National Assembly for Wales

Thank you. I'll come in on that question and, as you say, I think it has been a particular issue through the whole pandemic phase. To start with, I'll just emphasise that in our early stages of the response, the first thing we did in March was set up our own PPE cell, led by the director of nursing here in Hywel Dda, and really that was partly to ensure that, in those early stages, when guidance was fluid, that we had clear communication with our staff, that our staff knew what they should be wearing in which sort of situations, and really keeping people engaged with it. I think our overall approach has always been, and remains, to give staff confidence that we have the right PPE, they know what to wear in any situation and they're confident to do their jobs. Our primary concern in all of this has always been to protect our front line.

As we sit here today, we've got good levels of supply of all our PPE. We have a daily dashboard. We get the results back every day through that cell—everything I'm pleased to say is green with many days of cover, and that information, importantly, is shared with both our trade union representatives and our staff through our various channels. Again, it's about trying to make sure that people know that PPE is there and they're confident in the supply. We also, at a very early stage, reached out to local authorities, to our primary care colleagues in care homes to ensure that there was mutual aid in place and we were able to help, and we continue to do that today.

I guess, looking forward, there is always the ongoing risks, because the virus has not gone away, of a second or more than a second peak, and clearly we need to ensure our supply chains are robust and there are still some international worries about that, particularly around some masks—the FFP3 type masks. We've had a lot of local innovation around that. So, some of this is about how we ensure we've got alternatives available for people. I've probably learnt more about PPE and masks in the last few months than I have in my entire career to this point. But, also, we were completely overwhelmed at an early stage with the number of offers of help that we had from our local communities, from schools, from local firms, from individuals, and we've been able to source a number of things actually locally. Schools gave their science goggles, local people were making gowns for us that were washable, we had a local very rapid quality assessment run by our infection prevention and control team. So, we were able to work both with the national efforts around getting PPE into Wales, and also locally with local people, and we've been hugely grateful for that. 

Thank you very—

I think you've muted yourself there.

That's off mute now?

Yes.

Can you hear me? Thank you.

So, very, very similar to colleagues in Hywel Dda, and I guess the first thing to say is that the response from both the staff as well as the local community has been quite extraordinary right from the outset of all of this. I won't repeat all of the issues that Steve has discussed because they're just so similar. We have been sharing a lot of the experiences across the health boards right from the outset, so there's been a lot of cross-learning—where things have worked in one health board, we've adopted them in others. So, likewise, we had a very specific concentration on PPE; ours ran through the finance director lead because he ran procurement and he worked very closely with infection prevention and control colleagues because of all of those safety and quality issues. We spent quite a lot of time on well-being and psychological safety with our staff, because there was quite a lot of, I guess, fear in how you could become competent in donning and doffing PPE, using PPE, and then, particularly, as we started to get difficulties with some of the supply chains, the same items, which had different brands, looked very different and often also required further training. So, enabling the staff to become comfortable with multiple different brands of the same items has been one of the issues that we've worked through throughout.

As with Hywel Dda, we've kept the communication, I think, going very well with the staff, and that's been fed back to us quite consistently. We use PPE champions as well, particularly in the district general hospital sites, to enable people to have somebody to go to to ask questions where they were concerned. The same issues that Steve mentioned about supply chain concerns—we did have some areas, as with everybody else, where there were days where we were quite concerned about shortages, but that was worked through both in terms of the national mutual aid and working with national and local procurement. The local community's been marvellous with some of the offers, and, particularly, we work very closely with the Royal Mint, and as you're probably aware, that then became something that was open to the rest of Wales and beyond, indeed, particularly in respect of visors.

So, we too have a daily briefing, a daily stock take, of where we are with PPE across all of the areas. The working with local authorities and other partners has got stronger as the pandemic work has gone on, particularly in respect of things like mutual aid, where we can do that. I think, going forward, we would be very hopeful that all of the learning over the last while will ensure that our ability to work both with staff and partners on PPE—in respect of training, donning and doffing, mutual aid, how we deal with shortages of items—will become stronger and stronger. Clearly, we've got a much better view, from a planning perspective, of what we need to accommodate in each of our various areas. Clearly, the guidelines continue to change, so we've got to keep abreast of that. And as we continue to try to bring further non-COVID services back into the NHS, our PPE requirements on that have to be factored in, going forward.

Thank you. I guess this is one of the issues that we've got to really consider in a very live way and ensure that our supply chains are as strong as they can be. And some of the conversations, looking at local supply chains, will give us some confidence on particularly some of the PPE that will be used quite ubiquitously, whether that be masks, gloves, aprons, as opposed to the PPE that we will need in intensive care situations or on acute wards. So, I think it's paying attention to the full breadth of the services that we require to deliver to our patients and communities alongside our partners. There is no doubt in my mind that we will be requiring PPE in its various guises for quite some time to come. So, whether that be in general practice—. You'll know that dentistry, clearly, will have to have levels of PPE over the next while.

Keeping abreast of the transmission of the disease, what we know about the pandemic as it progresses, and what we understand about the science of the coronavirus, all of those things, I think, will guide how we need to develop and change what we're doing as we move forward.

Thank you. For our own staff, I don't think we have concerns around the capacity to do testing. Anyone who is symptomatic can get a test very quickly. We moved very early in setting up testing units across the whole Hywel Dda area. You'll be aware that we're very rural, so we needed to have a number of units around. We had five set up to start with, and we have the drive-through in the Carmarthen showground. So, our staff get good access when they need it. I don't have any concerns around the capacity. 

That's absolutely the same as Hywel Dda. We've got no issues with testing for our staff. The big issue is communication and ensuring that everybody absolutely understands and knows how to get hold of a test and what exactly to do, and we have to keep the communication running on that. The usual: you can never do enough communication.

Thank you. That’s an interesting question. I guess we’ve got to be very clear about why we would be introducing asymptomatic testing, and how we would go about doing that in a way that was absolutely systematic and confer value in terms of safety and value in terms of being able to keep our capacity up and running. And clearly, doing it in a way that is managed so that we don’t—. I mean, there’s a double jeopardy here, isn’t there? We absolutely want to know when we’ve got people infected so that we can isolate and so that we can manage the outbreak, but at the same time we need to keep our services up and running.

So, we have certainly, in Cwm Taf, been doing, every week, some testing of up to 50 different staff randomly in high-risk areas to try to keep that knowledge of what sort of level of transmission we’ve got in our staff, as well as being able to isolate staff in a managed way. We’re finding that the numbers of staff infected who are coming through those random samplings are low, which is good, and we continue to do that. So, certainly, as a strategy going forward, assuming that COVID remains with us for some time, as we want to bring more and more capacity in, and assuming that we can also continue to improve our turnaround times, I think it will be a tool that we will want to use more and more to enable that non-COVID capacity to come back on for our patients as well as to keep our staff as safe as we can.

Fifty is a pretty low proportion of your overall staffing, so you could imagine starting with increasing that tenfold, for example, just to get a bigger picture. Would that be something that would be attractive to you? It makes sense to me.

Yes. We started by doing this in what we called our high-risk areas—so, for example, the accident and emergency department, intensive care areas and the acute ward areas. So, I think there is a way of managing to do this, rolling it out carefully and thinking about those sorts of areas where staff may be most at risk, or, indeed, looking at it where we’re bringing in patients who may be the most vulnerable—that we want to secure things to be as safe as we can for them. So, I think there’s a way of doing this, and as we become confident that the capacity that we’ve got—that the tests can turn around—. Because we’ve never had a problem with sampling capacity; the issue has been being able to get the lab capacity ramped up to a level that could meet an increase in swabbing capacity. Because there is plenty—and I think you’ve heard evidence—of lab capacity now, and it’s about ensuring that the turnaround times in the labs are really smart so that we can really utilise the benefits. So, it’s something that antigen testing could bring for staff.

That’s all very, very useful. Thank you very much for that. If I could ask you at Hywel Dda, also, to tell us what you’re doing in terms of staff sampling and if you’re following a similar procedure to Cwm Taf, and also, what you would think of having firmer guidelines from Welsh Government, perhaps, on insisting that you test all, or at least a significant proportion, of your staff on a regular basis so that we can identify what’s happening out there.

Yes. On the first half of that, we’re very similar to Cwm Taf’s description. All I would add to that is that I was in Bronglais yesterday at the emergency department—and we’ve also started doing antibody testing for staff to see who’s had it in the past—and the lead nurse in the unit was telling me that they’ve done about 50 per cent of their staff there now and they were surprised at how low the antibody test positive rate was, which, in her view, probably demonstrated that PPE was being used appropriately and that staff didn’t get the exposure that maybe we were concerned about, which was really positive. So, we're continuing to—

Do you remember—? Sorry to interrupt. Do you remember what the figures were, roughly? Are we talking 10, 15 per cent, or—?

I think it was less than 10 per cent. I think she said they had four positives out of about 50 staff, but I'd have to double check that number.

And I guess all I would add is, in terms of the guidance, I think we need to be guided by what our microbiologists and virologists are saying about how best to use the testing. Because whilst I agree that we absolutely want to ensure that our staff are protected and that they in turn are protecting our patients as they come back in for non-COVID-related treatment, we need to be aware that you do get a level of false-positive rates. And as I understand it—I'm not an expert—but as the rates of transmission in the community fall, as they become very low, the risk of a false positive goes up. So, you may end up with many more—and I think we saw some of that, particularly in Ceredigion, where we know had some of the lowest rates of infection probably in the UK. So, there is some suspicion that a number of the tests coming back are false positives.

And getting false positives is better than getting false negatives, of course, in terms of addressing outbreaks. Is it your concern that you are putting your service delivery at risk because you're asking people to isolate who perhaps aren't positive after all and therefore aren't a threat to others?

That is a worry, because, of course, we've got four relatively small hospitals, with relatively small teams, and once you have a positive, you've then got to do all the contact tracing around that, which could mean you end up with entire teams being self-isolating. That could have an impact on our services. We've not seen it yet; I think it's just something to be aware of on the other side of the equation.

Okay. And Dr Hopkins said that she was concerned that the need to improve the rate of tests coming back within 24 hours—I don't think we need to labour this, because it's pretty obvious that we need tests to come back as quickly as possible. Is that a worry of yours, as well, when we've seen the number of tests taking more than 24 hours to come back actually increasing rather than the picture getting better in recent weeks?

I think it's really important. This picture is mixed, actually. So, for tests done using our own machines—we have machines in each of our main hospitals apart from Prince Philip now—we get those tests back within a matter of hours, which is really positive. But you're right, for those that go to the Welsh labs and the lighthouse labs, they're taking probably around 24 hours, but up to 72 hours, and clearly, when you're in a world where you need to contact trace rapidly, you need to know those results quickly so that you can get on with that as quickly as possible and break lines of transmission.

And this is what Betsi Cadwaladr told me yesterday in a briefing as well. That tells me that increased dependency on lighthouse, which is the direction that Welsh Government is moving in, is bad in terms of bringing us quicker results. Who's going to comment on that, perhaps?

I think, from my point of view—I know there's a lot of work going on to try and improve those turnaround times. Clearly, the closer the labs are to where we're doing the swabbing, the quicker the turnaround because you don't have things like courier services—that, naturally, banks the results, then. So, I think that's a fair comment. We'd want as much of it in Wales as we could, but, of course, I would say, in all of this, and it's been very true of the TTP process, we've been building, in a matter of weeks, what would normally take months or years to achieve. So, you know, that does need to be recognised, I think. 

Thank you, both. Thank you, Chair.

Diolch, Gadeirydd. Good morning, everyone. We appreciate fully the challenges that the health boards and the workforce have been facing through the pandemic, since the introduction of the changes by Welsh Government. But I suppose what we're trying to find out is where the most significant impact has been on your services during that time. I accept there's been a reduction in non-essential services because of the request from Welsh Government, but—. For example, when I read Cwm Taf board's papers, they actually indicated that there were five essential areas they couldn't deliver, particularly in relation to cancer. So, what has the most significant impact been on your service provision locally as a consequence of having to deal with the COVID-19 pandemic?

Cwm Taf first, then.

I think I'll take that one, if that's okay. I think it's probably fair to say that the COVID crisis did require many of our routine services to be paused, including elective surgery, some of our community services, and I think we probably have to remember that we have ramped up and managed to maintain many of our essential services, our emergency service, and we had a significant increase in things like critical care capacity. In doing so, that meant that our workforce had to be redeployed into those areas, which meant that some services did have to be paused. Actually, our activity has come back in line with where we were pre COVID. Our flows into our emergency departments are at about 85 per cent of what they were pre COVID, so the services are coming back in terms of our emergency flow.

But it's fair to say that probably the most significant pinch point within acute services has been around cancer and the associated diagnostics around endoscopy. Just taking the cancer position, we have managed to maintain things like chemotherapy and biologics in our off-site areas, which has been good, and we have managed to undertake some emergency care through our district general hospitals. Head and neck services, for example, for thyroid cancer in the Royal Glamorgan were undertaken, but at a significantly lower level. We have been fortunate to be able to use the Vale Hospital, the private hospital in our area, to deal with cancer surgery for patients that don't require critical care, and we've undertaken over 340 procedures over the course of the last three months, which meant that patients who don't require critical care are actually being seen, and being seen in a timely fashion.

However, we have got a number of patients who do require critical care facilities, and, at the moment—I looked at the figures yesterday—we've got about 90 patients who are awaiting surgery in classifications ASA III and IV. What we have managed to do there is that, as of this week, we have begun, on each of our three district general hospital sites, to be able to undertake that more complex surgery in what we've called our islands of green COVID-lite activity—so, access to theatres, beds and services—and taking a baby-steps approach to it, because we need to do it in as safe a way as we possibly can. We've already seen—I think it was 20 patients this week have gone through that, and we'll ramp it up to over 60 to 70 by the time we get into the beginning of August. So, you can see those more complex, urgent cancer surgeries are beginning to come back online.

You're right that, within our essential services space, there were a number of services that we were not able to provide in quarter 1. So, part of that was around upper and lower gastrointestinal, and, as I said, we're managing that and beginning to do that. Endoscopy services were only being provided on the Princess of Wales site in quarter 1. Endoscopy is now being provided across all three sites. We're about 40 per cent of activity we had pre COVID, and we'll be able to get that to about 70 per cent over the course of the next four to six weeks.

All of our urgent suspicion of cancers that required endoscopy have now been booked, so, again, that's a significant improvement in June to what we saw in April and May. So, I think what we can see there is our services are beginning to come back to life around that, but we've always got to be conscious of the risks around that, and, as Sharon mentioned previously, making sure we're testing staff and being able to test staff so we've got those COVID-lite areas in place, and also making sure we've got access to the personal protection equipment and making sure that patients are also able to self-isolate before they come in, because we need to make it as safe as we can for the patients and for staff around that.

There are clearly issues in mental health and primary care, but we'll be able to pick those up at a later stage during today.

That's the next question, don't worry.

Hywel Dda. 

Thank you. I won't repeat very similar issues, but just add a few add-ons from Hywel Dda's point of view. As has been said, the impact on electives of the suspension—it was the right thing to do at that moment; we needed the space and time to train our staff and organise our hospitals. But, clearly, the suspension of most routine activity across the health board has had a big impact. We had one of the best positions in Wales in Hywel Dda in terms of our waiting times for referral to treatment before we went into the pandemic. The worst we've ever been in the last five years has been about 7,000 people waiting more than 36 weeks. I think we'll very quickly get back to those levels, given the suspension.

However, we are, as Cwm Taf are, taking a cautious restart approach to this, and ensuring that we are starting to ramp up our services. I was in ward 7 at Prince Philip last week. They're quite excited about starting surgery again in Llanelli. Yesterday, I was in the Rhiannon ward in Bronglais, who are similarly excited to get started. Both of those hospitals have now restarted some of their electives, but we've got a long way to go to get back to where we were.

On cancer services, we did keep all of our chemotherapy going, similarly. I think one of the worries we had around cancer was the significant drop in referrals coming in, people seeking care at the beginning. We saw an average of about a 50 per cent drop in referrals, but in some areas, like head and neck cancers, we saw a more than 65 per cent drop. We did a lot of communication to people to ensure that, if you've got symptoms, please come forward. And I'm pleased to say we've now got back to more pre-COVID levels of referrals coming into the system.

And similarly for our urgent care, we saw a massive drop in people coming into our emergency departments. We're now back at about 98 per cent of where we were pre COVID. So, I think it is that step-by-step, cautious approach, communicating clearly with the public that primary care is still open, and if you've got certain symptoms you need to come forward, and us getting started in the background around particularly major surgery restarting. Andrew may want to come in on some of the more specific details for Hywel Dda if there's time to do that. 

Andrew.

Thank you. I think Steve and Alan have covered a lot of the detail that I would probably want to highlight. I think the key for us to remember with this is that probably the restart and restoration of services is more difficult and more challenging than perhaps planning and implementing the initial response—the simultaneous running of red and green pathways to help manage that COVID demand is a significant challenge on the way we provide services and maintain safety for patients and staff.

I think, as Steve has said, our main concern earlier on was just the noticeable reduction in referrals we saw for cancer, which were down about 49 per cent early on in the outbreak, and similarly for mental health and learning disability services. Depending on the nature of the service, we saw a reduction of between 25 and 60 per cent of referrals in. We're starting to see those referral levels return to a more normal level, and there are, obviously, as we've talked about, a number of challenges in restarting those services in terms of redeployment of staff. Our essential service provision has actually been fairly compliant throughout the period, and we have been offering services in Hywel Dda against the essential services framework. The big change really in recent weeks is the fact that we're starting to provide that on multiple sites now.

Okay. David.

Before I go on to the mental health agenda, which I want to ask questions on, both of you have indicated a reduction in referrals of cancer patients. I understand that, and that's probably because people are fearful of actually going into a hospital or a doctor environment, because of the fear of the virus. But for Cwm Taf, for example, I read the paper and it indicated that your diagnostic waiting times for eight weeks had gone up from about 1,800 to 10,500. Now, if those referrals had come in, could you have managed? Because that escalation in waiting times for eight weeks—that's huge. That's four times, actually five times, more than it was at the start. How would that impact upon your services? Could you have managed with those referrals being at standard levels?

Cwm Taf.

I think that's a very fair point. We know we've had a significant challenge in relation to diagnostics. Not all of that increase is associated with radiology, for example, and quite a large number of that was in endoscopy, and as I say, we are now beginning to get the endoscopy services up and running. We are working hard in terms of access to ultrasound, CT and MR across the patch. We have managed to get access to such facilities down in the Cardiff Bay private hospital, and therefore that's helping a little bit. Our radiologists are working through prioritising those patients that they would be seeing in terms of urgent suspicion of cancer. They are clinically prioritising those. So, I think you make a fair point. Had those referrals come in, it would have been a challenge, but we would have prioritised cancer patients in the first instance—and are doing.

Okay. Thank you. Let's go on to mental health, because you mentioned mental health as well, and mental health referrals. Again, there's been some deep concern over the issue of referrals and mental health and how the services would have been provided, and we've had indications that mental health services should normally be provided as they would have been, because it was a priority area. But we've also had notification that, actually, some of those services have not been delivered. What was the impact upon the delivery of mental health services in both health boards? So, I'll start with Cwm Taf and then we'll go to Hywel Dda.

Okay. As with physical health services, mental health services did prepare well for COVID. The key aim was agreed to protect our most in need and most vulnerable. We looked at our in-patient services first around that, and we prioritised all our in-patient units across the patch. They have remained open and well staffed, and in fact we increased the number of beds in the Royal Glamorgan by 10 and we increased the number of beds available within the Bridgend area for older people by 22. So, those—the most severe, the most in need, we've managed to maintain their services, and increase those services, because we felt that was really important.

That did require us to redeploy some of our staff from some of our community services, across all of our community services—so, local primary mental health services, community mental health teams, perinatal, eating disorders, substance misuse. Each and every single client that was on the books, they were reviewed, a clear plan was put in place as to whether or not they needed to have a face-to-face contact or whether it could be done with a telephone contact or video-conferencing. We've used the Attend Anywhere software quite extensively across mental health services.

In terms of older people's services, they are dealing with some of the most vulnerable patients. Memory assessment services and day services have been kept going on both a virtual basis and a face-to-face basis, where it was felt that was necessary. We've continued to provide some respite for those families who were in need of that sort of care, making sure that we were maintaining appropriate infection prevention and control and social distancing around that.

Our out-patient and psychology services have really taken on board video-conferencing and Skype calls, et cetera, and the feedback we're getting from patients is, actually, they quite like that. I have to say that the response from our third sector partners has been absolutely fantastic in the area, providing both direct support, digital solutions, Zoom support, going in and working with those who've been identified as socially isolated. We've had an absolutely fantastic response from them.

You mentioned referral rates into the system, and you were absolutely right. In terms of local primary mental health services, we've seen something like a 70 per cent reduction—something like about 1,000 referrals a month normally; down to about 340 a month over the last three months. But, in terms of our crisis services, psychology services and specialist mental health services, we've actually seen increases, and have been able to deal with those.

So, the really important point is: what are we doing about it? Well, our memory assessment services in terms of older people will be running back at full capacity from 1 August. We are beginning a slightly more reduced day dementia service from the end of July. We have ramped up the digital offer for our psychology services, and, most importantly, across our crisis resolution and treatment services, local primary mental health services and early intervention, we are planning for a 20 per cent increase in capacity around that, and some of that has already been taken up. We had six band 7 primary care nurses who were going to be going into primary care, and they are going into primary care to be working there, along with three advanced nurse practitioners, who had been working on care and treatment planning and are going to be deployed into our local primary mental health services to ensure that we've got capacity in there to deal with the referrals as they come forward.

Our mental health partnership, the 'Together for Mental Health' partnership, recognises that, to deal with the increases that we're going to have in terms of mental health referrals, there's got to be a multi-agency, multipartner response around that, and we've already begun work, looking at some of the evidence that's come out of England, from Louis Appleby's work in relation to where we're most likely to get suicide intent—in teenagers, adolescents and, actually, women over the age of 60—putting in support around teenage suicides, shielded families and those who have been bereaved and traumatised as part of the COVID response. So, there's a package of measures being worked on now in readiness for the late summer, early autumn, when we're going to start to see that coming through. I hope that answers the question.

Before we move on to Hywel Dda, one point: other than the last short piece about prevention for adults and young people with possible suicide prevention, I didn't hear, unless I missed it, about children's mental health services, because I know, for example, Cwm Taf deliver child and adolescent mental health services for a lot of health boards, and I would have expected to have some input as to how this has affected CAMHS. 

Yes, my apologies. So, what we did see in relation to CAMHS—and it has been our position, moving into the pre-COVID period, that we were very much improved from where we had been over the previous years—was the numbers of referrals coming in dropped off dramatically, and we actually deployed many of our primary care CAMHS teams into places like our T4 service in Tŷ Llidiard, again, trying to protect the most vulnerable children around that. 

We have restarted all of our primary CAMHS, secondary CAMHS community intensive treatment services, both across CTM and Swansea Bay. Access to those services is now within a week—less than a week, actually, in most services—but the number of referrals coming through are actually very small. So, we've begun a piece of work with our local authority partners, in particular with education, in terms of getting close to those children they are seeing on their pastoral care registers, and so on and so forth, to see if we can get closer to those, together with working with some of the circles of vulnerability that we have identified across CT and Bridgend in the past, and making sure that we're providing support into those areas too. 

I know Angela wants to come in. Just one point on that, then I'll let Angela in. You said you've transferred some of your primary care mental health into Tŷ Llidiard. Did that mean therefore that perhaps the less what I would term serious, which require specialist services in CAMHS—was there an impact on the assessments of those individual young people as a consequence of the transfer?

So, for every patient that they had on their caseloads—again, in the same way they did it with adult mental health services, every single child was reviewed, it was identified what ongoing care and treatment were required, and, where they required ongoing care and treatment, that was provided, sometimes on a face-to-face basis, sometimes via telephone contact, and so on and so forth.  

Angela, and we'll come back to you, David, then. [Interruption.] Sorry, Angela first, then we'll come back to Hywel Dda. Angela. 

It was just a quick point. I've been really interested in listening to everything, Alan, that you had to say, and it paints an extremely positive picture. But I do want to point out to the committee that yesterday I took part in a very large mental health round-table with all the third sector providers—Hafal, Samaritans, Mind, the Royal National Institute of Blind People and a number of others—and the story, the picture that they paint, from the user point of view is very, very different. Now, I'm not saying that it's Cwm Taf particularly—they were talking on a Wales-wide issue—but there's a real feeling on mental health that they were left behind because of the drive to deal with the pandemic. There are people with serious mental health issues who have still not been seen—one in five, I think it is, or one in four, have not yet had those referrals.

The words for CAMHS, which, I have to say, if Lynne Neagle were here, I'm sure she'd have something to say about this, but, in terms of CAMHS, the words 'utterly dysfunctional' and unable to provide these services, and there's a real sense that, because everybody's been very much concentrating on the physicality of trying to deal with COVID, there are a lot of people that have been left behind. And that's just people who you would say had the more middling to serious.

There's also a real concern going forward, and I'd be interested to hear the witnesses' views, on the fact that we mustn't over-medicalise what would be a very normal reaction to being in the pandemic. People will have lost their jobs, and so they're going to feel real pressure about that. People will have gone through all sorts of life changes, and we just need to make sure that we don't actually lump all of those people into, 'Oh my God, we've got to provide services', because we all have to deal with some of the stuff that life throws at us and not over-medicalise that lower level.

So, Alan, I'm absolutely not calling you out on this, because I think, by the sounds of it, you're doing really well, but, from the user's perspective, there's a real sense that there are a lot of kids who haven't had the help, they aren't far enough up the food chain, they've been refused by CAMHS, they've been told they're not sick enough, they're not unwell enough. There are a lot of adults who've yet to receive the treatment that they'd need, and there's a blockage as well at some of the severe mental health levels. 

Okay. We'll have Hywel Dda first, then we'll come back to you, Alan. Andrew Carruthers.

Thank you. One thing I omitted to say in my previous response was I'm very honoured to have been bestowed the honour of a doctorate through the course of the pandemic, but I'm not actually a doctor. So, I would feel a bit of a cheat and a fraud to continue with that belief, because there are far more qualified people on that front around this table than myself. In terms of mental health services for Hywel Dda, I'll try and address some of the points that Angela has just raised as well at the end from our perspective. 

But, very early on in the outbreak response, obviously, there was a natural pause to services as we redesigned and adapted to the way in which we had to work, but one thing we recognised very early on was that, actually, the best way for us to manage the complexity of the outbreak was to accelerate the 'Transforming Mental Health Services' strategy that we had signed off as a board around three years ago. I took up post on 1 December, and chaired my first transforming mental health strategy group at the beginning of the year, and I remember conversations there around changes and plans we wanted to make and initiate that were going to take probably time frames of a year to 18 months. Well, one of the positive aspects of the outbreak for us in Hywel Dda has been that we've really been able to accelerate the implementation of our transforming mental health strategy in terms of the service redesign and realignment of teams. So, on that front, we've managed to co-locate our community mental health teams and crisis resolution teams and we've been able to provide continuity over a seven-day period and provide extended hours. We've put in place single points of contacts for urgent referrals, for specialist CAHMS and for older adult mental health services to help us triage and identify high-risk patients quickly. We've centralised the section 136 suite, so we've now got that single place of safety.

We've worked—. One of the strengths of our response—I think it's been the same with our community response—is that round our local delivery team and implementation team we've had stakeholder involvement, both from local authorities and from the director of West Wales Action for Mental Health, which has helped inform and shape our response throughout the pandemic.

In terms of specialist child and mental health service crisis teams, we've continued to have face-to-face contact with all cases that are classified as high risk. And the early intervention in psychosis service moved to seven-day working, because we recognised that was a high-risk and vulnerable group.

As I outlined earlier, we've been concerned throughout this at the low level of referrals that we've been seeing into the service, although we have started to see that pick up in recent weeks. And I would echo, actually, some of your concerns, Angela, in terms of the over medicalisation of some of the response to this. I know that's a real concern for our mental health service and we're working—. We've actually set up—. One of the groups that gold command has set up is a public health cell, which is—. One of the tasks that they've been set is to specifically look at the well-being of not just us—obviously, there's a specific harm around staff—but also the psychological well-being of our population, how we support that, recognising that it's not necessarily defaulting to a mental health and learning disability service response.

So, I think—. As I say, from our perspective, we feel we've really managed to accelerate some of the transformational change that we really wanted to see. In mental health, we've managed to maintain services throughout the period. I think the big challenge has been that the default had to be moved to less face-to-face contact and more remote and the use of digital platforms, and, obviously, in terms of some of the interventions and therapies, that's a less effective way of treating patients. So, our big challenge over quarter 2 now is how we re-establish those face-to-face clinical sessions to really maximise the contact points we're having with patients. 

Okay, we need to move. David Rees. 

Thank you, Chair. Okay, we move on, and two quick questions then, in that case. Primary care—we've obviously been hearing about pressures in primary care services, and I just want to have an understanding of how you've been able to support the primary care services. We accept fully that—. Your papers indicate that GPs have been working to their full extent, as far as possible. But how are you supporting the primary care services? And I include, perhaps, dentistry and pharmacy and physiotherapy and all other types of primary care services to people, and I may even include district nurses, because, I would assume that, as people come out of COVID who have been in hospital, we are going to an increase in demand upon some of those district nurses services. 

Okay. Who wants to kick off there? Cwm Taf? 

Yes, Cwm Taf first. 

Okay. 

Don't be shy. Alan—[Laughter.] 

I'm not normally shy—[Laughter.] So, I could give you hours on primary care—

No, no, we haven't got hours—[Laughter.]

I'll get straight into the 'what we have done about it'. To take general medical services in the first place, we've got a strong resilient primary care service in Cwm Taf pre COVID, and I think that's really helped as we've moved through the pandemic process. What we've been doing, as a health board, to support them—where practices have been challenged, we've used our primary care support unit staff to deploy both GPs and nurses and some of our admin teams to go out to help practices where they had numbers of staff that were shielding and so on and so forth. Our primary care services were very agile and moved in very quickly to things like telephone-first models, video consultations, eConsult, and we rapidly deployed Attend Anywhere and eConsult out to all of our general medical services practices. The practices had a very strong desire to continue to operate rather than moving into hubs and spokes, and we supported them in doing so, but we had some very strong contingency planning put in place. And we used our military liaison officers to help us with that. They were really helpful in making sure our strong clusters could leap in should the need arise, and it has done on occasions.

We made things like our staff testing unit available to all primary care staff, so that if they needed to get staff tested, they could, and as quickly as our employed staff. We introduced our community respiratory hub, which allowed practitioners to use the hub to work with patients who had respiratory conditions and needed to be upping their medications and changing et cetera, to take a bit of work away from general practice.

We maintained weekly contact with each practice to make sure we know where they are, in terms of an escalation process around that. We have deployed a number of our healthcare support workers—some from our district nursing service, I have to say, and some from, perhaps, non-front-line services—into practices where they were struggling, particularly around things like phlebotomy, where they had issues around that. And I think, really importantly, we've managed to maintain a very robust urgent primary care service in the out-of-hours period. Had that failed in the out-of-hours period, that would have had a drastic impact in terms of daytime services, and we've managed to have a very robust out-of-hours service around that.

Turning to dentistry, we were able to establish very quickly five urgent dental centres across Cwm Taf, manned by our community dental service practitioners, and also practitioners from the dental teaching unit. They were able to provide urgent treatment, even including those where there were aerosol-generating procedures, using major PPE in the same way as actually they're using in our intensive therapy units. So, we were able to funnel PPE into our urgent dental centres, and also to some practices that were continuing to provide that level of care.

Just in terms of numbers, our urgent dental care centres in the first quarter triaged 3,000 patients and saw about 800, and did fairly complex procedures on them. Practices remained open for triage advice and scripts. We did supply PPE where we could and where it was needed around some face-to-face. They actually did 24,000 consultations over the telephone, and saw about 2,500. Slowly but surely dental services are coming back online. So, the urgent centres are continuing and will expand, and a small number of practices in each area will begin to open up to face-to-face contacts during quarter 2.

In terms of our district nursing services, they have been very resilient. We do have a very strong district nursing service in all parts of Cwm Taf. They have been particularly focusing on end-of-life care. So, the number of patients that we're dealing with in terms of end-of-life care who would have either been in one of our district general hospitals or within one of our palliative care units have actually been maintained at home. So, a significant increase around there. And we've been able to prioritise those patients. Equally, our district nursing services—where they've been able to do so, and where they've been required to do so—have focused attention around care homes that were having difficulties, linked in with our local authority partners around that.

So, it feels as though primary care services did what they needed to do, and did it well during the first quarter of this year, and are in a strong place to move forward. And the health board has been doing whatever it can to support them, as I've indicated around there. I probably could carry on for hours, but perhaps I'll give Andrew a chance to talk.

Andrew Carruthers.

Okay, thank you. Again, a lot of similarity and synergy with some of what Alan has said, as you'd expect. I think the areas where we've seen most significant challenge from a primary care perspective are around our community and general dental services, our community pharmacy and optometry. We've continued to provide—in terms of GMS, we've continued the provision of all essential services through the pandemic, and our national and local enhanced service provisions aligned with the national guidance on direct and enhanced services. We've had to—[Inaudible.]—in a number of our services, the red-to-green pathway concept, and we have found that useful across all of our services.

Community pharmacy—we particularly had issues early on with demand and the impact of increased demand, and also a reported increased anxiety amongst staff about what they were seeing and the risk to them, which we've worked with them to resolve. Dental services have been a particular challenge. We've had some capacity issues in our community dental services partly due to long-term sickness, but also the impacts of COVID and staff that have shielded and isolated. We have commissioned three additional—[Inaudible.]—centres and in terms of our current broader dental services, we've got five green emergency and urgent dental centres across Hywel Dda. We've established one red site in Llanelli, but to date that clinic's only seen one asymptomatic COVID patient.

Obviously, we've provided a lot of support as well in term of fit testing and support to staff through this and with the supply of PPE, and I think I'm probably, then, just in danger of repeating what Alan has already referred to if I go any further—

There's no need to repeat.

Okay. David, final question.

No, Chair, I'm conscious of the time and I think there are important questions as to where we go that need to be addressed first.

Thank you, Chair. I think you've mentioned in all of your papers around some of the key themes, and one of those was the support in place for staff to cope with the potential stress and burn-out arising from the pressures of the outbreak. Are you satisfied that there's enough support in place for your staff?

Hywel Dda. You're muted.

Sorry. I took my eyes off the screen for one second, sorry. [Laughter.]

New skills, new era. [Laughter.]

Thank you, Chair. At the very outset of the pandemic, we set up a steering group that I sponsored as chair, to give it the focus in the organisation. What I have heard when we've been going out is that staff are telling us they're actually looking after each other and haven't, since the beginning of the pandemic, accessed the support as much as we expected.

So, we provided a range of resources: the central hub of information, rapid psychological check-ins for staff and also for managers to help them to give them the skills to care for staff who are anxious et cetera. We've also learned from Italy: we've put face-to-face psychological support in the COVID parts of the organisation and into ITU, and we used—. We've had some fantastic donations from the public. So, we've put in place a rapid access for staff to access the moneys to help with their working environments, with wash kits. We learned from China and we put in place what we call 'calm rooms,' because staff said that what they really needed after a 12-hour shift in awful PPE and being very, very hot was somewhere that they could clean before they went home, where they could relax, where they could listen to apps, perhaps mindfulness. We call them the 'calm rooms' but the staff call them 'cwtsh rooms'. So, they're in place, but they're also in the community for district nursing staff; rainbow cards everywhere so people could see; there's been video messages from the chief executive and the executives—we've been out there.

But what we have seen is when you ask if it's enough, I think—well, we've had the greatest demand in June of the need for the psychological and emotional well-being services, and I think, as we get to this stage, then the demand is going to increase, almost as though we've gone through the tsunami. We know there are more waves ahead, and the calm is enabling people, really, to experience the stress and the anxiety that they've gone through.

So, one of the things that the chief executive has set up is a transformation steering group to learn the lessons from the pandemic for the future, and one of the key things there is what we're calling 'joy in work' or 'joy at work'. I think we need to build this support and continue it. I don't think it's just for this pandemic. It's something that really will be very high up and central to what we do in our organisation.

Thank you very much. So, very, very similar to what Maria has explained from Hywel Dda, we concentrated very heavily on listening to staff and trying to put in the supports that they felt would be useful to them, concentrating very heavily on well-being, both psychological and physical. The same issues on the rooms, and the resources have been increasingly made more use of by groups of staff, which is really terrific, right across the whole piece, and staff have been asking for all of these to continue. The well-being ones, similar to what Maria's talked about, have enabled—whether it be psychological counselling, whether it be meditation, head massages, all sorts of things—there's been quite a lot of working with the local communities on some of the things that have been offered in. We were already working on—I know in a lot of the other boards it's already done—our values and behaviours, and what had been coming through that prior to the pandemic was kindness and how we look after each other in order to be able to look after our patients. So, that work has really accelerated hugely during the pandemic, and a lot of the measures that have been put in place we will continue.

The staff communication, engagement and involvement—again, the same sorts of tools that Maria has talked about—video blogs, Microsoft Teams, big broad meetings with staff being able to come in. We've encouraged lots of discussion that it's okay to be worried, it's okay to feel tired, it's okay to feel a bit concerned, and it's how can we support each other through all of that. At the moment, I think our single biggest concern is the resilience, and, again, Maria mentioned—if people have been working on day and night on their adrenaline, in the last three or four months, we think the chances are that, going into the autumn and winter, things are going to be super busy again, so how do we encourage the staff to somehow get a little bit of rest, to recuperate, get that resilience back? We're working all the time on what that might that look like and what support might be used, and, of course, this is rather different, because with so many incidents in the past, work might be hugely stressful and very, very full on, but when you go home, you could get a bit of respite. But, of course, what everybody's been working with is not just all of that anxiety at work and all that stress at work, but when you go home to your home and your communities, COVID is impacting on every part of our lives. So, we're really working with the staff on what that sort of support might look like, and maybe being a little bit controversial, may I just maybe talk a little bit about some of the non-health-type support? So, the support that's been put in to look after children, for example, has been enormously well received, so we need to give some thought as to how we do those sorts of supports for our staff going forward, given what we're asking of them over the next little while.

Thank you. I realise that we don't really have actually much time before we potentially go into the autumn, so some of these things have to be put in place very quickly. And how are you measuring the staff responses and the feedback that you are getting on this? Because it's really good putting these things in place, but it's the reality on the ground and how people receive that. Are you adapting to what people are telling you at different times about how they would feel that—? The stress and burn-out: what could you do to help with them feeling stressed and burnt out?

Cwm Taf, then Hywel Dda.

So we're continuing on with the staff surveys. We do a whole lot of other tools: we've got a Facebook group, and we do Facebook questions and answers with different members of the executive team, which requires a direct response to our staff and—[Inaudible.]—said we did together; there are lots and lots of conversations down through the clinical leadership and into the management about what the staff want and require. I think we've got quite a number of examples of where things have been put in place as a direct result of conversations with the staff, whether that be the well-being room, the provision of free food during COVID, or, as Maria discussed, up in the ITU areas, enabling people to have all of those showering kits and things to enable them to have a better experience. Huge flexibilities; so being as flexible as we can with people's working environment and home environments, and really trying to listen hard. We don't get it right all of the time, but I think our channels for engagement, quite strangely, even though we can't do as much out and about and face to face, I think our channels for engagement and conversation have increased hugely over the last couple of months.

Okay. Hywel Dda, briefly, because we're on time here now. Hywel Dda.

Thank you. There are a number of ways in which we have listened and continue to listen, and will continue to listen. So, for example, we set up a closed Facebook for staff, with lots of messages, their views, and I think about 4,000 staff have been participating within that. The command centre was set up from the outset for staff, and it was a one-stop contact so they could go there with questions and also with their views. We've got virtual listening rooms as well, which have commenced this week. We've also undertaken a survey with Swansea University and the results came through last week, and there are some really interesting messages in there about the constant change and some inconsistences, so we'll be learning from those and we have a meeting on that next week. Our head of workforce has been meeting every week with the trade unions to listen with them. So it's constant and it will continue, and it's important—. We've also been out there, obviously physically at a social distance, to listen to staff, but it's important that staff also see the action from the messages that they've given to us, and we are committed to that. 

Okay, Jayne, are you—?

Okay, thanks. Yes, just my final question, Chair. Just looking back at the process for recruiting, deploying and managing additional returning staff, how have you felt that it's—? How do you feel it's gone and how do you think—? Do the individuals who came back feel that it was worth while and were you able to utilise all of those people who came back?

Okay. Cwm Taf.

Thank you. So, we didn't actually have a lot of success with returners; we had a much greater success with the call for staff to come in, new staff to come at a healthcare support worker level. However, of those that did come back, we had a couple of ITU nurses, which was absolutely phenomenal and really helped, and they've been great. So, the numbers were very, very small. I don't think we could have done anymore. We didn't expect to get a huge number of people coming back to Cwm Taf through that mechanism, but those that came through that mechanism were great. And I have to say that staff across the board, whether it was about retraining, redeployment—all of these issues—working with new staff in new roles, people have really risen to the challenge in a really amazing way.

Okay. Hywel Dda, briefly.

Yes, thank you. We were completely overwhelmed with offers of help down here, and you will see in the briefing note the number of people that we employed very rapidly. Our challenges are around registered nurses and doctors. The student nurses and the medical students intake that we were able to onboard was really helpful, but we also, I think—I'll have to double check the number, but we had, I think, more than 60 retired doctors locally all offer to help. Some of them were shielding at home, so they were doing stuff for us virtually, but some came back in and actually it was lovely to see some of their faces again because they've only recently retired from us. I think that just the general sense in west Wales of everybody wanting to pitch in was just remarkable. And the way the team worked, the workforce team, to employ people in a matter of weeks, with great support from Dyfed-Powys Police, for example, on background checking and getting that done very rapidly. We broke all records: in five days we interviewed hundreds and hundreds of staff. So I think it's been a real testament, and actually part of our wider transformation work is how we really build on that sense of community support for the local NHS going forward, because we still have challenges around ensuring that we've got enough nurses and doctors in this part of Wales. I think we've inspired a generation, actually, to think differently about potentially coming into the NHS, and we've got to capitalise on that.

Chair, if I could just add to that as well, one of the success stories was the retired GPs who came back, and they created a—well, they managed a virtual ward in the community. So those patients who'd had COVID, but it obviously was safer for them to go home rather than remain on the ward, we gave them equipment and enabled them to monitor their own oxygen saturation levels, and the GPs who came to work for us remotely checked in on them every day. There was an actual virtual ward. And we're looking and hoping to see if we can have that model continue within west Wales, which is a great model in a rural area.

Great. Time to move on with some agility, but some important issues from Angela Burns.

Steady on, Chair, you don't normally accuse me of agility. [Laughter.]

I'd like to ask a couple of strategic questions, and then a number of specific ones, because a lot of the things I was going to cover have already been covered.

I'm really grateful to both health boards for your written evidence. It was very detailed and full of hope and promise, whether it was Cwm Taf identifying areas where you wanted to let go and make transformation, or Hywel Dda talking about the transformation that you want to continue to evolve.

But I do want to pose a question: what is it about the pandemic, what was it that enabled the national health service in Wales to suddenly, after years of not being able to effect changes—Andrew is smiling—overnight, it has absolutely transformed the way that so many areas work? This is quite frustrating for those of us who sit on the sidelines, because we've had the parliamentary review, we've had endless Government initiatives about how we need to get the health boards and get the NHS in Wales to work in a completely different way. So, what was it? Because we didn't suddenly magic more people out of nowhere. There's been some money, but not a huge amount of money. So, what galvanised management to suddenly make those changes? What were the barriers before? The reason why we want to identify this is because this is really important to make sure that, as we go forward, we do not slip back into the old ways.

Excellent question, because we don't want to have to whistle up a pandemic every time we want structural change.

No. [Laughter.]

Who wants to kick off on that one? Go on then, Hywel Dda—Steve.

Yes, thank you, Angela. A really interesting question, upon which I have reflected myself. I think I've probably learnt more about being a chief exec in the last four months than I have in the 10 years that I'd been a chief exec up until that point. 

I think there are a lot of elements to what you've asked, and I think it's the right challenge for us, because we did make a remarkable amount of change almost overnight. I think part of that, from my point of view, looking into the organisation, was the clarity with which we made decisions. In some ways, it's easy to have a single thing that you have to deal with. Because what we were facing back in March, looking into Italy, seeing what was starting to emerge in Spain, was quite a simple, if you like, command requirement, which was: we need to double our bed base, we need to at least quadruple our ICU capacity. And people coalesced around those very simple instructions.

I think there is something for me about looking back at the previous world before the pandemic and the number of things that the NHS is asked to deliver, and whether actually that creates some of its own confusion in the system. 

I think the other thing I learnt, which is very much attached to that, is only make the decisions that you need to make at your level. A lot of the feedback—we've talked to about 170 of our staff about how it feels, and almost all of them have said they felt empowered, they could get on with things. And I think that's partly because, at the sort of gold command level that I chaired, we very much focused ourselves and were very clear about setting out what we were trying to achieve, but we allowed our teams to work out how to do that through the tactical and bronze groups that we set up. They came up with answers that we would never have dreamed of. So, that's something I want to keep going in the organisation. I want that sort of clarity to continue. 

But I will add to that the world was in some ways simpler back in March as well. There was less of a concern around some of the normal processes around developing business cases, around value for money checks, because we just had to get going. I want to try and see whether we can hold on to that clarity of decision making, that clarity of what the organisation's about, whilst recognising it's a much more complicated environment now than it was in the early stages of the pandemic. 

I think the other thing for me is I think it's probably changed the public's view about the NHS, both positively and negatively, I would say. The positive stuff is all the huge outpouring of support, how people wanted to help, the massive rise in volunteerism and just wanting to support your local teams. But on the other hand, I think it really underlined to people that hospitals are dangerous places, and viruses, whether it's this one or any other, they do find their way into our organisations. I think that's reset some of the behaviour for people. I mean, it's good to see that we're getting demand back into the system, but I think people are now, perhaps, clearer than ever about the need to ensure that we only bring them into our hospitals when we really need to, and maybe change people's views around things like the emergency departments.

So, I don't think we've quite—. I can't quite do justice to your question at the moment, because I think we're still cogitating a lot on that, but they would be my sort of early reflections.

Great. Cwm Taf.

Chair, if I can just come in. Thanks for the question, and I would agree with everything that Steve's said; I think it's very insightful. A couple of other key bits: one is money, you know, we were suddenly relieved of concerns about money, which are often very important. Secondly, I think there was a sense of priority, urgency and common purpose. For once, there was absolutely no doubt what it was that we were having to focus on and there was one priority, and that was really helpful. Thirdly, I think the decision-making mechanisms, as Steve said, are absolutely crucial: that sudden freeing up, that delegation and that empowerment of people, because there was no alternative, it had to be done because otherwise, we simply couldn't respond. And the fourth bit, the final bit I just wanted to throw in, which is an interesting one and probably a little controversial, is the element of trust. So, at each level in the system, I think people were having to trust the other levels. So, Welsh Government, for example, was having to relax a number of its normal processes; it simply had to trust people to get on, to prioritise and to do the right thing. And within the health board, we had to trust people to get on and do it. So, I think all of that was really helpful.

The key question, though, I think, from all of that is: if you can do it in war time, can you do it in peace time? And we're going to have to think very carefully through those now that the real world is starting to come back. But, really encouraging. And, in addition to all of that, lots of learning points along the way.

Okay. Angela.

Yes. Thank you for that. I think, actually, that's a really good analogy to use, Marcus, because I do fear that, as peace starts to break out, we'll slip back into this over-centralisation, this disempowerment. Years ago, I worked for a very, very extraordinary entrepreneur who said to me—his mantra to everyone was: I will never fire you for making a decision, but I will fire you for not making a decision. Because I think even if you make a wrong decision, you've moved on and you can learn. So, how do you think that you are going to be able to embed that?

And in reference, particularly, to Cwm Taf, have you managed to do all of that and still maintain the changes and the improvements that you were undertaking within the culture and the shift in culture that was needed after the maternity issues? How has that impacted it and has that still moved forward, because we were, as a committee, quite concerned about whether or not that would still be able to be embedded going forward? And we were actually, to be honest, as a committee, concerned about the pay-offs that we saw taking place and what impact they've had on staff morale and the people on the coalface, if you like, feeling that they've not been heard.

Cwm Taf, specifically. Who wants to—? Sharon.

Thank you for that. We had started an awful lot of work prior to the pandemic on things like values and behaviours, which I've already mentioned, the culture change, engagement and involvement. Our whole new approach was all about enablement, empowerment and decision making close to the coalface, and in a strange sort of way, the pandemic, although I really wish we hadn't had it, has absolutely fast-tracked all of those things that needed to happen.

Marcus mentioned trust. We're really having to trust our clinicians and our staff to do the right thing and for that trust to be very, very visible, and what that's done is that the teams, both the clinicians and all of our other disciplines—. It's done two things. One is the belief that we will enable them to do things, and this bit about empowerment and leadership across the system at all levels is real, and we have that in spades. It brought teams together in a way that we haven't seen for quite some time and probably would have taken an awfully long time when you're just doing culture change in a typical environment. And the value added—people learning the value added of multiple disciplines, whether it be the clinicians working with estates and caterers and porters. That sort of real multidisciplinary team working really took off. And we were fortunate that all of the work that had been done on quality and safety, and beginning to think about outcomes and the patient-, person-centred, again, was really fast tracked.

So, the eye wasn't taken off the ball, for example, on maternity. That work all continued. As to some of the engagement work that we've done into the communities and the staff, we fast-tracked from the learning from maternity, and that's really thrived over—certainly the staff involvement and engagement—the pandemic. And I think, then, there was the belief that we could strip away tiers of bureaucracy and control in a way that was value and made things better not worse.

We did have a few decisions that were made that turned out not to be the right ones, and the way those were dealt with was a conversation: 'Why has this not worked out the way in which we would have liked? What do we need to do about it? How do we move it on? Do we stop it, do we change it?' So, it's that active working, with, 'It's all right to get things wrong'. And I think, Angela, what you said about it being better to make a decision than no decision, the belief that this is how we really want to work—.

Bizarrely, we did manage to get our new operating model into place at the beginning of the pandemic, which is a clinical leadership model based on the localities, and what all of those teams are saying—and this has been under Alan's leadership, particularly—about the way they've been able to grasp the agenda, how they're trusted, how their teams are being built and supported, is that they're really energised. So, we have actually had quite a lot of energy and, I guess, new belief in that what we've set out for Cwm Taf as a way forward can indeed be delivered.

I don't want to be too 'rose-tinted spectacles' because, clearly, we've still got shedloads to do, and it's a big organisation now. We've still got lots of work to do with various staff groups, but when I think about what we were setting out last summer and where we are now, the pandemic, in many ways, as regards culture, values, behaviour, empowerment, clinical leadership, has enabled us to fast-track a lot of that. And even now, with the concentration on a quality impact assessment and harm impact of what we're doing, the impact of COVID is helping hugely to really put that lens of quality and safety right at the core of what we're doing. So, strangely, I actually think it's moved us forward. We've continued to work with our maturity matrix, through the targeted intervention issues, and what we've seen on that, in the discussions with Welsh Government, is that it's continuing to make steady progress. So, we don't think there are any areas in targeted intervention, quality governance, corporate governance, clinical leadership, empowerment, trust or reputation that have fallen backwards. And, indeed, I believe that some of those areas have materially moved forward over the last couple of months.

Okay. Angela.

Thank you. I'm going to ask one more general question, and I do want to get to some specifics, which I might just, for the sake of time, try to roll them all in. It's about the plans. So, I've had a look at some of the quarter 1 plans, and the outcome matrixes for some of the quarter 2 plans by health boards. And I suppose if Q1 was about intent, Q2 seems to be about, 'This is now what we're doing'. Although, even then, I still see that, you know, 'We're going to do it; we're going to do it in July; we're going to start this in August; we're going to move things forward', and it's slightly still ahead.

I know that, when the Minister asked you to put together your Q2 plans, he didn't put any criteria on you about winter pressures, although, Steve, I think, in your submission to the committee, you did talk about winter pressures. And my concern, I think, is that if, in Q2, we are still talking about, 'These are the things we're going to do; we're going to start services up at the end of July, in August,' then you're going to do Q3. Well, actually, winter pressures start happening to us, don't they, well before the winter—I mean, we start seeing that ramp up. So, it seems to me that the window for actually being able to try and catch up with some of this backlog, catch up with the diagnostic services, encouraging people who need help to start going back to their GPs, start all the referrals, is a very, very small window. My concern is that, by the time we get to Q3 and then Q4, that'll all be about how do we pull it all slowly back again in order to keep capacity and headroom for dealing with what we all believe will be COVID spikes throughout the winter. I just wondered if you could try and talk about that very small window of trying to catch up that we've got, what you think we can and should be looking forward for in terms of the winter pressures.

Will you also talk about whether or not you're able to implement or have thought about seven-day working, whether you've looked at how we're going to get the staff? Because, you've talked to Jayne about staff, you talked to David about redeploying staff and moving them around, and I was sitting there listening, thinking, 'Hang on, it's still the same pool of staff. These poor people are just being stretched more and more, moved around lots and lots, being told to acquire new skills and bounced about.' So, how are we going to be able to do all of that, given the staff haven't increased?

And there was one more: as well as the field hospitals, I wanted to ask about your thoughts on transferring to care settings and how that would go, given, again, that winter pressures really impact on care settings. There you are, Dai—I've asked all my questions in one go.  [Laughter.]

Great. Well, a quick trot through there because there are about 30 seconds each per question there, team. Dr Hopkins, do you want to kick off there, from the Cwm Taf point of view?

I'm going to pass straight over to Alan, because I think he is best placed to deal with some of the issues. What I'll say is that what you raise—. We don't have an answer to the staff issue yet, and that's probably our biggest single risk factor, going forward. Balancing all of those issues you talked about is a real challenge, and I think one of the biggest things that we're going to have to do over the next couple of months is that dialogue with our communities on what the resetting, accessing services and expectations are going to look like in reality, because they will not be the same. They absolutely will not be the same. I think some of the choices that we're going to have to make collectively are going to be quite tricky. So, I think that's going to be a really critical thing for us. But, on the detail, let me just pass over to Alan to do a little bit of the detail on where we've got with the winter planning to date.

So, I would agree, Angela, that quarter 1 did feel like getting intent, getting stuff ready, and, actually, quarter 2 has to be about the doing part of that. I now feel more confident, from the last week of June, the first week of July, that we have begun to do that kind of operating work that we were doing in the three DGHs, upping the work we're doing through the Vale Hospital, getting our endoscopy actually up to 40 per cent, 50 per cent in this month and then to 70 per cent next month. So, it does feel like we've moved from intent to action in a number of places around there.

In terms of the backlog, we have rolled out Attend Anywhere and Consultant Connect into a number of specialties, so it's being actively used by our GPs and consultants, and that'll be very good in terms of managing referrals into the system.

Sharon mentioned the integrated locality groups that we put in place. They're going to be fundamental in terms of that whole-system approach to how we move work in a transformational way out of hospital into the community, and they're already working and doing things around ophthalmology, heart failure, diabetes.

And we are working very hard at the moment in terms of what we could potentially do with Swansea Bay around Neath Port Talbot Hospital, which, although it doesn't have critical care capacity, has got theatres and beds. I know that's more in the kind of intent space, but, actually, there is some real, positive work around there.

I won't get into the detail of why we got the field hospitals. I could have, again, talked long and hard around that. However, what we have got is a facility in Bridgend that can be operationally ready within 14 days from a staffing perspective. It's using a GP and therapy-led model, and, therefore, will be ideal in terms of stepdown, recovery and rehab. And that's going to form part of our winter plan, because we have been using proactively our modelling capacity—I think we've suddenly become very aware of the modelling of healthcare numbers in terms of beds, et cetera. It's something we haven't done very well in Wales before, but we are using it a lot more proactively now, and we've mapped forward into quarter 3 and quarter 4 what we think the impact of winter is going to be in terms of emergency admissions over and above what a COVID spike might look like, and we've got that broken down by integrated locality group, and they're all now working through, 'What do I need in terms of COVID beds? What do I need in terms of non-COVID emergency beds, and what can we also continue to do in terms of elective surgery?' And the field hospital will form part of that metric. Not wanting to not use a field hospital until then, we're already using it for potentially—. No, we are going to be using it with the blood transfusion service, because they're running out of venues. We are going to be using it for some out-patient activity for the Bridgend and Taff Ely area, and the local authorities are very supportive of us using it around winter. We're also potentially using the field hospital capacity to locate our test, track and protect service down there.

Finally, linking into the care homes bit—I'm trying to run at 100 mph here—again, we actually discharged fewer people into care homes in February and March of this year than we normally do. We have got good relationships with our care homes, and, working with our three local authority partners, we meet on a twice-weekly basis. So, my deputy, along with the heads of adult services in Bridgend, Merthyr and RCT, meet to look at any escalation issues, and we have been identifying where care homes have got problems. We are putting in place support around that, and we're absolutely using the guidance that came out from Welsh Government around the 28-day rule, and so on and so forth. Sharon was absolutely instrumental in ensuring that, in our testing strategy, we actually proactively went into care homes, so we were even ahead of Welsh Government guidance around that. As it stands right now, actually, across the patch we have got quite a number of care homes who are quite happily accepting patients back out from hospitals, so we haven't got significant levels of delay in hospital activity associated with the 28-day rule. We are watching that on a day-to-day basis, so, if we do get a problem, we can be immediately on it. That's a bit of a quick trot through in terms of the numbers, but I hope that answers some of the questions there.

Alan, just very quickly, in that very small window we've got between Q2 and Q3 to try and catch up, do you have any feeling for how much catching up you might be able to do on the backlog?

I have to say, Angela, that's something that we are working through in terms of modelling our referral-to-treatment position. We have got substantial numbers of patients waiting over 52 and 36 weeks. The total quantum of the waiting list hasn't changed; so, there have been 62,000 people on the waiting list since October, but the numbers over 52 weeks have gone up by about 2,000, and the numbers over 36 weeks have gone up by 11,000 in that three-month period. I have to say, going back to conversations we had earlier in the morning, we have to take these baby steps in relation to what we can restart. Once we get more confidence around it, I think things will move, but we're not going to get into that backlog; it would be foolish for me to say that we are. I think we've got to keep it daily in our heads.

Hywel Dda.

I'll come in—I'll probably try and be quite brief. There'll be very similar issues, but I'll maybe just give some Hywel Dda specifics. Angela and I talk regularly, actually, about what's going on in Hywel Dda anyway.

I would say, in quarter 1, our plan was a very comprehensive plan. I think we got positive feedback from Welsh Government that actually we'd looked at all of the issues. Even in quarter 1, there were certain things that we were restarting, like our window of opportunity as you've described it—we were already trying to take some advantage of that, so, things like bronchoscopies restarting in Prince Philip Hospital, for example. And then we've got a very large number of people waiting for diagnostics now. For example, the numbers in June, they haven't grown any bigger; so, they stopped growing in May. There are still going to be challenges going forward, but it does feel like we're at least starting to make some headway in that area. As I mentioned earlier, I was in ward 7 in Prince Philip Hospital, and they'd started, I think it was last week, with day-case surgery, and they're going to start doing major surgery this week. The staff have all been trained and they're all feeling quite excited about starting. In Bronglais yesterday, similarly, they're starting on some day-case work this week and are looking to expand that. So, I think we are trying to get restarted in this window.

The things I would add—. One of the things I'm concerned about in all of this is, first of all, we need to take those cautious steps, as Alan said, and make sure that this is clinically led, clinically informed, but also I'm very conscious, going back to what Maria said, that our staff are very tired, so we also have to balance the fact that we're probably going to have a very difficult winter in any case. People also need a bit of a rest, so we need to strike the right balance between getting things restarted and giving people a chance to regroup on things. So, I just thought that was important to add.

Now, on the care setting stuff, I think we were the first place in Wales to develop an escalation framework for our care homes, and I think that was signed off by the three directors of social care. I think it has been instrumental in our care homes feeling very well supported through the pandemic. In places like Ceredigion, almost no infections in care homes, which has been fantastic to see. That's been a group effort, a real team effort with our experts in infection prevention being there on call, being able to give advice, being able to go in; being able to provide staff support where we needed to, particularly in the early stage of the pandemic, when we had some issues to deal with. But our GPs and our secondary care consultants have been very active in supporting the care homes.

On field hospitals, I would just add that as far as I am concerned, they are an insurance policy. As we go into the winter, we are doing detailed modelling about what we need. We started using Carmarthen leisure centre last week and, actually, the feedback from patients and staff has been really positive. In fact, some patients wanted to go there rather than staying in Glangwili, and some were saying they had the best night's sleep they've had in years. But it's important for us, because it's a way of trialling, before we get into the winter, how these things might work. Andrew could probably talk for an hour on those questions, but hopefully I've just given you a bit of a flavour of the sort of things that we're doing. I don't think we're wasting this window, but we are trying to balance it with the need for our staff. 

Thank you for that. I do appreciate it, and I know that we don't have very much time to ask you—. We've been asking you some very in-depth questions. I think that many of us on the committee have a real concern about the staff issue, and we have a concern about patients who have a real clinical need and need to be seen now are not either going to their GPs and getting the referrals, or there's still a blockage from GPs to refer in. 

I was interested in seeing that you're going to do a trial about extending to seven days a week in some areas just to try to make sure that places like out-patients and some of the clinics aren't overly crowded, and that's why I wondered about whether or not you could use field hospitals for some of that, although I appreciate that most of the diagnostic equipment sits inside a hospital. 

I think, just from my point of view, I'd be really interested, when you have had a chance to really flesh out your backlog issues—. I hope I'm not talking out of turn, Steve, when I say to the committee that you mentioned to me that this has set you back five years in some areas, which is a heck of a setback for the NHS, and I'm sure the same probably runs true in parts of Cwm Taf and other health boards. So, I'd be really interested, when you have had a chance to really flesh out what this backlog looks like, because, of course, if we were to have this conversation in March, then having gone through winter pressures and COVID spikes, I'm guessing that backlog will have increased again, so that the committee can have sight of what we might need to be trying to think of, I would have thought, Dai, going forward. 

Yes, excellent. Yes, because we're under time pressure here this morning. Obviously, in rugby international terms, we've gone into the red zone at the end of the game, and the next forward pass means it's the end, but David Rees has got some important questions on financial implications, so a short question and a short answer, David.

Thank you, Chair. It will be a short question. The Minister has indicated he's writing off the £470 million deficit of health boards. That's understandably very welcome. But I suppose what we want to try to find out is: will the costs of COVID-19 put you back into deficit as a consequence?

Who wants to start? Go on, then, Dr Hopkins.

Thank you. I guess it's going to completely depend, isn't it, on how everything is dealt with over the next year? So, coming into this year that we're in now, we came in in a reasonable way, but if we look at what we're doing underneath the COVID costs, we're doing all right. So, it's really going to depend on how, across Wales, with Welsh Government, it's all dealt with and—

Can I ask a question, then? We've already talked about the increased waiting lists and the blockages that have occurred, if you're having to tackle that without Welsh Government support, on that specific issue, is it going to be a financial problem for you?

I think there are two things there. One is how we max out all of the innovators and the different ways of practising first. But given what you've just heard about the backlogs, undoubtedly, that's going to cause financial difficulties. But I think there's a bigger issue than even that, which is about where is the workforce that could do that; where is the capacity that could do that? So, I think this is quite a different situation. It's not as simple as, 'We've got a backlog, let's outsource, let's do all the usual things that we do.' All those usual things aren't going to be available to us. So, the finances are going to be quite critical, but they're going to have to fall out of how on earth we go about tackling this, which will not be about using the methods that we've used in times gone past.

Okay. Hywel Dda—Steve. 

Thank you. All I would add to that is certainly, in normal times, the scale of waiting lists that we are seeing would create a financial issue in order to be able to clear it, and I'd agree with Sharon on the workforce issues. Two things I would add to that, however. One is assuming that COVID is going to be around for some time, there is a significant impact on our productivity in our elective care services because of donning and doffing and how we need to make sure that our theatres have clean air between cases. So, actually, it's going be—. It may be in some ways worse than the headline numbers of waiting, because we'll be able to do less on our existing sites. So, that is a worry, I think. 

And I think the second thing—it's difficult to get to know quite what the position is yet; it's about people's willingness to have their operations. We are asking people to self-isolate for 14 days and have a negative COVID test, but, again, it's part of the change of people's thinking about coming into health services, about whether they want some of their elective procedures. That's an unknown for us at the moment. 

So, I think there's a lot to work through here. I think the first thing we've got to do is try and get to a state where we've stabilised the situation, but I think it's going to be a really tough few years to get to where we need to, and get back to where we were before COVID because of those issues. 

Great. David.

I think that's important. Thanks, Chair. 

Good morning, everyone. Thank you very much. Just to say, thank you for the question and for the opportunity to talk to you today. We're in a much better position now in relation to PPE, as I'm sure colleagues are across the country. We feel we've got sufficient supplies. I think it would be fair to say it was a concern at the start—a concern of our staff and a concern for us. We have never been in a position where we've needed to issue the amount of PPE that we have had to during this pandemic. So, we did a lot of work in the health board to improve our systems—lots of support from the military. The logistics expertise in the military is fantastic and they have helped us with our stock system and our supply system to make sure, when we get our supplies, that they are getting to the right places. So, it started off being rather challenging, I have to say, and with anxiety, but we feel we are in a much better place now, and we are feeling much more confident about the supplies, both nationally and of local suppliers. 

Rhun.

Yes, so I think—. The systems that we've got in place—we monitor our PPE every minute. We have a live dashboard that can tell us exactly what we've got within our hospitals, within our system, so we know. And for many weeks now, that has been constantly green, in terms of days and weeks of supplies, so that gives us confidence. We know the supply system is better than it was at the start of the pandemic, and that gives us confidence. I pay tribute to the shared services partnership for the work that they have done.

We've learnt a lot, Rhun, I think it would be fair to say, in the last three or four months, and we are all, I think, in a much better place. That doesn't mean there won't be pinch points, but I think where there are pinch points, the system is much more united and much more solid in being able to deal with those.

In terms of the picture that Tracy outlined, I would concur with that, and I would say that Cardiff and Vale has experienced the same sort of picture where we're pretty confident now. We have been confident for quite some time in terms of the ability to source PPE and to deliver it to the front line. At the beginning of the pandemic, that was a problem. There wasn't a time when we couldn't supply PPE, but at times at the beginning our stocks could run low, and that would be on a national basis at shared services or even internally within our own particular facilities.

One of the things that we did do to try and raise confidence amongst our staff was we used to take our staff around our PPE store. So we let them see how much was in the store, just as a way of saying, 'When we're telling you there's enough PPE, you can come and have a look at it and see it.'

I think the only thing I would add to maybe Tracy's point is, at the beginning of the pandemic as well, there was a huge amount of differing advice that came out that ran counter to the public health advice that we were getting. So, we were very much working to the Public Health Wales advice, but some of the royal colleges would send out details to staff. So, the issue wasn’t as much, 'Have you got the PPE?'; it was 'Have you got the PPE that the staff wanted?', because their royal college had told them to use something quite different from what we were saying from Public Health Wales and from the guidelines that we were getting.

We appointed our nurse director, Ruth Walker, to be the lead for PPE, and we set up what we called a 'PPE cell' of people, which would include anaesthetists, it would have respiratory physicians, microbiologists, as well as nursing staff and therapy staff. And that was a weekly meeting at which we could update people on PPE, but it was also a meeting at which they could flag issues that they were hearing and were getting concerned about from the front line. That led us to review some of the issues around what was an aerosol-generating procedure, which would then elevate a particular procedure from one point, in terms of PPE, to another point, in terms of the requirements for PPE. And that developed over time. But actually, in doing that, and having front-line clinicians in those discussions, I think that generated a lot of confidence as well.

Those front-line clinicians would speak at our operational group, which was a big group where clinicians could come to. It was a daily meeting, where clinicians could come to if they had a concern. Whether it was PPE, whether it was anything else that was going on, they could turn up at that meeting and require us to give an explanation or a view on a particular issue. But we used those clinicians from the PPE cell to feed back to staff. So, they were hearing it from a clinical professional, not so much a chief executive or a chief operating officer. And I think that, again, instilled confidence.

So, all we can do, I think, is look back on the way in which the PPE supply chain has responded within Wales, and I think shared services, as Tracy identified, I pay tribute to shared services for the work that they have done. I think the supply of PPE in Wales has been better than in some of the other nations within the UK. I think, yes, there were times at which it was difficult. That was at the beginning of the pandemic. I think we grew in confidence as it went forward, and as things changed, we were able to issue new guidance; we were able to respond to that with the supply chain through shared services. Therefore, on the basis of that experience, my sense is, if guidance changes again, the system will respond positively to that. So, that would be—. We can't read the future, as I'm sure you appreciate, but that would be my basis for the confidence I've got. Over the period of the last four months, we have improved quite steadily over that whole four-month period to a point at which I think we're pretty confident as a system.

Come in there, yes.

Should I answer that? I don't think we have any significant concerns. I think the relationship and the way in which we've constructed our test, trace and protect teams between ourselves, local authorities, all joining together, we've been able to respond very quickly to the requirements of that and over the course of June that's worked very well and we have plans to be able to step that up if the requirement becomes more through a second peak, et cetera. So, we've got good plans, and again, we've got a month of history where it has worked well over the course of June.

Thank you. I'm sure Richard will add something to this as well, but I think we really need to be clear what we're testing for and I think we need to test with purpose. So, to test all of our staff all of the time without symptoms, we would need to be really clear why we would want to do that and what we would do as a consequence of it. So, I'm not an expert; I'm not a clinician or a public health specialist, but to me, it feels that we would need to be really careful to understand why we were doing it. It doesn't feel to me to be the right thing to do. When our staff need to be tested, they are tested. Our testing system is working very well. We are testing, we are swabbing our own people within 24 hours maximum, usually on the same day of any signs of any symptoms, but to test asymptomatic staff regularly, what would we do as a consequence of that? It's a difficult one, really—

Of course, but there is capacity in the system. The BMA this week, for example, called for the regular testing of doctors. Care staff are already routinely—for the time being—being tested. The purpose would be to try to catch those transmissions pre-symptomatic because we know that they occur and to be able to nip problems in the bud—identify potential outbreaks before they become problematic, using the capacity that there is in the system.

Richard, you're on—

You were muted for a second.

I've unmuted. [Laughter.] Thank you. I'll come in, briefly. I think there are a couple of important things. Since the beginning of the pandemic, one of the important things was a recognition that the symptoms weren't, perhaps, quite as straightforward as they seemed at first, in terms of having a fever and a cough. So, it's clear the messaging that we've had: it's the loss of taste and smell, it's generally feeling unwell, it's having been in contact with somebody and heightening that awareness that people get a test at an appropriate time. The point that Tracy's made is an important one, in that there are false positives and false negatives possible in either the antigen or the antibody testing, so interpreting those can be a challenge and in the context of the regularity of testing and the frequency, the science isn't clear at the minute on how frequently you should test, and to make that meaningful. And the important point in this for me is that I don't think we should let testing and the fact that there's a test available distract from the key issue, which is the importance of hand hygiene, of social isolation, of all those measures that protect individuals, public behaviour, protect people at large from acquiring the infection. Those are the key things and the fact that there's a test available at the minute isn't a panacea, and there is more understanding needed on its role.

Yes. I'll make clear that we're talking—sorry—about antigen here, you know, whether you have it. Cwm Taf seemed to me to have a sensible approach, which was to be randomly testing staff regularly, and they actually agreed that, yes, it might not be a bad idea to increase that random testing, so that they at least have a sampling process going on. Is that something that you do?

We don't currently randomly test, but we are looking in a couple of clinical areas about how testing may help and currently working through some of those challenges about an appropriate frequency of testing, and how that might be applied, so it's not something that we've implemented at the minute, but we're looking at how that might help.

Okay. Can I just stop you there? What are the downsides? Because we can think why testing would be a help, because you find, potentially, cases before they become problematic. What are the downsides?

I think first of all in terms of the false positives and false negatives, equally, you don't know for sure that people do test positive whether they're truly infectious. In terms of the timing of the test, we know from people who are infectious that it's possible to be infectious and test negative on one day and positive the next, and even within a day to flip positive and negative, so there's a risk of giving false reassurance in that, and so overreliance on the test itself is a concern. And then, in terms of impact potentially on how we staff clinical areas at already what's a challenging time, if you do pick up a positive test at a time when the number of cases in the community is low, it's actually more likely that you'll pick up a false positive test than a true positive test at the minute. The consequence is in terms of the requirement for colleagues to self-isolate, and therefore impact on clinical services, so our ability to deliver based on an unhelpful false positive, then, is quite a significant issue.

Okay. And to Cardiff and the Vale.

Again, I would just go along with what Richard has said. That's the same sort of conversation that is going on with our clinical staff, led by our medical director. There is controversy, isn't there, in the evidence and controversy in the approach around this, and I think until we can get the evidence as to what we should be doing, we currently are working to the guidance that has come out from Public Health Wales, which is to test symptomatic. But we're not doing the—as Cwm Taf have described for you—we're not doing the random sampling. There are continuous conversations around this. We have a testing group; our medical director is fundamentally engaged in that. He's also engaged in the national discussions around testing as well. So, he's appraised of the discussions that are going on, but our position remains one that is working within the public health guidelines, rather than coming up with any novel sorts of approaches.

Okay. Let me ask the question in a different way: I think we are within a few days, if I understand correctly, of getting a new testing strategy for Wales. I would hope that that would involve trying to maximise the capacity that we have, not in a scatter-gun way, but in a strategic way. In what ways would you think that that testing capacity could be best used in order to protect both your staff and the patients that you treat? Richard.

Hang on, you've gone mute again, Richard.

Sorry, I muted myself instead of unmuting myself there. I think there are a couple of areas in which we could use that in terms of making sure people who are particularly vulnerable are safe in terms of the testing capacity that's available. Certainly for in-patients coming into, maybe, some of our oncology services and cancer services, that's particularly where we're looking at the minute about whether we develop strategy around that; that's one potential.

We know already, in terms of how we use—. I mean, at the minute it might be spare capacity; I'm more than aware that there may be a need to respond to an increase in the number of cases in the community, and, certainly, in terms of our testing capacity at our two major units, we do have the capacity to step that up, with mobile units alongside those to deploy to sites within communities, care homes, as and when required. And so I think there will be points in the coming months where we will need to utilise that additional testing capacity to respond to active infection, and, in the meantime, I think, as Len said, there's more to be worked on and more to understand about how we might best use that meaningfully, in a hospital setting in particular, to protect patients who are coming into our facilities or for staff who are working in them.

Okay, and Cardiff.

So, we do do testing on elective patients in preparation for admission for an elective procedure. Through the whole pandemic, we've kept a stream of urgent cases being seen, particularly through our surgical specialty unit in UHW, in the Heath hospital, and also Spire hospital, but what we require people to do is to quarantine 14 days before they are scheduled to come in, and then we do a test at 72 hours before they come in so that we can get the result of that test, and that test has to be negative for them to proceed through to a procedure. So, from an operational perspective, we're using testing on patients to give some reassurance around they're not carrying COVID-19 and coming into a green area, as we call it, within the hospital. So, that's just an added thing that we are currently doing and we're exploring through the testing group whether there is more that we could do just to provide that reassurance around the separation of facilities in terms of green, i.e. non-COVID, areas within the hospital, and COVID or suspected COVID areas in the hospital. 

And finally from me, on the prompt processing of tests, we know there are concerns that we're heading in the wrong direction overall in terms of tests being completed within 24 hours. There's been an increase in recent weeks in the number of tests taking more than 24 hours to be returned. Is that an issue for you within your health boards? We know it's a problem overall, because we want tests to come back quickly so that tracing and isolating can begin, but is it a problem to you as health boards? Tracy Myhill, or Richard Evans.

I can come in first; I'm happy to come in on that. I think it's something that we can still work on. Certainly from our—. We've got two main facilities in Swansea Bay, at Margam and at the Liberty Stadium, and, at the Margam facility, 90 per cent are returned within 24 hours, and I think overall, for all the total numbers, it's about 96 per cent within 72 hours. So, the 24-hour performance is pretty good in those areas, but clearly an area for us to work on, and clearly aligned with that is having a test result come back and linking with the tracing team who then subsequently get in contact with the individual and do the contact tracing. And I think, as time goes on, we're all learning as part of that process, and I'm sure we will improve with that. 

And are tests being processed locally performing better in terms of return times than ones being sent away?

I don't think we've got that clarity of information exactly on that, no.

Okay. And finally to you in Cardiff and Vale—your experience.

Again, we're performing quite well. I think, overall—so, not per testing unit, but overall—we achieve 71 per cent within 24 hours, and 92 per cent within two days. It could be better. I think, with this, the quicker you know the result, you're either releasing the member of staff back to work if they're negative, or you're making sure we trace—isolation—if they're positive. Therefore, I think it could be better, but we are performing well. And, when you compare us against the rest of Wales, I think we're in the front of that. But, as Richard said, it could always be better; I'd like 100 per cent within one day.

Yes. What's going wrong with the—? There's a third not coming back within a day, which is troubling—what's going wrong with them?

So, it's the logistics of taking the swab, getting it to the lab, getting the lab to process it, getting the result back. We've seen a steady increase in our performance across Cardiff and Vale. We've looked at the processes and we've looked at how to get tests and swabs into the laboratory quickly, get them processed quickly, and then get them back out, and we just need to keep working on that. We just need to keep making that system more slick than it currently is. But, in a sense, the vast majority—92 per cent of them—are within two days. We're able to manage that at the moment, but I would like it to be better than that.

Thank you. Diolch, Cadeirydd.

Diolch, Cadeirydd. Good morning, all. We all appreciate the pressures that health boards and the workforce within the health boards have faced as a consequence of the pandemic, and we understand the decision of the Welsh Government to seek health boards to create capacity at the beginning as well. As a consequence of that, there were some changes to services. But what have been the most significant pressure pinch points you've noticed during the process? Where have they been? I think that's the first point I want to ask. Swansea Bay first, because it's my own area.

Thank you, David. So, as you said, at the beginning of the pandemic, we did take down quite a lot of routine activity, because we needed to create significant capacity to get ourselves ready for a peak, the predicted peak. So, for us in Swansea Bay, we needed to create an extra 1,200 beds—so, nearly doubling our bed base—and we needed to increase our critical care capacity by over 100—112—which was three times the normal capacity. So, the way that we did that was to remodel our existing capacity first, to do everything we could within our own estate, if you like, creating surge capacity on hospital sites and within the community, and then the super surges, you'll be aware, in the two field hospitals that we've prepared. 

We did that. We achieved that extra capacity. There's no way we could have done that without an impact, clearly, on some routine services, because, for one, we needed to train lots and lots of staff. So, lots of staff, theatre staff, needed to be trained to enable them to support us in critical care—150 people. So, whilst we did keep lots of services going around mental health, primary care, community, emergency essential services, we did have to pause some. 

So, in terms of the specific question, I guess, about where has the greatest impact been, it's been on routine surgeries—particularly orthopaedics would be one that I would say. Because, when we were creating all of this capacity, when we were trying to train our staff, when we were trying to get ready, that has undoubtedly taken a hit, and it will take us all some time to recover from that.

Before we go to Cardiff and the Vale for the same answer, have you calculated the additional number of patients that are now on the waiting list that have perhaps gone above 36 weeks waiting or even longer than that? In other words, have you worked out the impact on those waiting lists as a consequence of this?

So, yes, we have. I don't have those numbers in front of me. Richard might have them in his brain; we'll see in a minute. But, yes, we absolutely have. So, we are absolutely clear, we know the impact, we know the increase in the wait, and what we've developed in the health board is a modelling tool that enables us to look at the demand: how that's growing, where it is, what we can do, when we can do it, how it links to our workforce capacity, how it will link to our new infection, prevention and control procedures. It used to take, I think, seven staff to run a theatre list; now it's 20, because of the procedures we've got. So, we are modelling now in a completely different world. We've got some expert modellers in our digital team here and they're helping us to do that. So, we absolutely understand the scale of the challenge and we are bringing, as I say, services back cautiously, carefully. But it will be—you know, this is the position. It will be some time before we get to routine surgery in time lines that we would want. Richard, I don't know if you've got anything to add.

Yes, I have. I've got the number. I think the first thing I'd say is that it's important to bear in mind what continued during the last 12 weeks—so, 950 babies born in hospitals in Swansea; 29,000 people seen in A&E. We maintained a lot of out-patient appointments—25,000 people were seen virtually and 45,000 people were actually seen face to face, because that is still necessary, despite the pandemic.

Tracy said that, in terms of us maintaining particularly our emergency work and a lot of our urgent work through that period, it has meant that, unfortunately, as a result, what we would regard as routine are the services that, as a result, were stepped back. I would want to say that, although we might call them 'routine', that somehow sounds derogatory in the sense that we're under no illusions that those things are very significant for people; if you've got pain in a hip or a knee, that is a significant thing to have, and it's very unfortunate that we are in that position.

The number you asked for, David—as of June 2019, we had fewer than 1,000 people waiting more than 36 weeks. As of June 2020, we have over 11,000 people waiting for 36 weeks. The overall number of people waiting in total hasn't changed very much—it's only about 1 per cent—but obviously the impact of the last 12 weeks has meant that people have gone over those waiting time thresholds.

Cardiff and Vale.

Yes. Could I ask Steve Curry to come in on this as the chief operating officer? Because Steve has done a huge amount of work with the clinicians to really understand a risk-based approach to how we've managed those services that we've continued to run and those services that have been temporarily switched off. So, I don't know—Steve, do you want to come in?

Yes. Thanks, Len. Thank you. The profile of the impact has been similar for us—that being that the elective element of our work has had the most significant impact within that. Despite that, we have carried on, in a similar vein, a lot of work, where we can, through our reconfigured services, particularly around green zones and the use of Spire hospital, as an independent sector, which has been absolutely key. And during that time, for example, we've undertaken over 1,100 planned cancer-related and urgent-related operations and another 1,400 related to emergencies, which, given the logistics that Tracy mentioned is a significant undertaking and a significant task throughout the period.

Our greatest impact, I think, and our greatest concern, has been around the cancer impact in particular. Our referrals into cancer dropped to just below 30 per cent of what you would normally expect in April, and that has been a real concern, albeit that that is an improving situation. After a lot of work and communication, particularly through our primary care colleagues, that referral rate has come up to 41 per cent in May and now is 80 per cent in June. So, that's an encouraging increase, but we do appreciate that there will be a suppressed demand there that will need to be dealt with.

We kept essential services going throughout. As Len said, our clinicians came together in a way that we probably hadn't seen before to take the lead on this, and informed every decision we did take through that period. And through the development of green zones, through the use of the independent sector, which our three thousandth patient has gone through this week in terms of out-patients and procedures, and through clinical prioritisation, we kept those services going.

So, I've mentioned what's happened on referrals. On treatments, our treatment activity hasn't fallen off to the extent that we would have expected, although the treatment modality has changed somewhat in terms of that period, and so people are being treated perhaps in different ways. And that work continues to keep going as well.

We've got a quarter 2 plan in that will keep us increasing the amount of work we're doing. It's difficult to actually say in actual numbers what that will mean, but we have set an ambition for ourselves in our quarter 2 plan that starts to describe the percentages of activity that we are going to return to, or intend to return to, as compared to the pre-COVID levels of activity that we were doing. And that gives a mark, again, working with our clinicians, as to how we will move that forward.

We'll undertake that through an operating model that we have adjusted, which is embedded in the COVID-ready first principle, which is in keeping with the overall operating framework for Wales. Through good communication, through upstream analysis and surveillance of three types of activity now—not just COVID, but the unscheduled care returning to activity and the essential services and planned services all coming together, including a view into winter, to understand how we plan going forward—that feeds in analysis and a triggering on a six to eight-week planning horizon and then works into a gearing system that we're putting in place to be able to adjust our activity to be able to cope with various scenarios going forward.

So, a huge amount of work, clinically led, to be able to keep those essential services going, and there are much better prospects now for increasing our activity into Q2. But, of course, we still have significant challenges in throughput through our theatres, in the confidence of our clinicians, and in the confidence of the public to use the services, but there is a lot of work going on with that.

Okay. Thank you for that. I'm sure one of my colleagues will want to explore the future work ahead in further questioning. But can I also refer to mental health and how the mental health services have been addressed? Both of you reflect mental health in your written evidence to the committee, and if I'm reading Swansea Bay's, everything seems to be going hunky-dory and no problems whatsoever when I read that. But Mind indicate that one in five individuals are not able to access mental health, and though I'd like to think that Swansea Bay are not included, I'm sure there are members of the public in Swansea Bay who are also having difficulties accessing mental health services. And Angela highlighted quite clearly, in the previous session, some of the terms used by the organisations who provide mental health services in relation to that provision at this point in time. I won't repeat the words, but they were clearly damning, effectively, of the service provision. So, how are you ensuring that mental health services are going to be back up to the level they should have been, and what did you see, at that point in time, on delivery of mental health services? And remember, I understand the reduction in referrals, but a reduction in referrals is something that may come later on as far as more numbers coming in. So, that is more of how you're dealing with services for the people you currently have in the system. I'll start with Cardiff and Vale this time.

Okay. I think that's an important point—what's happened up to now and what will happen going forward, Chair, are two distinct things.

Our mental health services did keep going throughout the pandemic. Our in-patient services had availability all the way through the pandemic, and they had to reconfigure themselves as well—our crisis services, mental health services for older people, all of which continued through. We did see our primary care referrals reducing to about 80 per cent of what we'd seen before, and we did use much more alternative means for meeting need in terms of virtual meetings, more virtual group meetings, et cetera, et cetera in terms of therapies in that way.

But what we have done is had a really good session with our executive and our health system clinical boards. They're coming together specifically around mental health, understanding that that peak is one that is probably yet to hit us as opposed to having been through it up until now. And an excellent piece of work has been done to stratify that need and to reach beyond mental health and into the well-being services, because this is a continuum of need and isn't in one particular area. So, that stratification has taken place, and in well-being services we've worked closely with the voluntary sector. Indeed, last week, we've doubled the amount of contracts that we have with the voluntary sector to be able to meet well-being needs and to stream service users to the appropriate need across that.

And then, in the higher tiers of need, our mental health services have reconfigured, in expectation of further work. We're moving more and more online, where we can and where that works, and more and more virtual. And we're also bolstering the access through the national systems, such as the Community Advice and Listening Line. That has received a significant increase in calls more recently, and about 50 per cent of that increase has been from Cardiff and the Vale, so we're encouraged that people know to use that service and access that service.

Of course, Steps—or Stepiau—the other self-help website, is now up and going for us as well, and we will use those virtual means as a way of improving that. So, through that stratified approach to working across well-being and mental health need, I think our services are well placed to face what is in front of them, and it is very much featuring in our plans, and you will have seen that in our quarter 2 submission.

Just before I go on to Swansea Bay for an answer, can I just ask the question then—? You've talked about reconfiguring services and a different approach to some of the services. Have you increased the capacity or your resources to deliver? Because what you've already highlighted is there's an expectation of an increased demand for those services.

Yes. Some of it is about providing those services in a different way and some of it is about increasing capacity. One of the interesting things that the mental health team are telling us is, by actually bolstering our working with third sector bodies, it is creating some capacity within our mental health teams, because those 12 contracts that we've increased to 24 last week will, in some ways, allow us to stream the appropriate level of need. They tell us that this need is in many cases a healthy response to what everybody has been through, and that some of that is working through those patients who are responding to what has been a difficult time either in their professional or home lives over the period, and, therefore, it is expected. I think it's important—from their point of view, they tell us not to medicalise that too much and to ensure that we meet the need in the right way. In doing so, we displace and create capacity within mental health services. So, I think capacity is part of the answer.

Swansea Bay.

Thank you. I won't repeat what Steve has said, but a lot of what he said, I'm sure you'll appreciate, has been a similar approach here in terms of providing services differently. There are a few things I would add.

In terms of referrals for our primary mental health assessment, you'll be aware, under Part 1 of the Mental Health (Wales) Measure 2010, all of those referrals have been received and progressed in line with the 28-day target. There have been no breaches over the last four months in terms of referrals into that service. There are 16 people waiting at the moment, and they will all be seen well within the 28 days. I appreciate some of that will be a different type of service, but where a one-to-one service is needed, that is also provided. So, that's been really encouraging for us.

The other things that we have maintained are our monitoring clinics—so, bipolar, antipsychotic meds—to make sure that we support those people in our community. You talked about increases. We expanded our opiate substitute therapy as part of our drugs and therapeutic team during this time, because we could see that there would be a need for that. The third sector capacity that Steve mentioned has increased, and we've worked really well with the third sector in terms of well-being support.

And also, I'm not sure if you're referring to CAMHS as well, David, but we have invested different approaches within child and adolescent mental health services as well. So, we fast-tracked implementation of something called SPORT, which is the single point of referral team, to enable people to refer straight into us, so we can support our young people, particularly during this time. It's something that had been on the stocks, but we implemented it very quickly, given where we were. And so, there are interventions from that that we didn't have before. It includes mental health nurses and then a multidisciplinary approach with psychologists, family therapists, cognitive behavioural therapy practitioners. So, that's been quite positive.

Picking up Steve's point around emotional well-being, going forward, we are still expecting an increase, almost post the current position, where we are expecting all of the impacts of lockdown—loneliness, the anxiety that everyone feels—to increase. So, we are investing in additional emotional well-being posts as we speak so that we can make sure that we are there to support our population. Part of that is particularly working with schools—obviously, schools are back, and they'll be back more fully in September—to catch the children and young people.

A main area of concern has been behaviour, so we have provided a service in the last four months that, again, we have never done before, to support parents with behaviour, because we're all in very strange circumstances, aren't we? It's not something that we would do from a CAMHS specialist service normally, but we have done that—the first time that we've done it—to support our parents to support their children during these trying times.

I'm pleased you talked about CAMHS, because clearly the impact on children has been huge, and it's therefore important we address that. I just wondered perhaps on new referrals and the reduction of referrals, have you seen a reduction in referrals from children and young people in relation to mental health needs? Because I think that's a very important area we need to address.

We have. We've seen a 60 per cent reduction in CAMHS referrals through March and April. They are now steadily increasing, which is positive in the sense that there is demand there that is coming into the system. But of course, the SPORT system that I've just referred to will be taking some of those referrals. So, I don't think it's 60 per cent, because I think a lot of those would have gone into the new system and the single point of access, which is much easier to get support. There has been a reduction, but it is starting to increase now, which is why we need to put this extra support in for some time to come, I think.

There was a similar reduction we saw in Cardiff and the Vale. Those numbers are back now to the numbers we'd seen before. They're not beyond what we'd seen before; they're back to previous levels. Both in CAMHS and in adult mental health, our current position in terms of meeting 28-day access is beyond where it needs to be, so we are in a good position as far as that's concerned. The CAMHS team have been really active throughout this period, both in terms of meeting the need, but also taking the opportunity to deal with some of the backlogs that we had previously. Actually, that has left the service in an even better position to meet any demands that come forward now. It will be challenging. There still are areas of concern. In neurodevelopment, for example, we've managed to clear a number of reviews that needed to take place that could take place virtually, particularly medication reviews, et cetera. So that has improved hugely, although the new appointments that require a more intensive assessment with a multidisciplinary team is one that still needs to be worked upon. But the team are in a much better place and are working very hard to ensure that they can meet the need that's coming through.

Okay. Thank you. We're also concerned, clearly, about the pressures upon primary care services—and 'primary care services' covers not just the GPs, but all primary care services, including physiotherapy, dentists and optometrists. The question then, really, is: how have you managed to provide support to that sector to ensure that they're able to manage and continue to provide the services during this pandemic?

Who do you want to go first, David?

Well, go on, Tracy; since you've spoken, you might as well go first.

I'll remember that next time, thank you.

So, in primary care, I'm really pleased to say that all our 49 GP practices remained open—behind closed doors, and a different way of 'open', but certainly no walk-ins and pre-assessment by phone. Ninety per cent of our practices maintained core hours. Eighty-eight per cent of our practices still provided services from 5 p.m. to 6.30 p.m. in the evenings. We did lose, as with all of our staff—we lost 60 GPs at the peak, which was 25 per cent of our GPs, through self-isolation and shielding. We've currently got two in that category, so you can see how things have moved. So, we've worked very hard with primary care, particularly to support them digitally.

The digital transformation, I have to say, in the last four months is something we would normally take years to do. That's been absolutely phenomenal in terms of practices, and the organisation more generally, taking on new approaches. So, we have askmyGP digital interactions for patients and practices, which is something that we launched in Swansea Bay—72 per cent of the population are covered by that. We've got Attend Anywhere, which is video consultation, and again, 78 per cent of our practices are using that, and Consultant Connect, which enables primary care clinicians—not just GPs, but primary care clinicians—to connect in with our secondary care clinicians for advice. So, there's been quite a lot of rapid development and lots of support. We also provided primary care COVID hubs in seven of our cluster areas covering 32 practices, so that we could support patients with COVID through primary care.

You mentioned dental. Obviously the dental situation has been quite challenging in terms of what has been able to be done and what hasn't been able to be done with the advice, antibiotics and analgesia position. We have been open in terms of practices for simple procedures and for triage, but we did create a new urgent dental centre at Neath Port Talbot resource centre, which you will know very well. That was established to make sure that we could support people in the community with urgent dental needs. And 152 patients accessed that in April, 243 accessed that in May, and that gives the opportunity for our general dental practitioners to refer patients with COVID and patients without COVID into a specialised centre. I know that that has been warmly welcomed, in terms of giving access to support.

I think you mentioned optometry. We also have a primary care urgent eye centre, which we established in our Neath hub to make sure, again, where there was urgent need for optometry, that that could be provided.

Out-of-hours has obviously continued. We moved out-of-hours out of Morriston, because we needed to create space, so we moved it to the Beacon Centre for Health in SA1, but that's also been positive. All our 92 community pharmacies are open as well. Again, behind closed doors and a different sort of service, but they're now moving into almost a normal service. So, lots of work within community and primary care to make sure our patients are supported, but also our practitioners are supported. We've really enhanced our community teams, our community health and social care teams, with a single point of access for our patients for any health and social care need, which we've established. I met the team during the pandemic. They were very pleased with what had been done, but also our patients were pleased that there was a single route in.

So, we've tried to do as much as we can to make sure that people are supported in terms of our clinicians, professionals, but also clearly our patients. 

Yes, likewise. Sorry—okay, David?

Yes.

So, likewise in Cardiff and the Vale, a lot of effort has gone into supporting primary care colleagues, and a lot of involvement in primary care in supporting the overall response of the system. Our primary care clinicians have been absolutely remarkable and, indeed, front and centre in participating and informing that. As Len referred to earlier, I stood in the lecture theatre every morning over that period with clinicians from across the system, to take views on how we should face into this and what we should do. I'm really pleased to say that primary care clinicians had a voice there that I probably haven't heard for a long time, actually. They were very, very vocal and very constructive and productive, as you'd expect, in informing the response. 

We moved to cluster models where we could across our practices—our optometry and pharmacy colleagues were involved in those moves. There was a significant move to phone first. Fifty six out of our 62 practices are using Attend Anywhere for virtual and, as Tracy mentioned, we're using Consultant Connect in terms of that as well. Our pharmacies have been supplying palliative care medicines in a streamlined way, and we've been supporting them to do that. 

In terms of shielding, and in particular with GPs, we recognised early on that potential and we were at that 20 per cent mark as well in terms of losses. But, for a 12-week period we have provided extra GP services into practices, and that's still going aboard, where we source more GPs to help out in those practices, particularly where there were losses. We were very active in arranging buddying arrangements across practices and across clusters, to ensure that there was some resilience in the system, and we're having weekly CD meetings with the teams as well. Practical support, particularly around PPE and around general protection guidance and advice was really, really important to that. 

Beyond GPs, significant work has been done to facilitate wider primary care access, and I'll just point to one, for example, where our physio teams have now contacted, last week, 1,000 patients in a week, to follow them up and offer them some advice and virtual appointments in that respect. 

Primary care is actually helping us now prioritise the whole system. So, we will have some backlogs, we will have some priorities, going forward, and we've set up a number of workstreams, or alliances, as we're calling them, across primary and secondary care so that we can have a whole-system view as to what the priority is in terms of moving forward to address some of these backlogs.

And finally, one of the things that primary care has been particularly active on is understanding the real difference that we're seeing because of the change in unscheduled care access. As you know, we can't work in the way we did in terms of lots of people being, say, at the front end of our hospital or in an A&E department. We're developing an approach called Cardiff 24/7, which has the potential for a phone-first approach to urgent care, and primary care is front and centre in designing that and coming up with solutions upstream to be able to take that forward. We hope within the next few weeks to be able to launch that, and primary care, as I said, will be central to that.

So, a lot of work being done on that, and that included us keeping the emergency service going for dental at the dental hospital at UHW, but also providing cluster hubs at the services there as well. And, of course, PPE in dental was also something we had to support. 

Okay, thank you. And, Chair, at this point I'm conscious of the time and I know there are many questions to be asked on other areas, so I'll stop at this point and maybe come back later. 

Thank you, Chair. Just quickly, as you've said, the workforce have been immense in all of this, and many people have gone above and beyond their roles as well. I think we've mentioned today the pressure on the workforce. Do you think there's sufficient support available for potential stress and burn-out that's happened to staff, or the potential that they have now to go through that following the first wave, and how will that be managed over the summer before we potentially get into the autumn and winter cycle? 

Who wants to kick off there? 

Do you want me to kick off from Cardiff and Vale?

Yes, go on. 

Okay, thank you. We've put in a huge amount of support through the first wave. I realise your question is more about what that looks like going forward, but I just wanted to try and give you the story as to how this has developed. So, we put in what we call 'staff havens'. We put in psychological support for staff so that they could take themselves out of the workforce to talk to a psychologist, or invite a psychologist into the clinical setting to talk through some of the quite difficult things that our staff have had to deal with, not just in terms of workload. I heard one of our members of staff just saying that they hadn't experienced the number of deaths on a ward in the period of time that they'd been there before and that, psychologically, that was having an impact. So, we very much saw the value of psychology support for staff.

We saw the value in enabling staff, taking away the stresses and strains of people trying to get to work and back, to stay in hotels around and about us so that they had access to work if that's what they wanted, or if they wanted to shield from their family, because some of our staff were worried about going to work and then going back to the family and would they be a potential carrier. So, we did quite a bit of that. And then people will have seen, I'm sure, the way in which the community supported our staff through a number of restaurateurs just offering free food and bringing it to the staff havens for people. That was a great source of support as well. 

Because some of that is scaling back as some of those psychologists are going back to their normal clinical workload, what we're engaged in now with staff is what it is that they want—what could be helpful to them going forward. I know we're responding to a number of requests from individual groups of staff, to say, 'We got through the pandemic and we're now feeling the impact of it—we're now feeling the after-effects'. So, as an executive team, we have been out in the organisation sourcing those comments from people, so not just waiting for it to get into a crisis but actually going onto our wards and into our departments to talk to staff about what it is they need from us to support them through this next phase. It's not particularly in response to whether there's a second wave or not; I just think there is a pent-up anxiety, if that's the right word—I don't think it is—but a pent-up demand that's there. Irrespective of whether we have a second wave or not, we need to help our staff to work through that. We're in no doubt that we think it will be psychological support.

We've got our occupational health department that has been very focused on support for staff, and that is continuing. We have a number of well-being services in place that will continue. We've beefed them up through the first phase, and we'll continue to run those over the summer as well. But we're really just trying to, at this point, take stock of what staff want of us, rather than us think that we know what they need. And what's coming out of some of those discussions is quite varied. There are some people who want the group sessions with a psychologist, there are others who want to be seen individually, there are others who don't think they want anything but will come back to us, and we're trying to keep an eye on that.

Because I think the real success and the real positive thing that came out of this pandemic—and recognising the tragedy that is associated with it—and my sense is the way that staff stepped up and actually headed into this problem, took ownership of it and told us how they wanted to respond to it. That is the real success of the pandemic. We must not lose that by not looking after them now. That's a real priority for us in Cardiff and Vale. I'm sure that's the same in all of the health boards. We really must not lose that. We need to understand and then respond to what they want. 

Okay. Shall we kick off with Swansea Bay? Emma, I'm conscious that you haven't spoken yet—Swansea Bay. I realise, a bit like myself, you might be a little bit on the shy side, so do you want to kick off the Swansea Bay response?

Yes, of course, and Tracy might want to come in on some of the details. Very similar to what Len was describing for Cardiff and Vale, in terms of understanding what our staff want and putting in place measures, we have a piece of work that we've funded through charitable funds, called TRiM, which is helping the mental health of our staff. And, also, we have looked particularly at the occupational health service, which was re-engineered to deliver a seven-day service.

And we are also quite concerned—we had a discussion at our last board meeting—about the particular impact that COVID has had on our black and minority ethnic groups, and we're looking to do—. All of our independent members have signed up to be allies of our BME network, which is a very good thing. So, I don't know—Tracy, would you want to come in with any further details? It is something that we discuss; it's a major feature of all board discussions each month.  

Tracy. 

Just a few things to add but, first, just to echo everybody's tribute to staff. The staff have been absolutely amazing. It's just been incredible. We've had 900 staff doing different roles, stepping into territory they've never been in before, non-clinicians becoming healthcare support workers in COVID wards. We've had staff working in mortuary who'd never done that before. It's just been incredible, and the list of what people have done—therapy leaders project managing field hospitals. And the feedback we've had has been incredible, because a number of the staff are saying to us it's been the best time of their career. So, we need to capitalise on that as well.

It's been very, very stressful, of course, and very, very sad. We've lost members of our staff, as, I know, Cardiff and Vale have as well, and the impact that takes on people, teams and the organisation has been great. But the positives from this and people getting that opportunity have been great. So, in terms of preparing people, I guess, which is what you were saying, when we're asking people to do different roles it's really important that we provide them with mentorship and training, which is why we've focused a lot on making sure people are as prepared as they can be for taking on different roles, and what we are trying to do now is encourage people to take time off. I think we're all fairly confident this is not the end, but, at the moment, people should be trying to take some leave. I know we can't fly around the world, but staycations in Wales are pretty good, and we are really encouraging our people to do that, because we need people to take a break.

The other thing—. Emma's mentioned the TRiM, which is the trauma risk assessment management approach from the military. We've got 23 internal trainers trained in that. It's a peer support, so it's to spot if your colleague is struggling in a much more systematic way. So, that's been really positive. But I guess the other thing in terms of making sure we support our staff going forward is how we determine what services we bring back, how much headroom we create in our system, to make sure we don't finish them off in the next couple of months whilst we're waiting for the next peak, and then expect them to respond to the next peak when we'd only just—we're just coming out of a very challenging winter for us all as well.

So, we've got a modelling tool that we've developed here in Swansea Bay. I could go on about the digital stuff here forever, but it's really good, because what it does is it looks at the likely available staff based on vacancies, sickness, COVID absence, annual leave, and it analyses those numbers in relation to the R value. So, there are three scenarios that we link to the R value, and based on the data that we gather through the pandemic and that we gather every single day through our live dashboard, we factor in antibody testing—the staff we need to do that—we factor in the staff we need to do TTP. And then that gives us a much more solid picture of the numbers of staff we need to do the activity that we're trying to do. So, it's remarkable, I have to say, what people have done.

So, when we're bringing back services, we make sure that the workforce is a fundamental part of that consideration. So, those are some of the things that we're trying to do to make sure. And as Len said, we're just about—this month, we're doing a survey with all of our staff: what's worked; what has the impact been on your well-being; have the wobble rooms and all of the support that we’ve put in place been useful; what do you need moving forward? So, we are trying to take a bit of stock to make sure that they inform what we do as we get into the next quarter and through the winter.

Okay. Jayne.

Thanks, Chair. That's really good to hear. Just going back to the recruitment and bringing back retired staff—how did you feel that worked during the pandemic? And do you think they were utilised?

So, we—

Go on. You go, Tracy, then I will.

I don't mind, Len. Up to you. Go on—you've got the mike.

All right. So, we did bring some retired staff back, and they were very useful; there's absolutely no doubt about it. But I guess, if we picture that within the round, we appointed just less than 1,200 additional staff over the course of the pandemic. A small number of those were 'retire and return'.

We got a significant number of students—nursing students and medical staff students—who were absolutely fantastic. We've done a survey of them, and they say that it was also a great experience for them to get into clinical practice and to see that, and they see it as a really positive start to their careers going forward, because it was a great experience for them.

We had allied health professionals, pharmacy et cetera. So, we actually went out to recruit staff in, because we had a significant number of people shielding from the organisation. That currently stands at 550 at the moment, and therefore we wanted to backfill those with additional staff. And then, in addition to just replacing shielding, we also had the increase in capacity that we were creating for that first wave, and we wanted to try and resource that as well as we could.

So, 'retire and return' were a part of that, but they weren't a big part of it. I'd say the biggest group was those students that came in, and it's been a great experience for us and a good experience for them.

Okay. Tracy Myhill.

Similar numbers: so, we recruited 1,000 additional staff. So, I think that sounds fairly comparable. Our medical students were working as part of our community teams, they were doing phlebotomy, and I agree it's been a great experience for them. The returners, which was your specific point—we've had a similar experience; that's not been as successful as we would want. The pinch point has been registered nursing. So, we ended up with four registered nurses through that route—we had more interest, but people withdrew for all sorts of different reasons. So, that was the pinch point and that's a pinch point going forward, but we've been very successful in terms of support workers joining the organisation. As I say, the use of the students has been great. What we now need is a resilient workforce going forward, because we're going to lose some of those things, and that's why the modelling I talked about is really critical in terms of matching what we try to do service-wise with what we know the workforce will be.

Excellent. Jayne, are you done?

Thank you, Chair, yes.

Great. Moving forward now, Angela—a queen of agility now, because time is marching on. That's one of Angela's great strengths, obviously, is short, succinct questioning. Angela. 

Thank you very much. I enjoy the flattery, so I shall stop there. I'm really delighted, and thank you very much indeed for the extensive submissions that you gave us, but one of the things that does intrigue me, and I've asked this of the previous witnesses, so you may have already had a slight heads-up, is wanting to understand how you're going to really capitalise on the transformation that has been seen throughout the NHS in Wales because of the pandemic. We all recognise that there's been an enormous amount of work that's been undertaken by staff, by management staff, by clinicians, and changes in attitude and behaviours by the general public.

I'm interested to ask two questions, really. The first is: how are you going to capitalise on that so that we don't go back to the old ways of working? And why, in your view, has it been easier in three months to effect such a sea change in the way the NHS in Wales operates, when we've been driving for this sea change for, well, at least the last decade, to my knowledge, since I've become an MS? We've had report after report, Government project after Government project, we've had the parliamentary review, which was an all-party initiative, and nothing's happened. But, voila—three months and it's a completely different organisation. Why? What's the difference? What were the barriers that were taken down and can we keep them down, going forward?

Who wants to kick off there?

Can I start?

Go on, Emma.

It's a very interesting question, Angela, and something that I think we have spent some time thinking about here at Swansea Bay. The first observation I'd make is the NHS does respond to a crisis: it's what we do. It's what we should do; it's what we need to do. And I think Tracy's gone through—. I'm so proud of some of the things that we've delivered: the field hospitals; partnership working is in a completely different league; the retraining of staff and the new approach to services. And we must bottle those achievements that help in the long term.

One of the things that I did very early on was set up a recovery, learning and innovation group, chaired by an independent member, and the intention of that was to work out what of the things that we're doing are accelerations—and a lot of those things are accelerations of things we wanted to do anyway, and the crisis gives us an opportunity to do that. Some of the things are slightly inadvertent, but we must capture them and make sure that we continue them. So, that group has been there since the beginning. Recently, it has been looking at the reintroduction of essential services, because that, of course, is also requiring a huge amount of transformation, but, as that moves more into the performance and finance, as the governance systems start to come back to normal, that group will very much be looking at the learning and innovation and capturing that.

And the second part of your question was some of the reasons, and, again, I think that's really interesting to think about. To a certain extent, we've been governance-lite. So, right at the beginning, again, I was very keen to get the right balance between taking the burden off executives but recognising that the fundamental role of the board doesn't change—in some ways, it's even more critical. So, we put a number of things in place, some of which were a little bit more informal. So, I have a weekly conversation with independent members, which is on Teams. We had some informal briefings from key executives to committee members, and some of those things have actually worked, because it keeps the level of knowledge and helps the level of scrutiny and challenge, and we'll maintain a lot of that. Some of it, of course, has got to be backtracked; we are now back to formal committees and such like. Some of it's about thinking out of the box, and necessity breeds invention, and a lot of that is to keep and that's part of what the recovery, learning and innovation group will try to capture.

But also we need to recognise there's a lot we didn't do. Some of the things we didn't do were things we would perhaps like to continue not doing: so, meetings that don't need to happen, perhaps we should continue them not to happen. A lot of what we didn't do are things we've just been talking about—some of the essential services, some of the routine services. That's not sustainable, so there will be a necessity to return to normal and standard ways of working, and that will take longer to get things through.

And then, the final thing I would say is that, in terms of working practices, I can't ask my execs and my staff to continue working at the pace and level that they have been. They were working 24/7 at the beginning of this campaign, and so, whilst I am hugely grateful to everybody, I couldn't possibly ask them to continue. So, there's a mixture of things that we would want to continue, things that we would not want to continue, and things that we can't continue.

Cardiff and Vale.

Yes, can I come in, please?

Yes, go on, Charles.

Very similar to Emma in terms of the resolve of the organisation to capture these transformative pieces of work that had been going on religiously over the last few months, and a desire particularly not to go back, necessarily, to the old ways of working. The board has been very active in overseeing everything and very interested to know how we're going to resolve future issues when we get free of COVID and get back to more normal routines. But I use the word carefully, more 'normal', because we don't want it to be normal, we want it to be different and we want it to be better, and that's the aim and direction of travel that we'd like to go with as a board.

I think the answer to the question: 'Why has it been easier in the last few months?' Probably Emma summed it up in a nutshell: the NHS responds to an emergency. In this case, it wasn't just the NHS; I think it was the whole population of Wales that responded to this emergency, which has helped us. But it is fascinating to watch how our clinicians have actively been involved in developing our services, and changing the way they operate almost by the hour. Emma's right: our executive team here as well has been working non-stop, but so have our front-line staff, so have our clinicians, so have our porters, so have our people in the community. It's been a marvellous vision to watch from a chair's position, if you like. So, there's a definite resolve for us to capture this spirit and take it forward.

Do you want to add to that, Len?

Can I just add to it? It plays into what Emma said and Jan. We actually replaced governance, and quite heavy governance, with trust, and we engaged with our front-line clinical staff, and we said to them, 'This is what we think is going to happen. How do you think we should respond to it?' and we engaged them. We touched on earlier—. Steve touched on the operational meeting, the daily meeting that we had with clinical staff, which was an all-comers meeting—people could attend, there wasn't a set attendee list, and, basically, we put out the problems, we put out the, 'This is what we think is going to happen. You tell us how to respond.' Surprise, surprise—and I say it a bit facetiously, in a sense—they came up with fantastic ideas that they then went out of the room and implemented. And I think there are some real lessons in that for us in how we manage our organisations going forward. The hours and hours and hours of performance management meetings that don't actually deliver better performance, versus the: 'This is the problem that we're trying to solve. Can you help us solve this?' I think that's how we've got to go forward and that's what we've got to lock in. That will require the whole system to act very differently. Those relationships between Welsh Government and health boards, health boards and clinical boards, clinical boards and front-line clinicians—those relationships just have to change, and we replace some of that. We go to governance light and we trust in our experts and our professionals because they know what the solutions are to these things.

Okay. Angela.

That's such an interesting response from all three of you, and, Len, I think, particularly that bit about trust, because one of the things—. When we took evidence as a committee over the parliamentary review and we had the external members of the parliamentary review, the specialists from all of the UK that came in to help craft that parliamentary review, I remember so clearly that one of the things that came out of it was the fact that all the green shoots that happen everywhere in all health boards very often wither away and die, because as soon as they've proven they're successful, then the big teams move in to micromanage them to bits, and it falls apart because that ability to just get on and deliver gets subsumed in everything else. So, I do hope that, as Emma said, it's something that we can bottle and take forward.

And the other bit that I would like to have your opinion on how we might bottle and take forward is twofold. One is the public's different expectations of the NHS, and their ability to have moved with the times—you know, if you have a problem, you don't necessarily have to be seen by this person, but you can be seen by this person and this way, and how do we keep that going? Because, one of you said, and I'm sorry I forgot who it was, that already your A&E was coming back up to about 80 per cent, and, of course, A&E has always been one of our problem areas, hasn't it, with people overusing A&E? So, how do we push it back down to where the real emergencies come in, the people who need it, without suddenly that 80 per cent in a month's time having turned into 90, and a month after 100? 

Who wants to kick off on that one?

Can I come in on that, please?

Go on, Len.

I think this is a very—. This is what I mean by the system has to change. We have to change the way in which we discuss and have dialogue with the public about the NHS offer, in a sense. We're about to test some of that. Steve highlighted CAV 24/7, which is a phone-first response into our emergency department. So, don't turn up at the ED, phone in first. If you're coming by 999, that's fine; if you're coming because a GP has sent you in, then that's fine, but if you were just going to turn up, phone first and we'll have a dialogue with you about either an appointment in ED because we think you need to be seen, or an alternative because it isn't really an emergency, it is something that could be picked up by an alternative service in the community.

We want to have that dialogue with the public. It will test whether the public wants to go back to the way it was before or we want to capitalise on the current view. But the system needs to get behind us in that as well, because there will be teething problems with a brand-new service, but we want to have that dialogue. We're geared up to be doing that over the course of the next few weeks, because if that 80 per cent becomes 100 per cent of patients coming back to our ED, we'll have lost the opportunity, I think. And what we have seen as well is a general alignment between the clinical staff, and the leadership as well in the royal colleges, because the Royal College of Emergency Medicine did a piece of work not so long ago to say that the people who actually did stay away from the ED are potentially the people who shouldn't have been at the ED in the first place, and that there isn't an increase in harm as a result of those people not coming to an ED service. So, that's helped in galvanising, but the real question will be what the public think about that, and what we're trying to do is engage with them around that.

Emma Woollett.

Yes, just a brief—I know you're conscious of time. Len talked about the dialogue with the public and it being the system—I'd be cheeky and say all of us have got that obligation at different levels within the system. We've dipped our toe in the water recently, and, again, it's one of the transformations, in writing a public letter to the public thanking them for all that they have done, explaining where we are in terms of services, and it will be interesting to see how that pans out. But there is a need to have, at different levels, a much more honest communication with the public about what services we provide, how we provide them, what they want, and how that works in the long term.

Excellent. Angela.

Thank you. I hate to bring up the dreaded words 'winter pressures', but what I'd like to also understand is your view—. And I appreciate your quartative plans were not specifically about how you might start to cope with winter pressures. And as I said in a previous session, if we look at quarter 1, it was, 'This is what we intend to do and how we intend to get back towards normal', and quarter 2 was, 'Starting to action it', although I do know that some quarter 2 plans are still putting some of the actions in the future—'In August, we will open up this; in the end of July, we will do that.' And if we think that our winter pressures normally start sort of October/November, and that whole thing, we've got a very small window in play to try to catch up with the backlog that's developed, but also to start planning for winter pressures. And in response to Jayne, some of you really mentioned the importance of ensuring that our staff don't get burn-out, that they have time to recover, go on holidays, and just get back to normal, and that staff are being redeployed back to where they came from. So, again, that leaves holes where we've always traditionally had holes. And given we can't magic staff out of the blue, can you just give us an overview of how your thought processes are going towards maximising the window of opportunity you have to try to do some of the stuff that we need to do, plus the winter pressures, and how you might involve items such as field hospitals in that planning?

And a final question to just wrap the whole session up, then, would be how you will continue to liaise and to appropriately support our care homes, because of course winter pressures also hammer them as well.

Okay, who wants to kick off with that one? Brief answers if we could, because we're in injury time now. Tracy, do you want to kick off? [Interruption.]

I was just smiling at the 'brief answers' to the 72 questions that we've just had. [Laughter.] I think it's fair to say a lot of what we have done over the last three or four months is preparing us for this, in terms of the way we work, all the things we've done, the new approaches to work, the integrated teams, the better working with local authorities. All of the changes that we've introduced much more quickly than we ever would do will support us, Angela, in terms of winter pressures—absolutely no doubt.

We're already talking to the ambulance service as well, clearly. Emma and I met with the chair and chief exec of the ambulance service the week before last to just make sure we're doing everything that we can. The flu campaign we're already on to. We've got the potential here for flu, COVID and winter. So, we recognise that we've got a lot to do and it's going to be a slightly different campaign given the environment that we're in, but I feel as an organisation we are stronger. I think our systems are better, I think our partnerships are better. But I don't underestimate what may be coming.

We intend to keep field capacity, and we've got two field hospitals, as you know. We probably will go down to one. We are talking to partners about whether a regional capacity might be a more appropriate approach. We're not prepared to give those up yet, because we could have a worse winter given the pandemic that we're living through. So, whilst we will streamline, I am sure, we absolutely want to keep them.

And on your care homes point at the end, just to say, again, this is another area where I think working with the local authority and the health board our relationship has developed exponentially in a positive way. We have an externally commissioned care home group, we take a strategic approach now to the resilience of care homes in a way we never did before. So, again, that feels much more solid in terms of that we have a care home protocol that covers everything that care homes need to know in terms of PPE and COVID patients and how we provide support when people are in difficulty. We've provided staff to care homes. So, all of those things, it's back to your—we must bottle those things, hold on to them and use them to help us get through this winter, obviously in the best way that we possibly can.

Great. Steve.

I won't repeat Tracy's comments. Just to say that our approach to it has been one where we have had a phased approach, and phase 3 of that approach is in terms of the use of field hospitals, which I'll come back to.

But we've done the modelling and we've used the modelling from Welsh Government as well as our local modelling, and they are broadly aligned in terms of trying to understand what this means. So, during the acute phase of the crisis, it was pretty one-dimensional—what was happening with COVID. Now, it's three-dimensional: what's happening with COVID; what's happening with unscheduled care and we've talked about that; and what's happening with essential services moving into planned care. Those three moving parts are absolutely essential; we cannot plan for one without having a view on the other. So, what we'll do is deploy the operating model that I referred to earlier. Capacity planning is key to that. We are retaining our field hospital and looking at options for how we can right-size that, going forward, in terms of making sure that it fits in with that.

Our first principle will be to be COVID-ready. Partnership working will be absolutely key across the system and I've mentioned third sector services and local authorities there, and our governance going forward will be absolutely key in terms of retaining that—[Inaudible.]—leadership to clinical leadership that we've been establishing over the last while, and, of course, the wider governance. So, the same principles will apply for us and that's the approach we'll take.

Diolch yn fawr. Angela.

It's just the quickest of quick questions. Basically, you've talked about your modelling and how strong it is, and, Steve, you just mentioned that you also tie in with the Welsh Government's modelling. Do you, when you look at your modelling and your modelling for services, also look at, in your particular area, what would happen if the R number increases and would you be inclined to recommend local lockdowns?

Thanks. The R modelling in both scenarios, both in local and national work, is the basis for doing it. The R value itself is one thing, the duration of the increase in the R value is another. So, we're back into a volume issue as well as a timing issue in terms of that. And we're erring on the side of caution in that sense. So, one of the things that the national modelling has been doing is taking what they're referring to as a realistic view of what will happen within that. We've taken that view and looked at some work we've been doing with some information partners that we've been working with to run the same modelling, and we're coming up within, if you take it in bed terms, about 60 to 80 beds in terms of what we will need going into that. So, we're triangulating that to try and understand that that will work.

What we're also cognisant of is that what we're planning to, we're very hopeful will not happen, because we would expect that that wider policy would kick in as the R value rises, and that that would be mitigated, to some extent, although that has been factored in as well.

The last thing I'd say on that is that we have quite a sophisticated surveillance system in place now, which is being hosted with one of our local authority partners' websites, which is looking upstream to try and understand the activity in the community way before we see demand changes. So, understanding that it will include certain waste water measurements, it includes what's happening at GP level, it includes Google activity and Facebook activity, et cetera. So, that surveillance will form a part of us being prepared as well.

Thank you.

Just a very quick answer, if it helps—

Go on, Tracy.

The answer is 'yes'. We use the national modelling, but we absolutely link that in with our local lived experience, and our model has got a predictive model, so we look at what happens here to determine what we think is going to happen, as well as being guided by the national.

Excellent. That's the sort of answer I like. The last point now, then, and David Rees is going to wrap up with some financial considerations. David.

Thank you, Chair. I will be very brief. We appreciate that the Minister has actually decided this week and announced that he will write off the £470 million deficit debt amongst all health boards in Wales. I'm sure that that will help and be very good news for health boards; whether it's yours or not, I'm sure it will help. But regarding the consequences, how much has the pandemic cost the health boards, and are you seeing the costs that you're currently experiencing being reimbursed from Welsh Government? Or is it going to be a situation where, actually, this is going to put you back into deficit again?

Who wants to kick off on that one? Tracy, or were you smiling again?

I don't mind; I'm happy to kick off. So, yes, writing off the underlying debt is very helpful. In terms of what it does to day-to-day operations, it doesn't impact in that way. It's a cloud hanging over you that when you eventually get into surplus, you're going to have to pay it back. So, it's like a loan in a way. It's just making you worry about it, but it doesn't affect what you do day to day. That's not to take away from the positive response to that, because we are always knowing that, at some stage, we've got to pay back a significant sum. So, that is really helpful.

Our COVID costs, and I'm sure we're all doing the same, we're very keen to record what they are. They're over £100 million, estimated costs. That includes field hospitals and a number of the other changes that we've needed to make. We are in regular contact with Government, regular dialogue. We have had some field hospital costs reimbursed to the tune of, I think, £27 million; we had another £9 million, my finance director was telling me yesterday. So, we are seeing—. I mean, our initial estimates were assuming no income, although we knew we would get funding, and that was a very scary number, but that is coming down as we continue the dialogue with Government. So, we have seen some money in the bank, definitely, in the last couple of weeks from Welsh Government in terms of our COVID costs. It's not over yet and we are still in discussion.

Okay. Emma.

Can I just add, there is also an indirect cost of COVID, which is because we are not able to, and we are working—? We have an underlying deficit, and we're working to address that, but we also had a big savings plan, and because of COVID and because of the way we're operating, we will not be able to deliver. We are delivering £5 million of a £23 million plan, but that is a significant risk for us because it will increase our underlying deficit.

Yes. Good point. Cardiff and Vale.

So, the only thing I would add to that—well, it's not even adding, it's very similar—we're in constant dialogue with Welsh Government just to see how we can offset some of those COVID costs that were very necessary in the preparation for the pandemic and which may continue into the longer term. And I'd also re-endorse that point that Emma makes. There is an indirect cost of COVID going forward because we can't—. We've heard today about some of the difficulties of seeing planned work within theatres. It's a very different proposition now compared to what it was before. So, there is something, I think, about how, this year, we really develop our understanding of that and what our understanding means in terms of going forward. And I don't think any of us can really pinpoint that at the moment because we don't know whether there's going to be a second wave, and if there is, how big, et cetera. But also, we are just learning to work in a post-COVID world, in a sense, and that will have an impact on how we can deliver services. So, this year is really about learning and engagement with Welsh Government about how we handle that going forward.

I'm assuming that the three-year plans have been thrown out the window as a consequence of COVID.

So, at the beginning of this, the IMTPs were put on hold and therefore not thrown out the window, but they're on hold.

Well, yes. I say 'on hold' because, as we've already mentioned, there's going to be a backlog of work and an additional backlog of work, which will be all the ones that didn't come in when they perhaps could have come in.

That's right.

So, my assumption is that you'll be in discussions with Welsh Government to look at how the funding arrangements will be put in place, not just for this year, but as you say, for several years ahead of us.

Yes.

Definitely agree.

Okay.