients, for example, within diabetes and endocrinology, we know that there is much more to do for patients, particularly with type 1 diabetes, but also type 2 diabetes, closer to home, and helping patients to self-manage, but also helping them to have follow-ups in different ways. So, for example, some of our young diabetics accessing care through Skype clinics, those sorts of things.

There are a number of areas that are pressing the triggers, really, in terms of the actions that we want to see. One of the big areas that we want to get in with in the planned care programme board is around urology, so we have really good clinical buy-in around how we follow up patients who've got a raised prostate-specific antigen—potential prostate issues—and one of the areas that we haven't been able to deliver on this year has been around helping patients to self-manage, and that is linked to an electronic system. One of the Bevan exemplars around Patients Know Best down in Swansea, and it's also a system that is used in Cardiff, has indicated that, actually, it might be something that we could take off the shelf and use for those sorts of patients. Those are significant numbers—probably about 1,700 patients a year. So, that's really good for those patients in terms of their co-production of their appointments and their being able to manage their condition locally. But it also releases that capacity back into the system to be able to follow up some of the more complicated cancers or some of the more complicated benign work within urology. So, that is an area that we particularly will be focusing on.

How and why did you prioritise these specialities, and where are the gaps?

So, some of it is around opportunity and innovation. So, through our collaborative work that we do with our improvement scientists, we get clinicians coming forward with really good ideas. They have a good multidisciplinary team who are innovative and enthused and want to do things differently, so sometimes, it's around harnessing that expertise and enthusiasm from the team, but some of it is around managing clinical risk. Some of it is about learning from incidents and concerns, so, as Paul mentioned, we've got very low-level incidents and low-level concerns associated with delays for patients who've passed their follow-up targets. But nevertheless, there is learning in every one of those cases.

So, as Paul mentioned, the ophthalmology improvement work that we've done came from a number of incidents a couple of years ago where patients had delayed follow-ups and had impacts on their condition because of that. So the learning has come from those areas, or where people have had poor experiences through their pathways, they've been lost to follow-up. So, tightening up those and making sure that our processes around that mean that patients don't get lost. So, sometimes, it's driven by learning. Sometimes it's driven by volume, so if we've got particular pressures in a new aspect of the service—so, we've seen an increase in new demand for our orthopaedic services this year, so we need to make sure that we're balancing both new and follow-up demand, and that drives us into managing follow-up and new in a different way, and in an innovative way. Hence some of the work that we've done around virtual follow-ups in both new and in fracture clinics; 22 per cent of our fracture clinics are seeing virtually now. Again, that was driven by demand, so it was necessity, really, as well as the clinical condition of the patient.

One particularly exciting proposal actually has been prompted by Macmillan. So, they've approached us to say: would we want to work with them to try and limit the number of out-patient follow-ups that cancer patients have post cancer treatment? So we've worked with them and they’ve worked with us as well to appoint a nurse so that appropriate cancer patients will have their first follow-up by a consultant in the out-patient department. But then the six-month, 12-month and 18-month follow-ups will be undertaken over the telephone with the Macmillan nurse, and then the patient's obviously going into clinic if they need to, but avoiding unnecessary trips to hospital. So, that's really exciting. So, when Claire says some of the ideas are prompted by different people, both within the organisation and learning from others, it's also sometimes promoted by external organisations coming to us with a really good idea as well.

And what lesson is it you have learned from modernising the organisation in the last couple of years?

15:35

Oh, what lessons. I think it was something, actually, that the Wales Audit Office picked up when they came to do the 2014-15 review: we had already launched into an out-patient transformation programme, and we thought we were doing it quite well, but actually, in hindsight, we hadn't really prepared the organisation or the people to think about transformation, to think about putting aside the traditional ways of doing things and think about in what new ways we could do things. And one of the recommendations from the Wales Audit Office was to think differently about skilling people up, both in capability and capacity around transformation and improvement. So, the one thing I learned and we're still learning, probably, is to make sure that you work with and alongside people and prepare the ground, because some of this does challenge people's very long-standing traditions of how things should be done. 

Yes. If I may, I think there's been a long-standing need for the old medical model to take on board some new ways of thinking, in that, if you came to Aneurin Bevan, you'd hear the words 'quality', 'safety', 'value' and 'innovation' linked to performance, and you link to financial and clinical performance. I think that's really very important indeed. So, we see a lot of conversations and cross-fertilisation—ideas that come out of, say, one of the quality improvement collaboratives then touch upon the sort of the work we're doing in the value-based arena and that touches upon things that we are thinking about clinical safety. But it all means that, actually, there's a different kind of view about, really, what good performance and optimised performance look like, and optimised performance is about really getting that balance between the financial imperative and then the clinical need to make sure that you get the numbers through. 

Thank you. Judith, you just earlier said you meet these other organisations to improve your efficiency—great. So, are you involved or in touch with senior people—commissioners—to look after their medical needs in the NHS in the Nye Bevan area?

Other commissioners?

Oh, the older persons' commissioner. Yes, certainly, we have a long-standing relationship with the older persons' commissioner, particularly around the focused work we're doing around access to treatment, particularly access to primary care, actually—that's been the focus of that conversation in more recent months—but also the care of people in care homes as well and actually trying to make sure that we provide the best possible range and opportunity for older people as well. So, yes, but also the children's commissioner as well. We're doing some detailed redesign work of our child and adolescent mental health services, which is being supported through the national transformation fund and, again, we're working alongside the children's commissioner as well to take on board views about how those services can be better managed, and that includes the way in which we deal with people who need follow-up attendances as well. 

Thank you. The Royal College of Physicians published a report three or four months ago that identified various examples of good out-patient practice. Having read your report, were you mentioned in dispatches by them, because you—?

I can't remember. Paul will know. 

No, I don't think we were. I know 1000 Lives is in it. Our Aneurin Bevan continuous improvement lead now is leading Public Health Wales on 1000 Lives as an interim lead there. Our assistant medical director for value-based healthcare is also taking a lead for NHS Wales in that field. So, I think there's a lot of innovation that's taking place in Aneurin Bevan and it's just starting to see the performance that's coming through, but there's a lot more to go for. 

Some of it's so simple and so easy to implement, like, for example, using a medical photographer to photograph the affected skin area so the patient doesn't have to schlep all the way to the hospital. 

The imaging these days is so good that that will be just as good as what they see with the naked eye and, if in doubt, pull them in. 

And that's exactly what we do. We have a teledermatology service, we also have a telelid service, which looks at growths and other things on eyelids as well, but in the teledermatology service we use exactly that model. We have a medical illustrator who does clinics in various locations around our health board area, the patient goes there, has a high-quality image undertaken. That is sent digitally to the consultant dermatologist, who views the image and determines whether or not the patient needs to be seen for minor surgical procedure, or can be discharged. And about 19 per cent of our dermatology patients are seen through that, so that's 5,500 patients a year just in dermatology. I haven't got the number in ophthalmology, but we've used that for about two and a half years in our dermatology service. It's very successful and a very good way of making sure our consultant time is very productive. It's very good for patients because they don't need to travel so far, but it actually makes really good use of a consultant session as well. They see a high number of images in that session, many more than they would have seen of patients in an out-patient clinic. 

15:40

Presumably, the big risk area for something like that is undiagnosed skin cancer. 

Yes, and we haven't had any issues. So, we're looking at the evaluation of that, both from a patient experience point of view and an outcomes point of view. It hasn't raised any alerts or any harm at all. 

Probably about two and a half years. I can check exactly for you, but it's well established, yes.  

Okay. So, why aren't we all doing it? It's ridiculous. Could you just tell us a little bit more about the Patients Know Best self-management of urology—you know, prostate problems?

It hasn't started yet, but it's on our list to do in 2019-20. 

So, we have a platform that we use which is called DrDoctor that allows us to communicate with patients on the waiting list, allows us to have patient related experience measures and patient related outcome measures. We were hoping we would be able to use that system to allow patients with a raised PSA to self-manage their condition and seek advice from primary care or secondary care when they felt they needed support. That system isn't as patient facing as we would like it to be for that particular scheme, so that's why we've decided to look at Patients Know Best. And we're just in the process of making sure that that can link up with our specific information systems, and then we will procure that, based on some of the feedback that we've had from other health boards in Wales that it works really well.   

Okay. You're piloting the DrDoctor for heart failure, psoriasis and ankylosing spondylitis. At what point do you think the pilot will enable you to decide whether or not to roll that out across the patch?

In those fields, we're actually at the point of evaluating the data we have. With heart failure we've been particularly proactive in terms of collecting a large amount of outcome data, because that has been the prime issue at the moment—understanding the patient related outcome measures, whether they can be collected effectively and reliably and, actually, what does that mean for our shape of service. So, at this moment, we are evaluating those three pilots in our value-based healthcare team. By the middle of this year, we'll be in a position to understand what we do. With the heart failure initiatives, this may well be part of the national programme for value-based healthcare. So, I think we're taking a leading role in that, and that's likely to scale up and then become something that becomes a fundamental part of our approach to heart failure.

With ankylosing spondylitis and psoriasis, we've got a fairly small amount of data at the moment, so we need to collect more data to know exactly how that will pan out, and whether that can be reliably undertaken, because one of the issues about digital methods—and I really think this has been a learning point for us as we've started to become more mature in relation to using digital methods—is that patient selection is vital to getting the right kind of data that enables you then to decide whether this is a patient that could be redirected somewhere, and whether some patients could have a different approach. So, the reliability of collecting the data and ensuring data hygiene and how it would influence your shape of service going forward is important.  

So, yes, for heart failure, not so clear about the psoriasis and ankylosing spondylitis data at the moment. 

Okay, that's really good. Going back to the more basic issue around ear, nose and throat patients being able to self-refer and then being triaged by a nurse, it's a no-brainer: why isn't everybody doing it? 

I think that's part of the planned care programme roll-out. So, that was one of the schemes that our ENT surgeons and nursing teams had developed, and it was seen as excellent practice, and then it got taken into the national planned care programme. So, I think it's something that's being promulgated across Wales.

15:45