Y Pwyllgor Cyfrifon Cyhoeddus - Y Bumed Senedd
Public Accounts Committee - Fifth Senedd29/04/2019
Aelodau'r Pwyllgor a oedd yn bresennol
Committee Members in Attendance
|Adam Price AM|
|Jenny Rathbone AM|
|Mohammad Asghar AM|
|Neil Hamilton AM|
|Nick Ramsay AM||Cadeirydd y Pwyllgor|
|Rhianon Passmore AM|
Y rhai eraill a oedd yn bresennol
Others in Attendance
|Adrian Crompton||Archwilydd Cyffredinol Cymru|
|Auditor General for Wales|
|Dave Thomas||Swyddfa Archwilio Cymru|
|Wales Audit Office|
|Dr Andrew Goodall||Cyfarwyddwr Cyffredinol Iechyd a Gwasanaethau Cymdeithasol, Llywodraeth Cymru / Prif Weithredwr GIG Cymru|
|Director General, Health and Social Services, Welsh Government / Chief Executive, NHS Wales|
|Judith Paget||Prif Weithredwr Bwrdd Iechyd Lleol Prifysgol Aneurin Bevan, Cadeirydd Bwrdd Gofal Sylfaenol Gwladol ac Arweinydd Strategol Gwasanaeth y Tu Allan i Oriau|
|Chief Executive of Aneurin Bevan University Local Health Board, Chair of the National Primary Care Board and Strategic Lead for Out-of-hours Services|
|Simon Dean||Dirprwy Brif Weithredwr GIG Cymru|
|Deputy Chief Executive, NHS Wales|
|Stephen Lisle||Swyddfa Archwilio Cymru|
|Wales Audit Office|
Swyddogion y Senedd a oedd yn bresennol
Senedd Officials in Attendance
|Katie Wyatt||Cynghorydd Cyfreithiol|
|Meriel Singleton||Ail Glerc|
Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.
The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.
Dechreuodd y cyfarfod am 13:34.
The meeting began at 13:34.
Welcome, Members. Welcome back from your Easter recess and welcome to this afternoon's meeting of the Public Accounts Committee. As usual, headsets are available for translation and sound amplification. Please ensure any phones are on silent. In an emergency, follow the ushers. We've received one apology today from Vikki Howells and no substitutions. Are there any declarations of interest Members would like to make before we proceed? No.
Okay, item 2 and papers to note. In relation to a request for additional information, the Cardiff and Vale University Health Board have confirmed that there were two periods when increased rates for GPs were paid to fill out-of-hours shifts at short notice. These were in April and December 2018. There have also been two cases in the last year where there were complaints against the out-of-hours service, which the board accepted liability for and compensation was agreed. Can we note that paper?
And secondly, an update from the Welsh Government on the implementation of the report recommendations on Natural Resources Wales, and the Welsh Government have sent us an update on the implementation of recommendation 3 of that report. The Minister for Environment, Energy and Rural Affairs has advised that they're confident that the independent review of the governance of timber was sufficient and provides a comprehensive analysis of the issues and they do not believe that they need to seek a further review. Happy to note that paper?
And the Welsh Government have also provided information regarding the take-up of independent prescribing courses as part of their update to the committee on implementation of the recommendations made in our 'Medicines Management' report. We need to note that paper and also recognise that the Welsh Government will provide a further update in October of this year, so we look forward to receiving that.
Okay, item 3 and the Welsh Government's relationship with Pinewood. We're going to have a debate on this in Plenary on Wednesday, and we've received the Welsh Government's response. Auditor general, did your team want to make any comments on that?
Yes, just a few, Nick. Overall, from our perspective, we're pleased to see that the Government has accepted almost all of the committee's recommendations. The one exception is recommendation 8, relating to the need to acquire a survey for properties over a certain value. Though rejected as drafted, I think in principle it's clear that the Government has accepted the thrust of what the committee is after. So, from my perspective, I'm comfortable with that. The response refers to the production of a guide that they will apply to future property acquisitions, so my team can pick that up and check that it's been complied with in future work.
A couple of minor comments on some other of the recommendations. Recommendation 5, relating to conflict of interest: my comment there is that I think it's accepted, yes, but the response is quite narrowly drawn, relating solely to the Pinewood situation. Rather than exchange more correspondence, I suggest that's something you could pick up when Andrew Slade, the accounting officer, is in front of you in a few weeks' time in relation to business finance.
And, on the very first recommendation—accepted, which is great—the response refers to a lessons learned report. The committee might want to consider getting hold of that to see what lessons have been learned from how the Government has responded. But, overall, from our perspective, very pleased.
And we should have further financial and performance information in December, so we can return to that at that point. Okay, good. As I said earlier, we've got a Plenary debate on the Pinewood inquiry on 1 May, on Wednesday.
Moving on, item 4: primary care out-of-hours service. We've got an evidence session with the Welsh Government. I welcome our witnesses. Thank you for being with us today, and thank you for the evidence paper. Would you like to give your name and position for the record?
I'm Andrew Goodall. I'm the NHS Wales chief executive and director general.
Simon Dean, deputy chief executive, NHS Wales.
Judith Paget, chief executive of Aneurin Bevan University Health Board and strategic lead for out-of-hours services.
Chair, I'm grateful to Judith for joining us. Given she is overseeing some of the national work, it's helpful to have her alongside us with some of the reflections for you today.
Good to see you, Judith, in the Assembly rather than the meetings I have with you up in the constituency, but thanks for being with us this afternoon. We've got a fair number of questions for you, so I'll kick off with the first few and a general question to start. How would you classify the current state of primary care out-of-hours services in Wales? And can you say little bit more about the new model of primary care you refer to in your evidence paper?
Okay. First of all, just to acknowledge from the report that this was a very challenging and difficult report. I know that some time has passed since this was originally issued by the Wales Audit Office, but it would be right to say that out-of-hours remains a service that is under pressure in the Welsh context but across the UK. I hope that we've been able to put in a range of actions, at least, over the last couple of years since the helpful report, just to give some confidence and assurance, and, of course, recognising that local health boards retain the statutory responsibility for the provision of out-of-hours services. I was at least pleased within the Wales Audit Office report that the quality and satisfaction with the service remained high, but it's really important that we do focus on the fragility.
I think that out-of-hours services have moved on an awful lot over many years, so what was a more fragmented service—when we go back to 2004, in particular, I was around as a chief executive, as Judith was, at the time when the contract changes were made. Originally, out-of-hours services were run by local practices. Sometimes there were network arrangements in place with general practitioners, and we've moved what was a very local, accessible service to something now working on the health board templates, and, obviously, with national oversight at this stage. So, there's quite a lot of change that's happened over the years.
There are key factors still I think affecting services, not least the same difficulties that will apply to other services around staff recruitment, the ability to recruit in. There have been financial aspects around the services, so some impact of UK-level decisions that would've made perhaps different decisions, but I don't think any of that can remove from the fact that we have to focus on offering out-of-hours services from a staff perspective that are attractive for people to work within, that support them in terms of their conditions, and actually ensure that we have a real advantage to make sure that what used to be, I think, a GP-delivered service is actually GP-led with the right level of support and professional support around it.
I think that the changes that we've introduced more recently, which are connected to our statement around our primary care model for Wales, are really important. We feel that there is a real opportunity around out-of-hours services to make sure that patients don't always need to access the GP. They are an important part of our system and our oversight, but our own data would tell us that probably only around 30 per cent of all of the calls that we get into the system probably actually need a GP response; they can well access other practitioners within the system. And I think across Wales, it's still a system that occurs at scale. So, it has a really important role as a contribution to the way we run our unscheduled and urgent care services. A little bit of comparison on our numbers: out-of-hours calls every year—probably around 0.5 million coming through the system. If you compare that with other access points—the ambulance service itself has around 0.5 million calls. Our accident and emergency departments receive around a million individuals. That is still quite a high volume activity when you aggregate it across all of the range of health boards in Wales.
So, I think a particular change that we've introduced in response to the Wales Audit Office report is starting to be clearer about our national framework and our expectations, while still trying to secure that the responsibility for safe services locally must remain with the health boards as individual organisations. We have tried to focus on a number of areas there: a different approach to national recruitment, first of all; the introduction and oversight of peer review mechanisms, which didn't exist before; listening to our clinical teams about the standards that were in place, and we've developed those subsequently over the recent time. And I think a particular offer over this recent period of time has been just seeing the translation into the implementation of our 111 approach in Wales, and whilst that is associated with technology, the 111 approach is actually about service access for people to be able to go to the right practitioner at the right time—
You just mentioned—. I was going to ask you about the peer review process that you refer to in your evidence papers. What are the key learning points that have come out of that process?
I think the peer review process was set up firstly to make sure that whilst there were responsibilities locally and regionally, individual organisations could learn from each other. I would say that the tone of those has been well received by the clinicians. I think it's allowed them to understand that they can influence from a position of authority because of their direct experience of the services at this stage. I think, genuinely, every area of Wales—although they will have highlighted some concerns and some areas to address—has welcomed the approach.
On some of the summary messages here, I think the teams have wanted to see that there is a real declaration of support about how out-of-hours fits with the local services. It operates for the majority of our time within the service, and I think there were some worries that perhaps boards weren't receiving at such a high profile as was expected, so we've had a real change around that kind of support. We have allowed local organisations over time to build up their own approaches to how they calculate activity and workload. So, the peer review process has allowed us to bring through much more consistency around some of the processes there. We've been able to standardise some of the triage mechanisms. Some of the teams that are probably leading with some of their implementation and multidisciplinary teams, so, again, through the peer review process, experiences like ABMU—as was as an organisation—have been able to influence the practice of some of the roll-out of multidisciplinary teams as well. But I think they have also been able to demonstrate some really excellent experience of out-of-hours access to services. Not all are within perhaps the traditional out-of-hours service. So, as an example—I mean, Judith is alongside me, but particular reflections through the peer review process on the arrangements that were put in place in Aneurin Bevan about palliative care and oversight via district nursing services and the way in which that is accessed particularly standing out in Wales. So, whilst we accept that that is a good example from one of our health boards in Wales, the peer review process allows us to see whether we can look to roll that out and make sure that the learning is spread more widely. And not all of those things, I think, are resource issues; they are just questions and choices for individual services. Judith, you might have more experience, because you oversee it as the chair of the panel.
Yes, thank you.
It should operate automatically.
Oh, great, it is. I think, in terms of the peer review process, as Andrew has mentioned, it was very welcomed by clinicians and teams working in out-of-hours. I think it was welcomed by health boards as well, because it's allowing some sharing of good practice. In terms of the outcome, we've been able to be really clear about the things that need to be resolved at an individual health board level. So, there were some concerns in some parts of Wales about the accommodation that was used to deliver the out-of-hours service and that's been fed back to the health boards. There were some pieces of work that can be managed on a regional basis, so the introduction of 111 in Wales provides us the opportunity to have clinical hubs on a regional basis, so there's some opportunity there to have a consistency of approach in that region between health boards and the opportunity to do some different things like the introduction of mental health practitioners, or palliative care support services. And then there is a whole range of actions that we're now picking up nationally, whether it's around making sure we have a consistent approach to demand capacity modelling, whether it's for certain things—. We need a consistent approach to clinical pathways, training programmes, leadership programmes and a whole host of work around workforce development, recruitment, and making sure that we give the best chance and the best opportunity for out-of-hours services to attract people to come and work within them—so, a whole host of things that are being picked up, either at the health board level, regional level and national level. And the group that I'm currently overseeing on Andrew's behalf will make sure that we keep an eye on that and we will revisit health boards later this year, as we approach next winter, to actually check on the progress that's being made and any other things that we need to pick up as we move into the next winter period.
Okay. I think—
Sorry, Chair. One area that we're trying to ensure that happens—and you did ask me about our approach on primary care more broadly—is that there are specifics about out-of-hours services that we've wanted to focus on through some of the national work. But what we are trying to make sure is that we're able to balance and bring some level of consistency between out-of-hours and in-hours approaches of our normal set of GP practices and primary care access. So, I think, within the peer review process, there was a danger of sometimes perhaps forgetting about those hours and there are many things that we're looking to standardise, not least about access through the normal working hours that are still important, I think, to the development of out-of-hours too.
Just before we move on, I just wanted to get a bit of number crunching out of the way, because you mentioned 0.5 million people using the out-of-hours service, 0.5 million people ringing the ambulance and I think another 0.5 million using the emergency departments. I'm sure it's not the case that half of the population is using one of these services in any given year, and I just wondered if anybody within a health board has done any analysis of how much they're the same people using all three services.
Yes. There is some analysis, more probably within local organisations than at a national level, because we know that that's not necessarily individuals across Wales all just choosing to go at various stages; there are a number of people who are accessing the services on a more regular basis than—
Okay. Obviously, they'll be visitors and—
So, I would've thought that, if it helps, we could probably bring out some assessment, even if it's through the eyes of one of the health boards in Wales, just to demonstrate those differences. But there are issues of scale with our delivery of services across Wales, where we clearly have patients and communities wanting to access a wide variety of services. We have 3 million out-patient attendances a year and we have a population of 3 million. So, perhaps I could commit to doing some of that reconciliation for you at least for one organisation, and, if it's possible to do it nationally, we'll bring that to your attention.
Because I think it's important to understand is this because people aren't able to access the in-hours service and therefore they're coming to out-of-hours, or is it because, genuinely, something has occurred that means that they need to use out-of-hours.
We think there's some combination. In general terms, people seem to be broadly accessing out-of-hours for the right reasons. At times, it can show a lack of access, maybe, with issues in some areas, so there is some variation around dental access, for example, where I think that Cardiff have got themselves now to a very good point, but probably there is more work for us to do with Hywel Dda about making sure that people have the access to services.
I think, when we're looking at consistency around the standards that are available—because we measure some of the time and the response for our out-of-hours services—there is an underlying worry that, if it's understood that you can ring and be seen within two hours, four hours, six hours, does that affect the public's approach to how they access some of our services? It's a little similar to how accident and emergency departments work as well. You know broadly you are going to be seen within four hours. So, I think we have to give people confidence about the in-hours access, and you may recall that recently the health Minister had actually made an announcement about a change around access standards that we are now working with in the primary care system, hopefully to give a bit more reassurance that people can access those services when they need them at the right time.
Disappointing that the GPs' trade union then said that it wasn't possible to respond to those new standards. So, there are clearly some areas of conflict within the system that need resolving.
Indeed, and those standards are part of our normal contract negotiations, which happen every year, and I'm sure that they will, as usual, come to their fruition and will have the outcomes that we expect, which will improve access in these services. But, certainly, for the out-of-hours access at this stage, patients will inevitably turn up who have a different urgency as well. So, the fact that we have time standards that are for those who are most urgent and then those who can wait more routinely, I still think demonstrates that there is some opportunity to spread the load a little bit across our system.
Yes, I'd like to ask some questions about the public's understanding of how and when to use services, because, obviously, better signposting means that there's less time wasted on both sides. It benefits the patient and those providing the services. In the auditor general's report, the first recommendation was the need to standardise the way that out-of-hours services are described on NHS websites, phone lines and other sources of information, and, in particular, the need for a nationally agreed definition of out-of-hours services and their scope. Can you tell us how far you've got with this nationally agreed definition?
So, on the definition, I think, since the time of the WAO report and the response that we have been working through, a broader approach to defining primary care access on a 24/7 basis, rather than only focusing on out-of-hours very specifically—. So, I think there's been a changing context from the timing of the original review that has happened, and I think we have been building up on that. Some of the work that we did on the primary care model for Wales has been very focused on 24/7 access. So, I think there are components of out-of-hours that we do need to be more discrete about, notably, where there are recruitment difficulties, for example. But we've tried to talk more generally about a system that is about 24/7 access and accessing the right service across the range of primary care and urgent services.
But I think your point on public understanding is right. Inevitably, the way the NHS works can still feel very complicated, and I'm very mindful that, at the moments of greatest anxiety for our communities, when they're looking to access services, it's not always easy to make the choice that we would feel, technically, is the right choice to make. They simply want to access the service as soon as possible. So, whether that is knowing when to go to an out-of-hours service or to ring NHS Direct or to ring the ambulance service or to go to a 999 department—there is so much more that we need to do. I think we can help with some of that, though. So, certainly having a more common template for the way in which all of the health boards are describing these issues is important, but we have to continually evaluate, I think, some of the reasons why patients are attending, not least as your Assembly Member colleague was just asking as well. Judith, you probably have a little bit of experience of this in your local setting.
Yes, I think the way that we broadly describe the need is about urgent primary care: so, do you need access to something urgent whilst your doctor's surgery is closed that cannot wait until your doctor's surgery reopens again? That's the way that we describe it, and we promote the availability of our GP out-of-hours service proactively through social media, et cetera. I think the distinction and our ability to communicate with the population around numbers to call will be much easier when we simplify the system by having 111 as a national number available to everybody, because we'll be able to communicate that, if you've got something that threatens life or limb, you ring 999, and, if you're not sure about anything else, you ring 111 and let the call handler support you and help you. So, I think that will become simpler over time. In the meantime, this idea of being able to have access to urgent primary care over the 24/7 period, and that there will be somebody there when your doctor's surgery is closed to support you, is the best way that I've found of communicating that to people.
But we have signed off some technical areas. It was good to get agreement with the BMA, the general practitioners committee and the negotiating committee, just on the language that is used, for example, on the course, so, if people do have to ring their practice number, it's now standardised in terms of the messages that are given out, whereas I think there was variation before, which was one of the criticisms of the WAO report.
So, are you saying that you don't think there is quite the need that was originally anticipated for this nationally agreed definition, or—?
I think the way in which we've started to look more broadly at that 24/7 access and balancing out-of-hours alongside other urgent and emergency parts of our system, has just opened up that definition. What I would agree with, and the original WAO reflection, is that doesn't remove that there are some particular pressures around out-of-hours services, as I said, and the fact that we're doing some very specific recruitment activity on a national basis about attracting people into that through our 'Train. Work. Live.' campaign, demonstrates that we know that we've had to target it as an area. But, from a definition perspective, I see that as much broader.
Can I add to that, if that's okay? I think when GP out-of-hours was a traditional GP out-of-hours, i.e., the only option was to speak to a GP or see a GP, that would be one definition, but as we're moving now to how do we make sure that we design a service that is available over the 24/7 period, what might be available overnight or on weekends or on a bank holiday might be slightly different to what is available at other times of the week. But, actually, that broader definition is really important. If we define it too narrowly, our ability to flex the service model will be difficult.
There is a lot of anecdotal evidence that patients use out-of-hours services for routine care, and indeed in oral evidence from health boards we had evidence from Cardiff and Vale suggesting about 20 per cent of patients who contact out-of-hours services are referred to other health and care services. So, you're expecting that the simple move to a binary system, where it's either 111 or 999, is likely significantly to reduce percentages of that kind.
Yes, because patients are accessing services because they have a need, but that need doesn't always need to start with a default to an accident and emergency department, or indeed even to an urgent out-of-hours service, but what we do know is that they are looking for the right level of support to be available. So, technology can help us with that. Having a national approach around the directory of services, which has the available choices, ranging from the NHS, local government provision, through to third sector, is really important. And then we'll have to continue, I think, to work on experiences around this to get the balance correct.
I'm glad you mentioned the national directory of services, because your letter of 1 August 2018 mentioned ongoing work to develop an app using the national directory of services to help people make informed choices about where they need to go for whatever their particular need is. Can you tell us what progress you're making with that?
Yes. The app itself is a technical response, but the most important thing is actually making sure that we line up the directory of services. So, we have now got three sources of information: Dewis Cymru, we also have the NHS Direct, and we also have another information source that we've been trying to bring together at this stage. The app, in its development at the moment, has been completed in terms of what we wanted to pull together. We've managed to draw together experiences from local government, the third sector and the NHS more broadly to have that effectively in place. We're looking to launch that as part of an out-of-hours event that is occurring over the forthcoming weeks, so that we can make that visible and available. There's still just some outstanding work about making sure that the directory is at all times up to speed. It's not just a moment of time, it's something that has to be actively available, and we just want to have some confidence that that can happen at this stage. But, yes, the app has been developed itself, but the most important piece of work was actually drawing together the various parts of the information.
We have had experience of introducing other apps to just see whether we're able to signpost and support access in different ways. So, in fact, we have had an app available around A&E departments, just demonstrating that there are choices that people can make about alternative services there. So, we already have some experience at least of how this has started to change some of the flows, so that patients can make some decisions about what they're accessing. But when I say an event to come, literally over the forthcoming weeks was when we were looking to do that, and that was obviously with ministerial involvement.
Okay, thank you very much.
The auditor general's report highlighted the difficulties that health boards were having to meet the previous national standards for out-of-hours services and I wondered if you could tell us why you think health boards found it so difficult and continue to find it challenging to meet the targets.
I think some of the answer to that is actually through the reflections from the WAO themselves. Out-of-hours has been operating in a challenging and difficult environment and, clearly, if there was evidence of difficulties in filling shifts, in attracting the workforce to be retained, this would have an ongoing impact in terms of the ability to deal with some of the standards.
I think some of the tradition that I've tried to describe—. I won't go all the way back to 2004, but trying to bring a service that was, for all the right reasons, fragmented at a local level into something that is more standardised, at least a health board template into a national approach, is also part of that as well. But I think also, speaking openly, the way in which the standards themselves offer different, even improved access from what the in-hours system offers is probably a factor as well, because the majority of our workforce and the pairs of hands available to support patients through the system does operate more broadly nine to five, Monday to Friday, than it does on a 24/7 basis.
I think what we were struck by, however, and this is from reflections from some of the national work that Judith has been overseeing, is that the standards themselves weren't necessarily felt to be wholly right from a clinical perspective. So, whilst they gave you a time insight, there's been some real interest, not least about how we've tried to take forward the ambulance service model about trying to focus more on quality and outcomes for patients within that process, rather than just ticking the box because a routine patient has managed to get through a service in a number of hours.
So, particularly over these last few months—and we launched them at the beginning of April—we've now issued new standards, so there's a bit more of a clinical feel about what's able to be delivered. We've still continued to measure and monitor the old standards to this date, but the clinical teams seem happier that they've now got access to quality measures. We're looking at adverse incidents, we're looking at some of the Datix incident reporting system in a different way, and we've tried to embed a quality improvement approach, actually, into the out-of-hours service as well. So, we'll have to see how different that feels.
On our general performance on standards, whilst we've been short on access on some of the general measures of performance, we've at least seen some signs of improvement over the last 12 months in particular. I think we'd all reflect that, while it's been a very busy winter, even from an out-of-hours perspective, the service has felt more resilient, and that would be reinforced by things like the fill rate of shifts that have taken place. So we can't be complacent about that at this time, but we'd like to just make sure that the standards are seen to be genuinely another way of improving the standard.
If I just go back a year or so, back in 2017-18, when we produced the first summaries on a health board basis, generally speaking, the standards are able to be met in terms of the general principles; it's just more the access points that I think is the real area to look to change within the system, and I think that's where we've got to put most of our efforts in.
How much do you think it was due to boards not allocating the resources needed to employ the appropriate staff to properly have a sufficient crew of people to deliver the out-of-hours?
I'd probably stand back a little bit on that, because there's a danger of us fixing on some numbers that apply only on the out-of-hours side, and certainly we've tracked a budget that was originally handed over when the contract reform changes happened that was the very traditional approach to out-of-hours services. We have enhanced that, so there's been an ability to ensure extra investment to keep pace, but there's a danger, I think, of tracking the individual budget line, rather than looking at the wider range of services that are being put in place to access in out-of-hours.
Judith, I don't know if it's worth talking about the way in which frailty services and district nursing would be accessed, for example, where you have invested money and expanded.
Yes, certainly. From our health board's position, the investment was there. Some of the difficulties we encountered were actually our ability to recruit and attract GPs to work in the service. Our approach to that was very much about thinking about talking to GPs about what would encourage them to work in our service. Sometimes pay rates were discussed, but actually that wasn't a key issue; it was more about feeling supported, about having a team around them so they weren't feeling as though they were working as an isolated practitioner, that they had services they could draw on. So, we invested, then, in an overnight district nursing service so that the district nurses could be there overnight in support of GPs. Also, the service broadened out. So, we had frailty services that we jointly invested with our local authorities in so that, on weekends, they had access to other forms of service. And I think it's about training, education, support, making people feel listened to and putting all the usual mechanisms in to make the workforce feel as if they're valued and part of a team. So, I think that those were some of the things that we did, and that's certainly helped our fill rates. Our fill rates for GPs have gone up to about 90 per cent now over this winter. There's still more work to do, and the national work will really help. But I think it's not just about investment; it's about making the service an attractive place to work.
Okay. So, how much do you think that approach has rubbed off on other health boards?
I think, through the peer review process, one of the key aims of the peer review process was to find good practice that was out there across all of the health boards and provide a forum for sharing that. So, sharing that nationally, we're going to have—. Obviously, everybody's had their own local reports and there's been a national report that they've been able to see, and we're going to run a conference event in June to share that as well and to talk about some of the good practice. And I think it's about following that up and making sure that some of that good practice gets rolled out and adopted. Some of it we can do nationally. So, as Andrew mentioned, there was a particular reference in the Aneurin Bevan peer review about the work that teams were doing around verification of death and support to people following unexpected death at home, in terms of end-of-life care, and that's been picked up and will be issued nationally as a piece of work from Welsh Government. So, I think there are things we can do to make sure that those lessons are shared and adopted.
Just in terms of differences across health boards, Aneurin Bevan, I know, is partially represented by Judith being with us here today, but I would comment that, probably, those organisations taking a broader view around the multidisciplinary teams are making progress, and we certainly saw that as a key element of success about Abertawe Bro Morgannwg rolling out 111. They were the first phase, and, to be honest, I don't think they would have had such a successful arrangement if it had simply been only in the GP-delivered context. They had broadened out the teams to make sure that they were fully staffed to receive that. I sense, on the figures I see but I also saw the transcript of the session when Cardiff attended, that Cardiff are still thinking very much in this broader context of the services that are available. There are a couple of things that would reinforce that for me in terms of their local strategy as well.
And I would have said that probably it felt that Hywel Dda were struggling more so. I think the challenges of their rural area may be more so, but, again, I think they've made an awful lot of improvement and change over the course of the last couple of years. And, hopefully, the experiences of some of the other health boards would give them confidence that they are now focused on the right types of actions, even for that broader rural community.
You mentioned earlier the analysis of adverse incidents. How do you think the redefinition of national standards will ensure the consistency that we obviously will need to avoid adverse incidents?
There have genuinely been issues around the data comparison. So, whilst the standards framework itself has been consistent over time, unfortunately the data that has been brought out, because of some of the differences of systems across Wales, has been more problematic. So, certainly, we would be expecting an improvement around the consistency now with the Adastra system—everybody working off the same version at this stage. Of course, we do need to track—
So, they're not at the moment.
No. Six out of the seven organisations have the current same version. Cardiff is just imminently about to switch over, over the forthcoming weeks basically, which will give us that platform. And the secondary issue there will be the purchase of the 111 system and the procurement process that's happening around that. Again, that will bring a lot to bear.
On the application of the data and the consistency of the standards, Simon, anything you'd want to add?
I think it links into comments that colleagues have made. It was a key feed-in to the peer review process, so it's that mutual learning, in the sense of engagement with clinical teams. My sense is that it's made quite a big difference, actually, in the sense of prominence attached to it in individual health boards. Opportunities for learning are definitely there, and, as Andrew said, we've come from a legacy position of disparate services on very different information platforms, which is changing. There is more to do. We've got the procurement of the new IT system, which is going to take another couple of years to roll through, but we can see distinct signs of improvement, greater engagement and greater focus.
So, is it your responsibility to pull together the main findings coming from health boards' annual reports and how we get everybody up to the excellent level that we want?
Yes, we will be, as Dr Goodall said. The primary responsibility for delivery of out-of-hours services rests with health boards. We obviously want to make sure that they are discharging that effectively. For the work that was done on the individual health board annual reports last year, we used that as a key feed-in to the peer review process. We've recently issued guidance to health boards about the annual report for the year we've just finished, so 2018-19. The guidance went out in the middle of April, and we'll be expecting them to report back to us in July, I believe it is. So, that will have a couple of benefits. One is that that work will be able to be shared through the peer review process revisits that Judith mentioned, and will also produce an all-Wales view of what those data are telling us across the system. We do need to recognise that we will still have some data elements that are not as complete as we would like, but it should be more complete than last year's, if I can put it that way. So, we're going to need to put some caveats around it. But the key is about comparison and learning.
Okay. And this guidance has been published, or is it just a private correspondence between—
It's gone to health boards. It's not complex, it's simply a template—nothing particularly significant or substantial in it. So, we're just looking for consistency of response so that we can aggregate the data. If we didn't have a standard template, we would be trying to pull together very disparate presentations of the same data.
Jenny, I think Rhianon Passmore has a supplementary on this point, if I can just bring her in.
Just really, I suppose, to dig a little bit deeper in terms of the peer review process. Obviously, I welcome Judith to the pan-Wales table around this matter. So, these are very generic issues, in terms of workforce development, in terms of recruitment. You've mentioned district nursing, and supported teams, and wider multidisciplinary team working for GPs in this out-of-hours context. So, really, I'm trying to understand, further to the peer review process—and you've mentioned there'll be a conference, and you've mentioned the annual report—really, what other mechanism is there to be able to enforce less fragmentation in this regard, more consistency, which is what we'd all agree we need? There doesn't really seem to be any teeth, in terms of a mechanism to be able to get health boards to do what seems to be fairly standard agreed ways forwards, strategically. So, is it enough—the peer review process?
I think the peer review process has moved our environment on significantly. So, I accept that, whilst that is feeling more light touch about bringing our clinicians together in a room, it does come, actually, with raising the bar, I think, about some of those peer expectations. And in some of our experience, actually generating that understanding and even competition across clinical teams can be quite important, I think, to generate it. But it's really important that we find our own ways of drawing it in, without us encroaching on the day-to-day operational services but how we have the status of this recognised in terms of our expectations. And, over the last couple of years, we've also been converting discussions that maybe have been more local and discrete into using our quality and delivery meetings, about raising our expectations, about our mid-year and our end-of-year reviews with health boards, that these are dealt with through the annual reports that are being received by boards, with an expectation that that is discharging governance—
So, if I can just cut in, you're talking about raising expectation—that's more communicative and awareness building. I'm really asking what further mechanism can there be added, if you feel this is necessary, to what we currently have. Because it seems to be that we're all talking about these issues, and the peer review process has identified them, and I would have thought every professional worth their salt, in every health board, would be completely aware of the issues that we're talking about. So, in terms of pace and scale, internationally, are there other mechanisms that are used, in terms of being able to change what we've got so that we have that greater consistency?
Simon, any reflections from you?
I think that there's something for me in this about tone. I think if we were looking at out-of-hours services in the NHS and we couldn't see them wanting to develop, we couldn't see them wanting to learn, we couldn't see them wanting to innovate, we couldn't see them wanting to manage the challenges that they do face—very practical challenges—then perhaps that might lead to a different tone of conversation. But I think the fact that we can see those things, and I think the peer review process, as colleagues, Judith and Andrew, have outlined earlier, suggests that this is really pushing at an open door. So, I think it's about getting alongside the services and helping them find ways to achieve what they want to achieve, as opposed to having to wield a big stick to get people to do things that they don't want to do. So, it's about getting alongside and recognising that there are some things that out-of-hours services and health boards should simply be able to do and other things that are more challenging. So, some of the recruitment issues are more challenging, particularly for general practice; they can be ameliorated to a large extent, but not completely, by some of the things that Judith was outlining in terms of the availability of district nursing in palliative care, for example.
So, if I can, and briefly, Chair, if I may, from your perspective, Judith, what else is necessary to increase this pace of change, without using goodwill?
I think it's not just about goodwill. I think the work that's been done nationally around out-of-hours and the development of 111 is actually creating a different environment in which the out-of-hours service works. I think the primary care programme and the primary care plan, which focuses on many aspects of primary care delivery but making sure that we're clear on the 24/7 requirements, are also pointing us in the right direction.
I think the standards that have come out, the quality indicators, the performance measures and the context that Welsh Government colleagues are creating for health boards in terms of expectation are really important, but I do pick up Simon's point, which I think shouldn't be underestimated, about the goodwill that exists within the different out-of-hours services and the fact that the clinical leads from the out-of-hours are coming together. They've set up a separate quality forum where they can share good practice, understand what's coming out in terms of lessons learned from complaints or serious incidents, and they are actually working together to try and improve the system, which wouldn't have happened probably even maybe 18 months ago, two years ago, in terms of that openness about trying to improve things.
So, I think in terms of levers, there are many. I think in terms of goodwill, we're seeing that really good collaboration from the out-of-hours services. In terms of things that we can drive nationally through those groups, around workforce, around standards, around clinical pathways—the things where there needs to be one approach for Wales—we can do that through our national group. The things that need to be supported and developed through local out-of-hours services working together—I think the local out-of-hours clinical leads are really supportive of that as well. So, I think it's not a one-size-fits-alll; it's coming at it from the different directions and different levels.
I do think the roll-out of 111 has given some teeth, because that has converted what were local more parochial services into a national template, and I think we have been able to demonstrate that we can make progress on that.
Jenny, had you finished your questions?
I'll come back later.
Okay. Mohammad Asghar.
Thank you very much indeed, and good afternoon, panel. Before I ask my question, I'll ask Andrew: you just earlier mentioned that A&E get nearly 1 million calls a year. Am I right? So, that is the out-of-hours service and during the day. It's a staggering figure, 1 million. It's one in five—one in three, rather. It shows how pressured the NHS is in Wales. We visited the north Wales out-of-hours service and we visited the Aneurin Bevan hospital. Basically, if I give stars: five stars to Aneurin Bevan and one star to north Wales, Betsi Cadwaladr. Why is there so much difference, chief executive, on this side? Because out-of-hours is a very important service to the public. My question relates to morale and the capacity of the NHS and patient services in this area. Could you explain please why there is so much—? In your last report, when we met in August 2018, you said the Welsh Government had been working with other stakeholders over the previous 12 months, since 2017, and trying to understand how to make the out-of-hours service a more attractive place to work. What are the findings, please, from that work and how are you going to make it attractive for staff to work in this?
In respect of variation that exists across Wales, it's an inevitability because of that local accountability within health board organisations, and also the pattern of how those services have been provided historically. So, I think what we are trying to do is to respond to some of that.
On the experience around Betsi Cadwaladr, for example, we know that that was a service that was under particular pressure. It was a trigger point, amongst others, around special measures for that part. Obviously, I've been here to give evidence to the PAC previously around some of those reflections. Positively, however, that service, which has been under an enormous amount of pressure, has been able to be dropped as a special measures criteria, because they have made progress. We actually think that they helped with some of the general approach to the change standards in Wales, because there was work that was able to be done—I think Betsi Cadwaladr has been more a leading example of changes that have come elsewhere in Wales. But it's really important that we keep an eye on it, and of course there are features about the access and the balance of a range of services beyond out-of-hours itself. So, there's progress from Betsi Cadwaladr, but clearly we'll want to make sure that that is maintained at this stage. I do think that some of the clinicians up there have been doing a really good job in difficult circumstances.
On how do we make out-of-hours more attractive, there's sometimes a danger in our shorthand of almost defining out-of-hours services as being about locums—full shifts. Almost as if it's a temporary arrangement that we're putting right for the week ahead. And what we absolutely need to focus on is how do we have a substantive group of staff who are really committed to the delivery of out-of-hours services, who are owned and salaried by health boards because they operate those local services, who have a really balanced role alongside other colleagues. And, as Judith had reflected earlier, I think one of the dangers of our traditional approaches here was people feeling very isolated and, therefore, quite exposed often in difficult situations with potential incidents. I think we've taken a much more rounded approach on that.
I think we need to understand what is good about the service, though, because as we gather these national groups together there's a lot of passion and commitment from this group of staff, and I think we saw that through the peer review. So, showing that there is something about this service to attract people in is why I referred earlier to the 'Train. Work. Live.' approach, where we've now brought out-of-hours services in on that. And what's the best mechanism for promoting this? For those who are involved in the service to talk about their pride in it themselves. So, we have some ambassadors who are going to be part of that approach and working in these individual services and I think giving more of a voice to out-of-hours services. A couple of different examples—the development of the out-of-hours forum, the focus on quality and safety—I think have brought clinicians very much into a national forum, so, with shared problems and issues. But also, I think there has been definitely an upgrading of the nature of discussion of out-of-hours around the board tables in Wales. So, I do think that the health boards have actually had a much better focus of those.
But I sense that we're still going to have to work on lots of different issues. One of the pieces of work that I've commissioned Health Education and Improvement Wales to do, as our workforce organisation, is simply about how we promote website access, attract people in, provide the kind of information that is going to show them where they can choose to work in Wales in out-of-hours services, and that work should be completed shortly as well. So, I think we have to have a range of areas, not just one single issue on a local basis.
Thank you very much indeed. Dr Goodall, I know for a fact that you sent, just to improve the NHS in Wales, some doctors to the US for exploratory information from there—how we can improve our out-of-hours service. Have you got their report yet? And have you got anything to share with this committee?
I think that we need to recognise that we don't work in isolation. I think there are different models internationally, as well as in the UK, that allow us to learn about how we can provide these kinds of services. As England was going through its own 111 implementation, for example, which probably didn't quite engage at the start about the link between their own NHS Direct services and out-of-hours, there was quite a lot we could learn there. But certainly there are some international examples of how services that prevent people from landing in a hospital environment work. So, I know that Cardiff, for example, have got some good networks now linked with Canterbury in New Zealand, who have been going at a level of these changes over many years and their blend of alternative services as well as technology is quite important on that. So, I would definitely not wish us to be insular in Wales. I think we definitely need to look out at what is better for our patients.
Thank you very much. In our previous evidence session, Hywel Dda told us that the financial incentives were not successful in attracting GPs to fill certain shifts, and Cardiff and Vale told us that it had decided to invest in a second GP post overnight to ensure GPs are not isolated when working. To what extent is isolated working a barrier to attracting GPs to work in out-of-hours? And what is being done to address this issue please?
Judith, do you want to give a local example? And then I can maybe draw that into more of a national approach.
Certainly. When we were struggling to fill shifts in our out-of-hours service we actually took a lot of time talking to not only the GPs who were working in the service, but those who weren't about their reluctance to do so. I think that isolated working was a significant issue for them. And, of course, as in-day general practice becomes much more about a multidisciplinary team working together—. And if you can imagine, if you're a GP working in the in-hours service, you work as part of a much broader team in your surgery, to come into out-of-hours and be a single-handed doctor in an out-of-hours service in a clinic or primary care centre must be quite a difficult and different situation. So, the feedback we got very much was about isolated working, feeling unsupported and the consequences of that.
And that's why we started to broaden out to say, okay, so if in-day general practice is about multidisciplinary team working and working together as a team then we must bring that into the out-of-hours service. And hence the discussion around the added value that advanced nurse practice can bring, how district nursing working over 24/7 could add significant value to patient care and provide further support to that team working. We've had a mental health practitioner working in the out-of-hours service over the winter, we have pharmacists as well. It's about, actually, GPs working as part of a team, both in hours and out of hours. So, those sessional GPs who we rely on greatly now to work for us are feeling much more supported, I think, in terms of their working environment, which is really important.
I think the other thing is about induction. We've given people who weren't quite sure whether out-of-hours was for them the opportunity to come and have taster sessions. So, without any commitment, to come and sit alongside another GP and see what it's like. We've developed a clinical reference group that brings the GPs together. So, it's about actually creating this sense of team working and support for them in terms of when they work, but also being listened to in terms of their feedback as well.
Certainly it feels as though, broadly speaking, looking at this winter compared with the winter before, just about those filled shifts—the regular information that we have coming through is that there is some success happening on this, but there are still some areas of Wales that we'd want to still have more regularly filled shifts and they're still struggling. I think Judith certainly feels like they're now at the better end with some of the arrangements that they've put in place. So, again, we'll be looking for people to get to a more consistent, high level of filled shifts across Wales.
Okay. Thank you. In our previous session, Cardiff and Vale talked about the value in measuring fill rates for shifts as they are a good indicator of the pressures and staffing issues within out-of-hours services. Does the Welsh Government monitor fill rates and, if so, what are the trends across Wales?
We do think that they are a good measure. It wasn't as visible as we would have wished, although it would have been a key part of operational responses if we go back a couple of years or so. So, we've introduced a different expectation nationally over the last couple of years or so. We actually look prospectively at filled shifts on a weekly basis, we circulate them twice a week. Whilst that is every area being clear about potential problems that they may have or indeed being happy that they've got a 100 per cent rate, often it leads to other choices that can be made around the nature of the professionals who are involved in some of those shifts. We've had examples, for example, in Wales where the ambulance service may actually, rather than perhaps a missing nurse or some GP support, be able to offer a community-based paramedic, for example, that can provide some extra clinical expertise. We've also tried to raise its profile, however, just simply on our daily operational calls that take place about how we oversee the pressures on the system in Wales. So, as organisations virtually go around the table and describe what their plans are for the day ahead of them, they also comment on their compliance with the shift rates as well. I'd say that's quite a big change given the original analysis that was done by the Wales Audit Office, and that definitely helps us, I think, to manage some of the operational pressures in the system.
Thank you. Hywel Dda told us that they had experienced 99 base closures since May 2017. Does the Welsh Government monitor base closures, what are the implications of these closures on other parts of the NHS and how are the risks to patients managed in these circumstances?
I'll respond to that, if I may. It's really an extension of the response Dr Goodall's just given you a moment ago. We have an operational call every day, which is to manage operational pressures under the broad heading of unscheduled care and fill rates. Risks, therefore, to base opening hours are discussed at that call and then mutual aid arrangements are put in place. So, if there is a problem in a particular out-of-hours base in providing cover for a shift then the neighbouring out-of-hours will provide cover arrangements on a mutual aid basis across Wales. So, we do monitor them primarily as an operational tool, remembering that it's for the health board to ensure that it has effective out-of-hours services in operation. So, fill rates and base closures are indicators of immediate pressure on the system, which the NHS then responds to.
Okay. And finally, Hywel Dda and Cardiff and Vale health boards cited costs of £300,000 and £276,000 respectively in 2018-19 due to the impact of issues related to GP tax and employment status in their out-of-hours services. Has the Welsh Government calculated a figure for the overall cost across Wales, and what has the Welsh Government been doing to manage these issues?
As PAC colleagues will know from previous evidence, there were quite key changes that had an impact on out-of-hours services under direction of HMRC back in 2017. So, obviously, we've been tracking that over the course of these last couple of years. We're only just doing the annual accounts for 2018-19 at the moment, so it's the 2017-18 figures that we have available.
Five out of the seven health boards had an extra cost associated with them having to regularise and have GPs back as salaried individuals on their books, with the respective costs being worked through. So, irrespective of the Cardiff number you gave, which I think was around £300,000, the cost for Wales is probably of the order of around £2 million, which has had to be found, which effectively does need to be offset. So, those funds are clearly being used from health board allocations across Wales within the annual accounts process. So, on the one hand, whilst Welsh Government has put more money in to give general funding for the NHS, those would have been additional costs that we have incurred through those HMRC changes.
As a general point, our expectations about knock-on effects of some of those changes around IR35 and the HMRC changes, probably, speaking openly, haven't been quite as significant. So, once we've regularised in the first place, I think we've probably been able to work our way through that with GPs who work within our services. A greater focus on substantive staff definitely helps, rather than just chasing locums within the system, but it always probably feels tighter between January and March, mainly because it's the end point of the tax year so individuals will decide not to do shifts, for example, because they may go over certain thresholds at that time.
We were just talking ahead of today's session, Judith, and you were saying that, actually, for you, it had come down to probably more one individual that you'd had to resolve rather than tens of individuals.
Yes. We were very worried, as was the rest of Wales, around the IR35 and the implications that it had. Looking back now, we lost one GP who ended their arrangement with us and one GP who was about to start didn't start. So that was the impact we had. The tax issue generally though is more problematic. So, March for us is our most difficult period in terms of filling out-of-hours shifts because of coming towards the end of the tax year and people being concerned about their income going over tax thresholds. But, yes, the IR35 was not, thankfully, as big an issue, but, obviously, clearly an issue for general practice and people who work in out-of-hours.
The two organisations where it wasn't an issue: Powys, their main arrangements were brokered through Shropdoc, so it wasn't really an issue for them; and Betsi Cadwaladr just had a historically different set of arrangements in place, so there was nothing to be accounted for for north Wales, for example.
Thank you, Chair. The evidence paper mentions the change of context, and the Welsh Government response states that its more holistic primary care model sets out a rationale for the way of moving forward. So, in terms of the national workforce plan for out-of-hours now being perceived to be counter-productive, can you extrapolate on those two different approaches?
Yes. It will fit with what I was outlining earlier, which is just that our more recent reflection is to focus on 24/7 access to primary care and then work out, but it would be wrong to say that, therefore, everything is just thrown up in the air in a very general assessment. What I'm looking for is that out-of-hours is a feature of the workforce plan that's being pulled together for Health Education Improvement Wales because it needs to recognise that context in there. We just didn't want to have a separate plan as we'd committed a workforce plan within 'A Healthier Wales' when it was released last year.
I think there's also something though about making sure that some of this is about resilience at the more local level. So, we've got a particular focus at the moment on workforce plans within clusters across Wales—the 64 GP-led cluster arrangements or primary care clusters that are in place—and, equally, I'd want to make sure that they are able to give a really resilient response around the general access to services through the 24/7 period. So, that's going to be quite important for the workforce as well. So, I know it's a little bit of a trick, but we have to be general on that broader approach and then allow some of the particular problems around out-of-hours to feature within the general workforce plan for Wales.
And that seems eminently sensible, but in regard to the emphasis around out-of-hours and not losing that within the general holistic workforce development planning, is there appropriate emphasis then in terms of that workforce development around primary care?
I would hope that, with the approach HEIW are taking, yes, because they have actually been commissioned to do some very specific work on out-of-hours. So, whilst they are a new organisation in Wales and we wanted to ensure that they were established properly, in fact, one of the early priorities they've come to has actually been around out-of-hours services, and Alex Howells, as the chief executive, does sit round the unscheduled care board table, for that reason. But, Judith, I know you generated some of this through the national group.
Yes, certainly. And we met last week, actually, so some of this is fairly fresh in my memory.
So, most important, I think, is that we have a clear understanding of the demand that comes into out-of-hours—and in-hours as well, but I will just talk about out-of-hours for this moment—so this understanding of demand, and what sort of capacity we might need to meet that demand. HEIW are doing some work, broadly, as part of the work that Andrew's described, setting out some national role descriptions, so that we can have core competencies. So, they don't specifically talk about grades or professional groups, but talk about the core competencies that we might need in order to meet that demand. So, they're doing a whole host of work around those core competencies and role descriptions, and also looking at the current training and educational arrangements—how they might need to change in order to take account of that demand and what's coming through.
I think the other thing to remember is that health boards have got an important role to develop their own workforce plans, for their own services, whether that's in-hours or out-of-hours. So, taking the demand and capacity work, taking those core competencies and role descriptions, putting them together to develop a local workforce plan that gets reflected in our integrated medium-term plans, but then generates into a more national approach that HEIW then can hold together. So, I think—
So, in terms of national level actions across Wales, you see that golden thread—
Yes, absolutely. And it needs to be through local to national, and the local work can inform national competencies, or how training programmes need to change, or how new roles might need to develop. So, one of the new roles that is being explored at the moment is an urgent care practitioner; so, what are the core competencies of an urgent care practitioner, how might they be deployed, what sort of training might they need? So, it's looking at not only the existing roles we've got, but what new roles we might need to develop in order to meet that demand, but being really clear about a consistent approach to demand and capacity across NHS Wales. So, not having it done individually, in different ways by different out-of-hours services, is really important. So, a single approach to demand and capacity, some core understanding of role descriptions and core competencies, and then putting that together in terms of a workforce plan, both at a local level and a national level.
So that local workforce planning is an expectation.
It's an expectation, yes.
And then how is that monitored through the national level competency framework?
I'll probably need to refer back to Andrew.
We pick it up through our three-year planning process, the annual submissions that we have from the respective organisations in Wales, and we are seeing improvement, I think, in the level of detail available in those reports. Before, some of the workforce planning felt quite disconnected. Turning numbers into requirements nationally for more nurses for community nursing, for example, felt a little bit, over the years, like getting last year's number and raising it; I think we've intervened differently in that over the course of the last two or three years. Actually, we have proper commissioning numbers for some of our future expectations for community services, but the planning approach is the key every year. Simon.
Yes. Essentially, we're looking for organisations to describe to us and to their populations what they want to deliver. And then we want to see that they have all the enabling factors in place to allow them to do that, so that they've got the workforce to allow them to deliver what they need to deliver.
And you feel comfortable in terms of them telling you what they are going to be looking to achieve.
It's a discussion; it goes around in circles. So, we set out a planning framework that sets out the expectations that we would expect. So, Judith and her organisation, for example, to deliver—
That's what I'm struggling with. So, in terms of the monitoring and the more rigorous approach that there will now be, in terms of the development at the national level of that competency approach, how then is that going to be effectively given some fire, some pace, in terms of moving forward?
Well, we have a mechanism every year to translate it into our commissioning numbers for Wales. So, if we do need to expand, HEIW have that overarching responsibility at this stage. But, as Simon said, one reason it's a reciprocal arrangement is that it's not just simply everybody describing that they need 1,000 of this locally, you add it up for Wales, and you find you've got 9,000. Do that many staff exist? Are people actually competing for different staff across the area? And we hope that we bring, through our very extensive co-ordinating role and all of the evaluation that we need to do, the ability to make it a proper conversation about the numbers that are needed and that includes challenge. It's not only about the inputs.
Okay. In regard to the theme that there's been there constantly throughout our discussions around this, about the need to explore multidisciplinary models of working out-of-hours, in particular for this inquiry, the evidence we've heard so far, as you're fully aware, is that it's still very variable across Wales. We have touched upon this earlier. So, which health boards have made the most and least progress? I know that you don't particularly want to go into that realm, but in regard to that acknowledgement that there are those that are developing at a pace and there are those that are not, where do you feel there needs to be more emphasis and is there enough focus at a national level in that regard?
I would say, in my view, that Aneurin Bevan, Cardiff and ABMU probably more so around those areas. I think Betsi Cadwaladr, in terms of lifting out from out-of-hours into other services, would have been more challenged, just because of some of the concerns under the special measures label and having problems.
I'm specifically around the multidisciplinary.
Yes, on the multidisciplinary working. And I think that Hywel Dda still have a challenge around the rural recruitment and the balance of the teams that they have available. We've tried to come at this through a different route—so the announcement of the transformation fund moneys and the allocations that are being made there. I know they're broader than just an NHS set of services, aligned with local government, but they are very focused on achieving alternatives to hospital admission, which means that it's about access right through time, including the out-of-hours period as well. So, Hywel Dda have just had some recent approval there and there are a couple of outstanding ones to be made under the transformation fund as well. But I think I would start, as I think I reflected earlier, probably feeling that Cardiff, Aneurin Bevan and ABMU are probably more on the leading side. Some of you may not agree with me. Simon.
I would have probably hedged it a bit and said that I think everywhere is making progress and everywhere has challenges.
Yes, so in that regard, it's about getting a handle on the challenges in particular.
Yes. I think, over the winter months, we've been able to support most, if not all health boards actually, to try different things in terms of their out-of-hours arrangements—to try and build in some resilience over the winter months, knowing that it was likely to be quite busy. And each health board has actually tried to meet demand in a different way. So, in Hywel Dda, they actually used advanced paramedic practitioners to support home visiting and that's worked very successfully. Different health boards have had different arrangements and the primary care board is now going to evaluate all of those and actually say which 10 or 12 things that we've tried over the last winter—over the last six months—are actually the high-value things that we would then recommend are adopted across each of the health board areas. So, I think that different approach to trying new things this winter in out-of-hours is also going to help us with that promoting multidisciplinary team working, but also saying to health boards, 'Okay, if you want to know what order to do this in, because you can't do everything, these are the things that we recommend will give you greatest value in terms of the delivery and meeting demands.'
And is that imminent in terms of the primary care board?
Yes. So, the evaluation—. All the schemes were extended into April, so that they would provide further resilience over Easter, and then they're going to be evaluated over the next eight to 12 weeks. So, we should get something fairly quickly.
And will that come forward to this committee?
We're very happy to make sure that the committee is aware of some of the learning and the evaluation that has happened there. And hopefully, we can then roll those out and make them more consistent, not just for next winter, but on a substantive basis as well.
I'd be grateful if we could have that update as and when. Adam Price, some questions from you.
Thank you, Chair. Good afternoon. You allocate a notional budget on a national basis to out-of-hours services. That is correct, yes?
As we were saying earlier, it's not quite about the budget lines, but, yes, there's a budget line where we could probably track the traditional service, but then everything gets extended up to a broader assessment of what primary care represents. So, we may start with a figure of saying £36 million, but probably more like a fifth of our overall budget is associated with primary care services, for example. But there is a budget line that we can track from the traditional out-of-hours.
Right. I understand the wider context, but the answer is 'yes', you do have a budget line specifically allocated to out-of-hours services.
Well, not necessarily specifically allocated—one that we can track our original investment. Health boards now are investing in other alternative services, over and above out-of-hours services, that are accessed out of hours. And I think that has probably just confused some of the local assessments of it, so I can't just lift out a number, nationally, I would usually have to go and liaise on the detail within individual health boards.
Okay. Given that everything, ultimately, is interconnected—all of life—but given the fact that you do have a budget line, why do you have a budget line, then, if it actually obscures a more complex reality? Why do you think it's helpful?
Because it allows us to at least track a baseline, but we're going to have to convert it, and as we were reflecting earlier on, the definition of 'out-of-hours', how we're moving it to more 24/7 care, we may need, within our annual accounts process and our programme budgeting, to actually start to focus on that. It's a slightly different definition, but at least we can track the baseline.
Right. And does that baseline figure, that ex ante forecast of need—does that correlate to the actual budget line that is there on expenditure within the health boards?
Well, I can give you ours if that helps.
I know they spend more on it, but does it cover the same things? Before we talk about the actual figures, does it cover the same things?
It's an allocation that reflected the cost of a model of out-of-hours care at a point in time, when it was taken out of the general medical services contract. So, it's of historical relevance, I would suggest, rather than of practical relevance, because the model of out-of-hours care is different. So, I'm not sure—
Which does beg the question: why do you have it in your initial budgetary forecast, then, if it's not actually useful?
We've tended to move away from it. When I was responding to the WAO assessment, I was actually there outlining that there were already changes to even some of the figures that were featuring in that. So, I do think we need to reset it. What I can say, though, is that, certainly the figures that came to us via the WAO assessment, there has been an increase in those numbers, and the danger of tracking those because they are the original historical costs is that probably they give us more of a keeping up with inflation. What they don't really define is whether there has been any particular expansion in the services, so—
Right. The simple reading of the figures that I was going to walk us through was that you have a notional forecast figure, the actual figure is bigger—don't you think your notional figure is too small?
On that basis, yes, because I don't think it's capturing the current discharge of the service across Wales, nor some of our expectations about changes to the standards and the allocations. So, I would agree with the concerns there.
Right. Because the contrary view could be, 'Actually, no, the health boards are being inefficient. The assumptions in your formula are the correct ones and there's a variation across Wales and they should be more—'. So, you actually accept that, effectively, their actual figure is a better reflection of need, if you like.
Yes, in my response to the auditor general, I tried to recognise some of that broader context. And, yes, I would agree that we need it to be more flexible to accommodate those. And what I would hope that that would demonstrate over time is an ever-expanding investment therefore happening with local areas, because we are giving health boards allocations to make choices on behalf of their population. And as Judith said, she may do a demand-and-capacity assessment that says that there must be more investment in her local services. Swansea Bay University Health Board may do the same exercise and find actually they are pretty much in balance at this stage.
Yes, so the position that we've had in evidence from the British Medical Association, which essentially says that there's been underinvestment in the out-of-hours services generally over a signification period of time and there has been a rise in recent years, possibly playing catch-up—you broadly have some sympathy with that view is what you seem to be saying.
I think there are always choices that we have to make. We've been able to maintain the proportion of spend on primary care; we've actually made some interventions around primary care over the course of the last couple of years, with some quite significant moneys—moneys that were allocated to clusters, going back three years or so ago. We've uplifted investment within the GP contract over the course of the last two years; we're currently going through negotiations with GPs there. I think there is a change, I would suggest, that, whilst on the one hand, we maintain the traditional general medical services component of the budget—the GMS, that's your traditional GP with their practice—we and health boards, through their allocations, have been trying to raise investments in other individuals. So, if I could just give you one example, there is a benefit in a GP practice about pharmacists who are recruited to health boards, who are allocated to work with those areas, that won't feature as any part of the budget of the individual practice. But, obviously, there is a benefit from that extra investment in something that is about primary care and the way that we work. So, we've done some interesting work over time—we were trying to do an exercise of comparing where we were on some of the Scottish criteria, because our traditional budgets weren't really capturing in that way, and we were reasonably consistent, actually, with changes that were happening in other countries, in areas, but I think all of us have got traditional budgets that set out things in a particular way, and we're just mindful to try and provide a bit of consistency. But we have tried to make sure that there is an appropriate level of investment in primary care more broadly through our contractual discussions and through other mechanisms, as I said, like Ministers investing in clusters.
Despite the deficiencies of the budget line not being able to capture all of the complex reality, would we expect your notional pre-allocation and actual expenditure to converge over time?
To converge over time as in, yes, catch up with an ever-expanding investment and to get the description right, then, yes, they would converge. I don't think there's any sense in trying to keep them separate going forward, and, as we go through other allocation processes and work out our programmes, I do think we probably need to allow ourselves to put this right, because I think we'll always be understating the level of investment that's now happening around both our primary care, but also our out-of-hours services. So, that's a call that we—
Okay. You aim to bring forward a new budget line that will be more accurate, a richer description of the investment that you're putting into this general area and that, hopefully, will be reflected in the actual expenditure on the ground.
Just quickly running on to another issue, is there any evidence of which you're aware of competition between health boards for GPs' services as part of the out-of-hours service?
So, when I was talking earlier, I was saying one of the dangers is we can almost over-define out-of-hours services by locums and GPs, and I think what we are trying to do is to make sure that we have GPs who are substantively employed and committed to sessions on a more local basis. I think some of the success on the fill shifts is definitely associated with that. We've had anecdotes and some experiences over the year about the dangers that a GP could feel that they can go to the right-hand side of Wales and be offered a certain rate and then go to the left-hand side—. Certainly, Hywel Dda as an area seemed to be at the lower end of some of the rates that they were offering, but I know that they have done an awful lot to look to improve that, so there is now more of a standardised range. We haven't gone as far nationally yet to set a national framework; that's something that we could consider further. In fact, we have had some success on this in respect of other areas of agency and locum spend, but I think there's something with the out-of-hour service to probably just get it to a more resilient point at this time. But, definitely, what I don't want to happen is that we end up with health boards jostling for position and allowing individuals to just float across different areas, which is why, I think, we've put such a lot of focus on what's the environment that people want, what's the career development approach, how would people be attracted into working in an individual area, whether Hywel Dda or Cardiff, for example. But we have heard ourselves and we are aware there has been some evidence of some shifts going short because an individual has chosen to go somewhere else.
So, there's anecdotal evidence. You don't have data, as such, though it wouldn't be that difficult, because these are identifiable named individuals. I mean, if you wanted to analyse it, then you could, presumably.
We can certainly have that feedback from the local health boards and know who is struggling more from that than others. We don't have the national statistics in there, but I do think that one of the triggers that show whether it's a significant problem or not—I said earlier, this weekly process of looking at the compliance with the rates on shifts does give us a sense of which health boards are struggling. I feel, through that national oversight, it feels like we're having to ask fewer questions about it, which does feel like health boards feel that they have more filled shifts than not. Judith, you provide, potentially, some competition on this in your area—have you've seen a problem with your local area about accessing—?
No, not at all, and ourselves and Cardiff pay virtually similar rates, Cwm Taf slightly more, but we see very little movement between the three areas. In fact, what we're trying to do is build a commitment from sessional GPs to their local service through all the things that we've said, so that people feel, if they want to work an extra shift, they'll work that shift in the service where they're mostly located and working. So, no, we haven't seen great movement between health boards of people.
Okay. It's something that you'll keep under review, and you will take action.
I think so, yes.
Okay, thank you.
Clearly, if people turn up in the emergency department who don't need to be there, that's a cost, and also if there are adverse incidents that aren't identified adequately, there's also a significant financial cost, in some cases. I just wondered if you could tell us how improving the out-of-hours services sits within the priorities for the overall financial management and clinical excellence of the health service in Wales.
Two things strike me from your question—one is the importance that any approach we take always focuses on quality and safety issues for patients, so that will always be a driver for us looking at any particular range of services around. It would be true to say that we have to continue to focus on unscheduled care services that would cover urgent access as well as out-of-hours services as one of our very significant priorities in Wales. If we're unable to offer resilience in those services, then the public, for understandable reasons, will make their own choices about where they want to access. If they can't get an urgent response if they're out of hours, somebody does have the choice and discretion to go and turn up at an A&E department and feel that they're going to have a response, whether it's correct or appropriate, or not. So, I think it's a high priority for us.
It is within a mix of other areas—it often will feature as high priorities as well. But, certainly, if we were talking the Minister through a series of priorities in Wales, unscheduled care, and therefore that urgent access, would come through. My worry would be that over the years we've maybe brought A&E to the surface because it's a very significant, high-profile area, and probably out-of-hours would have felt that it was a slightly junior member of that consideration. Hopefully, with the focus that we've brought around the board tables in Wales, the expectations for the annual reports and expecting governance oversight of these, I think hopefully we've raised our expectations.
Yes, perhaps I'll highlight the links. I chair the unscheduled care board, and Judith mentioned the primary care work that she chairs. We have leads for primary care, leads for unscheduled care, leads for out-of-hours care, and there is a lot more connectivity between those. So, we're looking across the whole of the system. Of course, we're linking with social care colleagues as well. We do want to get our emergency departments functioning perfectly, but we have to have them as part of a system that's functioning perfectly, otherwise the problem simply moves to a different part of the system.
We're trying to use standards, clinically developed standards, and patient experience markers to help us to shape a system that is able to be successful on all fronts. We talked earlier about information for patients, and we have to make it straightforward for patients to know which parts of the system are best likely to meet their needs so that we can help to signpost people to the right services. Then, of course, we have to have the right demand analysis, leading to the right capacity to enable those correct services to be available at the right time, in the right quantity. So, it's a complex system that we're planning in a way that seeks to align to the in-hours primary care standards—how do they link with out-of-hours standards and how do they link with the work of our acute hospitals?
So, how crucial is it to get this new primary care model accepted by all stakeholders, to get the balance right in terms of demand and provision?
Really important. I think that we have got stakeholders with us on the primary care model. We've been working that up over the course of the last couple of years. It's captured significantly as part of our long-term plan, 'A Healthier Wales', released last year. That was done through a stakeholder mechanism, rather than only us sitting in a room writing the document and launching it. But I think the implementation of it is the critical thing at the moment, and we are having to look at the provision of primary care as a bit of a jigsaw. So, out-of-hours is one of our pieces and the in-hours access is another part. The alternative—community-based services—to hospital admission is another part, and we just need to draw together all of those strands. But we know that we're describing the right approach at this stage, we're just continuing through on the implementation phase at the moment. I do think that our cluster focus more broadly remains a pretty important part of what we've decided to do distinctively in Wales. It does seem that we have engineered that in quite a different manner in support of our communities.
Okay. The other tool in all this is the technology underpinning it. You've already mentioned that six of the seven health boards are now using this Adastra system—
The Adastra system, yes.
Does that mean that, in the six areas, an out-of-hours GP or nurse can access patients' notes as and when they need to, always, or are there still issues with that?
Yes. The access comes from that system. You'll find that health boards also have contingencies as well, because access to those records out of hours has been quite an important mainstay of our approach to unscheduled care. I know most organisations will also provide access as a contingency through the Welsh clinical portal, for example, which is another route in, so there's actually some resilience in there beyond it. I think, as we switch across to 111 and the implementation there, again, there'll be a further set of changes with that system being introduced over the next six to nine months.
It seems to me it's a crucial issue as to why, if you were a GP or nurse, you wouldn't want to work in out-of-hours, if you were acting like a vet, or relying on the accuracy of recall of the patient, who may be confused because they're unwell. So, once all seven health boards are on this new software, will they always be able to access the patient's primary care notes?
Yes. So, the Adastra system itself doesn't give access to the primary care notes. Having seven health boards all using the same system means that we are all using the same definitions, the same way of counting, to when we complete the standards and the quality indicators. Welsh Government can know that they're comparing apples with apples as opposed to what might have been some problematic issues around data collection in that each health board, even if they used Adastra, had a different version of Adastra, and two health boards didn't use Adastra at all. So, that's important for all sorts of things, because it makes compare and contrast and understanding improvement really important. Out-of-hours services now can see the patient's primary care record, or a summary of the primary care record of a patient. They can see what medication they're on for repeat prescriptions. They can see if they've had a consultation for any acute illness and any very recent blood test. So, the primary care clinician can have a quick look at that, and that will help them with their understanding of the presenting condition when the person has made contact with out-of-hours, and that is available now, yes.
Okay, so all GPs and nurses can see that.
All health boards can see that, yes.
Okay. Rhianon, back to you.
Thank you. In regard to the auditor general's national report, which highlights there are gaps of knowledge at a national level about the quality and safety of out-of-hours services, what is the Welsh Government doing to address this particular point? I believe there is a quality and safety committee that's been established. Could you extrapolate what that is doing in terms of key performance indicators around this matter?
In my evidence paper I refer to that, and that's partly trying to make sure that we're giving a framework for our clinicians across Wales to sit with each other and recommend. But it will link to the earlier conversation that we were having on the standards and what we're promoting there. Simon, I don't know if you'd want to more broadly comment, but a particular ask from the GPs and the clinicians involved in this was to try to start bringing some balance beyond just the response measures into quality. So, some of that is about making sure that the broader systems that we have in place in Wales apply equally to out-of-hours services—so, the Datix reporting, for example, the serious incident mechanisms. But there are some things here just to make sure that we're actually tracking through some of the outcomes the patients will be receiving to make sure that it's genuinely making a difference, but there will be come quality measures that we'll need to put in that even affect some of the data. So, at the moment we know that patients will be seen possibly by the out-of-hour service, but we don't have any way of knowing do they appear again in the system. So, on the Sunday afternoon, that's fine, and we're hopefully providing good care, but do we have any different reflections if the patient comes back in on the Wednesday evening, for example, for another out-of-hours contact. So, some way of assessing whether patients find their way back into the system over the course of the next 72 hours feels quite important.
So, how is this committee, as a mitigation, then, for this phased issue—how is that then going to be effectively implementing these types of difficult data collection?
Well, it starts with us coming together. I think if we went back two years, 18 months ago, out-of-hours services didn't meet together regularly across Wales. They now do, so there is a forum. Perhaps if I just run quickly through its purpose as described in its terms of reference—so, it's the all-Wales 111/out-of-hours quality and safety forum. It's purpose is to provide the Welsh ambulance NHS trust and local health boards with a number of things: evidence and timely advice related to the provision of urgent out-of-hospital healthcare; assurance in relation to arrangements for safeguarding and improving the quality and safety of the patient-centred healthcare by 111 Wales, provided by WAST and associated out-of-hours services; provide specific assurance in relation to the clinical support hub and its cross-organisational roles and responsibilities; implementation of ongoing improvements for 111; and to receive guidance from the urgent primary care out-of-hours task and finish board.
So, how does that look in terms of an out-of-hours service in a particular area in future? Because, obviously, this is at the very beginning, the embryonic stage, in this matter. Will there be a performance indicator around it? Will there be some sort of—? How can you explain to me how that works in terms of satisfying this issue?
It's part of the dialogue to have with the group as a whole and then with individual health boards and the Welsh ambulance service.
So, it's still obviously playing out and developing.
Yes, it's developing.
Because recommendation 5 does state that there needs to be a focus around that.
The new standards that have been developed and adopted by Welsh Government, issued to health boards, have a number of quality indicators within them. Clearly, the responsibility at a local level now is with health boards to ensure that they're able to meet the standards. The reporting for those at a local level will clearly be through their quality and patient safety governance mechanisms in each health board. So, each health board has a responsibility to do that.
So are those—to interrupt you—are those in situ?
They are, yes.
Are they going to be robust enough to be able to deal with this additionality?
Yes, absolutely. At a local level—I'll describe ours—within our out-of-hours service, there is a forum that comes together on a regular basis. In fact, they meet weekly to go through where they are against the standards and national indicators, review any incidents that have happened in the previous week and look at complaints. Then, on a regular basis, the standards and reporting will come to the health board's quality and patient safety committee.
At a national level, the clinical directors for out-of-hours and various others will come together and actually share that information across Wales. So, not only is there learning within an individual health board—so, health boards are not only learning from their own complaints, concerns and issues—but actually being alerted to things that have happened in other areas and are able to learn from that. If there are changes or modifications that need to be made in terms of the way of working or the standards by which out-of-hours work, then they can be considered as well. But it's enabling that sort of broad, across-Wales look at the quality and safety. If we remember that 111 will be rolled out across Wales at some point, having an overarching view about the quality and standard of services across Wales is going to be really important.
And in terms of the periodical assessment of that, will that be annual or—?
Yes, we see it more as an annual process. Clearly, there are opportunities for us to break into that, because it will be a regular part of local reporting within organisations; it's not going to only be on an annual basis. We can step into that using our monthly quality and delivery meetings, and our biannual reviews that take place equally are a way of delivering that as well. I don't know whether it would be worth us sharing the development of some of those indicators.
Speaking openly, there are a whole series of indicators that are now live and active and being measured as from 1 April, but we deliberately asked the clinical group to come up with more aspirational measures that are a little bit dependent on what we're going to be implementing with the new IT systems. So, they will be trickier to do, but we are very explicit about which are the development measures when the majority are actually available and are actively being monitored from 1 April this year.
I think that would be useful. Okay, thank you.
We had correspondence from Cardiff and the Vale where they indicated they'd had two cases last year where complaints led to the health board accepting liability and compensation being agreed. Is two about average for a health board? Obviously, it's a larger population than some others. Is that one of the indicators, where things obviously have gone wrong?
One of the indicators is on the complaints and concerns, and the explicitness of whether—if I can put it this way—a negligence case is agreed and therefore it's worked its way through litigation. I don't think it goes precisely into that sort of detail at that level, but certainly the overview of what the complaints and concerns are and how serious they are, that would be captured across Wales. Some of that may be less about the numbers. As you said there, it may just come down to an understanding about the one or two cases that are involved. But, in the same way that litigation can apply for patients in any of our services at this stage, out-of-hours would be no different from that. I wouldn't be able to comment with you whether that feels different or not. Probably it's been a little bit hidden in the background, maybe, in the past. There's been more of a dominance around the hospital-based services probably rather than out-of-hours, but we can perhaps go away and think about that on your behalf.
We've been talking about an out-of-hours national strategy for a very long time. Why has it been so long in the pipeline and what progress is being made with Judith Paget's work in this area?
Well, I think, to some extent, we've determined that we don't want to be explicit to have out-of-hours on its own. So, we've come to a judgment that I'll defend about us wanting to make sure that that primary care 24/7 environment is appropriate. I think, even at the outset of our conversation this afternoon, I probably have had to portray—and I've been around now for 14 years as a chief executive in Wales—there is a history about the development of these areas, which I think we're having to continue to make progress on and put right. We accepted, within the Wales Audit Office recommendations, about a need, however, to enhance some of that national leadership and oversight. And whilst individual health boards remain accountable, whilst we obviously have the Welsh Government oversight, I do think that Judith has added an enormous amount of time, attention and focus by gathering colleagues across Wales into these various fora. The critical issue for us on out-of-hours is that Judith has taken on some of this work alongside other areas that she happens to lead on in Wales, like the 111 roll-out and also primary care. So, I think that's been an advantage. But Judith is here, so she can probably answer.
I feel as if I'm marking my own homework. Andrew asked me to do four things, really: to lead a group that would review and assess the out-of-hours model, particularly with 111 on the horizon; advise on national actions; review and recommend a revised set of standards; and then advise on any resourcing requirements. So, we've done the peer review that has looked at the model, we've given national and local reports, and we're following those up. We've done the work to standardise the out-of-hours system by making resource available for the same version of Adastra to be in all seven health boards, and we've run a series of winter initiatives to allow people to test different ways of responding to out-of-hours demand, which are currently being evaluated. We've got to do a peer review of call handling in the WAST, which we will now do, and there's going to be a follow-up piece of work for the winter. As we discussed earlier, there's work on demand capacity to be completed, there's work on the national role descriptions to be completed, there's the evaluation of the winter plan, and there's a little bit more work to do around escalation and metrics. I haven't advised Andrew yet on the resourcing requirements but that might come later as well.
What about home visits and face-to-face visits. Has there been any evidence of good practice there that can be spread out across the rest of the system?
mYes, I think there's been—. So, we have a different—. Each health board out-of-hours service is in a slightly different position in terms of the proportion of face-to-face versus primary care visits versus advice over the telephone. We know that, when 111 goes in, demand to out-of-hours goes down slightly and the demand changes a little bit as well with more advice given, more face-to-face and fewer home visits. So, we're seeing how that changes over time. But, as I said earlier, in terms of even home visiting, we've been trialling in Hywel Dda the use of paramedics to help with home visiting, and that's been successful and we'll get the formal evaluation of that. So, there might be different approaches to how we deliver aspects of out-of-hours care that we can adopt and adapt across Wales as that evaluation takes place—but, yes.
And we're still maintaining a standards focus on monitoring the home visit aspect, so there are ways in which we can at least be aware of the pressures around those home-visit services as well.
And is the planning of out-of-hours making it far more integrated with the wider system than it has been in the past—is that really happening now on the ground?
Yes. I think the focus and attention that out-of-hours has given has been helpful and welcomed. I think 111 in the areas where it has already arrived, out-of-hours is a key component of that, and having a strong and resilient out-of-hours service is important when you launch 111. I think the other thing is that we now have a primary care plan for Wales and 24/7 working is a significant work stream within that, and then within that work stream, out-of-hours is really important. So, making sure we view primary care across the 24/7 period, having a similar approach but maybe slightly different services available in the out-of-hours, weekend or bank holidays than you might have on a day-to-day basis.
Just an underscoring of this—I accept fully what you've stated in terms of the considerable progress that's been made in terms of that primary care overarching model—how do we not lose the emphasis, then, on out-of-hours within that work stream? Is it a specific—? Just a little, tiny bit of information around that would be good—I know we're running out of time.
The work group that I've been leading will continue. So, at some point, we might decide that, actually, the primary care 24/7 group can pick that up, but our view at the moment is that I will continue to lead a separate piece of work on out-of-hours. But we have some similar people on the groups so that we've got consistency of membership between the people working on the 24/7 work and also the people working on out-of-hours, just to make sure it doesn't get lost in the short term, because I think we've made a lot of progress. We want that progress to continue, so we'll keep going at least for the rest of this calendar year and then review it again after that.
I'd left the criteria with Judith, but I don't think that was for all time. Equally, we have to continue to monitor where we stand against the Wales Audit Office recommendations, so that will also be part of our response.
Great. Neil Hamilton.
You said earlier on, Judith, that 111 will be rolled out fully at some stage. The Welsh Government's evidence is that that'll be by 2021-22—it will be completed. Why has it taken longer than anticipated to implement 111 across all areas of Wales?
I think the label of 111 has been different in the Welsh context than 111 implementation in England, which was lifting up the NHS Direct service equivalent and pushing that out. We've tried to be more rounded and stood back to make sure that we've aligned it as our NHS Direct service and out-of-hours together. Speaking frankly—and this came through the Wales Audit Office reflections as well—we deliberately paused to see how the roll-out across the rest of the UK was occurring, and I think we've been able to learn a lot of lessons on that. Also, these are big change programmes. So, 111 is not just about a system or technology—it's about changing the access point for patients and the way clinical teams work. That in itself is probably the most dominant issue to get here, but I think we've taken a lot of confidence about our early roll-out.
When we rolled Abertawe Bro Morgannwg out as the first, immediately there were outcomes and indicators demonstrating that this was a positive impact on the range of quality and services that were available locally. It was also of scale, and that's why we've moved on with the other implementation. We've got to make sure that we now lever through Aneurin Bevan and Cwm Taf Morgannwg during the course of 2019-20. So, through the course of the summer, Judith will be making a decision about pressing a button or not on the roll-out. We've built up a lot of experience, and then we will end up with the final two—Cardiff and Betsi Cadwaladr—hopefully now occurring in 2020-21.
There will be a little bit of a pause moment just at the end of this calendar year, just while we introduce the single technology for Wales. But, honestly, we've tried to learn along the way. We don't think we've made errors. We've tried to bring the clinical teams with us, and I think that's worked to our advantage at this time, because it is feeling that we are getting into a more resilient position.
Are you able to make any provisional evaluation of the strengths and weaknesses of the current situation regarding 111, Judith?
Yes, following the pathfinder in Abertawe Bro Morgannwg, which launched in October 2016, we did an extensive evaluation of that using external support, which looked at outcomes, patient experience—well, it was a whole range of indicators. On that basis, it was agreed that the roll-out would continue. It rolled out into Carmarthen, Ceredigion and Pembrokeshire. We've done further work to look at—with the help of the community health council—patient experience. Probably after ABM and Cwm Taf, as we have a break whilst we implement the new IT system, we might do some further work to evaluate up to that point, just in case there is further learning and lessons that we might implement then when we go to Cardiff and Betsi Cadwaladr after the new system goes in.
I notice we're over our time, so I'll just ask one more question: does the Welsh Government have a clear picture of what the 111 service will cost to roll out to all health boards, its ongoing running costs and the costs of the new integrated computer system that you've just mentioned, and the extent to which it'll provide better value for money than the predecessor arrangements?
So, obviously, we have to step up to have some resources in place just about managing the change, so I think our decision also over these last two or three years to have a clear central programme team and a programme director who leads on this and provides the expertise on the output—. Over time, when this comes through, we expect that, probably, it's around £3 million revenue cost to each organisation in Wales over the course of 14 years. There are options on the contract to extend that. Given the extent of out-of-hours services and their complexity, I think that feels like a good investment of money in the scheme of our overall budgets at this stage. But it's of that order on an annual basis.
When you say £3 million per organisation, that's per health board—
Per organisation. That's all the cost. It's £3 million for all the organisations—