National Assembly for Wales

Diolch, Gadeirydd. Morning, all. Clearly, there are some serious issues to be addressed, and you are needing to address those, but also making sure you address them for the safety of your patients and your residents. But I suppose we've fallen back to a situation here now of going back to the south Wales programme, which is to 2014. I remember going through all that trauma, and how it affected my area. But take the south Wales programme out of this—it didn't exist—what would you be doing now, if you were in a situation you find yourselves in, if there wasn't a south Wales programme? 

Shall I start, and then colleagues will come in? I think that's really helpful. We've had a number of people saying to us that, 'All you're doing is implementing the south Wales programme—you're blinkered and you're not able to take account of the realities of the situation.' I really don't think that's true.

For me, there are three key issues, really, in all of this that we've got to deal with, whether there was a south Wales programme or not. The first issue is that we've got a department now that we cannot say will remain safe for the foreseeable future. It's reached the point where there are significant risks now that have to be managed that are beyond what can just be managed in the normal process. So, that's the first issue. We've got a real problem to resolve.

The second issue is that it's substantially about key groups of medical staff, and there is a national UK shortage of those doctors that is not going to be resolved in the short term. So, we've got a real problem and we've got a real barrier to resolving that, which would simply be to recruit additional people.

The third issue, which is unique to us in this particular case, is, if you like, the topography of the region we're serving. So, that hospital, as we all know, serves a number of communities where communications are not easy; it's not easy to go east-west, particularly. So, we've got to find a solution as a health board that ensures safety, that recognises head on the fact that we can't simply recruit our way out of this easily, and, thirdly, we've got to provide safety for those communities that we're serving. So, the south Wales programme, in a sense, is neither here nor there. It's the facts on the ground that we're having to grapple with, I think.

Thank you. So, I think where we find ourselves is, as Marcus has said, with those three issues—they exist regardless of what went on in the past, and there may well be some conversation later about—

There will be.

—whether some of what went on in the past has contributed to where we are today. But when I came in in July, one of the things that gave me sleepless nights was looking at the accident and emergency services across Cwm Taf Morgannwg, particularly with respect to their sustainability and the level of risks that we were holding. The level of risks relate both to the staff—and we know that, through the summer, as we've had some of the independent bodies come in to look at the services, and I think you've had evidence in the pack, staff are reporting that some of the services that they're working in, particularly in the Royal Glamorgan Hospital, the environment and how the working conditions are managed, which relate to the locum doctors, and Nick will talk a little bit later about the impact of having a lot of doctors coming through teams—. Staff are very stressed, they're finding them very difficult working circumstances, and our levels of sickness go up and down. Part of that relates to when you're trying to work hard with teams, if you've got a continual change through the teams—and I think 50 doctors in the last year through the A&E team within the Royal Glamorgan, which makes it almost—well, I don't want to use 'impossible'. It makes it really, really difficult to get any cohesion, and we know from all the evidence that teams, managing risk, and safety, which relates both to patients and staff, are critical. So, we've got that as a big issue.

The issue of staffing in A&Es right across the UK has been getting worse over the last couple of years, not better. From the summertime, when I had a look at what we were dealing with, we didn't have sufficient staff in any of our A&E departments across the patch, but, particularly in Royal Glamorgan, we were relying almost exclusively on locum staff to run the services, and that's got a huge link back into the quality of services that we're able to provide. Laid over that—and this is really highly pertinent, because thinking about things like the impending Health and Social Care (Quality and Engagement) (Wales) Bill, the duty of candour and quality statements et cetera, we've got three current situations where there have been patient deaths that are going through the coroners courts—one has been publicly reported—where the coroner has made a direct link to that death—so, preventable issues for that death directly attributable to the level of locum services that exist within the A&E department. So, those three things—

I appreciate what you're trying to tell me, and I think the history of it is something that people will want to explore as to why we've got to this position, because it's six years since the south Wales programme. As you rightly pointed out, we understand there are challenges across the UK, so this is something that perhaps could have been anticipated. I suppose the question I want to ask is: in your view, irrespective of what you know, what type of service would you want to provide? Do you still think there is a need for an A&E service at the Royal Glamorgan? I didn't say 'to deliver it'. I said 'a need'. So, is there a need for an A&E service at the Royal Glamorgan?

There's a need to provide accident and emergency services for the communities we serve, and one of the reasons—. That's a prime site, the Royal Glamorgan Hospital, and one of the things we've said as a board is that we want to maximise the services in the Royal Glamorgan Hospital. You'll see that one of the options that we're currently working up looks at reduced hours, and that's because we believe that we have to find a way of providing as much service to the local population as we can at that high consultant level. But again, in modern practice, we know that huge numbers of patients that come to the Royal Glamorgan could be treated elsewhere. Now, when I say 'elsewhere' I'm thinking about minor injury and illness in particular, and we can talk a little bit later about the numbers on those, where we know there's a huge amount more that we could do, particularly in Ysbyty Cwm Rhondda and Ysbyty Cwm Cynon and then, because we're Cwm Taf Morgannwg, in Maesteg.

To increase the services there, again, there will be issues that we'll have to address about workforce, so we've been talking with HEIW and some of the workforce colleagues about how do we get a pipeline for the development and recruitment of what are called emergency nurse and emergency advanced practitioners. We've got some of those in the system at the moment, but if we're serious about really increasing the services closer to home, we've got to have a sustainability plan and a recruitment pipeline coming through. So, whatever we do going forward has absolutely got to be sustainable and fit for purpose.

So, what I would say is: yes, I believe that there is a need for some services to be at the Royal Glamorgan Hospital, as many as we can safely and sustainably provide, but I think we've got alternatives when you look at what people come to us with. There's a big question about: why do they just come to Royal Glamorgan? Why are we not enabling a lot of that care to happen elsewhere? So, I think that's where we are. In a modern health service, we've got to be looking all the time about how do we utilise—whether it's technologies, new ways of working—what the public actually require, what their health needs are, and how do we do that in a modern and fit-for-purpose way? I would say that having a 24/7 A&E—I think we said to you in our evidence that, if we could wave a magic wand, that would be very nice to be able to do that. But we would absolutely still be looking at why are we seeing all these people with minor injuries and illnesses at an acute hospital site. So, you see, there's quite a lot going on with that.

I don't dispute that. We have a minor injuries unit in Neath Port Talbot Hospital. We've gone through this process many years ago. I understand what they provide and the services they provide. But the question we're asking here is: is there a need for an A&E department? You've only just inherited Princess of Wales, it's coming up to a year now since you inherited it. Before that, if you didn't have that, you'd be looking at a situation where you only had two hospitals in your health board, and you might not be relying on transfer out to Princess of Wales as an option here. So, again, you've talked about topography, you've talked about the general public and the locations where numbers of people are now growing in areas. Do you still think there is a need for an A&E—and I'm not talking about a minor injuries unit—an A&E unit at Royal Glamorgan to serve the people in the communities that it currently serves? Do you think it's actually appropriate to transfer those to other locations that are quite some distance away? And we're talking about A&E—I'm not talking about a minor injuries unit—I'm talking about A&E patients who come in and have medical conditions and emergency conditions. Is the removal of those services at the Royal Glamorgan actually serving the patients in your communities?

We certainly have to come back to the fact that it's not as simple as that, because we've got to find a way of reconciling the issues that Marcus has talked about. So, how we do that in a way that maximises the services that people can get access to in the Royal Glamorgan, the A&E services they can access? That's where we're coming from. So, for example, when we start to look at exactly what do people come there with, one of the reasons why there's been a lot of work done on acute medical services is because, if you have a heart attack or if you have pulmonary disease, instead of going through A&E services, we can get you straight to the ward.

So, I think the issue is: what is the best possible pathway and the best possible way of getting the services that patients need to them? The core A&E service: there will be some A&E services that, yes, we absolutely require. One of the reasons why we've said as a board that we want to look at maximising the A&E services in this repurpose with the reduced hours overnight is partly because of that question: how can we maximise the services that we can provide? But we have to be realistic about the constraints within which we're working. So, it's not a simple equation, and it's all about: how do we get the best possible services to the patients, when they need it, in the right place, given the constraints that we're working within?

So, again, another example would be patients who've fractured their hip: a fractured neck of femur. At the moment, if you fracture your neck of femur, you come into the A&E department, you have an x-ray and you have bloods taken, you might wait there quite some time, and then you go up to the wards. Now, what we're looking at is: why do the patients have to go through A&E? Because when you've got a fractured neck of femur, the care you need is: into theatre, get your fractured neck of femur fixed. So, why do we do that extra step? Is there a way of changing that pathway so our patients go straight to the ward? In this case, then, if we were repurposing the hours of the A&E department, it wouldn't be about, necessarily, the A&E department, but rather saying, 'Actually, we've got a better way of providing that service.'

But that will be applicable to all your hospitals, not just that one.

It will, but isn't this the perfect example of: why are we not doing this quicker and sooner? So, if these are things that we can be doing that will enable patients to get even better care quicker, better care that they need, then why shouldn't we be doing it? This is a really wicked problem, and it is about how we maximise the services that we've got there for patients in a way that works within the constraints that we've got.

Angela.

Can I just add, very quickly? Having listened to your reply there to David, you're describing utopia, but in the years that I've sat on this health committee, and before, we've been promised by health boards across Wales and by successive health Ministers that these frailty pathways are already in place, or about to be implemented, or just under way, but here you are talking about it again: 'We've looked at this.' Wow. It's not new. This is really old knowledge. This is old science. We had the Royal College of Emergency Medicine come to us last year, and the year before, to say, 'This is what you have to do.' We've been referenced to places like Newcastle hospital where they have this kind of system beautifully running well. Lots of hospitals in London do it, where the frailty pathway is already there.

So, my question to you is: why now? Why haven't you done it before? What's taking so long? Is this just a reason to hang the whole changes on? And how can we be convinced that, if you were to proceed with your plans, all these frailty pathways and the rest of these pathways would actually exist? Because, to be frank, the NHS in Wales has been talking about it for a significant number of years, and it's not happening in a lot of places—including, obviously, your hospital.

It's incredibly difficult, isn't it? I think, at the Royal Glamorgan Hospital, it is probably second to none in Wales in terms of the quality of acute medicine; doing things differently, thinking imaginatively about how can the acute physicians support the emergency medicine consultants. So, there has been some fantastic work that is already in place, and continues to develop. In all three hospitals within the health board, there are examples of that. Very recently, in the Princess of Wales Hospital, a new ambulatory—a new walk-in pathway for surgical care was introduced, and that's had a significant impact on the department in terms of depressurising it, helping with our ambulance handovers, and making it a more pleasant environment both for patients and for staff. 

I take your challenge that there is still a huge amount more work to do, and I think, whilst we've been talking, in order to take away some of the safety risks in the Royal Glamorgan Hospital, we absolutely need to address staffing challenges in the short term, but it is also, in that hospital and across all the others, looking at new pathways. It's not just in frailties, it's in other pathways. So, it's spreading the good practice from each of the hospitals to the other two and across—[Inaudible.] So, a fair challenge, but a lot of work is in place, but a lot more does need to be done. 

Maybe if I can just clarify a little bit further? Looking at what has been done specifically within the Royal Glamorgan Hospital over the last couple of years, the acute medical model that Nick has referred to is a new model that has been put in place over the last couple of years in order to facilitate and enable medical pathways. So, that's new; it's been building; and it's very successful. There's a little bit more to be done, but our heart attack patients, for example, and a lot of our chronic obstructive pulmonary disease patients already go straight into the medical wards. The same with some of the frailty assessment work in the Royal Glamorgan. And that's new—those are new pathways that have been put in over the last couple of years. 

So, I have got a measure of confidence that, in the Royal Glamorgan, our clinicians and physicians know how to do these pathways and they see the benefit of them. Indeed, it's been interesting working with the orthopaedic surgeons just in the last, I guess, couple of months talking about the fractured neck of femur pathways. In the Princess of Wales Hospital, surgical assessment work has been done, again, having that conversation with the surgeons in Royal Glamorgan. 

The other thing that's been done over the last couple of years is strengthening of primary care services—although, again, there's much more to be done. A couple of years ago, the out-of-hours rotas for general practice across Merthyr, Cynon, Rhondda Taf, Ely were not full. Indeed, on Saturdays and Sundays, we were lucky, if I can use that term, if there would be a couple of shifts filled, never mind all of them. The recruitment over the last year year—in fact, it's in the last six months that we've done a huge amount of work, and out-of-hours services now are really well staffed, really well populated. We've got a great base on which now to move forward and look at the next phase of what more can be done at primary community with respect to the out-of-hours primary care services.

There's been a lot of work done through ICF and RPB work on integrated teams working with local authorities, mapped around clusters and general practice, and now we've got another lot of work coming onstream that will begin towards the end of March as a result of the transformation fund. That was a £22 million fund, I think, that was agreed with CTM almost a year ago now, back in last May. So, the recruitment for all of that programme of work has been happening over the last six to eight months. Those teams are beginning to start now, in March/April time. So, again, that's building the care in the community by which then some of these pathways enable either more care in the community or better flow through the hospitals and discharge. And I guess that'll be another conversation. Hospital isn't a good place to be for patients; we like them to come in, be treated, and get out as quickly as possible. 

So, there have been a lot of building blocks put in place, both in the primary care community and in the hospital, to facilitate changes in pathways and flow going forward, but there's yet more to do. So, I think that's why we've got a relative confidence. Then, when we see things like—I will call it the under-utilisation of Ysbyty Cwm Cynon, Ysbyty Cwm Rhondda and Maesteg with respect to minor illness and injury. We know that there are big opportunities there for enabling those units to be dealt with in a different way, but I come back to the point that we can't do that unless we've got a sustainable recruitment and development pipeline that sits behind it. 

David. 

You've opened up quite a lot of questions. You've mentioned now that your heart attack patients go straight into the ward. Is that still going to manage? Have you talked to WAST to ensure that, if patients have a situation, they can still come in if you decide to go to day and night sessions? 

Yes. 

So, you'll still be taking those individuals in. 

Yes. 

So, in a sense, I suppose, the question is: how many patients does A&E currently have who do not go straight in? Because when I saw the A&E close in Neath Port Talbot, they were just transferred to Morriston, and we all know the number of ambulances that stack up outside Morriston on a daily basis. I was there two weeks ago and there were 12 outside A&E. Is the service going to be available to actually deliver to both of those situations, to ensure that patients are not left in ambulances sitting outside hospitals?

The modelling work—and Nick will talk a little bit about some of the numbers—that's happening at the moment is trying to go through, in great detail, what we know about how patients present to us, what they've got wrong, what their presenting complaints are, and how they need to be cared for in the hospital. So, we're working through all of that.

So, you're doing modelling work now. 

We are. All of that modelling work, it's all—

So, how can you make an opinion on an option if you haven't done the modelling work?

Because—. Do you want to talk about that?

Just, basically, we haven't made a decision yet. So, the health board—. Just the last little bit of history. In January, we received a paper, which I think you've had a copy of, and what we asked the team to do was to look in detail at two options out of four that were presented to us. So, we're currently in the process of looking at that, in terms of modelling, in terms of conversations with staff, and also, most importantly, listening to what the community has to say about those. 

So, at our meeting this afternoon, we will have an update on all of that, and at our meeting next month, we will have all of that evidence gathered together. So, only really at that point will the health board be able actually to start to take a view on the relative merits of all these options. So, at the moment, all those options are absolutely in play. 

You said 'all', but you said you're just looking at two of them. 

And the third—. It isn't an option in the sense of a change, but the third thing that we are doing is, as we've said many times, leaving no stone unturned to see if we can actually make the current system safe and sustainable. So, there's a lot of work going on on that whilst the other two options are looked at in more detail.

So, you're currently reviewing three options in that case—the two you talked about, plus the continuation of services as they stand now. 

As they stand, but made safe and sustainable, yes. 

So, I think it's important to say that, again, the way we've gone at this is there's a set of wicked issues that have to be resolved. So, we've had quite a lot of conversation about what the potential models are that might give us a solution to those issues. Those are what we talked to the board about, and then sought the board's support in developing those up. So, again, no decisions made. And, in the meantime, there's contingency work going on that is saying 'Whilst we're trying to find a way that resolves all of those wicked issues, we have got to find a way of enabling the services to keep going.' I'll use the phrase 'limping along', and this is tricky because, of course, people will say 'Well, if you're able to mount a contingency plan that just is good enough for now—a sticking plaster again—why isn't that good enough for all the time?' So, that again is another tricky issue, but what we know is that allowing something to get to a critical point where you've just got to turn it off, so as what happened over Christmas, where there were a set of unforeseen circumstances and we had to divert all ambulances for one night, two nights, we don't want to get to that point. So, we're doing everything we can to enable contingency plans to give us the space to do the work on something that will be sustainable going forward. 

And because this isn't a simple issue, it needs time to be able to work up all of the modelling, to be able to test what we think is going to be viable, and to be able to work through all of the issues that people are raising as—. I'll put it this way—we're very good, aren't we, at saying 'Yes, this is a problem, but you can't do that solution, because we can't do this.' So, what we're trying to turn people's attention to is: 'This is the situation that we've got; it's real; we've got to find a sustainable solution to it; how are we going to do that together, in a way that maximises everything, gives us the best possible solution, and it's got to be sustainable?' And that's not easy. 

So, that's why we're trying to do it in this way. It's not a predetermined solution. But there are some things that are simply not going to work, which is why then we went to the board saying, 'We think that there are probably a couple of models that we know work elsewhere across the UK that probably might give us a solution, so, can we concentrate on starting to work those up?' Because, again, if we're trying to work, I don't know, 10 different models, that dilutes our workforce; that dilutes our ability to really look in detail, knowing that a number of these aren't operational anywhere in the UK. So, that's why we've gone the route that we've gone. 

I'll come back to that later on if that's okay. 

Okay. Well, in passing, I'll reflect on my earlier medical career as a junior hospital doctor back in the last century, and back in the day then, admissions, if you were a surgical house officer, or a medical officer, would come to the board; they wouldn't go anywhere near A&E. And as an orthopaedic junior, they would come to the orthopaedic ward direct. So this issue about whether it is a planned or an unplanned admission, as well as the normal people who would come to A&E, everybody goes to A&E, seems to be a fundamental weakness. I note what you're saying about pathways, but that seems to be what we did use to have in the days when we had more hospital beds, obviously, and obviously we had community hospital beds still under NHS control that we could do step-down discharges routinely without having to wait for home care packages and things. I don't know if your various pathways reflect previous experiences up to about 40 years ago, or not.

There is a curious irony that, yes, the models that we're now looking at as innovative, groundbreaking and improving the system are very similar to the models that I too had when I was a senior house officer working in an A&E department in north Wales, about 30 years ago. But I think we have to remember though that medicine has become significantly more technical since that time, and the variety of treatment options available to patients has hugely changed. But I think there is a huge amount of work that we can do to drive quality for our patients, and drive the experience for our patients, in all three of our departments, and learn from some of that history, I would absolutely agree.

Lynne.

It wasn't on this—it was on something else.

Oh right, okay; I'll come back to you then. Rhun, do you want to lead on on this?

Reference has been made already to us not being able to recruit our way out of this, so we have a problem now, but also too questions about how we've got to this stage. Can you describe how things have been allowed to deteriorate so much, in terms of recruitment to and retention of staffing at consultant level, senior level, within the emergency department at the Royal Glamorgan Hospital?

We can describe what actions have been taken over the last while. And the start point, I guess—and I'll hand over to Nick for the numbers—which does go back, I'm afraid, to the original south Wales plan considerations, at that time, it was all about a number of specialty areas where a consultant workforce was diminishing. And as people looked forward, that workforce is likely to get less. And part of that is due to specialisms, as you will know, Dai. So, back then, the three specialisms that were being talked about were: consultant-led maternity—so, obstetricians; A&E, consultant-led A&E; and paediatrics and neonates. And the work profile for those as shortage specialties—if I can call them that—at a consultant level, across the UK, hasn't changed; in fact, that's worsened. So, the original conversations around how are we going to enable consultant-led services, when we're in a diminishing workforce, to still pertain today.

Now, there's a wider question around what's happened with workforce planning over six years, and what I'd say to you—we might want to go into this in a bit more detail later—there's been a lot done, but, of course, it takes 14 years from the beginning of somebody going into their training and becoming a fully-fledged consultant. So even if we were to say 'We could have done more with workforce planning', we're only six years in to something that is at least a 14-year issue. So I'll hand to Nick to give you the detail of what the organisation did with recruitment over the last couple of years. 

And again, just a reminder that my question is why things have been allowed to deteriorate at the Royal Glamorgan Hospital. Because we know that other hospitals—all hospitals—struggle to various degrees to recruit, but we have a specific problem at the Royal Glam, and I want to know why that's been allowed to happen, and how you've tried to address the problems.

Would it be useful to clarify the numbers around the medical staff? Because I think there are various numbers floating around. So, at the Royal Glamorgan Hospital, with the recent resignation of the last remaining consultant, when he leaves, we will have no substantive—no employed—emergency department consultant at the Royal Glamorgan Hospital. The backbone of work done in the department is by the middle-grade doctors, and we have 1.6—sorry to speak in points—whole-time equivalents at the Royal Glamorgan Hospital. So, no substantive consultant and 1.6 middle-grade doctors. 

We know that this is where we are now. The question is: how have we got to this position?

So, the size of the problem, because there's huge shortfall there to where we have been, which we can come back and discuss later if that would be helpful. I think the south Wales programme, when agreed in 2014, it—for want of a better word—paralysed, or made recruitment more difficult. If I was a consultant, an emergency medicine doctor, would I come and work, move house, move my family and come and work in a department where it was a matter of public record that there was an intention to convert it into a minor injuries unit? 

And that is a serious admission—that the shadow of the programme itself has caused or has been a major contributor to the problem that we now face. 

And I think we've been quite open in the papers and in our meetings, to acknowledge that and say that is. There is an opportunity, working across the wider health board, though, to recruit to the health board and, in January, we recruited two new ED consultants—emergency medicine consultants—to the Princess of Wales Hospital and, as you probably know from the paper, that's enabled us to release doctors from the Princess of Wales to the Royal Glamorgan Hospital, at least in the short to medium term. And it is for that very reason—. We've talked about the concerns about safety, the huge fragility of the medical workforce in particular contributing to the safety concerns, and that's the very reason that we've brought this to the forefront in order that there needs to be a decision so we can recruit to whatever model is the right model. 

So, may I come in just for a moment, because I think these are assumptions, aren't they? And going back to the south Wales decisions, when those decisions were made, people must have talked about and known that the decisions that you're making—because you always do this: what is the likely impact of a decision that you make at the time? So, I'll come back to—. We'll make an assumption about the impact of that and we don't know what proportion. You said a 'significant contributor'; I don't know whether it was significant or whether it was a medium contributor but, no doubt, it made some contribution. But we are where we are now, and we've got an issue that we've somehow got to resolve now. I can't turn the clock back and I can't account for the decisions that we made back then. 

It does change the—. Sorry, to interrupt, but it does change the context and it's important for us to understand management culture at the hospital and the boards. What has been done; what has been attempted as a means to resolve problems gives us a guide to how much we should trust steps being put in place now. Perhaps you could give us—. And it's great news whenever you are able to recruit consultants, but perhaps you couldgive us a taste now and, perhaps provide written details afterwards of how many times, and in what ways, you've made attempts, over the past five years or since the south Wales plan, to recruit to the Royal Glam specifically, as consultant A&E— 

I'm more than happy to provide that in writing after this meeting. I think the concentration, the focus at the Royal Glamorgan has been to appoint locum doctors, rather than substantive consultants. But we can provide the detail on that. 

Okay. So, in what ways have you tired to recruit consultants, full-time consultants?

So, I have to be completely honest. I've only been in post since October last year, so some of that detail I don't have. 

Lynne's got a question. 

I think it is important to understand how you've got to this point actually. Cwm Taf signed up to the south Wales programme in 2014, and yet, only one of the agreed positions was actually implemented. Why didn't the health board actually implement the programme six years ago? 

So, from what I can see, having done the look-back, the issues that we talked about a little bit earlier on, around what are some of the building blocks that will be needed to—. At that stage, the sign-up was to a minor injuries unit. And when you look back, in order to facilitate a minor injuries unit, all of those pathways that were discussed needed to be put in place. So, the start point was the work on the acute medicine service. So, the board spent a lot of time putting that acute medicine service in, in order that it could accommodate many of the pathways. They also set about trying to put in place those things that I mentioned around primary care and community care—so, more services into the community that could enable some of the minor illnesses and injury services to be delivered.

It's really difficult, isn't it, because we're relatively new in, and we've got a rather privileged position of trying to look back—I don't know whether it's privileged, actually—trying to look back but not having been part of what the decision making and the views were? It seems that the definitive programme around how we would move from the service that there was in A&E back in 2014 to what was then envisaged—that programme of work perhaps wasn't as clear as it could have been. Unlike when you look at the work that was done around the consolidation of the maternity units, which was a very, very clear programme of work.

So, there's definitely been quite a lot of work done, because it's a huge thing—as you pointed out—to change an emergency service provision. A huge amount of building blocks have got to be put in place. So, we can see that there has been work done, but it's not sufficient. And we also know, as Nick has said, that the issue around exactly what this is going to be in the future colours how people engage in programmes to develop work.

So, when I talk about wicked issues, it is really difficult, and I think it's one of the reasons why, when we've looked at the position we're in, we're very, very keen to have a definitive decision. Because if we have a definitive decision within a definitive set of plans that we can work to, then we've got the best possible opportunity of getting to where we need to be.

The reason why Nick and I, certainly as clinicians, are unable to sit here and say, 'We definitively want to go for a 24/7 service', is because, when we look at the consultant workforce across the UK and we look at the vacancies, and we look at the middle grades and the vacancies, it just feels improbable that we're going to be able to service to the level we need, in the way in which the service is configured, for a department that can work at the risk levels that we would want.

Okay, back to the consultant numbers, and Rhun. We'll come back to that.

Just to pick up, again, you confirmed a few minutes ago that your predecessors were concentrating on trying to recruit locums. I've heard a suggestion that there's been no substantive effort made through advertisements to recruit consultants for maybe five years.

And that may well be true.

Why would that be the case, when you admit that recruitment was a problem? Wouldn't trying to recruit be an obvious answer to a recruitment problem?

Again, as Sharon said, it's difficult, having been new in post and looking back over the history and some of the conversations that must have been taken then around the correct mitigation of the staffing problems. I think all I can say is, now, as you'll know, we are absolutely recruiting vigorously and imaginatively for those substantive consultants to the health board, so that doctors coming in have the confidence that, whatever the future of the Royal Glamorgan Hospital, there is more than enough work for them in Cwm Taf Morgannwg across the department.

Has an assessment been made? Has an audit been carried out of—I think you mentioned 50 doctors passing through A&E—why it is that you were unable to find locums who wanted to turn those locum posts into substantive posts, or why locums didn't want to stay there very long, why there was such a huge turnover, what the blocks were to retention of doctors in A&E? I think it would probably be useful to you, because that would allow you to decide, 'Actually, are there things that we could change that would make it easier for us to recruit?' Because you've managed to recruit in other hospitals.

It's against the context of a national shortfall in emergency medicine consultants of around 1,200. So, across the UK, we're short that number of doctors. Therefore, for us just to put an advert up in the British Medical Journal or on one of the websites, and expect people to come and work for us without really understanding the issues, I think, is somewhat naive and unlikely to work. So, therefore, what are we doing?

Of those 50 locum doctors—many of whom aren't fully qualified to be consultants, many of whom have jobs elsewhere in Wales or elsewhere in the UK—what we're doing is sitting down with them on a one-to-one basis, all 50 plus of them, to say, 'What would it take for you to come and work for us? If you aren't a qualified consultant, but you're a very experienced emergency medicine doctor, can you come and work for us? And if you have an undertaking that you will stay here as a consultant, we'll pay for the remaining part of your training. We'll put you through our other departments to give you the experience that you need.'

It's talking to other doctors to say, 'Actually, what is it, in terms of remuneration, working conditions, that would make a job attractive to you?' Emergency medicine consultants like to work in the exciting trauma centres. They like the buzz of that sort of environment. So, again, rather than saying, 'Will you come and work in the Royal Glamorgan Hospital alone?'—magic as I think the Royal Glamorgan Hospital is—'Could you work for us four days a week and work in the major trauma centre in Cardiff for one day a week? Would that balance of portfolio make it an attractive job for you? If you're interested in education, if you're interested in training, if you're interested in research, then what can we do to make the job attractive to you?' Rather than just putting an advert out to say, 'This is what we need.' So, that detailed work to understand—not our workforce, but the doctors who are already familiar with our health board—what might work is already under way.

And all of that that you describe there, which is great and nobody would disagree with that as an approach, would be a means, would it not, potentially, to recruit to the Royal Glamorgan Hospital to make the emergency department sustainable there?

Absolutely so, but I think there is still that reality check for me—and why it would be dishonest of me as a clinician to say, 'This is an easily solvable problem'—that the shortfall in consultants across the health board is 17.

But it's a potentially solvable problem, without the downgrading of A&E as is currently proposed.

It is potentially so, and Marcus has already described that he's given that challenge to us that no stone should be unturned in doing that. But again, there is that reality check on us of the size of the task: 17 consultants, 20 middle-grade doctors. When we look at the response rates to adverts for these doctors, they are very low in A&E. There are so many jobs advertised nationally at the moment. I'm privileged to know a lot of medical directors across the UK, and I've rung them to say, 'How many responses have you had to your advert?', and every single one of them has come back and said, 'No responses at all.'

But you can make yourself more or less attractive. You mentioned training, for example. I wonder what consultation there's been with HEIW about the impact of proposed changes now on the training status of the Royal Glamorgan, given that we want it to be given the highest possible training status. Would, for example, the deanery be ready to allow the training of anaesthetists, without trauma and emergency surgery, at the Royal Glamorgan Hospital?

We have had conversations with HEIW. We're back to that difficult problem of, actually, has a decision as to which model we can proceed with been made? No. Is all the detailed information about that model yet available? No. Therefore, to be fair to HEIW, they aren't in a position to be able to approve or not approve a model until that detail is there. But we remain confident that, with the overnight closure model, that would not have an impact on training for anaesthetists and intensivists, nor an impact on training for our surgical doctors. Indeed, if we look at precedent from England, units that have overnight closures in their emergency departments retain training for emergency medicine doctor. So, I would have an optimism—because I agree, there's an optimism and a can-do attitude in this—that we would aspire to restore training to the emergency department at Royal Glamorgan Hospital. Clearly, that would only take place under the overnight closure model or if it was to remain open 24 hours, it wouldn't happen if there was a minor injury unit.

And just to clear that up: when do you think you'd be able to give an absolute assurance that there would be no threat to anaesthetists training at Royal Glamorgan through the proposed changes? You give the impression that you're fairly sure that that's the case; I can imagine some would like something a little bit more concrete than that.

Absolutely, and we do need to have that definitive decision. Only when that modelling is complete—. Would it be helpful to describe how that modelling is happening? Because we've touched on that a couple of times. So, I suppose the modelling is in two parts, if not three. One is: the crude numbers. How many patients attend our departments? And we're looking at all of the departments, not just the Royal Glamorgan Hospital, because we need to understand the impact across the whole health board. So, what are the numbers of patients? Where do they come from? What's wrong with them? How many of them are children? How many of them are adults? How many of them have a minor illness? How many of them have a minor injury? How many of them are more unwell and will need admission?

And you can imagine that that is a hugely complex piece of work. It was done in 2013-14, but it's now being redone to take account of and make absolutely sure that changes in local housing, changes in the way we provide healthcare, changes to the age of our population and the multimorbidity—the many things that may be wrong with patients—don't change the planning and the understanding that came out in 2013-14. It would appear that the numbers actually remain roughly the same, and that most of the housing changes were anticipated at that time. So, that huge number-crunching exercise is currently taking place.

There's a challenge to that, because some of the planning looks with the benefit of hindsight at where patients should have gone; but of course, as a patient, you don't know, always, where you should go. So, therefore, we're really challenging that by putting patient scenarios through to say, 'What about the mother with a young asthmatic child who lives in the Rhondda? What about a frail, elderly patient with dementia who lives in Llantrisant?', to give some reality to that modelling. I think, as a clinician, that gives me far more confidence that we can own that data and trust it.

The other bit of the modelling work—and why it's taking a significant amount of time before we can give HEIW that model to look at—is working with our clinicians. We have clinical reference groups looking from the various specialities, really looking at the numbers, looking at clinical pathways to say—with their huge clinical experience, both doctors and nurses—what does this mean for our patients? Do we think that this pathway could safely be delivered? What changes are possible? That also means they have to go and look at models of care from elsewhere in Wales, and elsewhere wider in the UK, as well as abroad, as to what are the options.

So, if there's that slight challenge from yourself as to why haven't we got the model for HEIW, it's because we don't want to go to HEIW until we're absolutely confident that we have clinical models that understand the risks to patients, that minimise those risks, that clinicians own, and would be deliverable. That's the work that's currently under way.

But you are in discussion with HEIW—

We are, yes.

—so they're aware of everything that's happening.

We're having that sense check on the models, and the sense check would suggest that the overnight closure would have a minimal impact on training. In fact, it has the opportunity to enhance it, whereas, clearly, the minor injury unit model would have a more significant impact. 

Okay?

Okay.

David, on this point.

Rhun started off asking the question, 'How did we get here?' Now, I understand all three of you were not in your posts in the 2014 programme, but it's clear that the situation is that we've been working—. It's been coming along the line. I suppose there is a very serious question as to the governance in this sense: why didn't action be taken sooner? Because the conspiracy theorist in me, if I had one, might say that the transfer of Princess of Wales let you off the hook a little bit, because you knew that you always had your next-door department that you could work with. This time last year, you didn't have POW in your pocket, in your armoury. But let's take that to one side.

Why do you think this wasn't addressed earlier than this? Because I think that's a very important question. You're facing a challenge now, I accept that; and you're looking at the models to provide a safe solution, I accept that; but why wasn't action taken sooner? Because if you only had one consultant and you knew they were due to retire—. If I remember right, the story was that he was due to retire in September anyway. You knew he was due to retire.

Absolutely. 

That was not going to be known two months ago, that would have been known years ago, because you would have worked out the age of the individual and when he was due to retire. So, why are we now finding ourselves with you having to make decisions that weren't made before? The models weren't put before. You're doing it now. Why weren't they done before? I think that's an important question to ask. 

I just can't answer that. I mean, what I do know is the organisation, previously, did concentrate very heavily on its finance and its activity, and that's been well evidenced through the reports that have come out during the summer. And I think you're absolutely right that the Bridgend boundary change was an enormous amount of work for the organisation, so, I think, certainly in the last year, when it was working through that boundary change, there were a number of things that perhaps it might have given more time and attention to that became slightly less important because of the work that was needed on the boundary change.

I think, looking back, that the work that was going on with respect to the emergency medical model and some of the strengthening into the community is, again, where the concentration was happening to try to build those building blocks. But, it is a really difficult question for us to answer. We've look back through—

Okay. I'll leave it to you. But, perhaps, this afternoon, in your board meeting, your board should reflect upon it and ask themselves the very same questions. Some of those board members would have been in position longer than you. 

Angela's got a supplementary on this point as well.

Yes, specifically on the point that David made, because, actually, you may be frustrated but, trust me, we are so frustrated because where's the corporate responsibility? 'Oh, look, a new team comes in, it's a brand-new ball game; we've got nothing to do with the past.' Well, somebody somewhere—. There is a chain of continuity. This health board didn't just suddenly reinvent itself when you guys turned up. There has to be corporate responsibility. You know, I have never run a health board, but I have run other smaller businesses, and when you go in and you take over a business, one of the first things you do is survey the canvas you have to work with; you find out what's happening, what's going wrong, what's working well, and build yourself forward. So, I struggle with the notion that you don't really know what went on in the past. I appreciate you may not want to say it for political reasons, or because you don't want to diss the previous incumbents, but nonetheless, I am horrified that if you really are going to sit here and say that you don't know what went wrong over those last few years, because you are, obviously, clearly, highly intelligent, driven and experienced people. You must have been able to walk into there and have a look. That's my first comment. 

And, my second comment, and it slightly comes back on the driver that Rhun was trying to push, is that it is important for us to challenge you on this, because, you know, it's not just about Cwm Taf—this is happening in other health boards all over Wales. Hospitals are allowed to wither on the vine for whatever reason, and we need to understand whether it's deliberate, whether it's accidental, whether it's because of workforce and cultural pressures. So, we have lessons to learn here so we will continue to press you on this, because I think it's really important. But that corporate responsibility is my issue.

And Lynne will continue to press you, as well. 

I totally agree, and it isn't just about Cwm Taf. I spent two hours yesterday in committee discussing why it will have taken us four or five years to deliver a mother and baby unit in Wales. You know, there are real issues here about health board delivery that we need to get to the bottom of, and, I think, we should have an explanation as to why insufficient action was taken from 2014. And I support the south Wales programme—it's great for my constituency and the surrounding area—but isn't it the case that Cwm Taf just didn't buy into it?

Can I perhaps try and help a little bit on this? So, this is an attempt to reconstruct the past, and so I may or may not be right, but, looking back over the—. For example, you can look back over our annual integrated medium-term plans—the plans that health boards produce. So, you can track that. That's an interesting indicator, really, of what was being said about these issues over the last five or six years, and I think what emerges from that, if my reading is correct, is that the health board accepted the decision, to take your point, accepted the decision around the south Wales programme—and we're talking now, particularly, about the emergency medicine bit, but, of course, there were two other bits as well, which have progressed at different rates.

I think what the health board were saying is that there are a number of enablers before we can implement the south Wales plan in relation to the A&E department at RGH. So, we need to develop the medical model, which we've heard a lot about; there were some capital schemes that needed to be put into place; we needed to develop the infrastructure in the community, which was crucial; and there was a lot of work around advanced nurse roles as well, to try and boost the department. So, I think what you see from looking back over those documents is the health board setting about those enablers, and they took some time.

In the meantime, I think what the health board was saying was, 'We will do everything that is necessary to ensure the safety of the department in the meantime', fully recognising that the numbers of staff actually decreased over that time, as people left, and it was difficult to replace them for the reasons that we've already spoken about. So, I think last summer, the department went from two consultants to one, and now we're going from one to zero, so you can see the gradual decline over that time for obvious reasons, I suppose. What the health board was trying to do, I think, was ensure the department was safe while putting the enablers in place.

The idea that we're now looking at in considerable detail of a reduced-hours consultant-led service—so a fully fledged consultant-led service, but for reduced hours—I can't find, unless I've missed it, any trace of that actually being considered before relatively recently. That's a departure from the south Wales plan; that's not in the south Wales plan. As far as the south Wales plan is concerned, the Royal Glamorgan would reduce to a minor injuries unit as soon as it was possible for that to be done when these enablers were in place. So, we've now put on the table a new idea. We're evaluating it, we need to see if it's going to work.

It does, at first sight, have some attractions. For example, it addresses the point that Rhun was making about the training of staff; it has the potential to do that. It has the potential to provide a consultant-led service for the vast majority of patients, actually, who currently attend RGH, and we're looking at the numbers there, but the vast majority. So, that's a new development that's come on track recently. I can't see signs of that being considered in the past.

So, that's my best attempt, really, to try and give you a thumbnail sketch of what's happened over those last five or six years. I think the health board were trying to put in place the enablers, and then we reached the situation that we're in now, which, as you say, is what was envisaged by the south Wales plan, really.

I feel I must slightly respond to your challenge, Angela, if I may, as well. So, yes, you're quite right, new teams come in and of course they have a very good look back at what we're receiving and where we think we need to go forward. So, as we sit here, there is a big organisational culture and structural programme at work, right across the board. It's got 10 very specific programmes that get right at the culture of the organisation, the approach it's taking, its operating model, how it's working, how staff can talk up, how patients, staff and people can engage. All of those things, I'm afraid, are material to how the board got to where it was.

So, the assessment of where we got to and why we got to there is quite complicated, as you would expect in a big, complicated healthcare organisation. I guess, in a sense, what we're talking about today in terms of the emergency department is one of the service issues that have to be tackled that perhaps have fallen out, in a way, because of all of those other bigger and wider systems issues.

So, I guess I felt I had to respond, because I wouldn't like you to be left with the thought that we haven't done a very extensive look back at the entirety of how the whole organisation has operated, conducted its business, all of those sorts of things, and then put in really enormous, extensive programmes to get quite a change going forward. But, whilst we're doing that, there are issues that will come up that we'll have to address. I think I said to you right at the outset, when I looked at what we were working with as a board, back in the summer, the situation with A&E was one of the things that we knew had to be worked through with some solutions one way or the other—definitive solutions coming out so we've got a coherent plan going forward.

I'm afraid I am back to this issue of—. I completely agree, we need to learn from the past, but at the same time, we are where we are, and we've got to try to find a resolution and a way of moving forward. Again, coming back to what Marcus has said at the board and what the board had said with regard to the 24/7, you specifically tasked the officers with leaving no stone unturned, which was absolutely about going back and revisiting the recruitment, ensuring that we are doing everything we can. We are in a slight chicken-and-egg situation, as Nick very well knows from some of the recruitment conversations we're having. People want certainty about whether we're going for something that is 12 hours or 14 hours, or are we going for 24 hours. The 24-hours one is a disbelief. This is tricky stuff, but we need a definitive vision and a definitive view that feels workable that we can start moving to. I guess where we are is we also have an interim contingency plan that keeps things safe and manages the risks at a level while we're trying to get to that longer term sustainable plan.

Rhun.

I'm not sure whether this is a comment or a question, really, but you said you had been taking a look back at how the organisation has been operating. You then started to address, actually, that you need to look back as well at what has been happening on the ground within A&E at the Royal Glamorgan Hospital. You, Mr Longley, talked about going from two full-time consultant posts down to one and now zero, as if that was totally inevitable, whereas perhaps if there was a real understanding of what was happening on the ground and what the barriers were to retaining it at two, or going from two to three, when in other hospitals you were able to recruit, what were those blocks? Are there ways, moving forward, of removing those blocks, so that you could be confident that you wouldn't actually be facing the same frustrations that you have been facing over the past five or six years in trying to recruit?

I think you're right. It's not the hard, what the minutes show of meetings, for me; it's actually what was being done, what was the soft information on the floor that was informing those conversations and the huge value we've had. Because three consultants have volunteered to move over from Princess of Wales Hospital to the Royal Glamorgan Hospital, albeit not working full time there—between them, they bring just over one full-time equivalent. With their huge experience, that's exactly the work that they're doing, understanding (a) what we can do now, as we've already discussed, but (b) what were the barriers and which of those barriers are real and which of those, actually, if we worked in a more flexible way, could we find a way around. 

And there is such a thing as turning a new leaf. I remember the fight to retain consultant-led maternity services at Ysbyty Gwynedd. We were told that the reason consultant-led maternity services had to go was because they couldn't recruit. Of course, when the decision was made that, actually, no, we do need to retain this consultant-led unit, surprise surprise, they were able to recruit, because a decision was made that, whatever the barriers were, they had to be taken on and passed. We now have a sustainable maternity unit, consultant led, at Ysbyty Gwynedd again. That's what supporters of retaining full-time A&E at the Royal Glamorgan want to see happening. Faith has been lost that every effort was made over the past six years in order to try to keep it. 

I'm confident that we can significantly improve our recruitment, that we will bring a number of consultants in and a number of middle-grade doctors in. However, it would be dishonest of me to say, 'Actually, I know we can do this', when every expert in the land I speak to says that, actually, the step-change that's needed in order to deliver the 24/7 cover is so huge that, actually, it doesn't look in the art of the possible. But I will always remain optimistic.

As I tell my children, it doesn't matter how you do, as long as you've done your best. In this case, we need to be able to measure very, very carefully whether your board has done its best. The conclusion that a number of us have come to is that, perhaps, you could have done better and you could have avoided the situation that we're in today. 

Perhaps, just to help, Rhun, I would pretty much agree with everything that you've said, I think. We've got a number of opportunities now. So, to be clear, the board has said, 'Leave no—', repeating the phrase again, 'Leave—', if I can say it properly, 'Leave no stone unturned.' And, we mean absolutely that. So, what does that phrase mean? Well, it means the sort of things that Nick's been describing, I think. You know, it is drilling down into, of these 50 doctors, for example, how many could be persuaded and what would we have to do to persuade them? It does mean—

And why did they leave at the time? 

Yes. Well, they haven't necessarily left, but, their style of working is to do—et cetera. To use the advantage that the Princess of Wales gives us now, actually—. And by that I mean the two or three really experienced, highly regarded and respected leaders of the profession, really, who we're lucky enough to have in our hospital now—to bring them in to do that work. So, fresh people, fresh approach and no assumptions from the past—all of that is, I think, really good. 

And the third point you emphasised, which I think is absolutely true, is about certainty in the future. If you do all of this in the absence of clarity about the future, it probably won't work. So, that's the bit that we now need to come to, which is, 'What is the future? Is it what the south Wales programme said, or is it something else?' And our real hope is that it can be something better than what the south Wales programme said, but we're not yet at the position to make—. And the last thing we must do is make a false promise and lead people up the garden path, and then disillusion people in a year's time. 

Okay. Angela, you've got some stones that need to be turned. 

Yes, a slightly different tack.

Sorry, hang on—.

Can I just follow up on a couple of points?

Of course, yes. No problem. 

I think that's crucial because what Rhun was saying—and you've talked about recruitment—is about the certainty of what lies in the future. So, are you saying to us that if you go for—and I'm not putting anything in your mind—14 hours open and night-time closure, that is going to be certain and long term, and therefore, you will be able to recruit? Because, if you still have this uncertainty over you, you're not going to recruit, because you're struggling now and you're not recruiting.     

We've set out a number of criteria that whatever option we go for has to meet, and absolutely at the top of that list is sustainability. So, there is no point going into something that is so fragile that you can't rely on it. How do we know it's going to be sustainable? Well, the answer is, we don't know for absolute certain, because we can't. 

But can you give a commitment that, no matter what, you will do everything to make it sustainable? 

Correct. 

And that includes no further considerations. You will go out and recruit if you have to go out and recruit.

Yes. And a very clear plan at the beginning about what exactly that means, so that the board, apart from anybody else, can be assured that we're not going into something that really doesn't actually solve the problem at all. 

Okay, back to Angela's un-turned-over stones. 

'The Parliamentary Review of Health and Social Care in Wales' recommendation 4: 'Put the people in control'. Can you tell us what you did to talk to the general public about these proposed plans? 

Chair, I'll start off. So, there are a number of bits to that. The Community Health Council, for example, is one point of reference for us and so there have been conversations with the Community Health Council. We have now started a whole programme of public events, if I can put it in those terms, so, opportunities for members of the public, whoever wants to, to come along and engage with us and to understand what it is that we're trying to solve, and in due course, what the proposals are. We've been very fortunate to have a number of public meetings just in the last few weeks organised by local politicians, which have been extremely well attended. 

They've been a rearguard action, Marcus, let's be frank about it.

I don't think rearguard, no, I think—. We very much welcome all opportunities to engage with people. There is loads of stuff around social media and so on and so on, but this is—. We're only just really starting this, there is still lots more to do be done.

One of the difficulties that we're grappling with—and you'll understand this—one argument is that, 'Well, we did all that back in 2014, and the decision was made and, therefore, all we've seen is a delayed implementation because various things had to be done in the meantime.' That's not a view that the board is accepting, because, well, I hope, for obvious reasons, the world has moved on in the last six years; a number of the people who were around then aren't around now, and anyway, you can't say to people, 'Well, you're bound by a decision that was made years ago that you know nothing about and you can't have a voice.' So, we are doing all we possibly can now to engage with people. We had a meeting yesterday with the campaign group that has been set up to save the A&E department in the Royal Glamorgan, and so on, and so on, and so on. So, we're doing all we can now to listen to people, and throughout all of that, to be painfully honest with people. The last thing we want to do is give false hope, but also, we must be optimistic and positive about the future, so we're trying to strike that balance. 

When the health board had its big conversation in 2017, did the challenges facing the A&E departments, and, in fact, the hospitals throughout the health board really get communicated to people, and what was the feedback you were getting from the general public, from stakeholders?

I'm not absolutely sure, because I think that sort of predated my arrival really, so all I know is second hand, from what I'm told. I think there was—. Certainly, certain facts about the situation were obvious—waiting times and so on, and people's experience of very busy departments, even three years ago was very evident, I think. And, I think, the line running through all of that is that we were, at that stage, I guess, part way through the implementation of the south Wales plan; these enabling measures that we've spoken about were in the process of being put into place, and a new model had to be found, new roles for nurses and so on in all of that. So, I don't know whether that really answers your question, and because I wasn't there experiencing it myself, I'm a bit cautious because this is all a bit second hand. 

I think one of the questions I'm trying to drill down to and understand is just how well informed the people who will be served by the services you provide are, and how much consultation has been given to them. Because consultation is such an easy word to bandy around, and it's bandied around on a frequent basis, but, actually, I find that people are very seldom not consulted as much as perhaps everyone claims they should be. I read with real interest your communications strategy, your communications and engagement strategy. When did you actually implement this, because the whole document is full of 'We will' not 'We are', so I wondered when it's actually going to start?

If I can, with that one, we started thinking about the communications back in September, when the conversation about needing to do the work on accident and emergency services started. So, the plan for intensive public engagement was programmed in for the beginning of March rather than February, and we've had to bring that forward. So, we were starting a series of public engagement and involvement sessions, which wasn't the formal consultation; it was about how we were going to talk with communities in communities. 

Why did you have to bring it forward, if I may interrupt?

Because of the issues, the risk issues that arose over Christmas, when we felt that we needed to bring the discussion about A&E forward, because of the risk issues—the consultant leaving, the level of locum et cetera. So, our plan for how this was going to work through the year, in a sense, the risk levels for the services that we were providing had gone up significantly, and we felt that we just couldn't leave that.

So, we planned in public engagement sessions, starting in March time. Those have been brought forward into February—our public engagement sessions; I'm not talking about the sessions that have been facilitated or organised by political colleagues. We've also been talking with the institute of consultation around public scrutiny sessions, which is quite an interesting methodology, where members of the public come and talk in a more, I guess it's a more organised way, in the sense that you can have a more—. I'm struggling with the words, but you can have quite a constructive conversation, because I guess what we're finding, although the political meetings have been very interesting and informative, it's been very difficult to have a conversation, whereas the engagement sessions that we've started to run—not as well attended yet as we would have hoped; I think we had 40 in the one in the Rhondda—where you're able to have smaller group conversations, and really listen to what people are saying, listen to their views, listen to where some of their solutions are—. So, we'll be running more of those public engagement sessions over the next month. If we need to extend that into April or May, we will.

And inevitably, once the board takes a view on what model it wants to go with, then there's the whole issue about formal consultation, but we're nowhere near that at the moment. What we're doing at the moment is the discussion around what the situation is, what the potential solutions are, listening to the public and listening to staff. And in a sense—I know we've had some criticism for this, because some folk have said, 'Well, why on earth haven't you come to us with very fully worked-up propositions and models?' But when we started talking about the propositions and models, the general advice that we were getting at that stage, and the conversation was that it would be much, much better to talk about the issues we're facing and listen to people's views, before we go out with very fully worked-up models.

So, we're betwixt and between, I guess. But at the moment, where we are is: how do we do active engagement and involvement—different to consultation? And when we get to that bit about statutory formal consultation, we will. And then back to Marcus's issue, of course, on the minor injuries unit piece, there was extensive involvement and consultation done back in, whenever it was—2012, 2013, and 2014. So that's where we are at the moment. And the engagement and involvement for us as an organisation is as important with the staff as it is important with the community. So we're learning how to do that well.

And in addition to that formal engagement and consultation, actually looking to see how we can involve service users in some of the design work, so, for instance, patients with particular access difficulties, or learning disabilities, or particular experiences with particular conditions. Whilst it is very powerful for the doctors and nurses and therapists to be involved in the workshops designing the model that will then be engaged, the formal consultation is actually using that patient experience to test and improve the design of. So it's those three stages.

And in a sense, the proof of the pudding is in the eating, isn't it? And the feedback we've had already, just in these few weeks, has been really helpful—honestly. So, people are raising issues with us that perhaps we wouldn't have prioritised sufficiently. But there's nothing like hearing people expressing their personal difficulties—so, particular service users, as Nick mentioned, people living in particular communities, all the various other challenges that people know about because they experience them. And that has been coming across really strongly and will change the thinking that we do—the number of factors we'll have to consider more seriously, perhaps, than we would have if we hadn't listened in the first place.

There are the three Cs, aren't there? It's communication, consultation, co-production. And any organisation, it doesn't matter whether they're a health board, or some mega—ICI, or whoever it might be, the British Army, whatever, any organisation, if it's trying to make strategic changes, has to really be on its game when it talks about communication. And I am always staggered by health boards' complete inability to do this. I have seen this in Hywel Dda, we have seen it in Betsi Cadwaladr, we are seeing it here, where it's too little too late—when the stable door's already been opened, and the herd is in full outrage mode, and charging down the street.

I read your communication and engagement strategy, and I was really concerned about some of the inference that I got from it. I didn't actually get the overriding belief that the population was a significant stakeholder—oh, they're a stakeholder, sure enough, but the real stakeholders are everybody else. The bit in here about how to communicate with the population is probably the smallest bit about it. I was just really concerned, and just want to make the comment—because it's not just you, it is throughout Wales—that we need to wake up. We're in a media-savvy world, social media is rife, there are a lot of people who will look, in great detail, at every minute that you ever produce, at every meeting you ever say. So as soon as that was first tabled—. There's nothing in this that says that there's a pre-discussion exercise. There's nothing in here that says, 'Before we get to the point where we're going to start actually saying to each other in public, "Oh, we think we might have to take these decisions", what do we do about making sure that some of the briars are taken away from the path so that people can understand where we're going, that it is a discussion and that they are involved?'

And you made the comment, Sharon, that we're learning about how to do a good—. Learning? Where's your team? It's not just your people who push out your standard major releases. I would expect that if you're doing something this significant, you actually have got really good professional people who are not doing what you do—because you're good at what you do—but you need people who are really good at what they do, and what they're good at doing is communicating—not the consultation bit, but the communicating bit. Because the scenes we've seen outside the Senedd: the hurt, the upset, the anger—. You've got a whole chunk in here about communicating with politicians. Well, you obviously didn't communicate with politicians, because all the politicians have been pretty outraged. Were they all fully briefed on the proposed changes?

They were.

Were they all—? Did you have meetings with every single one of them?

We did.

Every single politician involved in Cwm Taf?

We did.

Because I will go back to them if that's the case, because that's not what they're saying.

Did you outline the plans to help support staff, how to support the community, what the future vision is with the Royal Glamorgan Hospital? But when you had those meetings with them, did you actually take on board their feedback? When did you have those meetings with them? When have you had the meetings with all the staff at the Royal Glamorgan Hospital, the Prince Charles Hospital and the Princess of Wales Hospital? You know, the staff-side representatives. And then right at the back—right at the back—there's a teeny-weeny bit on poor old Joe public,

'To clearly understand what any proposals changes mean for them'.

And that's what I find the saddest, because I understand and recognise completely that medicine is changing. We cannot deliver services the way we've always, traditionally, delivered them: there are not enough people; there's not enough resource; everything is so much more expensive; and population expectations have changed. So, there are hard decisions that have to be made; there will be unpalatable decisions that have to be made. What I simply have never got my head around is the complete inability of those people who are charged with those decisions to not handle the situation better in terms of going out to the ordinary person who lives on the housing estates just behind that hospital, or up the valley, because they feel absolutely disenfranchised that they haven't been communicated with and that actually there's not a lot of point in communicating apart from shouting with rage, because whatever they say doesn't get listened to. How are you going to tackle that?

Can I come in first and then I'm sure Sharon and Nick may wish to as well? Angela, I wouldn't disagree with what I think is your central point: could we have done better? We clearly could. And I'm sure other health boards in other places over other times could have done better too. If you're comparing that with a gold-standard engagement, we are not gold-standard and we know that, and I think probably the health service has never been gold-standard. I think what we have done is to—. And recognising the factors that we've mentioned already about the accelerated timescale and so on and so on, but I don't want this to sound like we're looking for excuses. I think what we have done is that we have engaged conscientiously with politicians. Whether we've spoken to every single one or not, I don't know, but we have certainly done all that we feasibly could, I think, to engage with politicians—often one-to-one, but also in groups. So, I think we have a good understanding of politicians' views on this and there's a spectrum of views.

I think we have had some attempts, over the years, to engage with the population, but they have been a long way short of gold-standard. So, should we have done more? Probably. Could we have done more? Certainly. The only explanation I can give for that discrepancy is that the health board has a number of priorities and finite resources and we've tried over the years to strike a balance between those two things. And inevitably, in the reality of the world, prioritising clinical service delivery, ensuring safety and improving quality, perhaps too often, trump things like engagement with the population.

Yes, and I accept that there is a resource issue, but I think why I'm so exercised about it is because the entire parliamentary review, and then the subsequent vision for health—or 'A Healthier Wales', whatever it's called—it's predicated on the involvement of patients, population, staff. It's predicated on persuading people that they can do without seeing a GP; they can go and see an excellent nurse practitioner. It's predicated on saying, 'You don't have to go to hospital; you can have a community service.' It's predicated on saying, 'This is about you. You're the important thing. The whole point of the NHS is to serve you.' It's predicated on training, helping, developing, educating people to make better choices: so I eat less cream cakes, somebody else gives up smoking, somebody else has less to drink; whatever it might be. So, we talk about that as the—. And this is why I get so frustrated about this, because we talk about the fact that it's all about them and then stuff like this happens, when they are really just so far down the agenda.

So we take that completely on the chin. Could we continue to do staff involvement, engagement, people engagement, partners' engagement better? Absolutely. And one of the big planks of organisational systems change work is how we do engagement and involvement. We're growing the internal resource and trying to work out what that needs to look like to be able to do the sorts of things that you've been talking about, Angela, and we know we're a long way away from it. The new operating model is all designed around person and community, so going forward, we're not designing around services; we're designing around and we're organising ourselves around people and communities, so I take it completely on the chin. We're trying to do our best. It's not good enough, but we'll continue to work really hard on it, and it's one of the reasons why we've said that if we've got to extend the time required to get to whatever our eventual model is because we've got to do more involvement and engagement, so be it, we'll do that.

We are still learning, I'm afraid, and maybe that is a sad indictment. We've been trying lots and lots of different tools and methodologies over the last while. We're getting better at social media, including things like—I never thought I'd be doing these—Facebook Q&A sessions. Lots of face to faces. The face to faces tend not to work well, so a lot of our drop-ins are not well-attended either by staff or public, and even when people say, 'We want x drop-in': not well attended.

We're persisting with them because we haven't got the right mix of tools, but what we understand is this isn't about one size fits all. It's not about one methodology. We've got to have a whole suite, and it also builds up over time, because what is very, very clear when we talk with the public, and most of our staff are our communities, because it is—. We were at, what was it, the RCT scrutiny meeting, and when they were doing declarations of interest, I think almost every single member of the council had a declaration of interest with respect to and involvement with CTM.

So, our staff are also our communities, so they can give us a lot of information on how do we best engage, and the staff are saying to us, 'Actually, Sharon, we don't know how to do this either, because we're not used to it. We don't actually trust that you're serious about wanting to listen.' We've got pockets of staff. I don't think pockets of community, although maternity—ladies and families in maternity—are starting to trust that we really are listening. We've got pockets of staff starting to trust that what we're setting up and the direction we're going in truly is about listening, involvement and influencing, but my goodness, have we got a way to go. So I take that completely on the chin.

I don't underestimate the challenge, but I just think, if you can avoid an obvious own goal, that's the thing to do. I represent an area where we've had three absolutely disastrous attempts to reconfigure services, and to be honest, I think that they could rebuild Withybush, Glangwili, Prince Philip and Bronglais in shiny gold with every single thing in it, and the population still wouldn't trust the health board, because it's got that bad and my warning would be: don't let that happen. Don't let that happen. Take the people with you. That's what it's about, because it is there. It is theirs, and it is the fact that it's all about, the parliamentary review and the whole Government strategy, it's about taking people with them.

The board meeting later today is all about the board listening to what we've heard from the public and our staff, so far. So, today's not a decision-making meeting, it's talking about what we've heard so far. So, we are trying, but, granted—a long way to go. 

Okay. Can I just ask from the Chair, are there any changes or huge impacts for other staff—[Inaudible.]—situation at length? But, obviously, there are implications for nursing staff, as well, and obviously for the ambulance service. So, can you just detail what sort of discussions are ongoing with those particular facets, as well?

So, if I take the ambulance service first, because, absolutely, they are absolutely key, both to quality of access for patients to any service and if there are to be any changes in the service, what the implications are for them. So, the Welsh ambulance service are involved both in our project boards in the governance structure, at both our own internal project board and also the regional board. Because this does have potential implications for our neighbouring health boards, so we have a regional board structure that includes adjacent health boards but also includes the Welsh ambulance service. That's the right thing to do, but probably the most valuable thing to do is involving the Welsh Ambulance Services NHS Trust in those clinical reference groups, so that as our clinicians look at potential changes and how services could change—both between sites and within sites—that WAST are there in the room. So, for instance, coming back to that fractured neck of femur pathway, where we say that, actually, as in other parts of the UK, why does a patient with a fractured neck of femur need to go to an ED? Why can't they go straight to the orthopaedic ward? Well, it's all very well for me to say that that's a good thing to do, but, clearly, it's the ambulance service that convey that patient who needs to decide whether the patient does or doesn't have a fractured neck of femur. So, absolutely, closely working with them.

In terms of other members of staff, we have, perhaps wrongly—I don't know—made it a little doctor-centric thus far. Nurses have been involved, but, I think, in the next round of workshops, as well as that co-production with the public, is really making sure that we include the therapists and the nurses from within our health board. And, as the models develop over the next weeks and months, in particular is looking at working with colleagues in adjacent health boards. So, absolutely, I understand the importance of that.

Thank you. Angela.

And general practitioners. So many of the general practices in my particular constituency—one of the comments that has come out loud and clear many times, particularly in reference to whether Withybush disappears or not, has been that, to attract people into general practice, general practitioners like to be able to look over their shoulder and see a good, fully functioning, full-service hospital behind them. So, are you going to be talking to GPs about that element of—?

Not only are we, we already are. So, they are involved in a clinical reference group, and not just the GPs. I have a bias, I suppose; I am one, so I fully understand the potential for GPs, but also the wider primary care and community care facilities. It's also involving pharmacists, our community nurses, our community mental health teams in those discussions, because as well as addressing the fragility of our workforce, which we've been talking a great deal about, there is that potential to reduce the pressure on the emergency department, as we mentioned at the beginning, by stopping patients coming there in the first place or turning them around faster, and that's where primary care and community care are of particular importance. So, yes, that's happening. 

It's probably worth saying on that one, with the way we're reorganising how we work, the clinical director, the clinical leader of the Rhondda Taff Ely patch is actually a GP, so he's providing the clinical leadership over that whole grouping going forward.

Okay. David.

Thank you, Chair. We've had quite a discussion this morning on certain points, and when you go back to your board this afternoon, I hope they also reflect on not just what you've been told by staff, but also what actions they could have taken prior to this to ensure that we didn't arrive at this point. I think that's crucial, because we still haven't got down to the bottom of, 'Why did we get to where we are?' 

In relation to the models, just listening to what he just said—. Clearly the models are not going to be, necessarily, a quick process—it's going to take some time. So, I'm assuming, therefore, that we won't have a final definitive set of outcomes from the board until those models have been completed, so we may be several months away, possibly. In those models, will you do two things? You've talked about the training aspect and you've talked about HEIW, but are you also going to look at what the implications for those models are for the long-term service provision of other services at the hospital? Because I've seen, first-hand, how services do get moved once you lose an A&E department, and doctors don't always come to the hospital because it's not part of their rotation. But also, are you going to ensure that—? Can you give guarantees that the service that's currently available, which should be 24/7, will be fully operational, and supported and staffed in the meantime? Because you've highlighted—I think I've heard you highlight today—that there have been occasions when you've been forced to close or almost close. What people want to know is, whilst you're considering the final solution to the challenges you're facing, that there's a service that will be there, and that it's staffed properly. 

So, we are absolutely committed to providing that 24-hour service during this creation of the straw man, if I may use that term, describing what the model is and then working out all the operational aspects that would need to take place in order the enact that model. I can't give you that guarantee, though, because we saw, on Christmas Day and on Boxing Day, overnight, that we just weren't able to provide staff in the department. If we were to face further challenges, we remain optimistic that we could bring staff in and de-escalate the problem, but you'll understand that, at the end of the day, if we don't have the staff available overnight or at any other time of day, then we can't keep the service open with no staff.

So, what we'll be doing is—. The contingency planning is trying to maintain that 24/7 at a risk level that we think is—I don't even want to use the word 'acceptable', but a level that we can accept. It certainly won't be fully staffed—it can't be, because we've talked about the difficulty in getting consultant A&E staff, and the reason that we've been working with the consultant staff from POW, in particular, but we've been having conversations with Cardiff as well, is to try to get staff that will support our unit so that we can keep it as safe as it can be, 24/7, whilst we're working up the unit. But as Nick said, we can't guarantee it at the moment. So, what we're doing all the time is, you know—what our contingency is that manages the risks in that unit to a level that staff feel they can work with, and that we think is reasonable for the public as well.

I had hoped to have a very transparent escalation process, so that instead of relying—because I'm afraid these things always happen at a weekend or on a Friday night, that's the nature of healthcare, that's when problems occur. I had hoped, and still am hopeful, that we can create an absolutely clear escalation tool that says, 'If X happens, then you do Y to the department'—being really clear about the number of staff that we need. But the more we look at it, it's not that simple because it relies on the experience and the knowledge of the team that's there that night—the multidisciplinary team involving middle-grade doctors, consultants, junior grades, and how much cover is available from adjacent hospitals. So, although we are having that transparent objective escalation tool being embedded, I think there will always be a subjective assessment to that, which, I guess, is where, Sharon, I carry the can on that—making the call, as we have had to do on a couple of occasions recently, as to whether we can keep the department open. On both of those occasions, we were able to say, 'Yes, we can. We can mitigate the risk adequately.' 

And I'll just ask, in that case, in those circumstances, I'm assuming you have a plan in place to notify the public as to whether there's a situation in which you cannot deliver the service at Royal Glam? 

Of course, the honest answer to that is, 'If it's very last-minute, no we can't', as happened on Christmas Day. We recognise we had a very junior doctor in the department, supported by nurses, supported by doctors from other departments, but it was only at about 5 or 6 o'clock in the evening that we became aware that, due to sickness, we weren't able to adequately staff that rota. On that night, we were able to inform neighbouring health boards and WAST, the ambulance service, but, clearly, it would have been impossible on Christmas Day, at 5 o'clock, to notify the public.

What we are recognising, and it's only happened on two discrete occasions thus far, and we remain optimistic that it won't happen—. What I think we do recognise, however, is that if that was to be happening frequently, we couldn't continually be opening and closing the department, because that would just get so confusing for the population. But that last-minute unexpected closure—we've looked hard, talked to other organisations, and we found no way of effectively communicating that message.

Last question, Rhun, unless Angela's got one. Last-but-one question.

Is there a danger that where we're talking of the Royal Glamorgan Hospital as being a liability, in a way, in that shortages cause knock-ons for other hospitals, but, actually, the hospital and the emergency department—its capacity to deal with significant trauma there actually acts as a relief to other hospitals? I've heard reports of A&E consultants at the university hospital in Cardiff saying, 'For goodness' sake, don't close or downgrade A&E at the Royal Glam, because that will mean us here in Cardiff not being able to deal with it.' In the same way, do you have figures on how often the other two hospitals within your board area divert intakes to the Royal Glamorgan Hospital, because I've heard that perhaps those figures could be significant and that other hospitals are unable to deal with trauma at times, and there may be thousands of diverts to the Royal Glamorgan Hospital because of its role?

I think the definitions here are quite important, so at Christmas Day and Boxing Day, overnight, we remained open to walk-in patients, because of that lack of communication and were able to mitigate that by using other staff. So, we are in close communication with the other health boards as to how we would cope with those—I don't like the term 'walk-in', it doesn't sound very respectful of people who are particularly worried or vulnerable—but how could other organisations cope with those walk-in patients?

Trauma, of course, doesn't come to the Royal Glamorgan Hospital anyway, because trauma goes to Princess of Wales and to Prince Charles Hospital and then centralising down into Cardiff—

But there's a difference between significant trauma—some trauma does go to the Royal Glamorgan. Major trauma—

Absolutely, at a lower level, so your broken legs, your fractured necks and femurs will come to the Royal Glamorgan Hospital, but if you're involved in a car accident, it's more likely that you would go to Princess of Wales, UHW—University Hospital of Wales—or Prince Charles Hospital.

And I don't think anybody's arguing against that. 

So, that close communication as to where we can pick up that capacity most safely, with the minimum amount of travelling, is under constant discussion, also how we can move our staff around the health boards in the event of any short-term closures, but also, as we've seen with the Princess of Wales, have consultants supporting the hospital in the longer term.

But do you agree with the point I make that the Royal Glamorgan Hospital is useful in having that 24/7 capability now in keeping the pressure off other hospitals, be they within your board area or in other areas?

It's part of an active system, a dynamic system. The front door—we haven't had to close the other hospitals to admissions from ambulances at any stage, or at least since I've been here, and, to my knowledge, we haven't historically. We do, routinely—it's a part of routine management—actually look at the capacity in the emergency department, how many beds we have in the hospital and divert patients from, for example, Princess of Wales to the the Royal Glamorgan to de-escalate the Princess of Wales, and we work between health boards as well. Princess of Wales may take patients from Morriston Hospital to de-escalate the risk to patients at that time. So, it is an active and dynamic system, and, of course, if we take one piece out of that dynamic system, then it does put pressure on the other sites.

The straight answer to your question is the Royal Glamorgan is crucial. There is absolutely no way that we could sustain healthcare provision for our population without it, and there are 65,000 people currently attending the A&E department, and those are people who need and will always need help from the health service. Our challenge is how we do that in the appropriate place and safely and sustainably. But the Royal Glamorgan is absolutely crucial.

Okay—

One more question—

Go on, then.

Is the south Wales programme still fit for purpose in the context of population and demographic changes and house building projects—the sheer numbers of people that have been added to the mix and will be?

I think what I would say about that is the modelling work that was done is still extant, so I think that's still relevant. However, just by virtue of you seeing that we've put a proposal forward that is not part of the south Wales plan, that will tell you quite a lot about our view of service provision in the round, and how we think that needs to be rethought. 

We are modelling—. So, the specific issue about the housing developments—that's part of the modelling that Nick describes. So, that's absolutely integral, yes. 

Thanks. 

Okay. Angela. 

My question is—well, actually, yes, I think there's very little doubt that the health board's going through a fairly torrid time at present in a number of different areas, and there are lots of different inquiries and investigations that look at drill-downs going on throughout the whole health board. And I appreciate, totally, that you're the new team on the block, and you're about dealing with the situation as you find it, and moving forward, and that is absolutely right. But nonetheless, do you feel that you'll be in a position in the months to come to be able to pull together and identify certain golden threads of, basically, where it went wrong or where the focus got inappropriately shifted, or whatever, so that we can have a true lessons-learned exercise, which could actually apply not just to Cwm Taf, but actually throughout Wales?

One instance I would pick up big time, and even from what you've said here, is the culture within the staff and their ability to trust their employers, essentially. So, that's obviously a big golden thread where, for whatever reason, it's gone wrong. So, I just wondered if you might—. If you feel that—. Is your intention that, in maybe a year's time, you'll be able to do a look-back and say, 'Right, these was the lessons learned from Cwm Taf—how not to do it', so that we can actually apply that learning across Wales? 

I'll say a couple of things and then I'm sure Sharon will want to say a lot. Absolutely right, so we've been trying to strike this balance between getting on and tackling issues, but learning lessons from the past, and without doing too much of one or the other, because there are traps on both sides. I think we have learned an enormous amount over the last year or so, from all of the maternity work that was very, very instructive and, as you say, there have been other looks at other elements of the service. We have learned a lot and, I think, one of the golden threads, if you like, is regrounding this organisation in a set of values and behaviours that we're all absolutely clear about, which are very, very simple things, but that sometimes get lost in the hurly-burly of busy jobs and all the rest of it, and then to live those values so that we and the staff are in no doubt that what this organisation is about is these things, and that we can all be proud of those things.

Yes, and, actually, that piece of work is currently under way and it does involve patients, which, hopefully, will be quite beneficial. I think we've absolutely got to learn from the past, both good and bad, because, without that, you just, you know—. Any chance we've got of moving out of the cycle of doing things the same old way, well—. So, we've been trying to talk about how we glance back—concentrating on the future, but always glancing back. So, everything we do we're just asking, 'And what do we learn from going back?', but not to dwell on the past, because it does become quite tricky. And I guess the question will be, 'What's the next bit of concerted learning that we might need to do some review work on?' Because you'll know that in the summer—it was November, wasn't it—HIW and the Wales Audit Office published quite an intensive piece of work that was looking at governance around both corporate, quality, and it got into culture. The maternity work has been a drive for quite a lot of the culture work.

So, there may well be, as we're going through this—some of the specifics around whether it be recruitment, whether it be a response when there's an agreement about a plan—why has that not been delivered? We know that's going to be really useful learning because, with some of these things, I'm afraid, we do keep going around the cycle. The communication issues—really important. I think we've done a lot of learning already on communication, involvement and engagement, but we've got, as I said earlier, an awfully long way to go. So, this bit about glancing back, moving forward and looking forward but always keeping that—just always testing it against what's gone before—is part of the approach going forward. So, I would like to say, yes, in a year's time. But pinning us down to something when there's so much going on at the moment I think is—

I think it's more: is your intention to have a position where, at some point in the future, you'll be able to turn around and say, 'Well, this is how not to do it', and 'This is how we are doing it'?

Yes. 

And, as well as our leadership, our corporate responsibilities in that, there's also, really, I think, supporting individuals, because actually—. And that's in a holding people to account, formal way, but it's about holding the mirror up to individuals and saying, 'Actually, there's an awful lot you can do as an individual and you can do within your own team to change things and to look back'. So, absolutely, there is that responsibility for us as leaders, but I think it's a change in culture throughout the whole organisation. 

One of the tools that we will be using—again, we've been learning from maternity and elsewhere—is a maturity matrix alongside some of the big, organisational pieces. So, leadership and development, trust and confidence, engagement and involvement, using a maturity matrix approach—which has to be evidenced—where you can see progress as you're moving along in those big, chunky, organisation-wide areas. So, we've almost got those matrices completed, so those will be actively used to test the organisation as we move forward, which I think will be very helpful.

Thank you.