National Assembly for Wales

Bore da. Croeso, pawb. Good morning and welcome to today's meeting of the Public Accounts and Public Administration Committee in the Senedd, the Welsh Parliament. The meeting is bilingual; headsets will provide simultaneous translation on channel 1, and sound amplification on channel 2. Participants joining online can access translation by clicking on the globe icon on Zoom. We've not received any apologies for absence, although one Member, Rhianon Passmore, will be joining us later—oh, she has. Welcome, Rhianon; I can see you on the screen. Thank you. In which case, no apologies and all are present.

Do Members have any declarations of registrable interest they wish to raise at this point? I see no indications. I remind the public that such declarations are included on Members' registers of interest, which are accessible on the Senedd website. To inform the public, the committee will be visiting Ljubljana on 8 May 2025 as part of our inquiry into active travel, where we'll meet with a range of stakeholders to inform our inquiry.

We have a number of papers to note. The first two, papers 1 and 2, are lumped together: the first being a letter from the Chair of the Legislation, Justice and Constitution Committee to the Cabinet Secretary for Social Justice, Trefnydd and Chief Whip, Jane Hutt, regarding the Welsh Government's legislative consent memoranda on the Public Authorities (Fraud, Error and Recovery) Bill; the second being a response from Jane Hutt, as Cabinet Secretary, regarding the Welsh Government's legislative consent memoranda on the Public Authorities (Fraud, Error and Recovery) Bill.

We were copied in to the Legislation, Justice and Constitution Committee's letters to the Cabinet Secretary regarding said legislative consent memoranda, and the letter raises similar concerns to our letter of 14 March regarding the need for consent for only some of the clauses in Part 1 of the Bill. The Cabinet Secretary responded to both the committees on 28 March, reaffirming the Welsh Government's view that

'only clauses 1, 2, 5, 6, 7 (and Schedule 1), 9, 10, 64, 65, 67 and 69 (and Schedule 2) of the Bill'

meet the test for approval. Whilst the committee remains of the view that consent should be required for all of Part 1, the committee accepts the issue cannot be progressed further—or I assume the committee accepts the issue cannot be progressed further, and therefore invite Members to comment on the letter if you wish to.

I see no indications from Members—maybe Members want longer to read it—in which case, I'll conclude that we do accept that the issue cannot be progressed further.

The next paper to note is a letter from the Future Generations Commissioner for Wales to myself as Chair, with an update on recommendations 8 and 10 in 'Scrutiny of Accounts: the Future Generations Commissioner for Wales 2022-23'. This includes an update on the future generations leadership academy, their international programme and the funding allocated towards it, and an update on the work being done to attract disabled people to the workforce at the commissioner’s office. Can I invite the auditor general to comment?

Nothing specific from me.

Lovely, short and concise. So, nothing from the auditor general. Members, do you have any comments? I can't see any indications from any Members, in which case I shall assume that Members are content and move on.

The next item is a letter from Andrew Slade, director general for economy, energy and transport in the Welsh Government, regarding the Wales life sciences investment fund. He wrote to us in response to our letter of 3 December last year, which requested a final update on the closure of the fund. The response includes information prepared jointly with the Development Bank of Wales. It also includes a report prepared by the chief executive of the development bank, Giles Thorley, with reflections on the fund and key lessons to be considered in the event a similar fund is established in the future. Again, does the auditor general have any comment?

I won't go into a huge amount of detail, Mark, because there is a lot of detail in the response and the committee has already gathered considerable evidence. I imagine—and you may want to discuss this in the private session later—if the committee is looking to bring this piece of work to some conclusion, we can certainly work with the secretariat to feed in our thoughts. I guess, at a high level, the committee will note that the lessons learned report indicates that the assessment is that all the objectives of the fund were met. I am sure we will have some observations on that, given some of the issues that you've identified. But as I said, I am very happy to work through the detail with you and the secretariat as you draw it to a close.

Thank you very much indeed. As you've indicated, Members will have the opportunity to discuss this further and the next steps in our private session later. Do any Members have any comments on the letter at this point, or are you content to note it? 

Thank you. Well, as indicated, we will pick up on that later. Rhianon. You’re silent. Is it just me? Can anybody hear? No. I'm afraid we can't hear you, but hopefully you'll have an opportunity later, when we discuss this in private, to raise your points. Are there any other comments at this stage on this item? In which case, we will note for now and pick up later.

The next paper to note is a letter from Andrew Goodall, Permanent Secretary in the Welsh Government, regarding the scrutiny of accounts of the Welsh Government 2023-24, responding to outstanding queries concerning said accounts following our scrutiny on 19 February this year. A draft report is currently being drafted and will be considered by the committee in due course. The contents of this update will be reflected in this draft, and a further committee discussion can take place when the report is considered. Any thoughts from the auditor general?

Not given what you've just said, Mark—we can feed into that as the committee works through.

Members, any comments yourselves? No, not that I can see. In which case, we will note the letter.

Right, well, if we can break for three and a half minutes, until 9.30 a.m., then we will recommence—[Interruption.]. Oh, give me one moment.

Sorry, there's one further PTN to consider—2.6.

Oh, I apologise, there is a further paper to note, a response from Dr Tracey Cooper, Public Health Wales, to myself as Chair regarding cancer services in Wales. This includes information from the Wales Cancer Intelligence and Surveillance Unit, run by Public Health Wales, and provides a summary of the latest mortality data, as well as responses to specific queries raised by this committee. Our next item is an evidence session with the Welsh Government on this inquiry, and many of the issues contained in the briefing will be reflected during that session. But before we go into that session, do Members have any comments on this letter? Not that I can see. In which case, we will note the letter, but, obviously, you will have an opportunity to pick up on any themes within it during our next session.

On that note, could we break for two and a half minutes? We will reopen with that session with Welsh Government officials. Thank you.

Bore da. Croeso. Good morning and welcome to the witnesses who've joined us now for our evidence session. I'll start by just noting that Judith Paget, the director general for health, social care and early years group, and NHS Wales chief executive, has unfortunately had to offer her apologies and is unable to join us today. We nonetheless have a good representation with us, and I'd therefore be grateful if you could start by introducing yourselves and stating the roles you hold.

Thank you Chair. My name is Dr Keith Reid. I'm deputy chief medical officer with responsibility for public health in the Welsh Government.

Morning. Nick Wood. I'm deputy chief executive of NHS Wales in Welsh Government.

Good morning. Bore da. I'm Professor Tom Crosby. I'm a clinical oncologist by day, but I'm here as clinical director for cancer services in Wales.

Bore da. I'm Iain Hardcastle. I'm the national director of planning within the NHS exec and, as of 1 April, have oversight of the single cancer team within the NHS executive. 

Again, thanks for joining us today. I'll remind everybody that there will be a short break at 10.35 a.m. for 10 minutes before we take up the second part of this evidence session. As witnesses might expect, we have a number of questions, therefore I'd be grateful if both Members and witnesses could be as succinct as possible in your questions and answers, to enable us to cover as many of the issues we hope to that are generated by this topic. As convention would have it, as Chair, I will start the questioning before bringing in colleagues.

A very general question: what are your overall reflections on the issues identified in the Auditor General for Wales's report, and in particular whether the problems around national leadership described in the report were known to Welsh Government beforehand?

So, I think we welcome the auditor general's report on cancer, and, as you can see from the response that Welsh Government submitted back to Audit Wales, I think we accepted all bar one of the recommendations, and that one was an in-part acceptance. There is a slight error in our response, because I think, on one of them, we hadn't put that we'd accepted the recommendation. So, broadly we accept the recommendations and would recognise the issues that are described within the report, in particular in the recommendations.

We had brought together a number of functions in Wales when we formed the NHS executive in 2022, which included the cancer network, the planned care team et cetera. We'd recognised earlier on that the combined functions weren't working as effectively as they could and should within the construct of the executive, and had therefore conducted our own internal review of the approach and leadership of cancer, prior to the auditor general's review. The findings of that internal review were broadly the same, and we paused the implementation of the changes until we'd had the auditor general's review, when it was published in January. So, yes, I think we welcome it. We've acted subsequently on all of the recommendations and are actively pursuing a change in the approach and leadership to cancer services in Wales, with a much clearer remit and way forward.

Okay, thank you. Any other contributors? Yes, Mr Hardcastle.

Thank you. So, I think, from an NHS exec perspective, I'd just like to say that I think that we recognise the challenges that were in the auditor general's report, and as Nick has said, we support them in terms of the work, and that there were a number of changes that were taking place, and we have put some of those changes in place. As I mentioned earlier, I've come into post on 1 April to have an oversight of the single cancer team, and it's just to say that the single cancer team is absolutely focused on the delivery, moving forward, and recognises the challenges that were in the auditor general's report. I think it's also right to focus on some of the complexities that the report highlighted within the system—the delivery against the 62 days, and also in terms of the elements around equality of access and the pathways for treatment for first definitive treatment. So, I think they were worth noting, and certainly ones that we've taken in from an exec perspective.

Thank you. You referred to the 62-day target, so we'll just develop that a little further. How do you respond to the concern that the continued failure in overall terms to meet the national 62-day target for starting cancer treatment is unacceptable and that many patients may have poorer outcomes as a result?

We have a target that is for 75 per cent of patients to be treated on the single cancer pathway within 62 days; 60 per cent is clearly an unacceptable level in terms of performance for those patients. The target is very challenging in order to be delivered, but doesn't necessarily reflect the experience of a huge number of people who are on the cancer pathway. It only reflects those that go through and have treatment for cancer.

If I can just give you some figures from February 2025, there were 13,074 people in Wales who were told they didn't have cancer in that month. They will have all been on the single cancer pathway at some point, but are not part of the performance element of 62 days. There were 1,830 people who started their treatment in February for cancer, 1,101 of those within 62 days. So, that's where we get the 62-day performance from—the number who started their treatment within the 62 days, so 1,100 of the 1,800.

In essence, there were nearly 15,000 people who either completed or were taken off the single cancer pathway in a single month, in February. The 62 per cent doesn't reflect the performance of all of those people. It is obviously the national target of those that are treated, and we accept that, but there's much more to the performance of cancer services that sits underneath the 62-day target.

I think it's also worth reflecting on the comparative level of performance compared to what we saw pre pandemic, because I think we're still in that recovery and post-pandemic phase, although it is five years ago. In February 2020, which is the comparable month pre pandemic, 1,300 started treatment, of which 783 were within the target. We're treating 500 patients more every month who have cancer and we're informing between 4,000 and 5,000 more people every month that they don't have cancer, since the pandemic.

It's unacceptable that we're only at 60 per cent, but there is a lot more that sits below the headline figure, which I think is important for people, and people's experience of cancer services in Wales. We're actively seeking to improve performance consistently, and the challenge is really about, for patient outcomes, getting people onto the pathway more quickly, getting that diagnosis phase more quickly and the referral for treatment phase more quickly, because that's what will then drive the overall performance number, but more importantly, will drive their outcome and their life expectancy on the back of what stage of cancer we are treating them at.

The headline figures are not great, but actually, what's going on in the system and the excess demand and the way that that's being dealt with is a real challenge that we're trying to meet as we move forward.

Thanks for sharing those statistics. Could you, therefore, just confirm, to help my understanding, and, no doubt, that of others, that the figures we're talking about on the 62-day target only apply to those who need to start treatment, not those who are told they don't need treatment?

Correct.

And given the increase in demand, the increase in presentations you've indicated—was it 5,000?

In terms of the demand into cancer, on a monthly basis, referrals are anywhere between 10 per cent and 20 per cent up on a month-on-month, year-on-year basis. It varies, clearly, through the year, but we've seen a significant demand increase over the last five years that's consistently gone up.

Is the target realistic, given that increased demand? In terms of personal experience, it's essential, but in terms of delivery, is it realistic?

I’ll defer to Tom in a second, but we have to set an ambitious target. I think it’s important that we maintain that ambition that three quarters of the population who are being treated for cancer get treated within 62 days, because there is clinical evidence to support the delivery of the target. And the important bit is that we take actions that drive the improvement in that, whether that be early-stage diagnosis or early-stage referral to treatment.   

Firstly, I would say that the single cancer pathway—it was something I was involved in, in terms of developing as a policy—is the right approach. I think we really welcome the Minister at the time, who took a brave decision to say we would measure things according to the advice of our clinical colleagues in a better way, I would say, than other parts of the United Kingdom. That means that we measure every patient who comes into the pathway, from the time that they are told that they may have cancer, which is clearly a really worrying time for anybody being told that.

We ask our system to track all of those patients coming in, whether they’re referred by their GP as an urgent suspected cancer, whether they come in as an emergency presentation, whether they come in as screening, or just a surprise finding from a diagnostic test. That is now classified as the point of suspicion. And I think that does reflect patient experience better than other systems that really only focus on primary care referrals, two-week wait pathways for people coming into the system.

It is extremely challenging, and we’ll probably discuss the reasons for those challenges this morning as we go through. But we have an ageing population. We have a rising incidence of cancer. We’re trying to persuade primary care colleagues to refer more patients in who might have cancer, and not necessarily hold them back and gate-keep for secondary care because they may have cancer.

I would say that we mustn’t normalise long waiting times for patients, from being told you might have cancer until you’re told, as Nick has said, that you don’t have cancer, hopefully within 28 days, or if you do have cancer, that we diagnose and treat those patients within 62 days. That’s two months. I have three or four calls a week from colleagues, friends, who have been told that information and they’re waiting for tests or treatment. We mustn’t accept that we can’t achieve that.

We don’t measure suspensions anymore, so if patients decide to go on holiday or can’t attend appointments. We found that there was a huge variation in terms of the use of those suspensions across Wales, and it was a massive industry in itself. So, the fact is that we don’t, we have accommodated that in the target. I think we probably shouldn’t extend the target further beyond the 75 per cent. I think that’s about fair as it is at the moment. But reflecting and building on what Nick has said, the vast majority of patients coming into the pathway are not going to have cancer and need to be told that as soon as possible.  

Thank you. Building on what you’ve told us, can you tell us any more about what you’re doing to understand what sits behind the underperformance, and to hold health boards to account for their failures to meet the national target and other aspects of cancer service delivery?  

Clearly, the cancer target is one of a suite of performance measures that we have in Wales for the NHS. We measure and report on those performance measures on a monthly basis. Part of my remit within the Welsh Government is for performance, oversight and delivery. We convene a monthly meeting with all health boards, which is called an integrated quality and performance delivery meeting, every month, which is focused on areas where we expect each individual health board to improve, whether that be cancer, planned care or other performance measures. So, cancer will be picked up as part of that overall assessment of a health board’s performance on a monthly basis.

Those meetings are supported by colleagues in the NHS executive, and Iain can perhaps describe a little bit more about how the exec has worked in terms of driving performance improvement. We have also, because of the challenges that we recognised in the cancer pathway, implemented a single cancer pathway recovery team as part of the NHS executive and the planned care programme a couple of years ago, with the aim of them intervening at a health board level to drive performance and improvement on particular aspects that we'd identified that would improve performance—so, the optimum pathways, as Tom has referred to, that straight-to-test approach and the early diagnosis.

On the back of that, the NHS exec support Welsh Government colleagues with—. I think it is biweekly, actually, it's certainly more than monthly, where we meet with the cancer leads for each health board and go through a suite of measures that we expect them to improve upon. So, it's not the 62-day target per se, but it's all of the quality and performance indicators that sit below that, where we then assess where a health board is at with their local cancer lead and our Welsh Government and NHS exec cancer team. So, we can drive the underlying drivers of performance, if you like, so that we hopefully then start to see that come through in the overall 62-day target.

I don't know, Iain, do you want to come in on how the exec is working around that particular improvement methodology?

Thank you. In terms of the exec, our purpose and function is to support and enable the NHS on a day-to-day, week-by-week basis. Our teams are set up to absolutely be outward facing into NHS Wales, as well as working with the Welsh Government in terms of some of those challenges. So, at any point, the teams across the NHS exec will be liaising and working with health boards, trusts and special health authorities to support in terms of improvement or any other areas of concern, but also to enable good practice and the rolling out of good practice in those areas.

As an example, from a cancer perspective, we are currently focusing on five key pathways in terms of the tumour sites. We are looking at breast, gynaecology, urology, lower gastrointestinal and skin, recognising that there are some challenges from a performance perspective in those. And we are working with the system to enable there to be less variation, less unwarranted variation, ensuring that we are understanding the challenges that the health boards have, but working with them to reduce that variation in that space.

That doesn't just involve the single cancer team that we have discussed that sits within the NHS exec, we have a number of areas of specialism. We have a performance and assurance team that are able to provide some support; we have specialist finance colleagues that are able to support; we also have professional improvement colleagues that are able to go in and describe and support the challenges and changes that are required from a pathway perspective and help and support NHS Wales in terms of those improvements there. So, across the functions that we have, not just from a single cancer team perspective, we are there to support, not just from a cancer perspective, but across the many challenges that we see across the NHS in that space.

Thank you. Notwithstanding your comments—and I think two or three of you referred to the 75 per cent of patients achieving the target—to what extent do you think there is a realistic prospect of meeting the new target that 80 per cent of cancer patients should start treatment within 62 days by March 2026?

We set out an ambition in the planned care recovery programme in 2022 to move the single cancer target to 80 per cent. I think we need to reflect on experience and what has happened in the years since then. You probably will have seen that the ministerial advisory group reported on Tuesday of this week. I think some of their recommendations are helpful in terms of stating that, at this point, it's probably ill-advised to move the target to 80 per cent when there isn't really a realistic proposition of us getting to 80 per cent over the next 12 months. A continued focus on getting up to 70 per cent and then 75 per cent would be a more advisable approach. We have not made a formal decision in terms of stepping away from that 80 per cent, but that is one of the recommendations from the ministerial advisory group, and we've accepted all of the recommendations within that report. So, I think it would be fair to say that we need to review that position and focus on continuous improvement, if you like, from the current position of 60 per cent, to 65, to 70, to 75 per cent before we consider going one further than that.

Okay. Thank you. And what is the Welsh Government and the NHS executive doing to support improvement in cancer services beyond what you've already shared with us this morning, including the sharing of learning and good practice between health boards?

I'd perhaps bring some colleagues in. I think it's just important to say, again just referring to what the ministerial advisory group has seen, in its report into productivity and performances, there is a lot of good practice in Wales. There are a lot of really good innovations. We don't lack new ideas or new improvements. What we lack is an ability to deliver those consistently across seven health boards or 12 tumour sites or 15 different hospitals. And I think what our focus has got to be on is taking the key initiatives and delivering them at pace without variation across all seven health boards so that the public get equal access, if you like, to all of those things. So, a good example would be faecal immunochemical test testing for people with lower gastrointestinal and upper GI cancer approaches. We've got examples of FIT testing in a number of health boards, but not consistent focused delivery of that. And that would just be one example of how fully implementing that approach would make a huge difference to the time, timeliness and demand on the pathway. But I don't know, Tom or Iain, whether you feel there are other areas we could move to? 

I think we must recognise that the performance against the single cancer pathway is one measure of quality of care, and I think it is a barometer for wider cancer and even healthcare services in terms of how healthy they are themselves. And I do welcome the reports from the audit office and also from MAG as well, and also appreciate that the Welsh Government have accepted the recommendations made, which are saying there are huge challenges in the system that we face at the moment. But there's also unwarranted variation across the system, and that's what we see in the services, sometimes not very far apart, but there may be a 20 per cent difference in outcomes, or a two to threefold variation in terms of performance.

So, I think, on some of the directions and recommendations that have been made in terms of a focus on a smaller set of pathways, which Iain has described, and some of the steps in those pathways, we welcome that. I think we also welcome some of the initiatives around regional working, around organisations working together more closely across organisational boundaries. But we certainly have regular meetings, both with executive leads for cancer across all organisations and with operational managers and clinical leads, and we have excellent clinical leadership in pockets in Wales. And I think it's about—and I welcome the Cabinet Secretary and others who've emphasised the importance of clinical leadership at the moment—us enabling them to lead the service to have more equitable outcomes in terms of performance and, ultimately, the quality of care that we deliver. At the moment, I think we have to accept and acknowledge that there is unacceptable variation in our service across Wales.

Okay, well—. Sorry. Yes, Iain.

I think the first element is the lessons that we've identified within the exec of having separate cancer teams or separate teams that have cancer. So, the first part is that we have brought those lessons from an exec perspective to create a single cancer team, and then working out with health boards. Everybody within the health boards and everybody within the exec that I speak to is absolutely patient focused and looking at how we support patients in that space, and the sharing of good practice happens on a regular basis. So, Nick's mentioned a number of areas in terms of the the FIT testing in that space. I think what we also see is that, when we bring the clinical leaders together, as Tom has described, when we bring the operational managers together, we see real leadership in that space. Only on Tuesday, I was having a conversation with senior colleagues across the NHS around how, with the exec and with health boards and trusts, we come together to look at those five pathways and really share best practice, understand where the challenges are and come together, rather than doing things seven or eight different times—do that once and understand where those challenges are. So, I think that is probably where I would go down as well, if that's okay.

Thank you. You acknowledge the variation, the importance of enablement, you indicated a number of gatherings, groups, meetings where information and good practice can be shared, but, systemically, what, if anything, is the Welsh Government doing, or proposing to do to ensure that that learning and good practice are shared? 

So, we've set out very clearly, both in terms of the existing plans, whether it be the quality statement for cancer or this year's health board planning guidance, and the Cabinet Secretary's clear list of priorities, a set of non-variable, if you like, enabling actions, which are set out very clearly for health boards. We refer to them as 'just do its', basically, and they would include a number of initiatives, ways of working for cancer, where we're saying to health boards, 'Adopt or justify why you do not do this.' That would reduce variation. There's a very clear focus from the Cabinet Secretary down to enable health boards and trusts to enact that non-variation.

He's also been extremely clear on the five key areas that he's focused on this year and the deliverables. Our job in the Welsh Government in following that through is that we will then pick up on a monthly basis with health boards their delivery against those current variables to ensure that we narrow down that variation. Both from a clinical leadership perspective and an operational leadership perspective, we've got to be relentless in our focus on those to ensure that we don't get distracted into different initiatives or different ways of working. So, that's the approach that we've put in place and will take forward as we move through this year. 

Okay. Thank you. Tom Giffard, did you indicate you wish to speak?

No, sorry, that wasn't me.

I just saw your hand.

Sorry. 

In which case, can I invite Mike Hedges to take up the questions?

Please correct me if I get any of this wrong, but my understanding is that to drive improvement in cancer mortality and survival of cancer in Welsh patients, we need more patients to be found to have cancer early. The late diagnosis is causing serious problems. If we agree that, what is the Welsh Government doing to drive improvement in the number of patients diagnosed at an early stage? We know there are some cancers where nearly everybody is diagnosed at stage 3 and stage 4, and they have very, very poor survival rates.

Thanks. I'll respond initially. So, a big part of that would be the screening programmes that we have in Wales, which we have for the most important cancers. We've seen, for example, a successful roll-out of bowel cancer screening, and an optimisation of that with improved sensitivity of the tests used to try and capture more suspected cancers. We've got an established breast cancer screening programme that works to capture women with suspected breast cancer—well, offer a periodic test mammogram to women to identify early changes suspicious of breast cancer and move on to further testing, diagnosis and, if necessary, treatment. And we've got the cervical screening programme as well.

So, those would be key programmes operating at a whole-of-high-risk population basis to facilitate just what you talked about—the early diagnosis of individuals at risk. The other element that was touched on earlier was about encouraging general practitioners, when they see patients with red flags, which are symptoms or signs highly suspicious of cancer, not to manage that risk in primary care but to refer on at an earlier stage so that individuals with those suspicious signs can be investigated and then get to the position we talked about earlier, saying either, 'Yes, this is cancer and you're going on a further pathway,' or, 'No, this is not cancer at this stage. It's something else,' and you get appropriate management. So, I think there are a number of initiatives in play around that.

The other element that we may come on to again later about lung cancer screening is that that's a particular case in point where, traditionally, 75 per cent of cases are diagnosed at stage 4 and the implication of moving to a targeted lung screening approach would be that we could shift that, where 75 per cent of cases were diagnosed at stages 1 or 2, which would allow for, in many cases, curative treatment or certainly a much better series of outcomes.

So, screening is a foundation of that. The other element is about getting better access to investigation and a diagnosis at an earlier stage, and that does require a change in clinical practice, but it also requires a change in individual behaviour, in a willingness to seek medical care at an earlier stage, rather than sit at home, potentially allowing things to develop and not seeking care. So, the element of health-seeking behaviour and how individuals interact with the health service is also important here.

Okay. Thank you, Chair.

Just to follow on and build on what Keith has said then, I think it’s important to highlight that we have undertaken a really successful pilot in lung cancer health checks in Wales, and the clinical lead and programme lead who led that pilot with as good an uptake that we’ve seen anywhere in the UK, I think, has been really in a great position to inform the hopefully national programme that we roll out in the future, albeit that there will be lots of pressures on the diagnostic and treatment services as a result of that, and, indeed, in terms of the performance of our pathways, because patients with earlier diagnoses do tend to have more complex pathways than patients who have palliative treatment.

And I think there is a little nuance in terms of access to diagnostics—that primary and secondary care interface. My primary care colleagues are desperate, where possible, to have access to their own diagnostic tests to be able to keep people well in the community, but we need to ensure that they have access to FIT, that they don’t need to refer young women with breast pain on an urgent suspected cancer pathway but they have alternative approaches that might address those things, and also, for things like skin cancers, that we’re able to share high-quality images that secondary care can triage in terms of only seeing the patients who really need to be seen. So, wherever possible, it is keeping the right people in the primary and community care setting, but, as Keith says, those patients who do need to be seen, we need to see them as soon as possible. So, that’s very much the primary and secondary care working together.

It was quite interesting when someone—I can't remember who, now—mentioned lung cancer and the screening, and how successful it is. Is it working for everybody? I mean, is there a deprivation difference? Are people in socioeconomic groups A and B doing better than those in socioeconomic classes D and E in attending—or by geography?

The pilot was geographically limited. So, in terms of geography, it is difficult to draw any conclusions around that—broader conclusions—but that will be something that we will have to look at really closely as the programme is expanded across the rest of Wales.

In terms of social gradient and participation, because of the way the risk assessment is being done—. So, individuals who are deemed potentially eligible for lung cancer screening on the basis of a smoking history, there is a risk assessment that determines whether they are in a high-risk category and will go forward to receive the CT scan. Because of the distribution of smoking and the prevalence of smoking and the social gradient in smoking, there is a disproportionate number of individuals who are in the lower socioeconomic groups who are coming in at high risk. So, the inherent approach of the programme is biased very heavily towards invitation and participation of those groups, and the pilot demonstrated that those groups, when called, were coming forward. So, there is, if you like, a reverse gradient compared with some of the other screening programmes in the lung cancer screening, where the benefit is accruing perhaps disproportionately, perhaps as we would like to see, to those in lower socioeconomic groups.

Thank you. We talked about breast and cervical screening earlier, and I'll throw in bowel cancer screening as well. How do we get an uptick in people taking part in that screening? And I'm sure that if you went around this building that you're in now, you'd probably find a 90 to 95 per cent uptake of those people who are eligible. I also suggest that, if you went around some of the poorer communities that I represent, you'd be running at under 50 per cent uptake. I know lots of people who are enthusiastic about taking any test that they're ever given, because they think it can increase their lives. Others think, 'I'm feeling okay, why bother?'

Yes. So, I think there are no—. As you've highlighted, there's no single solution to this. Public Health Wales, who are responsible for the issuing of invitations and the running of the screening programmes, have a screening engagement team, which works very closely with communities and with local health boards and local third sector and other community organisations to understand need in the community. I think there's more that can be done in that arena, particularly about improving the links with local health boards and individual local health practitioners who understand the communities and have that more close connection and more profound knowledge of what's going on. So, I think there's a platform to build on there, but I would personally like to see more work in that arena.

The other element is about an understanding that, for some, access to screening is a problem. So, there is more use of weekend and evening appointments, so that gets around some of the disruption associated with having to take time off work, for example, and perhaps losing income to attend a screening appointment, or the need to arrange child or other care arrangements to attend a screening programme.

So, I think there are a range of approaches that are identified and are being implemented. The question is how we can continue to work in that vein and continue to adapt and modify the screening offer so that it is more attractive to more people and it accommodates some of the barriers that are identified. I think there is more opportunity for Public Health Wales, working with local health boards and local groups, to begin to get into that space and begin to look at those solutions.

I don't think there's any—. There's no opposition to doing that. It's a question of the scale and pace at which we can begin to do that. One of the things that Public Health Wales has highlighted recently is using more real-time performance data, so looking at those who are not attending for appointments in a much more real-time way and following them up whilst, for example, a mobile screening unit is still in the location. So, if someone has failed to attend their appointment, then to contact them and try and understand why, and to offer them an alternative appointment at the time that the screening is available in the location. I think that more proactive management of non-attendance is also going to play an important part.

I agree with you. Can I also congratulate you on putting the screening for breast cancer, especially, in easily accessible places? We often have it in the car park of Tesco's in Llansamlet, which is easily accessible, lots of car parking around it, and that really has worked well. Does that happen everywhere, or are we just lucky in Swansea?

It is a key part of the strategy, and it's precisely for that reason. It's to get out into the community, make the screening location accessible, and calling people who are in close proximity to that mobile unit in for a fixed period. That's why the follow-up in real time is really important—it's to optimise the use of that resource.

What is the Welsh Government doing to manage variations in the timing of the colonoscopies for bowel screening patients?

That is a challenging question. We as Welsh Government also hold to account Public Health Wales, alongside health boards. Screening colonoscopy is reported by Public Health Wales in terms of their suite of measures and deliverables. We're trying to highlight with them the differences and the challenges, so that we can really start to drive out the variation, but I think we would accept that, currently, delivery of colonoscopy on the timeline post bowel screening is not where it needs to be, and we need a real focus on improving that. There's quite significant investment into the national diagnostics programme around all forms of endoscopy and colonoscopy, but it will take some time to come through in terms of available capacity. But it is a—. We recognise it is a serious challenge that we need a clear and deliverable plan for. I don't know, Keith, if you have a view on that.

Yes. So, just to be clear, the colonoscopies are not undertaken by Public Health Wales; they are undertaken by the local health boards. So, there is an interface issue here where a positive screening test, which is undertaken by Public Health Wales, is then transferred over to the health board for the colonoscopy to happen. And there has been concern expressed that that is potentially contributing to the delay. So, there is a need to monitor that and to drive down any extension of time that is associated with that, and that is a relatively easy fix in terms of ensuring that screening referrals and the timeline for a screening referral to receive colonoscopy are well understood in the system.

The other issue is around capacity. I think all bowel cancer screening programmes in the UK are faced with a similar issue around the increased demand, the difficulties of maintaining throughput in colonoscopy, the difficulties of training screeners—screening colonoscopists—and retaining screening colonoscopists, and the competition for colonoscopy capacity between those who have symptomatic conditions who require colonoscopies and those coming from screening. So, it's not a unique situation to Wales, but it is something that, with careful pathway management and attention to capacity, can be certainly mitigated and, hopefully, over time get everyone within the required time intervals.

That led me on nicely, because productivity—I know it sounds like a rude word in the health service—what progress is being made in improving productivity and using artificial intelligence to help with productivity? And I know in England, from reported information, when there was a 20 per cent increase in resources, there was a 2 per cent increase in patients being treated.

Are you referring to artificial intelligence within the diagnostic phase? 

Yes.

There is clearly quite a lot of innovation currently around artificial intelligence or AI reporting of diagnostic tests, radiology scans in particular, which is being deployed. I think we've got quite an enhanced and advanced research and innovation programme in Wales, which is driving a lot of these improvements, many of which are picked up by the Cabinet Secretary's oversight board. I think it's called ‘making it happen’ or ‘tackling cancer’—innovation that would feature and try and progress the sort of AI or other technical innovations that are starting to come through. So, it is something that we are fully aware of and trying to deploy in different areas, and obviously would drive some elements of productivity.

Apart from people, which are the major resource, the most expensive resource, and the most important resource, is there any other lack of resources that are slowing down treatment and slowing down the ability to identify whether people have or have not got cancer? 

Yes. I think it builds on the previous point as well. We do know that we have got capacity issues in the system. We have talked about the demand on the system and the capacity broadly is around people, our workforce, our fantastic workforce, that, once in the system, patients have a very good experience of the services that they have delivered. But there is much more that we can do. I think it is sometimes about equipment, it is sometimes about the configuration of the services that we have and separating out elective and acute services so that we can improve that productivity. We'll come on, I am sure, about the digital agenda. If we can digitise images and pathology specimens, that gives us the opportunity to, No. 1, have tests done locally but reported regionally or nationally, but also for us to use those AI systems on those digital images or pathology specimens. We’ve got, again, examples of really innovative practice going on in the imaging academy in Pencoed and also in north Wales around pathology and AI specimens. So, it will speed up the reporting, it'll speed up the quality assurance of that reporting, but it'll also mean that we will improve the productivity, ultimately, of the capacity that we do have in the system, which we want more of, but we also need to do more with what we do have.

On the imaging academy, their graduates, are they employed throughout the different health boards, filling gaps? 

So, in terms of the imaging academy, HEIW—so, Health Education and Improvement Wales—commissions the postgraduate training programme in Wales. It's a minimum of five years. We've increased the number of radiology trainees in particular to meet future demand—I think somewhere between 90 and 100 trainees will come out in this year. It's hosted by a health board. It's really been helpful in expanding the workforce. The challenge we've had has been those graduates and those people coming out of training then becoming employed within Wales within health boards. So, when the numbers first increased, I think we struggled with a number of those graduates then going and finding jobs elsewhere, whether it be over the border or elsewhere, and our aim really was to keep as many of those people working in Wales as possible, and to make Wales the choice for retention. So, retention wasn't great in 2024, and we are now in the process of really working, or getting HEIW to work, with the health boards to support that workforce planning, so we can utilise trainees as they come out.

So, one of the ways that we can do that is the development of our regional diagnostics and imaging programme, where we're building additional capacity—so, we're building additional capacity, for example, in Llantrisant, in south Wales, we're looking at additional capacity in north Wales—and we can then use the graduates that come out of the training scheme as being the key workforce to start to fill the gaps that will exist in those regional spaces. So, we're trying to really encourage the health boards—who, obviously, are the employers, at the end of the day—to utilise that increase in training as they come out of the programme.

And finally from me, on diagnostic imaging equipment, have we sufficient up-to-date diagnostic imaging equipment, and are we at a danger of some of it breaking down, thus slowing the whole system down?

So, I think there are two parts to your question there: do we have sufficient diagnostic capacity, and, secondly, is that capacity then fit for purpose and modern, and, as you say, doesn't break down? I think we've recognised, with the increases in demand—and we talked about the increase in demand for cancer—. If you think about the potential lung screening programme, which will then result in a huge number of diagnostic tests being required, the colonoscopy demand—all of those things demonstrate that we probably have insufficient diagnostic equipment and facilities in Wales. We've recognised that and set out a very clear five-year forward look in terms of a diagnostic programme. The Cabinet Secretary, in the current budget announcement, has endorsed funding of £30 million for this year, and £15 million for next year, to support replacement and new equipment. So, where we've got machinery that is dated or in need of further maintenance, there's a programme of replacement now across Wales. What tends to happen, when they are replaced, is they are replaced with much more advanced machines, which are much more productive in their diagnostic capacity. And also, we are in the process of purchasing considerable amounts of new diagnostic equipment. Alongside that this year, we're also, from a resource funding perspective, buying additional diagnostic capacity from other providers to provide a temporary solution to the gap, if you like, in diagnostic demand and capacity, which will see us through until some of our new equipment is on-boarded, if you like. So, there's a whole series of programmes and investments around that. I think we recognise that, in comparable terms, we don't have enough diagnostic equipment per head of population, and that's something that we're actively pursuing and trying to fix as we move forward.

Okay. Thank you very much.

Thank you. Before I bring in Tom Giffard, I've got a couple of supplementary questions myself. Clearly, a key role in cancer support is provided through the third sector as well. On Tuesday, Macmillan Cancer Support hosted a round-table in the Senedd on metastatic breast cancer. They said, while there have been some positive developments, including an increase in Macmillan breast clinical nurse specialists, much remains to be done to ensure equitable care for all metastatic breast cancer patients. One of the key issues they highlighted, and patients themselves highlighted, as well as clinicians, was the data gap, so preventing data-led system design and delivery. I wonder how you would respond to that. Obviously, setting up data management systems are resource intensive, but once they're there, they run themselves, if they're performance-managed.

The second related question, which has been raised very recently with me by Young Lives vs Cancer, is that younger cancer patients take longer to get the diagnosis, because, initially, there's scepticism about their symptoms because they're young, and statistically they're less likely to have cancer when they do, and it's how we can remedy that to improve the experience of young cancer patients.

I was at that meeting. I had a fairly, and very reasonably, tough time from that metastatic breast cancer community, and rightly so. I had spent most of the day looking at the ministerial advisory group report, talking about very narrow areas of focus on the upstream pathway. But I think that was a very salient message that we heard that evening, to say that there are quality metrics and support measures we need to focus on that are outside of that point of suspicion to first definitive therapy.

I think there was credit that evening to clinical leadership again, who have developed, I think the first in the UK, a national optimum pathway for patients with metastatic breast cancer. And within that, we discussed that evening about all patients receiving consistent information, having the support of a specialist nurse. But also we've had a struggle over many years in terms of the digital agenda more generally, but particularly focusing on patients with metastatic cancer. As part of that pathway, and part of a national audit that we're participating in, which is mandated, we have provided a new data set form on a new digital platform that every clinician in Wales can now complete. I think what we heard that night is that that message has not necessarily got through. The way they're collecting that information is too top-heavy, based on big teams of working, rather than funding a co-ordinator or the coding person to be able to sort of complete that data. I expect that, when we go to submit the data to that national audit, we will see we haven't got the right level of information. It was really interesting to hear the patients saying, 'This is not acceptable, that we don't have the information on all of us in Wales who have this type of disease.'

So, we have the tools, we have the mandate, I think it's now getting out to, as is often the case, implementing at pace and scale, with us all working in a similar and more consistent way. So, I really hope, Chair, that we will make significant progress in that area over 12 months. As you can expect, I've sent some e-mails since that meeting, in terms of us understanding how we can better implement that process.

And the younger cancer patients?

Yes. I think, then, there are hard-to-serve areas, aren't there? We've talked about deprivation, we've talked about patients who are not necessarily forthcoming in coming forward. But we've also got those younger patient groups who are really unlikely to have cancer. But when they do, and they're seeing primary care and community care services who have eight-minute appointments and trying to work out whether they do have an alarm symptom or not, that is a huge challenge.

What I think the audit report has emphasised is that we need to have better granularity and transparency of that data, both reflecting young children's and teenage and young adults' services, but also issues around ethnicity as well that we're not routinely collecting. Now, some of those issues are much bigger than cancer alone; they apply to all healthcare services. So, I think there are some challenges there. But I think the MAG report and the Cabinet Secretary have both pointed out that we do need greater granularity of information, and we also need more transparency in that information.

Perhaps I should disclose that one of my children travelled that journey. However, Tom Giffard.

Thank you. Just for clarity, Chair, I know you were discussing having a break at 10.30 a.m., so I don't know whether you want me to carry on—

At 10.35 a.m. So, if you could go ahead with your questions, we'll then have the break.

You'll just interrupt me, yes, when we're ready? Yes. Okay, great. Thank you.

So, thank you all for coming. I wonder whether the Welsh Government agrees with the view expressed by third sector witnesses that Wales needs a long-term cancer strategy?

I think it's fair to say that the third sector has been very consistent in calling for a cancer strategy. We understand the preference that they have, but I think we feel we've already got in place the relevant policy and plans to deliver the improvements in cancer services that we're all seeking to deliver, and we certainly—. We don't want to sort of pause at this point and delay progress in our commitments around the cancer improvement and cancer recovery programmes, and also the delivery of the quality statement.

So, we brought all of this together under one auspice of a sort of national cancer leadership board with a very clear cancer improvement plan; our focus is on delivery of the existing plans rather than the development of a new strategy. And I think that was borne out by the MAG recommendations on Tuesday, which said very clearly that Welsh Government—. And not just with cancer, but generally, across the board, we don't need any more plans; what we need to do is deliver the plans that are in hand. And I think that's—. The Cabinet Secretary's been very clear and I think we've been very clear with health boards that we need to get on and deliver those plans.

I think what comes post delivery of those plans is a different question, and engaging with the third sector around what that long-term plan, strategy looks like is something that we would approach once we feel that we've delivered the existing commitments within the plans that are currently outstanding.

Okay. Can I ask why the Welsh Government has not provided more support to ensure successful implementation of the cancer improvement plan, despite the plan being a direct request from the then Minister?

So, I'm not sure that I would agree that we haven't provided the support for the delivery of the cancer improvement plan. If we look at financial resources that go into the system, over the last five or so years, the investment in cancer services is up 54 per cent or so. We provided a direct £2 million to support the implementation of cancer improvement in Wales on a three-year basis a couple of years ago. We've re-targeted some of that money, so initially, when the money went into the system, we felt there was too much money put into people rather than initiatives that were supported in the cancer improvement plan, so we've rowed back and there's now, I think, £1.2 million or £1.3 million of the £2 million that has gone into support those initiatives that are described in the improvement plan.

I think if you look at the assessment that's been done of the cancer improvement plan, which we did—I think it was the summer of last year; I think we reported it in July of last year—the vast majority of the actions that are described for each of the health boards within that plan have either been delivered or are in the process of being delivered, recognising that it was a 2023 to 2026-27 plan. So, halfway through the implementation period, I would say 70 per cent of the actions have been delivered and the remainder are being delivered, they're in the process of being delivered, in the health boards. We've actively supported that through the major health conditions policy team within Welsh Government and by the deployment of a team in the NHS executive to support directly health boards in the delivery of the cancer improvement plan.

Does the Welsh Government consider itself accountable for delivering any part of the cancer improvement plan?

So, the plan came out of the—. I think we'd had a number of cancer summits that the then Minister had held around the importance of cancer and the result was the production of this plan. Welsh Ministers are, of course, accountable for all for all NHS services and plans, and we use official mechanisms that I referenced earlier in the meeting, the integrated quality and delivery meetings that we have, and the one-to-ones on cancer. And Ministers have required national reporting against the cancer improvement plan. We could have reported earlier. I think we accept that we were a bit slow in reporting the progress with that, particularly to the Cancer Alliance. But, yes, Ministers are accountable for the delivery of all the NHS plans in Wales.

But the way, I suppose, the cancer improvement plan, specifically, is constructed is beyond the kind of statutory duties placed upon Ministers—

Yes. 

—and the Welsh Government itself might not be responsible for its implementation. I take it, from your answer to the question, that the Welsh Government, perhaps, beyond the normal ways in which Ministers are held responsible for service delivery, on the cancer improvement plan, doesn't consider itself accountable for delivering the cancer improvement plan.

No, because all of the actions—I think you're right—that are contained within the cancer improvement plan relate to delivery by, in the main, the health boards. The plan was published by the NHS executive, just after it was formed, actually; I think there’s a lovely picture of Tom on the cover. But it was an NHS plan, supported by Welsh Government, and we have supported the delivery of that. And it was something that came out of the ministerial summits that we’d had. So, it wouldn’t fall directly within the statutory accountabilities, as you described them.

Okay, thank you. And how does the Welsh Government intend to monitor and report progress in implementing the plan, and how does it plan to communicate that progress to the public and to other interested parties?

So, the improvement plan is on the NHS executive website, and, obviously, it’s come to Senedd committees before, so it is in the public domain. We intend to publish the next—. So, we’re taking an update on the actions in the spring of this year, through May and June, and we will publish the report on progress against those actions on the NHS executive’s website, once that is published. And when the Cabinet Secretary meets with the Cancer Alliance, which is twice yearly, we will be taking that update to that meeting to communicate that to stakeholders and other interested parties at that point. And we will continue to monitor the implementation through our normal and regular interface with the health boards, and through the new national cancer leadership board as well.

So, we’ve combined all of the cancer improvement plans into one. The work plan for that is coming to tomorrow’s cancer leadership board, which is the third meeting we’ve had of the leadership board. That will then be signed off, and that will be monitored through that process, which, again, is reported both to Ministers and to officials in Welsh Government.

I’m curious about the question—. It's obviously about the reporting and making available on the website, but I suppose my question is about how that is planned to be communicated to the public and to other stakeholders, beyond just sort of putting it on the website.

That’s a good question. I’m not sure how we would—. My personal view is that the outcomes for cancer, and the quality of the cancer services, which is what we’re trying to improve through the cancer improvement plan, should be what speaks to the public, in terms of what they experience when they move into any cancer service. So, if we publish an action plan—. I’m happy to publish an action plan and communicate where we’ve got to with that action plan, but it’s the outcome that I think is more important to the public than what the plan actually says or delivers.

And how does the national strategic approach consider the very different needs and views of children and young people? I know the Chair touched on this in one of his last questions, but how does that approach differ for children and young people?

Our policy and approach is always about guidelines, clinical guidelines, and standards and funding, whether it be the recommended therapies, or funding the services that are delivered through national pathways. We aim to do that for all of the population. I think that specific focus on children and young people is something that we've not delivered as well as we could have done over the past few years, certainly through the recovery from the pandemic. We recognise, for example, in the planned care programme the need to focus on young people who are on waiting lists, because the proportion of their life that they could spend on a waiting list was considerably more than somebody who was in their late fifties or sixties. I think we need to take a similar approach with children and young people and be much more active in the way that the service is delivered, to listen to what they've got to say and listen to their concerns and issues and making access to services much easier for them. I think there's a lot of work to do. Perhaps, Tom, I don't know whether you would agree with that.

I think we've touched on having the intelligence around the experience of children and young adults and I think then having that intelligence and using it to improve the experience and outcomes for that population. We do have children and young adult standards and guidelines, as Nick has said. I think there have been some specific challenges about transport for appointments, for instance, which we have heard have a deleterious effect on whether those children attend or are supported through that programme. I think that's something we do need to look at.

For example, one of the questions that was raised was whether we should move services that are commissioned by the joint commissioning committee from 18 to 16, and we're certainly having active dialogue about what the implications of that would be and how we might implement that change, which I think is an important one.

We're certainly working very hard with the third sector, who are really important stakeholders to work alongside, in terms of advice, in terms of patient advocacy, but also in terms of support for delivery and policy as well. We have very close links with the third sector, particularly with charities, but also with industry partners as well. I think they're very important stakeholders in terms of driving improvement in the service. So we certainly are listening to those concerns.

Thank you. I wanted to move on to ask about national leadership roles and responsibilities for cancer services in Wales. Can I start by asking who it is that's ultimately accountable for system-wide improvement in cancer services and how the dual role of the chief exec of NHS Wales and director general for health and social services fits into those accountability arrangements?

In essence, the DG or chief exec of NHS Wales is accountable for cancer improvement and cancer delivery. My role within the Welsh Government is that one of my directorships is for performance and delivery. So ultimately, I am accountable for holding to account health boards for the delivery of their cancer services and their cancer performance.

I think we've had a confusing leadership arrangement previously, whether that be through the network, which almost sat independently; we had a cancer improvement team that sat within planned care; we had a senior responsible officer within the NHS executive who was meant to be overseeing cancer services alongside some of these other functions; we have a chief digital officer, who picks up some of the replacement, for example, for the cancer information system. So there was a whole body of people who were actively playing some leadership role in different parts of the cancer system. I think we recognise—and certainly the auditor general's report made it very clear—that that was very confusing and didn't provide clarity to the system.

The way in which we've approached that is to say we need clinical leadership. So the new deputy chief medical officer, who will be in post in the next two or three months, will chair the national cancer leadership group, which brings together all of those component parts that I've just described under one auspice. I will sit alongside the DCMO, as deputy chair of that group. So, we're very clear that the two of us have both clinical governance accountability and performance accountability and are able to draw on all of the resources available to seek to drive the improvement and provide clarity to the service, which ultimately delivers the patient treatments and patient services that we've got.

Thank you. Who's accountable for the work of the NHS executive? 

The NHS executive is a hosted body of Public Health Wales and ultimately is part of the Welsh Government and falls under the director general and chief executive of NHS Wales remit and accountability. So, ultimately, they are accountable to Judith. There are a number of directors within the Welsh Government executive director team who have line management responsibility for some of the functions within the NHS executive. I have had delegated responsibility from the DG and chief exec of NHS Wales to have oversight for the establishment of the executive and the, if you like, day-to-day running of the executive to make sure that it's delivering its remit as we set out in the remit letter.

Following on from your answer to the previous question, is that as clear as it could be?

I think it is now. I think there was a lot of blurring of lines, to be fair, when Audit Wales did their review. I think we're also in a period of transition from a number of individuals who had either left their posts or were being replaced—so, a new DCMO; a new CMO; Iain, on my right, who is the new networks director within the executive. So, there's been a degree of confusion, I think that would be fair to say, and I think it is much, much clearer. Tom, as the national clinical lead who sits on the network, I think one of your comments—I won't call it a complaint but a comment—was on the lack of clarity. Tom, I don't know whether you feel that we've tackled that.

I think we certainly welcome the fairness and the accuracy of the reports that we receive from the audit office and MAG. I think there has been a period of some fragmentation and confusion in terms of who was in charge of delivery. I do think that this is a team approach. You quite rightly asked about the role of the Welsh Government and also the NHS executive, but certainly, as clinical lead in the service, I think I'm part of this team and I take my roles very seriously.

I think there is certainly greater clarity now with the establishment of a single leadership board. I do think there's greater clarity in terms of the work plan, bringing together the improvement plan that we've discussed and also the recovery programme plan. We're really clear about the priorities that we have to deliver over the next 12 months, and also inform planning for next year.

Are we there yet in terms of establishing some processes and supporting clinical leadership? I really welcome that. I think, in terms of delivery, we've got a huge agenda over the next 12 months to get over the line. Obviously, the proof of the pudding et cetera will be seeing how we do deliver that. Particularly going to the meeting tomorrow is a proposal around a digital and data road map that we need to develop, because we've already touched on the fact that we don't necessarily have the intelligence that we need to drive improvement in the service. So, a step in the right direction, definitely, but we still have to deliver against those plans.

Do you mind if I just come in? A single team in the NHS exec—so, not a number of teams that sit differently from a cancer perspective reporting to different directors, but a single team in a single place, a single director that reports into the Welsh Government—is really helpful, and a single plan that we've brought together in terms of delivery is incredibly helpful now. The cancer leadership board is there to provide that direction as well. So, from an NHS exec perspective, cancer has become far clearer in our role and how we work together, not just with the NHS, but also with the Welsh Government in that space.

Thank you. Finally from me, how will the Welsh Government respond to the Wales Cancer Alliance's suggestion that the third sector 

'has experienced a period of disengagement'?

Why do you think they feel that way, and what is the Welsh Government going to do to make a more inclusive approach as it progresses its response to the auditor general's report? 

We are clearly committed to working with the third sector in Wales. Specifically in cancer, they're a really important part of the system, because they, obviously, provide funding for research and some service provision as well as providing a voice for the public and other stakeholders. The Cabinet Secretary meets with the cancer alliance, which is 29 of the charities, biannually to discuss cancer services in Wales. As I referenced earlier, the cancer improvement plan, which came partly from one of the cancer summits, which also had representation from the third sector on it, has been reported to the cancer alliance and will continue to be reported to that third sector body as we move forward.

We're keen to build on this, and we've asked them to join the national cancer innovation and some of the tackling cancer improvements work that we're doing. But I think we also need to be really clear about getting the balance right in terms of their engagement in the right forum and in the right way, but also ensuring that we as the Welsh Government can discharge our own internal decision making effectively. We can't, obviously, have the third sector in the room when there are decisions made around some of the funding models or commissioning of particular services, because they, maybe, have conflicts or otherwise. We're really keen to actively engage, but making sure we do it in the right places at the right time and to ensure that they're engaged in those things that really can influence some of the stakeholders.

I can see that Rhianon wants to come in, Chair.

Yes, please.

Hello.

We can hear you. Thank you.

Thank you. I've had a number of different challenges with the laptop and audio, so apologies for seeming to be in and out of screen, et cetera. On that particular point, and I fully understand what has been said in terms of commissioning of services and interest, et cetera, et cetera, I think there was a clear message when we had our witnesses from the third sector that they felt outside of the table in terms of providers, key providers for the Welsh Government, and that this was a new phenomenon, and that they were much more within a co-constructive mandate in previous years and had a seat at the table. I fully understand what you're saying in terms of any conflicts of interests around commissioning, but it was tangible. I don't know what your comments are around how you can rebuild those relationships and construct a forum whereby you rebuild those relationships, because we definitely need them. Thank you. 

Were they able to describe what the difference was from what they saw as previous relationships to now? I think we've included them, clearly, within parts of the network arrangements. There is that interface with the Cabinet Secretary on a biannual basis. There's quite significant third sector engagement, from my understanding, having worked in a health board, at a health board level. I'm unsure as to what—

Okay. I think in terms of— 

I think we do need to explore it, but I'm unsure what further they would be seeking.

Well, I think that's a really good question to ask. It was clearly put to us in committee that there was a diminution in that important communication as a forum with the Welsh Government, and I think that's for you to explore with them. You can, obviously, have the minutes from the committee meeting that we had recently, but it was a very clear theme, and so I think it's really useful that you ask that question to them and do that work. I don't know what the Chair would think about that, but that's my response.

It was a strong and consistent message from the witnesses, representing not only a collective body but a number of individual charities on that occasion. It is all in the minutes of the meeting. Could we perhaps send the minutes, drawing attention to the relevant paragraphs so that you can see verbatim—

We'll absolutely follow that up. We're in constant conversation with the alliance. On the suggestion by the Member there, I will ask them that question, because I think that it's important that we do engage. We absolutely recognise that things have changed, and, sometimes, that change can cause that friction, if you like. I think we need to pick that up.

Yes. Okay. If we can have a short break. It's now 10:55. Shall we say 11:03? Until 11:03. Thank you.

Bore da. Welcome back to this morning's meeting of the Public Accounts and Public Administration Committee for the second part of our evidence session on cancer services in Wales with Welsh Government officials.

If I can begin with a question picking up from a session on screening earlier before I pass over to colleagues, why do you believe that it took so long for the Welsh Government to ask Public Health Wales to develop proposals for a national lung screening programme, and what are the timescales now, for a decision?

I'll take that. Thank you, Chair. I guess the timeline is a matter of record. The UK National Screening Committee, which is a standing advisory committee to the UK Government, recommended targeted screening for lung cancer in June 2022, and in December of that same year, there was an initial business case to Welsh Government, submitted by Public Health Wales, for the establishment of a project to examine a lung screening programme. Then, there was a response submitted within a matter of a few weeks by Welsh Government officials requesting some further scoping work to answer some important questions about the running costs of any intended screening programme, and also the impacts of any screening programme on wider health services. Because, of course, a screening programme doesn't stand in isolation; as we have heard already, those who test positive at a screening are then referred into the wider system for further investigation, follow-up and, if necessary, treatment and follow-up again. So, the implications of that needed to be understood before there was a position to commission any screening programme.

There was then a series of discussions to and fro, bilateral discussions, through the late spring of 2023, a revamping of the initial programme proposal by Public Health Wales in the autumn of 2023, and then a decision was made to fund an initial scoping project in November 2023 for six months of work. The final report on the scoping work has been received, or, sorry, an interim report on the pilot proposal in Cwm Taf Morgannwg has been received into Welsh Government. A decision has been made not to require a further final report. The view in Welsh Government is that the current information on the back of the pilots, plus some supplementary information received from Public Health Wales, is adequate on which to make a decision, and ministerial advice is being drafted and will be sent up very shortly to the Ministers for a final decision on whether or not to proceed with a lung cancer programme across Wales.

My observations would be that these are complex programmes to get right. There is a wide range of material factors to consider. It's a different approach in Wales to the approach that has been adopted in England, which was a regional approach, where there was essentially an agreed national protocol and it was implemented in different ways according to whatever regional resources were available. The idea in Wales is that we would have a single national programme operating to a consistent set of standards, and so that has added an extra level of complexity. But, as I said, the belief within Welsh Government is that the information that we hold is sufficient to make a recommendation to the Minister on the future of a lung cancer screening programme for all of Wales.

Okay, thank you. Well, I have to move on. Could I please remind Members attending remotely that if you wish to speak, please raise your hand physically rather than remotely, because it's causing technical problems? Now, could I bring in Rhianon Passmore, who has some questions for you?

Thank you very much, and I’m assuming that you can hear me clearly. Moving on slightly, but I want to juxtapose some of these questions, actually. Would you accept, in the response that you’ve just given to the Chair, that decision making associated with lung cancer screening and digital cellular pathology has been slow, or too slow? And as a result of that, if that's your conclusion, what learning has been taken from that process to implement new and innovative approaches across Wales? Because we know of that benefit to patients across Wales. 

Yes, I think in both, if you take the lung screening process, the digital cellular pathology, then we would obviously have liked to have seen faster progress, I think, in terms of implementation of some of these elements, but I think we need to—

So, can I just pick you up on that? Sorry to interrupt you, but from what you've just said, that you'd have liked to have seen faster implementation, in terms of learning, why wasn't there faster implementation? I would have thought you could have explained the reasoning from your assessments as to why there wasn't a faster implementation. 

A faster implementation of the lung screening programme? 

Yes, in particular.

I think we've learnt the lesson, which is that we've conducted a trial in a specific health board location, in CTM, and we've not expected a full report to come to us before we considered the business case to nationally roll out the scheme. In the past, we would have gone, ‘We did a trial, here's an interim report, let's do a full report, and then let's pull together a business case.’ What we've actually done this time is we've said, ‘We've done a six-month trial, there's clearly enough evidence to support the roll-out of a national programme’, and therefore we reviewed it last week. The national business case has been produced by Public Health Wales and ministerial advice is being prepared for us to be able to give advice to the Minister as to whether he wants to set out the funding to support the roll-out of a national lung screening programme.

So, I think we've learnt to some extent. A lot of these schemes are very complex, and they're multi-million pound decisions, and I think it's important that we take appropriate lengths of time to consider the evidence and the outcomes from them. There are different challenges and different learning from things like digital cellular pathology or the cancer information system replacement, which have different learning, and we've applied that different learning and they don't necessarily correlate with what we've done with the lung screening programme, for example.

Okay. I get that differentiation, but in regard then to your comments that it could have been—. You know, in particular with dealing with a different basket of fruit here, what I'm trying to get at is: do you feel that the process of roll-out, bearing in mind that these are multi-million pound programmes and initiatives across Wales, do you feel that the pace of the process is in itself too slow, or do you feel that it is thorough? Because the accusation on the opposite side of the coin will be that it is too slow. I'm trying to understand from yourselves, as our witnesses today, whether you have any element that would agree with that overall, or whether you think it's all purposeful. 

So, I think if we go back to 2022, when the initial lung screening proposal was prepared by Public Health Wales, I think we were perhaps being over-thorough, as well as slow and over-process-driven in terms of the back and forth before the trial got under way. So, I think, in answer to your question about—. There has got to be a balance between thoroughness and appropriateness—

Yes, I accept that.

—and speed, of course, but I think what we've done is learnt the lesson from that in the application of a full national roll-out by not playing business case back and forth with Public Health Wales at this point for the national roll-out, and saying, 'We've got sufficient evidence, produce us a case, we'll consider the case', all of which has been done in probably a two to three-month period, whereas we had, in 2022-23, a six-month back and forth of, 'We need a bit more information for this and that.' So, I think we've learnt the lesson, and there is a real focus, I think, on learning lessons from previous programmes, whether they be digital, whether they be roll-outs of initiatives, to put some pace behind them without losing the oversight and governance that we require as we're spending considerable sums of public money.

Okay. This is a similar question, but perhaps you could extrapolate a bit more. On the Welsh Government's role in supporting development of the pan-Wales approach to digital cellular pathology, as you said yourself, it has taken a while for the national pathology programme to develop that business case for scanning equipment and digital storage. Building on what you've just said, do you feel that the Welsh Government's role could have been more impactful in terms of the roll-out of the all-Wales approach, or the development of that, in that particular case?

The short answer is probably 'yes'. I think we need to, again, keep learning lessons from all of these approaches. I don't know whether Tom, who's been quite involved in some of this, would have a view.

Yes. My reflections and observations are: I think it would have been helpful in terms of lung health checks to have made a statement of intent—that we plan to proceed with the national programme. How we do that is incredibly complex, incredibly expensive, and we'll almost certainly have to phase it in because we don't have the capacity to deliver that overnight. I think that initial statement of intent, if we really are hard about ourselves in terms of reflection, I think that would be fair.

I think there is also something about being clear about national decision making—that we are clear what our direction of travel is, and I think Nick has spoken to that very well. So, I think we could have been clearer around digital cellular pathology, that this was a national programme that we expected to roll out.

I think, just adding to that, I would say that implementation of policy and also of positive evaluations of pilots are sometimes slow and fragmented, and it is difficult to take every organisation with us. I think there's a recognition that we suffer from pilotitis: we do lots of pilots, we evaluate them, positively approve them, and then doing that seven times across Wales sometimes leads to differential implementation. I'm really pleased, as we've spoken about already, that that is now happening—

Sorry, what is—? Sorry, to interrupt you. When you say—

So, the roll-out of digital—

What is happening? Is it going to be over-assessed and analysed in seven different regions? Could you be specific about—? You've identified there's an issue there, so what is happening to combat that?

I think there is a proposed plan for a national roll-out, based on a local, regional and national perspective, through the diagnostic programme of planned care now for digital pathology services to be taken up across the whole of the service. I haven't got the timelines in front of me.

The digital roll-out of digital cell path starts in June 2025—so, next month now—and that is a national roll-out.

Okay. It would be quite useful for that to be, if it's not already—I apologise if it has been—if that could be shared with committee in terms of our ability to scrutinise. Because, obviously, in terms of these hugely expensive, complex and complicated often, programmes and initiatives, especially in this area, we all agree it needs to be thorough and it needs to be workable and affordable and sustainable and with capacity. But, equally, when we know that we have something that works in one pilot area or more, then we have a duty of care to our citizenry to be able to roll that out without bureaucracy that is unnecessary, which you've already identified.

I'm going to move on, if I may, to question 9, Chair, unless anybody wants to pick up on anything else on that line. No. Okay. So, in terms of exploring Welsh Government oversight of cancer services, what do you think, going forward, the Welsh Government is going to do differently, apart from explaining how cancer performance is going to be measured in the quality statement? You've mentioned before, on the previous question, the statement of intent, but, to broaden, what is Welsh Government going to do to broaden, I suppose, and extrapolate its reach and oversights in order—this is a really old theme—to hold NHS bodies to account for delivery of that statement of principles? Because, when we know something works, we need that to be implemented. Have we enough hold over the NHS bodies to be able to do that? I don't know who'd like to—.

Yes, I think, as you've referenced, that's been an ongoing challenge, hasn't it, in terms of our ability to hold the NHS, or the delivery organisations, to account for both performance standards, but, more importantly, I think, the quality and variation that we see in any number of services. I think we've made some progress in some areas. So, the development of the optimum pathways specifically for cancer, which talk about reduced variation, a very clear approach to both referral, diagnosis and treatment on a particular tumour, and a particular group of tumour sites, is broadly accepted by the clinical community and the operational community within each health board and each service area. What we've got much better at, I think, is measuring the variation on those specific factors. So, I referenced earlier the straight to test, the 21-days referral to treatment; those elements, and the 14-day pathway, are really key if we're going to improve cancer services and cancer outcomes in Wales.

We now have data and are able to measure every health board on those particular key measures, and we meet with them in what we call cancer one-to-ones on a monthly basis to go through that data and variation. So, we're not just focused, then, on 'Where are you with the 62-day pathway, or the backlog?' We are, 'This is a clinical optimum pathway. Ninety-five per cent of your patients in Aneurin Bevan are going straight to test, yet, in Cwm Taf, it's 45 per cent. What are you doing about it?' That, I think, gives us the levers to be able to really start to influence that reduction in variation that we're all keen to see.

Okay. So, can I just interrupt you on that particular point, if I may, Chair? Because, yes, we need the data collation, and we have that now, I would presume—if not, why not—but that doesn't seem to be much further forward in terms of being able to hold those health bodies to account for that, if there were such a variance, for instance. How are you able to, in that example, use teeth to be able to push any individual health board that has a drastically different key performance indicator in such an area? Because that doesn't seem to be any further forward, to me, than we were 10 years ago.

Well, I would argue that the escalation and intervention framework that we'd put in place a couple of years ago has absolutely driven—. There is a sanction now, which, broadly, as a health board goes into escalation and up the grading from a one to a five, five being the special measures—. And we can do that for specific services or groups of services, and we have done that. And we've put a number of health boards into levels of escalation for performance and delivery, and worked with them for them to be de-escalated. So, the system works. You can say, 'Well, every health board's in escalation; it's clearly not working'. Well, actually, yes, every health board may be in escalation for certain things, but what we are seeing are improvements and de-escalation.

I think what the Cabinet Secretary is currently working through with us is a rewards and sanctions approach where we—. For example, I talked earlier about the £2 million that we put into the cancer improvement fund; I think the MAG have recommended—and we would absolutely support this recommendation—that we use that money to incentivise a reduction in variation, an approach to improving performance. We've adopted that approach in our planned care recovery plan for this year, where health boards will not be able to access additional money or capital moneys if they are not delivering the enabling actions or just-do-its that we talked about earlier on in this committee.

So, I think we're starting to put levers in place; it is—. It's a difficult one, because what are the sanctions and what are the levers for improvement that we can use in a system where, broadly, you know, you've got—? There is huge variation, there's huge variation in the population, so defining those measures where you escalate and de-escalate and/or reward and/or sanction is quite challenging. But I think we are absolutely moving to that and we've got evidence to support that we have escalated and de-escalated organisations for performance and delivery. And the enabling actions that we've set out in this year's planning framework, which apply equally to cancer and other services, will be used to drive that reduced variation and give access to health boards for additional capital moneys or revenue moneys. So, I think that's broadly all that's within our remit of being able to do and influence the service in that respect.

So, you would suggest that, when you're developing further arrangements—you've mentioned the reward scheme and the £2 million, which is welcomed—. So, when you're overseeing the compliance with the national optimum pathways, do you see the role of Welsh Government here being maxed out in terms of impacting those variants? Because, without the intel and the data, which we now seem to have, you know, in one health board, it may be diagnostic equipment, but, in another, it may well just be a lack of capacity of staff. So, do you feel you have the tools, as Welsh Government now, to be able to collate those optimum pathways and develop them? And if not, in terms of looking wider afield—in Scotland, Northern Ireland or Europe or internationally—is there something missing? Because, you know, as I've said repeatedly, you know, over the almost 10 years that I've been at the Senedd, we have had these issues. And I agree in terms of people are varied, geographically, our catchments are varied, but we all know very well that there shouldn't be a big variance in terms of our data for our citizens. So, I'm trying to ask you: is there something missing, do you think, from the development of Welsh Government's oversight around that, or do you feel that you're on the right path?

We're on the—

As I said at the beginning, the clock is, unfortunately, against us. Could I please ask Members and witnesses to be as succinct as possible?

So, I think we've got more of the tools in place and we are utilising them more effectively on that journey. The reason that we established the NHS executive was to act as the central guiding hand, if you like, from a Welsh Government perspective, into the service, and reduce that variation. I think one of the other opportunities that we're only just starting to take to reduce the variation and oversight is the instructions around regional working and regional services, and we've established two regional committees that have, in effect—I don't want to use the word 'forced' but have—encouraged strongly health boards in the south-west and the south-east of Wales to work together to deliver those services. So, I think all of those things are starting to come through.

Okay. Thank you, Chair.

Okay. Thank you very much indeed. Adam Price.

Thank you for that question. So, at the moment, there is an analysis of spending and prevention going on within Welsh Government to get a clear understanding of the baseline from which we start, and then there will be a process of prioritisation of prevention initiatives looking at the return on investment and what health gain will be achieved by specific prevention interventions.

In relation to cancer, there are a number of cross-benefits, if you like, from existing prevention initiatives, which also flow to cancer. So, smoking is a clear example of that. We’ve seen a reduction in smoking rates, from over 63 per cent in the 1950s to less than 13 per cent now, and an intent to continue to drive those rates down. But that’s a good example of the time it takes to make the kinds of profound changes that are required.

Perhaps a different example would be around immunisation and the human papillomavirus vaccination programme, which has been successful in driving down cancer—cervical cancer rates—in younger women by nearly 90 per cent. And that’s something that has been going for only 15 to 18 years in Wales, and now extended, of course, to all young people in Wales. And we’d expect to see continued benefit from that.

But, if you look at prevention in cancer, most of the prevention will be—. Well, the easiest things are through smoking and tackling overweight and obesity. Those will get the biggest gains in preventable cancers. And those are currently funded campaigns, and clearly have benefit across a wider range of health conditions than just cancer; they also have an impact on cardiovascular disease, on musculoskeletal disease, on dementia and mental health. But—. Sorry.

Yes, so, my personal and professional view is that alcohol hasn’t had the same attention and focus as other drugs in substance misuse. There are many reasons for that. One of the reasons for that is that the licensing regulatory regime is a reserved matter. And so, one of the key controls around alcohol, that of supply, we’re beholden to Westminster legislation for that. Notwithstanding that, Welsh Government has, really importantly, put in place minimum unit pricing, and has renewed that, and that is a really effective measure in reducing alcohol-related harm at the most extreme end of the spectrum.

But we know from research evidence, and from the recent World Health Organization statement, that there is no safe level of drinking alcohol, and that the increased risk of cancer occurs with even the first drink. We also know of the specific risks associated with alcohol use with, particularly, breast cancer in women. So, I think that there is a significant amount of further work to be done in relation to improving awareness of alcohol, but also in reducing alcohol consumption, and improving the awareness of the relationship between alcohol and cancer, as well as its other social and physical harms.

I think there is—well, there is—a national commitment to implementing prehabilitation and rehabilitation on all pathways. And there was a recent research study this week, which re-emphasises the importance of physical activity, in particular, in recovery from cancer treatment. But I think probably Professor Crosby is best placed to answer this one, in relation to clinical pathways.

Yes, I think this is key, because we know the impact of keeping patients well while they’re waiting, empowering the patients to help themselves through digital support mechanisms, making sure that we don’t exclude some members of the community.

In terms of—. For cancer specifically—and, again, this is wider than a cancer issue—we are developing specific prehabilitation standards that we hope to publish this year. There is a Macmillan report coming out very shortly, so we need to be mindful of that. But there is also work going on across the NHS executive, wider than cancer, and we need to ensure that the standards for patients with cancer are similar to those without cancer.

But we will build in those standards and recommendations into our optimum pathways, so that we maximally support patients as they go through the pathway.

I can talk to cancer, but maybe we might put beyond cancer through the NHS executive and the 3Ps programme, et cetera.

So, in terms of cancer, it is to develop those standards, then to work with lead clinicians, but predominantly allied health professionals in all organisations to undertake some audits and particularly peer review. So, this is a really important mechanism for sharing examples of best practice, but also constructively challenging some services that aren't delivering those support tools. Again, I would come back to implementation and standardising and improving the consistency of implementation across Wales, but also using technology such as, as I say, digital support tools to ensure that patients and carers can help themselves through the pathway. 

I'm not certain that there's anything that I think we can't do. As has been pointed out in the audit office report, and something I have been championing for some years, there are some key elements of data and intelligence that we don't have at the moment. So, for example, we report on urology and gynaecological cancers, but not necessarily prostate-specific or uterine or cervical cancers, et cetera. That is a key development—tumour subtypes. And that is almost over the line, and we need to accelerate that process.

There's also the component wait—so, how long somebody waits after an endoscopy to have a CT scan. That should only be a couple of days, but we haven't got the tools yet to measure the granularity of that information. Similarly, with routes to diagnosis and also stage of diagnosis, we need better intelligence in those areas—all brought out in the audit office report. I think that is why the leadership board will be meeting tomorrow with a proposal for how we take a data and digital road map forwards. I think that will be a huge priority for us. I am already having conversations with colleagues in Digital Health and Care Wales about how we might work a little bit differently to accelerate that implementation.

I think we’ve touched on this this morning. We do need greater granularity of data. The issues around ethnicity are absolutely key if we’re going to better support underserved communities. We need to know where these patients are from and the types of communities they’re from, and we don’t have that. It is a bigger issue than cancer, again, alone. That needs to be coded for all healthcare services better than it is at the moment. And I think I’ve touched on the children and young persons—it’s important to have the granularity of that data for that population particularly.

I don't think we necessarily have a specific target. We're very clear, as Tom has referred to, that it's not just the cancer pathway; it's our whole ability to collect ethnicity and other elements of data. It is a clear focus and clear target for the coming year, and I don't think we're setting a target on when we get there, if you like. 

And could I just add in one point about some things we do need to bear in mind? When we get down to very rare cancers and occurrences in, for instance, a very young patient population, if we identify a small number of people from a specific area, it is a caution around whether those patients may then be identifiable. So, we do have some restrictions in that area.

I may defer to Nick in terms of targets specifically, but we have replaced a digital platform, called the Cancer Network Information System Cymru, with a new system that is more integrated into the national IT architecture. We have done that on a much more resilient platform that is now supported, and the system hasn't fallen over, so we've got to recognise the success in that.

As part of that, we've developed two products: one around how multidisciplinary teams work, but also around how we collect data, and that is on data set forms. That has just been implemented in the last 12 months. And through that system, we will be able to better report out with a much more rapid approach to the collection of that data. At the moment, we have to acknowledge that, over the next 12 months, there is going to be a paucity of the completeness of that data, but, after that, we will be much more compliant with things like national audit and rapid data sets. At the moment, the gold standard from the registry does take some years to collate, but, with these data set forms, we will have better access to that rapidly available information and intelligence.

So, the roll-out—. I've got a bit of a timetable somewhere. We've invested £12 million in replacing the system, and trying to use additional functionality of the national architecture, I think, has been really useful. Phase one has concluded and, as part of DHCW's remit letter for this year, the aim is to move to business as usual by the end of this financial year, so 2025-26.

I wouldn't know that. I'd have to—

A sort of order of magnitude.

I must admit, I don't really understand the—

I think there's definitely a strategic direction in terms of paperless working, and so we're moving away from the use of paper. I have to say that that's not complete, but when you come to the clinics that I work in, you won't see many pieces of paper being written on anymore. 

It's not about paper, then. So, even with digital systems, you can have systems that are automated or where they involve manual rekeying on a computer. Is that an issue of discussion? Am I way off—

It definitely is, and moving from paperless to digital, then digital to automation. So, we should be collecting this data from source information, from our radiotherapy, our chemotherapy and our surgical management systems. Increasingly, we are doing that, but there is definitely more we can do in that space.

I think ,as everybody moves on to the same system, that starts to reduce the regional or digital barriers to working. But it's important to state that a lot of cancer care is currently delivered on a regionalised basis. So, radiotherapy, anti-cancer therapies, quite a lot of the complex surgery, whether that be lung or liver, are delivered through our regional centres. So, for those people who have cancer and then go on to treatment, quite a significant amount is delivered regionally. I think there's an argument to go further, particularly around medicines preparation and diagnostics, and the move to more advanced diagnostics will require specialist equipment, which we'll probably deliver on a regional basis, while maintaining local provision for the more simple diagnostics, shall I say?

There isn't specifically on the board, but there is digital, DHCW representation, through the chief digital officer, on that group. So, I suppose you'd call them associate members of the board. So, when we're at the point of discussion of those sorts of things, then they are available to be part of that. As Tom has alluded to, tomorrow's meeting is very much focused on the digital road map. So, all of those parties will be at the board tomorrow.

Diolch. Well, before we conclude, one final question: what, if any, further comments do you have on issues flowing from the auditor general's report and all the Welsh Government's plans for cancer services?

From a personal perspective, I think we've covered virtually everything that was in the auditor general's report, and, as I said at the beginning, we welcomed it. We've been absolutely clear that we will act on the recommendations and, as the Cabinet Secretary has pointed out this year, we are really focused on delivery, performance improvement and quality through the next 12 months. That applies to cancer as it does to all of the other services.

Thank you. That summarises it for all four—

I completely agree with that, and I think it is around delivery, delivery, delivery. But there is also something about a continuously improving system. So, although we haven't touched on it a lot today, we have alluded to the Making It Happen and Tackling Cancer initiatives, both around research and development and also innovation. Those do directly feed into the new leadership board.

Okay. Thank you very much indeed. You'll be very sorry to learn that that brings us to the end of our evidence session. As you'll be aware, we will send a copy of the transcript of today's meeting for you to check for any factual inaccuracies. Otherwise, thanks once again for attending and may the rest of your day go well.

Thank you.

Thank you very much.

Okay, Members, I propose that, in accordance with Standing Order 17.42(ix), the committee resolves to meet in private for the remainder of today's meeting. Are Members content? I see that Members are content. I'd be grateful if we could go into private session.