National Assembly for Wales

Good afternoon, everyone, and welcome to this afternoon's meeting of the Public Accounts Committee. I also welcome our witnesses. Thanks for being with us. As usual, headsets are available for translation or amplification. In the event of a fire, follow the ushers. We have received one apology, from Adam Price, today. Do Members have any declarations of interest they'd like to declare? No. 

Item 2, then, and we are following up with our primary care out-of-hours service, and we have an evidence session today with Hywel Dda university health board. Would you like to give your name and position for the Record of Proceedings?

Good afternoon. I'm Joe Teape, I'm the deputy chief executive and director of operations for Hywel Dda university health board. 

I'm Dr Richard Archer. I'm a full-time salaried GP and also the clinical lead for the Hywel Dda out-of-hours service. 

Great. Thanks for being with us today and taking part in our latest inquiry. I'll kick off with the first question. By way of introduction, can you outline what the health board has been doing to implement the auditor general's local and national recommendations?

Certainly, Chair. Perhaps if I could start, it would be fair to say that we've had probably quite a turbulent time with our out-of-hours service over the last three years. We had the demise of the Primecare contract in Carmarthenshire in 2017, and had a period where we had to pick up that work through our care on call process. We then migrated Carmarthenshire to 111, and then spent the next year working to get Pembrokeshire and Ceredigion migrated, and achieved that in October 2018. 

There are probably three areas of the Wales Audit Office report that were relevant to us in terms of key themes. One was around governance arrangements, one was around financial and clinical sustainability, and one was around performance and patient experience. I know you'll cover the detail of some of those during this afternoon's session, so I'll just perhaps give a few headlines now, and then that will give the committee the opportunity to explore some of that further. 

In terms of governance, we've done a few things to try and increase the profile of the service within the health board. Firstly, we've got Richard as clinical lead, and we've extended Richard's hours to six clinical management sessions to enable there to be the right level of clinical leadership within the service. We've also embedded the out-of-hours service and merged the out-of-hours service into my core operational team, so rather than sit outside within the Pembrokeshire county management arrangements, which is where they were previously, they're now very much a key part of the central ops team and part of our operational delivery arm of the health board. That means that, for performance management, for example, the team come and meet with the chief executive and the executive directors quarterly to make sure that we go through the whole range of workforce indicators, access, quality, safety, experience, et cetera. So it gives an opportunity and a platform for the service to meet with the executive team quarterly.

Then, under the governance heading, in terms of interface with the rest of the organisation, Richard is a key member of our unscheduled care board, which I chair. So out-of-hours is now a key feature of our unscheduled care action plans, and Richard also supports areas—we've done some work in paediatrics, for example, and out-of-hours has been a key stakeholder within that. So, I think there's more to do still, but we feel like, in governance terms, we've improved the profile of the out-of-hours team.

In terms of financial and clinical sustainability, one of the key elements that we've changed over the last few years is we were an outlier in terms of GP pay rates, and we changed those a few years back, and we're now perhaps more in the middle of the pack in terms of pay rates for self-employed GPs who do sessions within the service. We changed our pay rates. We've also developed some of our workforce models. We've got now advanced paramedic practitioners rotating through and working within the service, supervised by Dr Archer and his colleagues, and we've got advanced nurse practitioners working within the service. Again, lots of work to do still in terms of our workforce development, but some improvements since the Wales Audit Office report. 

The big change, which I mentioned at the outset, was the standardisation of all of our processes through 111 implementation. Historically, within Hywel Dda, we'd run three almost separate models within the different parts of the system and, through the implementation of 111, we now do have regularly—largely through goodwill—lots of GPs who now support each other across the three counties and, when we're down on shifts, GPs will cover and cross-cover.

And probably the third bit under financial and clinical sustainability is our engagement with the GP community in that I think that was very much isolated, with not really much interface with senior management, and Richard and I now have regular meetings with all of the GPs across the three counties and we've also established the GP—

Is that a recent innovation, because a lot of the stuff you've said sounds very encouraging, but clearly some of these issues have been going on for a very long time, and previous attempts to deal with them haven't worked, so is that an example of something that's being done differently this time that, hopefully, will get to grips with it?

Yes—probably over the last couple of years, we've had the GP meetings. In a way, if I'm honest, some of them due to the unhappiness of some of the GPs around Carmarthenshire in terms of the 111 roll-out, but we've really built on that. We've had some very, very difficult and challenging meetings with the GP community, who were certainly forthright in coming forward with their views, but that's enabled us to respond to issues where we can. We've made some significant improvements to some of the 111 early lessons as a result of that GP feedback, and we've also got a separate clinical advisory forum, that a number of GPs volunteered to come forward to to help us in terms of determining and devising the long-term models for out-of-hours within Hywel Dda. So, we're certainly grateful to a number of GPs for their contributions to that. They turn up in the evenings, after busy days, often, or often going off to work nights, but come in and help us with some of those.

And then probably the last thing in terms of the progress in terms of the Wales Audit Office recommendations is in some of the performance and patient experience elements, in that 111 enabled us to—. One of the big recommendations was around triage and the fact that, within Hywel Dda, we were seeing a lot more face-to-face and treatment centre visits, and through the implementation of 111 and more effective GP triage systems being in place, we've seen the swing of that change to more normal levels, as per other health boards, with a larger number of patients triaged—

You've spurred some interest among the committee on that. Rhianon Passmore, do you have a supplementary?

Very briefly. In regard to extrapolation of the issues that you had with GP out-of-hours, what were the main concerns? You mentioned Carmarthen and the 111 roll-out, and very briefly, in terms of being in the middle of the pack in terms of payments for out-of-hours, obviously, this is all tempered by the financial envelope, but is that the correct position to be in, in your circumstance?

It wasn't, I think, and that's why for the pay rates, we—. In the first meeting that I had with the GP community, there was a lot of unhappiness around, perhaps, GPs not having had a pay rise for a long period of time, and we were able to address that quite quickly through bringing the pay rates for the GPs who do those ad-hoc sessions up to a level that was more appropriate. 

In terms of the 111 issues, the key issue in Carmarthenshire was that the GPs there had been used to doing very little amounts of triage, because that was dealt with through the Primecare contractual arrangements we had, and most of their work was home visits and centre visits. Now, that was a model that was in place regularly within Pembrokeshire and Ceredigion already, but because this was a big change for the GPs on the advent of 111—.  And, if I'm honest to the committee, that was something that we didn't really anticipate, that swing in the work and the fact that it would change the dynamic of the work so much for those GPs, and because they very much in Carmarthenshire had enjoyed the shifts with face-to-face patient contacts, the fact that it moved to, probably, 50 per cent of the work being telephone triage work didn't suit all of the GPs, and there were some very unhappy colleagues as part of that, which, over time, we've tried to mitigate by improving the way that calls are directed to them. We've settled down now and the the model in Carmarthenshire has settled down, but it was certainly a turbulent time for them and also, therefore, very stressful for us. 

I'm sure we'll drill down into that a little bit later on. Thank you. 

Great. Thanks. I'll bring in Vikki Howells. 

Thank you, Chair. One of the most important ways to alleviate pressure on the NHS system is to ensure that patients are bring signposted to the correct model of care. So, with that in mind, what is your health board doing to help the public understand the most appropriate circumstances in which to access out-of-hours services?

Perhaps if I give some headlines, and then Richard might want to give some live examples where it doesn't always work. The first thing is, with the advent of 111, for us, that was a good step forward in terms of public messaging, because now there's one number for members of the public to call where they can be signposted to a range of services. As part of the migration to 111, we worked on our directory of services to make sure that available alternatives were clearer. We also have standard messaging now within all of our primary care facilities, so if somebody rings out of hours to a GP practice, there'll be a standard set of messages. We work really hard on weekend and some of the Choose Well campaigns through our winter planning. We've worked hard to signpost pharmacy and other services that are available. I guess when our bases are down, we do proactive communications regularly at the start of each weekend if we're going to have a base closure, to make sure the public is signposted to appropriate services. 

I would say there's more to do with all of that. Richard, in his briefing for this committee to me, said that there's probably more to do at the source, because often once somebody's ringing, you've already missed the opportunity to get them to access the right services in the right place, rather than by the time they've rung the number, sometimes that can be too late down the pathway. And there will be still live examples, I guess, where patients still don't get signposted to the right place. I don't know, Richard, if you wanted to give some views.  

We often talk about that, particularly with regard to walking into the accident and emergency department, and the Choose Well sign is there, when the Choose Well sign should have been way before that point. And certainly, ideally, we'd love to be able to set up Choose Well sites within supermarkets, schools, crèches, council buildings, health board premises, GP surgeries, places of worship, swimming pools—anywhere where there is an opportunity for health promotion to explain what sort of germs that may be going around, emphasising the need for flu vaccinations and getting kiddies to be fully vaccinated as much as possible. Also, making full use of, particularly, our community pharmacy colleagues. I had a meeting with our local Boots representative pharmacist in Haverfordwest 10 days ago, and she explained to me the full range of services they provide, including vaccinations, emergency contraception—they do the minor ailments scheme. And I think there is great potential to be able to make use of these professional colleagues, and I have great experience of working with pharmacy colleagues in the clinical support hub, where I've supported them and I've done shifts. Unfortunately, we've been so busy that I've not been able to do clinical support hub shifts since a year ago November, but I am mentoring a pharmacist who's doing his face-to-face training collaboratively with two colleagues in Carmarthen. That colleague was passed down to us through the senior pharmacist in the clinical support hub. So, we are trying to get as much of that co-operation and cross-border working to get colleagues up to a grade as quickly as possible.

But the ones who don't want to do that, we can still make use of them in the community pharmacies, and I think this message getting out earlier—and we have IT-literate people who are social media stars—we can do that through the social media aspect of our comms department, on Facebook, and there is a progressive campaign each time we have an issue, our comms team are very, very responsive. We generally have a frantic hour or two as the e-mails go flying backwards and forwards, and then we get a message out. So, we are very, very proactive about that. We hate to miss a trick when it comes to those rapid IT messages.     

Going back to the very basic but crucial points you made there about advertising Choose Well with posters in different areas publicly, are there any barriers to actually doing that—to putting posters in libraries or supermarkets? 

I don't think there are any barriers, apart from just finding the time to be able to manage and be proactive in doing this. And certainly, as far as I'm concerned, when we were going through 111, we got a close relationship with the comms team but, unfortunately, after 111, we've gone straight into the winter. We've been trying to facilitate our APP pilot, where we're trying to be innovative there. Sadly, I had my appraisal—. Last year, I had my revalidation, my appraisal of the peer review visit. Lots of things were happening as well as the roll-out of 111 and the pilot, so things really snowballed. But I'm hoping now that we've successfully got through here, the next big thing for me is going to be a six-month review of the advanced paramedic pilot with Andy Swinburn, the national head of paramedicine. And I would hope that until then in April, we're going to start to find a bit more time, and we'll start working with the comms team, same as we do with the community health council. We had a meeting with our local representative for Hywel Dda two weeks ago, and we facilitated her urgent need for a survey into out-of-hours, and we managed to get it done in a weekend, because we just wanted to be as proactive as possible.   

Thank you. 

One of the things that we did, just to add some detail perhaps as part of the 111 communication exercise, we did reach 92,000 social media posts, with post-launch messaging, we know, reaching in excess of 66,000 people, and we sent promotional material out to 690 practices, dental surgeries, et cetera. So, there was a big effort as part of the 111 roll-out to make sure that the communication with the public was very good.

Thank you. And have you got any figures on how much demand your out-of-hours service actually experiences from patients who would have been better served by accessing a different service? I'm thinking of dentistry as one example there.

It's probably quite anecdotal in terms of—. The service will get 6,000 to 8,000 calls a month. I think one of the things we'll come on to, perhaps, is the information we get out of the systems that we've run. We've run on different systems, and so the consolidation of systems and a new IT system across Wales would be very welcome from our perspective in that, again, I think some of the information we've had has been quite anecdotal. We've often had, for example, suggestions of inappropriate referrals into the ED or the minor injuries services, and when we've tracked those back, often the referral from out-of-hours has been a very good one.

Interestingly, with regard to dental, there are some contentious things to do with 111, and perhaps you may want to come back to that later. But, for instance, in the case of dental issues, we have a massive concern, and when we were rolling out 111, one of the things that I disagreed on quite noticeably with my colleagues in 111 was that the idea of the prudent healthcare process is a fabulous idea, but I don't think it works for rural Wales. Now, the reason why I don't think it works for rural Wales is that if you empower GPs to say, 'The right person to do the right job'—and in my case, I was particularly concerned about dental and about mental health sections—if you facilitated a GP to say, 'That's not my job. There should be a psychiatrist available, there should be a dentist available', I wholeheartedly agree. But, by definition, I cannot allow any of my patients in Hywel Dda, and particularly in Ceredigion, where there is a noticeable lack of dental provision, and also across the whole board—trying to get a psychiatrist to do a section assessment can be very difficult—. As far as I'm concerned, if you have a GP who's being paid a lot of money, and they are quiet enough to go and help that patient, they should be seeing those dental patients, they should be seeing those sectioned patients, and they should be looking after them. Irrespective of the great principles of prudent healthcare, the patient must come first, and I cannot bear the idea—. For instance, with catheterisation, we often have frail elderly people who need to be catheterised. You can't have a GP saying, 'That's not my job; that's a district nurse's job'. If the acute response team nurse overnight is running around like mad and she can't get to do a catheter and the doctor's not doing anything, the doctor should go. We pay our doctors a lot of money, and I have no problems when I do five or six catheters a night because I know I'm doing somebody a favour and I'm looking after them. That's why it should be done. So, that is something where we have had our disagreements with 111.

That's very useful. Thank you very much. You'll be aware, of course, that the auditor general's national report recommends the development of a nationally agreed definition of the scope of out-of-hours services, and your written evidence clearly supports the need for such a definition. And you've referred to some of the work that you've been doing there around standardised messages on GP answer phones, for example. So, how do you think that such a definition would actually help to improve the out-of-hours service?

Well, I think clarifying the definition of what the out-of-hours service should provide can only help with regard to the provision of services. It can help with the idea of prudent healthcare and who should be doing what, as long as it is flexible enough to take account that there sometimes will be exceptions to the rule. It would also allow the health board to focus on where their resources need to be.

The difficulty, I suppose, I have, personally for me, is that I have a different vision of how the future should be, and perhaps my desire for how out-of-hours should be progressing in the future, and perhaps having a bigger, more encompassing out-of-hours that provides more services. But I think, in the short term, across the whole of Wales, there should be a restriction of this, particularly until we get the whole of 111 rolled out, to get conformity across the country, and at least that way we can make sure that the resources are available to a reasonable level across the board and ensure that everybody receives a fair level of care.

Thank you. Moving on to call handling, the auditor general's local report highlighted within your health board some comparatively poor performance regarding call taking, call terminations, and home visits for very urgent cases. So, since that report was published in July of last year, have these aspects of your service's performance improved? What is your overall performance now against the national standards?

Perhaps I can start. One thing we didn't put into our evidence submission, I don't think, was performance data. One of the issues for us has been running different systems and therefore not having always a consistent view of that. Firstly, for treatment centre visits, we looked at the last four months' data. We now have better data because we are now with 111 completely. So, the 111 system now will deal with the telephone call aspects of our service.

For home visits, for the P2 visits, our range in the last four months has been between 70 per cent and 80 per cent for achievement of the standard, which is obviously some way below the standard. For the P6 category, we are above 95 per cent, but still not achieving the standard. For treatment centres, for the P2 category, we're just above 91 per cent to 95 per cent for the last four months. And for P6, we're around 95 per cent to 96 per cent.

One of the things that we would perhaps discuss as part of that would be that some of the standards would work very much maybe in an urban system. For us, in the rural areas—within Hywel Dda, we've got five centres running across the geographical area of Ceredigion, Pembrokeshire and Carmarthenshire, and sometimes some of those bases are also closed—some of the standards in terms of access are very challenging.

Also we would say—and this is something that Richard, in real time, would do every day—we would place clinical urgency above maybe meeting the target, if it came to it. So, as to the GPs that we have, we have some very experienced GPs working in the service that will always, in real time, assess clinical risk of the patients who are polling on the screens and deal with them in the order of urgency wherever possible, which would probably trump the targets. That said, I think Richard will have some live examples. When the new 111 standards that have been proposed to come in from—sorry, the Welsh Government out-of-hours standards that have been proposed for April 2019, of this year, they've reduced some of the triage times down to 90 per cent, and for the assessment and home visits. Looking at our data, we will be in a much more favourable position with that. The 98 per cent is something that we haven't consistently achieved as a health board, largely because of the rural nature of our services.

With regard to the rural nature of our services, one of the problems that we have sadly is that— . Take yesterday, for example—one of my colleagues, a GP, was on with an advanced paramedic practitioner who came in and did an additional shift to help us. As the paramedic told me—because I've worked the last three nights, and when I went on duty last night at 7 o'clock I was chatting to him about how the day had gone—as he explained, my colleague the GP had gone north in Pembrokeshire and he'd gone south. What happens in that situation is that the GP tries to cover the visits in a particular area. The issue that you have is if, at times, you are down to one visiting clinician due to rota problems or whatever—sickness—if you have a GP with two separate priority 2 calls but between the two priority 2 calls there are some priority 4 or 6 calls, and they are the ones that you're passing next geographically on your route, it's very, very difficult to not visit those people and sort them out. Then, sadly, some of our P2s suffer because of that. So, although the individual example is a worry for us, because we'd love to achieve the P2s, in the realistic world of actually where we live and manage things on shift, we actually then have to accept sometimes, with some of the P2s, after assessment by the visiting doctor, we will then decide, 'That can actually wait. I'll do these couple of P6s because they've been waiting too long. So, I can do those and clear those', or they may be particularly short so they can be dealt with expeditiously and be resolved.

So, do you think, then, that the system against which you're judged needs to be tweaked so that it takes into account the complexities of operating in that rural environment?

I would say it's difficult, because my view would be if you kept the standards, then they are something that we should use to be able to go back and say, 'No, we need to learn from this. Is there any way that we could have made this better?' We should be harsh on ourselves and look very impartially as to where we went wrong, where we could have reprioritised things, whether perhaps an advice doctor could have actually said, 'Actually, that second P2, that's now becoming an ambulance. We need to get you an ambulance response. Or we need to ask WAST if they have a rapid response vehicle they could send in place of the GP.' So, there are ways that we are trying to be more proactive and learning from each experience.

I think there should be some recognition that—. I did write a couple of pages to compare the difference between 111 urban and 111 rural, because I've worked in the clinical support hub, and there are differences that need to take some consideration, but I don't think they should trump an ideal to try and achieve the standards for everybody, because as long as somebody made an honest assessment of what that original priority was, then that's fine—that patient should be seen at that time. If, however, a doctor looks at that priority and says, 'No, actually, they can wait', then that's fine. For instance, on Saturday night, we were down to two doctors out of five overnight, and my colleague was visiting from Aberystwyth, and I'd brought him down to Carmarthen to do the visits there, whereas I did all the advices for the night, whist I did three other visits of my own. But that was apportioning the correct priority to the patients that I saw. Now, they will have breached the standards, but they were safety-netted by my assessment of them, which, being the senior GP there, I was able to do. And although it would breach the standards, it made sure the patients were safe or they were advised to attend A&E or whatever the disposition was to ensure that they were okay. So, being proactive like that on shift is how we need to be, with the acknowledgment it's never going to be perfect.

Okay, thank you. One quick question from me to finish, because I'm conscious of my colleagues and of time. So, specifically, in relation to call-handling capacity—because I know that the Royal College of GPs made a recommendation around that—what actions have you taken to review and increase your call-handling capacity?

We've actually now lost all our call handlers. When we migrated to 111, at the end of October last year, we moved our call handlers and our triage nurses into 111. They stayed within our call centre in Withybush. Fortunately, we managed to retain that as a resource, because NHS Direct, in their wisdom, could see that they had the three main national centres of Gwent, Thanet House in Swansea and Bangor, but having a spoke from Thanet House in Swansea down to Withybush allowed them to actually have the opportunity to have access to a new pool of clinicians and call handlers, and we've managed to keep some of those people working. And I understand that there's been some talk that there may be some more advertising to get more colleagues working in our call centre for NHSD to try and expand on the few that are left as well as the supervisors that come there regularly.

Thank you.

Great. Jenny Rathbone.

So, am I right in understanding that, when you say you've lost your call handlers and receptionists because they've moved into the 111 service, surely they're still doing the same triaging they were doing when they were attached to out-of-hours, aren't they?

Yes, they are; they're doing it for 111. The only call handlers that we retain now are the ones that we use to staff our professional line. And our professional line is something that we run to allow paramedics, district nurses and other colleagues, nursing homes to be able to ring through and get an urgent prioritisation of their call. Indeed, we've always maintained that to try and release an ambulance, we should have a 10-minute response time of getting back to a paramedic as soon as the call has arrived. We highlight them in a different colour to make sure that we do that, in the same way district nurses may have a concern particularly about a palliative care patient—we want to be able to respond to them as quickly as possible. So, we give those an urgent priority and we try and respond to them within 20 minutes. But, yes, the colleagues that moved across and were TUPE'd into NHSD 111, they continued working and they finished their training with us, and we're waiting to see how that progresses.

Fine. But I'm struggling to understand how that affects your achievement of standards, because the patient doesn't care whether the service is being delivered by 111 or by the out-of-hours service. They've just got a particular issue that they want resolved.

I think it would improve the standards, on an honest basis of they have more supervisors and they have a more rigid way of working—

Who's 'they', sorry?

NHSD and 111. So, moving our colleagues across from our call centre to have a more supervised and controlled call-centre environment, with a rotation of staff and supervisors coming from Thanet House as a main centre, actually allows us to maintain, I think, better standards with these colleagues. But, of course, they're not our colleagues any more, because they've TUPE'd into 111; they're handling calls across the whole country now.

Okay, so that's—. Well, across the whole of the patch.

Yes, oh yes. Well, the whole of Wales; they take calls from anywhere.

Oh, okay. That means that they're likely—. Their triaging decisions are likely to be sound. I mean, I'm not saying they weren't sound previously, but if you've got better supervision, you are going to have more confidence, are you not, in the quality of the triaging? 

Yes. Yes, and one of the things we did try: we tried to use a computer system to improve the quality of our triage with our call handlers a couple of years ago, but sadly what we found was that they were not using it, or we hadn't trained them properly, so that was a bit of an own goal on our part. We think we hadn't trained them enough to use it, so they were naturally defaulting to a higher disposition, and so we had to abandon that, whereas I know one of my colleagues who was a clinical director in Gwent said the amount of training that they put in was larger and it worked for them with this computer programme.

So, now that you've got more supervised triaging going on at Withybush hospital, does it mean that there's less need for the limited number of GPs and paramedics you've got to need to reorder the priority of calls or visits?

No, because the triage is still being done nationally. With the three NHSD/111 call centres, as I mentioned—Gwent, Swansea and Bangor—any one of those colleagues can jump onto a call, because it comes into a loop. So, the calls are looping around the three bases, and our one in Withybush is like a spoke that's attached. So, as the calls come around, the next person who's free gets a call, so you may actually have, for example, a holidaymaker from Bristol camping near St David's who is answered by a call handler in Bangor. So, they would have no idea of the geography, but they could safely triage the call, because they're under the supervision of their supervisors there. So, that is better, I think.

It don't know whether it would be useful to clarify that one of the key changes as a result of the new 111 standards is that the Welsh Ambulance Services NHS Trust will become responsible for calls and triage, and then the local health boards will be responsible for treatment centres and face-to-face visits. I think it would probably be fair to say that we've focused on our 111 roll-out, given that we knew that that would be a change that would be imminent in the future. And so, the call handling has transferred responsibility from the local health board in our case to WAST, but that wouldn't be the case in, say, Cardiff, for example, where the local health board will still be responsible for the call handling as well as the face-to-face contacts with patients.

Okay. I suppose what I'm trying to ascertain is whether you think that the new national 111 system is minimising the clinical risks that you're obviously carrying of a really serious issue not being attended to as quickly as it should have been.

Richard will definitely have the better view of this. I was just going to say, when we piloted Carmarthenshire, we did a risk assessment before we rolled out 111 to Ceredigion and Pembrokeshire on the basis that we knew we had a very fragile GP workforce, and the overriding decision that we took at that time was that we were better with the clinical support hub that 111 brings than we were without it. So, our judgment at that time, taking all the risks together, was that we would be better in 111 than not in 111, given the fragile nature of some of our services. But I guess Richard would have a more front-line view.

Yes. I think, with regard to your particular point about 111/NHSD making the system safer, I don't necessarily think that it did to begin with, and the reason for that was that it was agreed at the all-Wales out-of-hours forum that the 111/NHSD system should be very, very risk averse, and that far more patients should be put into the urgent 20-minute priority to make sure nobody was missed because we were getting used it and we didn't want to make the mistakes of NHS 111 in England. We certainly didn't want to make that mistake. And we'd learnt some lessons from Scotland and Northern Ireland. I wasn't on the group that did that, but I attended and obviously caught up with things in each forum meeting.

The problem with having too many 20-minute priorities to make the system safer is that the genuine ones get lost amongst the whole bunch, and so there is a big job for the GPs and clinicians on the front line sifting out the true 20-minute priorities. However, they've now brought in, through a lot of encouragement and support and open dialogue with us, they've now brought in tier 3 changes into NHSD, and the tier 3 changes have reduced the 20-minute priorities from 32 per cent, 34 per cent in November 2017 down to 10 or 11 per cent at the current system. So there's a far more realistic viewpoint of what those level of priorities are, and there's a far easier number to cope with. For instance, in November 2017, there was 28 per cent one-hour dispositions. So, actually 60 per cent were one-hour dispositions, or within one hour, in November 2017, which is why the doctors reacted against it, because a one-hour disposition is the equivalent of an urgent call, and in general practice you don't have 60 per cent of your workload as urgent work. It's probably 2 to 5 per cent at most. So, now we are really getting to a far more realistic system, and it is safer because the true 20-minute calls, with the odd exception—somebody's being over-zealous, which is fair enough—but we're getting the really sick ones getting through, and getting prioritised quite safely.

That's good to know. Just in terms of redefining national standards, and you're in favour of that, could you tell us what problems you envisage being caused by the lack of consistency of standards between out-of-hours primary care services and other urgent health services, which would include the Welsh ambulance service trust and emergency?

I think the problem that I have with regard to the out-of-hours standards is that we've always consistently, particularly in discussion in the all-Wales out-of-hours forum, recognised that we are really holding ourselves up to an incredibly high standard that daytime practice and other colleagues don't have to achieve. I think there's been an acknowledgement on our part that, if we were to do that, that may actually lend the idea of a sea change in everybody's standards, and that we would perhaps try and cascade an improvement in standards across the board, in all forms of medicine or specialities to do with providing care for patients. It's purely a desire and a wish, so we wanted to just try and improve our standards to make it as safe as possible, particularly with vulnerable times overnight, when perhaps clinicians are at a low ebb, and other situations, so that we can just try and focus on that. But we also acknowledge that daytime practice is a totally different thing, and that you can't actually compare like with like. But it's the desire to try and improve our standards and see if we can cascade that idea across to everybody else.

Okay, thank you.

Mohammad Asghar.

Thank you very much, Chair, and thank you, doctor. Just before I ask the question, there is a report by the Royal College of General Practitioners and they say, the report states, that

'At present, GPs and other out-of-hours staff go over and beyond to try to make things work in extremely difficult circumstances. This is not sustainable. Things need to change; services need to be safe and pleasant place to work.'

So, you're not in a safe and pleasant working position at the moment? This is GPs—your own report is saying this. So could you elaborate on that, about circumstances and safety?

I think the first thing to do is to acknowledge what you've said. And going back to where we started to, perhaps, get more involved from an executive level in out-of-hours oversight, there was certainly a lot of frustration, not just from GPs, but also the drivers and receptionists within the service. I think it would be right to say that morale generally was quite low. One of the things that we've tried to do through the work that Richard and I have led is through better engagement with teams. So, we've consolidated our own out-of-hours service, we've got regular meetings with all of the staff groups within the service, we've dealt with things that we mentioned like the pay rates, we've tried to improve some of the environmental issues, so, for example, a lot of our GPs gave us examples where they wouldn't feel welcome if they were working within a hospital or in an out-patients department as a base. They would never feel welcome there, so having a kettle, or some of the little things that make a difference towards working—and I think that's one of the areas that we're trying to work on. We've tried to improve the environment in the areas. We're moving the base in Withybush to a much better environment for the out-of-hours teams. We've been working with the GP advisory group on a memorandum of understanding with them, to set out the commitments of the health board to them, as much as what is expected of them to make sure that it's not a one-way relationship, but that we're valuing these colleagues for the excellent work that they actually do for us every single night.

I would say that the peer review done by Dr Chris Jones said that there was absolute dedication and commitment demonstrated by all of our staff within Hywel Dda, and we're exceptionally lucky, I would say, to have the GPs that we have now, because they will continually go over and above to maintain the patient safety issue. So, doctors from Ceredigion will regularly cover patients from Pembrokeshire and Carmarthenshire, and vice versa, and we're incredibly lucky to have the GPs that we have to do that. But then the other side of that is that some of those GPs aren't getting any younger, either, and the long-term model needs to dramatically change, in that we won't be able to carry on running five centres in the way that we've run them historically and we need to embrace some of the new workforce models. We need to look at some of Richard's ideas around having a supervisory GP who is managing three counties, and then a whole range of other staff who can deal with it through our clinical strategy development.

Within Hywel Dda, we've got a real opportunity to interface the out-of-hours service with other urgent services out of hours, and I feel we're making reasonably good progress with that—that we have a really strong interface operationally, now, every week with the minor injuries units, the accident and emergency departments, and the acute response teams, and the other teams that are working in those areas to try and maintain patient safety. I think, through our dialogue with GPs, we have a very good and strong feedback directly from GPs around any patient safety issues. So, again, Dr Archer has established a system whereby the GPs can feed in any concerns through health professionals directly to the service, and we have a regular dialogue with 111.

So what I would say honestly is: I think it's correct that morale has been low within the service. That's not to criticise any of those colleagues within the service. In fact, it's a board level issue to take this as a really high priority for us as an organisation. In the last year, we've taken reports through our business planning committee, our safety and quality committee. Our vice-chair, Judith Hardisty, has been very active in her oversight and scrutiny of out-of-hours, in a very supportive way, to try and get the rest of the organisation to really see this as the valuable service that it is and to feel really embedded within our operational services day to day. I think we're on a journey with that, but we're certainly not there yet and there's much more to do in terms of the retention of colleagues, and keeping up the face-to-face dialogue that we have with GPs would be key to that, I guess. But, again, I think Richard would probably have a better view of some of the morale issues and patient safety issues. 

I think it was a good point about the accommodation, and certainly there are some strange things about accommodation. We did have colleagues in Carmarthen who actually voted to remain in a very draughty, unpleasant out-patient department when we wanted to try and move them to a relatively brand-new day hospital environment. They kept talking about it being their club, for want of a better phrase, because they'd all worked there for years and years. But this was also back in the days of Primecare, and the whole system needed to change. So, although they weren't in favour of it, we moved them to far, far better premises. We gave them far better rooms, we gave them access to more phone recording to make sure that their life was safer online, with reduced clinical risk, because we were concerned about that and the fact that their use of the phone system was voluntary and we wanted to make sure it was mandatory, organised by the shift organisers so they didn't have to worry about it. So, moving them to that new environment worked brilliantly and they have begun to appreciate it.

We tried to do the same thing in Llanelli, in Prince Philip Hospital, but unfortunately we couldn't get enough rooms and so the GPs migrated back to their, once again, less-than-perfect orthopaedic out-patients. In Withybush, we were in the brand new emergency and unscheduled care centre. We moved there a few days after it was opened. But, unfortunately, because of how busy we are activity wise, and because of how many patients we were shifting through the system, there was this slight disagreement with the idea of GPs hot-desking. And, as I made the point, no GP ever hot-desks within a surgery or any department. So, after a period of a couple of years, we decided we would move out and we have had a temporary residence, which has been really pretty poor. It's the old A&E department. But now Joe has facilitated us moving to the original out-patient department where we were before we integrated into the emergency and urgent care centre, and it's a much better environment. The GPs are looking forward to going there, and it is going to make life more pleasant when we've got busy surgeries or quiet, and we're going to enjoy it.

With regard to actually working with A&Es or within A&Es, there is a point that I would make there that whilst we agree—generally, all of us—that working in A&E and being able to see patients is the best thing we can do to support A&E, we have a massive reluctance amongst most GPs to not be permanently based in A&E, and the reason for that is that if you're a risk-taking middle-aged GP who can see people, use a stethoscope, decide they don't need any number of blood tests or anything, and you can actually discharge them safely—. If you're in an environment where every other clinician is doing every blood test under the sun, asking for every x-ray to cover themselves medically legally, within three to six months you will downplay your skills. You will start to erode them. And instead of being that clinician that can do that job at home in patients' houses and look after them there, and be able to prioritise—as I said I did on Saturday night when I was managing my colleague—you lose those abilities, and that's incredibly sad.

And so, what I would say is if ever we wanted to push an agenda of integrating GPs into A&E, we should pluck the young ones who have just qualified or who have recently done their A&E jobs, give them positions in A&E because they will thrive in that position, and reserve the older GPs to do the stand-alone work where they can then mentor other colleagues to give them that risk-taking skill set. Because one of my biggest worries is that in the next five to 10 years, we have a demographic time bomb of GPs retiring, and the GPs of my age who have their skill sets and ability to take risks, and proactively look after patients with minimal investigations and other interventions—we're all going to start retiring. And we need to transfer those skills that are within our heads into as many of our colleagues as we can and, ideally, because of the shortage of GPs, we would make it as many advanced practitioners of all sorts—advanced nurses, paramedics, pharmacists, anybody that we can actually get to take those skills and get them into the new out-of-hours service of the future. 

Thank you very much indeed. And the thing is—now I come to the question of staffing issues, including morale and capacity in your own system. Your service is beyond anybody's expectation—a wonderful NHS service; I accept that. You just earlier, doctor, said that patients come first, so that explains itself and your service. I've only changed GPs three times in my life—when I changed address, the second actually retired, and the third one now I'm with, and I class him as a family member. It's a wonderful service that GPs are giving, but what I hear now, and this is something of an eye-opener, is that it looks like the standard is not there. This survey was conducted: in 74 per cent morale was low. That is what I calculated; I think only 26 per cent was saying that morale was good, so if you look at the other side—74 per cent of morale was not that good. So, that was worse than the whole of Wales, so it can't be sustained; you can't carry on like this, because staff are your backbone. They work with you, and they're your eyes, arms and hands, and they give you the information. What have you been doing to make out-of-hours services a more attractive and safe place to work, both locally and working with other health boards and the Welsh Government at a national level?   

Perhaps, again, if I start. One of the—. Again, to acknowledge what you said in that—certainly the GP community that work for us are incredibly hard-working, and have certainly expressed some of the views that you've—. I don't have the numbers, but I wouldn't argue against the numbers that you've quoted. We've had 99 base closures since May 2017, and one of the biggest issues of morale for us is that there's quite a vicious circle, really, that once people know that all of the shifts aren't going to be covered, they don't want to take up a shift and know that they're going to be working on a shift under heightened pressure. So, it's a difficult situation. If all of the bases are covered, we get a higher demand for people wanting to work in the service. If people expect there to be gaps in the service—

You're in a vicious circle there, really—if you have fewer shifts, then fewer people want to do the shifts that are left, so you've got to—

That's exactly the situation that we're in. So, when people look ahead to—. If on a Monday they look ahead to a weekend ahead where it's going to be fraught with difficulties, then the incentive to do that is much, much, much less, because they don't want to be finding themselves in a shift where they're having to cover across counties with heightened pressure and stress on them, which is completely understandable. There are other workforce issues as well that have changed that dynamic, which we may come on to, around some of the taxation and pensions and other things, but there's a bit of a mixed view of that. Some GPs really don't like the—. And I understand that there's a suggestion that money's an issue, but, for some of them, actually, money completely isn't an issue—they're 100 per cent there to provide care for their patients, as they all are—for others, money can be a bit more of an incentive to help at times of duress.

In terms of the long-term view, one of the things that we've started to develop within Hywel Dda is the different workforce models that Richard has done. We've had six APPs, which we've funded, some of these, ourselves this year—the advanced paramedic practitioners, who've covered regularly now, over Monday to Friday and weekends, shifts within the service. Not all GPs have welcomed that, in that some—because, when you bring in lower graded professions, if I could put it that way without being disrespectful to those, then they need clinical supervision from GPs and not all of the GPs, again, are comfortable with providing that level of oversight and supervision. And we've also got advanced nurse practitioners and we've also got some pilots running with healthcare support workers doing more work.

Just on this point, I think, Rhianon, did you have a supplementary question?

Very, very quickly—you're covering the point that I wanted to ask majoritively, I hope, but, in terms of the scale and pace and understanding the difficulties around acceptance of the new APP model, and bearing in mind the recommendations from the royal college and also in terms of the auditor general's points around this, do you feel that you are sufficiently implementing this model enough as a potential lever of change and assistance around the whole workforce pressure?

We think we can go—. One of the issues—. We think we can go a lot faster with that. There's certainly a demand for paramedics to train as advanced paramedics; it's a fantastic workforce that—

So, what is stopping that scale up of change?

We got an offer this year; we could put another 10 paramedics through the programme within Hywel Dda. The difficulty for us as a health board is it would take us a year. To do that, we would need to backfill 10—

I think the most important thing, actually, is that we're not going to deplete WAST of their critically important workforce. We have to acknowledge that the only source of paramedics at the present moment is WAST, so—

I'm not just referring to paramedics, with respect, it's the nurse practitioners as well.

I know, but that's the main reason for me, clinically, in my conversations with Andy Swinburn.

And one of the issues as well is money, which I was coming on to. To get 10 advanced paramedics through a year's fast-track programme—we would need to backfill 10 paramedics to enable those colleagues to be released. The cost of that would be around £600,000 as a one-off cost. That would be exceptionally good value, and the right thing to do in terms of the long-term benefit, but, in the very short term, there is finding £600,000 out of the baseline budget.

Okay. We'll come—. Thank you, Chair.

Okay. Back to you, Oscar.

One of the more serious points about Hywel Dda is you have a shortage of doctors that caused you to close off weekends, out-of-hours services, that sort of thing. Is that the fact? And, secondly, this national insurance contribution that's £300,000—employer national insurance—is a financial strain on your board. So, could you elaborate on those areas, please?

Yes. With the HMRC issues, there was—. I think it's covered in our briefing, but others—. Probably the committee will be well aware of the ongoing dialogue about the employment status of GPs, and it was determined that they would be deemed employed—these are the GPs that do what I'd call ad hoc shifts, so they do shifts as and when, but they're self-employed contractors. As they came onto the books, that gave then the requirement for the health board to meet the costs of the employer's national insurance, which, for us, was around £300,000 in the year 2018-19, and, in reality, that took us by surprise, really. It was an additional financial burden on the service that the health board has picked up. At the moment, that's been charged to the out-of-hours budgets, and one of the things that Richard and I have been arguing is that we would hope that that could be met from more of a central reserve within the health board to make sure that that doesn't detract from some of the front-line money that we can invest in the out-of-hours services. That's the ongoing discussion as we go into the next year's planning round within the health board.

And what about this shortage of doctors?

I think some of the issues to do with shortage of doctors involve geography. In Carmarthen, we have almost a completely sessional GP service, our ad hoc GP service, and they are GPs who come from their daytime practice. Historically, when Primecare used to handle the contract and they had very little to do apart from face-to-face contacts, we never had any empty shifts in Carmarthen. As the workload has increased because the contract has changed, because it changed to a lesser Primecare contract and then we merged into Care on Call, and then we've come to 111, the front-line workload has actually increased dramatically for the GPs. Whilst the end result has ended up with fewer home visits and fewer treatment centre consultations, the doctor advice to begin with, which they often find quite stressful because they're assessing people over the phone—not every GP is like me and is happy to run three counties on a Saturday night on their own. A lot of the GPs don't want to do that because they're happy to triage in their own surgery because they've got the patients' records in front of them on the computer, they probably know the family, they probably know the support, they know who can get them a script and they can print it, and their computer will tell them about drug interactions and other problems, so they're very happy to do that, but in out-of-hours, they're not so happy to do that. So, although the model, we think, is better with 111 in the long term, in the short term it has caused problems. However, in Carmarthen, we've actually had as many young doctors come forward to join the service as we have had older doctors leave. 

In Ceredigion, there is more of a mixed workforce of, say, 50:50 salaried and sessional GPs. The salaried GPs in Ceredigion are also, actually, daytime GPs, a lot of them, so they've taken a salaried contract to do specific hours. In Pembrokeshire, there is more of a split in that. The nights are done by salaried GPs because none of the daytime GPs will do that work, but the weekend days are done mostly by sessional GPs from the daytime.

So, all three counties are different in their set-up and they're all affected differently. When you have colleagues coming along the M4 corridor being picked off by other health boards with different locum rates—there was a bit of a locum-rate war a couple of years ago, until we agreed that we would try to get some consensus—we never got anybody making it to Carmarthen. Now that we've also had the change to the GP trainee golden handshake, we are seeing an increase and probable retention of GP trainees in Pembrokeshire. So, we are hopeful that that will lead to an increase in GPs, but it is difficult. A lot of the GPs are getting older and a lot of the younger GPs want a portfolio career: they want a portfolio life, they want to do a bit of this, a bit of that, a bit of daytime practice, a dip into out-of-hours at the weekend, but not nights. And, sadly, some of them we're losing to Canada and Australia. I know and I've lost several friends who've gone because they just see it as being attractive and less of a workload. 

So, we are trying to address that, we are trying to make the environment better, we are trying, at times, to offer increased wages, as Joe has mentioned. But we did actually do one weekend where we spent £16,000 offering incentivised shifts to GPs and we didn't get a single extra hour of cover. The same GPs stayed and worked those shifts, but we didn't get any more, so we abandoned that as not being an answer for our GPs, because, for some of our GPs, money is not the answer and there's actually a few of them who are very vocal that it wouldn't matter what we paid them—if they're on their own without a colleague, they will not work, because they just don't want that. They don't want to be that isolated.

So, because there's a melting pot of different personalities and different reasons for doing out-of-hours, no one solution is going to fix it all. That's why I think, personally, in the longer term, we need to change the workforce and we need to move it from being a GP-provided service to a GP-led and then, finally, a GP-supervised service, as the numbers decrease as the years go by, and then we make use by backfilling with all these other colleagues as we grow them. The problem that we have is that our training institutions are not growing enough of them. I really am concerned that we probably need to try and grow a lot more, not just for general practice in out-of-hours, but for daytime general practice. I actually mentioned to my paramedic colleague who worked yesterday—if there were any of his colleagues who were perhaps interested in cardiology, would they mind doing a hospital-based junior doctor equivalent position in coronary care. There's a lot of interest in these young clinicians coming forward to do these things if we facilitate them to get their training and we grow enough of them to do it.

The other concern is that, as I said, the mentorship business—they've only a got a few years where we need to look at being able to provide that mentorship before they would all become very risk averse like our younger GPs are. 

Thank you very much indeed, doctor.

Okay, very briefly, before I bring in Jenny Rathbone, Rhianon Passmore.

In that regard—and you've mentioned what you're doing around growing your own in terms of, perhaps, senior nurse practitioners—your health board has a massive role here as well, in terms of growing your own. So, my question still remains: are you moving at a fast enough scale in terms of that wider APP model?

I think we could move faster.

So, what's stopping you moving faster?

I think the issue in terms of the APP—. This year, we've funded some of the additional APP roles ourselves, out of the out-of-hours budgets. In fact, the 111 team supported us over the winter period to do—

Because that's had a dividend, hasn't it, in terms of—

It's largely a money—. As I said, it's largely a money issue in that, as I say, to commission 10 additional APPs into not just the out-of-hours but the wider Hywel Dda clinical delivery service would need about a £600,000 investment, and that's the choice for the health board.

We are trying to fund the APPs out of empty shifts but, ideally, we would want a pot of money to actually grow them as a cohort of colleagues. Whilst I'm very happy that we should mentor them in out-of-hours, I'd be more than happy if they went to daytime practice, or they went to A&E, or wherever they work. Linda Dykes in Bangor A&E has got five or six paramedics working in her department, and they are absolutely brilliant, acting as juniors. The potential is there.

If I could say, though, that, ultimately, the money is a choice for the health board in that we have an £800 million budget. So, I wasn't trying to externalise the—. I wasn't trying to externalise that.

Okay. We need to make some progress because I'm mindful that we've got quite a few questions left. So, if Members can be succinct—. Jenny.

Yes, if we can all be succinct—. I'm struggling to understand just how far you've got with the multi-disciplinary model. We know that you introduced six APPs working Mondays to Fridays and at weekends, and you've got two advanced nurse practitioners trained up by WAST. But you've got five treatment centres, covering your large geographical area. But I've also heard you say that some GPs simply don't want to act like the consultants that they are. They are consultants in general practice, which means that they must be in charge of a team and provide clinical leadership in that team. I'm struggling to understand how people are saying, 'Well, I'll do this, but I won't do that.'

Right, okay. A quick potted history. We've had APPs since 2004. We had three of them in about 2010—when I was working and I first became clinical lead—of different grades and experience. Since then we've been trying to grow more. We've lost one to Port Talbot and one went to daytime practice in Newport in Pembs. The issue that we have with regard to the GPs is that there are some GPs who do not wish to have a multi-disciplinary team. They wish to have a purely medical model. We have some GPs who, on shift, will say, 'An APP doesn't count as an equal colleague. I'm not working with one. If there's not a GP, I'm pulling out of that shift.' However, in Pembrokeshire, and with some isolated colleagues in Ceredigion and Carmarthen, we know that there is a massive interest—because I've polled for a massive interest in who is willing to support these colleagues. Now, some of the ones who are willing to do this in out-of-hours are also being innovative in daytime practice: Mohammad Imam in Lampeter, Mark Thomas in—

I don't need to know the names.

But these colleagues are being very innovative. They've taken on physician's assistants; they're taking on paramedics; they're taking on pharmacists, OTs, physios. So, they are willing to do this to improve their lot in daytime practice. However, they do sometimes say, 'I know those people. They are my colleagues. I understand them. So, I'm happy to sign this prescription for them. I'm happy to okay what they are doing.' But the ones that we would meet in out-of-ours—it's a whole new creature that they're learning and they are finding difficulty understanding that and adapting to that. So, these ones are trying to run with the idea and want to work with them. But the ones who are more risk averse just want to have the medical model.  

Okay. So, how are you using this £600,000 investment, then?

Well, what we would do is we would—

You 'would' do. You haven't actually invested.

What we want to do is we want to fast-track. In conversation with Andy Swinburn, we want to fast-track a cohort of colleagues of 10 through Swansea or another university in a year's rapid course, to be mentored within their training time, ensuring that they have enough mentorship time as well as education time, so that, at the end of the year, instead of two or three years, they are ready to hit the ground running.

Okay. So, that's work in progress. But I just want to establish that the GPs, the people on the ground doing home visits where clinically necessary—do they have a driver so they can pick up the GP's records whilst they're travelling? The GP or the advanced practitioner has a driver to assist them so that when they arrive at the house they know exactly what they're dealing with. 

Yes. We invested in laptops and we have an electronic copy of the record come down. We used to have fax machines and we took paper copies out. So, we're trying to be up to date and have up to date records. 

Okay, so the GP who's only content being able to see the patient's records and knowing the family, they still can see the patient's records, even if they've never heard of this person before. 

Yes. They can access the individual health record to get a summary of that, but quite often we just use our previous encounters if it's a regular caller, and we use those to guide us on our assessment of the patient. 

Okay, but where it's—. Clearly, where you've previously encountered them, you have much more information anyway.  

Yes. 

The danger zone is where you've no prior information about somebody and you need to assess whether it's serious or can wait til the morning. 

Yes, absolutely. The problem that you have is that some GPs will take the view, 'I can't assess the patient adequately or completely without access to the individual health record or previous encounters'. Whereas there are some GPs who, like myself, will go into a situation and just take the patient as they are at face value and make a clinical assessment, and we're comfortable doing that. 

So, you're quite some way off getting to the multidisciplinary model, it would appear, that is deemed to be the only resilient way of working in this field.

We're not as close as we would like to be. Yes, you're right. But I think the issue there is that there are more and more GPs who are beginning to see the utility of these colleagues, and barriers are breaking down. 

Okay, thank you.

Rhianon Passmore. 

Thank you, and, before I go into my line of questioning—. So, in regard to that cultural change, and obviously it's a generational thing—there's a massive generational divide, I think, from what you're saying, in regard to GPs across Wales, particularly, perhaps, more in rural areas—you say that those barriers are starting to break down. In terms of your dialogue, as a clinical lead, No. 1: do you need more capacity in your what seems to be a field of one? Do there need to be more mechanisms within the health board in terms of creating that absolutely essential dialogue in what is a very entrenched historical, cultural beast? And it is a beast. So, do you have the capacity to do your job in your role? 

I did ask—or I did explain to Stephen when he came round that I wanted to be able to increase my clinical lead time to three days a week, and Joe has authorised that, and we have been working— 

Is that enough, bearing in mind the scale of the challenge?   

No, it's not, I'll be honest with you. The problem that I have is that if— 

And that should not be up to you to determine, so it's really a question for the health board, bearing in mind the importance of this dialogue, as referenced by many, including the Aneurin Bevan health board and many others, that this is absolutely critical to this cultural issue. To the health board—is there any resistance to that? You may not want to answer that, but—. 

No, I don't think there's resistance, but my point would be that I haven't pushed the agenda too much. I have expressed to our colleague, between Joe and myself, that in an ideal world I would work five days a week as clinical lead, because then I would spend my time mentoring and bringing these processes in. However, I cannot afford to take six nights off the rota. 

And I understand that. 

So, I am in this middle ground of trying to push things with Joe gently, but we know that the actual desire and need to accelerate is building rapidly. 

Okay. So, strategically, you understand the necessity of that, and does the health board understand the importance of the role itself? 

Yes, I think so. It was one of the things that Dr Jones picked up as part of the peer review when he fed back to all of the executive team in terms of needing the whole of the organisation to get round out-of-hours, not just me as exec lead but all of the other functions, to make sure that it is—

So, what's going to change, then, in the immediate future around this strategic issue?

Richard and I were discussing this before, in that there's a balance between Richard being a very prolific GP in out-of-hours, as against the time he's got for some of the management resource. And one of the things we discussed was perhaps there also needs to be some more managerial support around the out-of-hours teams again to strengthen further how far it's embedded within the operational areas. One of the things that I did want to come back on in terms of the—. I think some of the GPs don't want to embrace some of the change because of the service pressures that they're under. So, I wouldn't necessarily see that as a negative point in that it's that vicious cycle again, whereby because they're so busy on shifts and having to cope in often quite difficult circumstances, then being given extra supervisory roles or other things to do sometimes—. So, I don't necessarily see it as GPs not wanting to modernise or change the way the service is run, but more that we need—in the line of questioning that you've done—to find a way to create more capacity for those to be able to lead. So, I think there is something for us to reflect on in that, in terms of how much senior management and clinical lead support we give, albeit we did try to respond to the Wales Audit Office recommendations by increasing that, and we've now appointed as well a permanent out-of-hours general manager. But there's more we can do.

Thank you for that. In regard to the auditor general's local report, which suggests that your health board's spending on out-of-hours is comparatively high and has increased, your written evidence—and as you've stated today—suggests that's because of your number of bases and your rurality. You've already stated that, if there were to be clinical strategic development and supervisory GPs over, say, perhaps three counties, this would assist in that matter. My question, really, then is: have you done enough around that, in terms of the level of spending being appropriate, that you are moving to a different model?

We don't feel like we're wasting any money in the service at the moment in terms of—. Money is not a key driver. We're not trying to save money by not filling shifts; we're actually trying to actively still spend the money that we've got on making sure that we've got five centres covered for all the reasons that we've discussed, in that not having that then can cause the service to be demotivated, it—

So, you feel that level of spend is appropriate.

I think so. We've got a rural—. I don't think you could compare us to the centre of Swansea or Cardiff, in that we're covering such a wide geographical area, and, if you look at the way our bases are located, they're quite strategically placed. If anything, over the winter period, we've extended some of our spend by putting in place an advice doctor over the winter period to try and give ourselves more resilience. I think there are always things you can do, and one of the things we discussed last week with some GP colleagues—. For example, we have a minor injuries unit in Llanelli that has a 24/7 GP service. There are always ways you can look at the model, but, actually, for palliative treatments particularly, you're always going to need a GP to be able to go and visit a patient at home, and the geographic area that we're covering needs to make sure that we've got that sufficient senior cover in place.

And I understand that particular point. So, in regard to the notional allocation and the fact that you're quite a bit over that, if you'd spent that, you don't feel that that would have been appropriate.

I think it's probably wrapped up in the deficit of the health board, in that we've got a big deficit, and one of the reasons for that will be that we're spending more money than the notional allocation. The one thing I would say, as managers running the service, is that it makes new moneys much more difficult to direct towards a service that might need it because of the current disparity between—

So, would you suggest or would you state to this committee that you feel this is a sustainable financial model wrapped around the current ways of working for the future, bearing in mind your deficit?

As a health board, we don't have a sustainable financial plan as we sit here today, nor an approved integrated medium-term plan. So, we need to look at all of our services and ensure that we're making sure that we're giving absolute best value to the taxpayer. What I would say within out-of-hours is we would need to do that work very carefully because, actually, if there are 8,000 contacts a month with the service, we need to make sure that those patients are well looked after at—

So, do you believe this current way of working is sustainable financially?

No, I don't think—. I would say, firstly, clinically it's not sustainable going forward, and our first priority would be to make sure that we can provide good access and safe caring services to people out of hours. That means this model has to change. We've made some steps on that journey, as we've outlined to the committee, but we need to do much more.

Do you feel those steps are significant enough?

I think we need to do much more to define more clearly through our clinical strategic processes what the future model of 24/7 primary care services looks like. So, I would say, 'Not at this point in time.' We don't have yet a clear enough vision of the long-term future of how the service will look.

Okay, thank you. Finally, I'm going to ask around potential competition and back-filling. So, to what extent in your view, or not, are health boards competing with one another as opposed to collaborating—I obviously understand the geographical areas that you're covering—to fill GP shifts, and what are you attempting to do about that if that is an issue for you?

I think the locum war's payments from a couple of years ago is a sign of how desperate each of the individual health boards are, and I don't think there is a collaborative approach to this matter. There is, amongst the all-Wales out-of-hours forum, where people do talk about working collaboratively, but that is the forum and—

How can that become more systemic in terms of perhaps the Welsh Government, bearing in mind that we all know that GPs and the royal colleges and the British Medical Association are all very, very protective of their interests, and rightly so?

I would say that there's good evidence from the all-Wales price cap in hospitals in terms of payments for locums, consultants and junior doctors, et cetera. We made very good progress within Hywel Dda by implementing a cap-based system. I think there's something in primary care where that will be replicated, in that Welsh Government will be picking up some of those pay-cap arrangements across other areas. I think it's much less of an issue now, in that we've changed our rates, we've got rates much closer to the rest of Wales. There's always the odd colleague that will go and work in Swansea, for example, rather than within Hywel Dda, but again I would come back to—most of our GPs within our area do their shifts because they care for their patients in the area within which they work. There are many for whom money is not the primary factor—

But GPs are well paid, in the main.

Sure, yes. But then, long term, strategically, we need to look at some of the GPs that we need to keep in the service and make sure that they are well rewarded for all the services they provide. 

I'm concerned that, until we have a plan where we actually grow enough of these clinicians, the desire of daytime practice, once they get over their relative concern, is that they have a massive capacity to absorb these colleagues. That's why I think there has to be some control on it. We need a massive increase in the numbers. We need to ensure that people realise they're not a threat but they're a colleague to co-work—same as physicians' associates and independent prescribing pharmacists. That's why we're doing this work in out-of-hours to mentor these colleagues. But I think, unless we grow enough of them, there will be that continual in-fighting as to who's going to control the most. I think, unless there are enough of them grown and we have a discussion about how they are grown—.

I can only explain what's been said to me. I have colleagues who say that one institution produces a highly academic course with a highly academic advanced practitioner. Another institution doesn't produce such a highly academic colleague but has a higher pass rate. My personal feeling is I'd rather have the less well-trained colleagues, because most of the job is learnt on the job. So, I'd far rather we have more of those coming out, because they don't actually end up using many of those skills from the more academic institutions. So, I think there has to be an honest debate about that.

So, is there a fundamental issue then in regard to higher education and in regard to the actual training content of our medical registrars when they come out?

I think there probably is and I think there probably is a concern about rigid thinking in nursing, paramedics, medical circles, and I think there should be an open discussion about—we are one set of colleagues, we all have different skill sets. The future will be this progressive morphing of this GP led and GP supervised in daytime and in out-of-hours practice with far more of these other colleagues. But, in an ideal world as well, we would have far more healthcare assistants in the community. My particular plan that I would wish to bring in for the future would have a single supervising GP twice during the day—a daytime and a night one—a tranche of middle grade GPs, paramedics, nurse practitioners, and a much larger cohort of less well-trained healthcare assistants who provide care. That set-up would allow us to keep far more people at home, would allow us to prevent bedblocking, would keep the frail elderly at home where they are safe and where they end up with no pyjama paralysis, not picking up germs in hospital. All these other things would be so much better and you'd have holistic care at home. But, that's the reason why GPs don't keep them at home, because they don't have the care at home to keep them at home.

Okay. I'm conscious of the question to come after me, and I'm interested in what you're saying, but I need to move on. So, finally from me, in terms of how often you as a health board are making ad hoc payments and enhancements to GPs who are willing to fill those shifts at short notice, what sort of quantification can you give me? How much of an amount is that taking from you? What are you doing to address that issue? It's the sort of same question, really.

We've virtually never done it in recent times. We had the example that Richard gave where, one weekend, we tried to incentivise—. We couldn't pay just the GP who turned up at the last minute, we had to pay all GPs. It cost £16,000, it didn't make a difference.

I think that's quite illuminating, actually.

What we are doing, if I could just quickly finish that—we are looking at that again now in terms of, given that we've got five centres, when we ask a GP to work alone or cover more than one county, we are looking at an incentivised arrangement, but we're doing that in collaboration with the GPs to try and really reward somebody for actually helping us and shoring up the service at times of duress.

Okay. And obviously there are other incentives, other than financial, but we won't go there at the moment. Thank you, Chair.

Mohammad Asghar.

Thank you very much, Chair, and thank you, doctor. My final question is that the auditor general's national report highlights that there was no clear vision of how out-of-hours services should provide face-to-face appointments and home visits. Does your health board have any particular difficulties in providing these face-to-face aspects, as opposed to the telephone-based aspects of out-of-hours services?

No. We have no problems with that. The only problem that we have is just our capacity at times. With regard to that issue, it may seem a strange thing to say, but our slowest, most cautious clinician that we have working for our service—by 8 o'clock each morning, he has caught up and he has seen all the patients he needed to see, and he has a very low threshold for seeing people face-to-face. So, we have a broad church of some colleagues who are willing to do a lot of advice, like I do, and advise people away and bring them back, safety-net them or do the advice for colleagues and get them to their front line so they don't have to worry about the advice so much; we have other colleagues who will only ring a patient and say, 'You need to come in. I'm not going to advise you on the phone.' So, even when we are short on capacity, we always prioritise our work, and we generally in that situation are looking at it and, if we have to defer to, say, ambulance for a visit that can't wait, we'll continue in the treatment centre until they're all cleared, and we'll make sure that, essentially, everybody's seen. It is hard work, and it does take time, but we never prevent people coming in. We never ever prevent—. If somebody asks to be seen, we always allow that; we never deny that.

Okay. Rhianon, did you have any questions left?

I do, in terms of—

The vision and strategy.

Sixteen and 17, am I, Chair?

Yes.

Okay. So, in terms of your local vision and strategy or a refreshed action plan that sets out the future model for out-of-hours care services, how has this been developed and communicated? Sorry, not 'care services'—out-of-hours services.

I would say we're working with a GP—. We've got action plans to the Wales Audit Office report and to the out-of-hours peer review, which we've been routinely monitoring as a health board. I would say the long-term strategic future of the service is what we are now developing with the GP advisory group, which we've established, which includes colleagues from other parts of the health system as well in terms of A&E doctors, the lead for the minor injuries unit, et cetera. Richard has a vision, which he has articulated to this meeting, as part of our transforming clinical services programme of work, where we've developed the seven integrated localities and have a 24/7 primary and community care system. I think the detail of that needs to be worked through as part of that process.

And in regard to your comments around prudent healthcare, the fact that there may be, from what you stated to this committee, an almost in-built 'that's not my job' concern, do you see any difficulties around amalgamation around both your vision and the wider strategy around prudent healthcare, or are they synergetic?

I think, culturally, for us as a health board—every one of our patients is every one of our patients, and we work hard always in the operational arena that a patient who needs any service is equally as important as another. We had a meeting last week with all of our GP cluster leaders, with all of our hospital and mental health clinical directors around how we work as one system, and I think, as a health board, we haven't yet realised the benefits of being integrated and there's still a lot we can do to do that. But our vision described through our transforming clinical services programme is that every single patient is all of our patients, and that the parts of the system need to work together to make sure that for anyone in our population our services are seamless, and that includes social care as well.

So, in regard to the pressures and challenges that you are facing currently, do you believe that a national strategy for out-of-hours would have affected your health board in any significant way if it were being implemented?

I think that, generally, we have good support in terms of the out-of-hours systems. Certainly some of the new standards are welcome from our point of view. To me, it's a cultural thing; if, as a board, we're chasing the target to please Welsh Government, that would be the wrong thing. We would always look for—

I mean, Welsh Government would argue that it's there for an absolute outcomes-focused purpose, not just to tick a box.

Absolutely, and I would agree with that. I think targets, generally, are a good thing. If you look across the list of targets that we aim to achieve, I think that's implemented in a system whereby the patient and population are genuinely put first. In some of the examples that Richard gave, you don't penalise a service for not meeting the standard if they've actually done the right thing. That's a cultural issue for me in terms of how boards look at targets.

Okay. Thank you. And finally, in regard to any particular difficulties from your health board, do you have any particular difficulties that you want to articulate in providing the face-to-face aspects further than what you've already stated to us, as opposed to the telephone-based aspect of the out-of-hours service?

No, I don't think we have any problems with the face to face. It is the preferred means of meeting patients for a lot of our colleagues, and they will generally stay on and continue to provide the service until everybody's seen, or we are able to safety-net to other bases to ensure they are. So, no, that's not a concern.

Okay. Thank you.

Jenny Rathbone, did you have any outstanding questions?

Mr Teape, you're the deputy chief executive. How much does the board own the challenges that you face in this service?

I think it's improved significantly, partly through the fact that we've taken much more reports through to the board. As I said earlier, we've taken papers to the business planning and performance committee and to the safety and quality committee, and our vice-chair, Judith Hardesty, who's now, actually, our acting interim chair, has been very active in her leadership of the primary care agenda. So, the out-of-hours risks would be one of our top risks as an organisation, and they would be very visible, the challenges that we face within the service. And there's escalation now to all of the executives each week when the out-of-hours service is in challenge. The gap is now to, more clearly, have that vision for the future nailed down and then for us to be working in steps towards that. I think, through the implementation of our strategy, there's a good opportunity now for us to do that.

Okay. So, what's the board's attitude to the hiatus in the flow of data to the Welsh Government because of the issues relating to the reporting criteria? I wonder how the board knows what's going on if there's a hiatus of reporting data, actually.

We've had, I think, a gap temporarily for periods since we've migrated, but that will be resolved in due course, and one of the things—

In due course—by when?

This is reporting for out-of-hours standards to Welsh Government.

Okay. I mean, which is presumably the same data that the board relies on to know what's going on in out-of-hours, is it not?

One of the things we haven't been particularly clear on in this meeting is in terms of the standards that come up from the service. They would need to be—they're not at the moment—built into our integrated performance management system that goes to the board. But the executive team meet with the team quarterly, as was referred earlier, through performance management processes, where we would go through that data, but also, safety, quality, access, experience, finance, workforce issues with each service.

Because, obviously, that was really my last area of questioning, which is how your planning out-of-hours is truly integrated with the planning of other health and care services. I was a little surprised when you said earlier that you have to have a GP to care for somebody who's requiring palliative care. I would've thought a palliative care nurse was more appropriate.

If they existed. There's not enough of them.

They don't exist in your area.

Well, there's not enough of them. What I would say is the main problem with being a GP in out-of-hours is that the GP can do everything, and also they can do it very quickly. So, I can go in and I can see a palliative patient and write a prescription and be out of the door in five minutes. Some of my colleagues can do it in less than that. We don't do that, because it's a holistic approach and you want to spend time with the patient and develop the rapport. The issue for nurses, particularly palliative care nurses and Macmillan nurses and other colleagues, is that they spend a lot longer time. So, there isn't—

Okay. So, this is a particular rurality problem, is it, because that wouldn't—?

No, I think it's more to do with how they function as colleagues and I think how they've been trained to work. A lot of people acknowledge or accept that they might get five minutes with the GP in the surgery, or 10 minutes for a consultation, but they'd expect 20 minutes with the practice nurse. There is an expectation that you see GPs very rapidly and get a very rapid assessment and treatment, and I think that is one of the areas where we need far more of these other colleagues who are not GPs, so the future workforce, whatever we may want, is going to have to be much larger to be able to provide the same productivity as the GPs. Because to cope with the numbers, we need more of them to be able to do this.

Okay, well, this is a lengthy conversation that we probably haven't got time for.

No, we definitely haven't.

The thing is, I don't like you not having answers.

No, I understand that, but I'm just surprised, you know—.  If somebody's in need of palliative care, they want—

Well, to give you one idea, the first time the paramedics started working with us, they were taking 40 minutes to confirm a death. It takes me two minutes. And it's only as long as that because I don't want to appear rude to a distressed family.

Yes, well, I quite agree.

But that is the sort of timescale or duration difference that we're dealing with and that, to me, is why we need this plan for a much, much larger workforce to achieve all the things that you and we would want to achieve.

Okay, thank you.

Any further questions from anyone? No. Can I just end, finally, then, by asking: you've touched on the 111, so in your overall opinion, what would be the weaknesses of that system and how it's working at the moment that you would seek to alleviate over the next months and years?

Okay. I think 111 is great, and I think it's great because I've worked within it and I've worked within the clinical support hub. And the concept of the clinical support hub where you have a highly experienced GP and perhaps a second GP, two pharmacists, a nurse and an admin support person in Thanet House in Swansea, where they can pluck from the triage queues of both health boards complicated cases, palliative care cases and cases where a front-line GP might spend an excess of time by having these experienced and better qualified or knowledgeable colleagues, they can help the workload on the front line by these colleagues dipping in, taking these calls out and resolving them.

The concerns about 111 were resolved initially about the excess of 20-minute appointments, which we accepted because of the risk averseness. The current main concern about 111 for a front-line GP is a concept called the prescription pick-up queue. That is causing a massive amount of angst, but it is where somebody in one area sends a prescription to be issued by a doctor who hasn't seen the patient. Now, that causes massive consternation and there have been some clinical concerns that are being fed back to the senior pharmacists and the clinical lead for 111. So, we are addressing those issues.

Personally, for my colleagues in Hywel Dda, whom I've done a straw poll of and got e-mail responses, there is a massive concern about the prescription pick-up queue and often reference to the General Medical Council rules on that—whoever signs the script is the one who is responsible. So, from that point of view, if somebody in Thanet House or 20 miles or 30 miles away talks to a patient on the phone and says, 'You need some amoxicillin, because you've got earache', to then expect a front-line doctor, without seeing a child or a person, to just give them amoxicillin, a form of penicillin, is something that they find very unpleasant to deal with, and that is a big concern. What my suggestion is is that, instead of having the prescription pick-up queue, we become more versatile and we use something called the treatment centre holding queue—sorry to go too much into the jargon—but we basically have the patients sent to that base, but the GP then has the option, or the paramedic or the clinician has the option to say, 'I'm happy to issue the script' or 'No, I'm not happy; tell the patient to come in'. That's a safety net for both colleague and patient, but it also allows for those doctors who are happy to carry on using the prescription pick-up queue, and we are trying to push that through. I mentioned these issues in the last all-Wales out-of-hours forum a week ago on Wednesday. 

Great, thank you. Thanks, Joe Teape and Richard Archer, for being with us this afternoon—that's been really helpful. We'll send you a transcript of today's questions and answers for you to check before it's published.

Fabulous, thank you very much.

Thank you.

Thanks for helping with our inquiry.

Okay, our next witnesses are due at 3 o'clock, so a 10-minute break.

Welcome back to this afternoon's meeting of the Public Accounts Committee. Can I welcome our witnesses? Thanks for being with us this afternoon and helping us with our inquiry into out-of-hours services in Wales. Would you like to give your name and position for the record?

Yes. Good afternoon. My name's Steve Curry. I'm chief operating officer for Cardiff and Vale University Local Health Board. I'm responsible for directing the day-to-day operations across the health board. 

I'm Sherard Lemaitre. I'm a GP and I'm also the clinical director for the Cardiff and Vale out-of-hours service. 

And I'm Lisa Dunsford, the director of ops for the primary and community care clinical board within the health board. 

Great. We've got a number of questions for you, so I'll kick off with the first one. Can you outline what the health board has been doing to implement the auditor general's local and national recommendations and to address the issues raised in the peer review process?

Sure. Shall I start? Thank you for that, and thanks for the opportunity to present on primary out-of-hours services. Yes, I think the health board has been on quite a journey over the last 12 to 18 months on the primary care out-of-hours services. A lot's been happening over that period to improve resilience across the service in terms of that. There are a number of key areas in the report when it was presented. Funding was one of those areas. Our performance was another area and some general governance issues were picked up as well. I think we'll be able to discuss today some progress in those areas. We hope to be able to demonstrate to you that that is the case. I think we've had a significant increase in funding for the service. Again, we'll go through that in the meeting, I'm sure. There is some continuous improvement now in our performance position over last year and this year, so we're hoping to be able to share that with you too, and some of that was in the report that we gave you. And we have embedded the primary care out-of-hours service firmly in the strategic direction for the health board. It features heavily in our board meetings, and we have developed a workforce plan also, which is a key area of improvement over the last 12 to 18 months.

The improvement we are seeing—which is not complete and is not where it needs to be yet, but it is going in the right direction, we believe—is through reform and investment. We need to continue that to ensure that we meet Welsh Government targets that have been set. In this period, like other services, we have undergone an out-of-hours peer review. That was a very positive overview that we had back from that. Clearly, there are challenges for us, but, clearly, a recognition of significant improvements in resilience. In that review, there were a number of areas of practice within our service that were recommended on an all-Wales level, and we're very grateful to colleagues in the peer review who did that.   

Were those areas that were recommended for improvement—were those new areas or had those been identified in previous reviews but not enacted? 

No, they're very much aligned. They were very much in keeping with what was coming through in the audit report, and very much in keeping with the themes of the issues that we've been facing generally, mainly around recruitment, but also about the opportunity to develop the service model further. So, there were some areas that were really helpful and aligned to some of the action plans that we're putting in place after the audit report. 

So, going forward for us, then, it's about developing the model. There are a number of areas where we still have much to do. They fall roughly into recruitment and retention, into further integration of the service, into service redesign going forward and into further public engagement around the service. So, those are the areas and priorities that we would want to take forward in this journey of improving the service overall. Thank you. 

Good. Clearly, some of these problems have been very long-standing, so are you confident—we may have been through all this before—that the areas for improvement identified now and some of the solutions are going to work this time? 

Yes. They have been long-standing, and as I know you'll be fully aware, they're not unique to our service. But I think some of the wider indications that we have now of where we are on the macro level, if you look at our shift fill, for example, related to our ability to recruit, we're seeing year-on-year improvement. Last month, for example, we filled shifts to 82 per cent, whereas it was about 78, 79 per cent in the same period last year. Our performance measures are showing some constant continuous improvement, so that access element appears to be improving as well. We covered 10 per cent more hours this year than we did last year—we covered 40,000 hours last year; we covered 44,000 hours this year. And the investment in financial terms in the service is going up. All of those are giving us an indication that it is going in the right direction, but there is absolutely more for us to do, particularly around recruitment, retention and further developing the service model going forward.   

Great, thanks. Vikki Howells. 

Thank you, Chair. I have some questions around out-of-hours provision for you. Firstly, what's your health board doing to help the public to understand the most appropriate circumstances in which to actually access out-of-hours care?   

Lisa, do you want to pick up on the signposting? 

Yes. I think in terms of the signposting, we have looked at our website, which is the place that people go to. So, again, we've updated information there that clearly sets out the opening times, when you should use the urgent out-of-hours primary care service, and we've also included information in there about what other services are available, so whether it's pharmacy, dentistry, optometry. So, we have updated the information on the website. We've worked with GP practices and others as well to develop posters to put up, so people are clearly aware again of when they should use the urgent out-of-hours primary care service. I think, again, from our perspective, it's also looking at some of the national messaging. So, you've got the information again around how you should be contacting all the different services. So, we've just tried to keep a consistent message there. And the other thing that we have also done is to roll out a consistent message on the answer phones for GP practices across Cardiff and Vale.

Well, that's good news, because the evidence we've had here was that that was something that still needed to be worked on. So, that's been a very recent change then, has it?

Yes. We have been doing spot checks on the consistent answer phone messages. So, as I say, those were rolled out. There were one or two that didn't have them at one stage, and some of that was the Welsh language element as well. But we have and will continue to do those sorts of checks. But the information on the website, again, I do look regularly at that, and that has all been updated.

How much demand is your out-of-hours service experiencing from patients who would have been better served by accessing a different service?

It does vary, but we're looking at about—. We can refer out about 20 per cent of patients who do contact the service. This doesn't mean they're inappropriately contacting the service overall, but they could have maybe gone somewhere else to meet that demand. And I think that, sometimes, patients don't know where to go, and so the default always is a GP, and the GP in hours receives things that are inappropriate that could have gone somewhere else, and, by extension, the out-of-hours service receives that contact. I think there is an issue at the moment with signposting patients to other services. So, this could be community opticians, community pharmacists, dentistry sometimes, and also sometimes, actually, not needing to contact anybody at all, and self-help—so using symptom checkers online. Because we are in an age now where everything is available online, but if you don't use a proper checker—. If you go on Google now, with any condition, it's either going to be cancer or a heart attack you're going to have. And so, using a symptom checker, which is available sometimes through NHS Direct, may also help streamline people to the most appropriate service. But the default has always been I think in healthcare to speak to the GP, and then that's where we tend to signpost people to.

So those 20 per cent, would they actually present at out-of-hours centres, or would they have been dealt with over the phone—?

No. We're a phone-first service; we're not a direct walk-in service, so this will usually be over the phone. Some conditions may be able to be redirected at our call-handler stage, so this is before even getting to a clinician, and these are where we have our Choose Well messages—directing to pharmacy for repeat prescriptions sometimes, and also our community opticians. We do have what we call a decision-support template, where we can redirect people in that direction as well.

And what about dentistry, because your written evidence suggests that 8 per cent of calls to your out-of-hours service relate to dental calls? Are dental conditions formally within the scope of your out-of-hours service, and would you say that's typical across Wales?

We're different from other health boards in that we actually directly manage dentistry. This is done by dental nurses. We have hired dental nurses who do work for our service. Sometimes we may have GPs who have been trained to do some dental triage, but the vast majority are done by dental nurses.

That's very interesting, thank you. The auditor general's national report recommends the development of a nationally agreed definition of the scope of out-of-hours services. Do you think such a definition would help your local out-of-hours service and, if so, in what way?

I think defining the service is really important, and I think that happening nationally as well as locally is really key and helpful. Defining it as urgent primary care is really important—it's as much about what it is and what it isn't, I think is really helpful. I think it's helpful in managing patient expectations, because the standards of access, in hours and out of hours, are different. But actually, in the out-of-hours service, it's often quicker in terms of that, and understanding when it should and shouldn't be used in that sense. Finally, I would say it's really important in terms of where it sits in the overall unscheduled care pathways—so it's clear the role that the primary care out-of-hours service plays in that overall pathway in the end-to-end position, so that, actually, if we can explain that clearly, I think people will have a better understanding as to what points and where to access the service along the pathway.

Okay. Thank you. The auditor general's local report highlighted some comparatively poor performance from your local health board regarding call-backs to patients and some mixed performance also in the timeliness of home visits and appointments. Your written evidence certainly suggests an improvement in the timeliness of triage, home visits and appointments. So, how have you achieved these improvements, and what further actions are you planning to ensure compliance with the national standards?