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Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

13/06/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Dai Lloyd AM Cadeirydd y Pwyllgor
Committee Chair
Darren Millar AM Yn dirprwyo ar ran Angela Burns
Substitute for Angela Burns
David Rees AM
Helen Mary Jones AM
Jayne Bryant AM
Lynne Neagle AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Carol Shillabeer Bwrdd Iechyd Addysgu Powys
Powys Teaching Health Board
Dr Philip Kloer Bwrdd Iechyd Prifysgol Hywel Dda
Hywel Dda University Health Board
Hayley Thomas Bwrdd Iechyd Addysgu Powys
Powys Teaching Health Board
Joe Teape Bwrdd Iechyd Prifysgol Hywel Dda
Hywel Dda University Health Board
Rhiannon Jones Bwrdd Iechyd Addysgu Powys
Powys Teaching Health Board
Steve Moore Bwrdd Iechyd Prifysgol Hywel Dda
Hywel Dda University Health Board
Wyn Parry Bwrdd Iechyd Addysgu Powys
Powys Teaching Health Board

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Philippa Watkins Ymchwilydd
Researcher
Sarah Beasley Clerc
Clerk
Tanwen Summers Dirprwy Glerc
Deputy 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 09:29.

The meeting began at 09:29.

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

Bore da ichi i gyd a chroeso i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd. O dan eitem 1, cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau, allaf i groesawu fy nghyd-Aelodau i'r pwyllgor yma y bore yma? A hefyd gan ddweud rydym ni wedi derbyn ymddiheuriadau gan Angela Burns, ac mae Darren Millar yma yn dirprwyo ar ei rhan. Ac, hefyd, rydym ni wedi derbyn ymddiheuriadau gan Dawn Bowden am y bore yma.

A allaf yn bellach gyhoeddi bod y cyfarfod yma yn naturiol ddwyieithog? Gellir defnyddio'r clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. Nid oes angen cyffwrdd â'r meicroffonau; maen nhw'n gweithio yn awtomatig gyda'r system sain fendigedig y tu ôl i ni. A dydyn ni ddim yn disgwyl unrhyw larwm tân bore yma. Felly, nid oes ymarfer, felly os oes yna larwm tân yn canu, dylid dilyn cyfarwyddiadau'r tywyswyr a gadael yr adeilad mewn ffordd drefnus.

Good morning, all, and welcome to the latest meeting of the Health, Social Care and Sport Committee here in the Senedd. Under item 1, introductions, apologies, substitutions, and declarations of interest, may I welcome my fellow Members to this meeting this morning? And, also, to say that we've received apologies from Angela Burns, and Darren Millar is here as a substitute. And we've also received apologies from Dawn Bowden for this morning.

Can I also announce that this meeting naturally is bilingual? Headphones can be used for simultaneous translation from Welsh to English on channel 1, or for amplification in the original language on channel 2. There's no need to touch the microphones; they work automatically with the wonderful sound system behind us. And we're not expecting a fire alarm this morning. So, there is no drill, so if an alarm does sound, we should follow the directions of the ushers and leave the building in an orderly manner. 

09:30
2. Gwaith craffu cyffredinol: Sesiwn dystiolaeth gyda Bwrdd Iechyd Lleol Prifysgol Hywel Dda
2. General scrutiny: Evidence session with Hywel Dda University Local Health Board

Sydd yn dod â ni i eitem 2 a gwaith craffu cyffredinol y pwyllgor yma—sesiwn dystiolaeth gyda Bwrdd Iechyd Prifysgol Hywel Dda. Croeso i chi'ch tri. Rydym ni wedi derbyn eich tystiolaeth ysgrifenedig ymlaen llaw, a diolch yn fawr iawn i chi am hynny. Ac yn seiliedig ar hynny, mae gyda ni res weddol faith, a dweud y gwir, o gwestiynau i fynd ar ôl y manylion. Felly, byddwch yn barod. Felly, i'r perwyl yna, gallaf i groesawu i'r bwrdd Steve Moore, prif weithredwr bwrdd iechyd Hywel Dda; Joe Teape, dirprwy brif weithredwr a chyfarwyddwr gweithrediadau; a hefyd Dr Phil Kloer, cyfarwyddwr meddygol a chyfarwyddwr strategaeth glinigol Bwrdd Iechyd Prifysgol Hywel Dda. Felly, gyda chymaint â hynny o ragymadrodd, croeso i'r tri ohonoch chi, ac fe wnawn ni ddechrau ein cwestiynau gyda chwestiynau Lynne Neagle. 

Which brings us to item 2 and the general scrutiny work of this committee—an evidence session with Hywel Dda University Health Board. Welcome to the three of you. We've received your written evidence before hand, and thank you very much for that. And based on that, we have quite a long series of questions to get into the detail this morning. So, be ready. So, to that extent, may I welcome to the table, Steve Moore, chief executive of the Hywel Dda health board; Joe Teape, deputy chief executive and director of operations; and, also, Dr Phil Kloer, medical director and director of clinical strategy of Hywel Dda University Health Board? So, with those few words of introduction, welcome to the three of you, and we'll start our questions with questions from Lynne Neagle.

Thanks, Chair. Good morning. Following the zero-based review, the Welsh Government allocated an extra £27 million recurrent funding to the health board, reporting that that would put your funding on a fair funding basis. Do you agree with that assessment?

Yes, it was a very welcome piece of work that we did jointly with the Welsh Government, to look at the particular issues around Hywel Dda, linked largely to our demography, but also to our geography as well, and some of the challenges that we face. We do think that has put us on a much more stable footing. Clearly, we still have a deficit that we need to deal with, but it has recognised for us some of the particular challenges that we face with what is already an older population than the average for Wales, and indeed in quite a rural setting, with many of our hospital services spread quite thinly, which also has an impact on our finances. So, it has put us in a much stronger position. It does mean that we can now face the future with some confidence about being able to deliver a three-year plan. That will be the first time we've done that in our existence, actually, but we recognise there's still an awful lot more work to do to get us to that point. 

Okay. So, what's the reported outturn then for 2018 to 2019? How does that compare to the controls set by Welsh Government, and how would you describe the current financial position of the health board?

The year 2018-19 was really important for us for all sorts of reasons, and we may well touch on some of the more strategic issues as well. But one of the things that was important for us was that it was the first year that we have reduced our deficit year on year since as far back as I can see in our records. So, the £27 million was clearly a big part of that. We ended the year at £35.4 million against a plan of £35.5 million. So, slightly below. But, even within that figure, we also reduced, taking into account that £27 million, by £7 million ourselves in year. So, we've shown that we've turned the boat, if you like, and this year we're aiming to reduce that further to £25 million. That's the control total that's been set. So, that's another £10 million reduction. So, it feels like, after many years of challenges, largely linked to our workforce challenges and the ability to ensure that we've got a fully substantive workforce, we have now turned the corner on that and I think we've done some really good work. We voluntarily put ourselves into a turnaround process two years ago in order to help with that, and I think we're starting to see the fruits of that now. 

Okay. Thank you. So, in his structured assessment report 2018, the Auditor General for Wales noted that the auditors were

'not yet confident that there is sufficient financial accountability and, irrespective of the control arrangements in place, the Health Board continues to overspend against its allocation.'

What changes have you made in the light of the auditor's report?

Well, we've been making changes for quite a long time, and certainly the feedback we had from the Wales Audit Office was that they could see good progress being made. However, it is still in the context of having a deficit. We've had that deficit, actually, for many years, but we are showing that we can make progress on that now in a way that we've not been able to do previously.

As I've mentioned, one of the key things we did two years ago was to put ourselves into a voluntary turnaround process—so, bringing in a turnaround director, setting up a process that is from my level right down through the organisation of holding to account for individual directorates. We've done that in a way that always values the work that our teams do, so it's about how we can improve services. Whilst there's a financial narrative, it's built on how we can improve the quality of what we do, as well as save the money.

And I think we've struck that balance very well this year, with, for example, being able to remove a number of beds within our Carmarthenshire system whilst holding our performance, particularly in unscheduled care. Those were bed days that were being used by patients who were in our hospitals who didn't need to be, if we were doing something more positive. And we've demonstrated that with some investment around things like therapies, we've been able to take those beds out, save the money, particularly around variable pay and nurse agency, as well as improve the quality of the service being delivered overall.

So, it's a very difficult balancing act. I think that, as the zero-based review said at the time, there are some very deep-seated financial issues within Hywel Dda, but I do think we are now making progress on those.

09:35

Helen Mary's got a supplementary. We'll then come back to Lynne.

I just wanted to ask quickly in terms of the reduction of that bed capacity. How confident are you that that will carry on being sustainable in terms of not impacting on service delivery, particularly in the context of possible winter pressures? I mean, we didn't have a very difficult winter this year, did we? So I think my concern is that, if we did have another really difficult winter for whatever reason, would those beds that you've taken out for very good reasons, would the system be able to cope.

Yes. And I guess the first thing to say on that is we took those beds out during the period of last year, including through winter. And you're right, it wasn't as challenging a winter, particularly with flu, as we'd had the previous year, but it was still a very challenging winter. And actually, for I think all of us, and not just Hywel Dda, it doesn't feel like we ever come out of winter actually—it's pretty much a round-year thing.

What I would say is that, in the context of taking those beds out, we were able to ring-fence our elective capacity. So we were also, in all of that busyness, able to deliver the best referral-to-treatment targets that we've ever achieved as a health board, by eliminating all our 36-week waits. I think you'll see in the briefing, we had 7,000 of those just a few years ago. Prince Philip Hospital was our main source of that and they were able to maintain those elective beds through the winter with fewer beds in the system than they'd had in previous years. And I think, for me, it demonstrates the ethos and approach of turnaround, which is we absolutely have to deal with our financial issues, that the challenge around the zero-based review is, 'It's over to you now, health board, to sort the rest out', which is completely fair. We can demonstrate that we can make progress on that, and we've done that for the first time last year, we're hoping to do it again this year.

Your annual plan states that its budgeted deficit reflects a number of assumptions, including savings of £23.9 million, a greater proportion of which are meant to come from recurrent sources. Are you on track to deliver those savings?

It's always a challenge, but we have savings plans. I would say that the turnaround process drives all of this for us. So every directorate will set its budget and will have developed its savings plans. Actually our position now, with our control total target, is that we need to deliver savings of around £29 million. That compares to last year, where we delivered about £26.6 million, so it's a further step up for us. And within that, £24 million of that needs to be recurrent. At the moment, we've got around £20 million in place with some risk around it, and we've got a set of pipeline schemes to deal with the rest, and that's being taken through this turnaround process.

I wouldn't like to say that we've got this absolutely nailed. There was a lot of work going on in all of our services. I meet with all of my directorates every month to go through where they are with those plans, which schemes are on track, which ones they're developing, which ones need to get over the line. We are pushing on all fronts, but we are doing it. Although as I say there's a financial narrative, I would want to be clear that we're doing it from the point of view of how do we improve the quality of the service that we provide.

Okay. And when you gave evidence to the Public Accounts Committee last June, you said that the health board has an opportunity to develop a plan to achieve break-even in the medium term. Is that still the case, and when will you be in a position to present a balanced financial plan?

We are in the process of developing what we hope will be our first three-year plan this year, so going into the next three years beyond 2019-20. We are optimistic, although we haven't got all the answers yet, that in that period we can get to a balanced position. We are in discussion with Welsh Government about the relationship between that and our wider strategy. Because one of the issues that we face and one of the drivers of our strategy—by no means the only one—was the relative fragility of some of our services in the south of the patch. And, actually, there are a set of costs that are tied up within that that are going to be very difficult to go at until we bring those services together in the way that we announced. So, we need to talk to Welsh Government about how we can handle that over the medium term, but we're convinced that, in that timescale, we can get the health board back to a sound financial position.

09:40

Reit, troi rŵan at adran arall, sef agenda Llywodraeth Cymru o 'Cymru Iachach' a'r angen i drawsffurfio gwasanaethau, ac mae gan Darren Millar gwestiynau.

Right, turning now to another section, which is the agenda of the Welsh Government, namely 'A Healthier Wales' and the need to transform services, and Darren Millar has questions.

Can you give us an update on the work that you're doing to transform services in the health board area?

Yes, thank you. There's been a huge amount of work. The other important issue for us in 2018-19 was the development of our first strategy. That strategy, fundamentally, is built on 'A Healthier Wales'. It came out almost in tandem with it. We started our consultation process almost in tandem with the publication. But, actually, Hwyel Dda was also a key player in the development of the underlying design principles of the all-Wales strategy, so, in some ways, the DNA of our strategy is within that. We've called ours 'A Healthier Mid and West Wales', because, actually, it does fundamentally embrace all of those principles about moving to a much more social model for health: how do we help people to stay well, that prevention agenda, as well as the reconfiguration of services to ensure that we can maintain our services on a substantive basis.

In the short term, however, we know that we can't just wait for all that to happen—there are things that need to happen on the ground. We spent a lot of time last year looking across the world at who is doing well on things like enabling people to stay well in their own homes, supporting particularly our rural, isolated communities, and our bids that went into the transformation fund through our regional partnership board arrangements, signed off by all the organisations—our local authority partners included—were fundamentally about making some really key steps in that transformation journey.

We're hoping—for example, we've been approved to move forward with a technology-enabled care programme for the whole of Hywel Dda, based on and inspired by work that's been done in Spain, in Bilbao, and places like Barcelona, which is about a much more proactive model for people to stay well. We think that's part of the future for us—about how we support the population—and it's based on an understanding that, in terms of people's health and well-being, the NHS, probably—research says—contributes about 15 per cent to that. It's a much wider issue than just us. So, our strategy and our transformation is about how do we engage communities, and how do we support communities to look after themselves, to look after, particularly, our vulnerable elderly population? So, we're looking to make progress on that in the short term with the transformation fund. But I think our overall transformation strategy is pretty ambitious, actually, to take us forward.

To what extent do your financial challenges hinder you in making any progress on transforming services? We just talked about your in-year deficit. It's gone slightly up again, as I understand it, this year—is that right?

Okay. So, to what extent is that proving to add a challenge and a block in the way of transforming services?

That is one of the key issues within our strategy. So, just to note that the deficit last year was £35.4 million; we're aiming for £25 million this year, so it will be a bigger step down than we've ever achieved. But we are—. The challenge we face is that a lot of that deficit is tied up in the fact that our current system pulls people into the hospital-based system and actually what we need to do is invest in the things that we know are going to stop that from happening, but we're writing the cheques over here. So, how do you get the leverage, when you have a deficit, as you say?

That's why, for us, the transformation fund isn't the whole answer, but it gives us a point of leverage. So, it's new money into the system so that we can try these new things that should shift our demand. If it does that sustainably, we can then fund that from mainstream health budgets, because we've seen the change, particularly, in our hospital waste system. That's the nub of our challenge, I think, over the next three years, and we've got to describe the way in which we're going to achieve that, and we've got to be absolutely convinced that the way we're spending this money is going to have the impact, because there's no other place to go.

So, you've had £11 million from the transformation fund, as I understand it at the moment. You've talked about some of the things that you're spending that on. So, what savings are you expecting to achieve as a result of that in order to make it more sustainable?

Well, what we want to do at least is ensure that we take as much out of the hospital-based system to make them sustainable. So, there are only two answers really with the transformation fund: either it creates sufficient savings to sustain itself, because we can make savings from the hospital system, or it doesn't work, and we have to look at it and either tweak it or stop doing it. So, it does give us an opportunity also to try things, which I think is part of the—. Innovation, sometimes you have to fail sometimes you have to fail. But that for us is the really important point of leverage—will these things happen?

09:45

So, what's the evidence so far in terms of it paying for itself?

Well, the evidence that we've got is from the international examples that we've got. We haven't got it on the ground yet—the money's not come out to us yet. We are doing our own work around trying to support people better to reduce demand into the secondary care system, as well as to pull people out of the hospital more quickly. So, during the winter, for example, we had a bridging team process in place, funded with winter money, to enable people to get out of the hospitals more quickly and get back into their own homes. So, there is a lot of small-scale stuff going on, but we are hampered by the fact we can't invest significantly with our deficit. The transformation fund—that £12 million—will be transformative in the way that we can actually make a step change in what we're delivering.

You talked about the need to take the public with you when you're transforming services. What are you doing in terms of talking to the public at the moment in Hywel Dda? Because it's been a horror story in the past for you, hasn't it?

Yes, it has, and I think it's worth reflecting that there have been some big issues in the past and some lack of trust, I think, out there. We have worked really hard. Our transformation consultation last year, last summer, which was on the back of an engagement event we did the summer before, was probably one of the most wide-ranging consultation processes we've ever run. We had many of our staff, many clinicians, in individual conversations with the public about what we're planning, what their views were. In fact, it got a good practice award from the health consultation institute just for the scale and depth of what we'd done. We'd never done anything at that scale before.

However, moving forward, we know that we've got to continue to talk to our public and our stakeholders. So, alongside the strategy that we published in November, in January the board signed off a continuous engagement strategy, completely supported by our community health council, which is about how, at our locality level, we continue the conversations about how we design services, how we can best support people. We see that as really key to this, because, whilst we can have a long-term vision about where we think we want to go broadly, actually, firstly, we have to have the humility to know we don't have all the answers, and we don't see everything. And, secondly, we can only design those well if we've got the public alongside us. So, our commitment is we want to do that every day—

Are you able to demonstrate from your consultation exercise that listening to the public has made a difference to your plans?

Yes. The board paper that went—

Well, in September, the paper that went back to the board following the consultation report showed a number of examples where the public had—members of the public had—raised specific concerns about our proposals, and we were able to give a clear view about whether we were going to change things. For example, down in Llanelli there was some feedback about could we establish a maternity-led unit in Llanelli, which wasn't in our plans at all. That's something we've said we're now going to fully consider, because it seems like a good proposal. In Amman Valley there was a great deal of concern around the proposals around those beds. I met with the pressure groups myself. Actually, we're thinking about that differently, and we're talking to the local groups up there about, 'Actually, this resource—how would you like to use it?', whether that's in beds or in community-based care, because there are trade-offs in that. So, I think there are a number of examples, through everything that we've done, where we have taken back that learning and we've changed our plans. Clearly, for some things that the public were concerned about—Withybush is probably the clearest example of that, and the future of the emergency department—we've tried to be very honest and transparent about the reasons why we can't do the things that the public hoped that we would be able to do for them, the nature of the challenge that we face, and we'll continue to have that discussion across the patch, because we need to be an organisation and we are—. I think a hallmark of our organisation is one that is genuinely open to all of those discussions, but being very honest about the challenges and how we can fix those.

Helen Mary has got a supplementary. Then back to you, Darren.

I know that you're aware of the history and the depth of distrust that you're facing in some communities. Would you accept that the reality is that, for some places, people are going to continue to be a bit sceptical until they actually see the change on the ground? And, in that context, are you getting the transformation fund money out fast enough for communities to be able to see that and to see—? I'm thinking, for example, of some of the proactive telecare that we've discussed in the past. You might want to share some of that with the committee. But there is still that sense of scepticism, isn't there? I think you'd—. I hope you'd acknowledge that, in fact, people have got to see the change in some places before they're going to believe in what you say.

09:50

Absolutely. I do, absolutely—and I think the whole board acknowledges the worries that people have, and we have to be open about those worries. We also need to be open about what we can do about them practically, because, actually, every day our system is very stretched. We are struggling to fill rotas. People are waiting too long to get into our system, particularly in emergency departments in Glangwili and Withybush. We have to put forward proposals that are going to be better. Sorry, I lost the thread of your question then.

Just the sort of the—. I guess I'm looking for an acknowledgement that—. I know the effort you're putting in with public engagement, but people will say to me as a local representative, 'Yes, but we've heard all of that before', and I think the challenge for you is you've got to be seen to deliver some of that change, haven't you? And, of course, you've got a very big patch. So, delivering change in Llanelli is not going to convince people in Aberystwyth that you've done what you're going to do. And the other bit of the question was about: are you getting that transformation fund money out fast enough to be able to make some of those changes that people can see?

So, on the first point, we got a lot of that feedback from the public, and the NHS is littered with examples—I'm not just talking Hywel Dda, here—about maybe a temptation to overpromise and take services away before you put other things in place. We've been very clear: we have no choice, actually, but to put the new things in place. We want to do it anyway, but we can't continue the way we're going. If we do have a new hospital build, that's at least seven, maybe 10, years away. Actually, in those seven to 10 years, we've been very clear that we've got to do things that are going to change the system quite quickly so that we can manage what we've currently got, given that that new hospital won't be in existence until then.

So, actually, we will have to put new services on the ground in the Dale peninsula, in Fishguard, in a lot of our rural communities, and, actually, we want to design those with the local population. So, it's fundamental to our survival, actually. And I think, linked to that, also we're very clear we have to integrate. Integration with social care is no longer something we just want to talk about. It's something we absolutely have to do because it won't make sense to people if we don't. So, I think, in some ways, the strategy forces us to do the things you're saying, put the new things in first, because we've got to because the new hospital is so far away.

On the transformation fund, we've designed all of the services. We are just waiting for final confirmation around the money. So, we do need to get that in place, and, clearly, we're being very careful to ensure that what we design is properly evaluated, that we know what success looks like, because, in two years' time, that money goes, and, actually, what we've got to do is demonstrate a system shift, or indeed not—you know, learning is good on both sides. So, actually, that work is going on now, but the services will come in in the second half of the year.

You referred to performance against waiting times earlier on and the fact that you'd managed to eliminate the 36-week wait. I wish that was the case in my own health board area in north Wales, I have to say. But, clearly, you've made some progress on that. We saw some figures this week on eye care, and it's quite clear that around two thirds of your patients are not being seen—and these are at high risk of losing their sight—within the appropriate timescale. What action are you taking to address that, and when can we expect to see all of those being dealt with within the appropriate timescales so that they can save their sight?

Yes, it's clearly a worry for us. I'm going to ask Joe to answer this question.

Thank you. Obviously, we actually welcome very much the publication of the eye care measures and the introduction of those, because, historically, we've been measured largely on the referral-to-treatment targets, which we've—as you've acknowledged—reduced down to zero for cataract surgery, for example, but the new eye care measures now look at the follow-up backlogs, which, obviously—for many of our patients, it will be held up, delayed, on the follow-up backlog.

I think we're lucky in our ophthalmology services. We've got a really good multidisciplinary team. We're lucky to have David O'Sullivan, the national optometric adviser, who sits on our eye care board. We've got good input from our consultant team and also we're developing new roles around nurse injectors, for example, in wet age-related macular degeneration pathways.

In terms of specifics around the eye care measures, we've appointed four eye care co-ordinators, which, effectively, work with each of the clinical leads under each of those pathways—so, for example, for cataracts, glaucoma, wet AMD—and they're employed specifically to track patients now within the system. So, looking forward, we've been successful with a bid to Welsh Government through the eye care measures. We've received £420,000 in this year to develop solutions to our backlog, which, at the end of April, was around 7,500 patients delayed, and we're doing a couple of things with that. We're going through—.

Firstly, by September, we would've attributed a risk factor to every single one of those patients, so we can see those of highest risk needing to be seen sooner, particularly for glaucoma patients. To be honest, most of the risk sits in glaucoma. We've arranged a tender with the optometric community, which is now out to market, it's been launched, and we're expecting that to generate a lot of interest from our accredited optometric practices within Hywel Dda. And that will see 5,000 patients on the glaucoma pathway seen in primary care with a shared care arrangement with our clinical lead, Mr Evans, within ophthalmology, who will then only see the patients who need to be seen in secondary care. That, in turn, will also release capacity in our secondary care system and enable us, then, to see those patients within that part of the system who really need to see us.

I think the thing to acknowledge there is that, in many of our services, we have workforce challenges across the board. It's great to work with a community of colleagues in primary care who are actually able, willing and have capacity to help us with one of our challenges, and that's why the relationship with the optometric community is great. We've also got optometric practitioners who are working with our cataract pathway, and we'll be the first health board in Wales to implement a direct listing. So, somebody will see an optometrist and go straight into a cataract pathway. So, we need to acknowledge we have, and have had, incredible challenges in eye care because of the workforce issues that we've faced in terms of consultant recruitment particularly. But the eye care measures funding has given us a real opportunity to do something different for our population, and we have such good engagement from our clinical teams as well.

09:55

Does the fact that the Welsh Government's eye health care plan, which expired in 2018, as I understand it, back in March last year—? So, it's just sort of being continued, as it were, without reflecting on this new measure of risk and the way that you care for people in accordance with risk rather than the arbitrary waiting time target. Is that a help or a hindrance? What discussions have there been around redeploying a new eye health care plan and developing a new eye health care plan with the board?

We've always worried about the eye care list. We've had regular discussions with our quality and safety committee over a number of years around eye care harm in relation to eye care services. And our consultant body—. I chair our our eye care group, which has got—. Again, it's a multidisciplinary group including the RNIB as members of that group. And our consultant body are very active in reporting any harm as well. So, we have a very good governance system within that. If we feel that there are issues, they are highlighted, we apply redress to those, we investigate those and we're trying to learn—. We've always reviewed our eye care list to try to look at the clinical conditions within that to make sure we prioritise those patients most in need.

You didn't quite answer my question there. It'd be interesting to know how many people have lost their sight as a result of waiting too long, by the way, if you've got those figures with you. But I was more interested in Welsh Government's eye health care plan. It expired and went past its sell-by date in March last year. I understand there's not going to be a new plan until at least 2020, so we've got two years with no plan, effectively, or an extension of the existing one. The existing plan doesn't match up with these new measures now, does it, and the new approach that you're being encouraged to take as a health board.

I think there's a similar theme to all of it. I mean, we've been active members of the national eye care meetings, the eye care services have very good leadership within them nationally, both in terms of the planned care programme—

So you've got good leadership even though there's no eye care delivery plan.

I think there's lots of specific actions and sharing of best practice within the eye care community nationally, and that's driven (a) the publication of the measures, but (b) then some of the work that you see going on now across Wales in terms of pathways within different services.

So, what discussions have there been about a new eye health care delivery plan with you as a board?

We have our own eye care action plan within our own health board—

But in terms of a national plan that you're all following so that people can get consistent care and access to care across the country, there haven't been any discussions with the Welsh Government and you as a health board.

There are discussions at the national eye care meetings that we attend as a health board—

And what have those discussions said about a new eye health care plan?

I think, in the interim, there's a continuation of where we are, because there's a lot of new initiatives, there's a lot of new pathways, lots of best practice, the health boards are trying, we're sharing those examples. We had a good example at the last meeting: Aneurin Bevan, for example, are doing lots of work on communication and social media, and a lot more active communication with the public. So, the national eye care group are looking at that as one example. So, I think the work continues. I think the publication of a document, to be honest, from my perspective, operationally, is not a big issue and our concern—

10:00

It doesn't matter if there's no eye health care plan ever published again, as far as you're concerned.

I think we always look, in all of the delivery plans, for the best practice within those to try and guide, help and steer us, and we're still doing that. The fact that the old plan has gone doesn't mean we're not continually searching for the best practice across Wales. We're leading some of that. There's other good practice in other parts of the system that we're trying to adopt and implement. We feel that we've got a good plan, now, for our follow-up patients. It's dependent upon, obviously, generating capacity within primary care, which we think we can do. We've got exceptional leadership in all of our ophthalmology consultants. Every one of them leads on a sub-specialty within the service. We're developing a cataract—looking at our cataract activity and how we can do more of that internally within the health board. So, we think we're in a good place. We've got direct access with Mr Evans, the ophthalmology lead within the health board—he's got direct access with Phil, Steve and I on a regular basis, discussing eye care issues. So, we feel that we've got a lot to do and we acknowledge that, but we think that we've got a good plan moving forward, and we feel confident that over the next year or so we'll see our backlog significantly reduce.

Okay. It would be good if we could have the figures on those patients who have lost their sight or come to harm as a result of waiting on those lists.

We've certainly reported that to our quality and safety committee, and we can certainly, through you, Chair, provide that to the committee.

Grêt. Diolch yn fawr. Symudwn ymlaen i adran arall, rŵan, sef gofal sylfaenol, ac mae yna gwestiynau gan David Rees.

Great. Thank you very much. We move on, now, to another section, namely primary care, and the questions are from David Rees.

Diolch, Gadeirydd. Good morning. Primary care, obviously, you've talked about a little bit in your transformation model as to where you want to see more patients cared for in the community and fewer coming into the hospital sector as much as possible. I understand that. But perhaps before we start talking about where we want to go, can we have a look at where we are? That's currently the clusters—we have a cluster model. Are the clusters currently helping you reduce the need for patients to come into hospital services?

I may ask Dr Kloer to come in on the specifics of that, but just in general terms, all of our cluster leads were very engaged in our transformation programme last year. So, actually, they were part designers alongside our hospital doctors and our other professions. They are very wedded to this, and actually, some of the work that they've done in clusters using their cluster money has been highlighted as the things we want to take forward on a much wider basis. And there have been some really good examples—things like pre-diabetes checks in Ceredigion, where we've taken that and we want to make that work across the health board, and 'stay well' plans that are part of our transformation fund bid, now, to widen out. So, there's mainstreaming of the sorts of things that they've been able to do on a relatively small scale, both within the short term and in our longer-term strategy. But I'll hand over to Dr Kloer to give some more examples.

Sure. Thank you. I suppose what we're trying to do when we're considering the transformation of community and primary care is we're trying to link the work that the clusters are doing with the work that we're intending to do with the transformation fund money and, of course, the integrated care fund money. So, we've linked together with our local authority colleagues and set up an integrated executive group, where I, Joe Teape, all three directors of social services, our director of public health and our director of partnerships all sit together to consider that in the round. So, it's going to be important that we consider all aspects of primary care connected with community services.

Over recent years, each of the clusters have undertaken some really impressive work within their communities, and they've picked different programmes of work, because we've allowed them to consider their own population need and the things that they feel will make the most difference to those communities. So, whilst in some ways, people find it a bit odd that each cluster focuses on something different, it has come from the needs of the local communities and where they think services need to be strengthened. So, if I take a few examples, perhaps, of—

You don't need to give us examples. The simple question is: based upon that decision to look at best practice or local needs, have those clusters, effectively, now been able to help you reduce your need for services at hospitals? Is the model, therefore, working to actually deliver what you want to deliver?

10:05

I suppose, the reason—. I'll give, perhaps, one example that might help give some confidence on that, in a way. So, I'll pick the Llanelli pharmacy care homes model, where they've reviewed medications of 400 residents across Llanelli in care homes. They've stopped over 400 medications. They believe they've reduced 800 GP appointments, which means then the GPs—. We think, therefore, we've freed up all of that time for the GPs, which means they can then spend much more time on patients who definitely need to see them. We've also saved £39,000 on medication, just through that project alone. When you consider that each of those interactions could end up with a hospital admission—. I suppose one of the points I would make is that there's no single action that will change our system. It's the multiplicity of actions, whether it be those cluster projects, whether it be in, for example—to pick Llanelli again, because there's a synergy with it—our specialist elderly care consultants going out into the larger care homes to support those residents staying in the care home, rather than having to come into hospital, or whether it be our plans around technology-enabled care to allow people to live independently at home and be less likely to come into hospital and support social isolation. So, for us, I think, when we look at the impact of the initiatives that happen in our communities, it's sometimes difficult to pick a direct cause and effect from one specific project from the cluster on its own to a number of hospital admissions. But we know the things they're doing are important.

Can I ask, then—? Obviously, in your paper, you highlight that you have four managed practices. That's nothing new, because managed practices are across the whole of Wales. How are those managed practices now fitting into the cluster model as well? Because clearly they are managed by yourselves, they're not independent contractors, so how does that fit into the cluster model? Is that working well?

One of the steps we're taking with the managed practices is to implement the new primary care model. I suppose, with the managed practice construct, of course, it allows us to have more control over that. So, having the variety of healthcare professionals supporting the work of the practice—whether they be the community pharmacists, who are excellent, obviously, at making sure that patients are on the right medication and not too much medication, because we know there is overmedication across society, whether it be our advanced paramedics who are excellent at dealing with people with acute care needs, or advanced nurses dealing with palliative care needs—there's a whole range of skills that they bring to the practices, where we know that if it's just provided by a GP, it means the GPs are clogged up dealing with issues that could probably be much better dealt with by another professional, because we tend to overmedicalise the care. So, it's allowed us to implement that model in our managed practices.

Having said that, there are a range of practices in our area that have implemented that themselves, sometimes out of necessity. We've seen practices go from a situation where they're quite vulnerable, with GPs leaving, to situations where they're vibrant now, and when you go and speak to the lead GP in the practice, they're excited about the future in their practice. So, Tŷ Elli practice in Llanelli is an excellent example of that. And I suppose it's not just the health professionals. The other point I would say is that in many of our practices, we're starting to have community connectors, and we're much more connected with our local authority colleagues. Argyle Street is a good example of that. So, I would say our managed practices have allowed us to have some control over that development, but it's something that's starting to spread throughout our practices.

Your paper identifies that you expect perhaps three of those four managed practices to go back to the independent contractor model. So I'm assuming you believe those practices now are going to be sustainable, will develop and build, basically, and will spread the message out in the independent sector models that are out there.

10:10

Just on that, we did have one of the highest numbers of managed practices, I think, of the health boards, with five last year and one returning last year. Just on the point around cluster engagement with these managed practices, when we first get into these situations, so quite often when a practice is in some difficulty, actually the role of the cluster in that is often to support us, to wrap around us and help us to support that practice. We saw that in Llanelli when we had some real challenges down there, and then over time, as they become more stable, they actually become full members of the cluster work, so the relationship changes over time.

We are feeling quite optimistic now with, as you say, three out of the four that we still have on our books, that we'll get a strong response when we offer those back out to independent contractor status this year, which will be a bit of a transformation for us. I think it reflects what Phil was saying around being able to develop the new model, the primary care model; that's become very attractive because it allows GPs to spend time doing the things that only GPs can do, and ensuring there are other professions there who can do the other work that best fits patients' needs. So it does feel to me that, after quite a few years where we were worried, we're coming out of that now with much more of a sense of sustainability within our primary care system. I'm by no means saying that we haven't got risks, just like everybody else.

Helen has a point, and we'll come back to you then, Dai.

Yes, slightly playing devil's advocate here, Doctor Kloer, you had some really positive things to say about what you were able to achieve using those managed practices. I'd like to challenge the assumption a bit, and it's not an assumption that's just common to you; it's that actually independent contractor status is better. We know there are people, particularly young women doctors, who may want to work in primary care, but may not want all the hassle of being effectively a small independent business. So I'm just challenging the assumption that it's a bad thing to have managed practices. Because you've just been telling us all the stuff that you were able to achieve with managed practices, which you cannot do in quite such a direct way with the independent contractors. I suppose I come from a position, Chair, where I think that that independent status of GPs, effectively what you're doing is you're contracting with a private company every time you contract with an independent GP, and it may be that, in the long term, that isn't necessarily going to be the only model for providing primary care. So I don't know if you've got any comment on that. I just think we're in a bit of a state where we think that a health board is in trouble if it's directly managing primary care, but we don't think you're in trouble when you're directly managing hospitals. I just think it's a bit odd.

I'll come in a bit, and Phil might want to come in as well. I guess the issue around managed practices is that the reason we get into them is because they are in some distress. So actually you've got a self-selecting group that is quite often the most challenged practices in some of our most challenged areas. So there is the nature of that, and getting back to independent contractor status, at one level, is to show that what we've got is a sustainable model that is attractive.

I think the wider point for me, and it is slightly philosophical policy, is what's the future of primary care, and whether it's a general medical services model or something else is probably secondary to me than what is the workforce that we need out there, and what can we offer people who wish to get into, or are potentially thinking about getting into, a general practice role. That's increasingly about portfolio careers, actually, spending some time in primary care, some time in hospital settings, and we've got examples of that now in the health board, but our job, I think, is to put that in place so that we make primary care, whatever the contractual model, the most attractive it can be.

On the multidisciplinary approach in primary care that you're talking about, I certainly talk to nurses who would much prefer to work in a setting where they're directly managed by the health board and they get all the terms and conditions and time off to train and learn. We know that nurses working in GP practices, directly employed by the GPs, often don't get that. So I completely take what you say, Steve, that you only end up managing the practices as things stand when there are problems, so they're a problem before you take them over, but if you're going to have those effective multidisciplinary teams, the traditional GP model where the doctors are in charge and everybody else works for the doctors isn't necessarily going to help long term with that transformation of community care that you're talking about.

No, and I think it is a difficult issue because there are also many GPs who do like that model and that's how they want to stay. For me, it's about how do we put in place the right offer in Hywel Dda to attract general practitioners or anybody else who wishes to work in primary care. And on the issue of training and development, it's how do we treat them, whether they've got a contract with them or not, as one team, as one workforce, and increasingly it's the same with social care and domiciliary care as well—how do we jointly train together, how do we do learning and development together. In some ways, the contract doesn't need to be an impediment to that; we just need to think differently about how we work together. So, I think there might be a policy discussion around what the future of primary care is. It's probably above my pay grade but, actually, I think we do have some positive views locally about how we can attract trainee GPs in, for example, how we create a different model and how we break down the barriers between primary, community and hospital care, so that we can move people around according to their career aspirations. I think you can still do that with the current system—you can find ways through it.  

10:15

Since we're on that question about recruitment and staffing, you also highlight in your paper that you are facing an ageing workforce as well. So, you have a managed practice system operational that seems to be quite effective. Are you looking to perhaps now start looking at whether you need to implement that type of approach in other practices across your region, because of GP recruitment? You've identified that south Ceredigion did the golden welcome and it hadn't effectively worked. So, how are you looking at recruiting and how are you looking, if you fail to recruit, at more managed practices? 

So, just on that particular point in the evidence that we provided about the extra money for the GPs, that was referring to the extra money for the training GPs. And what that was referring to was the fact that those training GPs haven't come off the system yet, so it was extremely effective at attracting training GPs to Ceredigion and Pembrokeshire. In fact, for the first time in a long time, those training schemes were full. The problem is that in the meantime, whilst they go through their training, we do have some gaps. So, we're trying to be as creative as we can to fill those gaps whilst they come off the training skilled to fill them. 

Having said that, we do have some—. It's quite variable across our patch. As I said, there are some really thriving practices but there are some practices that are struggling, and you're right to say that there are challenges around a workforce that will retire soon. There are also issues, I think, that smaller practices now find it hard to deliver the same services as larger practices. So, whereas in the past we'd have called practices a moderate-sized practice, I think now they would be considered a small practice, and the reason for that is because the new primary care model is so much more effective, it's difficult to provide that when you've only got one or two partners in a contracted practice. So, we are seeing, and we have seen over a number of years now, practices either merging or we've seen, as in north Ceredigion, which has been very effective, we've seen them federate so that they share services and work very much more together across a number of contractor practices. 

I do think, though, that that training—. The fact that our training scheme has been full in Pembrokeshire and in Ceredigion will bear fruit in the next few years when they come off the scheme. 

Okay, thank you for that, and thank you for your positive view of what I asked about south Ceredigion, but in your words and I'll repeat it—these are your words and not mine:  

'The South Ceredigion cluster funded a golden hello as a mechanism to attract GPs; unfortunately, this has been unsuccessful'.

So, that is what you said, not what I said. 

We recognise that's slightly misleading, so we're trying to clarify that. 

And perhaps the final question on GPs is, if you are looking at GP recruitment and you are talking about the training, I'm assuming that your primary care academy that's being discussed with Swansea University is part of your training concept and programme that you want to use to attract more people to come into the area to train in the area. And as we are told quite often, once you train in an area, you tend to stay in an area.  

For definite, and so that's certainly—. There are a number of things we're working with our universities on, not only the primary care academy, which, as you say, is really important because once they work in the area, some of them may stay. We need the footfall. But also, we're looking constantly with both Swansea University and Cardiff University, not just with medical schools, actually, but also other schools, to get students training within the Hywel Dda area. We've got a successful programme called the CARER programme—the Community and Rural Education Route—up in Ceredigion with Cardiff University, where we have a number of students who've chosen to work in primary care up in Ceredigion. I met them at the local medical committee and they were extremely enthusiastic about their experience, and they only spend a little bit of their time in the hospitals. And we're looking at similar arrangements with Swansea University.

Another thing we're looking at is that some GPs don't want to go straight into partnership and into practice when they finish their training. So, we're looking at a scheme where they can work with us and be supported in their first year in general practice, but also have part of their time in hospital. And we can offer them whichever specialty they would like to take an interest in, because, as Steve was saying, GPs now, many of them, don't want to just do general practice; they'd like a portfolio career. So, it's not just one action we're taking; it's quite a number of actions to try and improve the situation. 

10:20

Symud ymlaen i faterion gweithlu ychydig bach yn ehangach na dim ond y meddygon teulu rŵan. Ac, wedyn, mae gan Jayne Bryant gwestiynau. 

Moving on now to workforce issues, more broadly speaking than GPs. And Jayne Bryant has those questions. 

Thank you, Chair. You've mentioned workforce challenges, and we've touched on the GPs. What would you say the most significant workforce pressures currently are, and where are they?

Gosh, I'll attempt to answer some of that, but some of my colleagues might want to come in. Clearly, we've had, for a number of years, a real challenge around nursing healthcare support workers. We still have some very high vacancy rates across the area, and we are working hard to fill all those. I think we were one of the only health boards that had a net increase in nurses last year. That's the case with that drop in nurses retiring and new ones coming in. So, there's been some success there, but when you look at, say, Bronglais, we have a 40 per cent vacancy rate for nursing up there, which is a real worry, actually. 

In medical specialities, we have a number of specialities that are quite fragile from a medical point of view. But particularly on our minds would be things like radiology, and, of course, the new academy will really help us with that in the medium term, as an increased number of radiologists come out of that. In mental health, a lot of the issues that underpin some of our challenges in mental health are our ability to appoint to psychiatry posts in particular, and there's a UK-wide issue there. But, also, as we've mentioned, in general practice, and ensuring we're doing all we can.

Although, in many of these areas—and I'd include nursing in this—it does feel that we're starting to make progress now on dealing with them. But there are still many areas where I think we have some significant workforce challenges. Of course, it's a UK-wide issue; everyone is struggling with it, but I think there's also an additional issue when you're in a rural community at the end of the M4 about attracting people to the area. And we have seen, over the last few years, our recruitment processes, our ability to attract people has transformed really. We're using the all-Wales 'Train. Work. Live.' and using a lot more of our social media. We've seen some real successes in that, things that have even surprised us, but we have to bat above our weight all the time to ensure that we're on the map for that. 

It links for us to our strategy as well, because we're trying to set out what we think is a very positive view of the future about what we want to create in west Wales, and we've done that, firstly, in transforming mental health, which was about a year before our main strategy, and now, in the main strategy. We're hoping, and we're seeing some evidence, that people are attracted to want to come and work here as a result of those things, but probably at the core of many of our challenges will be workforce of one form or another. 

Okay. Thank you. I know, obviously, from your written evidence, you've talked about the healthcare apprenticeship, which has recently been launched. Can you perhaps tell us a bit more about that?

Yes. It was a fab moment at the board last month when we formally launched our apprenticeship scheme. We've had lots of really good examples over the years, particularly for our healthcare support workers, supporting them into getting nursing qualifications. And in a place like west Wales, with our local population, quite often it is very difficult for people to travel into centres and get the support. So, the apprenticeship scheme is a completely new offer for us about how we can support people to come in and work with us, get their training on the ground, and then, if they wish to, progress towards their nursing qualification over a series of steps. We launched it all on social media on the day of the board meeting, and we've had massive interest, which is really positive for us, and we see that as one of our big opportunities for the future, and we want to see it grow. 

It sounds interesting. So, how many people would that involve at the moment, or how many people expressed an interest?

I'm not sure I've got the numbers, but, certainly, I was watching the Facebook page, and the number of people who were sharing it—I just ran out of time to scroll through it. The numbers that will go through in the first year will be 40—we've got 40 places. So, quite a step change for us, but, even so, it's still, I think, a first step—I'd like to see it expand. And of course we'd also like to see it expand beyond nursing into other professions—engineering, catering, a whole range of things that we can offer careers on. So, in the first year, there'll be 20 in Carmarthenshire, 10 in Pembrokeshire, and 10 in Ceredigion. And it's just been such a huge amount of positivity, I have a feeling we're not going to be able to keep control of it—it's going to really run.

10:25

Great. What action has the health board taken to support the health and well-being of the workforce?

Again, a really important thing for us, particularly with our workforce challenges. We need to ensure that the workforce that we do have we look after, and we support. So, there's the usual governance-type thing, so ensuring, for example, that we manage sickness absence well, and I review that with all of the teams regularly. And that's about ensuring that we understand the reasons for that—both long term and short term—and there are proper audits in place, and people are supported to come back, as well as ensuring that things like performance appraisals are done. And we've seen big progress on our delivery of that this year, because actually giving people time to be appraised and get feedback, and feed back their development is important. Beyond that, we have a staff psychological well-being service, which is offered across all three counties to our staff, and of course an occupational health service as well, which includes physiotherapy, because, quite often, one of the issues is around musculoskeletal problems. And we recently launched, through our occupational health service, a health screening service for our staff, which looks at general health issues for those who need it—so, that could be mental health issues that people maybe have, or physical health issues—but also offers specific screening around cardiovascular risk for our staff. So, we're trying to wrap as much as we can around it.

Are you seeing good take-up of those services by staff?

I think it's been very positive—I don't have the numbers, but I think it's been very positively received. We do know, however—you know, our staff do work in very challenging environments, particularly in our unscheduled care system, so I don't think this is everything that we need to be doing. We developed a set of values for the organisation some two years ago, and we use that now in all of our work, whether that's recruitment or staff training. I think there's further we can be going on that as well, about how do we make this a great place to work, even when we do have pressures in the system. But these things, for us, I do think give an offer to staff around, 'You will be supported in your development. If you need help, there is help there—there's psychological support there, there's well-being support'. But I'm keen that we continue to build an organisation that actually has a really strong offer for the whole well-being of our staff.

Okay. What progress is being made on reducing agency staff?

It links to our workforce challenges. We probably have had the biggest variable pay challenge in Wales, and that's agency, bank and locum. Over the last three years, we've seen significant reductions in our nurse agency spending. However, it is still very high for us—I think it was about £14 million last year. It had come down from previous years. There are two issues within that. One is our continued need to ensure that we grow our own workforce, which is things like the apprenticeship scheme, which will really help in the medium term, and we see as an important step forward, but also ensuring that, for those staff that we have, we look after them and we don't have the turnover—our turnover rate is slightly higher than the all-Wales average, so that's an issue that we need to deal with. But, in terms of agency nursing, the other issue here is to ensure, through the Nurse Staffing Levels (Wales) Act 2016, that we have safe levels of staffing. And that's meant, when we don't have a healthcare support worker or substantive nurses, we have had to sometimes bring in locum or agency staff, which has meant, for the last year, we've seen a flattening out of our reduction in nursing. So, we've still got issues there.

On the medical front, I think we have made significant progress. Our delivery of the agency cap I think was one of the highest in Wales—the last number I saw, which was a little time ago now, was about 68 per cent, around a 35 per cent target—again, challenging to stay within that cap, particularly when you need to keep services going. But we've seen a significant reduction in our use of agency medical, premium medical staff over the last few years. I was just going to look at the number while I was talking. We were spending £7.4 million on medical agency back in 2018-19—sorry, 2017-18—and last year we spent £4 million. So, we've seen almost a halving of that level, but, clearly, we've still got very fragile services. So, it remains a challenge for us.

10:30

You mentioned the nurse staffing levels. Is the health board compliant with the nurse staffing levels?

Yes, we've taken a very careful approach. Our quality and safety committee reviews all of this. We've taken very detailed reports to board. We are compliant with the Act, and that's been confirmed a number of times at board. It does mean we need to be clear about where our acuity levels are, and we've got 31 wards that fall within the Act and, of course, more to come. But we are clear in those areas, with the lead nurses in those areas, how we can deal with the gaps that they have, and that's sometimes does mean we have to bring in agency.

So, how are you planning for the extension of the Act? Are you preparing for that?

We haven't had confirmation yet, but clearly we're working on all of the areas that it could potentially be extended to. We're anticipating it'll probably be in paediatrics next, so we are looking at all of those—mental health, paediatrics and others—around the acuity measures, ensuring that we know what our baseline data is. So, we're as ready as we can be to extend that, but we also—as an organisation, we review all of our staffing regularly, regardless of whether it'll be extended, to ensure we have safe levels of staffing across the organisation, which, as I say, continues to be a challenge for us.

Alreit, Jayne. Symud ymlaen rŵan at faterion gwasanaethau mamolaeth, ac mae gan Helen Mary Jones gyfres o gwestiynau.

All right, Jayne. We move on now to maternity services, and Helen Mary Jones has a series of questions. 

Diolch, Cadeirydd; thank you, Chair. If I can start looking at maternity services, obviously the Minister wrote to all health boards in the light of what was uncovered in Cwm Taf, asking you about the safety, quality and sustainability of maternity services. There are obviously some Hywel Dda-specific concerns around the centralisation of consultant-led services in Carmarthen, and the effect of the public concern, certainly, and we did have a loss, didn't we, where a mother and baby didn't get quickly enough to the consultant-led services. So, what assurances have you been able to provide the Minister, and what assurances can you provide us today with, about the safety, quality and sustainability of services in the health board, completely acknowledging, as I ask that, you've got big challenges in terms of delivering that because of the rurality and distance?

Just to acknowledge, firstly, the change of service that happened in 2014, and the concern that caused. We did bring in five royal colleges to review all of that for us, just after I joined the organisation, and that was able to give assurance on that specific issue whilst acknowledging the concerns that still exist, particularly in Pembrokeshire, around that move. Of course, part of our strategy is to try and bring that further west now, with the potential new hospital build, if we can get the business case together. 

Generally on maternity services, I guess the first thing to say is I've been in the NHS for 30 years—these sorts of reports, wherever they are, always make really hard reading for all of us. They always cause us, and caused Hywel Dda as a board, a real moment of wanting to look hard and long at where we get our assurances from, how assured can we be, because, clearly, we've got systems that tell us all of that, and sitting down with the senior clinical team to look really honestly at what came out of the royal college report into Cwm Taf and where we were with that. 

We were able to write back to the Welsh Government request for that assurance being quite confident, actually, about where we stood, and that wasn't confidence based on the fact that we don't have challenges. It was probably based more on the fact that we knew what our challenges were, they were fully acknowledged, and we knew how we were managing them.

But that source of confidence for me probably came from five different areas, because actually governance is as much of an art as it is a science. You can have all the dashboards in the world, but if you don't have a wider view, a triangulated view, you can miss things. So, the first thing was the culture of openness within the women and children's directorate. So, I met with them very soon afterwards. Our quality and safety committee have done the same with the deep dive. I was just struck with a palpable sense of their focus on safety—from all of the clinical team, all the senior clinical leaders. Actually, they've put things in place that I think we can learn for the rest of the organisation in terms of their culture and their response, and they were very open with us about where our challenges are. So, we know, for example, that we're not birthrate-plus compliant across the health board. Again, it's part of our workforce challenge. However, they were very clear about all the mitigations they put in place to manage that. They acknowledged that and they are clear about their escalation arrangements too. 

We also know that we have a higher than average cesarean section rate—higher than the Welsh average. Again, they acknowledge that and there's work going on. We've seen an improving trend; we're about 30 per cent now, against an all-Wales average of 26 per cent. But that's an improving picture.

We have particular issues around Bronglais, again which they were fully acknowledging to us, about running what is a relatively small service in a rural area and ensuring it stays safe. Again, they were able to describe to us all the work that they're doing to keep that safe. We had an improvement plan in place 18 months ago, the vast majority of which they've now delivered. So, the culture, if you like, was one of the first tests for me. The second was to look at their formal governance processes, and again they were able to describe to us a whole range of things that they do as a team—so, the monthly quality and safety meetings that they have, they have a clinical dashboard for maternity and neonatal services, they have a labour ward and wider staff forum so staff can feel engaged, they've got very tight processes around their incidents. They were also able to point out the Wales Audit Office report that noted good quality and safety practices within—. So, there was a bit of triangulation in all of that.

As part of my performance regime within the organisation, I meet with every directorate regularly to go through a whole, rounded picture of their performance. I was able to meet them just after that report to look at things like their sickness rates, their compliance with performance appraisal and development reviews, all of which are in a good position. So, if we're thinking about how it feels for the team, people are getting their core skills training, they're getting appraisals, job planning is in a good place, their finances are okay; I reviewed their risk register with them, which they've got a very tight process around. And our quality and safety committee, as I mentioned, have been and done a deep dive as well and were able to reflect back some strong assurance to the board. 

The third thing was around actually how do we hear from patients in all of this, because clearly they're an important voice. They described to me the process they have in place, called a 'Did we deliver?' survey—so, for every patient who goes through the system there, they're offered the opportunity to take a survey in what their experiences were, good and bad—and how they built that into their learning and improvement system. One of the feedbacks from an earlier report was that the use of social media can be helpful, so there is a closed Facebook group and the directorate act immediately on any concerns that any of the patients, mums or dads raise on that system. 

Our CHC colleagues go in regularly. They went in twice last year and they were able to feed back positive reports to us about how that looked for both the staff support and the care being provided, and also the Welsh Risk Pool have been in. So, there was a degree of triangulation, with various different people looking at the services from a patient point of view and the ability of patients to feed back. We do want to go further as a health board. We'd like to implement the friends and family test across the organisation, and actually they were very positive about that, and that may be the place we go to first.

The fourth area we looked at was around just seeing how the well-being of our staff in all of this was being looked after. So, we looked at the deanery report, for example, because quite often it's junior doctors who can raise issues, and that confirmed for us that there was good leadership and clinical support in place across the team, and actually some really good, strong feedback. We want to feed that process into all of our other systems as well, so we ensure that junior doctor feedback forms formally part of our quality and safety system. They also have very strong systems in place to ensure that midwives don't work beyond the European working time directive, and they've got escalation processes in place to enable that, particularly when we haven't got enough staff to fulfil Birthrate Plus. That's a really key for us to ensure midwives are being looked after. Also, our use of agency and locum is very low in that organisation, and that can quite often impact on substantive staff if you have very high numbers of short-term workforce. So, that again gave us some positivity. 

Then, finally, we looked at—we questioned how easy it was for staff to raise concerns. We looked at the staff survey and that showed in all three areas actually we'd improved as a health board. It was great to see that—for all of our staff, so, this was not just women's and children's—pride in the organisation in Hywel Dda had increased by 8 per cent between the two years, so was at 73 per cent, which I think was a really positive thing for us, but showed that, as an organisation, we may be on the right track, with further to go. As a team, we try to be very visible. It's quite challenging in a health board with a footprint of our size, but we are out there, able to be approached by staff both face to face and through social media; we're all regular users of that. It was also good to see in the staff survey that more staff reported knowing the executive team in Hywel Dda than was the average across Wales. So, I wouldn't say—as I said at the beginning, we always take a moment when these sort of things happen, and I think there is more work for us to do and we've agreed some further actions with the team, but I was struck, actually, just by the culture and that sort of palpable sense, as I say, of the quality and safety culture within the women's.

10:35

That's helpful, thank you. I want to take us—and you've begun to touch on this, actually, already—out from maternity services. We know, of course, that in Cwm Taf culture was a big issue, so I want to look at some of the issues around culture and concerns handling more broadly, and that might give you a chance to expand a little bit on some of the things that you've touched on already. So, how confident are you that the culture across the health board—and you described that in women and children's services you do have that confidence—is one where staff genuinely feel supported if they raise concerns? What's your basis for your understanding of whether or not that culture is in place?

10:40

So, it is always a work in progress, I think, to ensure that all staff feel supported. When I joined the organisation back in 2015, it was a clear opportunity for me and the board to set out our stall about this actually being an organisation where the job of the board is to make our staff's lives as good as they can be, because they are the ones who provide good quality care to our patients. That linked to the values work that we did very early on as an organisation.

It is a very large organisation, however, so we need to ensure that we continue to work and push those messages. I do feel that I am confident that staff would be able to raise issues at any level. We implemented a few years ago a directorate structure that put in strong management teams, led by a doctor, a nurse and a manager, across all of our directorates, all of whom regularly look at their concerns, their incidents. They've got a process in place for that. As an organisation as well, we were very poor at concerns handling back in 2015, and—

I brought in a previous colleague of mine to do an external governance review when I arrived, and one of the very strong bits of feedback that she gave to the board was, 'If you talk about putting patients at the centre of everything that you do but it takes you a year to get back to someone, I'm not sure you are living that.' That was quite a hard message for us.

We have made huge progress on that over the years, both in terms of supporting people to deal with their issues before they become concerns—so, investment in things like PALS services—but also in our complaints handling. We've seen significant improvement in that. We are not quite at the target yet, but we are getting there. We're in the high seventies—I'm just looking down at the numbers—for getting back to people within 30 days. So, there's something about that.

Within the organisation and ensuring that staff feel supported and able, I think there is always more that we can do. But, again, the staff survey shows that people do feel more engaged; they do feel that they know the exec team to a good degree. We are constantly giving that message out that we want people to be involved in the future of services.

I think one of the hallmarks of our strategy development last year—. I talked about the consultation process with the public. There was a huge amount of work done with our staff, actually, to engage them, both in the initial conversations about, 'What isn't working for you?' and 'How does it feel to be here?'. and secondly, 'Can you help us design these services?' I think that the success of the strategy has been down to the consensus that we've had from a wide range of our staff to support the direction of travel. But, clearly, we are a very large organisation, and that means that there are always corners that you need to ensure that you're looking into. So, I would never say it was a job done. 

That's encouraging. Just in the context of it never being 'job done', what level of board-level scrutiny is there of the addressing of staff and patient concerns? What are the kind of mechanisms that you've got in place to be able to see where those dark corners are popping up and shine a light on them?  

So, the first issue sits with the exec team, with me and members of the board, and that's around our performance management framework. Rather than having a tier 1 target or a money focus, this is about the whole directorate. So, it is from going through the risk register, going through where they are with their complaints, their incident reporting, what their timescales are, have they got back to people in the timescales, as well as all the workforce issues that I mentioned earlier. So, at that level, the exec team is taking a much wider-ranging view of the directorate.

Through our public reporting to the board, all of that comes through our integrated performance reports. So, we try to take, again, a rounded view of each of the directorates about their performance, their issues, where we are with workforce, where we are with complaints. That's all formally part of it. We take a patient experience report alongside that as well, regularly. So, it is about seeing the wood for the trees in all of that, and ensuring that the board can be sighted on the areas that are of key risk. The process that we've got in place, I think, has put us in a much better position to be able to do that. I think there is still, again, further work to do as a board to ensure that we are clear, across an organisation with such a wide remit, that we can see the places that we really need to see.

That's useful. Can you tell us a bit more about what three of those processes—how you learn from complaints and incidents and concerns? And can you also tell us something about how you support patients when they raise concerns? It's encouraging to hear that you're up to the high seventies with the 30-day response, but if you're a patient who's been distressed by something, 30 days in itself is a long time to wait, isn't it? So, can you tell us a bit more about that—the kind of support that's in place—and how you learn from complaints and incidents? 

10:45

On the learning front, I might ask Dr Kloer to come in on that.

We do have patient support services, which obviously keep very close contact with people, because, as you're saying, at even at 30 days it's quite a number of sleepless nights. We very much recognise that and, as Steve said, we've seen some improvement in the speed of it, but it's still not quick enough, at times.

I think, in terms of the learning, at a directorate level, we've got quality and governance meetings in each of our directorates where concerns are reviewed, whether they be incidents or complaints. So, there's a learning within the directorate. We also have whole-hospital audit meetings in each of our hospitals where the key learning from complaints or incidents or other issues are brought into those forums. And then, we have an improving experience committee, which is chaired by one of our independent members, where we look at a whole range of things, not only concerns, considering communication and language of choice, for example, advocacy for young people or vulnerable older people. We consider our equalities plan there. So, that's the sort of committee, I suppose, at board level that reports into our quality, safety and experience assurance committee, which then provides the assurance to board. That's the kind of mechanism through there from the independent chair point of view. But we do have, as Steve said, that executive oversight through the performance management route, and that also considers actually Welsh language rates and clinical audit, as much as the RTT and the finances. So, it's a broad review of each directorate. 

Shall I come back on the second issue around supporting patients? Again, I think we're still in an improvement area. I've just found the number; its was 75 per cent. I was looking down and couldn't quite see it. So, we've gone from 58 per cent two years ago and in April we were at 75 per cent, so making some good progress. However, beyond that, I think there are still times when I don't think we support patients as much as we could. However, we have done some really positive things.

Through our PALS service, firstly we try to deal with issues in the moment they arise, so that they don't then have to crystallise into a complaint, and I think we're increasingly doing that. Depending on the issue, but, generally, we'll offer meetings first with either the key clinicians or other members of staff to talk through and get a real understanding of what the complaint is. We try to keep in contact, ensure that patients know where we are. We do fall down on that sometimes. There will be examples I'm sure when people have felt they don't know what's going on, but that's our aspiration—to ensure we keep people in contact. And, of course, we use the 30-day target as a way of ensuring that we get back to people quickly in the first instance. We also have the community health council advocacy route as well to ensure that patients who wish to raise complaints have that support if they need it to go through that process. 

We still have more to do, I would say, but we did come from a very low position a few years ago. We've seen a reduction in the number of ombudsman reviews undertaken. They've gone down from 38 to 20—that's almost halving. However, we have seen more of those upheld than in previous years, which I think is bucking the trend of health boards. So, that demonstrates for me there is still more we can do at the other end of complaints handling about whether we've really addressed the issue to the patient's satisfaction, and we've got some weaknesses there that we need to deal with. So, again, it's not job done for us. There's still a lot more to do.  

Okay. Moving on, some agility is required now, Helen Mary, because there are only a few minutes left. And you're the queen of agility. 

Oh, shut up. He's like this all the time; I don't know why we put up with it. [Laughter.] Can we just talk a little bit about winter pressures, then? You touched on it earlier and some of the stuff that you've done to protect the elective capacity. Can you tell us a little bit about out-of-hours GP services in terms of high-pressure times and ambulance response and handover times, and, I think, particularly A&E waiting times, which I think you've flagged as an issue yourselves?

10:50

I'm going to ask Joe to take this.

Thank you. Perhaps if I do out-of-hours first. I did attend a meeting in this building around the out-of-hours inquiry on behalf of the health board. We run five out-of-hours centres for primary care, for GPs. We've implemented 111 now across all the health board and we do have challenges, as the committee I'm sure will 'know, in filling all of our out-of-hours shifts. And in response to that, we've got a number of developing plans, but particularly the advanced paramedic practitioners that we've recruited, who rotate through our out-of-hours services. So, for example, in April we would normally have around 3,500 hours to cover in the out-of-hours service across our five centres, and we missed covering about 550 of those. So, about 15 per cent of the coverage wasn't there. But we only closed centres down for about 5 per cent of time because we were able to either cross-cover with other GPs, put in place advance paramedic practitioners, nurses, and we also put in an advice doctor. So, the out-of-hours position is very challenging in the primary care element, but we are managing to maintain the services through new roles and new models.

If I perhaps turn to the ambulance response times and winter generally, across our hospitals, as Steve, I think, said earlier, we've generally performed okay over winter if you look at the year-to-year comparators, in that we had a really carefully planned winter plan this year, which was developed jointly with the Welsh ambulance service and the three local authorities. It was the first time ever that we had all five logos of the organisations on a really integrated winter plan. We had good support from Welsh Government with funding for winter. We were able to put in place a number of additional schemes to help us cope through the winter period. For the first time, we really invested in some of the community services capacity over winter. We put a lot of extra capacity on in weekends in the hospitals. We put on a GP advice doctor in, as I say, the out-of-hours practitioners through the period.

We feel that the one big success to call out is that we also implemented a 'treat and repatriate' scheme for cardiac patients. So, they were cohorted in Prince Phillip and Glangwili, from Bronglais and Withybush, and the patients, every day, went first up to Morriston to be treated, and that really transformed our cardiac wait. The year before, we may have had up to 40 patients waiting to go to the specialist centre. This year, we had lengths of stays that were comparable with Morriston, and we managed to get patients treated much sooner, which was a really good development for us, and one that we’ve been able to maintain out of winter.

So, when we look at the overall evaluation of our winter period, we've generally seen lower escalation levels. Where we’ve seen a significant deterioration across the health board is in just one of our hospitals at Withybush. So, if we took Withybush out of our performance numbers, we would have had lower ambulance delays, we would have improved the four-hour standard, we would have had fewer 12-hour waiters et cetera, but Withybush has had a particularly challenging period. The ambulance delays in Withybush went up by 144 per cent, lost hours by 126 per cent, and 12-hour waiters by 51 per cent. So, there’s a particular—

There's been a particular issue there and, of course, the system’s very multifactorial. There’s not been a significant activity increase, particularly, at Withybush. We've seen a 2 per cent attendance growth across the health board in A&E attendances, and we've seen ambulances slightly reduce, if anything. But the ambulances that have conveyed to hospitals have had a greater acuity, more older people have gone in, and we've also seen, in the Pembrokeshire system, a very challenging domiciliary care position as well. So, we've seen the medically optimised numbers within the hospital beds increase over the period. That won't be the single answer, but we've seen length of stay in Withybush go up, but from across the health board, length of stay for patients, winter to winter, has been broadly flat. This winter, over the five months for Withybush, it went up from 7.5 days to 10 days. So, that’s a lot in terms of we know there’s a good evidence base that if we can keep patients out of hospital, if we can give them better care at the front end of their care pathway, there will be less of a demand on social care downstream as well. So, we've got a significant amount of improvement work going on at Withybush. I would say we've got a really good leadership team at Withybush who are deeply committed and worked very long hours over that period to try and keep the hospital safe and keep patients well looked after, and very engaged, very good senior nurses in the wards, and a very engaged medical body as well, and so it's not a 'lack of effort on their part' problem.

So, we've got a significant amount of improvement work going on. There's probably not time in the committee today to run through that, but that impacts on every step in the system. So, working in A&E, we're relooking at the assessment units. We're implementing changes within the wards in terms of the way that the ward care is produced, and there's a significant action plan within Pembrokeshire council in relation to domiciliary care and reablement capacity as well. So, there's a lot going on, but if we could turn the tide within Withybush in the hospital system, we would see improvement in all of the key indicators significantly improve.

10:55

Yr eitem olaf, oherwydd yr amser, ydy iechyd meddwl. David Rees.

The final item, because of the time, is mental health, and it's David Rees.

I'll try and be as quick as possible. I'm very conscious of the time. I know that you put in your paper that you're looking at a new model of care for mental health, and I'll probably come back to that in a minute. But, just looking at your performance to date, in your written evidence you actually have one sentence that says,

'performance has been achieved throughout 2018/19 in respect of Parts 2 and 3 of the Mental Health (Wales) Measure 2010 targets.'

End of. So, are you saying to this committee that, for both adults and children, you are satisfied with the performance of mental health services and there are no challenges facing you?

No, I think it's fair to say absolutely not, but I'm going to ask Joe if he can pick up the specifics, because we do certainly have challenges outside of the things that are formally measured through those two measures that you mentioned.

Yes. Thank you, Steve. The measures themselves, we do reasonably well, as you'll see, but, in reality, we obviously want to do—. The care we provide to people beyond the measures is what we care about. So, for example, with care and treatment plans, we had a meeting this week with West Wales Action for Mental Health around how we want to really improve the quality of those and that we can hit the target on the numbers, but actually what matters to families, patients and carers is the quality of the assessments that are done and the quality of the plans within somebody's record and how they're involved in those.

Probably the big area to call out in terms of mental health services, and—. It's a shame we don't have time to talk more about the transformation agenda, because we feel we're making good progress in terms of implementing some of our new models of care across the health board. But the big area where we have, I think, some significant challenges still, is in relation to the ASD wait for children, particularly, whereby we've seen those actually grow over the last year. We had a very large backlog of over 600 children waiting to be assessed in 2015, and we did a lot of work to deal with that backlog and, in fact, we reduced that historical backlog to zero. But what we've seen over recent times is a steady growth in—. There's a growth in demand for children to be assessed, and we've seen a steady growth in our backlog. We currently have around 500 children waiting for assessment within the CAMHS service, and 298 of those waiting longer than 26 weeks. We've got some targeted work going on within the service to try and improve that.

I think one of the areas that's very difficult is again linked to a previous discussion around the workforce availability to deal with some of those issues. Previously, we've outsourced bits of that work, but they're very complex assessments, so we'd rather keep that in-house. The team, now, are working with the delivery unit as part of Welsh Government, looking at demand and capacity within the ASD service and how we can look at new models of care—different practitioners involved in those assessments so they're not all dependent upon psychiatry input, for example, which is very challenged in terms of dealing with that. It was something we actually discussed in the review meeting. Over the last month, we've built the ASD/ADHD waits into our board information pack as well, so the board have clear visibility of that, so it may not sit as one of our tier 1 deliverables, but, for us, we're trying to find those targets that matter most to families, and that they're clearly reported to the board and there are clear actions around trying to address those.

Okay. So, you've had a historical backlog of 500, which you've cleared. You've now got another backlog of 500. So, effectively, you still have a backlog of 500. That's still a very serious challenge to address those. Are those all ASD, or is some of that backlog actually other conditions?

That's the specific ASD waiting list that I was referring to. We've got some—. In children's ADHD services, for example, which is more—. Contributing to that is more from the paediatric service rather than the mental health service, but there is a joint MDT around those children. We've pretty much stabilised that. We still have a backlog within ADHD waits, and it's, again, a very fragile service if, for example, one of our community paediatricians is not available, and that can have a challenge in terms of that. But that's a more stable backlog. The ASD, probably, is our big challenge.

11:00

So, what about CAMHS? Obviously, there's a specialist—. We have many young people out there facing many challenges in mental health, and it's not all ASD or ADHD. There are other conditions as well. So, how are you managing those?

Access to CAMHS is generally very good. The more urgent access—. Some of the targets—. I can't find the targets in our pack, but we achieve the measures in terms of some of the more urgent children requiring access to CAMHS services. I think there's a bigger issue in the ASD cohort of patients.

Can I clarify that access to CAMHS services is not simply a referral and then being seen once; it's actually being treated? So, are you also in the process of making sure those young people are actually receiving the care and treatment that they need?

Yes. Again, we've got a significant input into CAMHS. We've got our doctor, Warren Lloyd, our associate medical director for the health board for mental health and learning disabilities, as the lead consultant within the CAMHS service, and our general manager within our CAMHS service contributes a lot to all-Wales work, and we've got significant numbers of examples we can give around best practice within our specialist CAMHS service. So, of course, we've got challenges, like we recognise in all of our services, but we feel that we have a good leadership team and some good examples of practice within the service.

A number of health boards are transforming their CAMHS services now to focus much more on early intervention to try and reach the young people who are known as the 'missing middle'. Is there anything transformative going on in your health board?

We could pick up on the transforming mental health strategy at this point.

But I think it's part of the ethos that we're also taking to CAMHS around having a service that people can access without having to wait, particularly at the mild-to-moderate end. That's part of our ambition. We're further ahead with adults, I would say, because of the transforming mental health strategy, but that is absolutely part of the ethos for the CAMHS service as well. I don't know if Joe has—

I've got some examples in our briefing around some of these things. We've got the in-reach pilot in Ceredigion, into the schools there; we've got the single point of contact for all referrals into the CAMHS service, which was highlighted by the delivery unit as good evidence; we've got a young person's forum within the specialist CAMHS service to inform the work we do; there's the Surf Tonic surf therapy programme for children and young people, which is delivered as an alternative therapy to some of the medicalised areas; we've got age-appropriate beds in collaboration with the paediatric service for young children in distress; we're appointing peer mentor support workers in the early intervention service within the CAMHS service; staff from the early intervention service participating in the Run 4 Wales initiative in partnership with Carmarthenshire County Council; and we've got bilingual teaching resources within the services as well. So, I think there's a lot of good examples and it's a shame we don't have some further time to explore that with you, with the committee, and with some of our practitioners.

Okay. Obviously, the transforming model, which you've talked about very briefly—and I appreciate it's the time—but you also mentioned earlier on you have a challenge as to psychiatrists. Do you have a challenge with other staff within the mental health services? It's not just psychiatrists; there are many other staff who are needed to be able to deliver service and care because these are some of the most vulnerable individuals facing difficult times. Are you now also in a position where you can actually deliver the model because you have sufficient staff on your books, basically, to say, 'Right, we can now do that. We know we can manage it. We know we can address and help those people'?

Yes, you're absolutely right. It is beyond just psychiatrists. I mean, for some of our most challenged areas, specialist psychiatry input is absolutely vital. So, you described the work around the ASD service, but, beyond that, we do have challenges in nursing and mental health nursing. But probably less so than in some other parts of the health board in our general nursing service. So, whilst it's still an issue, for us, the red flashing light is around psychiatrists themselves—

When you say 'nursing', are there also community mental health nurses? Because, clearly, the more we want to put out in the community, the more support we have to put in the community to ensure that that can be delivered.

11:05

The whole model of transforming mental health is predicated on a community-based model. We've got our crisis teams for out-of-hours, a nurse-based, we've got some good interface now between the community nurse teams and the crisis response teams. We're running a pilot in Aberystwyth, where we're bringing those teams together and looking to quickly develop a 24/7 drop-in service. We're running some pilots in Llanelli with third sector organisations around drop-in at the optimum times when people may feel that they need some support.

And the whole model of transforming mental health is predicated on a different workforce. So, we know that we're not going to set a service up in the future that's going to be a doctor-based service but one that's based on a community-based service with far more peer-support mentors and others within the service providing support to people. For example, we've got 50 mental health champions within the service. They're champions for the transforming mental health programme and are working with our staff groups. We're developing new roles within that. We're already developing job descriptions for the new types of practitioners who will work across the service in more generic ways so we don't need to rely on some specialist recruitment. We think the pipeline of recruiting to that type of workforce model will be achievable.

Obviously, the whole premise is that we would have less in-patient-based care; we would have one assessment unit, one treatment unit, but community mental health centres that are hospitality based but focused on recovery principles and focused on wellness rather than illness. And that's the premise of the transforming mental health programme underpinned by a very different workforce in the long term.

You're going to have a bit more of a challenge than perhaps my own health board, because we are more dense population wise. You are geographically larger, with a population that is spread more. And, obviously, in situations where people find it difficult, sometimes, to actually even travel, you're going to have to ensure that you have sufficient resources to have different hubs in different locations. That's a challenge I assume you're still facing.

It is, but what we need is a local presence for people who need it locally. So, the commitment within the programme is that we would have those community hubs in each of our counties, and they would be therefore accessible to people who needed them, underpinned by a lot of work we're doing on transport as well, because we recognise that transport is a big issue in our communities. In fact, one of our work streams within the transforming mental health programme is a transport work stream, looking at how vulnerable people, but also families, can be transported at different times of the day. We'll have a single point of contact for them to help them with that, and also, on a needs basis, reimburse people for that travel, to make sure that people can access services at all times of the day within Hywel Dda.

Ocê. Rŷn ni allan o amser. Mae yna gwpl o faterion eraill y bydden ni wedi hoffi gofyn cwestiynau ichi arnynt, felly fe wnawn ni ysgrifennu cwestiynau ysgrifenedig atoch chi. Ac, wrth gwrs, roeddech chi wedi gwirfoddoli i ddarparu gwybodaeth ychwanegol inni hefyd, felly byddwn ni'n edrych ymlaen at dderbyn hynny fel rhan o'r broses craffu fydd yn parhau. Ond a allaf i ddiolch ichi am eich presenoldeb? Diolch i chi hefyd am eich tystiolaeth ysgrifenedig ymlaen llaw, a hefyd rwy'n cadarnhau y byddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma er mwyn ichi allu cadarnhau eu bod nhw'n ffeithiol gywir. Gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i'r tri ohonoch chi.

Gallaf gyhoeddi i'm cyd-Aelodau y cawn ni egwyl byr rŵan am bum munud a nôl am 11:15 efo'r tystion nesaf. Diolch yn fawr.

We have now run out of time. There are a couple of other issues that we would've liked to ask you about, so we'll write to you with those questions. And, of course, you did volunteer to provide additional information, so we'll be looking forward to receiving that as part of the ongoing scrutiny process. But could I thank you for your attendance and thank you also for your written evidence beforehand? I would also confirm that you will receive a transcript of these discussions so that you can confirm they're factually accurate. With those few words, thank you very much to the three of you.

I inform my fellow Members that we'll now take a short break, for five minutes, returning by 11:15 for the next set of witnesses. Thank you.

Gohiriwyd y cyfarfod rhwng 11:08 ac 11:16.

The meeting adjourned between 11:08 and 11:16.

11:15
3. Gwaith craffu cyffredinol: Sesiwn dystiolaeth gyda Bwrdd Iechyd Lleol Addysgu Powys
3. General scrutiny: Evidence session with Powys Teaching Local Health Board

Croeso nôl i bawb, wedi'r egwyl fer yna, i adran nesaf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd. Dŷn ni wedi cyrraedd eitem 3 rŵan a pharhad efo'n gwaith craffu cyffredinol, gyda sesiwn dystiolaeth gyda Bwrdd Iechyd Lleol Addysgu Powys. Croeso i'r pedwar ohonoch chi a diolch am y dystiolaeth ysgrifenedig gwnaethoch chi ei chyflwyno ymlaen llaw. Fel cefndir, wrth gwrs, dyma'r pumed yn ein cyfres o sesiynau craffu cyffredinol gyda'r holl fyrddau iechyd lleol yma yng Nghymru. Felly, mae cyfle i Bowys ddisgleirio nawr. Rwy'n falch iawn i groesawu'r bwrdd, felly: Carol Shillabeer, y prif weithredwr; Hayley Thomas, cyfarwyddwr cynllunio a pherfformiad; Wyn Parry, cyfarwyddwr meddygol; a Rhiannon Jones, cyfarwyddwr nyrsio. Croeso i'r pedwar ohonoch chi, ac yn ôl ein traddodiad awn ni'n syth i mewn i gwestiynu ac mae Lynne Neagle yn mynd i ddechrau.

Welcome back to the meeting, following that short break, to the next session of the Health, Social Care and Sport Committee here in the Senedd. We've reached item 3 and our continuing general scrutiny, with an evidence session with the Powys Teaching Local Health Board. Welcome to the four of you and thank you for the written evidence that you submitted beforehand. As a background, this is the fifth in our series of general scrutiny sessions with all the local health boards here in Wales. So, there's an opportunity for Powys to shine. I'm very pleased to welcome the board: Carol Shillabeer, chief executive; Hayley Thomas, director of planning and performance; Wyn Parry, medical director; and Rhiannon Jones, director of nursing. Welcome to the four of you, and in accordance with our traditions, we will go straight to questions and Lynne Neagle will start.

Thanks, Chair. Good morning. How would you describe the health board's current financial position, and what is your expected outturn for 2018-19?

Thanks very much for that question. So, over the last few years, we've had good financial performance. Just in the year we've closed recently, we met our financial targets in terms of revenue, capital and in terms of the public sector payment policy. Over the three-year period of the last integrated medium-term plan, we generated a very small surplus—£240,000-odd—and so we've been in a period of a stable financial position over the last few years. That said, we've had to have savings plans in place—last year, savings in the region of £3 million, and, going forward, we've got a savings plan this year of £3.5 million. I think it'll be important to recognise the support we had from Welsh Government back in 2014-15 to enable us to deal with what had been a long-term deficit. The requirement for us in terms of performance was to manage within our budget, which we've been able to do, and at this stage now, we're in a strong position moving forward.

Okay, thank you. You've told us in your paper that operating within your funding allocations is going to be 

'a significant challenge over the next three years.'

Can you just tell us why and what you're planning to do to mitigate those challenges? 

Thanks for that. So, I think there are a couple of areas, really. One is, and I'm sure we're likely to come on to this later on, the increasing demand for services and the sustainability issues in primary care, needing to change the model to fully implement the national primary care model—we think there'll be some investment requirements there. We are also seeing demand for secondary care services going up. We want to be able to recommission right across the pathway in order to have more care at the earliest stage, but at this stage, we are seeing demand for secondary care services going up. So, there's pressure in what we call our commissioned services.

And then the other area where we think there's pressure is we've got an ambitious change programme, and we want to be able to move to a place where we're implementing our health and care strategy, but we know that we're in, if you like, the old system as we are, so there's that need for bridging/transformation funding to help us to move across there. If that isn't forthcoming—our desire is to move forward with that, so that may well end up being a financial pressure for us to manage.

11:20

Okay, thank you. Your IMTP identifies a saving target of £3.5 million and an additional expenditure reduction of £1.5 million in 2019-20, and those have been classified as targets to pursue, subject to further work. Can you just tell us what the plans are to meet those targets?

Yes, thanks very much. I just alluded to the whole-system commissioning and taking a look at where services are currently provided. We've got four key clinical change programmes, and we know that—. So, we've just started something called a Breathe Well programme, which is about respiratory care. We know that if we can redesign those pathways, we will save money and improve the experience of people. We also know that, with our track record of providing more care closer to home, that does provide opportunity for services to be, if you like, almost better value for money from the patient's perspective, because they're closer, and starts to reduce the pressure on out-of-county referrals. So, managing the commissioning budgets is key.

We've got our general provider budget. You'll know that a quarter of our budget goes on directly provided services, so having good financial management and good discipline in there. We've got a track record now of that and we need to continue that as well. And then we're looking at joint opportunities with local authorities, our local authority, around how we do things differently, around children's services, for example, but care of older people as well. 

Rydych chi wedi sôn ychydig am drawsffurfio gwasanaethau, ac mae yna ragor o gwestiynau ar hynny nawr gan David Rees. 

You've mentioned a little about the transformation of services. There are now questions on that from David Rees. 

Diolch, Gadeirydd. Good morning; yes, it's still morning. You've already talked about your financial model, and looking forward, and you've mentioned your care strategy is going forward. I suppose we've seen the Welsh Government come up with this 'A Healthier Wales' plan, and expectations of transformation of care throughout Wales. Have you got any transformation projects that are under way, in the pipeline, and what do you expect to get out of those? How do you see those delivering changes to the people in Powys?

Thanks very much. I'll bring in colleagues with this one as well. So, we developed our health and care strategy. It's a Powys County Council and Powys Teaching Health Board strategy, so it's the first health and social care strategy developed at the time we approved that, both organisations, in 2017. So, we have been working since that approval on how we are going to transform services. When 'A Healthier Wales' was published, we were pleased that they aligned, so that was great. And we have, to date, submitted one, and been successful with one, transformation fund proposal—we'll come on to that—in terms of north Powys well-being programme. We've got two others in the pipeline at this stage, which hopefully we can share with you in a little bit more detail. One is around a health and care academy, about education and training in the county, and the third one is around more primary and community development, as we talked about, the national primary care model, and actually having more services closer to home. So, they're the three, but if I could just hand over to Hayley about the north Powys well-being programme. 

Yes, we're very pleased to have received some transformation funding from Welsh Government to take forward what we consider this flagship programme, working in partnership with our regional partnership board partners, but also particularly with the local authority. We've been working closely to think about how we can completely remodel our health and care provision in the area for north Powys, and as part of our health and care strategy we identified the need to look at the concept from the point of view of regional services for the region, as well as the needs of communities, particularly around Newtown, and we set that as a key priority. It's really important for us. This is broader than the traditional joined-up care that we're looking for in health and care. This is, broadly speaking, not only to 'A Healthier Wales' and our local health and care strategy, but also to 'Prosperity for All'. There's a really strong join-up with the local authority on plans around twenty-first century schools, but also housing, leisure and the broader need to develop the area economically.

So, this programme of work is starting in earnest. In fact, we've got launch events tomorrow locally in the region. We've been really keen to work—this is very much on the principles of co-production—with the local communities and stakeholders, and we will be looking to develop that model now over the next few months, over the next couple of years, so that we can completely transform the offer.

We've got a number of pressures we're trying to address. Obviously, the demographic challenges within Powys are quite significant. But also there are a number of opportunities. There are some strategic changes around our borders in Powys, particularly. I'm sure the committee is aware of the planned changes around Future Fit in the Shrewsbury and Telford area. So, it's really important for us to take care closer to home, and to increase as many services as we're able to provide safely and effectively within the area in north Powys. And that's part of our plans—to see how we can increase and repatriate as many outpatient and other diagnostic services in the area as well.

11:25

Helen Mary's got a point here. We'll come back to you, David.

It's really encouraging to hear you talk about that positive working relationship with Powys County Council, but they are facing some significant challenges—and I'm thinking particularly of real challenges in their children's social services. I just wonder if you can tell us a little bit about how that impacts on your work, thinking about child and adolescent mental health services, around preventative services for children and young people, and is that a difficulty?

If I make a start, and then hand over to Rhiannon. You're absolutely right—I think Powys County Council has a number of challenges. We know about the budgetary settlements—so, nine out of the last 10 years I think they've had a budgetary cut, and that is clearly having an impact. We recognise that we've got a valuable arrangement of being coterminous—we're the only health board and local authority coterminous—so they're our population, and we're together on that. Hayley just mentioned the regional partnership board. We've got a strong regional partnership board, and sitting under that are a number of partnership groups. One is the Start Well partnership, which brings together the health service, the local authority and the third sector, and Rhiannon co-chairs that, so I'm sure will want to give a bit more detail.

Thank you. So, in terms of the Start Well programme, it is co-chaired with the local authority. We're clearly well aware of the challenges for the local authority, not just in terms of the budgetary position, but also the children's improvement plan and the Care Inspectorate Wales review for both children and adult services. And we are working closely. Our door is very much open from a health board perspective, and the children's improvement plan is a key agenda item within the Start Well programme. So, we have a bimonthly review, an oversight of the improvements that are being made from a partner perspective, but additionally some of the priorities that have been identified by the Start Well programme board, which includes early intervention. And one of the key pieces of work currently, which is joint with—well, it's more than joint; it's multi-agency, in terms of the council, the health board and third sector—is around one-stop shops and the access point, single point of access, for children, and particularly children that are reaching crisis. We've supported the edge of care programme through the regional partnership board and the allocation of integrated clinical funding—ICF funding. And we've got a programme that's just about to commence, in terms of managing edge of care, and a piece of work that's about the single point of access. And they're motoring quite rapidly in terms of that, and that all feeds into the regional partnership board. So, there are challenges, but I think that relationships are strengthening, and we're all on the same page.

Thank you, Chair. Following on from the answer in relation to the work in north Powys, clearly, there's a question—you're changing the service approach, and service transformation is one of the key things that the Welsh Government requires. Will that change your financial model? Because you talk about 25 per cent only on directed services, and you're talking about bringing more back in now. So, is that going to change your financial model, and how are you going to make sure that's sustainable?

Thanks very much. You're absolutely right—25 per cent is directly provided. About 25 per cent is around primary care contracting, and then 50 per cent to external. The conversations we've been having with what we call external providers, and particularly in Shropshire—Shrewsbury and Telford hospitals—is around a different offer. So, how we manage to provide care closer to home is to work with our partners, and there's a lot of in-reach. So, the services we've already got, for example in Breconshire War Memorial Hospital, and in Llandrindod Wells Hospital, are supported by clinicians coming across, often from Aneurin Bevan in the south, Cwm Taf Morgannwg, and from Wye Valley NHS Trust. The arrangement that we want to try to generate for the north of the patch is to get that type of outreach from Shrewsbury and Telford Hospital NHS Trust in. So, we may have consultants travelling in, rather than patients travelling out, and much more in terms of the digital exchange of services. So, our financial flows themselves may remain reasonably stable in terms of where they are now, but what we get for that money and how that gets delivered will be different. We have, over the years, seen a marginal lift in the directly provided service budget, and we want to see more of that. But it isn't about—I want to be really clear—it's not about necessarily taking money and making that shift. We need the resource and the expertise to come into Powys, and we're willing to pay for that.

11:30

So, it's more of a reconfiguration of what services you're purchasing in, basically.

Okay. Quickly, then, can I just ask this? Welsh Government wants as much service transformation as possible to be out of your core funding, effectively, so not out of the transformation fund, as such. So, it's important—[Inaudible.] I read your paper and it says that actually you've done a lot of stakeholder engagement in relation to these transformations. I'm assuming you're continuing those stakeholder transformation discussions. Can I just ask, are the stakeholders, including the patients, who are the most important stakeholders, satisfied with the engagement they have and are they buying into the transformation you're proposing?

I'll just hand over to Hayley on the engagement. 

As part of the health and care strategy that we did for healthier care in Powys, we had thousands of conversations across Powys to help shape that strategy and our long-term vision for the 10 years. In terms of the specific transformation funding we've had for the north Powys well-being programme, it is at the inception stage, so we're starting that programme of work now. From the outset, certainly, we've had a lot of contact with stakeholders, members of the public, we've held a number of engagement events across the patch, and we've been talking about the concept of it, rather than raising people's expectations that we are able to drive very quickly on this agenda.

So, this week, we've got the formal launch, and there has been significant feedback that we've gained, not only through specific work we've done in Powys through our engagement work but also when we've been consulting on engagement on other service changes—Hywel Dda on transforming clinical services, Future Fit et cetera—a lot of insights. And there's a lot of information that we've gleaned from the public that says that what they want is very much in line and is reflected in the health and care strategy that we've set. There's a huge amount of ambition in north Powys to work with us on this project. We've invested—part of the funding that we've received is actually about resources to engage properly on this programme. We've got a very clear communication and engagement plan for the work to move forward.

So, I'm confident that we've got a good foundation, a good platform, but in terms of the specifics around what this model of care is going to look like—because it is about the whole resources that we have available to us and how we use that, and that was part of our answer to the transformation funding about having an exit strategy. This is about investment to enable us to change the way in which we do our businesses as usual. We will be fully committed to engaging the public and stakeholders and I am very confident at this stage that we've got a lot of support from a number of areas. Clearly, there's a lot of focus on Newtown as a locality at the moment, but we've also got clear plans to engage across the whole of north Powys, and it's going to be very important to get the right balance between the community-based developments that we need to have on a very hyperlocal level as well as engaging on a regional footprint.

Can I ask a question on transformation? Obviously, as you say, you're unique. You're not unique in the sense that you're aligned with Powys County Council, but you're unique in the sense that you don't have a GDH and you buy a lot of your services in. Everybody is going through transformation models and service changes. Therefore, some of the services you're talking about perhaps purchasing are also going through service changes. What discussions do you have with those other boards and how engaged are you with them to look at how that impacts upon your patients?

Thanks for that question. In the submission, there's a map with a lot of hoops on—

Hopefully, the colours are in—

We've given it a title as well. I'm not sure it's a very healthy title, but 'spaghetti hoops' is what we've called it, because it's—

The low-salt version. [Laughter.]

11:35

Thank you, Rhi. So, that is there to try to describe the complexity that you've just asked about, really. We have got, potentially, change programmes all the way around our borders that affect the people of Powys. A couple of years ago, we took the decision that our main task is to provide a coherence to our Powys population and the pathways for them. We stepped up our capability, our capacity, our ability to really get in early, influence these changes, make sure that the voice of Powys residents was heard. And so, when we refer to, for example, the Future Fit in Shropshire and Telford, we’ve worked very hard with our local communities to really get those views across on the options that they had.

We’ve worked with Hywel Dda health board—who I know you’ve seen earlier—around Bronglais and the whole mid-Wales joint committee, mid-Wales collaborative work, which we’re very committed to. And we were a key part of the south Wales programme. We have mechanisms in place because, as you say, we buy in services. When we talk about commissioning, we’re not just talking about contracting. We really try to get in amongst what are the fragile services that may well need changing. So, we’ve got something called a fragile services log where we track all of those. We  discuss those at both board level, but certainly at executive-committee level, in terms of the ones that are most likely to affect Powys patients, and how we’re going to handle that. And then we have those direct discussions with those organisations. Hayley’s team leads that, but from a clinical perspective, it is very much a team effort. And if I just draw one example—there are conversations going on at the moment about hyper-acute stroke services in the Herefordshire/Worcestershire area. So, we’re working through what those changes would look like for our population, and what might an alternative offer be, if we needed to make one, if we didn’t feel we could support that. So, quite a lot of our time and effort is going into managing, both in terms of surveillance and understanding the impact, and then intervening and influencing decisions.

Have you found, as a consequence of that, there's a need to look for additional financial input into this system? Has it been an additional financial burden to the health board? If you are looking at service changes, you may need to, actually, get more resources in, because you have to do some of that work yourselves now.

I referred in the opening remarks about finance to some structural support that Welsh Government allocated to us. My predecessor started that work, but that followed a review of what the construct of Powys means in terms of funding, and the fact that we are such a big commissioner, and how we realise the benefits of service change—basically, we weren’t able to do that very well. So, Welsh Government recognised that we were incurring more costs, perhaps because of our unique nature, and looked to address that. We are really mindful, not just about the finance—which we may well incur as a result of changes—but the impact on patients and the access and the travel arrangements. So, we’re trying to weigh all of those things up. What we have found is that, if we’re trying to deliver care closer to home, often we can do that at really quite competitive prices, if you like. So, things like our wet age-related macular degeneration service in our community hospitals—we established that quite quickly, we were quite nimble around that. That saved patients up to 100,000 miles of travel going to district general hospitals, and we renegotiate with those DGHs the type of support that we need. Sorry, that was quite a long answer.

No, it's an important area to address, because, very often, with service changes elsewhere—you are clearly the one, by looking at the map, that is impacted upon by a combination of various boards around you, which impact upon the service you give.

Just one final question from me in that case: obviously, the other 25 per cent we talked about is primary care—are you in a situation where you're comfortable that your primary care services and your GP recruitment are sustainable to ensure that you can continue to deliver those elements of your service?

I'll ask Wyn to comment in a moment, but if I just make a start to say—well, look, we've got sustainability issues around primary care in Powys. I think in some ways that's a barometer of the national picture, because Powys has had a long track record of having really strong primary care services, really strong GP networks, actually very good GPs who work, I think, to the very top of the GP expertise in a range of matters. So, we have got GP vacancies. We have had to recently take a very difficult decision to support an application for closure of a branch in Cemmaes Road. We were very reluctant to do that, but we were balancing up safety considerations, staffing considerations for the practice in Machynlleth. We have—and practices have grasped hold of this in quite a big way—looked to change the model, and it's completely in line with the national model. At this stage, that is going well. There are some practices who haven't got to that point yet, so we're just needing to encourage that thinking: don't wait for the inevitable to happen where you have a GP retirement and you can't recruit—let's make sure we're moving forward in that more multidisciplinary way now. But we've got three practices at the moment that are on our high-rated sustainability list. We only manage one practice at the moment in Powys, and for a very long time we managed no practices ourselves, but we know that there may be occasions where we may need to step in and manage. We're doing all that we can with practices to ensure that they're supported not to get to that position. Wyn, I don't know if you want to add.

11:40

Thanks. I've managed to get a word in between three ladies here. [Laughter.] I arrived in Powys in September of last year as medical director, with a strong focus on education in the broadest sense, and then, of course, that plays directly into the sustainability issue. I think one of the hallmarks of Powys is that my GP colleagues are fantastically committed to the work that they do, reflecting the fact that rural medicine is very different to urban medicine. Working in the centre of Cardiff as a GP is very different to working in the centre of Montgomery as a GP. As Carol has alluded to, the range of work that my primary care colleagues carry out is far in excess of anything that a GP in an urban environment might do.

We've also looked as well at supporting delivery of healthcare in different ways. So, we will, by the end of this year have—you're probably aware of it—the grade of physician associate. So, it's a well-trained individual who will be able to carry out a large number of functions that a doctor would be able to do. So, we've got a number of practices where we've got physician associates, and we've built up further links with the university in Swansea to train further physician associates. I'm particularly interested in extending that out into the secondary care provision that we have as well. We've also looked successfully at extending the role of our specialist nurses, paramedics et cetera, to support the service.

I think you probably will be aware of the Nuffield report that was published in May of this year that looked at healthcare recruitment. One part of it focused on GPs, and the number of GPs, of course, has fallen across the UK. I think it's at its lowest level now since about the 1960s, so it's a significant problem. In Wales, we are not so badly off compared to the rest of the UK, but there is a difficulty in recruiting individuals into general practice particularly, so we've done a lot of work looking at building up links with the medical schools. In fact, the day before yesterday, I had an approach from the medical school in Cardiff about having students on longer placements so they experience what rural primary care is like, and more and more students are now becoming interested in rural healthcare as a future career path. So, I think we are well advanced in our plans to support the sustainability question, because, as Carol said, it is an issue for all of Wales, but for us in particular.

Just finally, then, you manage one practice; there are three on your watch list, shall we say. Are there plans in place to ensure that you may manage those, and if you do start managing these practices, are you moving towards the Welsh Government's primary care models to actually look at actually having a spread of professions in the practice?

11:45

Yes, absolutely. So, we have developed contingency plans to step in, should we need to. We really don't want to do that. So, at the stage before we need to do that, there's what's called a sustainability plan put in place. We do provide some additional funding to support, and often those solutions are about having different types of practitioners looking at things differently. So, we have that sustainability fund and that development plan in place, but we've got to have contingency just in case. It is a duty on us to provide general medical services. And even if we then did, our solutions would be the same as we're trying to support, which is about that more multidisciplinary-type approach. We've got pharmacists in practices; we've got first-contact physiotherapy in practices; we've got, actually, some mental health support and third sector support directly into practices as well—our community connectors. So, we're really trying to get that more multidisciplinary approach, and that would be what we would be doing if we were directly managing it as well. 

Symud ymlaen i faterion y gweithlu'n ehangach, ac mae cwestiynau gan Jayne Bryant. 

Moving on to broader workforce issues, and Jayne Bryant has questions. 

Thank you, Chair. Aside from the challenges in general practice with recruitment and retention issues, what are the most significant workforce pressures in other areas? What settings and what professions, would you say?

Thanks very much. I'll hand over to my clinical colleagues in a moment, but just to do an introductory comment to say our workforce profile for Powys is very different to the other health boards because we don't have district general hospital services per se, directly provided by us. So, the shape of our workforce is largely around our community care. That's the directly employed, obviously primary care, which we've just touched on. But I'll ask Rhi to give some comments as well on this.

Yes, thank you. There are a number of areas. So, again, we've got a bit of a profile in terms of where we've got issues. One of the positive things is, despite the ageing workforce and our workforce plans in terms of addressing that, we've got a number of areas where we've got no recruitment difficulties, and so it's really positive that, in district nursing, health visiting, mental health, we haven't got issues, particularly in nursing. I think, in terms of the areas we have struggled with in the past, certainly CAMHS consultants—Wyn might want to come in there—we've had more luck recently and we've filled our vacancies.

But, certainly, our community hospitals is one of our areas of greatest risk in terms of the recruitment of registered nurses. At any one time we've got over 30 registered nurse vacancies, which does impact on our banking agency use within those areas. Other areas include therapists, and speech and language therapy, again, is a particular area of concern for us, particularly within the specialty of learning difficulty disability. That enables us or helps us to look at different models of care. We're certainly doing that within the community hospitals whilst cognisant of the Nurse Staffing Levels (Wales) Act 2016, but we are looking at alternative approaches to staffing above and beyond registered nurses. One of the other areas of work in speech and language therapy is how we can look very differently at the sub-specialty. So, for people with an LD, what elements of the speech and language therapy intervention can be done by other practitioners—the speech and language therapists who perhaps work in children's services and adult services—and how do we risk assess based on that and have an alternative plan for delivery. We're just working through some of those areas currently.

But I think our approach, like every other health board and trust in Wales, is very much about our recruitment approach. We're pleased to be able to report that we've done significant work to reduce the length of time it takes to recruit. We're very much engaged in 'Train. Work. Live' and we're working very closely with universities across the piece—albeit we haven't got a specific university in our patch—and HEIW, to ensure that our workforce planning is as robust as it needs to be, particularly because of our ageing workforce.

You've mentioned about associates in primary care and, perhaps, looking to expand those into other areas. I note from your written evidence you're employing the first joint health and social care workforce planning manager in Wales. Can you expand on a few of those things and perhaps say a bit more about what you're doing to try to solve these recruitment problems?

11:50

Yes, if I pick that up and then—. So, under the regional partnership board, the strategy that we discussed earlier, the whole partnership felt that workforce was going to be absolutely critical to the delivery of that. So, we allocated funding to develop a joint role, a health and social care role. That role is helping us with intelligence, not just about the directly employed workforce of the health board and the county council, but also the voluntary sector, carers, the independent sector—so, what does the workforce look like? By the autumn of this year we should have to approve, hopefully, our first workforce future strategic framework. That's very much in line with the work that Health Education and Improvement Wales and Social Care Wales are doing on the 10-year workforce plan for Wales. So, we have been working with them.

But I know colleagues might want to just pick up the ambition that we've got around the health and care academy, because Rhiannon said that we don't have a university in our patch, but we work with other universities, so we need to step up our offer as to what we can provide, and provide those pathways as well as the post-registration education, really.

Happy to pick up on this, and thanks, Carol. I touched earlier on the significant difficulties between rural healthcare and other settings, and I think we were very fortunate, to pick up on Rhi's point, to recruit CAMHS consultants, because if we just look at the medical side of things for a moment, we are recruiting in hard-to-recruit specialties—old-age psychiatry, child and adolescent mental health. They are extremely difficult areas to recruit in and I think we've been extremely fortunate that senior medical staff have chosen to work in Powys. I would like to think it's because of the opportunities that we give them to work in a rather different way.

But, going back to the issue around training and the possibility of a health and social care academy, I think previous doctors in Powys have been very involved in rural health and the concept of training for rural health. We want to build on that foundation and build on the academic links that we have to support that across the board—I'm not talking about medics now; I'm talking about all healthcare professionals—as a means very much of providing comprehensive training that will, hopefully, of course, support our own recruitment issues in the future, but will support recruitment into rural healthcare in other parts of the country, maybe even other parts of the world.

Yes, just one follow-up on this. I was pleased to hear in your response earlier this reference to physician associates being used to assist in terms of some of these workforce challenges, and I notice in your paper you make reference to some of the psychology assistants you've been taking on as well. Is that an agenda that is a national agenda, because I haven't heard about those sorts of appointments in other parts of Wales at the moment? I know that NHS England has been using physician associates, certainly, for quite some time and is increasingly doing so, but the concept of the psychology assistants as well, and not having heard of them elsewhere from any of the other health boards, I'd just be grateful to know how that's panning out, really.

It is exciting and it's come about as a result of the challenges that we've got in terms of recruiting psychologists, and since the repatriation of mental health services back into Powys, our challenge around meeting the psychology waiting time targets. When you've got challenges like that, it does enable you to look at things differently, and, actually, if you take a prudent healthcare approach and only use people to do what they need to do, because there are other people who can do other things. So, the psychology assistants, we've been fortunate in terms of recruitment, and we've got more to do. It's been enabled through the mental health transformation fund—

It's part of that. It is exciting, and we'd be more than happy to provide you with additional information. But some of the areas that we're working through are in terms of triage, so when the referrals come in, there's a triage approach, and it is allocating the individual to the right person, so that we haven't got these issues in terms of long waits, which, unfortunately, we're still in the position of having as a challenge. So, we're very confident about the improving trajectory and the use of alternative approaches.

So, that was part of that transformation fund resource that you had from Welsh Government. 

It was. Yes.

11:55

And in terms of whether other Welsh health boards are learning from that sort of approach, is that happening or is it just Powys that this is focused on at the moment?

Well, without a doubt, there's sharing across the psychological therapies management group across Wales. So, in terms of all the transformation funds, there needs to be evaluation and sharing of learning, so we're doing that. It's still early days, but we're already seeing an impact. So, I think watch this space, really, in terms of the spread.

Yes. And others. We've got the SilverCloud, which is online cognitive behavioural therapy. We've driven that across Powys and we're leading the spread of that across Wales, which is really positive.

Thank you. Supporting the health and well-being of the workforce can play a crucial role in recruitment and retention. What are you doing to make sure that your workforce is supported?

Thanks for that question. It's really key, and in many respects, you think the geography of Powys is a bit of a challenge in terms of visibility and being able to connect to the front line, but also because we're a smaller organisation, it's a very personal place to be, Powys, with a lot of direct contact from clinical executives to the front line through the professional routes. At the moment, we are enjoying very high attendance rates at work. That gives us confidence that people are able to come to work. So, our sickness absence rates are lower than the Welsh Government target that was set, so we're doing well there.

But there are two areas, really, where staff spend most of their time, if you like, off sick. Those two areas are stress and the other one is musculoskeletal. If I just pick up stress and general anxiety, Rhiannon just referred to SilverCloud— computerised CBT. We've opened that up to staff this year through occupational health referral at this stage, although as we move forward over the next few months there will be direct self-referral into that. That has had good pick-up and really good evaluation, so we're really excited about that. Seven hundred people have used that; that's staff and patients so far and the numbers are growing. So, we've got that service to offer as well as face-to-face counselling. We reviewed the service there and we changed our provider for that, and that's working well as well.

On musculoskeletal—and I declare I use the service myself—it's a self-referral directly to physio. Staff can refer in and get that support, and through personal experience, I thought it was excellent. It's a very well-evaluated service. So, we've got some of those services that we have put in place to try to address our biggest issues there.

Some of the other areas that tell us, actually, we're on the right track are things like the staff survey and the response we had around the staff survey. So, we know that we've got a high and an improving staff engagement score. We've got the highest of all the health boards in Wales at the moment; we're very pleased with that, but we know we've got more work to do. And there are certain areas where there's a real focus. Each director has got a plan for their own area in terms of supporting that.

And then, importantly, we've got—it's a bit like a staff movement, really. It's called the Chat to Change engagement approach. It's a group of champions across the organisation who are working collectively with us to drive well-being. So, things like well-being at work breaks, and there are a couple of walking routes. You see people walking at lunch time; we're trying to encourage that. We had a focus on lunch boxes and what people are eating, and encouraging healthy eating. And in our staff restaurant, cafe, we had a big look at the menus and portion sizes. So, we're talking about diet, exercise, mental health, stress and musculoskeletal. It feels like there's always going to be more to do in this area.

We need to look at stress again, although we've done quite a bit. And we also need to look at bullying, harassment and abuse because in our staff survey, the level of report went up. We were really interested in that and, when the company came to give us the feedback, first of all we felt, 'Oh my goodness me, this is terrible', but the sense of, 'Is this happening elsewhere?' and they reported to us that there has been an increase, not just across Wales, but across the UK where they're doing this survey. So, something is happening there. A lot of the discussions are around culture, the reporting culture, how we encourage people to speak up and feel safe to speak up. And then, when we've done that, what is the decisive action that we take to make those improvements?

And then, just finally, what I would say is that we've got a level of optimism here, because staff report—. I think it was—I've written it down—something like 72 per cent of staff report their line managers to be caring and supportive of them, so we have got a good foundation, but there's much more to do. I don't know if any colleagues want to add anything to that.

12:00

Just on the bullying and harassment part, are you looking at advancements, or what other organisations—not just in the health service, but other areas—are doing on that? Is that something you'd look into, or—?

Yes, absolutely. I think there's a sense of—. I was talking to someone the other week from the Office of National Statistics and how they've taken forward some of the developments. That was really around mental health, but the sense of looking outside the health service to draw in. That said, I think there's more for us to do about sharing what is going on in the health service as well in different types of schemes—so, for example, ambassadors for cultural change or external support that's brought in that's completely separate from the health organisation. So, I think there's a number of routes to explore here. And, actually, making sure we continue to build on the strong relationships we have with trade unions, as well; they're often our eyes and ears of what's going on, they can direct us into places, but we certainly need to—. The challenge to us is to look more broadly.

Okay, thank you. You've touched on the nurse staffing levels Act, and, just to ask you a quick couple of questions on that, do you have a clear picture of how compliant your commissioned services are with the requirements of the nurse staffing Act?

So, the requirements for us are part of our commissioning assurance framework, and nurse staffing is included in all the long-term agreements that we've got with the 15 NHS providers. Now, the staffing Act is not applicable to England, but, even so, England do monitor their staffing, so we've got that information available, yes.

And can you provide assurances about safe nurse staffing levels in the community hospitals?

Yes. Fine, great. Okay. And, just about commissioned services, externally commissioned services, you've touched on quite a lot of that with David's questions, but when a commissioned provider service isn't—. You're not happy with it, it's unsatisfactory—what action is taken by the health board?

Okay, if I make a start, I'll bring Hayley in on that and then Rhi and Wyn. So, a couple of years ago, we took a whole review of how we were managing and dealing with other organisations and commissioning in terms of the whole patient pathway and our level of monitoring and intervention in those services. We developed something called a commissioning assurance framework that sets out how that—our approach to that. I think Hayley will probably give you a little bit more detail on that and on the escalations as well.

Okay. So, in our commissioning assurance framework, we look across a number of domains in terms of looking at the quality and issues within our provider services. We look at access—so, how long are people waiting for treatment; we look at, also, quality and safety—so, we gather a lot of intelligence around the quality and safety indicators of our providers. We also consider finance and activity levels—so, the volume of patients people are seeing—and the costs, and whether there's overperformance or underperformance. And I think two other domains that we've brought in that are really important are patient experience—so, we really bring together the information we can gather from patient experience feedback, complaints, concerns, and a member of the team, the quality and safety team, is looking at that across our commissioned services—and also organisational governance, as well as sustainability. So, we look at the domain around what is the level of regulator intervention in that service, and also are there any planned or unplanned changes to services that are happening. We mentioned earlier about fragile services. Quite often, within strategic changes that are planned, there have been fragile services where we've had to respond to particular issues as a commissioner and put alternatives in place.

So, looking across all of those domains, we assess those. We have a red, amber and green rating system, and as part of that, then, there's a clear escalation process to determine whether our providers are in routine monitoring—so, we gather the usual intelligence—or whether we've got escalated intervention, and any of those providers that are above a level 3 in our commissioning assurance framework, the leadership is at director or at chief executive level.

We've also got a different approach in handling organisations that have special measures or other targeted interventions for particular issues. Part of that is that we have monthly contract quality performance review meetings with our providers, but also we have things like provider summits, so, where there are particular concerns with a provider, we will pull together the right personnel to consider those issues. An example of that would be—Wye Valley trust, not so long ago, was in special measures. We held a very comprehensive multidisciplinary provider summit, not only as Powys health board, but also with the executive members of Wye Valley trust. We developed a risk-based plan about how we were going to work together and address those issues, and then we monitor that on an ongoing basis. But that, I hope, gives a bit of an insight into—a number of issues could potentially trigger escalation or additional monitoring and discussions with our commissioned service providers.

12:05

Yes, I just want to ask you—you mentioned financial cost there, and, obviously, there was a situation that arose in north Wales between the Countess of Chester Hospital and Betsi over the NHS England tariff rates, which, of course, are not set in Wales, they're set outside of Wales, but have a big financial impact for anyone purchasing from those English trusts, and, in your case, that's a significant part of your expenditure. Can you tell us—are you confident that you have the resources to meet the significant increase that there was this year in terms of the NHS England tariff and that you are now part of the discussion in setting those tariff rates? I appreciate the situation is slightly different for you versus Countess of Chester, because of the different referral patterns in the whole of the north-west of England. I suppose Telford and Shrewsbury, in particular, rely significantly on your business, as it were, from your patients. But just to give us some confidence that that is something that you are on top of, which you're confident you can deal with.

I'll start, and then perhaps Hayley will add in. So, absolutely, HRG4+ has been issue of discussion between ourselves and mainly Shrewsbury, Telford and Wye Valley trusts. Our finance director, Eifion Williams, has been part of the all-Wales working group, working with colleagues in England on this issue. We have very good relationships with Shrewsbury and Telford and with Wye Valley. We don't let the finances get in the way, we have a commitment to ensure that the patient flows are key, and you're absolutely right, for Shrewsbury and Telford, we're quite a big provider of resource, and the same for Wye Valley. So, there's an interest in this for all organisations. So, we have worked productively around that.

In terms of Eifion working with Welsh Government finance colleagues, part of that negotiation—I understand the agreement that's now been reached, and we're confident that that will now resolve that matter.

We do need to, I think, operate—. We're operating two different systems, so we do need to make sure we've got good expertise and understanding of the English system. They've got commissioning for quality and innovation, they've got payment by results; it's very different in Wales. So, we do need to maintain our own expertise and track on that.

It also just gives me an opportunity, if I may, to say that there have, from time to time, over the years, been things said such as, 'Oh, Powys doesn't pay its bills,' or 'Wales isn't paying it's bills'. I can absolutely categorically say that is not the case. We do, from time to time, get a patient saying, 'Oh well, we have to wait longer', and all of that. We've got an absolute agreement between our organisations that patient care comes first, and if there are financial matters then we deal with them through our negotiations in that positive way. 

12:10

We've been a member of the cross-border network for many years and, in particular, last year the statement of values and principles—the cross-border statement—that was agreed between the Department of Health in England and Welsh Government, and also with the clinical commissioning groups in England and with us as well as a health board; it went through our board. And I think the principles in that cross-border statement are very important, which are, whilst things are being worked through sometimes, in terms of responsible commissioner, there is not going to be a delay to the treatment of that patient, and it clearly sets out information sharing, how we should be working together, and picks up some of those financial issues.

I just wanted to mention that, and, certainly, in terms of that relationship, we have got a grip. For example, we've got a number of patients who are resident in Powys but are registered with practices in England. There's about just over 5,000 patients where that is the case, and then you've got also English residents who are registered in Welsh practices. Again, that's about 3,500 patients. So, again, for us, it's part of our core business to have a grip on the situation. So, I'm mentioning that because it's not just about the acute secondary care and also specialist care cross-border agreements; we've also got this mutual day-to-day working in terms of our primary and community services as well.    

I know that NHS England have stepped in to resolve the difference in the price that's paid, effectively, between the NHS England tariff and what the Welsh Government is able to pay. Does it concern you—? That's only a temporary agreement, of course; they're going to be involved in the decision making going forward. But, if there is a significant shift in what you have to pay per patient for patient activity in England, that could have a big impact on your finances, couldn't it? You're aware, obviously, of that risk. Is that something that the Welsh Government is going to help with? Have they given you assurances about that? It's a lot of money, isn't it, that you're going to lose out on otherwise. What is the cost, roughly? If you were paying NHS England tariffs, what would the cost be to your budget? 

So, in terms of our integrated medium term plan, we'd already planned around 2 per cent uplift in terms of our baseline allocation. In terms of HRG4+ implications, that's excluding CQUIN, which is the commissioning for quality and innovation. That's, again, about an additional 2 per cent, which for us is about £2 million, and we've had discussions and assurances—a letter from Welsh Government—that they will be supporting us with that additional cost. 

Just to underline the point, so that—. Telford are actually dependent on Powys. 

Just in case some people get the idea that Wales is always dependent on England, but this is a reverse dependence, for you to bear in mind that.  

Well, that was the point I made. The situation is different in Chester, of course, because it's not dependent on the activity from north Wales, which is quite different than the two, certainly Telford and Shrewsbury. 

Reit, mae amser yn symud ymlaen, felly trafodaeth ar wasanaethau mamolaeth rŵan. Helen Mary Jones. 

Time is moving on; now a discussion on maternity services with Helen Mary Jones. 

Yes. I think the whole of the healthcare system in Wales was obviously very shocked by the situation in Cwm Taf, and the Minister wrote to all the health boards asking you questions about the quality, safety and sustainability of maternity services. In your case, of course, it's not only services you might be directly providing, but it's the ones that you purchase. Were you able to provide the Minister with assurances around those safety, quality and sustainability issues, and could you provide us with those assurances too?  

Yes. Thank you very much. I'll hand over to Rhiannon in a moment, but you're absolutely right; it was a very serious report, one that we considered at our board and our executive committee, and one where there is reflection for wider learning. So, we absolutely feel a responsibility in terms of looking under every stone. We look with a provider and commissioner lens here, an