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Y Pwyllgor Cyfrifon Cyhoeddus

Public Accounts Committee

08/07/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

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

Y rhai eraill a oedd yn bresennol

Others in Attendance

Adrian Crompton Archwilydd Cyffredinol Cymru
Auditor General for Wales
Glyn Jones Cyfarwyddwr Cyllid a Pherfformiad, Bwrdd Iechyd Prifysgol Aneurin Bevan
Director of Finance and Performance, Aneurin Bevan University Health Board
Huw Thomas Cyfarwyddwr Cyllid, Bwrdd Iechyd Prifysgol Hywel Dda
Director of Finance, Hywel Dda University Health Board
Joe Teape Dirprwy Brif Weithredwr/ Cyfarwyddwr Gweithrediadau, Bwrdd Iechyd Prifysgol Hywel Dda
Deputy Chief Executive/Director of Operations, Hywel Dda University Health Board
Judith Paget Prif Weithredwr, Bwrdd Iechyd Prifysgol Aneurin Bevan
Chief Executive, Aneurin Bevan University Health Board
Mandy Rayani Cyfarwyddwr Nyrsio, Ansawdd a Phrofiad Cleifion, Bwrdd Iechyd Prifysgol Hywel Dda
Director of Nursing, Quality and Patient Experience, Hywel Dda University Health Board
Mark Jeffs Swyddfa Archwilio Cymru
Wales Audit Office
Martine Price Cyfarwyddwr Nyrsio Dros Dro, Bwrdd Iechyd Prifysgol Aneurin Bevan
Interim Director of Nursing, Aneurin Bevan University Health Board
Matthew Mortlock Swyddfa Archwilio Cymru
Wales Audit Office

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

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

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

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

Dechreuodd y cyfarfod am 14:11.

The meeting began at 14:11.

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

Nid oes recordiad ar gael o ddechrau’r cyfarfod.

No recording is available of the start of the meeting.

[Inaudible.]—apologies. Do Members have any declarations of interest they'd like to make? No. 

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

Okay. Item 4: you've received a number of papers to note in your pack, the first being the Auditor General for Wales report on the Wales Audit Office annual report and accounts. It's more an issue for the Finance Committee rather than us, but we have it for the committee here as a matter of courtesy. So, are you happy to note that report? Then, a couple of letters from the Chair of the Children, Young People and Education Committee. And, also, a letter from the Welsh Government referring to information that we requested at a previous meeting. Happy to note those? And, also, another letter from the Welsh Government on the management of follow-up out-patients from across Wales, and the Welsh Government have responded on the action points that arose from that session. So, we need to note that letter. 

5. Gweithredu Deddf Cyllid y GIG (Cymru) 2014: Sesiwn dystiolaeth gyda Bwrdd Iechyd Prifysgol Hywel Dda
5. Implementation of the NHS Finance (Wales) Act 2014: Evidence Session with Hywel Dda University Health Board

Okay. Item 5 and the implementation of the NHS Finance (Wales) Act 2014. We have an evidence session today with Hywel Dda University Health Board, and thanks for being with us today. Would you like to give your names and positions for the Record of Proceedings?

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

Prynhawn da, good afternoon. I'm Huw Thomas, I'm the director of finance. 

Prynhawn da. I'm Mandy Rayani, I'm the director of nursing quality and patient experience. 

Great. Welcome to today's meeting. I'll kick off with the first question. It's certainly positive that you're making progress in reducing your overspend each year, but when do you think that you will finally be able to say that you've balanced the books?

Thank you. If I may start just by giving some context to where we've come from. Clearly, the health board has a long history of not having been able to break even, certainly on an underlying basis. So, we welcome very much the Welsh Government's zero-based review into the health board's finances, and that highlighted a number of issues for the health board and allowed a consensus around those issues. And the particular challenges that we have around demographic challenges were recognised with additional funding of £27 million.

So, over the last three years, and after adjusting for that additional funding, the health board's deficit has reduced from £42 million in 2017-18, £35 million in 2018-19, and a plan to deliver £25 million this year. Delivering this year isn't without its challenges, but it does demonstrate the trajectory that we're on. So, with that context and looking forward, now, for the first time in west Wales, we've got a clinical strategy, which emphasises the importance of working with a greater focus on a more social, community-based model of care, working in an integrated way with local authorities and other partners, and focusing on well-being, as well as reconfiguring secondary care and our mental health services. I'm sure we'll come on to more of that later. 

Now that we've got greater control, therefore, over our operational finances, and that we've got in place a long-term clinical strategy, the focus is understanding our key underlying deficit and the drivers to that. And with the Welsh Government—Welsh Government have commissioned for us a piece of work, through the targeted intervention framework, to understand the key drivers to our deficit and how those can be addressed. So that work is ongoing, and while it's challenging to give a direct answer at this stage, given all of that, we're currently developing a three-year plan, and would certainly anticipate, over that cycle, reaching in-year break-even by the end of that three-year cycle.

14:15

So, in answer to my original question, at what point do you think that the books will be balanced? Do you have a date?

It will be over that three-year cycle is the ambition. So, by 2023 is where we are focusing on.

Thanks, Chair. We know from the data tool used by the auditor general that Hywel Dda has the third highest allocation per head of the health boards, behind Cwm Taf and Powys. Do you think that your allocation that you have now fairly reflects the funding needs of Hywel Dda, relative to the other health boards?

Thank you. I alluded to the zero-based review that's been conducted last year and the additional allocation that came out of that. As a result of that additional allocation, I would say that's an independent external assessment of our position, and I've got no reason to conclude that the funding is either over or under our requirements in Hywel Dda.

Okay. Thanks. How involved have you been in the Welsh Government's ongoing work to review the formula for funding health boards and revisiting the allocations, and do you have any learning to share from your experiences of the zero-based review that you've just mentioned?

Thank you. I think the development of working through a new funding formula is to be welcomed. I think the Townsend formula has been around now for quite some years and needed updating. I haven't been directly involved in the funding formula development, but there is representation from the local health board directors of finance peer group on the steering group to develop the new formula. I'm aware that the work that was done on our zero-based review has formed at least a basis for understanding of some of the challenges that were faced by us. So, on that basis, I feel assured over the process. There also has been engagement with directors of finance more generally across Wales, as a result of that development. And I think there are two critical elements for me that offer a good opportunity for us in the future with the funding formula that weren't there in the past. The first is transparency. So, I think it's quite clear now how each element of the funding formula will be developed, and that will be something that we will look at further when the details come out. But secondly is scalability. So, previously, the formula was at a health board level, which in and of itself is useful, but actually doesn't help me in my role. The new funding formula will allow us to dig down into local authority level and beneath that into a locality level—we have seven localities in our health board. And, if we can link the theoretical funding allocation with the resources consumed and outcomes for patients at that locality level, it offers us a very interesting way to look at our health board in the future, and we've got variation in practice across our health board.

Thank you. In regard to the statement that you are—that there is some loss of confidence that there is sufficient financial accountability within the health board, how do you react to that?

Sorry, which statement is that?

In terms of the auditor general—so, that there is insufficient financial accountability. How do you react to that, because that's quite a statement?

Absolutely. I—

And also in regard to the fact that there is a statement to say that you are overspending as a health board. How do you respond? Sorry.

I think it's fair to say that we take that responsibility very seriously. We recognise as a health board that we're not where we should be. Our plan this year is to overspend. That's not an acceptable position, either to us as professionals, to the board, or indeed to Welsh Government. So, I do recognise that that's not somewhere that is sustainable at all. Our focus is very much on getting to break even, and doing that with pace, but it's doing it in a way that is sustainable for the local communities that we serve as well and doesn't have a detrimental impact on the quality and safety of the services we provide to our patients.

In some ways, achieving financial balance isn't difficult, if you're not concerned about the impact that that would have on our residents. So, it's very much a balance and one that we take very seriously. Obviously, we're in a targeted intervention framework, which reflects the challenges we have, and we work very closely with officials in Welsh Government on our planning for the year and on our delivery throughout the year. So, it's not something that I accept lightly. 

In terms of the auditor general's comments, that's not something that we accept lightly either. Clearly, good governance is fundamental, and, over the last year, 18 months, through—. Two years ago, we put ourselves into a turnaround process, and that process has enabled us to focus increasingly on providing a better control environment for the organisation and—

14:20

So, is it now sufficient, I suppose is my more direct question?

There's probably further to go. So, there is a—

We're a complex organisation. So, making sure that we've got the right control environment across the organisation consistently applied is a challenge, but that's an area that we are focused on.

Thank you, Chair. While recognising, obviously, that you're still in a budget deficit, it is true to say that you've increased your reported savings for three years in a row now. How have you managed to have done that?

This possibly answers part of the previous question as well, if I think about this in terms of our governance arrangements. So, the first significant issue is making sure that we've got the right leadership in place. So, certainly through the board, the chief executive, and the processes that we've got in place at the board level, that's been very critical and we've got a real focus on financial delivery through the finance committee we have, providing assurance to the board. The chief executive then leads our process to embed turnaround within the organisation and we have got a very well-defined turnaround process now operating within the organisation and clinical engagement. None of this can be achieved without good clinical engagement, and Mandy sits around the group that steers our turnaround process and provides that clinical oversight for us on the impact on quality and safety.

Could you tell a bit more about the turnaround programme—how it actually works in practice?

Of course. There are probably—. There are three key elements of it. If I start off with planning, we've got a process now that looks increasingly at ensuring that we are targeting savings where the greatest opportunity arises. So, we've got benchmarking that we use, there's the NHS finance delivery unit, which provides quite some support for us in understanding the broader environment. It allows us to identify best practice to incorporate. That helps us to plan our services better.

Then there's a process of delivery and focusing on delivery, and there are a number of methodologies that we use through that, including what we call 60-day cycles, which get a real grip on an issue quite quickly and turn an issue around quite quickly.

Then the last bit is the escalation and monitoring process—or monitoring and escalation, I should say—where issues are escalated if there is an issue with delivery not happening at sufficient pace, or maybe something blocking a change that needs maybe executive oversight to unblock. That ultimately culminates in a process we've got, through the chief executive's holding to account process, where we understand what's happening and can use that forum to facilitate a change.

After so many years of having to make savings, it must be increasingly difficult to find the areas where those savings can be made. Are you finding that a challenge now and do you think that that's going to become more of a challenge moving forward?

There are, I guess—. There is always an element of transactional savings that you will always pick up. So, if I think about procurement savings or savings within prescribing, where drugs stop being on patent and you end up with generics—now, there's always a degree to which you can get some savings from those areas, but we're not wholly reliant on those. They're not going to deliver the scale of saving that we need within the health board.

So, our focus is increasingly on benchmarking and learning from others, and that gives an external view on the organisation and a focus on our areas of efficiency. But also, as we increasingly move into tracking outcomes, functional outcomes for our patients, that gives us a very different way of looking at how we're spending money, because those first two elements are quite traditional, quite transactional. Looking at how we are making a difference to patients and how we allocate our resources gives us a very different way of looking at savings in the future.

14:25

Thank you. Despite increasing the amount of savings, you still fell short of your target by some 19 percentage points. Does that suggest that, perhaps, you were over-optimistic in setting those targets, and how did you bridge the resulting gap?

Okay. So, there is always an issue when you plan for the year around the savings that you think that you need to create a balanced plan. In terms of the current savings that we were able to deliver, they did fall short. We were able to, in-year, offset those with some nonrecurrent one-off gains to ensure that we ended up the year within our planned position—the first time the health board has achieved that. But it does give us a challenge then, looking into the future, because you've got to work that little bit harder, then, to make sure that you recover that position in following years. That's been part of our consideration as part of the planning cycle going in to this year.  

That leads me nicely into my next question, actually, where I wanted to mention the fact that the auditor general's 2018 structured assessment described your current approach as focused on the in-year position. So, I was interested to try and find out what you are doing to take a longer term approach to planning and achieving the savings.

I might come on to Joe to answer a couple of points on that. But, in terms of our approach this year, it's been somewhat different, in that we have used a more targeted approach to make sure that we are generating efficiencies on a longer term basis that are sustainable, because I think that point is very well made. Our approach historically, and certainly last year, was moving away from that but was still overly reliant on in-year measures to achieve the position. We are now probably moving into a space where we need to change the services that we are providing. So, if I bring Joe in.

Of course, yes. Hopefully, the committee will know that, at the end of 2018, we agreed our first clinical strategy for the health board, 'A Healthier Mid and West Wales'. That really set out both the 20-year population health view of the future, but also a 10-year plan for our clinical services strategy. Within that, we've set up now—. We've spent a little bit of time working out how to set up that programme, and we've now got three key programmes: around transforming hospital care, transforming mental health and learning disabilities, which builds on our previous engagement work, and transforming community services.

We've spent a little bit of time within each of those programmes looking at what the year one deliverables will be in terms of the plan for the next year ahead, and that's enabling us to take a slightly longer term view, in that we know where our destination is headed now and that we have a clear sense of direction. So, now, working back from that is helping us build our transformation programme for the next three years, and linking that into our turnaround processes. So, for every year that we go on the journey, we know that the direction of travel that we're designing for each year's plans is in line with our long-term strategic intent.

We have some very good examples, as we go through things like our winter planning cycle, where we're already testing some of these new things. We've got some good examples this year around some of the unscheduled care system, for example, where we put—geriatricians in Llanelli worked in one of the care homes and we boosted the front door of the hospital with additional therapy staff, and that has made a big impact in terms of the way that the hospital ran over this winter period. Also, there was a big quality aspect of that as well. The number of admissions from the care home reduced by 50 per cent, the DNACPRs went up by a lot, the 'no to hospital' went from 1 per cent to 40 per cent and numbers of patients had reduced medicines as a result of that. 

So, there are lots of opportunities as we look ahead. We've also got, obviously, our transformation programme with our local authority partners as well, where we've had three bids accepted by the Welsh Government as part of our transformation schemes, and we're working closely with the three local authorities on those three areas. And, again, they involve steps on our strategic journey, in that they're looking at faster access response teams within the community, in a tech-enabled way, to enable people to stay out of hospital for as long as possible and to have rapid response in the community, rather than being brought to hospital. There are lots of other examples that I could give, if we want to go through any of those.

14:30

Thank you. I was going to ask about the reference in the report to unplanned cost growth in scheduled and unscheduled care and care packages. The information you gave there has answered that question perfectly for me. Just one thing I wanted to clear up, before I finish, and that's the new business partnering approach. Were any of the examples that you've given so far linked to that new business partnering approach, or can you explain that a bit more for us? 

Yes, definitely. I can perhaps help and then Huw obviously. One of the things we did over the last couple of years is strengthen our finance team, as one example of the business partnering approach, and that's meant that we've had, in the operational teams, a senior finance business partner working closely with each of our clinical teams. So, each of our services within the health board is led by a triumvirate team, which includes effectively a medical director, a nursing director and a general manager, and they're now being supplemented by a senior finance person and a senior HR person, and hopefully, as we develop the model, senior informatics. That's enabling us, in the way we want to develop the organisation, to devolve accountability and responsibility for the redesign of services, and I don't mean this in a hierarchical way, but as close to the front line as we possibly can, so those that are closest to delivering care can implement the changes that we need to see as we go through our strategic approach.

And lots of our saving schemes around mental health and learning disabilities, around some of the unscheduled care system particularly, some of the ward reconfiguration we've done within Glangwili and Prince Philip hospitals particularly, wouldn't really have been achieved without that senior level of support from some of the other support functions. And so the model really is predicated on, as executives, perhaps having less of a hands-on approach, but trusting those who are closest to the front line to be able to make the right decisions for our patients and population.

I think it's fair to add that that's a model that has now been in place for some 12, 18 months with the business partner support. It's growing in maturity and it's developing. But that focus on looking at a directorate, our operational teams, as a business unit, and that close working between the clinical lead, the operational lead, the manager, the accountant and the HR professional, actually I think that's a model that allows a more mature dialogue and a more business focus. 

Thank you. I believe your chief executive gave evidence to the Health, Social Care and Sport Committee last June, so about a year ago, and he talked about using the transformation fund—the £11 million you've had from the Welsh Government—for projects that are going to shift demand and activity out of hospitals. So, how's that going? Are you managing to achieve what you were setting out to do? 

Yes. It's early days for those, because we haven't had any of the money actually released yet from the transformation fund. We're just working now with local authority partners to agree actual detailed profiles of where the spend will be incurred and where the benefits will be realised. We're literally on the brink of getting going; if not, we've already started on some of the design of those schemes.

One of the things around the context of this is I feel that we are quite advanced, as a health board, with our relationships with local authorities. Obviously, there's the formal structure of the regional partnership boards, but we also meet—myself, the medical director, the community lead for the health board, the public health director and our partnerships lead meet with the three local authority directors of social services on a weekly basis. So, that gives us a really good mechanism by which to oversee the transformation fund. The three schemes approved are the tech-enabled care, the fast-tracked integration of services, which is about having rapid response teams in the community to deal with patients in distress or in need, and also creating connections for all, which is a community connectors scheme working with the voluntary sector. So, we've got a weekly meeting. We've got a clear benefits realisation around those schemes. There's a really good evidence base that if we can implement some of those and keep people away from hospitals, unless they really need them, that there's also a downstream benefit to some of the packages of care and social care demand as well.

So, that's the basis of the transformation programme. As I say, we're literally on the cusp now of starting. There are already integrated teams in place. For example, in Carmarthenshire, we're discussing an integrated county director role within that county to try and lead some of that work jointly on behalf of Carmarthenshire and for us, as a health board, and we have various stages of teams in the making to deliver the work ahead.

14:35

So, why has it taken a year to get that level of partnership agreed, because keeping people out of hospital is, obviously, a benefit to the patient primarily?

Sure. We've been, obviously, working on a number of those things. As I say, in Carmarthenshire, there's been an integrated team for a number of years already and there are some good examples again through our winter plan working with Carmarthenshire council, where, for example, we put in place bridging services to get people out of hospital quicker. And some of the evidence of that showed that people who may have been delayed for 16 days previously were out of hospital within 24 hours, by having that joint interface between social care and health.

We've had a long-standing, joint set of integrated teams within the Carmarthenshire locality across our three systems. The work hasn't really just started as a result of the transformation fund; we've always been working as a system, working together on these projects. What the transformation fund does for us is it gives us a real opportunity to try some different things out, to try some new stuff. For us, it would be okay if a few of those things failed, because the idea is that we try things, we test them, we try and evaluate them carefully, there’s a careful evaluation around them, and then we roll out at scale those things.

Okay. So, do you want to give us a taster of the sort of things you're planning to trial to see whether they work? Because you're obviously trying to keep people in the community rather than in hospital.

So, rapid response would be a good example of that whereby, firstly, anybody that you think is at need within a community will have, effectively, a stay-well plan that will set out their needs. And if they ever come into distress or need to have access to health or social care, there will then be a proactive system whereby a team will be set up within the community, which will include a geriatrician, a GP, a therapist and social work and nursing, that will go and see that person in their own home or at a different place of—.

But this is the sort of thing that’s been going on in other health boards and in other parts of the country for quite a while, so why do you think it’s taken so long to get the local authorities and yourselves—?

We've got similar things ourselves as well; this just enables us to upscale so we're really developing our intermediate care system. So, the evidence around the evaluation we're looking at in Carmarthenshire, we would be looking at around 15,000 bed days within the acute setting being saved if we could implement this type of rapid response team. And also, some of the staffing challenges that we face as well enable us to try some different things, maybe with staff groups that we can employ rather than some of those that we can't. So, it’s a good opportunity for us to try some different things out.

You've got the path-breaking Solva Care in your patch. Why has it not been possible to get similar sorts of things going in other parts of the community?

That will be some of the work that’s being looked at as part of the other transformation schemes. We have a number of service level agreements and agreements with the voluntary and charitable sector across the whole of the health board, and a key part of our work going forward will be to use some of those local resources in those place-based areas. Whilst Solva is very groundbreaking in Wales, it doesn't necessarily mean Solve Care would work everywhere. So, sometimes communities have different needs, and we'd be very respectful of that and try to build very much locality-based plans that come from what individual communities need.

Okay. So, how confident are you that the transformation that you're still to launch is going to lead to the cost reductions that you need to make?

I think there's—and I've given a few of those—some really strong evidence around whereby sometimes quite a small investment can make big differences. I think I came to a committee previously around things like out-of-hours services where the advance paramedic practitioners had been seeing one in five home visits rather than patients needing to see a GP, which, relative to trying to pay sometimes a more expensive professional, you can make some big changes. So, all of our transformation is based on a quality improvement focus.

In our turnaround process, building on Huw's comments previously, we haven't gone through any cost-cutting with any of the work that we've done. We've tried to build all of our work on a quality improvement focus—what's better for families and for one of our loved ones, rather than something that's just squeezing a bit more. There are always bits of technical efficiency that we can do, but this is really about system change and getting people seen in the most appropriate setting by the most appropriate professional, and also reducing harm. Again, lots of the evidence around long stays in hospital are that that then has a poorer outcome for patients. So, there was a real shift from an acute secondary care base, both in mental health and in our hospital-based services, to much more of a community place-based approach, keeping people at home with loved ones as long as possible and away from the acute settings.

14:40

I'm not arguing against that. It's just, really—. Convince us that you have the capacity in your health board to take forward this transformation, because these things have been talked about across the NHS for many years now.

Yes. We're building a lot of capacity within the health board. Mandy might want to run through some of that.

I think, for me, it's about the capacity. It's the skills, the knowledge and the ability to actually make change, and for me it's very much about supporting the culture change that we're driving as an organisation and building from the bottom up. So, many of the savings that have been identified here and also the transformation and the way we're going to model our future services are actually coming from practitioners on the ground. I think, in terms specifically about the capacity and the resources, we've undertaken a number of initiatives, I suppose. There's one around the development of the transformation resource that we're identifying and we're currently out to advert for a number of those posts, and they are really to give us some pace and impetus to some of the plans that we've got in place around the implementation of the health and care strategy.

Looking at our workforce and organisational development model, have we got the right skill set? Have we got the right resilience and resource within that? And looking also—. I know that the director of workforce and OD is looking again at whether a business partnering model, similar to that that's been introduced within the finance team, would be one that would be able to actually support front-line staff and also the directorate teams.

In addition to that, and it's one that I'm going to tell you about regardless, I'm sure, is about our quality improvement programme that we've implemented within the health board, and Joe referenced the quality improvement strategic framework that we've got in place that absolutely drives at the values and at the heart of what we're trying to achieve, so about the harm reduction, looking at how we reduce variation, waste within the system. One of the questions previously about whether there are any other opportunities that we can go at, given that we've been going at savings for some period of time, actually our front-line staff know where there are opportunities for savings. One of the quality goals that I think I'm particularly passionate about is what matters to people, so that we're actually shaping and driving our services in that direction.

So, our quality improvement programme, the QuIP programme, kicked off two weeks ago, where we had multidisciplinary teams from across the organisation taking forward improvement projects—not only those that are linked into our turnaround programme, but also those that will enhance patient experience and patient outcomes. So, it's the first time that the organisation has actually had an improvement programme, and the plan is very much that we will have a second cohort of improvement teams going forward. That isn't just about driving single improvement; that's actually about improving the capacity of our workforce to implement change as we go forward in the transformation space.

The other thing that we've been doing very proactively is looking at the development models and programmes that we need to support our staff to be able to support the changes that need to be made. So, looking at our aspiring medical leaders programme, our SLP programme, which is for our senior leadership team; developing and building the skills and capacity within the workforce; looking at our ward and team leader development programmes as well; looking at, also, a piece of work that we're particularly pleased with, which is the joint induction training framework; working across health and social care to drive the workforce and look at new models and new roles as well. So, all of that is about the capacity and developing the resources that we have available to us within the workforce to actually make these changes happen.

14:45

Okay. So, you think that the teams you've got are being given the authority and the initiative to get on and deliver the service that the individuals require?

Yes. I think, certainly, the approach that we've adopted through these various programmes is actually all intended to drive that moving the decision making to as close to the front line as possible. I think there's been a tendency for decision making to be driven up and we're looking at how we support staff to feel confident and capable to actually make those decisions as close to the point of care as possible.

Okay. Well, that's crucial. The chief executive told the health committee that he was confident about delivering a balanced three-year plan beyond 2019-20, but did nevertheless flag up some challenges around the fragility and cost of services in the south of your patch. I wonder if you could tell me how you've addressed those challenges in order to ensure that you are trained to deliver a balanced budget?

Obviously, I think Steve's comment around the three-year plan and the expectations around that was really building on some of the things that we've already covered, in that we now have the clinical strategy in place; we have the three-year—the three programmes in place; we have the transformation programme with our local authority partners in place; we've got a programme management office established now to deliver some of this work; and we've got—I would say, over the last couple of years, generally—a track record of doing what we said we would do in terms of some of the performance and money issues that we've managed to deal with as a health board. We've got a clinical leadership structure in place and a very stable board now. So, in a way, a lot of the foundations are there to do that.

I think, in terms of some of the specific areas, we've also got some very fragile services, as you've mentioned, where we're still struggling to run some of our rotas day-to-day and there's a daily effort from the operational teams in some areas to keep the show on the road, and, again, if I could use out-of-hours as an example—we didn't have any GPs in the south of the health board on Saturday night, for example, across Llanelli, Glangwili and Withybush. So, that required a GP from Llandysul to then relocate and cover the south of the health board.

We'll have similar issues in some of our services like trauma care. We struggle with running some of our trauma rotas across sites. A&E is very challenged at the moment. We've got some fragile services in some of the diagnostic areas, histopathology and radiology, which we struggle to recruit—again, particularly senior medics—and psychiatry as well. So, there's a number of those areas and that's why a lot of the transformation programme is built around trying to do different things and look at new models of care where we're not dependent on thinking that whilst we will carry on trying to recruit in some of those hard-pressed specialties, we also can't rely on that in terms of our long-term strategic plan, which is why in areas, for example, like mental health, we've looked at a 24/7 unscheduled care system that doesn't always rely immediately on doctors. So, we've got crisis response that's built around that. In out-of-hours, we've advanced the nurse practitioners and paramedics rather than relying on thinking that we can run five GP centres forever with GPs. So, it's that type of change that we're leading through these various programmes of work, particularly looking at different roles and particularly advanced practice where there are very good examples already within the health board but also emerging examples where you don't always need a doctor to run some of the services—pharmacy and other areas.

Just before Jenny comes back in—Rhianon Passmore, do you have a short supplementary?

You've strategically diluted your medical agency spend, in terms of the information that I've got in front of me, so in that regard, has that had any knock-on effect, then, in terms of your staff shortages and are you growing any of your own?

On the spending one, we did a lot of work with our agency spend in terms of medical agency spend when he the cap was introduced within Wales a couple of years ago, and you'll see from the papers we had a lot of successes with that, and that wasn't, again, about cutting costs. That was about looking actively at all the areas where we were incurring agency spend and working out how we could convert that into substantive costs in the main. So, we did a lot of work with every individual medic, where we had high-cost locums, to look to see how many of those we could bring back, for example, onto the books. And we did a lot of work with individuals, trying to encourage those to come back and work within the health board, and we were very successful with that. We also implemented some of the price caps. We worked hard on some of the control environments, which Huw has done. We implemented our own internal price cap for staff that weren't through agencies but within our own additional hours payments. Effectively, we capped those as well, and we were very successful in doing that. And, yes, we looked then also at alternative roles in some of our rotas. For example in Glangwili hospital, there'll be advanced nurse practitioners that now effectively work at the level of a junior doctor in some of the hard-pressed areas, and there are similar examples in other parts of the health board. I don't know if Mandy wants to—.

14:50

Yes. I think one of the most recent examples that I can give is a conversation of only last week, where our team actually identified the opportunity in breast care services to replace a consultant vacancy with additional and new roles from a nursing perspective. And, actually, that's not just about the saving of the money and filling a doctor shortage; that's actually because it's a better model of care for our patients, and that is always the primary driver for those sorts of changes. So, that's just one very small example of how we're looking at how we fill our hard-to-fill vacancies and gaps in rotas.

The auditor general's findings highlighted that a lot more needs to be done to co-ordinate and integrate plans from different directorates in order to strengthen the health board's capacity to deliver on all the things that you've been talking about. So, how far have you managed to achieve that co-ordination and integration?

Yes, I think there's still some way for us to go with that—that would be the honest response to that. One of the things that we've done, which I think has been a positive step, is that a lot of our operational teams do work as one team, so we work across primary, community mental health and acute services now as one team. We have an operational board where we come together. There's a medical leadership forum, which I attended last week, where the seven GP cluster leaders meet with secondary care physicians and the mental health clinical director, so we work as one team at that level. We brought together the primary care and community services into one team, where, previously, we had a primary care director and community services sat under different leadership arrangements. And then, outside of the health board, we have a much more integrated planning system with local authority partners, as we've covered.

So, I think there's a bit of a journey there, but it's really as an executive team—. And one of our objectives going forward has been that we really will work to one plan, that we'll have one process whereby we work with all of our teams and everybody's clear that there is an integrated planning cycle. So, I think it's a fair criticism of us historically, but I think we're now in a much better position going forward to make sure that we have our plans completely aligned and integrated.

Okay. So, which is the bit of co-ordination and integration that you still need to address?

I think the mechanism is there now for the planning cycle as we go forward. Our winter plan would be a good example. It was the first time ever that we had five organisational logos on our winter plan, where we worked with our three local authorities and the Welsh Ambulance Services NHS Trust partners. That plan was signed off by all five organisations and came to our board as a single winter plan for the Hywel Dda footprint. Similarly, in the mid Wales arena, there is mid Wales work that's led, in fact, by our chief executive, who's the lead chief exec for the mid Wales work. Again, that is an integrated strategic piece of work for Powys, Betsi and Hywel Dda. Again, that's on an integrated footprint. Our transformation programmes are on integrated footprints for the health board. I think some of the internal mechanisms are some of the things that we perhaps have needed to tighten up, and I think they're now in place for the planning cycles ahead, and we're working really as one team through the long-term plan and the turnaround processes.

I guess one thing to add to that is that, of course, it would have been a challenge to do that without an agreed clinical strategy, and now that we've got that in place that makes integration a lot easier.

So, as the director of finance, do you think that you are going to achieve this balanced three-year plan—not in this financial year, but in years 2 and 3?

Yes, and it comes back to the answer to the first question. Certainly, our ambition is to achieve a balanced in-year position over that planning cycle, so before year 3. That's our ambition and that's what we're working towards at the moment—working on the elements of the system that need to change in order to deliver that and the efficiencies we can get out of the system in delivering towards that.

14:55

Thank you very much, Chair. My question to the panel will be around the impact of the National Health Service Finance (Wales) Act 2014—well, a couple of questions, anyway. How is the requirement under the Well-being of Future Generations (Wales) Act 2015 to plan for the longer term fitting into the three-year framework of the integrated medium-term plan process? Is there a need to take a longer term view and approach as part of integrated planning?

I think our experience in Hywel Dda is: absolutely, yes, it's imperative to be thinking about the longer term. I don't think they offer—. Clearly, there are challenges, but, actually, thinking over the longer term in terms of the well-being of future generations is imperative in delivering a three-year plan. And if I just think about some of the disciplines that the Act brings in, thinking about long-term integration, collaboration, prevention and involvement, they are all elements that we've incorporated into our longer term strategic planning. So, we've got a 20-year vision for population health and well-being, a 10-year health and car plan, and then, of course, the three-year IMTP is just the first three years of that journey. And if I think about the key things that we are focused on, certainly integration and working much more closely with local authorities, and collaborating with local authorities—it's absolutely critical to that. That long-term prevention approach is absolutely critical. So, I think there are elements of this that link in and complement the three-year planning cycle quite well.

You mention challenges. Do you have the tools to work around that? And from your perspective, has the NHS finances Act enabled the health board to change its focus from the short term to the long term?

I think it's been a challenge, particularly for us as an organisation that is in targeted intervention, because we're not delivering on our finances, so, clearly, that is an issue. But the discipline of planning over the three-year horizon has been a challenge because we've not had a clinical strategy. Now that we've got a clinical strategy that's been approved and is in place, we've got something to aim to, we've got a vision that's very clear, we've also got a very long-term vision that's very clear in terms of population health. So, delivering, therefore, against the disciplines of the three-year planning cycle I think becomes a lot more achievable for us. It's still not without its challenges, and I think Joe alluded to some of those with the response to the integration of our plans, but it's much more achievable than it was. It's a good discipline to have in place.

Thank you. And what is your understanding about the £193 million deficit you have built up since 2014-15? Do you think the Welsh Government has been sufficiently clear as to whether, and if so, how and when, this will need to be recovered? 

Okay. I think, clearly, having a historic deficit of that nature is a significant concern to the health board and, I'm sure, to Welsh Government. Our focus within the health board and, indeed, in discussions with Welsh Government through the targeted intervention framework—our focus is about getting ourselves into a recurrently balanced position so that we are balanced year in, year out. We haven't had discussion around recovery of the historic deficit as yet because our focus is very much on getting to break even. I'm sure discussions will evolve over the coming few years, but there are a few things that are probably worth considering as part of that discussion, and I'm sure will form a part of it. And the first is the zero-based review that resulted in additional funding coming to the health board. The second is the clinical strategy that we're working towards because that gives us a framework for a stable, sustainable health board going forward. And lastly—the funding allocation and the change to the funding allocation. So, we will need to think about it in the round with those three critical issues in mind.

15:00

You've already touched on issues around agency expenditure, and I'd like to just focus on medical agency costs particularly; I think somebody else will cover nursing agency expenditure. There's been a reduction in medical agency spend, I believe I'm right, going back to 2013-14 and in the four years since then. How does the reduction at Hywel Dda compare to the national trend, roughly?

I'm not sure how it compares to the national trend. I think our focus is on what we can do within the health board to reduce our own reliance on medical agency. And that focus—. I think Joe has probably alluded to what we've done there in terms of looking at our control environment, looking at, certainly, the impact of the price cap—our own price cap internally—and understanding how we can resolve issues that occur as they occur.

The figures that I have in front of me—I'm just reading out—show that it's reduced by 40 per cent in Hywel Dda over the last two financial years, and 72 per cent nationally. So, anyway, I suppose it depends on the baseline starting point. Just out of interest, is there a knock-on effect between reducing external medical agency and then increasing the overtime expenditure on in-house staff?

Are you looking in the context of medical agency?

Yes, very simply, if you bundle those two together, they're both a kind of different solution to the same problem. So, are you just shifting one expenditure over to a different form in the use of temporary resource, if you like?

I think we did a lot more than just shift in terms of the savings that we achieved. There was a lot more than just shifting costs from one part of the system to another— 

But on the specifics, has there been an increase in the use of overtime, as you've reduced the reliance on medical agency staff?

One of the things would be—. I don't have the specific details of that, but one of the things we've tried to do is, obviously, with our own internal rate, just encourage our own staff, where possible, to cover work if they can do that in a safe way, because having our own permanent staff is much better than having locums from elsewhere who aren't used to working within our hospitals and within the health board. But I think the work that we did on the medical agency was significant. One of the things around capacity and capability that's interesting with that is we appointed a very senior workforce person who dedicated her time to project managing that work. We had a weekly meeting set up to try and oversee that through what we called an urgent response group, and that had a big impact. We got all of our services across mental health—primary care and the hospitals—involved in that work, and that's how we made the impact on that. It was by the week-on-week rigour of reviewing every penny that we were spending in that arena, and particularly we converted a lot of staff who were in high-cost agency posts into Hywel Dda employees as well, as part of that.

If I can just add as well, the workforce control panel that we put in place, which is chaired by the executive director for workforce and organisational development, has really helped us to ask questions about, actually, whether this is the role that is required at this moment in time—looking at how we can use that discussion as part of our modernisation around roles, and thinking about is it a physician's assistant that you need, is it an advanced practitioner, a consultant, another practitioner nurse or allied health professional? And that has certainly helped us in terms of focusing and changing the model of workforce that we have to meet patient need.

Okay, but I can take from—. Overtime doesn't seem to be a big issue for you. You weren't able to say whether it's gone up or down, but it's not something that you're aware of as a major issue. Presumably, you're governed by the working time directive, so there's a limit to the amount of overtime, anyway, that clinical staff—

15:05

Yes, and one of the issues with that is, just to take a year-on-year-on-year comparator, there may be waiting list initiatives and all sorts of other things going on to try and reduce, for example, waiting lists, that we may be paying our staff to do that wouldn't necessarily be overtime to cover rotas that were once covered by an agency doctor. So, there may be year-on-year changes that we would need to analyse to give a proper answer to the committee on that.

Okay, if you could maybe write to the committee, with the permission of the Chair. Just on waiting times, the other question that I was going to ask is: are you confident that a reduction in medical agency expenditure, which is often used to address particular problems in particular areas, hasn't exacerbated or reduced the ability to address those waiting-time problems that you've got in particular areas?

We've managed those reductions really carefully, and, as Mandy said, every individual post is reviewed around the work that any individuals are actually producing. Obviously, our waiting times for referral to treatment, for example, have improved from a list of 7,500 in 36-week breaches in 2015 down to zero at the end of last year. So, there hasn't been a detrimental impact on waiting times. That's not to say, for example in dermatology, if we lose a single-handed consultant—that happened in dermatology—. That can suddenly have an immediate impact on waiting times, and we're then looking for alternative solutions. So, it comes back to the fragile services discussion. We're very dependent, sometimes, on a few very dedicated individuals, and so if we lose capacity in any of those areas, that can have an impact on some of the numbers that we're discussing today.

How are you doing with some of the really long-term drivers of your need for medical agency staff? So, things like your long-standing recruitment problems in particular disciplines, but overall, attracting people to come and work in rural hospitals in west Wales, managing service demand as well. So, is part of the strategy, as well, trying to address those long-term factors?

If I start, the strategy that we've put in place is absolutely looking at how we deliver safe, effective services to our population. Often, I suspect, it's through refined and new pathways that are less reliant upon a medical workforce. That doesn't mean to say we don't need our doctors, but what we do need is for them to be in the right place with the right skill set at the right time, as you would expect me to say. Certainly, in terms of thinking about the challenge that we've got around recruitment, as the Deloitte review indicated, one of the challenges we have is the remoteness of the population that we serve, the footprint that we cover. I think that, going forward, the new health and care strategy that we've put in place is going to actually make some of the roles that we have available for our medical workforce more attractive as the demands around on-call change, as the model of care and service changes.

The other thing that I would say is that the very active participation that the organisation has had in the—and I've got to look at this, because I always get it in the wrong order—'Train. Work. Live'—I always get it the wrong way around—campaign has paid dividends. Certainly, I know of a number of doctors that we've managed to recruit through adverts, for example, on the London Underground and other places. So, that has actually been something that's been a success for us. It doesn't mean to say we haven't got our challenges, but there are ways in which we are going out and having conversations with medics and others to actually recruit into our services. I don't know if that answers the question.

Thank you. So, you mentioned—I always say 'live, work, train' and I always get that wrong [Laughter.] And west Wales has been receiving that, and you've mentioned the fragility in the south and you've mentioned the transformational working and the multidisciplinary team working. I'm just surprised that there hasn't been more emphasis in those areas that you know are fragile in terms of that lack of capacity in terms of that investment. So, my question, really, is, before I go to these, what are the fundamental issues that you have in regard to your overspend in terms of currently and in terms of the past? Because, in contrast to other health boards, you are in a different position, as you recognise, so what are the big issues for you as a health board? You've mentioned rurality.

15:10

If I start, I think the zero-based review report is a helpful framing of some of the challenges that we face. The demographic issue, certainly in the past, has been an issue, although that's now been addressed through the additional allocation from Welsh Government. So, the elderly population in west Wales as a proportion of our whole population exceeds the average in the rest of Wales, which clearly has an impact on our resource requirements. So, that's been an issue.

I think there were four elements to that review: demographics is one of them; scale of services, which I think is partially an issue for us, and providing a number of services across the patch does give us a particular issue that we need to deal with in terms of the benefits of scale, and that's something that's possible to address, but not, potentially, over the short term. So, that's what the long-term strategy entails.

So why are these factors—and I know that you've mentioned the review—why are they contributing—very briefly, if you can—to this current situation?  And also, if you could just respond to my question around: you've had the moneys around this particular issue, and fragility, and multidisciplinary working, so you know the areas of lack of capacity. So, I'm interested in terms of why you've still got that issue.

I think, on the scale issue, I was reflecting with you earlier that the hospital that I worked at in England before I came here was a district general hospital for a population of 450,000 people, and that was on one single site in a city, serving the areas around. We're running four separate hospitals across a population of 380,000 plus elements of Powys and Betsi, and with that we've got three accident and emergency departments we're running, three acute surgical rotas, three acute trauma rotas, et cetera. So, there's a scale issue that came out of the—. As you said, that was part of the Deloitte review, in terms of scale—that's there's an impact there of running, and there are only so many—. Our rotas are also very challenging in that a number of—. In a bigger hospital, you may be working a one in 24 rota. Our most generous areas would be a one in 12, but some of our colleagues would be working a one in three or one in four rota in areas like Bronglais. So, the scale issue is certainly one of our challenges, and I guess the workforce issues as well have it—

But that is not going to change—the scale issue. So, in that regard, do you find a one-off payment to get rid of that 90 per cent gap, as you said, in your savings targets—. I would presume that's not going to happen again. So, fundamentally, what has changed? You've mentioned a number of different ways of working in terms of the business model response and, obviously, the transformational fund, which you haven't accessed yet, because you can't yet, but what is fundamentally going to be different moving forward?

I think one of the things that's fundamentally going to help us, as we've alluded to on a number of occasions, is around the clinical strategy that we now have in place, and that is absolutely going to drive not just new ways of working, but the focus around how and where we deliver services. Obviously, as we go through—. We've had a significant number of engagement events—I think it's over 140 engagement events—with our local population to really understand what it is they want and need to ensure that we can deliver care to them. Part of that is inevitably going to drive the way in which we change services so that services, as Joe has alluded to—. We're looking at whether we still need the number of front doors that we have. If we change that, what does that mean in terms of local service provision versus specialist service provision where people travel to a specialist but come back to the home base as quickly as possible? All of that is part of our clinical strategy, and that is going to enable us to actually change pathways, which means the reliance on the current workforce and the new roles that we introduce is fundamentally going to help us transition and address some of the rurality, the remoteness issues, the scale of services as well.

And in terms of where you're at in that journey, where would you place yourselves, bearing in mind you've only just got a clinical strategy?

I would say we're at the start.

You're right at the start. Okay, thank you. So, in regard, then, to expenditure, we've touched upon recruitment and agency staffing, but, in regard to nursing agency staffing, why do you spend more on this—you've partly referenced this—than other health boards?

15:15

So, we have, over the last two years, seen a reduction in our agency spend on nursing. We've put a number of initiatives in place to take greater control and oversight around the utilisation of agency spend, particularly for nursing, and what I would say is that the utilisation varies across staff groups and also, if we're thinking just about nursing, across directorates, and some of that is linked, inevitably, to the additional demand that is placed—so, where we have to surge on occasions to be able to meet the demand into our hospitals, looking at unprecedented sickness absence leave. In some directorates, I'm aware that we've had increased maternity needs—maternity cover needs—for example. So, all of that makes up a different picture as to what individual directorates require.

That said, some of the control measures that we've put in have been involving executive director authorisation involvement in the authorisation processes; looking at improved controls around how we monitor and manage unpaid breaks for, particularly, agency workers, so that is helping us drive down some of the spend; the recruitment strategies that we've had. Reducing time to hire as well has had an impact as well, because obviously the quicker we can get our own staff into post, the less reliant we are upon temporary workforce—

So, in that regard—and it's the same theme as previously—what are you doing to grow your own, in terms of what you can do as a health board?

I'm really pleased you've asked that question, because actually we're very proud of the work that we're doing around 'grow your own' within Hywel Dda, because we've recognised that, actually, we need to be able to grow a sustainable workforce as local as possible to the services that we need to provide. So, very, very recently, in the last few weeks, we've launched our apprenticeship academy and, actually, today the interviews are taking place for Carmarthenshire recruits. We will be looking at having 40 apprentices working across the organisation—20 for Carmarthenshire, 10 for Pembrokeshire and 10 for Ceredigion. And whilst it's a long journey for those apprentices, potentially up to eight years before they get to being a registered nurse, we believe that's absolutely the right thing to do. So, that is just one of the initiatives that we're taking forward, together with working with and having conversations with Health Education and Improvement Wales to look at how we utilise our commission numbers for the nursing workforce as well, so that we can look at part-time programmes, again to support our healthcare support workers, going forward. We've also been doing some work around the band 4 roles that we can introduce within the organisation as well. 

And in regard to retaining them, once you've recruited them and they have been trained, what incentivisation pathways have you?

For those who are going, certainly, through the apprenticeship programme, then there is an expectation that they will stay and work with us for the two-year period, akin to the bursary arrangements across NHS Wales. The other thing that's really important is staff health and well-being as well, and we are looking very much at how do we support our staff to stay well. The other thing as well is the retire and return arrangements that we've got in place, and actually that's got a very positive uptake of staff who, for whatever reason, are choosing to retire and return to practice not necessarily full-time, but actually on a part-time basis to suit their work-life balance.

Okay. Thank you. In regard, then, finally, to the Nurse Staffing Levels (Wales) Act 2016, has that had any impact, in terms of staffing availability?

I think what I would start by saying is, actually, the Act itself has brought a much sharper focus on nurse staffing levels and, actually, the whole board are understanding and owning the issues associated with the implementation of the Act. For us, that impacts upon 31 clinical areas—19 medical wards and 12 surgical wards—and we're in our third cycle of calculations for the Act. What it has meant is that we are focusing our recruitment into our areas based upon the acuity, the metrics that we're looking at, and professional judgment. So, with the best will in the world, if we were trying to fill every single shift that could possibly be covered, we wouldn't do it, because, even with high-cost agency, Ofcom-tracked agency, there just aren't the bodies out there to be able to support us filling every gap. 

The other thing that we are very mindful of, particularly in west Wales, is the impact of the nurse staffing levels Act on the wider health and care workforce, because what we can't do is denude that social care workforce in terms of bringing staff in and recruiting them into all of our vacancies. So, one of the things that we've actually focused on is looking at what other roles do we need to support the registered nurse to actually be able to operate at the top of practice, at the top of their licence. So, we've introduced some new roles around our healthcare support workers, assistant practitioners. We've done a lot of work around developing our senior sisters and our junior sisters as well. So, it's not been without its challenges and its difficulties but, actually, for me, it's a positive approach that we're taking, and I'm hopeful that, by 2021, we will actually have moved to a place where our establishments match our calculations, match the funding, and that, actually, we've got a very robust process in place of ensuring that our wards are absolutely staffed to the best level, with as many of our permanent staff as possible.

15:20

Great, thank you. I think—. Thanks for bearing with us; we were running a little bit behind schedule earlier and we are now, so I propose to end the session at this point. We did have a couple more questions for you, so are you okay if we write to you with those? 

Excellent. That's been a really useful session, and we'll feed that into our inquiry. We've got another session, another evidence session, shortly, but I propose we take a short five-minute break just to refresh and comfort. But thanks for your help today. 

We'll send you a transcript as well of that for you to finalise before it's published. 

Gohiriwyd y cyfarfod rhwng 15:21 a 15:29.

The meeting adjourned between 15:21 and 15:29.

15:25
6. Gweithredu Deddf Cyllid y GIG (Cymru) 2014: Sesiwn dystiolaeth gyda Bwrdd Iechyd Prifysgol Aneurin Bevan
6. Implementation of the NHS Finance (Wales) Act 2014: Evidence Session with Aneurin Bevan University Health Board

Can I welcome Members and witnesses to this afternoon's meeting of the Public Accounts Committee? Thanks for being with us. Would you like to give your name and position in the organisation for the Record of Proceedings?

Okay. Thank you. Glyn Jones—I'm the director of finance and performance and deputy chief executive in the health board. 

15:30

Judith Paget, chief executive. 

Hello. I'm Martine Price—I'm the interim director of nursing. 

Great. Thanks for being with us—again, I should say, this afternoon, Judith. 

You're welcome. 

I'll kick off with the first question. Before moving on to the detail, could you give us an overall sense of how tough it's been to meet your financial duties and what have been the key challenges and pressures?

Thank you. I think it has been challenging, and continues to be challenging. We take our responsibility to meet our two financial duties very seriously as a health board, but we also take all our responsibilities as a health board very seriously: so, the responsibility to improve our services, to improve access and quality, our performance, and the well-being of our staff. And so the focus on money cannot be at the expense of all the other areas. And so we're constantly trying to take a rounded view. So, the most challenging thing is to keep taking the rounded view and to make sure that we steer strategically and operationally, and probably tactically, on a day-to-day basis through all those issues, making sure that we try to do the right thing. 

I think there are a couple of fundamentals that we have in place. So, we have what we believe to be good board governance and oversight of our responsibilities, but particularly in relation to those things that I have mentioned. We've got clear accountability arrangements that work through the organisation. It's really important that everybody's clear about what we're trying to achieve and how we want that to work. And I think our approach to our financial duties takes a fairly structured approach, which is top-down in terms of looking at the opportunities that benchmarking and other things give us, as well as talking through with our clinical teams, our directorates and our services about the opportunities that they see as well.

So, the challenge is about trying to keep rounded at all times, and making sure that we have a top-down, as well as a bottom-up, approach to what we're doing, but also, then, act and think in the short term around this year, next year, and the year after, but to think strategically as well. And I think some of the things that we've introduced in our health board around quality improvement and value-based healthcare, which we can talk a little bit more about, are helping us get our basic infrastructure in place that actually addresses some of our financial issues in the longer term. So, the challenge always is about being rounded, taking all our responsibilities seriously. 

Thanks, Chair. We know from the auditor general's data tool that your allocation per head of population was below average, and indeed the second lowest of all the health boards. So, (1) do you think that the health board is fairly funded through that current formula, and (2) have you been involved in the work to revisit that funding formula?

Okay. Over to Glyn.

Okay. If I can just talk about that for a little while, I think it's fair to say the current revenue funding formula actually reflects a number of different relevant factors relating to populations. Importantly for us, it reflects the health needs factor. And you're probably aware that the current formula is being used to actually distribute additional growth funding. So, actually, over time, the health board should move closer to the level of funding that we would receive if the allocation was applied in full. 

Sorry, a point of clarification—could you explain a little bit more please?

Yes, sure. So, each of the health boards has had, if you like, a historical level of funding, which goes back a number of years. When this particular funding formula was implemented, it was used, effectively, to move health boards closer to their, if you like, target share of funding, using additional growth funding that was agreed each year. So, over time, what we've seen is that Aneurin Bevan health board has gradually moved closer to the level of funding it would receive if the funding formula was applied in full. 

And that was—. Sorry to interrupt, that would reflect the level of need, based on those things, yes?

That's right. That's one of the key—

Because you're currently in a very low position. Okay. 

Yes. So, just to give you an indication, in terms of the 2019-20 baseline allocations that were set at the beginning of this financial year, I think we calculated that we were probably about £4 million away from our target allocation, which I guess, on a budget of £1.2 billion, is relatively close.

15:35

And were you involved in the revisiting of the funding formula?

In the revisiting? We've had some involvement in it. I understand work is still ongoing to actually look at the new formula. Clearly, as a health board, we believe that that component around health need, understanding and reflecting poor health in your communities, is an important part of any formula going forward. And I think the Health Foundation report that was published back in 2016 recognised that, actually, the prevalence of things like chronic illnesses, chronic conditions, is a key driver in the way that health systems spend the money. So, again, I would argue that it's important to make sure that that's properly reflected in any new funding formula going forward.

Thank you, Chair. We know you've increased the level of savings, and you're meeting your savings targets now for several years in a row. What good practice can the health board share with regard to that?

Okay. There's probably a number of factors, I think, in terms of savings plans. And savings plans, I think, are just one element of good financial management across the health board. Firstly, savings and how we manage the finances don't sit in isolation. So the way that we actually plan services, and deliver them, we do in a very integrated way. So, actually, when we develop our service plans, we do that alongside understanding what the workforce solution should be, and actually how much we think it's going to cost to deliver those. So, we take a very integrated approach in terms of service workforce and finance. Understanding levels of efficiency, where we're doing things particularly efficiently, or not so efficiently, feature in part of developing those integrated plans. So, to a certain extent, our savings plans come out of that integrated planning, so that's what we would probably term as our bottom-up planning approach. At the same time, as a health board, we look strategically at what the opportunities are. So we use a lot of the benchmarking data that's available to identify strategically where should we focus a lot of our efficiency and savings plans.

I'd also say there are two broad categories of savings and efficiencies. There are the typical day-to-day operational efficiencies that you can make—so, can we change the skill mix in a safe way around the way we deliver a current service, can we get better value for money out of a particular contract. The one area that we're really focusing more on now—probably in the last couple of years—is our approach to what we would call allocated value, and this is what we call our value-based healthcare programme. So this is very much looking at how we deliver services, understanding what matters to patients in terms of outcomes to patients, and then how you look to redesign the system, or the pathway, to improve outcomes for patients and make better use of resources. And again, we've got a number of examples of where we're doing that. And we're really in the process of trying to build that up and embed it in the organisation. So, that allows us to take a longer-term approach to how we make sure that services are appropriate, but also sustainable going forward. So we're doing that alongside trying to deliver the operational efficiencies.

Have you had to make any tough choices on savings along the way that have impacted on levels or quality of service?

We find that sometimes—. I mean, there are always occasions where you find the financial position isn't exactly where you would expect it to be. I think our approach as a board, and as an executive team, is we take collective responsibility around all of the issues that we face. So, whether it's an issue around maintaining safe services, the quality of care, or managing the finances, we do that as a collective. And, very often, what we'll find is that, if the financial position isn't exactly where we'd want it to be, actually, we may have to make some short-term decisions about do we defer some investments to later on in the year, are there areas where we can perhaps contain our spending in the short term, knowing that, actually, once we get back on track, we can then carry on investing. And, again, it comes back to investing in the right areas. So, generally, I would say that's where we find ourselves as a health board.

15:40

It's mostly a phasing issue, rather than a 'not doing it' issue—so, in what order do we do things in. The range of choices that we have, especially if we have a range of investments we would like to make—it's about which order do we do them in. We might not be able to do them all in one year, and it's how do we phase that. That's the benefit of having a three-year plan as well, because that can set out for you the choices that you've made, justify those choices, but people can see where the resources are being committed and how you are trying to improve your services. 

Thank you. The auditor general's structured assessment says that you've improved the financial information that you provide to your board, in particular around savings plans. Could you tell us a bit more about those changes and the impacts that they've had?

Yes. The financial information that we produce for our board we typically review every year, and I think that's just part of what we consider as being good practice—to actually review the needs of the board and change the focus. Very often, between board reports, we will change the actual focus of the board report if we feel there's a particular area that we want to highlight.

I think in terms of that particular structured assessment, if I remember correctly, there was a survey undertaken of some of our independent members. I think at the time a number of those were quite new into their board role, and they were probably looking for a lot more information as part of just getting a better understanding, probably better assurance and confidence around what we were actually telling them in the report. So, when the structured assessment came out, we were actually already aware of that because we'd had those conversations with independent members.

Simply, what we've done is provided more detailed information. We've also looked more around how we do our risk assessment of savings, particularly with some of our bigger savings plans, assessing the risk of when they will deliver. Making sure that actually in terms of safety and quality they're absolutely the right thing to do is something that we've probably focused on more. So, I'd say that's where there's an increased emphasis in terms of more information.

Thank you. One final question from me: could you give us more detail on how you use benchmarking to identify and deliver your efficiency savings?

Yes, okay. We've got a wide range of benchmarking information and business intelligence. A few years ago, what we did within the health board was we developed what we called an efficiency framework, which very simply meant we brought together in one repository all the different sources of benchmarking information. So, you have things like CHKS, which benchmarks a lot of performance around clinical service. There is other benchmarking information on things like facilities, hotel services, estates. We're also a member of the NHS benchmarking network. So, what we did is we brought all of that together in effectively one place and made it available to budget holders online so that they could access it quite easily.

What that's done is enabled us to look quite easily and strategically where we would focus on efficiency, but it also makes it very easy for budget holders to look at their own areas and understand what the efficiency opportunities are to them as individual budget holders. I'm aware that the finance delivery unit in Welsh Government have actually built on that efficiency framework and they've actually extended and enhanced that so that actually a lot of that information is now easily available across NHS Wales. So, that's generally our approach to benchmarking. Then, the other element that I mentioned before is around our value-based programme, which takes it a step further in terms of not just about can we be more efficient, but actually are we doing the right things for patients in terms of giving them the right outcomes, which again I'm more than happy to talk about.

Thank you. You've mentioned that Welsh Government has in a sense looked at this repository, this portal for benchmarking. Do other health boards do a similar model of performance data benchmarking that they share at the operational level?

I'm aware that they have access to a lot of this information. So, things like CHKS, which I mentioned—that's nationally available across the whole of the UK. So, most of these are national sources of benchmarking data. They would also have access to the efficiency framework that the finance delivery unit have now developed and have made available. As to how they use it, I would only really know in terms of some of the work that we do across NHS Wales. Clearly, they make some use of it, because we often focus on certain problematic issues nationally. 

15:45

Okay. Could you update us on the progress with the Grange hospital construction project, and then, really the steps that you're taking around the service transformation that you expect this important development to—?

Sure. So, I'll pick that up. The Grange university hospital build programme is on time, which is really good. I think the most important thing with the Grange hospital, although we often talk about it, as lots of people in our community do, is to recognise that it is one aspect of a transformation programme around Clinical Futures. So, the build is progressing, but the most important thing is that the services are changing around the hospital. So, by the time the hospital opens, the way in which we deliver our services in our area will either have changed or will be in the process of changing.

We have our transformation programme that is structured. We've put additional resources in. The health board has prioritised the use of its resources to put an extensive programme in place to ensure that the elements of transformation that are needed across clinical pathways have the resource, and we have the capacity in the organisation to move forward with that. We are at the stage now where we've completed—whilst the building is going up—a fundamental review of all the service models that will operate, both inside the hospital, but outside it as well. We've undertaken a review of the future roles of the Royal Gwent and Nevill Hall and our hospital in Ystrad Mynach, and also looked at the investment and changes that are required in certain pathways that spread from home to home. So, it's hospital, primary, community and hospital services, not just what happens in the hospital. So, that work is progressing very well. 

We're at the stage now where we're starting to have initial dialogue with staff around the changes and what this might mean for them. We won't be entering into formal consultation with the staff until early next year. But we want to have conversations with our staff this year about the service model, what it means, what services will be at the Royal Gwent and what services will be at Nevill Hall. And clearly, we'll be entering into some of the public conversations around that as well at the same time. 

And with regard to the general conversation around transformation, could you just very succinctly describe how it will be a different way of working? 

So, the hospital itself will have all the arrangements for very highly specialist and critical care. All the things that we can't provide over multiple hospital sites will be located there. The system around it will operate as a network of local general hospitals. So, the Royal Gwent, Nevill Hall and the hospital at Ystrad Mynach will operate as a network of local general hospitals, supported by a much stronger infrastructure around primary and community services, including a much more integrated offer with social care and the third sector around care at home, closer to home, as well.   

That was the original idea of the Gwent Clinical Futures, wasn't it? That the whole of the pyramid was supported by the very strong local services, which we don't often talk about. Everyone talks about the criticial care.   

I think the issue is that everybody can see the hospital, but primary and community services are not visible, unless you use them or they are pointed out to you. So, people see the Clinical Futures programme as about the hospitals and the hospitals changing. Actually, our approach to prevention, well-being, integrated care delivery, a whole range of other things, is happening at the same time. 

You've partially gone into this. How are you managing the risk, or any risk, in terms of the focus on a new building, which could potentially distract from the wider transformational working? It sounds to me as if it's integral and aligned. 

Yes, it absolutely is. So, whilst we have a very small number of people who are making sure that the hospital gets built properly and opened on time, the actual larger programme, the programme team, is about the transformation. So, we've invested probably about £1 million in additional capacity. That's not just planning, planners, but clinical support, organisational development, workforce support—a whole range of people to support the whole of the transformation programme across the system, including bringing GPs in to help, having clinical leads from nursing and therapies and doctors as well. So, it's about creating a programme that's not just about the hospital. Of course, the hospital does need to get built on time on budget, and function when it does, but, actually, it's about how the system is changing around it as well.

15:50

And, obviously, this is the Public Accounts Committee, but if you could just allude to this—I'd be grateful if the Chair will let me—. In terms of how you measure the success of this really exciting transformational project—how would you measure its success?

When we prepared the business case originally, we had set out in there—and we are using it as a tracking—a whole myriad of benefits realisation measures. And they are whole-system measures, so they’re not just about the hospital functioning, but they are about the contribution around well-being, around patient safety, around access, around improving the health of our population. So, we have got a whole range of measures that we continue to keep updated, but we will track at the end of the Grange opening, looking back in terms of those measures.

Okay, thank you. We’ve mentioned that the project is on time. Is it on cost?

Yes, it is on budget.

That's a very simple answer to that simple question. So, could you tell us a bit more about the value-based healthcare work you've been involved with—we understand that there's been an award that has followed through from that—what the main initiatives were and are, and what benefits will be delivered to patients and the health board's financial position? There are quite a few points in there.

I'm going to ask Glyn to answer that one. He and our medical director are the two executive directors who are leading this work for us, although a lot of us are involved in it. But I'll ask Glyn to answer that.

Yes, there's quite a lot in there.

There is quite a lot in there. Do you want me to repeat any of it?

That's okay—you can pick me up if I don't cover anything. Clearly, the aim of a value-based approach is to deliver better outcomes—ideally, optimal outcomes—for patients within the resources that you’ve got. That’s the very simple equation, if you like. A lot of it is around culture change within not just the organisation, but the wider system. So, this is about clinicians, patients, members of the finance team working in a way together where you collect outcomes, you understand what it is that really matters to the patient, in terms of improving their health, not just delivering better quality healthcare, and how, by looking at pathways in a different way, you could potentially reallocate resources to have a better impact on those outcomes. So, it may be that there are certain interventions that are undertaken that, when you actually ask the patient, have very little or minimal benefit to them, and you can then redesign the pathway.

Some of it is about having better conversations with patients around what the alternatives to a particular condition are. Very often, people will lead automatically to perhaps surgery as being the option, and it may well be that there are other things that, actually, will be far more appropriate to do, and the patient would wish to do, before considering potentially major complex surgery. So, at the detailed level, that’s actually applying value-based healthcare in practice.

There are a number of areas—we’ve got about 18 different projects at the moment within the overall programme—and each of those look at different care pathways for patients. If I just name a couple for you. So, in terms of cataract surgery, which we looked at, we costed the pathway, looked at where there was variation in the pathway, and I think, invaluably, what it did was it allowed a different type of conversation between healthcare professionals and patients about: actually, do we need to do that in that particular way? Can we take a more simplistic approach that actually doesn’t worsen the outcomes? In some cases it may actually improve them, particularly if it means that patients perhaps don’t have to come back to hospital, either for an out-patient attendance or a particular intervention. That’s better for the patient as well.

We also collected outcomes along the cataract pathway, and, again, what that showed us was that, in many cases, depending on when the patient actually had the surgery, their visual acuity didn't always improve. In some cases it actually got worse. So, again, it allows us to create a different conversation between clinicians and patients about—depending on how bad your eyesight is—whether having cataract surgery is the right thing to do at this particular time.

We've got other examples around things like inflammatory bowel disease, where one of gastroenterologists has taken the lead to look at how they run their follow-up out-patient clinics. And, again, by collecting data through what we call a 'PROM'—a patient-reported outcome measure—we're able to see what the condition of many of our patients are, who have this unfortunate chronic disease. And in many cases, you find that actually their condition can be stable for quite a long period of time, and therefore what we're doing is we're beginning to change the way we deliver that service, so that if their condition is fairly stable, they enter the information as part of their outcome measures, the clinician can see that, actually, there's nothing particularly to worry about, and it prevents the patient from actually having to come to hospital for, potentially, an unnecessary out-patient appointment.

15:55

Okay, so I don't know—if I can cut in—if you've shared this information with us as a committee in terms of best practice, which leads me on to my final question: that's great; how are you sharing it with other health boards? What mechanisms are there, and how can we improve them?

Okay. There are a number of ways that we're doing that. Some of the work that we're doing, around cataract surgery, around orthopaedics, we're actually leading and supporting other health boards to do a national piece of work on understanding cost variation in those particular pathways. Our programme—

Are there any correlations to other specific pathways, or do you just see this model of benchmarking pertinent to the two areas that you've talked about? Or is it sort of a generic tool?

No, I think it applies to pretty—. Yes, I mean, the programme that we're developing now, we aim to try and now collect outcomes across the pathway in each area. It is quite time-consuming, but we think it's the right way to go, and, importantly, it's just embedding a different way of working in the organisation.

Can I just add one thing—two other things—in terms of sharing the data? So, there is a national value-based programme now. The lead for that, Dr Sally Lewis, was a former member of our staff, who we host. We link with her quite a lot, so everything we are doing she is aware of, and she is using some of that to promulgate across Wales, and also, we did hold a national conference. We organised and held a national conference in our area a couple of months ago, and we invited the whole of the rest of Wales to join us at that, and we showcased some of the work that we were doing.

We do keep returning to this issue of data sharing, don't we, and the difficulties of ensuring a joined-up system?

And from that, we've had quite a lot of joined-up contact, yes, and follow-up.

I think they all did. Off the top of my head, I think they all did, yes. They all came up.

In terms of those types of models of sharing good methodology and good practice, is there any room for mandation of health boards to attend such events, or is that not necessary?

It wasn't mandated. It was an initiative we took on our own and invited lots of people, including Welsh Government, so Welsh Government colleagues were there as well. In fact, we had quite a lot of visitors from over the border as well, in England, who joined us on the day, and it was seen as quite a big showcase event. So, I'm fairly confident that there were representatives from all health boards there, and I know from a conversation with Sally that lots of them have made contact with her afterwards to try and promote and follow up on some of that work.

Thank you, Chair. Thank you very much. I'm very much pleased with the report I read about Aneurin Bevan health board. I think if every health board in Wales was like you, we probably wouldn't be having this sort of conversation, because you're one of the beacons of the best service in cost, increased structured saving, and the clinical futures strategy is one of the best.

A couple of questions from me regarding the future planning. Could you tell us why you did not have an approved plan in 2014-15? What lessons did you learn from that to enable you to have an approved plan in all the subsequent years? Is your financial plan always fully financially balanced, or do you go into each year needing to bridge an unidentified savings gap?

Okay. So, learning from 2014-15, yes, we definitely learnt from 2014-15. Do you want to—?

16:00

Do you want me to—? Yes. I was just trying to cast my mind back to then, actually. I think, to be fair, where we found ourselves back in 2014-15 was at that point in time when we had to submit an IMTP. The board, and probably the exec team, didn't have the level of confidence, if you like, that actually it had a fully integrated plan that balanced at that point in time. So, I think that I would say it was recognising that we had further work to do, that we weren't able to submit an IMPT within the timescale back then. 

Subsequently, what happened was we were able to do some further work during the course of the year and we effectively had approved a one-year plan for that particular year. I think we learned a great deal from that particular year, both as a board and as an organisation, and every year, incrementally, we've focused on how we can have a more integrated plan, so making sure that our service plans, workforce plans and the financial plans are far more closely integrated so that, actually, when we're presenting a three-year plan to our board, we're a lot clearer about the interrelationships, what the level of risk is. And, I guess, the fact that we were actually able to deliver the financial targets in 2014-15 demonstrated that we were able to get to a balanced plan. So, I think we've learned from that. I think the board has confidence that we're now able to submit and deliver approved IMTPs.

Thank you. Could you tell us about the strengths of your approach to demand and capacity planning as part of the IMTP and what you are doing in response to the auditor general’s observations in your structured assessment that your approach is not as strong in primary care, frailty and district nursing?

Okay. In terms of the demand and capacity plans, if we talk very briefly about secondary care, it's been a fundamental part of being able to develop an integrated plan that you know what your demand and capacity is for each of your key services. So, I think that just requires a lot of rigour, scrutiny and a lot of hard work and effort to do that. It's not perfect, by any means, and we know that there are things that sometimes happen after you've developed your plan that cause it to go off track. 

As far as primary care is concerned, I think we are now developing those plans. Our neighbourhood care networks have done a lot of great work and are now producing plans on an NCN basis as well. So, again, we have a better idea of what the service plans and, critically, what the workforce plans are for each of those areas, going forward. And I think with things like value-based healthcare, it actually allows us to start to integrate primary and secondary care, because you're always looking along a patient pathway. So, it starts to break down the barriers between primary and secondary care. 

Yes, I just wanted to say—and Glyn won't be aware of this, so apologies—one of our neighbourhood care network leads has been doing some really excellent work in one of our areas to look at the demand that's coming in to GP practices. They have coded all that demand, with particular codes, and they're now able to analyse precisely what's coming through the door, how it's being seen and who is seeing it. The importance of that is that we can then start putting our workforce plan against the demand that's being seen. I had the first run-through of that last week. It looked really promising, and we're going to apply it to a greater number of practices, but with the new primary care workforce model and the new primary care model, it will help us work out what particular demand only a GP needs to see, but what other demand could be seen by other healthcare professionals in the multidisciplinary team. So, that work has started to take shape and it looks very promising indeed. 

Thank you. Your written evidence from last year refers to the way you have integrated your plan across divisions and with social care and other stakeholders. Could you tell us more about what this involves in practice, the benefits and how you overcome the challenges of collaboration across internal and external boundaries?

16:05

Thank you, yes. In terms of our planning internally, I think we have, now, over a number of years, got a very strong internal planning arrangement with our internal divisions. What we've now been able to do, through the work of the public services boards and the regional partnership board, is make sure that our IMTP takes account of the wider responsibilities and wider issues that are being developed through those planning arenas. So, in terms of integrated working, the work that we're doing through the regional partnership board is around strengthening our community services, around developing our care closer to home, and making sure that, when we do our IMTP, we're taking the broadest view around finance planning and workforce, not just a very narrow health board view.

Thank you. Can you tell us more about the additional capacity you have put into your planning team, in particular why you felt the need to do this, how much additional capacity you put in place and what benefits you're getting out of it?

Yes, sure. I think it refers back to an earlier question. Our Clinical Futures programme is a significant programme of transformation. We have, through our planning director, introduced and invested in a significant team to support that work. It does have a number of what you'd call 'planners' in there, but it does have other people as well, so it does have clinical support staff, workforce people, organisational development, communications—it's a broad team, but it sits under the director of planning. I think, from our point of view, the rigour with which we're having to make sure that our Clinical Futures plans are tested, reviewed and agreed means that that investment in a strong transformation team and a strong plan is really important, because it's absolutely critical that we give this the best possible chance of success, and in order to do that, we have to apply rigour and discipline around the work that we're doing to make sure that when that new hospital opens, the system around it works well.

Because all of these bits have got to fit together, haven't they, for the critical—? 

They have absolutely got to fit together. It can be perceived as what we're doing is building a hospital. We are building a hospital, but the hospital is part of a system. The health and care system needs to work and it needs to work reliably to make sure that we're able to give good-quality, accessible care to people.

Oscar, just before you finish, I think Jenny Rathbone had a supplementary question on the previous point and then I'll come back to you.

I just wanted to go back to the question about how you're integrating social care with other stakeholders. You're one of the pilots for Buurtzorg—

—and I just wondered if you could tell us a little bit about how that's going and whether you think, in the long term, that can be made cost-neutral.

The Buurtzorg relates to district nursing and we're one of the pilot sites in relation to that. I think that is key in terms of our care closer to home and part of the Clinical Futures strategy, so I think that's one important point, that that doesn't sit alone, it sits as part of our overall strategy in primary care. And obviously, district nursing is absolutely key to that. So, the pilot, we call it 'neighbourhood nursing' in terms of the district nursing, and how that's going forward is looking at the skills of those nurses, so that we can ensure that that patient and their family are well supported and that we're making good use of all the resources in that community to support that, but also in terms of making sure that the person who is seeing that patient is the right person seeing that patient, and they're not then having to see someone else the next day or being referred on, so it's much more appropriate care. Some of the areas we're particularly focusing that on relate to the diabetes pathway for patients and looking around end of life—obviously that's a key area.

Some of the work that we've done, obviously we've had the first year of the project, has been in terms of some core training for our staff around that. It's called care skills training for staff in terms of how they work as multidisciplinary teams, and we focus this in the Newport area. We're developing new roles in terms of band 4 roles and how they're working with the team, and supporting and developing leadership capacity in the team as well. And I think this second year, now, of the project is really starting to focus on the outcomes in key areas. So, it's a very important project for us. It absolutely, as I say, doesn't stand alone and it aligns into that whole work in primary care, so that we maximise all of that resource that we have. 

16:10

Okay. So, I appreciate you've had pump-priming to get things started, but can you envisage it being cost-neutral once it's embedded as a way of working?

So, I think in terms of it actually being part of what we do, as I say, when we're looking at that resource that we have in primary care we have to look at the whole, so in terms of all the skill and resource that we have there. So we've needed that pump-priming. I think it also aligns to the work around district nursing principles that you'll be aware of in terms of actually looking at what those teams need to look like. So there may well be some investment required overall, but we have looked, as an executive team, in terms of what is that resource in primary care in all areas, and actually are we making the best use of that? So, it's not being looked at in isolation is the key point. 

Thank you very much, Chair. My final question to the panel is: in expanding your planning team, was it difficult to recruit or develop people with the necessary skills and experience?

The short answer is 'no'. What we tried to do was create a blended approach where we recruited some people from within the organisation, because they understand how the organisation works and really understand what Clinical Futures was about, and bought into that as a concept and a plan, and then we did bring some new people in from other areas as well. So we've tried to have a blended approach to that, and we've had no difficulty whatsoever in recruiting really good-quality people into the team. We've been really fortunate. 

Yes, I just wanted to ask about—how do you think the requirements of the Well-being of Future Generations (Wales) Act 2015 have influenced your longer term focus within the context of the IMTP?

I think the five ways of working are really quite embedded now in the way in which we're approaching our thinking and our plans. I think we're quite fortunate in having a clinical and service strategy in Clinical Futures that is long-term anyway. I think what the five ways of working are allowing us to do is to test our thinking quite significantly. So, I think I mentioned earlier that we'd looked at 47 service models as we've been going through the last six to nine months to make sure that they were refreshed, that they were evidence-based, and that they were in keeping with the principles that we were trying to adopt within the Clinical Futures programme. But every one of those was tested against the five ways of working, and that's weaved into our IMTP now, and it'll be further weaved into the next IMTP that we write later on this year. 

So, I think over time it's definitely becoming embedded in our thinking. I think more and more it will become embedded in the decisions we make about the use of resources as well, and I think the long-term integration, et cetera, will be absolutely fundamental in terms of that influence. But my view is it's already started to have that influence, which is really positive. 

Okay. And how do you think the National Health Service Finance (Wales) Act 2014 has enabled the health board to focus on the longer term rather than just the next financial year?

In terms of that particular Act, obviously it looks at a three-year rolling financial duty. I think it has enabled us to look more across the three-year period of the plan itself. We've had probably one example of where we've used the flexibilities within the Act, in that we were able to broker funding that we didn't actually need in one particular financial year and actually receive that funding back the following year to make important investments in services. So I think probably within the three-year time frame of the IMTP, we've probably had that one occasion where we found the flexibilities in the finance Act were very helpful. 

Can I ask you about medical agency expenditure? Your expenditure on this category—so, medical agency staff—has risen over the last two years by £3 million. That's equivalent to a 40 per cent increase. Is that right? 

16:15

And whatever the comparable percentage is, it has fallen quite considerably across Wales. So, how do you explain—? You've been going, unfortunately, in an upward direction; the rest of Wales is going the opposite way overall. 

So, in overall context, just to put that, our use of temporary staffing across our health board is about 11 per cent of our pay bill. That was the same in 2018-19 as it was in 2017-18, and the percentage on agency is about 3.85, 3.9 per cent, and that's the same. So, overall, our temporary staffing requirements are about the same. What has happened is that we have shifted in terms of more agency being used, both in nursing and medical staffing, and both of those fundamentally relate to the number of vacancies that we've got in our system. So, both in medical staffing and in nursing, our vacancies have increased. So, 87 per cent of our agency spending in medical is due to vacancies, and we have some particular specialties where we've got some significant issues.

Some of them are related to decisions we've made, so if I can give you an example. A number of years ago, the Wales Deanery asked us to remove doctors in training from Nevill Hall Hospital in paediatrics and obstetrics, which we did. They wanted us to concentrate the training doctors at the Royal Gwent Hospital. That left a significant issue for us in terms of medical staffing for paediatrics and obstetrics at Nevill Hall, and the health board took the decision that they would recruit non-training grades to take the place of those training doctors, which we did. The resources were put aside for that and we went out and recruited non-training grade doctors. Our ability to do that over recent years has become quite difficult, and so we have become more reliant on agency doctors in order to sustain that service than we would want. But the need to sustain the service is important, and so the health board has committed to that resource. 

In other areas such as ophthalmology, we've had long-standing vacancies. We've had five vacancies in our ophthalmology service. We want to make sure that we're able to deliver as much ophthalmology care as possible, and make sure we continue to meet not only emergency eyecare demand, but elective requests for treatment. And so, we have put agency ophthalmologists into our ophthalmology service whilst we recruit substantive doctors. We have now recruited three, so that's good. 

So, there are various services. We also now directly manage four GP practices in the health board, and we've struggled to get substantive doctors recruited to all of those, and so we have relied on agency doctors there. So, in some ways, the spend on agency is related to sometimes the decisions we've made as a board to change the service, or to meet requirements for referral-to-treatment times, or, where there may be gaps in junior doctors' rotas, we will make sure that the service is safe, and in order to make sure the rosters are safe and fully staffed, we will deploy agency.   

Compared to other forms of temporary staffing, what are the advantages or the attractions of agency staff as a solution? 

In medical particularly, or—

So, in terms of our temporary staffing, it's probably equally split between locum doctors where our own doctors do locum work for us, or doctors we know do locum work for us, and agency. So, it's split evenly. We probably use about 69 whole time equivalents a week in terms of temporary medical staffing, and that's split between agency and locums, probably 50:50 I would say. The cost of the agency element of that is significant; it's probably twice the cost of the locums. That's where we need to be and we are continuing to focus our effort on making sure that those areas where we're over-reliant on agency doctors, we make the right call. So, in terms of ophthalmology, we've now been able to recruit. We'll see that diminish. In terms of managed practices, we might do something different, and we might see that diminish. 

16:20

So, is the decision path that, if you have a gap, you first try and fill it with a locum? 

We absolutely try and fill it with locums, or our own staff doing extra hours, or things. But you have to be quite careful about how many hours people are working extra to make sure that they don't breach—

Yes, and then agency as a last resort. 

Yes, absolutely. 

So, the attraction is that, with an agency, you're going to be able to plug that gap essentially because of the higher rate and—

Yes. We have an internal process around whether the gap needs to be plugged, what processes people have gone through to try and offer additional hours, or to try and find a locum. And, then, there's a decision-making process around, 'Okay, so, we need to fill that gap, so we will use an agency doctor.' 

I'd just like finally to ask you about the Welsh Government's October 2017 circular, which you'll be more familiar with than me, probably. But, that was targeted at trying to help control medical agency costs and limit the use of medical agency staff. Has it been successful? Has it helped?

For our organisation, we have struggled. We started at a very low baseline. So, when the circular came out, we were already in a low spending position compared to other health boards. So, trying to realise another 35 per cent saving on that was always going to be a real struggle for us, and we did indicate to Welsh Government colleagues at the time.

One of the issues for us is, when we do go to agency, that rate that the agencies are offering us is far in excess of the capped rate that's set out in the circular. So, we have a difficult dilemma then about whether we pay the breached cap rates or do we not cover the roster, and our view is always that we try our very best to work within the capped rate, but, at the end of the day, we want to make sure that our services are delivered. 

Do you have a figure for the proportion of your total spend, or the total number of engagements, or however you want to measure it, in which you breached the price cap rate?

It's about 63 per cent—

It's about 60 per cent. 

—outside the cap rate. 

You've already explained to us why you had to fill some gaps in your medical staffing because of specific issues. Could you just explain to us why you've had to increase your expenditure on nursing staffing, because I would expect it to be more of a steady-state situation?

Yes. I'll bring Martine in. So, the number of nurses we have in our organisation is pretty much stabilised. There have been some specific things that have happened in the last year around a peak in retirements that caused us some issues, but also our need for nursing numbers has increased as well. So, our establishment has gone up, and it's there where we now have vacancies that we're trying to fill. So, I'll bring Martine in; she'll make a much better job of answering the question than me. 

I think it's important to note that that is set within the context of the significant work that was done a few years ago, back in 2016, in terms of actually coming off contract and reducing our agency spend, and, actually, how that has been sustained around the very robust governance, as Judith has described for medical agency, that we have in place for nursing—the governance around that—and actually looking at the usage, but also in terms of maintaining quality and safety. So, very good controls around the management of using that nursing agency spend. 

But, as Judith has said, the single biggest reason for use is in regard to vacancies. So, 78 per cent of our agency spend on nursing is against vacancies. And, obviously over the winter period, in terms of opening up additional capacity, that's in acute areas where you do need the registered nurses—so, in unscheduled care, and that's where we have seen the need. So, that's been another factor in terms of that increase. And we have seen an increase in our vacancies particularly at Nevill Hall Hospital as well, in unscheduled care and in scheduled care on the wards. So, that has been a factor. So, that's why we've seen an increase in the use of agency nurses. We have, obviously—. We look very carefully around the quality of the agency nurses that we use, to try and ensure that agency nurses work consistently in an area, and we provide additional staffing and support as well, and monitor that very carefully.

16:25

You mentioned—or I think Judith mentioned—that there'd been a spike in retirements. Isn't that a predictable area? On the whole, people say, 'Yes, I'm going to retire at'—

It is predictable. So, we know in terms of our workforce there are nurses that have that choice, in terms of to retire, and we have done a huge amount of work around retaining nurses and giving them options around retirement and return. And we do have a high number that return. Obviously, they tend to come back on reduced hours. But also we look to offer other places to work in the health board that might not be so intense an area to work in. So, we've had a huge amount of focus around retention, understanding the choices that nurses are making, and looking at offering very flexibly. There are nurses that may wish to come back and still work with us, and a proportion do. But there is no doubt, when we've looked at our workforce plans, we have seen that increase in nurses that have got that opportunity to retire. As we look, as that goes over the next few years, we see that the position will start to improve, and also we have the position with the commissioned number of nurses that are coming in as well.

What impact, if any, has the implementation of the Nurse Staffing Levels (Wales) Act 2016 had on your nursing agency expenditure?

So, for us, in terms of the Nurse Staffing Levels (Wales) Act 2016, in terms of—. You have the overarching duty, so it applies, obviously, to all areas in terms of ensuring that we provide safe care for our patients. The nurse staffing Act currently, in terms of medical surgical wards, for us, is 29 wards, and we had a well-established process in place. Obviously, reviewing your establishments is fundamental, on an ongoing basis, to ensure you have enough nurses planned in that roster to care for patients. So, we had a process of reviewing the establishments. Obviously, with the Act and the calculation, what we have seen, yes, it has had an impact, in terms of—. We've seen differences in the acuity of our patients in areas and therefore the requirement for more registered nurses. So, that's on some of our unscheduled care wards. We've also seen in areas, for example, such as orthopaedics, with the increase in activity, the requirement for more registered nurses. So, that does have an impact on that overall picture of our workforce. But it's absolutely right, in terms of that review and calculation, and then looking at that, and it's very transparent at the board, in terms of that information that's going to the board as well.

Okay. Clearly, you're going to need to get in temporary or agency when somebody is sick, but what more do you think you can do to reduce the demand for having to take on nursing agency staff, which is extremely more expensive than substantive staff?

There are a number of elements to that. Obviously, the key one relates to recruitment. So, we have a very significant and wide-ranging recruitment plan, which includes, obviously, maximising all the students we can that come out through the streamlining process. We've undertaken work looking in our local community at nurses that have trained overseas but haven't achieved their registration to work as a registered nurse in the UK. So, we've been supporting a number of nurses through that process who already live locally. We're looking at return to practice. Recently, we've been recruiting from our borders as well and secured nine nurses in that way. So, I think a very multi-faceted recruitment strategy, which we regularly review, is absolute key to that.

The other element, which aligns to Clinical Futures, because that underpins our workforce plans, is actually looking at what you need a registered nurse really to do. And actually we have many examples where we're looking at new roles and the impact that they can have on our wards but also in primary care as well. We have six physician associates in post and we've just recruited a further 11 in post. So, I think that's an important area. Obviously, with healthcare support workers, and developing new roles—band 4 roles—we have well established in areas, looking at our complex care packages at home, band 4 roles that are performing very well.

So, I think there are a number of areas in terms of reducing that reliance on agency. Absolutely underpinning all of that is having very good governance arrangements and control so that you have the assurance that, when you do need a registered nurse, it is a registered nurse that is there. 

16:30

Thank you. Just looking at the vacancy rate overall, you've already explained why you've had to recruit new people in obs and gynae and paediatrics at Nevill Hall, but I'm a bit surprised to see you've had to advertise between four and nine times for each vacancy in the last 12 months. I wonder if you can give us some insight into why it's been so difficult to fill vacancy rates, particularly as, for example, in trauma and orthopaedics, you seem to be sector leading in the way you're approaching these issues.

I think it's primarily related to a national shortage in specialties, in particular in paediatrics and obstetrics. Both are middle grade and senior level—very difficult to recruit. We're continuously trying to recruit. Ophthalmology is the same. Occupational health is the same. There are a number of specialties where we have found it increasingly difficult to recruit, but we also have specialties where we have no difficulty recruiting as well. So, I don't think it's an issue of people not being attracted to the organisation to work with us; I think it's just that those particular specialties are just not available.

We feel really fortunate that, in terms of ophthalmology—we've been carrying five vacancies for some time—we've now recruited to three, we'll continue to try and recruit to the other two. But I think, for some specialties, we know that it's going to be increasingly difficult to recruit. So, the configuration of the services is what's required. And in relation to paediatrics and obstetrics and gynaecology, we know that all those services will be moving in to the Grange hospital at a consultant level, so that means that we'll be able to consolidate on one site and therefore equate some sort of economies of scale by doing that. So, that's positive. For many of these, there is light at the end of the tunnel, but in the current situation we're in now, we're struggling in some specialty areas. 

Okay, so, in the meatime, are you having to use golden hellos and these sort of things that they use?

No, we haven't gone outside the normal pay and terms and conditions arrangements for medical staff.

Focusing on the money, are you able to tell us how much money your health board would save if you were able to employ permanent staff to fill vacant posts?

In relation to nursing, we use about approximately 83 whole-time equivalent nurses each week. 

From agency, yes. We use, obviously, from our internal bank—so, 83 agency nurses each week. The premium for each of those is about £13,000 per whole-time equivalent. So, that would be about a £1 million that we would save if we filled all those posts permanently. I think we've got 60 whole-time equivalents in the plan for this year, so we are quite optimistic that our number of vacancies and our need to use agency will reduce over time. In relation to medical staff, I think Glyn had done a calculation for me, which we think is more in the region of £3 million to £5 million. If we could fill all posts on a substantive basis, then the savings would be significant.

Okay, and how many vacancies are you having to fill in this agency way?

It's about 170 medical vacancies.

Yes, there are about 170 in total. 

There are 170 medical vacancies. Obviously, that's a signifiant number.

Plus 10 in primary care, if you want the complete number. So, 180, if you want both. 

I think I'm pretty much done. But do you envisage that, with the amalgamation of the hospital services onto the Grange site, you'll then be able to massively, or significantly bring down the medical vacancies?

I think for some services it will help, but it won't help for all services. One of the pieces of work that we're doing at the moment in relation to the service models is we've already started to recruit to test the market for some specialties and some doctors. And to be fair, we're getting very positive results to those early advertisements. So, I think for some specialties, where there is a consolidation from two sites to one, it will help, but with other specialties, we are making sure that we consistently test the market to fill the vacancies that we’ve got. And they will be across all sorts of grades, from junior, middle, clinical fellows, up to consultants—they are a wide range. So, that 180 spans across the whole gambit of the medical workforce—lots of specialties—and includes GPs and dentists as well, not just doctors.

16:35

Great. We had a couple more questions for you, but is it okay if we write to you with those to save some time?

Absolutely. No problem.

That's the approach we took with the previous evidence session with Hywel Dda. Great. Can I thank you for being with us today, Judith Paget and your colleagues? We'll send you a transcript of today's proceedings for you to check for accuracy. Thanks for being with us. 

7. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o'r cyfarfod
7. Motion under Standing Order 17.42 to resolve to exclude the public from the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod, ac eitem 1 o'r cyfarfod ar 15 Gorffennaf, yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting, and item 1 of the meeting on 15 July, in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

I move Standing Order 17.42 to meet in private for items 8, 9 and 10 of today's meeting and item 1 of next week's meeting.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 16:36.

Motion agreed.

The public part of the meeting ended at 16:36.

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