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Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

03/10/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns AM
Dai Lloyd AM Cadeirydd y Pwyllgor
Committee Chair
Jayne Bryant AM
Lynne Neagle AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Deborah Carter Bwrdd Iechyd Prifysgol Betsi Cadwaladr
Betsi Cadwaladr University Health Board
Gary Doherty Bwrdd Iechyd Prifysgol Betsi Cadwaladr
Betsi Cadwaladr University Health Board
Gillian Baranski Arolygiaeth Gofal Cymru
Care Inspectorate Wales
Mark Polin Bwrdd Iechyd Prifysgol Betsi Cadwaladr
Betsi Cadwaladr University Health Board
Rhys Jones Arolygiaeth Gofal Iechyd Cymru
Healthcare Inspectorate Wales
Sue Hill Bwrdd Iechyd Prifysgol Betsi Cadwaladr
Betsi Cadwaladr University Health Board
Tania Osborne Arolygiaeth Carchardai Ei Mawrhydi
Her Majesty's Inspectorate of Prisons

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Lowri Jones Dirprwy Glerc
Deputy Clerk
Philippa Watkins Ymchwilydd
Researcher
Sarah Beasley Clerc
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 09:30.

The meeting began at 09:30.

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. Rydyn ni wedi cyrraedd eitem 1, cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau. Allaf i groesawu fy nghyd-Aelodau i'r cyfarfod? Allaf i ddatgan hefyd rydyn ni wedi derbyn ymddiheuriadau gan Helen Mary Jones a David Rees, achos mae salwch ar y ddau? Gallaf i bellach esbonio bod y cyfarfod yma yn naturiol ddwyieithog. Gellir defnyddio 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. Os bydd y larwm tân yn canu, dylid dilyn cyfarwyddiadau'r tywyswyr, achos dydyn ni ddim yn disgwyl ymarferiad y bore yma. 

Good morning to you all, and welcome to the latest meeting of the Health, Social Care and Sport Committee here at the Senedd. We have reached item 1, introductions, apologies, substitutions and declarations of interest. May I welcome my fellow Members to this meeting? May I also state that we have received apologies from Helen Mary Jones and David Rees, because both are ill? May I also explain that this meeting is naturally bilingual? Headphones are available to hear simultaneous translation from Welsh to English on channel 1, or to hear contributions in the original language better on channel 2. If the fire alarm does sound, you should follow the instructions of the ushers, but we don't expect a drill this morning.

2. Craffu cyffredinol: Sesiwn dystiolaeth gyda Bwrdd Iechyd Prifysgol Betsi Cadwaladr
2. General scrutiny: Evidence session with Betsi Cadwaladr University Health Board

Mae hynna yn mynd â ni drwyddo i'r ail eitem, sef gwaith craffu cyffredinol: sesiwn dystiolaeth gyda Bwrdd Iechyd Prifysgol Betsi Cadwaladr. Dyma'r sesiwn olaf yn ein cyfres o sesiynau craffu cyffredinol gyda holl fyrddau iechyd lleol Cymru. I'r perwyl yna, allaf i groesawu i'r bwrdd y cynrychiolwyr o Fwrdd Iechyd Prifysgol Betsi Cadwaladr? Diolch yn fawr iawn ichi am y dystiolaeth ysgrifenedig rydych chi wedi ei chyflwyno ymlaen llaw. Yn bellach, allaf i groesawu i'r bwrdd Mark Polin, cadeirydd Bwrdd Iechyd Prifysgol Betsi Cadwaladr; Gary Doherty, prif weithredwr Bwrdd Iechyd Prifysgol Betsi Cadwaladr; Deborah Carter, cyfarwyddwr gweithredol dros dro nyrsio Bwrdd Iechyd Prifysgol Betsi Cadwaladr; a Sue Hill, cyfarwyddwr gweithredol cyllid Bwrdd Iechyd Prifysgol Betsi Cadwaladr? Croeso i'r pedwar ohonoch chi. Mi fyddwch chi'n ymwybodol bod y meicroffonau'n gweithio'n awtomatig; mae pobl tu ôl y llenni, a does dim eisiau cyffwrdd â dim byd. A hefyd, mae gyda ni res o gwestiynau, felly, dwi ddim yn disgwyl i'r pedwar ohonoch chi i ateb pob cwestiwn, gwnaiff un y tro, yn sylfaenol, pwy bynnag sydd eisiau arwain.

Felly, i'r perwyl yna, caiff Angela ddechrau. Angela.

That takes us, therefore, to item 2 on our agenda, which is general scrutiny, and this is an evidence session with Betsi Cadwaladr University Health Board. This is the final session in our series of general scrutiny sessions with all the local health boards in Wales. To that end, therefore, may I welcome to the table representatives from Betsi Cadwaladr University Health Board? Thank you very much for the written submissions that you have submitted beforehand. May I welcome to the table Mark Polin, who is the chair of Betsi Cadwaladr UHB; Gary Doherty, who is the chief executive; Deborah Carter who is acting executive director of nursing at Betsi Cadwaladr; and Sue Hill, who is the executive director of finance at Betsi Cadwaladr UHB? Welcome to the four of you. You'll be aware that the microphones work automatically; there are people behind the scenes—you don't need to touch a thing. And also, we have a series of questions and therefore I'm not expecting the four of you to answer each question; one of you will do, so whoever wants to lead on those.

To that end, therefore, Angela Burns may start.

Thank you, Chair. Good morning, and thank you very much indeed for the information that you brought to us. I think our primary question would be: why do you think, after four years, Betsi Cadwaladr University Health Board is still in special measures and what would you identify as the key barriers to getting out of special measures?

Hello, good morning. Bore da. I think there are a whole range of challenges as to why we are still within special measures. What I would emphasise is that I think if you look at where we were at the beginning of that special measures designation, there were a significant range of concerns around quality, safety, around planning, around governance, around our waiting times, around staff morale in the organisation, staff engagement. I'd clearly start by emphasising that I think, in a significant number of those areas, we've made progress, and, obviously, the committee, I know, will be aware that there are areas where we've exited special measures. I'd be anticipating that mental health services and our learning disability services will, I believe, be in a position to be added to that list, although clearly that's not my call to make—quite rightly. So, I think we've made those steps around quality and safety and in some specific service areas.

Where we are still needing to make that progress is around a significant number of core areas still, which would be around our financial position—which I'm sure we'll talk about this morning, and the committee will want to drill into—and some of our waiting times, because, as I say, fundamentally, when people are accessing our service, the quality and safety are good, but the waits to get into our service are still far too high. Those are some of the key areas that still place us within special measures.

The challenges that sit underneath, if you like, some of those underlying features, I would say are workforce challenges; some of the challenges that we have around the efficiency and productivity of our services; some of it is around some of the issues of providing services at scale and scope across some of the areas that we cover, and some of the challenges that that would give us. But I think that, fundamentally, we've delivered improvements. We've got a long way to go. Looking at the way that we utilise our workforce, looking at different ways of working, looking—to use that word I'm sure you'll hear a lot when you get into these—to transform the way we do things is what we'll need. In particular, working with partners and our staff to take them with us is the only way that we'll be able to do those things that I've just talked about.

09:35

Thank you. I know that my colleagues will be drilling down into some of the key areas that you've just mentioned there, but are you able to identify a list of the things that you still need to, areas that you need to, sort out in order to exit special measures? Because 2014 is when it all started, and we are now in 2019, and it's still looking unclear.

Well, I just want to say, obviously—

You said finances, waiting times—workforce, was that one?

Well, we're working on—. Obviously, as we've been through special measures, we've had a framework agreed with Welsh Government in terms of how we would monitor progress in the key areas we need to focus on. So, we are currently looking at that framework because, as I've said, as we've gone along, some things have now left special measures. Areas where we've made progress obviously don't need to be on it anymore in a number of areas, so that gets refined as we go along. The fundamentals, right here right now, would be around getting our waiting times down, and that includes elective surgery—so, planned operations—but also our emergency waiting times are a fundamental part of that too.

Getting our finances in order to the point where we can make sustained improvement on that, that obviously needs to be underpinned by a set of plans and governance that can give the confidence that that will be delivered. Also, of course, within that, I would emphasise that that can only be done in partnership. So, seeing that partnership agenda, whether that's partnership inside the organisation, partnership across health and social care—. That's our list of key tasks that we have to address. And, obviously, within each of those, there's a whole range of things that we need to do to deliver them.  

Fine, there'll be more details on financials now in a minute. Mr Polin wanted to weigh in on this point. 

Yes, I would just sum it up in terms of five areas. The first is leadership, and leadership from the executive team and from board. There have been changes in terms of the leadership executive team this year, which has brought some new skills to the table. Secondly, governance has not been strong enough in the past, and I'm more than happy to evidence how governance has changed in the organisation, and you will all know that good governance makes for good performance, so that's important.

Secondly, a clear sense of direction: the executive team have always done a lot of work around seeking to articulate the direction of the organisation, but that wasn't clear enough and not being delivered speedily enough, which we unpicked last year. The plan this year is tighter. There's more focus around what's being delivered and why, and the measurement of that delivery. And that extends to—. There is now an estate strategy. There is now a workforce strategy. A digital strategy is in the process of being finalised. Work has commenced on the clinical services strategy, which is key, moving forward, in terms of transformation.

The next area is finance. We have had a review by PricewaterhouseCoopers that we commissioned, funded by Welsh Government. That has produced a number of documents that we can talk about later. It provides a real sense of where we need to go at in terms of the finance, and a recovery director has been brought in to assist us in doing so.

Performance: Gary's mentioned planned care and unscheduled care. You'll hear that, from an unscheduled care perspective, there's a planned programme of improvement in place, being led by Deborah at the moment. There's more work to do around planned care, but that is being picked up and has been subject to active conversation this week.

And then, finally, the point around partnerships—as Gary has already mentioned, we have not been visible enough in the partnership landscape in the past. We've upped our attendance in terms of the regional partnership board. I'm meeting with the leaders of the councils on Friday, for example. Gary meets with the chief executives. That's a space that I don't think we are in sufficiently—you can't expect your partners to support you if you are not engaged in conversations with them—and we are picking that up too.   

Yes, thank you. That's really clear and it lays out the—. Because I think we're slightly foggy about why you went so far off track all those years ago. So, that sort of identifies it. And, in fact, it's one of the questions I wanted to ask on finance. Because, since the introduction of the National Health Service Finance (Wales) Act in 2014, the health board has not broken even in any of the subsequent years. I wondered if there was a larger reason than, perhaps, you haven't got enough money. Is it because of the extraordinary geography that you have to cover and the difficulty—you know, what is it? Because there are a couple of health boards that have really struggled to break even, and some are because they are facing enormous challenges. But I know the Minister has been before us before and has indicated that he fails to see why Betsi has not been able to break even financially. 

I think that there are a number of things. You're absolutely right that the geography of the health board doesn't help. Mark referred to the PwC review that took place in the first few months of this year. They did quite a detailed piece of work looking at what the issues are for the health board. One of the actions that we've got out of that is to look at the drivers of the deficit for the health board, and that's something that we're taking to finance and performance and board in the next two months—trying to understand what's different about Betsi that means that we have struggled to get to a break-even position. It's not that we haven't delivered savings, because we have delivered significant levels of savings over the last five years. So we need to look at whether it is around the estate of the health board. We have a number of properties—I think it's over 150 properties—and then we've got to manage to staff those areas as well as to get our patients to the right place. So, I think we will have a bit more detail around that over the next couple of months.

09:40

I have to say that the auditor general was pretty direct in his assessment of the health board's ability, and I think, to quote:

'it is not yet clear there is sufficient financial accountability in place, and irrespective of the control arrangements in place, the health board continues to overspend'.

So, he's basically saying you haven't got all your fingers on all your pies, really. If that's a simile. [Laughter.]

Well, Sue has mentioned the work that we've done with PwC, and one of the things that they have rightly challenged us on is what they would term—and it's a phrase that we now use—grip and control. So, part of the key things that they've worked with us on, and this year what we put in place, are a number of very different, more stringent controls around, in a sense, pay and non-pay expenditure. We have slightly different processes for each, because they're two slightly different things. We have plans to put more things in place around there to get that accountability. I changed then the way that I hold—because clearly finance in a sense—. The organisation commits resources across the whole organisation; it's not the finance department that does that. Accountability is about everybody in the organisation, so whether it's the way that I sit down and hold people to account, whether it's objective and PADR setting, whether it's then, obviously, leadership development that has to alongside this, because holding people to account is about challenging them, but equally they'll need some support to do the jobs that they need to do. So, I think that that is a criticism that we take on board, and have done something about in terms of our action plan. That action plan is now monitored through our finance and performance committee and for our financial recovery group. We've brought in some expertise as well to help us, because, to some extent, that part of it is getting people to come in and give us some support in that, and that has equally assisted us—

Can I just ask, then, Gary, because it seems to us that you've just done the PwC report, you've just appointed a recovery director—why wasn't that done nearer the beginning? It seems like it's four years too late. We've lost a lot of ground in the last four years.

We have looked at ways to approach the delivery of financial turnaround in the organisation and we've utilised more internal resources so far to do that. Those internal resources are less costly than some of the ways that we're now approaching it, so there's a balance to be struck between, if you like, invest to save—. Fundamentally, as I've said, as the organisation—if you go back to where we started, where I started from at least, there were a whole range of challenges that we faced and we had to make progress on each of them. I think the committee would probably rightly expect us to prioritise the quality and safety agenda. That's not to say that we weren't looking to deliver on everything. In the years that Sue's mentioned, throughout the organisation, while I've been here, we've delivered material savings every year, as well as then addressing those quality and safety issues that I talked about, as well as investing something like £1.5 million, for example, into our obstetrics and maternity service since I've been here. We've invested in mental health, we've invested in our new sub-regional neonatal intensive care centre, we've invested in our new vascular service, so, as ever, there is a range of things—and I suspect the committee will pick up on them as we go through today—that we as an organisation are responsible for driving improvement on. We have not driven enough improvement on our finances. Those improvements we've delivered have not been enough. The grip and control that sits behind it has not been enough. But, clearly, I wouldn't want to give the impression today that we've not been doing things. The decision that we've taken to get in an external recovery director now rather than the previous approaches that we've used, as I say, is a cost—it’s a cost I believe we are seeing the fruits of, so I think it is an investment that is a good one, but we as an organisation clearly can't get away from the fact that, whilst there are areas where we have made the right progress over the last few years, finance is one where we haven't.

Just on what Gary says, there is no denying your question is right in terms of its merit. We should have got to this before, notwithstanding the savings we've delivered. That's why, fundamentally, a different external review was commissioned to understand what was going on and not going on. That's what's reshaped the approach. But more importantly, of course, it weakens our position in terms of understanding whether the underlying deficit is something we can resolve entirely, because until you can actually demonstrate that you've got internal financial grip and control, it makes that further conversation difficult. So, notwithstanding the work that Sue is about to undertake, that is the dilemma we face.

Originally, as I understand it, the board was planning to be in a period of stabilisation last year. Because it didn't get to the deficit or performance, we weren't in stabilisation last year, we're in stabilisation this year. And, of course, we've now got to make the switch from getting in charge of the finances, grip and control, to determining how we move forward and transform, which will deliver the cross-cutting, higher level of savings, in all probability. So, we are in a bit of a fix, and there can be no denying that. What I would say is, the board is responding accordingly, as Gary has described. As an aside, I chair the finance and performance committee personally, because they are the key obstacles to improvement. And we had a very long conversation, as you might imagine, this week at F&P around the financial approach and how we move forward.

09:45

And I think you've hit the nail on the head about the fact that, until the finances are really understood, you will not know why you cannot make your targets in terms of that. So, if you look at Hywel Dda, it's very clear that, actually, they had an underfunding issue. Put that right and then, in theory, they should be able to break even and move forward. But that question mark is still over Betsi, because it's not clear where that issue is. And I think our frustration as a committee—and we've gone through this with every health board that's come before us—is why is it taking so long? Because, of course, ultimately the people of north Wales—they need a different service.

And in the conversation with Welsh Government and the commissioner of the review, the conversation was around the fact that we can't commission a review of the underlying deficit because you can't—we can't—demonstrate financial control sufficiently. So, you can't put the cart before the horse, so that's why we've pursued the approach that we have in terms of the review and what it's been focused upon.

Are you happy for me to carry on, because I've got loads more?

Great. So, is the financial issue the reason why you have not been able to put in your integrated medium-term plan and get that accepted, or is that more to do with the clinical element of the challenge you face?

I think it's a number of factors. If you look at the health board and its approach to having a clear direction and strategy and then plans to implement that strategy, if you go back, some years ago, the health board began some of that work with 'Healthcare in North Wales is Changing'. When I arrived in the organisation, that was our fundamental strategic change strategy.

Clearly, what we had to do and did do was respond to some of the key issues where we needed immediate focus and immediate engagement with partners and our staff to come up with what we were going to do. And those areas, as you might imagine, and it won't surprise you to know, were mental health, primary care and maternity services. So, the health board, if you like, was at that point, I have to say, in quite a reactive place. And that, as I say, is not a great place to be, but equally, clearly, we had no choice other than to address the significant issues in those services.

We then began to put more of what I would call a whole-system, whole-organisation strategy together in 'Living Healthier, Staying Well', but that, whilst it did lay out some real detail in a number of areas of where we wanted to get to, was still not really giving us the absolute detail that you'd need to really have the confidence to sign off an IMTP, although it was a step, I have to say, absolutely, in the right direction and we had good engagement with staff and partners.

So, where we are right now, I think, is that, to have an IMTP that would be approvable, we've got work to do. There is work around performance, because an IMTP that has performance, either in financial or waiting-list terms—that is where we are today—could not be signed off. But then in terms of our clinical strategy that really gets into the level of detail, building on the strategies that Mark has mentioned in our estates, then bringing all of that together, that's the job of work that we need to do to have an IMTP that can be signed off. Obviously, in the meantime, as you would expect, we have very clear plans. Our plan for this year is very clear. What we obviously want to do is get into that three-year space. So, we obviously want to get to the point where we've got an IMTP signed off, for the good of our staff.

Do you have a timescale for when you hope to have an IMTP?

Well, I guess, to an extent—

Well, I think our focus has to be on doing the things I've just said as quickly as possible. Delivering this year's plan. Part of our plan this year—

Well, in a sense, I think the issue with giving a timescale for it is we would immediately get into, 'Well, what are the things that we'd need to do to deliver the timescale I've just said?' So, I'm on to the things that we need to do and, essentially, that will then put us into the point when we've done that to get into the IMTP space. Mark, do you want to come in? 

09:50

So, IMTP will not be submitted this year; that would be foolhardy to do so. I would anticipate we're aiming for the back end of next year so that we move to IMTP territory in 2021-2. What that will require us to do in the meantime—and you'll be as much aware of this as I am—is to join up finance with performance. That will require the clinical services strategy that Gary's referred to, and there is a need for us, because of where we've been, to get into a place whereby we can have conversations with Welsh Government, in particular, around service improvement as against meeting a deficit and what the respective challenges are, and where there can be a meeting in the middle around some of that.

At the moment, because the organisation's been occupied with finance on the one hand, performance on another, and on occasion has not drawn those two things together, it's very difficult to have a searching conversation around how you balance financial recovery with service improvement. There are going to have to be some service changes and we need to call that out, and we need to call that out, of course, in consultation and engagement with our communities, our stakeholders and staff, but also the stakeholders that include Government.

I want to touch on one of those, actually, in just a minute, but can I just quickly ask: your recovery director is charged with the recovery of the financial position, and your turnaround director is charged with the clinical services, is it?

We don't have a turnaround director, we have a recovery director. 

Oh, right. Okay. Oh, right, because I thought I read that there were—. No. Okay, so it's—

No, sorry—if that came across, that's not correct. So, we have a recovery director who fundamentally is focused on delivering this year's financial plan and setting us up to deliver the next year's financial plan, because my anticipation is that that person will be leaving us roughly at the end of March. What I would emphasise, though, is clearly some of the initial work that he has got into I would say was particularly, if you like, finance focused. To really deliver our plan this year, it's about how we can work across services to change services. The grip and control agenda, if you like, leads you into, 'What do we need to do to change our workforce models, the fact that we've got at the moment a number of patients that, at whatever stage in our process, are either being brought into the acute side of our organisation that maybe could be cared for in a different way, or are in the acute or community side of our organisation for too long, which disables them effectively, and obviously is high cost?'

So, the work that the recovery director is doing is a service improvement transformation, because the only way we'll change some of those things, for example to do more operations as day cases—those things that would go with that. So, he clearly has a very clear financial focus, but there are elements of service improvement that we need to get into with that, too. And, as I say, his timeline now will be to be with us until the end of the year, delivering this year's financial plan and setting us up to go into next year with a robust plan.

Okay. So, the last couple of quick financially based ones, then: given what you've just said, are you going to be able to deliver your savings target, because I think the Minister said that little or no progress had been made by the health board in pursuing potential savings? I think he said that in June of this year. I just wondered why those savings hadn't been achieved, and also are you going to be able to deliver the Welsh Government control total for the end of this year? Sorry—Sue.

So, we're working really hard to drive towards that £25 million control total. We understand that it's really critical that we show a marked improvement this year against previous years' performance. We really do see this year as the line-in-the-sand year where we have to make a difference. To achieve the £25 million control total, we need to deliver around £35 million of cash-releasing savings this year. And as we stand at the moment, we have identified £25 million against that target, of which £16 million is green, and about £6.7 million has been delivered at month 5, which is 19 per cent. But there is a real focus in the organisation now, so in conjunction with the recovery director, we've put a real framework around that, which, effectively, means we have a financial recovery group that meets on a fortnightly basis, which, as Mark said, reports into the finance and performance committee. We have divisional review meetings every fortnight with each division within the health board, and this is all driving towards identification and conversion of savings schemes and ideas through into delivery for this year. That is absolutely our target but, at the moment, the forecasts for the health board remains at £35 million, which was the draft plan, because we don't want to be setting expectations that we're not sure that we can deliver. But that confidence will increase, and, I think, compared to last year, we are doing very well in terms of identification of those savings.

I think the other thing that's worth mentioning is that we have set up improvement groups across the health board. So, there are 12 of them, and they are focused on looking at more transformational schemes that will actually hopefully fill that £10 million gap that we have got at month five. 

09:55

So, as part of your savings drive, is that why you've engaged in this restructuring of the nurse staff, of the staffing rotas, because, of course, that's caused a huge furore? It's been of great concern to us as a committee, and to the Assembly as a whole, as you will know, because I'm sure you watch us every week. We've discussed it in all seriousness, because what we see is a health board that's been in a lot of pain for a lot of years, that is not achieving all the things on a year-by-year basis it says it's going to do. There's been report after report after report that centres around poor patient care, poor delivery. North Wales Assembly Members of all political spectrums stand up on a regular basis to say that patients are not getting the services that they need. The providers of those services are the staff, and then this happened, and we just saw what appeared to be an enormous collapse in staff morale. So, it just seems like we're heaping pain upon pain upon pain, and I just wondered what the rationale was behind that, and is it part of the efficiency savings grab to make the money, and is it the wisest place to go for that money?

May I answer?

Thank you. So, I think you're absolutely right to draw the point out in terms of the simultaneous arrival at the point— does one drive the other? I think the answer has to be that it is coincidental that we get to this point in terms of looking at our rotas. We've invested as a health board very heavily in our electronic rostering system, and what that has identified for us is that the shift pattern across our organisation is unwieldy. We have almost 100-plus different shift rota patterns, and what's been really clear through the work that we've been doing with our safe care work, to deliver the nurse roster system and really identify whether our rotas provide equity across our whole nursing workforce, is that it doesn't. So, we have a whole range of rosters, we have a range of processes in place, and we've got inequity between individual groups of staff. 

So, what the sensible thing to do is to ask our staff what they think about that, which we've spent an awful lot of time over the past few months doing. We've done that under a good governance process of organisational change. We're at the point of receiving all that feedback from our staff, both positive and negative. Our staff are concerned as well that they feel there's inequity, and what we seek to do now, through having the voices of our staff captured, is really look responsibly at what we can do as employers to make sure we can reduce some of the variants in terms of shift rotas. And what's come out of the process is there is huge inequality in terms of what staff do get paid for, or don't get paid for, in terms of staff breaks. We've identified what we now need to do is really start to drive that and introduce sensible equity and fairness, and be really clear that we work with our staff-side partners to do that, and our staff groups. 

So, we've paused our plans to take cognisance of the reviews that we've got back from our staff, and we aim to work with our staff, and our staff-side groups, to really get to a better position. The concerns have not just been expressed by staff, but also by their managers. We want to take all of that now and really come up with something that enables us to move forward sensibly and in an honest and equitable way. 

I'm pleased to hear that you've paused the plans, and I assume you've re-engaged with the unions and the staff. 

Absolutely. A massive number of consultations have taken place, and we've got the voices of our staff captured across every aspect of our services. 

I think, again, from our perspective, it's just this whole sort of PR disaster, that, actually, kind of all snowballed, and now you're saying 'Well, we're going to stop it and reconsult.' But, then, you ask the question: where is it in the governance or the culture of the health board that that didn't happen before, or it wasn't really understood what the staff were saying before? Because if it had happened before and you really understood what the staff were saying, I would have thought there was mitigation that could have been put in place so that you wouldn't then have this absolute furore that happened subsequently. So, it's yet another thing that Betsi Cadwaladr appear to have not managed supremely well.

10:00

I don't think it's just Betsi that have not managed it well. I think many organisations have found themselves in this position. The timing, I accept, is challenging for us, but I think we've not stopped; we've paused to reflect on what our staff are saying to us and what our mangers are saying. The right thing to do is to have balance and equity, and the right thing to do is to ensure that staff are paid appropriately and remunerated in the way that is right. So, we want to really be clear about that, and are heavily supported by our unions and staff-side colleagues to get that right now that we know what we know.

So, I think it's absolutely the responsible thing to do, recognising, as you mentioned earlier, that the geography of our organisation is very disparate. So, it's not just about our acute services; it's very much about some of our community hospitals as well, where we have reduced staffing, particularly overnight. So, some of the things we need to do, we'll have to have variance built in. We can't say that we're going to take break times off people where there are very low numbers of staff overnight. So, we do need to be mindful of all of that and some of the unique challenges we have based on our geography.

One point that I will just make is I think there are certainly some things that we need to reflect on, because the dialogue that we have both with our staff side—. I personally met with all of the relevant staff-side reps over the last few weeks to discuss how we've got to this point, as you'd expect me to. So, I think there are things for us to reflect on there, because generally that conversation and dialogue works very well, whether that's the more formal mechanisms or the informal mechanisms.

So, here is an example where it has not gone as you'd want it to go. I think that one of the things that I just want to emphasise to the committee is, if you look at what has happened at Betsi Cadwaladr over the last few years, in staff survey terms—it doesn't happen every year, as you know—if you take it back to 2013, there are a lot of measures in that, so I'm not expecting the committee to be familiar with them all, but I always hone in on the key ones of,  'Are you proud to work at Betsi? Would you recommend to your friends and relatives to come and work at Betsi, and would you recommend to you relatives and friends to get treated at Betsi?'

And just picking up the point around report after report that you mentioned, about things not going well, those fundamental measures show that there have been the biggest increases in Wales, in Betsi, in terms of the answers to those three questions. So, about 20 percentage to 30 percentage point jumps in each of them. And that's despite all the things we've been doing and despite the fact that, since 2013, it has not been easy to work in Betsi and it has not been the kind of calm environment that you might ideally want to be in.

But on those measures of, 'Are you proud to say you work here?', 'Would you recommend working here?', 'Would you want to get treated here and recommend to your friends and family to get treated here?', the way we treat our staff and the way we treat our patients are captured in those measures, and those have shown improvements that have taken us to what is, fundamentally, I would accept, the Welsh average pretty much, and I would like to be much better then average.

I read with real pleasure your list of achievements and things like that, and there's no doubt there are changes that have happened, but we've got to be clear that it was at a really low base—

—and there is only one way, and that's up, because you can't possibly get worse. So, I'm really pleased that that has changed. But Betsi has been on the lips of Assembly Members for years.

Well, I guess what I'd say is that if you go back to 2013, it did get worse, because from that point on we got put in special measures. So, I'm not sure that, if you go back to that baseline, the only way was up, actually, having been put in special measures, the way could have been down. So, we started in 2013 at a low base, we then got put in special measures, but what we have seen are those improvements. I am not suggesting for a second that that is something that is anything other than basically a return to where we should have been. I agree. And our challenge now is to get it to where I want it to be, which is the best in Wales in those measures.

I was going to say, too, no-one can ever have their cake and eat it, and we have got to, I think, all recognise that the status quo, moving forward, is not an option. If we are to address the challenges that face the health board, there are going to be some uncomfortable, challenging decisions to come. And I would say, having arrived at the board not long after a year ago, there isn't sufficient impetus around the organisation and understanding that to live within a deficit is just not acceptable—to not seek out, even on a very tactical level, the scope to improve our efficiency, productivity and savings. And when you extend that outwards to stakeholders, we are going to have to change some of our services. That will give rise to challenges in the engagement and consultation, of course, but this will pale into insignificance when it comes to some of the other service changes and challenges we've got to face and resolve. So, I don't for one minute defend this could have been handled better, but, on the other hand, our internal staff groups, our unions, our stakeholders outside have got to accept too that you can't keep criticising us and then say, 'You can't change anything.'

10:05

No, and I take that point completely. I come from west Wales, where we've had a huge amount of challenges, but the politicians are now able to row in behind the health board, more or less, because actually the health board have been very focused, very clear in their direction of travel, they've put their money where their mouth is. It's not great, there are things that are still going wrong, but improvement is demonstrable and the patient outcomes are really improving. So, now, we can stop carping, if you like, from the sidelines and say, 'Okay.' So, we say to our constituents, 'You don't like this, but you know what, if you want this to continue getting better you're going to have to suck it up, and that's the way we've got to go.'

We can't yet do that with you guys because we haven't seen, after four years, that enormous sea change that allows the politicians to row in behind you and say, 'You know what, you might be about to do something that's really difficult and it's going to be wildly unpopular with people, but we're going to support you on it because it's going to make a fundamental change to the long-term health of the population there.' And until you can do some of that stuff, we are going to keep challenging you, because that's our role.

And on the challenge element, my final question, Chair, because I know that time is passing, actually is, given the issues around the staffing and the uncertainty, are you confident that, first of all, the safe staff—? I never get this right. The nurse staffing Act—we were going to call it the safe nurse staffing Act, weren't we, and then it all got changed. But, are the levels are all being met appropriately in the relevant departments? You've got 653 nursing and midwifery vacancies. Given that people might be looking at, 'Do I want to come and work for Betsi?', recruitment issues, which we know that all our health boards struggle with, how confident are you that you're meeting the current Act and how confident are you that you can recruit the additional nurses and midwives that you obviously need? 

If I may, I'll take it in the two parts you've asked me the question. So, absolutely, in terms of the staffing Act, we report to our board on a regular basis on our compliance with the Act, and we are compliant. We monitor every level of that and we have an electronic rostering system that enables us to do that in a qualified way. So, I'm very confident that we are meeting the Act and working hard to do that. 

In terms of our vacancies, we've improved our vacancy rate significantly across a number of our services. So, vacancies in maternity services, we don't have any more. Our maternity services are out of special measures, as you're aware, and part of that has been a really successful recruitment drive, and that's at every level in staffing in maternity services. We have some particularly challenged areas—so our vacancies predominantly now sit within our acute services. We have no vacancies in community, we've got very low vacancies in our community hospitals.

We've had significant challenges in CAMHS and we've had a very successful recruitment campaign recently where we've been able to fill those vacancies. We are still slightly challenged in a couple of our areas in CAMHS but are very confident that we've got a plan to move that forward and some new models of working that will enable us to use other workers to help us to support children more appropriately. 

Into our acute services and the vacancies that we have there, we've had a huge, successful recruitment campaign recently and we're continuing with that. We've managed to fill a number of what we would call critical shifts, in the hundreds now, and are very confident with the plans moving forward that we'll continue to do that. You'll be aware success breeds success, and we need to build on that. We need to really build on the positives that we've seen within our maternity services where, in terms of feeling slightly beleaguered, we couldn't recruit into that, but we've now turned that around completely—very positive, a waiting list. We're seeing really positive feedback from the numbers of students that we train in Wales and students who train and want to stay and live in north Wales, which is very positive. 

So, we're continuing to build on that, and our 'Train. Work. Live.' strategy is really starting to bite now in terms of helping us to move forward. But we are not resting on our laurels. We're absolutely actively recruiting at every event we possibly can. We're exploring different types of recruitment models. We've been working with a company to look at some overseas recruitment, in particular. But we really want to build a workforce that lives and trains and works in north Wales. So, we're not complacent about that. We'll need a number of years to build it up, but we really want to build a workforce that serves the people of north Wales and lives among them.

10:10

Just emphasising that: the work that we're doing with our educational partners, whether it's around medical students spending a greater amount of their training up in north Wales—we're seeing benefits from that—whether it's with some of our education providers around therapy courses, getting therapy courses back up into north Wales that haven't been there before, so people come up and train. Clearly, we're hoping that then they'll stick around. Some of them won't, but an awful lot of them will. The feedback that we do get is very good from people who come and train and then live, hopefully, on a permanent basis in north Wales.

Obviously, one of the other areas that we are looking at is getting people to come and choose to work with us, which is obviously great. Obviously, what we want to focus on—which goes back to your previous point, I know—is around retention. So, what can we do around the way that we work with people, whether it's the way that they get chances to develop, whether it's the way that they experience an average shift—what's it like? So, that retention element.

Obviously, if people do leave the organisation, it is about understanding why. A number go on for promotions or for family reasons, but there are instances where we need to learn when people have left because things haven't gone well. So, there's an 'attracting people in and keeping them' package, and treating them well, which I do think Deborah is right to highlight we've made some positive success on. Equally, from a financial consistency and service perspective, if we didn't have over 600 vacancies, and we didn't have over 100 medical and dental vacancies, clearly, we would be in a better position. That's what we've got to keep driving towards.

Can you assure us that workforce retention and recruitment is at the highest level in the organisation—at board level? Because the RCN came and gave us evidence only a few weeks ago that, in fact, no health boards in Wales—I think it was no health boards in Wales—discussed workforce planning, recruitment and retention at board level, having examined all the minutes for the last six months or year. So, I just want to make sure that it's really high up your pecking order.

So, it may not have been in board in that sense. It's been the subject of detailed examination in the finance and performance committee. We've had discrete and comprehensive papers on recruitment and retention. In my chair's assurance report from F&P, I relay what was discussed in board. I absolutely feel that F&P is the right place to have that conversation, because we get into real depth there.

Fe wnawn ni symud ymlaen nawr at faterion yn ymwneud ag iechyd meddwl—Lynne Neagle.

We'll move on now to mental health services—Lynne Neagle. 

Thank you, Chair. Can I ask you for your assessment of the health board's progress in implementing the Health and Social Care Advisory Service and Donna Ockenden recommendations? In what areas is further work needed, and what are the main challenges in delivering on those recommendations?  

Do you mind if I cover the HASCAS and Ockenden recommendations together? You will be aware that there were 35 key recommendations from both of those reports. The health board has established a taskforce to deliver against those recommendations, with a detailed programme of governance that underpins it, which includes stakeholder engagement as well. We have a wide-ranging stakeholder group from external partners, but also from families who had loved ones within the Tawel Fan ward. The aim of that is to have a service delivery group that is overseen by the health board. Also, then, we have ex-service users and external partners who can provide us with some checks and balances in terms of the actions that we're taking.

All of those recommendations are managed robustly on a regular basis. We meet monthly. All those actions are tracked to make sure we are balancing the improvements that are being done. Many of them have been delivered now. So, of the 35, there are only a very small number—. None of them are red rated. Only a small number are requiring additional activity to support; there are only two of those at the moment. We have closed a significant number of them, and a number of them are on green and planning to deliver.

You'll be aware that there were things in there that went from appoint another consultant nurse in dementia, which was an action that we could resolve quickly and close—and we have done that—and then, there was an action around improving culture across the organisation. That's a green action at the moment, but it's an action that has got real traction. The work that we are doing around the staff survey, the 'be proud' work, and the work that we are doing with our teams is helping us to really demonstrate evidence around how we're improving and moving forward in those areas.

10:15

Okay. And the Public Accounts Committee made recommendations in May 2019 about mental health services and they actually expressed concern about the lack of engagement with the stakeholder group that you've referred to. How do you respond to that?

I think there are challenges with working with stakeholders who have a very firmly held view about our services because of their lived experience. The majority of stakeholders we have seen engage with us and comment very positively on the work that we're doing. They're actively engaged with us and participate across the organisation. It's hard to reconcile, sometimes, one view against what we see in practice. Certainly, the chairman attended recently a stakeholder group with the stakeholders. They're actively involved in the development of the Ablett unit; they want to get involved in that group. They're involved in recruitment of people in our organisation and also in testing some of the things that we're doing. So, one of the areas that they've been—. A couple of the areas that they've been concerned about have been dementia, end-of-life care and restrictive restraint. They have actively tested across our organisation those three areas and we've had positives feedback on all of them from them.

So, I think, in terms of people who have had devastating experiences, it is really hard to get to a point of perfect assurance, but we're certainly accepting we're on a journey of improvement and are monitoring alongside the feedback from that group the feedback we get from many other groups, our independent sector providers and in terms of Caniad, who work with us to bring in volunteers and supporters. We get very positive feedback from them as well. And the work we're doing on I CAN: we've seen over the past few months massive traction with our I CAN work and the impact it's having in supporting patients who can be cared for in a different way rather than turning into our A&E departments.

So, we're seeing some real positives. I'm not sure if you saw recently we launched some free mental health training awareness sessions and within 24 hours we'd had 1,000 people across our communities in north Wales sign up to join us. That number is now at 1,500, and we'll be providing support to all of those people to provide active mental health support in their communities. We've been working with barber shops to have some good conversations with people who are having their hair cut, and a whole range of other things, and people are getting behind us on that. I CAN is really spreading—so, 'I CAN work', 'I CAN run', I CAN all sorts of things, but 'I CAN improve my mental health' is really important and that's the message we're trying to get across north Wales.

Just on the stakeholder point, I did attend one of the stakeholder reference group meetings. I found it challenging and robust. It's quite clear that the stakeholders and the CHC who were present wished to be engaged in securing the right level of confidence around the progress of the recommendations, and I do think there has been considerable improvement. We discussed at board last time the need, for us—particularly as a board but with the stakeholders—to be very clear about what it is we think we need to do now to discharge the recommendations. Because what we want to focus on with the stakeholders is how we look forward, and there's a lot of good work taking us forward, but to successfully move forward I think we've got to demonstrate robustly we're discharging the recommendations, all of them. So, that needs to be the focus as we move forward with the stakeholders.

Just to emphasise that when Deborah was referring to people getting involved with us and testing, what we fundamentally mean there is members of the stakeholder group and the families group going out to wards, talking to staff, talking to families, talking to patients, just out and about. So, when we say 'testing', it isn't sitting in a room with us and receiving reports, it's literally out and about, touching and feeling, for want of a better term. And that report—. And I think when we say, 'Getting involved in recruitment', we mean sitting on panels and deciding who we should recruit. So, it's a genuine and real involvement, I'd say, and that brings us challenges, for us and to them, as Deborah says, given their experiences in the past where, for some of them, their experience with Betsi Cadwaladr had not been good. And I've sat down with them and, obviously, I won't go into detail here, but I've been through their individual HASCAS reports with them, and I am, therefore, very grateful to them for the input that they do give us now. And there are times when they are critical, and that, I think, is quite right.

Your own paper identifies that rebuilding the trust and the confidence of the public is a key challenge for you generally around mental health. So, what can you tell the committee about how you're actually going to meet that challenge?

For mental health in particular? 

10:20

I think, fundamentally, it is, to some degree, around some of the things that we've talked about, which are: we're getting the right people involved with us to come and check that what we're doing is correct; getting our staff speaking, listening, co-producing the care with people, really accepting that the models that we've got now need to change, that the way we work now needs to change, that, obviously, when we get—and we have regular inspections, and we've had some recently that we've not got the formal reports for yet—but where we get external inspections from HIW, unannounced, that we're able to give that to people as some evidence to corroborate what we're saying. But, fundamentally, to keep doing the right thing and changing our services so that they are giving people what they want. Because, picking up some of Deborah's point, I've met with some of the groups of our mental health clients who do some of our running clubs, and that is the kind of thing that people want us to do, so they will have confidence when they see us listening to them and really working with them, rather than, perhaps, what has been a more traditional response, which is to do what we want to do. And then, obviously, fundamentally, I would also say when we don't get it right—because there are times when we don't—I think what will restore confidence is what we are doing, I believe, which is being open, being transparent about when we don't get things right, encouraging people to tell us that and then trying to do our best to do something about it.

I wanted to ask specifically now about your performance against mental health targets, both for adults and children, because the Minister described real improvements in access times for both child and adolescent mental health services and adult services back in June 2019. Can we just start with adult services, and can you tell us to what extent the health board is actually meeting its targets for both urgent and routine access to mental health services?

The adult side of things over the last three months has plateaued slightly. So, on that one, we've not sustained those, we've not kept going—

Well, fundamentally, there are some areas where we need to get our processes changed, so people can access things more quickly and that we get rid of some of the delays in processing people through into appointments. So, that's some of the work that we're doing around that. There are still some gaps around staffing and recruitment, and we're trying to plug those and work with those more effectively.

There is also, clearly, then a bigger piece of work, which is how our mental health services work with our primary care and community services to support, if you like, them and train them and work with them to give the support that's needed so people don't go into a situation where they need to escalate through the mental health pathway. Because clearly, there's a great deal of mental health support that goes on in GP services every day. There's a great deal of work that we've done, sometimes around targeted groups, such as homeless groups and other people, where if we're able to work and get mental health expertise into those more upstream interactions, then people will not get to the point where they need specialist mental health support, and that includes working around housing and other things to keep that going. So, those, I think, are the areas—.

On CAMHS, we have seen that improvement keep going, and really, our biggest challenges around child mental health services, at the moment, are in our central patch. The west and the east are in a much better place. Some of that is around demand and some of it is around staffing there, so we have recently received additional resources, so we'll be out to commit those, so I'd be expecting to keep seeing those improvements.

Are you able to share with the committee the percentage of young people who are seen within 48 hours for an urgent referral, and within 28 days for routine referral?

We can share the actual numbers. I haven't got them, but we are in line with our required targets with those numbers.

I think it would be helpful to see that. I wanted to ask as well specifically about neurodevelopmental, because when the children's committee looked at this previously, the waiting times in Betsi were the worst in Wales for neurodevelopmental, with families waiting years, really, to get an assessment. Are you able to assure the committee that things are better? Have you got any figures you can share with us on neurodevelopmental as well?

Yes, we certainly can share them with you. We've done some recent work around our investment in those services and have seen some improvements made over the previous few months, so we can certainly share those numbers with you.

Just in terms of the 28-day target, for adults, it was, as at the last performance report, 73.8 against the overall target set by Welsh Government of 80. And in terms of CAMHS, it was running at 80.1 compared with a target of 80. So, CAMHS was on target, adults was below.

10:25

On neurodevelopmental, we'll get the exact numbers for you, but we have done work, and we've done work on two things. One is how we can try to get the waiting time down for definitive assessment, and then treatment plans. But one of the things we've also put some effort into, which we'll try and give you some more briefing on when we give you the detail, is: clearly, while people are waiting—because obviously, across the whole of the UK, there is a waiting time for neurodevelopmental assessment—there are a number of things that, even in the absence of a definitive diagnosis, can be done. Because in a sense, to some degree, not irrespective of—but you don't need the definitive diagnosis to know that there are things that will help and things we can do to support.

So, we have also tried to put some effort into whether it's support groups of parents meeting up, whether it's help and advice we can give to people, whether it's third sector organisations that can help—everything from, in a sense, parenting skills to just coping mechanisms. So, the waiting times have improved, but they're still too long on neurodevelopmental. Clearly, demand, particularly around all issues around child services, has increased substantially, but we will also lay out for you some support we try to give to people while they are waiting, because that is—. When I've spoken to people, for some people, that has made a real difference and is a really important part of what we do, irrespective, in a sense, of what the waiting time is.

And can I ask about the CAMHS unit in Abergele, then? Can you confirm for the committee that there is still a restriction in place on the unit admitting young people who are suicidal or self-harming?

In—? I'm not sure I can answer that. We've got 12 beds opened in the centre—

But there was a restriction in place, wasn't there, so that the unit there, and in Tŷ Llidiard, actually, weren't permitted to take what would be considered to be high-risk young people—young people who are at risk of dying by suicide or were self-harming. I'm just interested to know whether that restriction is still in place.

I mean, obviously, the Abergele site is an off—it's not on one of our acute sites. So, there are some issues about cases that can be put in there. I'd have to just get back on that specific to you in terms of what exactly their admission criteria is today. What I do know, as Deborah's identified, is that we're not able, in staffing terms, to get to the point where we can fully open the beds in the unit.

Well, I am disappointed, really, that you can't answer that, because the Abergele unit has been operating below capacity for several years, and the health Minister assured the children and young people committee that the health board were on top of trying to address the staffing issues that are causing a problem there. And it sounds as if you don't really know that there is a restriction in place.

Well, what we do is we are constantly looking to recruit to the vacancies that we've got there to be able to open the beds. As Deborah said, we've got 12 open at this point in time. That's not—

It would be, I think, 24 capacity, so it's running at about half its capacity. It's the part around, within—. I mean, obviously, we're admitting patients there every day. It's the point that I'm struggling to answer for you in terms of the actual—. It's whether things are excluded from their admissions criteria that I'd have to get back to you on in terms of that, because I wouldn't like to speculate on that today. But we are fully on to—. What we would want to do is fully open that capacity up. Now, what we do know is, in terms of, clearly, having the right capacity in north Wales, if we haven't got that, the danger is people have to go out of area. What we do know is that in terms of our CAMHS services today, we've got two out-of-area patients, I think it is, and both of them are for services that, even if that unit was running at 24 beds, we couldn't provide because they're very, very specialist national services that people are accessing.

So, what specifically are you doing, then, to fill the staff vacancies in Abergele? Because this has been going on for several years now, really. I am genuinely interested in what specific steps the health board is taking. I know that there's been a challenge with staff wanting to work in the community, but, you know, we have to get over that so that we have got a service for young people who need that kind of very specialised input.

Well, fundamentally, I guess it's the similar kind of actions that we take in areas where we've got staffing gaps. So, one of our key ones is, obviously, retain the staff that we've got, make sure the staff that we've got are getting good development, good treatment, et cetera, et cetera, looking to get out and advertise in a whole raft of ways—so, whether it's recruitment fairs, whether it's microsites and social media, whether it's international, as Deborah's outlined, trying to see where we can get, for those staff, additional development courses where people are trained so they might get more training in north Wales. Child and adolescent mental health services across the country are struggling. It's a shortage specialty. So, it is one where we—. Fundamentally, we would want to see that unit fully open, as I said. But, we do constantly keep going around trying to attract staff in there, and that, fundamentally for us—and I accept the frustration—is an ongoing challenge. It's not one that we've been able to fully staff up. Obviously, I would struggle to give a definitive time that we'd be definitely able to do so. But, certainly, the effort that goes into it is—there is no lack of effort. Because clearly, I have been there many times. You can see the space where—. Obviously, we use that space at the moment for therapeutic interventions. The space is used. It's not just sat there empty in that regard. But it would be better for us to be able to staff it to its full capacity.

10:30

Well, if we could maybe have some clarity on the issue of the restriction, that would be very helpful. If I can move on to concerns, then, what progress has the health board made in terms of improving patient experience of concerns, not just in terms of timeliness but also in relation to the issues that were picked up about concerns handling in the Ockenden review?

Significant improvements have been made on complaints processes. So, the health board was criticised, rightly, particularly in the Ockenden report, around the number of complaints that were open for significant amounts of time and around our responsiveness to complainants—to really hear the concerns of our patients and their carers in a compassionate way. So, we have worked hard to drive down our complaint waiting times, and we have done that with good success. Our response times have improved significantly. We have worked hard to hear the voices of our patients. So, we've tried to use technology to improve the way that patients can raise concerns with us. So, we've got an electronic complaint recording process now. We've also invested in a patient advice and liaison service, so that we have people out on the ground who can go and gather concerns in real time and support families to raise those in a way that they have perhaps not been able to do before.

We have tried to balance the voice of our patients by not necessarily having to raise a complaint, but by being able to give us feedback through other methods as well. So, we have introduced an electronic feedback system, which enables patients and carers to give us some really quick feedback, either electronically or through cards that we then convert to electronic recording. Eighty-seven per cent of the feedback that we get from patients is very positive, and a significant amount of it is around things that frustrate them. We know that a lot of it is about communication around treatment and access times. So, they are the things that we are working on as well to make better for our patients.

But in terms of the health board being really responsible in doing that, the investment that has been made is helping us to get better at it. But, we are also supporting our staff to hear those voices, so we're making sure that we can do—. We do things like 'feel-good Friday'. So, we make sure that comments go out to all of our staff, so that they are hearing the voices of patients. We do lots of reports out to ensure that they are doing that. We really offer now at the outset of anyone raising concerns, a face-to-face meeting, or at least a conversation over the phone. That's offered to everyone who raises a concern with the health board. We are really trying to proactively manage those so that we can help quickly. If it's an appointment issue, someone shouldn't have to raise a complaint because they are worried about an appointment. We should be able to deal with that in as much real time as possible—so, really, grading complaints and dealing with them in different ways.

On the very serious complaints that we get, which have reduced but we do get a number of, we try to manage those by giving them a real point of contact, so that they have got someone that they can ring and call and speak to about their concerns—but doing much more meetings with families as well around how we can work with them to resolve some of their concerns.   

That sounds very positive, but how is all that then communicated at board level, and how can you assure us that the board is sufficiently aware of the value of complaints, really, and the messages that they are giving in terms of managing performance?

The quality, safety and experience committee oversees the work around concerns and complaints management, and has really driven the agenda on that. We always open the meeting with a patient story, positive or negative. We try to spread across the breadth of our services to make sure that we get the voice of patients heard there. They receive reports at every meeting on our performance and on the level of granularity within them so that they can see that we are improving. We've invested in our teams across north Wales, so rather than have a silo working relationship with our teams, we have a north Wales approach now, which we introduced six months ago, so complaints, incidents and claims are managed on a north Wales approach and then we're spreading the learning, and that is all shared through the board, through the quality and safety executive committee, through their briefings up to board, but also we take regular reports to board as well.

10:35

Can I just make a comment on that? I did refer earlier on to the change in governance. The first thing to say is that governance arrangements are far more robust now. I've got a high level of confidence in terms of the chair of the quality and safety committee, and I'm very confident too that, if she felt that there was a concern about any aspect of QSE, she would report it to me. At the most recent board meeting we had the annual report on 'Putting Things Right', which was examined in some depth. We are just about to respond to the annual letter from the ombudsman, and it's not that long ago that I met with the ombudsman too. So, I'm entirely comfortable with the fact that the issues that need to be reported to board, particularly in that regard, are being reported.

Okay. Thank you. And what about staff? How are you supporting staff to raise any concerns that they've got?

We have a number of different ways that we do that. We have a system where staff can report anonymously concerns if they want to, through our safe haven work, but also, we are out and about in terms of our executive leadership functions to ensure that staff can express those concerns with them, and we treat them incredibly responsibly. So, if staff are raising concerns, the main thing is that we deal with them in real time and that we take time to listen to them and that we spread that throughout all of our leadership teams and groups, because they're as important as patient complaints, aren't they, and they help us to really understand. So, working with the unions and the staff side, as Gary's described, really helps to have very many different routes into us for raising concerns, but then our actions back to staff to make sure that they are being heard. And I've seen the narrative shift in the time that I've worked in Betsi, from staff expressing that they don't feel that people are listening to them to a very different approach.

Through the 'be proud' work—we want our staff to be proud to work in north Wales. That has been a challenge whilst we've been in special measures, and I don't think we do celebrate well enough some of the work that our staff do that is fantastic and we should be proud of. A lot of our groups of staff now, who are working through the 'be proud' work, have got things on their wards and in their departments that they're calling either 'wonder walls' or things like that that they write on—things that they're pleased about and things that we can improve. And when we attend our wards, which we do on a regular basis, we can focus on those to really talk with staff about their experiences of working with us and for us.

Amser i symud ymlaen nawr ac i droi at faterion yn ymwneud â gofal sylfaenol yn y lle cyntaf. Mae Jayne Bryant yn mynd i ofyn y cwestiynau—Jayne.

Time to move on now and turn to issues regarding primary care in the first instance. Jayne Bryant is going to ask those questions—Jayne. 

Thank you, Chair. Good morning. We've talked about some of the significant financial pressures and you answered those in relation to Angela's questions. The Wales Audit Office also found significant workforce challenges in primary care. What is the health board doing to address those significant workforce challenges?

I can start, to give Deborah a rest, but I'm sure she'll want to come in. I'd emphasise a really key difference now to where we were before in the health board, which is around—. When I arrived in the health board, I don't think we had a functioning set of clusters, which, I'm sure the committee will be aware, is effectively your groups of—. We divide the health board into three areas—east, centre and west—but we've got 14 GP clusters, and obviously, those are groups of GPs working together who know their patch, know their people, they know their partners and they know the local circumstance that they're dealing with, and obviously, some of those local circumstances can be quite different in north Wales depending which population and area you're looking at.

So, we didn't have GPs—and obviously, what you want is a GP to lead each cluster and then you want a programme of work that would say, 'How can we work differently? How can we work better? What good ideas have we got?' et cetera, and 'How can we bring in new models?' which I'll come to in a moment. Now, as I said, we didn't even have 14 lead GPs to lead those clusters, so by definition, they weren't functioning as they should. So, those clusters I think now are in a much better position in the sense that they tell us what to do in that regard and come up with ideas. And they're coming up with ideas in terms of where we can bring in new models that will be new workforce models. For example, we've got some really good examples both in Blaenau Ffestiniog and in Prestatyn and other areas where we've put in a new workforce model, new processes, new ways of working in primary care. That means you get different staff groups coming in, who I think are better able to meet the multidisciplinary patients' needs, but means that you can, potentially, not to a radical degree, but potentially means that you can run with a lower level of GPs than you previously had, particularly in areas where you can't get those GPs. But my genuine belief is that is the right model of care, and, obviously, that's the new model of primary care that all health boards are trying to bring in.

So, in terms of what we're trying to do about that staffing, there's increasing the number of people who train in north Wales; there is bringing in new models where we are less reliant upon GPs, but we're still able to properly, and, I believe, in a better way, meet patients' needs; there is listening to our clusters about what it is that would keep and retain GPs in north Wales and how we can work differently and better; there's bringing in new skills and academy training, and having some of our areas working on particular schemes—we have a leadership scheme where GPs lead with us on; and then one area that I just didn't mention earlier on, but bringing in completely new staff. So, some of our primary care audiologists—. Listening issues are a significant issue for our population, both in terms of the obvious point of them, but the isolation, mental health and other issues, and also the risks of people being injured, if you like, as a result of them. So, we're now the only health board in Wales where we've got primary care audiology developed to such an extent that that can take a real workload both off primary care, but also avoiding referrals into our—. Those people are highly trained, highly skilled, they've got top-notch equipment, and that's a new thing that we've brought in that other health boards are now trying to learn from. But I'm sure there are some other areas that Deborah might want to mention.

10:40

Before Deborah does, can I—? The first key appointment is the director of primary care, who is a GP, and is now in the executive team, supported by their former board secretary who, of course, understands the GP business, because he's a GP and is highly focused on leading our transformation programme around primary care, to which there are many different aspects. If he were here, he'd describe it—and Gary's touched upon some of those. That transformation programme, of course, needs to be aligned to the direction of the organisation. You'll know care closer to home is one of our priorities, another is health inequalities and prevention, and so part of that strategy refers to health and well-being centres. There are moves afoot to increase the number of those centres that exist across north Wales and which will assist to deliver the changes to the workforce model that we think are necessary to provide greater levels of sustainability in our communities.

At the same time, there are conversations going on with other partners. I met with the leader of Anglesey the other day, with the chief executive, where we spoke about providing primary and community services, particularly in the mental health context, but also more generally. So, we are keen to ensure, through the transformation funding that we've been successful in four bids for, and the further work we do with partners, that we approach the resilience of primary care and community services from a partnership perspective. That is writ large in the conversations we're having with partners.

Brilliant, thank you. How many practices are being directly managed by the health board at the moment?

There are 16 at the moment, with three about to transfer back into their own arrangements.

And what is the resource impact for the health board?

It's significant in terms of supporting and ensuring that they can provide the quality assurance that they need to do to function, and that's predominantly around a staffing resource to help them to move to where they need to be to put the quality checks in place. So, it is significant.

So, we've got 16, which will go down to 13 very shortly. That's a dynamic position, so, as I say, we've had those three practices come into the health board, and I think it's great that we're able to have them return back, because fundamentally, to me, it is about providing a service to patients. The way we do it—. There had been suggestions, I think, at one point, that the health board wants to manage practices, but I want to give a service to patients, however we are able to do that. We've got 105 practices, so most of our practices are not managed practices.

Whilst there is a level of input and expertise and resource that we then need to put into those practices, because, generally, the reason why we have practices return back to the health board is because they are struggling and there is an issue—so, generally, there is resource—one thing I would say is that, having worked with those practices in a much more direct sense than you would with a non-directly managed practice, we are trying to say, 'Are there things that we can do as a health board, then, for all practices in Wales where we've had experience of doing it in that one practice that we manage that will help them deliver just in a general sense?' But also the new general medical services contract that we've got will give GPs opportunities to work in different ways and get more resource into their practices. If we can provide some different services in from the health board to all our practices, because we've had that experience of running them, we can do that in a cost-effective, north-Wales-wide scale. That means that they can get more benefit from those resources coming in, get a good service, and they don't need to all run it themselves, then, in that regard. So, there's a kind of learning and development for us that, having run those practices, is a benefit, then, for all of the practices in north Wales.

So, I think there are those benefits that would come from it. Equally, Deborah has identified that there are resources and there are costs, and, clearly for us, as I say, the fact that we've got—. I don't know about other health boards, where they've had practices coming in and then going back out again, but I do think that is a very positive message.

10:45

Yes, I was just going to ask about evidence of how managed practices are meeting patient needs. There are some examples—the one you mentioned, in Blaenau Ffestiniog, is that related to that? Do you want to give us some examples?

So, those examples that I gave, and there's also the practice—I can remember the name of the GP, but I can't remember where it is—. So, there are a number of practices where what we have got is a more multidisciplinary team than perhaps has been traditional. Because, clearly, you will be conscious and very aware that, in each GP practice, there are GPs, obviously, there are usually practice nurses, but what you'll find in some of the examples I'm giving you is that we've gone beyond that—whether it be audiologists, therapists, specialist nurses, advanced nurse practitioners, use of third sector partners, and also navigators and trackers, which again are things that I think you'll have picked up. And there is a lot of evidence that suggests—. The thing I always think is that when you go into acute care, if, for example, you have respiratory issues and went into our respiratory service, the chances are quite a substantial chunk of your interaction would be via a respiratory specialist nurse. Obviously you would see the consultant and, if you were receiving treatment, you may see oncologists and other people, but that multidisciplinary team picking up the whole holistic, for want of a better term, with each member of the team having an expertise, but some of those navigators then joining up the whole picture for patients, I think is about that new model of primary care, and I think it's a real benefit for us. Clearly, fundamentally then that gives you some other workforce challenges, and there is always, then, the challenge of those—. What you need are good processes for those multiple professionals to have multidisciplinary conferences, which, of course, we have in the acute services, especially in cancer services. So, you need to join it up, because if you've now got six or seven people working with me rather than two, we need to join that up. But I think that is a better model of care and one that we're looking to roll out, and obviously also other health boards are, too. But I think we've probably got more experience than other health boards of actually doing it that we can use.

Just going to what Gary said a moment ago, I think the test case of bringing three back into practice is really important. The director of primary care and I met with the lead GP in the consortium the other day, because that is a test to demonstrate the board is prepared to be flexible, innovative and to support the return, and I would hope, if we get that right, that will signal opportunities to others.

Yes, because the key point is that they're not going back to the traditional approach, as to how it was before when we had the problems that led us to come back to the health board; it's a very different model.

The second thing is, and this is not me taking an opportunity to score a point, but IT is a key enabler, and we stand little chance of joining up the health system in they way that we should, particularly between primary and secondary care, unless we get it right. I think the announcement this week about NHS Wales Informatics Service and moving to something different is really, really important to service improvement, as I'm sure you'll recognise.

Just finally on this part of primary care, I think, Mr Polin, you've touched on it, really, but how do you feel the scrutiny at board level is on the performance of primary care?

Not sufficient, because there is an absence of lead indicators and measures. There is national work going on around that, and we wait with interest to see what comes of that particular piece of work being led at the centre by Welsh Government. So, if you were to look at our performance report, the measures that we've got around primary care are far fewer than we've got for acute care, for example. Where there is clear transparency around reporting—and the director of primary care is due to provide a presentation and report to the next board—is, 'Okay, describe to us how the transformation programme is moving forward, where are the deliverables in that programme, are they being delivered, what are the obstacles to improvement,' and so on and so forth. So, there is a focus about how we move forward, but the measures at the moment is an area that is lacking. We've looked at it ourselves, but we are now also waiting to see what happens from a Welsh Government perspective. 

10:50

Okay. There's a need for some agility now, because time is pressing. Jayne here is our resident expert on agility, so no pressure. 

No pressure on this one. [Laughter.] 

On elective care, in your written response to us you said that elective access waiting times are still far too long. What are the barriers to improving waiting times for elective care?

Shall I pick that one up? Yes, they are way too long, not in every specialty, but in particular in key services like orthopaedics, ophthalmology, urology. Those are some of the key areas where we've got a struggle. So, in terms of why, or what can we do to address those, I think there are a whole range of steps that can be taken that, in particular, are around that patient pathway. If you take that for elective care, and if we take orthopaedics as an example, I think there's a good deal of work that we can do around how people can be supported to be fit and active. So, get north Wales moving; how people can be encouraged. As I said earlier on, we can tie that in, then, to some of our, for example, mental health issues, where that exercise and getting outdoors, particularly into the great outdoors of north Wales, is a real opportunity for us. So, whether it's healthy eating, whether it's working with schools, there's a big package of work there to keep people well, which obviously is important to us.

Then, when you need orthopaedic treatment or when you have an issue with musculoskeletal pain, what we need to get into, then, is whether there are alternatives to surgery, because in some of those instances those alternatives are very, very good. We've got some good services there, but, this year, we're looking to build on them. So we're expanding our clinical musculoskeletal assessment and treatment service, which is more of a therapy approach to musculoskeletal pain than a surgical intervention approach. So, that's part of our plan as well.

The other part of our plan, then, is—. There will be people who need surgery, no matter how good you are at those other things. So, what we've done is we've taken and published, and started with, a business case to the board that laid out the whole of that pathway and what we needed to do on each step along it. We need more surgery, we need more surgeons, we need to just do more activity, because even though there are those opportunities, that's not going to solve the problem. So, we have a case that we've agreed to recruit six extra orthopaedic surgeons. What we are looking at within that, though, is getting more efficient and effective about the way we use what we've got—so, bringing down the number of areas where we provide it, getting better economies of scale.

In a number of areas, we are leading the way in Wales in terms of innovation in orthopaedics, in terms of day-case knee operations, but getting better at using what we've got is part of that, but then we need some more. So, we're out to recruit for six orthopaedic surgeons and we've had a couple of bites at that cherry. We've recruited some, but we've not recruited them all yet. We've got some more interviews coming. We've got 50 applicants for this next round, actually, so that's then part of that. So, our package of activity, then, this year, for orthopaedics, also includes commissioning additional activities from other providers—so, the Countess of Chester Hospital and Gobowen. So, that doing more is then part of our package, and also doing some additional lists with our own staff—doing some extras, if you like, as overtime, for want of a better term. 

Yes. On to unscheduled care, your paper actually states that focused action through an unscheduled care improvement group is ensuring a whole-system approach to improving services. What do you expect to see and to what timescales? What improvements?

We have improvement trajectories within the organisation that we are monitoring very tightly. We expect to see, and have seen, improvements across the whole of the pathway. Across the main targets that we talk about, the four and the 12-hour, we expect to see improvements against both of those, and we are. We're in a much better place than we were this time last year. In terms of our ambulance handover times, we are doing incredibly well with some of those and have reduced the number of patients who are delayed. We saw some real challenges in our ambulance handovers, which presented a real problem for our community. That has been mitigated by a really robust response to making sure that we can release ambulances in a timely manner, and we're performing incredibly well on that. 

Okay. Do you have a robust plan—we're coming into winter now—for winter preparedness for this year, and what are the pressure points likely to be?

I think many of us would probably say we'd had a winter in our summer, because winter doesn't feel like it ever went away, but we've had our winter planning going on throughout the whole of summer. We're absolutely ready for winter, with some key things that we're going to be doing differently, and those have started to come in. We've opened our new A&E department in Bangor. We've opened new services in our centre in Ysbyty Glan Clwyd, so our same-day emergency care has gone live and is really working well to produce some good results. And we're just getting ready to open our new acute care model within Wrexham, which we anticipate will see some significant improvements and help us to really manage winter in a much better way. 

10:55

That's 4 November that will go live. 

Right, okay. Thank you. Just moving on to cross-border issues, we know that earlier this year there were some difficulties there. Can you assure us that patients will have timely access to secondary and specialist care services across the border, when appropriate? 

I can assure you that our relationships with those organisations are good. Our administrative, managerial and clinical leadership links with those organisations are good and, indeed, developing, and we see new things happening every year. As I just mentioned, part of our orthopaedic plan this year is sending additional cases to Chester. Clearly, within that, there are elements of financial flows that are, quite rightly, nationally determined across the two countries that are obviously setting situations that I will work within.

So, my view is that where—. We've ended up with resolution to those issues this year, as you'll be aware, so that's obviously a situation that, to some extent, is not one that I'm immediately party to. But the assurance that I can give you is that our links, our working, our opportunities to work in partnership, are very, very strong—as strong as they've ever been—and will stay that way. 

There was a hiccup earlier this year with the Countess of Chester Hospital. I presume everybody's kissed and made up now, have they? 

Well, we were kissing before it and we were kissing during it. So, both publicly and privately, the chief executive at the Countess of Chester has been clear that her relationship with us is good and my relationship with her is good and, more importantly perhaps than that, our teams and the clinicians that work together are good. That did, however, come to a position that I certainly would not have wanted it to, and I wouldn't want to be back there. And, obviously, in that national work, I will certainly do what I can do to make sure that we don't end up back there, and I would like to think that that won't happen again.  

Just on that point, Chair, as chair, and a new chair coming in at that point, I'm absolutely convinced the organisation was doing all it could to resolve the difficulty with the Countess, but it went beyond the control of the board. 

Okay. Angela's got one final question in the three minutes that remain. 

Yes. I just wondered, actually, if you could perhaps give us an update by paper, probably, after this, on the endoscopy waiting times and the endoscopy service. The reason why I ask that is because there's been a lot of discussion today about the emphasis put on recruitment and training of staff, and yet I hear from people on the ground in Betsi that the endoscopy service was allowed to fall apart. Those were the words that a number of people have used to me, in that there were three endoscopists or gastroenterologists, one retired, one moved away into England, that left one, and that the planning wasn't put into place quickly enough to stop that from happening—not to stop it, because obviously people are going to move—but to start replacing. So, it's sort of like an after the event. So, I just wondered, from your perspective, if you've done any work on it or if you would just have a look at it, and perhaps reassure us that, this workforce planning, some of the low-level detail is actually filtering up to you guys in enough quantity, because I appreciate you can't possibly have tabs on absolutely everything throughout the board. But what I am worried about is that stuff like that happens on the ground level, and it just simply doesn't filter through to you until there's a problem. 

We can get back in writing on that, both in terms of reflections on, if you like, how the problem arose—there were workforce issues on it; there were estates issues. You'll know the roof fell in and we had some delays in terms of various estates things. So, there were two things that came together—workforce reduction, building reduction. But, if we come back to you with what reflections we might have on what could or couldn't have been done, and also where we are now in terms of the plan we've put in place to put it right—. 

Grêt. Diolch yn fawr. Rydyn ni allan o amser. Mae pethau wedi eu hamseru yn berffaith. Diolch yn fawr i chi am eich presenoldeb. Diolch yn fawr hefyd am yr adroddiad y gwnaethoch chi ei gyflwyno yn ysgrifenedig ymlaen llaw. Gallaf i gadarnhau y byddwch chi yn derbyn trawsgrifiad o'r trafodaethau yma er mwyn i chi allu gwirio eu bod nhw'n ffeithiol gywir, ond, gyda hynny, diolch yn fawr iawn i chi. Ac i'm cyd-Aelodau, fe wnawn ni dorri am egwyl o bum munud nawr cyn y tystion nesaf. Diolch yn fawr.    

Great. Thank you very much. We're out of time. Things have been timed perfectly. Thank you very much for attending. Thank you as well for the report that you submitted in written form beforehand. I'll confirm that you will receive a transcript of these proceedings so that you can check it for factual accuracy, but, with those few words, thank you very much. To my fellow Members, we will have a five-minute break now before the next witnesses. Thank you. 

Gohiriwyd y cyfarfod rhwng 10:59 a 11:09.

The meeting adjourned between 10:59 and 11:09.

11:05
3. Darparu gofal iechyd a gofal cymdeithasol ar yr ystâd carchardai i oedolion: Sesiwn dystiolaeth gydag Arolygiaeth Gofal Iechyd Cymru, Arolygiaeth Carchardai Ei Mawrhydi ac Arolygiaeth Gofal Cymru
3. Provision of health and social care in the adult prison estate: Evidence session with Healthcare Inspectorate Wales, Her Majesty's Inspectorate of Prisons and Care Inspectorate Wales

Croeso yn ôl i bawb wedi'r toriad. Rydyn ni wedi cyrraedd eitem 3 nawr ar agenda'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd. Eitem 3 ydy ein hymchwiliad ni i ddarparu gofal iechyd a gofal cymdeithasol ar yr ystâd carchardai i oedolion. Mi fydd Aelodau'n cofio, wrth gwrs, ein bod ni wedi bod ar ymweliadau swyddogol yng ngharchar Berwyn ac yng ngharchar Caerdydd ac yng ngharchar Parc ar wahanol ddyddiau dros y tri mis diwethaf, yn astudio sut mae'r ddarpariaeth gofal iechyd a gofal cymdeithasol yn digwydd yn y carchardai hynny. Felly, yn dilyn o hynny, fel rhan o'r parhad i'n hymchwiliad, dyma'r sesiwn dystiolaeth gyntaf ar yr ymchwiliad yma i ddarparu gofal iechyd a gofal cymdeithasol ar yr ystâd carchardai i oedolion yma yng Nghymru.

Felly, i'r perwyl yma, dwi'n falch iawn o groesawu Rhys Jones, pennaeth uwch gyfeirio a gorfodi Arolygiaeth Gofal Iechyd Cymru, Tania Osborne, pennaeth arolygu iechyd a gofal cymdeithasol, Arolygiaeth Carchardai ei Mawrhydi, a hefyd Gillian Baranski, prif arolygydd, Arolygiaeth Gofal Cymru. Croeso i chi'ch tri. Diolch yn fawr iawn i chi am eich tystiolaeth ysgrifenedig rydyn ni wedi ei derbyn ymlaen llaw. Yn seiliedig ar honno, mae gyda ni gyfres o gwestiynau eithaf hawdd i'w hateb, buaswn i'n meddwl, ac wedyn gwnawn ni fwrw yn syth ymlaen. Does dim rhaid i chi gyffwrdd â'r meicroffonau o gwbl. Mae popeth yn digwydd yn awtomatig tu ôl i'r llenni. Felly, gwnawn ni ddechrau i ffwrdd efo cwestiynau gan Lynne Neagle. 

Welcome back, everyone, following the break. We've reached item 3 now on the agenda for the Health, Social Care and Sport Committee here at the Senedd. Item 3 is our inquiry into the provision of health and social care in the adult prison estate. Members will remember, of course, that we've been on official visits to Berwyn prison and Cardiff prison and also to Parc prison on different days over the past three months, studying the ways in which the health and social care provision is delivered in those prisons. So, following on from that, as part of the continuation of our inquiry, this is the first evidence session on this inquiry into the provision of the health and social care in the adult prison estate here in Wales. 

So, to that end, I'm very happy to welcome Rhys Jones, who is the head of escalation and enforcement, Health Inspectorate Wales, Tania Osborne, who is the head of health and social care inspection, Her Majesty’s Inspectorate of Prisons, and also Gillian Baranski, who is the chief inspector at Care Inspectorate Wales. Welcome to all three of you. Thank you very much for your written evidence beforehand, which we've received. Based on that, we have a series of questions that are quite easy to answer, I'd assume, and then we'll go straight into the questions. You don't need to touch the microphones at all. Everything happens automatically behind the scenes. So, we'll begin, therefore, with questions from Lynne Neagle. 

11:10

Thank you, Chair. Good morning. The Welsh Government’s stated intention is that prisoners should receive the same level of healthcare as the general population. Is that happening in our prisons in Wales?

Shall I start?

Crack on. By the way, not all three of you have got to answer all questions, by the way. We won't put you on the spot. 

So, Her Majesty's inspectorate, of course, have visited all the prisons over the last two to three years. We think that, in general, the health provision is of a reasonable standard, except for some areas. So, if we were to try and summarise that briefly for you, I think we would say that there are some gaps. So, we would say that some of the more evident gaps are in the provision of mental health services. We would say we feel that there are some gaps around substance misuse services, and part of that would be in relation to the oversight as well, in relation to some of the monitoring of that. So, we would say that for those deficits to have been ongoing there must be some lack of oversight of those. But, generally, we would say that there are lots of people doing a lot of good work in prisons. There are lots of very committed clinical staff working in prisons these days, and there's a general improvement in how things are looking across the piste, I would say, in relation generally to health services in prisons. 

So, who should be doing the oversight in your opinion? Where is this missing lack of oversight? Who's responsible for that? 

So, there are several layers of oversight in relation to each of the prison provisions. So, we, as the inspectorate, would like to see a service that is basically based on a prisoner's needs, and those needs are very different in each site. So, we would expect some kind of evaluation of that and that comes from—. I think, in Wales, the health boards are committed to doing that. So, that needs to be robust. To be able to do that, though, you need a good ongoing evaluation of what's going on in prison health. So, you would expect data collection, you'd expect contracts reviews, you would expect some kind of oversight. So, that's the higher level oversight and that sits at the health board. And, then, locally, you would expect a service provider to have governance in place—so, things like medicines management monitoring, you'd expect incidents to be reviewed, deaths in custody to be reviewed, and you'd also expect robust systems so people could complain if they're not happy with the services. So, there's a lower level of oversight and governance of what's happening on the ground. Does that answer the question?

Okay. Well, I think we'll probably unpick it as we go through. So, collaboration then is particularly important in the delivery of prison healthcare. How effective are health boards, local authorities and health providers in planning, commissioning and delivering prison healthcare services in Wales?

11:15

Okay. So, I think I touched on it, slightly, in the last answer. There are partnership board meetings, so we see that the right people are getting together. So, we’d expect governors, we’d expect health boards, and we’d expect providers to be taking into account what they’ve been delivering. And I think that is happening across the Welsh prisons. I think there are some gaps. Nothing is perfect, and, again, you'd have to challenge how robust that is when there are continuing, ongoing concerns. Say, for example, even though they might be acknowledging problems with gaps in mental health or the way that the services are provided, what’s being done about that in relation to collaborative working? And there are other issues in relation to being able to deliver a service. So, for example, if there’s not enough space and there are not enough officers to be able to get prisoners to healthcare, what is being done about that? So, I think that’s what we would—. So, I think the right people are meeting, but maybe not all of the critical issues are being drilled into and progress made in some areas.

Okay. So, Care Inspectorate Wales, Estyn and Healthcare Inspectorate Wales have a memorandum of understanding in place to contribute to prison inspections in Wales. How effectively is that working?

So, yes, we've got a memorandum of understanding with HMIP, and I think that underpins the relationship that we have with them, and I think HMIP is the body that has the statutory responsibility to undertake the inspections and has the expertise to do that. I think we very much feel that, from our perspective, their work is effective and we’re happy with the work they do and how often the programme of inspections are, and I think we play a part in that. I think we share information with HMIP that might arise from our own work on death in custody, for instance. And we also attend inspections to be part of the inspections as well. So, I think we’re broadly content with how things are going in terms of our relationships, in terms of the effectiveness of the process. I think, as with most things, there are probably areas we’d like to strengthen, and we’ve had those conversations, in terms of how we’re working together either jointly or as the three bodies. But, broadly speaking, we feel that they’re working effectively at the moment, yes.

And the responsibilities for local authorities are relatively new—they came in in the 2014 Act and came into force in 2016. And I think it’s fair to say that the local authorities seem to have embraced this new work. We’ve been working closely with HIW and colleagues in HMIP. We regard HMIP as the lead in this, and we co-operate and support inspections when asked. So, we’re involved in the thematic review. I think, like Rhys has said, there are always areas for improvement, and I think we have a clear way forward as to how we can develop these relationships even further.

Okay. Thank you. And if I can ask HIW, then, about the written evidence where you've highlighted a number of concerns relating to the provision of health and social care services at HMP Swansea, in what circumstances would HIW consider conducting your own investigations of prison healthcare separate to the ones undertaken by the prison service?

So, these were issues that had arisen at the inspection that HMIP led and which we were at as well. In terms of the specifics of the Swansea case, as I said, we were at that inspection, so we know about the issues, and I think, as with, I guess, most inspection regimes, when you find things that need improvement, you'd need to allow that service to make the necessary changes and allow them time to make those changes. So, whilst we haven’t done anything specifically separate since then, I think what we do is take assurance from the next HMIP visit, whenever that may be, as to what differences have been made in terms of the issues that have been found—whether the issues have been addressed, recommendations have been addressed, for instance.

I think there’s probably a broader point around whether we should be doing something separate ourselves, and I think, again, that would need to be a considered decision on our part, because, as I've said, I think the requisite expertise sits with HMIP in terms of the prison inspections. Doing a prison inspection is a very different environment to a hospital inspection, for instance. So, I think we take a lot of assurance from them and the expertise that they have, and I think that has worked well. Whether we do some separate—. There is always the possibility, as with any issue that arises, that we might want to explore further ourselves. That hasn't happened to date, but, again, I think that possibility is always on the horizon, potentially.

11:20

Okay, thank you. So, the Welsh Government's prison health delivery plan focuses on four key priorities, but it also says,

'We want to maximise the opportunity we have while an individual is in prison to return them to the community with an improved health status'.

To what extent is that happening, because, for example, when we visited Cardiff prison, we heard about prisoners being maintained on methadone rather than taken off it completely because there was a calculation made that they would just relapse as soon as they went into the community? To what extent are we actually genuinely trying to improve people's health while they're in prison?

I think it's definitely a priority for the health providers, delivering care in prisons. I think, in the individual case you spoke about, actually, there are some very clear clinical reasons why somebody may need to be maintained and it may be, actually, quite a positive. For some people, that might be a positive health improvement. So, they might have been on the street on heroin and have a very short sentence and may need to be maintained until they're released because, actually, the realistic opportunities of withdrawing somebody is not just physical; obviously, it's the psychological work that would be required to remove somebody from opiate use would be quite significant, particularly if they've been on it all their life. So, I can't really judge on that particular case, but, yes, there's definitely an ambition. We're talking about people whose health requirements are mostly greater. They come from areas where they've not been accessing healthcare, maybe. So, I think, not to have that ambition would be a shame. I think, as an inspectorate, we want to basically meet need. We want to see people meeting their needs. And those needs might be greater, or they might be less, depending—. Not everybody has great need.

So, maybe I could give you an example. If somebody comes into prison and they have a dental need, the chances are that there's an opportunity there for them to have their dental needs met, actually, while they're in prison and go out with much better dental health. So, there's definitely, even if it's not—. Each little improvement is a benefit also for the community because, actually, those people would be accessing community health services because their health had deteriorated because they hadn't accessed the services. So, there's definitely an ambition for that and an opportunity.

And one of the things that we heard when we were visiting was that there can be difficulties accessing health records of prisoners from Wales. What's your comment on any difficulties that there are in transferring records from NHS Wales to the prison service, and how do we resolve those problems?

Okay. As an inspectorate, we definitely see that being a challenge. I mean, I'm not sure how difficult that is in the community, but, basically, when people come into the prison system—. What's good about the prison health clinical information system is that it's all connected. There's a bespoke clinical information system for prisoners. So, if they transfer in and out of different prisons, their medical records are sustained and transferred electronically. So, that's very good. Across Wales—and I think that this isn't just a problem within Wales—there's historically been a problem with people coming in and they may have never accessed health services or we don't know where they've accessed health services. So, there's definitely a requirement to go out and search for that information, particularly if it's about maintaining somebody's care or assuring what care they were previously having. So, it's definitely a problem. It's definitely a risk. At the moment, it's reliant on people going out and finding those records.

In relation to a solution, I think that's something that needs to be looked at. I think there are other areas outside Wales where there's a plan in place in relation to joining to the spine. So, it's possible, and that's a good thing. With the use of NHS numbers for prisoners, there's a possibility to connect. There is an opportunity to connect, but how that's done and how that's planned would be a decision outside, obviously, the prison capacity. As inspectors, we would be pleased to see that connectivity because it would improve patient outcomes.

11:25

Okay. In your answer to me in my opening question, you referred to mental health as being one of the problem areas where you felt things needed to improve. In what way, specifically, would you like to see mental health provision improved in prisons?

We look at outcomes. We don't look at what the model necessarily looks like or who's providing or how—well, we do, in some ways, if the outcomes are affected—but we want to see people's needs being met. So, when we see a deficit—. For example, I think there's a couple of examples in our evidence where we say that the higher level mental health is being met. In quite a lot of the prisons, a lot of the higher level is being met, but the lower level mental health is not being met. And we all know if you input health downstream, or upstream—sorry, I might get that wrong; whichever way, yes, upstream—it's much, much better, in relation to resourcing. And so, if you get somebody before they become depressed or before they become clinically psychotic, you're in a better place. So, I think we see some deficits there.

How that's resolved, it's not just a case of—. I think it's about reviewing what the needs are—really drilling down. Because, quite often in prisons, the resources aren't being used as they could be. So, it looks like there's not a good enough resource, but there are so many other, what we call, prison pressures that affect the delivery and the efficacy of the staff who are working in that environment. So, a very clear example is, if you give somebody an appointment and they don't come, they have to then go back on the waiting list, so your waiting lists look long. But actually it might not be a resource issue; it might just be an access issue. So, in relation to resolving it, I think it needs to be reviewed in relation to what's the need, what's there, how that's being used, and whether there are other things that can be done to improve that.

Okay. This committee has taken a very keen interest in suicide prevention, and we know that prisoners are a higher risk group for suicides. How concerned are you at the levels of suicide and self-harm in prisons in Wales?

In terms of suicides, we do death in custody reviews. The numbers have been actually, I'd say, on a downward trajectory over the last four of five years in terms of actual numbers. We, clearly, only get to look at the suicides that have actually taken place, not necessarily all the self-harm events that may not have resulted in a suicide. I think, from our death in custody work, yes, we'd support what Tania said about concerns around mental health. That has been a theme that has emerged in terms of the adequacy of support, the quality of the risk assessments, and the documentation relating to those individuals. That has emerged as a theme, so I guess our findings, to a large extent, mirror the wider findings when the inspections take place. But, however, albeit the numbers aren't high in the first place in terms of a statistical basis, I guess, the numbers are actually slightly on a downwards trend, which is clearly encouraging. But I think there are still issues over mental health, yes.

And what about self-harm, then? Who is actually monitoring the levels of self-harm? Because we know that self-harm is a suicide risk in itself and that increases the older the person who is actually involved in self-harming. So, who is actually responsible for monitoring that?

As an inspectorate, we find self-harm is increasing. There may be many reasons for that, and that's why the burden is shared, actually, in relation to making sure that it's not just a health responsibility. Historically, many years ago, it was, but now there's a recognition that, actually, day-to-day living, those relationships are very important for trying to reduce risks of self-harm and knowing the people who live in prisons, understanding who they are. And I think we've seen—we've got some examples—that, yes, basically, in Swansea, self-harm has increased threefold since our previous inspection. Some things are just transient, but we actually are seeing that increasing, and it's a whole-prison responsibility. So, as much as health input into that process, there's a responsibility for officers to understand it, for them to manage them, to put plans in place—so, for example, if they need to ring their family, or they need to get to the gym more. But those things are—you know, they're out of the control of health, but in the control of—. It's a multidisciplinary care package. And we also find that those are in place but they're not necessarily as effective as they could be. So, we, obviously, in our reports, write that there are some concerns around the quality of the very clear guidance on how we manage people who are at risk, or they manage people who are at risk.

11:30

So, you feel that the guidance isn't being followed in all instances.

So, yes. I agree, yes, that the guidance isn't being followed in all instances.

Okay, thank you. Can I just ask about transfers from prison to hospital under the mental health Act, which, we understand, should take no more than 14 days? But, in your written evidence, you say that inspections have found instances where prisoners did face unacceptable delays. What should we do to stop that being the case, given their acute vulnerability, really?

Obviously, we definitely don't think it's a good place to keep people who are acutely unwell. The simple answer would be, 'We should have lots of beds to put people in', but, actually, that's not the reality, and, actually, having empty beds that cost money isn't really a good idea either, for this public money, ultimately. But I think there's—. I think there's some prioritisation in relation to making sure that the assessments are done quicker. And some of this is obviously not the responsibility of people who are delivering health in prisons; it's the wider provision. And I believe that there's a review of the mental health—. There's been some consultation going on recently around that and looking at whether they should extend the wait, in some ways, and prioritise the people within that who are waiting. So, people who are acutely psychotic may need to get a bed quicker than those who maybe need a personality disorder bed who are not a risk to themselves. That's not for us, as an inspectorate, to make that decision. What we would like to see is people being in the right place when they're not well and not being held, for example, in segregation units, where, basically, it's not therapeutic or clinically—. And they deteriorate as well, which is really not good for us to see. So, I don't have the answer for that question, but—.

Diolch, Lynne. Does yna ddim dwywaith bod yna heriau aruthrol, achos y dystiolaeth roedden ni'n ei chael wrth fynd rownd oedd bod cyfraddau o garcharorion a oedd yn dioddef efo heriau iechyd meddwl—roedd y niferoedd yn enfawr, a dweud y gwir, a dyna ydy'r her, rwy'n credu, sut dŷn ni'n delio â'r don enfawr yna o heriau. Bydd fy nghyd Aelodau'n gwybod, rhyw 37 mlynedd yn ôl, roeddwn i'n gwneud seiciatreg fel meddyg ifanc ym Mhen-y-bont, ac yn y dyddiau hynny, roedd tair ysbyty meddwl ar agor ym Mhen-y-bont—Glanrhyd, Penyfai ac Ysbyty'r Parc. Ac, wrth gwrs, ar safle Ysbyty’r Parc nawr ydy'r carchar preifat Parc, a buasai rhai ohonom ni'n dadlau bod yr un un bobl oedd yn arfer bod yn ein hysbyty meddwl ni nawr yn y carchar ar yr un un safle, ond fuaswn i ddim yn disgwyl i chi ymateb i hynna. Troi, rŵan, at driniaethau camddefnyddio sylweddau ac mae Jayne Bryant yn mynd i arwain ar hyn.

Thank you, Lynne. There's no doubt that there are great challenges, because the evidence we received as we went round was that the rates of prisoners who were suffering with mental health challenges—those numbers were very great in reality, and that's the challenge, I think, how we deal with that wave of challenges. My fellow Members will know that, about 37 years ago, I did psychiatry as a young doctor in Bridgend, and, in those days, there were three mental health hospitals open—Glanrhyd, Penyfai and the Parc Hospital. And, the site of that hospital currently is the private prison, Parc, site, and some would argue that the same people who were in our mental health hospital are now in the prison on the same site, but I wouldn't expect you to respond to that. Turning now to treatments for the misuse of substances, and Jayne Bryant is leading on this.

Thank you, Chair. Good morning. In your first answer to one of the questions, you identified gaps in substance misuse services. Could you identify what those gaps are?

I can't be site-specific unless I refer to my notes, but, ultimately, I think we saw on at least two or three sites where we were concerned about some of the overnight monitoring for people who might be withdrawing from drugs from the streets, particularly alcohol. So, we would expect people to be monitored to make sure—. There's quite a risk with alcohol withdrawal; there is a risk of a quite severe reaction. So, we saw some of that not happening, which, obviously, to us was one of the most critical concerns. We felt that there were some gaps in relation to people's withdrawal monitoring and treatment, particularly when we associate that with the number of people around the drug strategy, which isn't necessarily based around health, but drug strategy, supply reduction and the amount of people who say that it's easy to get drugs.

Generally, people who feel that they're withdrawing and not having a substitute will seek out other illicit substances. So, we saw that—in fact, in some places, it was agreed by the prison that that's what was happening in relation to violence, debt, and it was drug-seeking behaviour. And it's difficult not to link that. I can't say that that's exactly what was happening, but, in relation to health, we definitely saw some things that, for outcomes for patients, we would prefer to see in a better position.

11:35

Okay, thank you. During our visits to prisons, we noticed that there was a different approach in England and Wales to drug treatments, and some of the prisoners were telling us how that was a real problem, especially those being transferred from England to Wales, and also around the delays of getting drug treatments. Do you have any comments on that?

For us, as an inspectorate, we like to see continuity of care. That's something we definitely—so, if clinicians have made a decision around somebody's care, we would like to see that being transferred, because, obviously, it's distressing to have another full assessment and then the treatment plan is changed.

In relation to policy, I think we're less inclined to review the detail of the policy unless it's impacting on patient outcomes. So, there are lots of different policies floating around in relation to lots of health issues from prison to prison, but, actually, it's about how that's managed, and so we don't necessarily go, 'This is happening because this is a different policy,' we just see that patients are not perhaps—or, you know, are distressed. I suppose, for us, what's important is the outcome of what's happened rather than whose policies say what. We would expect—. There is a national policy—as in national, agreed by England and Welsh Governments. There is a national drug treatment guidance—not policy, guidance. But, again, sometimes it's about the application of that, and for us it's more about what's happening locally and what is happening to patients. Does that answer your question?

Yes. Yes, that does, thank you. Another issue that came up, particularly in one prison, was around prisoners who had taken spice. I think there was a problem for a while, and then that dropped off, and I think there'd been a dramatic increase in ambulances being called out. Have you raised—? To what extent has the inspectorate raised concerns around the use of psychoactive substances, whether that's spice or anything else?

So, we definitely look for it when we're inspecting, particularly in relation to what's being—. There are two aspects to it. So, the non-health side—we work collaboratively with the inspectorate, who look at drug strategies via reduction, what's the intelligence, how is that—. We look at whether they're helping the health service in some ways by reducing the supply of drugs coming through the door or through the drone or whatever inventive mechanism they get to bring it in. We also look at the amount it's impacting on health services, so, if there's a lot of new psychoactive substances and it's a bad batch, for example, which—. When I say 'bad batch', there's not a good batch, but as in it's much more damaging, so you might get people unconscious and being very unwell. That's got an impact on the emergency response of healthcare services, who then have to leave other clinical delivery, so we definitely comment on that and we would make recommendations around how that needs to be more of a collaborative approach if it doesn't feel like there is, and we definitely recognise that it can impact other things within health.

Okay, thank you. Just about medicines management, Welsh Government identified medicines management as one of its four priorities in the prison health delivery plan. In your written evidence, you've stated that it's improving in prisons across Wales. Are there specific deficiencies in medicines management that should be focused on?

I think medicines management is quite a high-risk area of health delivery, particularly in prisons. Just getting medicines right is a challenge in itself, I'm sure, not that I've been involved in it particularly. But I think when you then put that in the environment of a secure environment where it's a tradable commodity, it becomes very, very complicated. So, in relation to outcomes for patients, I think we would expect there to be good access to medicine. So, if you or I went out and got our prescription, we would be able to go to a pharmacy and be able to get that prescription reasonably easily. I have seen—you know, sometimes it's not in stock, and you have to go to many pharmacies and wait several days, but we expect something very similar in the prison environment. So, access is really important, and then the right drug to the right person at the right time is really important, and that's impacted by the regime, by whether somebody can get to you, whether they've been supplied with an identification badge; there are all sorts of complications.

So, in relation to outcomes, we expect the medicines management process to be robust, so oversight by pharmacy. There are lots of things we want to see because it's such a high-risk area of health. And also reviews—individual reviews of care. Is your blood pressure tablet working? Are people being reviewed after they've been given antidepressants for, you know, three months? This is quite a wide area as well, and it impacts on primary, mental health and all of the areas of health and social care that we look at. So, yes, we know it's a high risk area. We expect it to be as good as access in the community. In particular, there's always—in relation to Wales and what we're seeing, I think one of the themes we've seen across some of the prisons is access to pain relief medicines. So, for example, if you had a toothache in the middle of the night, that can be quite significant, and I think in some places the access to an appropriate pain-relieving tablet is quite a challenge for some places, which has an impact then in relation to that person may then deciding to break their cell because they're in pain, and then they get into trouble. So, there are all sorts of impacts of not getting what you need at the right time.

11:40

Okay, thank you. And, just moving on to the social care needs of prisoners, Care Inspectorate Wales had identified in written evidence that the demand for social care and support provision across the Welsh adult prison estate is low, and we know that there's an ageing prison population. Do you think there are sufficient steps being taken to meet this?

I think, bearing in mind how relatively new this is a responsibility for local authorities, it's encouraging that each of the five local authorities with a prison in their area has a memorandum of understanding between itself, the prison and providers. Each of the five local authorities has appointed a designated social care lead and interestingly we've just completed a series of thematic inspections in partnership with HIW looking at promoting independence and preventing escalation of needs. In one of the local authorities we went to, which was Monmouthshire, one of the standard questions is, 'Tell us something you're particularly proud of', and they referred to the work that was going on in the prison. So, we went into the prison and ran a focus group with prisoners and with the social work staff working there, and I think what was particularly encouraging for us—I know this is something that's been identified in the thematic about work that HMIP led on as good practice—is the outcomes for individuals who are part of that scheme were very positive, and also the work that the social work team was doing in connection with promoting inclusion for some of the older patients they work with. So, some good work has begun, and clearly it's about sharing that good work and ensuring that each of the prisons has similar ambitions in terms of the work it does for social care as well as healthcare.

Okay, thank you. HMIP has consistently recommended that a national strategy for older prisoners is needed. Were you disappointed that it was not in the newly developed health delivery plan?

I think in our reference to the strategy, I think we were looking—I think our recommendation went to the Secretary of State, I believe—for a more strategic, overarching view of older prisoners and how they're managed across the estate generally, and that includes health, but generally there are a lot of aspects of what is happening in prisons with older people. We have seen an upward trajectory, although we know that can be transient and it can go up and down. However, we're still aware that there's a significant percentage of older people in prisons. And it was less about local management of older people, because I think there is some good practice going on in lots of places. I think it's about—. We can't come up with the solution as to what that strategy should look like as HMIP, but we definitely feel that there should be something around where they're being held, how they're being—just getting a better understanding of what's happening with older people and where they are in the prison system and how that's—. There should be a strategy. I could come up with some ideas, but actually it's for a higher-level strategy to be developed. So, in answer to the question, I'm not necessarily disappointed, no; it is a wider issue, I think. 

11:45

Well, actually, it was about the demand for social care and support across the adult prison estate being low. You talked about local authorities having a lead and that you were really impressed by the fact that each local authority had appointed a social work lead to look at this issue, but can you just tell me where's the crossover, once somebody starts to transition out of prison? Where's the responsibility for the provision of any social care that that individual might need? I'm not quite clear on that demarcation line. 

I suspect a lot would depend where the person is transitioning to. So, if you think, many people in our Welsh prisons will be returning home into England, and so I think HMIP may be able to answer how that transition works. Within Wales, if they transition into a local authority within Wales, then clearly the local authority that they then live in becomes responsible for assessments and provision and support, providing, of course, the local authority is aware of those needs. 

So, have you looked at that area to see if that transition arrangement within Wales works and that the local authorities do pick up prisoners as they come out? Because a lot of them will have social needs, even if they're not—. I notice that some of the prisons say they have very low demand or no demand, but as soon as they come out, there's going to be a pressure on them, isn't there?

Yes. And I think that's what's been particularly interesting for us in the work around the thematic—. It has identified ongoing work in terms of our review work with local authorities, because our remit is that we engage with local authorities about improvements they're doing around social care and their statutory functions. And clearly now this is one of their statutory functions, in our follow-up quarterly review meetings that we have with local authorities, this is beginning to become a theme of discussion as to, if there are gaps, what, if anything, can be done to ensure that information that's held in the prison gets passed with them, because, as we all know, transition is one of the most difficult times for individuals. 

Thank you. I just want to move on to talk about the prison environment. We've seen the challenges with older prisons and the buildings and that sort of environment. What would you think the main health risks are from the prison environment?

One of the benefits of being within HMIP is that we can look across, and not just look at health. So it is quite helpful in the fact that we look at the bigger picture. So, in relation to the environment, there are lots of things—what we call 'prison pressures' that impact on health. And I could just name a few. So, basically, the actual clinical environment. The prison service own the building, so we're like lodgers in some ways. So, if they're not fit for purpose, it's challenging in relation to trying to deliver. You might go into a doctor's surgery and it's got artex on the wall, and to try and clean all the germs off that is really hard. So, the environment is challenging in relation to just the physical structure. Sometimes, it's just getting the dental chairs and the equipment, which, again, is a responsibility of the prison system. So, sometimes, you might have a dental chair that's out of action for quite a significant amount of time. So, again, you might have good health provision—there might be a dentist waiting to deliver care—but they can't deliver it because the chair's not serviced. So, there are lots of those things. There are lots in relation to the environment—getting people from the wing, maybe, to health services. We definitely comment on this; it's what we call—it's a bit jargony—but we call it the 'enablement of health' by the prison service. We definitely realise there's a big impact, and that collaborative working is really important in relation to making sure that the environmental challenges are met. In some places, they get that right and, in other places, it's ongoing and feels like it's the same message round and round and round. Does that your answer your question? 

11:50

That's great, thanks. One of the things we came across on our visit was around staffing issues that affected prisoners being taken to external medical appointments. Is that something that you've come across, and how is that being monitored if it is?  

I think we have a varied picture across Wales. I think in three sites, we had very clear monitoring, very few appointments were being cancelled, and we thought that was commendable, actually, because of some of the additional pressures on the prison system. And I think it was being prioritised, which is great, and that's around the good partnership working and making sure that people who needed to get out got out. As an inspectorate, we're less worried about the quantity of cancellations; it's more about whether they've breached the requirements within the health—. So, if you've had a couple of appointments cancelled but you're still seen within the target for assessment and treatment times into secondary care services, then we don't start counting numbers. But in relation to some of the other sites we went to, we found no monitoring. So, it would be difficult to say whether or not people were getting out on time, because it was literally not monitored at all, which is concerning. It makes us worry about the lack of oversight. So, it could be a problem in those sites, or it may all be perfectly fine. We don't know, which is more worrying.  

I think another one of the issues was people going to medical appointments onsite, when there were nurses, and that being dependent on staff. People weren't turning up to appointments. Do you look at that as well? 

Yes, that's all part of what we call—. You know, in relation to use of—. If we definitely feel that clinical resources are being wasted, we'll definitely say that. We quite often recommend that this is picked up by the partnership board in relation to making sure that these things are resolved. Particularly—not in Wales—but you can see up to 60 per cent of GP appointments being cancelled, so it's not a problem just for Wales, it's across the piece. But yes, we definitely look at that, and often, again—I'm sure I've said it—it looks like there's—. You might talk to a patient and they say, 'It takes ages to get to see somebody', but, actually, what they don't really understand is that it's probably because you weren't enabled to get to where you needed to get to.  

Okay. Just going a bit back to the prison estate, really. Some of the clinical buildings on the prison estate didn't seem fit for purpose, and I think even some that were new, if I recall, that had been designed, it actually meant that it was difficult for the clinician to sort of—. It wasn't very practical, it wasn't designed in a practical way and sometimes it didn't particularly have the safety of the clinicians at heart, either. Is that something you've identified at all?  

Sorry, what was the first one? 

First of all, even new buildings or new facilities that have been built don't really seem practical for clinicians. I think there was one where there was just a wall in the way, or a curtain wasn't—. You know, you weren't able to see somebody sufficiently because there was something in the way. And then, there was another incidence where perhaps an alarm was too far away; the way they had to sit was not really close to an alarm. Is that something you look at? 

So, we are mostly around patient outcomes. So, for example, when we went to Berwyn, a brand new build, you expect bells and whistles in some ways. The clinical rooms were good. Some of the design—not everybody's aware of what the design should look like, but there wasn't enough space. We wouldn't have put that in our report, because it's not impacting patient outcomes as it stands. Sometimes, the commitment and drive of the clinicians to make it work—they make sure it doesn't impact on patient outcomes. So, they work around things, and they have quite a difficult time doing that, but it's good for patient outcomes, so we report on that.

We also do a report on things that might be a problem. So, in relation to Berwyn, we know the population was below what it should have been, so space will become—. It's a potential. But we can't write about potential problems in our reports. It's not something that we—. It has to be factual. It has to be our judgments and observations at the time. So, yes, if it's impacting patient outcomes, we would write it, but there are probably things that impact the staff that we wouldn't necessarily put in our report. If it's very unsafe, we would recommend what we call a safe system of work, so that everything is reassessed in relation to the safety—so, have they got enough radios, have they got enough bells. But that's less about patient outcomes. It might be something where we're giving feedback and say, 'This needs to be resolved'. But if there's an alarm bell missing, we would definitely say, 'This is problematic.'

11:55

Okay. Thank you. The Welsh Affairs Select Committee recommended the Ministry of Justice should tackle gang-related problems at HMP Parc. During our visit to Parc, we were assured it wasn't a problem. Is this something that your inspectors have come across?

In relation to health in Parc, in relation to patient outcomes, I don't believe we—. On the health side of things, I don't think we felt it was impacting. Don't get me wrong, it can sometimes, with the 'keep apart' lists being something that impacts health. But, I don't believe that was the case at Parc. I think in relation to the wider inspection, there was an acknowledgement by the officers that they felt it was an emerging theme and they were monitoring it.

Ocê. Hapus? Wrth gwrs, fel roedd pobl yn dweud wrthym ni pan aethom ni i Berwyn, ac i Gaerdydd, yn enwedig—yn Berwyn, wrth gwrs, roedd yr uned wedi'i hadeiladu o'r newydd ac roedden nhw'n gallu cynllunio'r uned canolfan iechyd hefyd o'r newydd. Mae e fel rhyw fath o ysbyty bach cyffredinol yng nghanol y lle. Ac wrth gwrs, roedd hyn yn golygu bod yna lai o reidrwydd i gleifion adael y lle i fynd i'r ysbytai lleol, achos roedd popeth, bron â bod, ar y safle. Wrth gwrs, i gymharu efo Caerdydd, mae'r sefyllfa'n wahanol; mae'n hen adeilad ac, wrth gwrs, ddim i fyny i safon Berwyn. Ac wrth gwrs roedd mwy o reidrwydd i'r carcharorion adael y safle i fynd i'r ysbyty lleol achos doedd y ddarpariaeth ddim yna. Fel rydych chi'n gwybod, mae sganiau a pelydr-x a phopeth yn Berwyn ei hunan a does dim rhaid gadael y lle. Ond wrth gwrs, mae un yn ddrud iawn i'w ddarparu a'r llall ddim. Ond wrth gwrs, fe allech chi wneud y ddadl dros y costau gwahanol os ydych chi hefyd yn cymryd y costau bob tro mae'n rhaid i garcharor adael y carchar i fynd i ysbyty efo'r staff ac ati a'r amseroedd—i gysoni'r costau. Ydych chi'n rhan o unrhyw feddylfryd fel yna o gwbl pan rydych chi'n ymweld a'r carchardai yma?

Okay. Happy? Of course, as people were telling us when we went to Berwyn and to Cardiff, in particular—in Berwyn, of course, the unit had been built from new and they could plan the health unit from scratch. It's like a small general hospital in the centre of it. But that of course meant that there was less of a necessity on patients to leave the centre to go to the local hospital, because there was help on the site. That compares to Cardiff, where of course the situation is different; you have an old building and not up to the standard of Berwyn. There was more of a necessity there for prisoners to leave to go to a local hospital because the provision wasn't there. There are scans and x-rays in Berwyn itself and they didn't have to leave. One is very expensive to provide and the other one isn't. But, you could argue for different costs on the basis that if you looked at the costs each time a prisoner has to leave prison to go to a hospital with the staff—you could look at that to balance the costs. Are you thinking like that when you visit these prisons?

We don't look at costs. We don't inspect commissioning. We look at patient outcomes. When we went to Berwyn, we did think there was some good practice in relation to how things worked—so, the fact that you could have an x-ray and the x-ray would come up in the local hospital through the IT technology for the specialists. So, they weren't being deprived of the specialist access; it was just beautifully linked. So, we thought that was great. And the same with some of the—. They had a pilot with the emergency services and the Welsh ambulance service—although some prisons employ paramedics—but they were—what's the word—they were actually intrinsic within the prison, so they were called via the normal ambulance service process. It was a pilot. I don't know—we couldn't make too much of a comment on it because we weren't sure if it was going to continue. So, yes, there are definitely some things that we would comment on in relation to good outcomes for patients. So, we make a comment, but it's out of our remit to talk about money and resources and commissioning. We thought that what we can do is say that this is a good model for Berwyn, and that it works quite well and has advantages.

In relation to cost savings, I think, again, it's about the oversight of that. The cost of transporting prisoners outside for health appointments—the burden remains with the NHS. So, the money is still within the NHS. So, there's an opportunity for those resources to be reviewed and overseen by the health boards, and how that's managed.

12:00

Ocê. Trown nawr at Angela am gyfres o gwestiynau. Angela.

Okay.Turning now to Angela for a series of questions. Angela.

Thank you, and thank you for your written evidence. The primary priority area of the prison health delivery plan—or the first one that's enumerated, so I assume it's probably the overriding one—is to ensure that prison environments in Wales promote health and well-being for all. So, how do you feel that that chimes with the excessive waiting times in primary care clinics within prisons? This must be having, I assume, an enormous impact on the health and well-being of prisoners. Can you perhaps just elucidate on that a little bit more, and also perhaps give us an overview of what sanctions are in play on organisations that don't deliver on No. 1 of the prison health delivery plan?

Sorry, could you just repeat the first bit of what you asked there? Sorry, I didn't—

Okay. The prison health delivery plan is very clear about the four key areas that have to be delivered. The first one is ensuring that prison environments in Wales promote health and well-being for all. And yet, we have excessive—in your own report, it says 'excessive'—waiting times for primary care clinics, which obviously impacts on their health and well-being. So, I just wondered if you could elucidate on that a little bit, on the effect you think it has on the prison population, and on what sanctions are in play against the organisations that are not meeting the No. 1 priority of the health delivery plan for prisons?

Okay, so, in relation to—. I see that in two different ways. So, I see environmental issues being the sort of wider determinants of health—so, access to open space and good nutrition. That also includes time out of cell. So, time out of cell—in some prisons, time out of cell is very restricted. Sometimes that means that they have to get to healthcare, they have to shower, they have to ring their family, which also impacts on their prioritisation. So, some people might choose not to come to healthcare because of the impact on time out of cell, for example.

Generally, obviously, the impact of long waiting lists, if they are impacting—. Anybody who waits too long in relation to—. When we talk about 'too long' we have some targets that we look at. So, in relation to dental treatment, we expect people to be seen within six weeks if it's a routine appointment. If it's an emergency, we expect them to be seen as an emergency. When those things are impacted, yes, we definitely see that. We saw that, particularly with dental waiting times. You must have seen from our evidence that, at Berwyn, it was at 11 months. Usk was 10 months to see a dentist.

Now, as much as you can mitigate some of that by making sure that there are lots and lots of emergency slots so that you could assure yourself that people in pain were being seen very quickly, actually, people's health deteriorates in that period. So, if you keep putting all of the emergencies at the front, the people who've been waiting 11 months—their teeth are deteriorating, unless it's just for a check-up, which is very rare. It's not that many who just need a check-up—they need a filling or something that's non-pain—and, actually, their health deteriorates. So, we definitely see that and we definitely make a comment on that.

I think in Wales, at Berwyn, we had quite a quick response, actually. We spoke to Healthcare Inspectorate Wales, and they picked it up and went back to the health board. There was communication about how that needs to be resolved reasonably quickly. So, I think, when it's picked up and we see that there's an impact, I think the escalation was through Healthcare Inspectorate Wales.

12:05

So, to carry that through, I guess our responsibility is to scrutinise the health boards. So, the health boards provide those services into those prisons, so it’s not for us necessarily to hold Berwyn to account on the dental issues—it’s more around, well, actually, what are Betsi Cadwaladr doing around it? Yes, the issue is escalating, so we’ve been in contact with the health board. I think, from our perspective, we could see that Berwyn features relatively prominently on Betsi Cadwaladr’s line of sight, in terms of scrutiny at the quality and safety committee for instance. The HMIP inspection was taken through that last week. We can see that there are actions being put in place to remedy, for instance, the dental issue. In terms of the general accountability question, certainly from a health board perspective, the ultimate sanction from our perspective would be using the NHS escalation and intervention framework, and, clearly, issues that we think are worthy of consideration arising from that could ultimately affect the health board’s overall escalation status. So, from our perspective, that’s how we would see that as a mechanism for continual non-delivery or issues that cause rise for concern.

So—and I'm quoting evidence—you identify excessive waiting times for primary care clinics in prisons in Wales. So, are we really only talking about the one prison, then—Berwyn?

I think we see longer waiting times than we would expect to see, and we’re talking about equivalency with the community. So, if you were expecting to see a diabetic nurse, we would expect that to be done within a reasonable time frame. We tend to generalise and not list everything, so sometimes it’s just this very small specialism. So, it might be access to a diabetic nurse or a physio—we class that under primary care. So, I think it can be seen as—. It could only be a small pocket, or it could be generally across the board. So, it’s not that all primary care has excessive waiting times. What we’re saying is, some sites have more, particularly when there are staffing pressures. And then staffing pressures could be difficulty recruiting, it could be sickness, and it could be just that there isn’t enough in the profile. So, there are lots of different reasons why there’s no staffing or there’s not enough staffing.

Okay, so it's more to do with—. Right, okay. I just think that that language—. You've just indicated to us that it was a serious problem throughout all prisons in primary care clinics, but you're very clearly saying it's just some of the clinics in some of the prisons.

In some of the prisons. Yes.

Quite different. So, you talked about the health inspectorate, Rhys. Can you clarify what happens at Parc with primary care services? Because, of course, that’s delivered privately, or it’s a private organisation. You don’t have the right, I understand, to inspect, so how can you be confident that the primary care delivery at Parc is meeting the standards you would expect from an NHS-delivered primary care service?

I think the reality is, in terms of a pure legal basis, our remit doesn’t extend to primary care in Parc because of the way that’s contracted privately by G4S. For any NHS care that’s provided or staff that work at Parc, we would have a role and responsibility to certainly scrutinise that. I think, on a practical level, we do 'death in custody' reports, and I know that HMIP does its inspections—that hasn’t necessarily hindered or inhibited our ability to undertake that work. So, whenever we’ve undertaken 'death in custody' reviews, we've had full access to everything—all the records and interviews et cetera. That’s not actually hindered us, but it’s fair to say that there is a potential regulatory gap there, because the primary care services are exempt from the regulations that we work to, in terms of whether there would be a registerable service. They are not—we cannot register them as things stand. And I guess that’s true—there is no other way around that. There is certainly, I guess, a gap there, and potentially something that might need to be addressed in any future change to legislation, I think. So, whilst on a practical level we can still undertake our work, if you’re talking about, I guess, accountability or scrutiny, maybe there is a gap there.

12:10

Yes, because we were quite surprised, I think, about that. One would have expected that whoever wrote the contract would have said, as a rider in the contract, 'You will allow our inspection teams in to double-check that you're providing the services to the standards we wish to set.' Can I assume that there will be a service level agreement in play for the delivery of primary care at Parc? Even if you don't have sight of it, would you know if that exists?

Normally with the PFI contracts, it's part of the overall Ministry of Justice provider contract that, obviously, goes out to tender. I don't know—. I have not—. We don't look at contracts. There's usually a section around health. I'm not sure if it's around a contract agreement. I wasn't sure if this was more around the legislation.

The gap—yes, so it is specifically exempt from the regulations that we would register our services under—there's a specific exemption for services provided within a prison. So, that's the issue.

Yes, I get that. I can see that there's a legislative gap—totally understand that. One would hope that whenever you see a legislative gap, and you're paying good money to have a service provided by a private company, that you would then put a service level agreement in to mitigate the gap because then you have the right to measure them in a different way. It may not be yourselves that measure, it may be the contract management, but they would want a bunch of reports to ensure that things were happening. So, perhaps that's something we can just try and have a little nose around that area to see what the reality is.

Recruitment and training of the healthcare workforce in prisons: I understand that there are real healthcare staff shortages. Have you identified if action has been taken—? During your inspections, have you identified whether or not there's a programme in play to try to tackle the healthcare shortages? And have you also identified whether or not the prison service has identified which element of the healthcare workforce is particularly short-staffed? Is it nursing care, healthcare professionals—? Dentists, I think, you mentioned—whatever it might be. If you haven't, don't worry, just say. I just wondered if you'd—

We do have those conversations. So, if we see that there's recruitment—. We probably don't put the detail in our report around that. So, if we feel that there's recruitment campaigns or they've used incentives or the security clearances, which may have been delayed, are being discussed at partnership—if we feel that there's something being implemented, then we probably don't go into great detail, but we'll just say, 'There's still an impact on the outcomes of patients.' But, no, I suppose the answer in relation to, 'Do we detail the strategies for recruitment?'—I think we're also aware of the national shortage of clinical staff and that they're in that same pool, but, for us, we don't give any concession for that. We just say there's an impact in patient outcome. So, we do look at it, but probably don't put much in the reports in relation to what's been happening, unless it's significant that they're doing nothing, and then we'll go, 'There appears to be nothing happening', which, I think, we have not said in a Welsh report so far.

Okay, thank you. Can we just spend a moment or two on 'death in custody' reviews, because I was actually quite shocked by the statistics? Sixty one deaths in the last five years. Eighteen deaths in 2018-19. I appreciate they're for a variety of reasons—death by suicide, natural causes—but you've been quite strong on your, sort of, inspection of this and my understanding is you review every death in custody situation. Are you content that what you find is what you would expect? And are you content that recommendations that you make following an inspection of a death in custody are being appropriately implemented by the prison service?

I think I mentioned earlier that the standard is that the care should be equal to that in the community, and, I think, generally, across most of those cases we looked at, that is the case, notwithstanding areas that might need improvement. So, I think there have not been many deaths in custody where we've been particularly critical or damning of that overall standard.

I think below that, the themes that are emerging, as I mentioned earlier, were around the quality of the healthcare documentation and mental health support. There have been a couple of cases in Cardiff recently that we have grave concerns around as, actually, the same things have arisen in two cases around quality documentation. So, as I mentioned earlier, our role then is—. Well, actually, we've gone to the health board directly on that to escalate the matter and to really bring it to their attention, so we can understand what's being done around this—this has happened twice now within a short frame of time—and to hold them to account in that regard. Clearly we'd like to see—. So, next time, if we deal with another death in custody, we'd like to see improvement, or if it's the next inspection that HMIP does in terms of that.

On a local level, we get an understanding of what happens if we escalate something to a health board and what their response is to us. I would say, from our perspective in terms of whether health boards are learning systematically after each death in custody review, I think it's probably an area to strengthen. My experience has been that, in certain health boards, prison healthcare features more prominently on their overall agenda than others. Berwyn, for instance, does; maybe that's because it's a new prison, but either way, I can see that at Betsi Cadwaladr they are looking at Berwyn and monitoring it, and it's in their line of sight. I don't think it is as much for some of the other health boards. So, there's something on a local level around, 'Well, actually, our health board's fully aware of what's going on in their prisons.' I'm not sure that's the case, from our experience.

12:15

So, that might be a really useful recommendation that we as a committee could make, in your opinion.

Yes. It would. That kind of local ownership, I guess, from our experience, hasn't been as strong as we would maybe expect.

And of the deaths in custody that you've seen, we've got death by suicide and natural causes. Are the natural causes natural causes or do they also include attacks? You know, somebody's died because they've been attacked by somebody.

There was one case we've done that would be a homicide. So, that was to be dealt with as a homicide.

So, that would be a separate—. That would be identified.

But, effectively, yes, they're the two categories: suicide and natural deaths are, essentially, everything else, I guess.