Y Pwyllgor Cyfrifon Cyhoeddus - Y Bumed Senedd

Public Accounts Committee - Fifth Senedd


Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Adam Price
Jenny Rathbone
Mohammad Asghar
Nick Ramsay Cadeirydd y Pwyllgor
Committee Chair
Rhianon Passmore
Vikki Howells

Y rhai eraill a oedd yn bresennol

Others in Attendance

Adrian Crompton Archwilydd Cyffredinol Cymru
Auditor General for Wales
Dave Thomas Swyddfa Archwilio Cymru
Wales Audit Office
Dr Andrew Goodall Cyfarwyddwr Cyffredinol Iechyd a Gwasanaethau Cymdeithasol, Llywodraeth Cymru / Prif Weithredwr GIG Cymru
Director General, Health and Social Services, Welsh Government / Chief Executive NHS Wales
Dr Chris Jones Dirprwy Brif Swyddog Meddygol, Llywodraeth Cymru
Deputy Chief Medical Officer, Welsh Government

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Elin Sutton Dirprwy Glerc
Deputy Clerk
Meriel Singleton Ail Glerc
Second Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 13:30.

The meeting began at 13:30.

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

Welcome, Members, to this afternoon's meeting of the Public Accounts Committee. Headsets are available in the room for translation and sound amplification as usual. Please ensure any phones are on silent. In an emergency, follow the ushers. We have received no apologies today.

Do Members have any declarations of interest they'd like to make? No.

2. Rheoli apwyntiadau cleifion allanol ar draws Cymru: Sesiwn dystiolaeth gyda Llywodraeth Cymru
2. Management of follow up out-patients across Wales: Evidence session with the Welsh Government

Okay, item 2 is the management of follow-up out-patients across Wales, and we have an evidence session with the Welsh Government. Can I welcome our witnesses to this afternoon's meeting? Thanks for being with us. Would you like to give your name and position for the Record of Proceedings?

Andrew Goodall, director general, and NHS Wales chief executive.

I'm Chris Jones; I'm deputy chief medical officer.

And I should point out that Simon Dean, the deputy chief executive of NHS Wales, was due to be with us today, but he's unable to be here for understandable reasons that I'm aware of.

Okay. We've got a number of questions for you, and the first is from me. The auditor general first identified problems with patients waiting for follow-up out-patient appointments in the 2015-16 year. His 2018 report shows the situation had got worse. Can you tell us what the reasons are behind this deterioration in performance, and why was it allowed to happen?

So, Chair, I think there would be three factors that I would draw out just initially for consideration, and then perhaps I can reflect on some performance since the auditor general's report. Firstly, I think it was necessary to introduce measurement within the system to focus on the data to make sure we were capturing—. Whilst we've tracked follow-up waiting lists over the years, there have been a number of areas where we have had to introduce new, more detailed measures of process and performance. We have needed the system to catch up on that. There have been some data issues for some organisations. I know you took the evidence from Cardiff, for example, in respect of the time that it took them to amend their patient management system. But I do think that we've ended up where, certainly by the time we got to February 2018, we felt that that was the first time that we had a comprehensive view of the nature of the issue that we were looking to improve.

The second thing I would say around out-patients is that it's not a static environment. We're not simply dealing with the numbers of patients that we were three or four years or so ago. They continue to increase. So, just in context there, we have seen a 10 per cent increase in our referrals over the last five years. We've got some specialties that are particularly under pressure—areas like ophthalmology, where there's been about a 20 per cent increase in referrals, just for some of their more individual areas, which I'm sure we'll explore. We also had an increase in our out-patient activity that has tried to balance that and mitigate it. All of this is in a system where we have tried to introduce new ways of supporting out-patients so that we don't just simply default to going to hospital. So, there is also a peripheral level of activity around community-based services, which are not included in those figures.

And I think the third issue, which will be a challenge for all of us working in the NHS—and I know it's an area that we're looking at, irrespective of the different countries operating in the NHS as well—is simply how we embark on and deliver a transformation around the out-patient service model. The offer that is still made to our patients now, despite all of the innovation happening, is still really about coming in to see a senior clinician in a hospital environment, and, whilst we have tried to shift a number of the pathways there, I think that's probably the bigger issue for us: how do you transform a service that has had this model in place for the last 70 years or so?

So, those would be the starting three areas. In terms of what's happened since the Wales Audit Office report and the auditor general's report came out, certainly now I think with accuracy issues around the data in place and having a clearer baseline established, I think, over this last 12 months in particular, we have seen improvement on some of the underlying figures. So, we have seen an improvement, for example, in the number of patients who have not got their follow-up date booked. That's been a material reduction over the last 15 months or so—around a 75 per cent improvement. We've also seen a reverse and now an improvement in the total follow-up waiting list. That had gone as high as well over a million. At the end of March, that was down to around 896,000 patients.

There will always be a need for patients to be held on a waiting list. What we're trying to ensure is that they're seen within target. Also, we have needed to focus on the accuracy issues and the support for patients who are waiting in excess of the set times. So, once we have improved the booking time—the assessments that are being made by our clinical teams—we've then obviously needed to improve. And whilst I know that that has deteriorated in itself, you would expect that in part because we have at least been giving clinical dates for many more patients. So, I wouldn't want that, however, to feel complacent. There is much more that we need to do in this area, and we are introducing a number of mechanisms to continue the progress, not least a further set of targets that has been introduced.

A couple of follow-up questions from that answer: it's fair to say there's a significant variation across health boards. So, do you appreciate that, when people talk about the postcode lottery in the NHS, as it's often termed, it's understandable why people think that if you've got that variation? How can you deal with that?


One of our roles nationally is to be really clear on the consistent frameworks that are in place, to be clear on the expectations to make sure that we have, ourselves, a consistent approach to the monitoring and also to the performance management mechanism. But, clearly, we've got health boards that are in different positions around the way in which they have been improving their respective positions. I know that, when you chose your focus for your evidence sessions, you were choosing an organisation that seemed to be more delivering and making progress, alongside another organisation that had more historically struggled. So, yes, there is variation across health boards at this stage, but we have introduced a consistent mechanism for the reporting and for the monitoring and are applying consistent expectations from a performance management perspective.

And spreading good practice from the good ones to the other areas?

Indeed. The planned care programme has had a really significant role from the very beginning. It started off, deliberately so, as an enabling and supporting mechanism, particularly because what we wanted to do through that was to make sure that we had clinical involvement and ownership from clinical teams who were able to come to a consensus on the nature of these services across Wales. But one of the key things, through the contact that's happened across Wales, has actually been the ability to find our own examples of good practice and innovation in Wales. I think their role on the planned care programme board has changed a little, so they have started to have mechanisms where individual health boards are now leading the implementation of individual areas, not necessarily just on behalf of their own organisations, but actually spreading it more broadly. And I think we've had to also make sure that we're not just looking at this in an insular manner in Wales.

We have wanted to go searching for the good practice that exists across boundaries as well—so, working with colleagues in Scotland about progress and looking at some of the examples in England. But it's clear, in particular over the last couple of years, that some good, clinically owned examples of good practice are occurring within the Welsh NHS as well. And we just need to step up and, as usual, make that more of a universal experience, rather than just a pocket of good practice.

The British Medical Association and the Royal College of Physicians have provided evidence that suggests that pressure to achieve referral targets means that first out-patient appointments are prioritised over follow-up appointments, and that doesn't relate to the clinical need. Do you accept that that is happening?

I think there can be definitely tensions that exist if the system doesn't focus on it in the right way. I mean, my own view is that we have to make progress on both. We know that, on any survey that we do of areas for priority within the NHS, when we're asking the public and patients what they think, waiting times and access is always the predominant issue, and we have seen an increase in the way in which we have focused on referral-to-treatment over the course of the last four or five years or so and, on those measures, we're at least seeing progress where we have got some of the best positions for around six years or so. But, if we're not careful, there can be perverse incentives. We try to mitigate and manage that, and in part, I think, to give some clearer and more explicit balance, that's why, also, we're endorsing a different range of follow-up targets that have been in place for 2019-20, and we'll be tracking those through monitoring on the back of some of the progress that we've made.

But,certainly, our responsibility, I think, is not to do one or the other; what we have to do is to make sure that we're able to offer that first appointment or access to treatment that's necessary, and then we also need to make sure that people are supported through their patient experience.

Some of the follow-up pathways that are being measured are part of the RTT process as well, in any case. I wonder if I could comment on the postcode lottery question, because the planned care programme has achieved—. Well, firstly, this is a very large and well-established system that we're trying to change here. I think the planned care programme has made very considerable progress in gaining clinical consensus about what evidence allows in terms of change. And then, generally, when you want to influence change at such large scale, you would need small cycles of change where you engage with those most willing to experiment first of all and learn from that, and then spread the best practice. So, I don't think it's entirely surprising that we'll see change happening at different rates in different specialties in different parts of the country. I think that's the nature of the process. I think it's unrealistic to think that everybody will change together.

Spreading the good practice from those areas is more important.

Yes, and that's part of the function of the programme board.

And, Chair, insisting on some of the templates. So, one of the pieces of work that the planned care programme did was to come out with a more standard perspective of musculoskeletal services across the whole of Wales. So, whilst we had lots of examples of different health boards developing more community-based approaches—you know, physios leading approaches—and it wasn't just about drawing everybody to health boards, there was still some inconsistency in the models. So, one of the pieces of work that the planned care board did was actually to focus on what the core characteristics of the successful models are, so that we had consistency, and, whilst we're always looking for a little bit of local innovation and there may be some practice that we want to pick up on, just looking to standardise that kind of approach a bit more.

But, I think it also reflects in part the function that we allocated to the planned care board. Its role initially was to develop the reporting. It was to provide more of a supportive and an enabling mechanism, as Chris has described, around clinicians. The performance management of the system wasn't ever intended to be for the planned care programme. Obviously, that has to fit into more of our normal performance management approaches with the health boards and with the system across Wales.


How much additional funding was allocated to improve referral-to-treatment performance in 2018-19, and was anything done alongside that to ensure that sufficient focus on the follow-up appointments was maintained?

So, we have two examples of funding. We deliberately targeted referral-to-treatment as a target and looked for investment in services, and the funding that was allocated across Wales in 2018-19 was £50 million. That was additional within the system. That was focused on wanting to track and improve overall waiting times. It wasn't explicitly there for tracking through the follow-ups, but inevitably as you look at various mechanisms around waiting lists, including validation and services, there'll be some improvement that comes from that.

We obviously provide the overall allocations to health boards to make choices on the back of the services and the support for their population. So, there was also in 2018-19 an enhancement in the allocations, but they will have chosen to use some of that, and certainly as we've tracked improvement through 2018-19 on follow-up activity, that wasn't an improvement that happened through targeted funding that we provided; that was more about health boards themselves demonstrating a real commitment to it.

We have, though, tried to put in some additional money that will apply through 2019-20 at the moment. So, two announcements that Assembly Members may have seen: one was around eye care, where there's been a specific announcement of funding—

That will target around eye care measures in particular, but, as well as setting a different set of measures within the system, we wanted to make sure that there was genuinely funding within the system, albeit that some of that is non-recurrent, to improve the system. That has been planned. Also, the Minister announced around £7 million in addition, which was to support an eye care IT system, again on the recommendations of clinicians, to cover support right through from optometry and opticians to the hospital side of the services.

On that additional funding for ophthalmology, which will obviously be welcome, what sort of proportion of the overall amount of money that's being allocated is that?

Well, if you look at referral-to-treatment time targets across all specialties, we put in £50 million, which was for all specialties, and we're looking to make progress, which we have done over the last 12 months. It's about 20 per cent of the amount that we allocated as an additional amount, so we do think that that will make a difference. But the eye care measures money was more about enabling the follow-up activity because we have introduced a new set of measures, working really closely with stakeholders in order to provide a real focus on experience for patients. We could have assumed that was going to be dealt with through the allocations, but I do think we needed to enhance things.

I suppose the other feeling I have about this is that prevention would be better than just increasing capacity for follow-ups. I noticed in the BMA evidence that you received that, when they looked at 100 urology patients waiting for follow-up appointments, I think 6 per cent definitely needed to be seen, but maybe the other large proportion didn't have such a pressing need. If those less needy patients had not been offered a follow-up appointment, then it clearly would have been possible to deal with those that needed them in a more timely fashion. I think there is quite a lot of evidence that we're probably offering follow-up appointments when they're not always very high value, so we are approaching that through value-based healthcare, which is our way of interpreting the prudent healthcare philosophy—

There's another approach to this, which is it could be more efficient and that the follow-up is not necessarily the best way to go.

I think there's a danger that all we do is end up trying to reduce the numbers without changing and transforming the system, and we have tried to make sure, again through the planned care programme, that the focus has been on a sustainable approach to services, not simply just tracking numbers and throwing very traditional methods around this. Would we carry on doing the waiting list initiative equivalent for follow-ups, for example? Having said that, I do think that there is still a lot within the system about improving some of the administrative processes, certainly around validation, and also allowing a different mechanism around the way in which we support our clinical teams to undertake clinical reviews. So, I think there are opportunities to do it, but I was quite struck as we went through the eye care process and the initial bids—and I think this was probably reinforced in some of the evidence from the RNIB—that almost the first tranche of examples that were provided by individual health boards across Wales to improve things felt very traditional; more of the same. We actually pushed back on those original bids using some of the advice of the stakeholders around the table, because we were looking for something that was more transformational, more focused on community equivalents and how we could genuinely support the follow-up pathways that were in place. I think we have got a better set of proposals as a result of that, as well.

Looking forward for the year that we're in, though, we are looking at some advice for the Minister on choices about how we would underpin and support the system. There are some choices for us, certainly by being more explicit about a target for follow-ups, about whether there would be some choice to allocate some resources directly on that, which would be for other specialties other than just eye care.


Okay. I need to bring in other Members now. First of all, Rhianon Passmore. 

Thank you, Chair. Obviously, an awful lot of work streams are going on in parallel. In regard to that transformational change that you're talking about, which is critical in terms of being able to make this as successful and optimal as possible around clinical professional practice change, the planned care programme you've talked about isn't, obviously, a performance management model, so in regard to the sharing of good practice—I accept totally that we'll be looking at those health boards that are coming forward to say, 'We want to pilot. We want to be the first in the queue'—but in regard to the succession of that planned care programme board, is there anything more in the pipe that you can say will actually turn around and spread that good practice now in a secondary phase, because obviously the pace of that change is going to be absolutely critical to managing the lists that you were talking about? 

It has gone through a change itself about our expectations of it, so I feel in a more confident place with that really strong clinical support for what we've established there. Yes, of course, they've gathered a lot of material so there is a compendium of good practice, they have been carrying out learning events, and I've attended some of those myself, where we're actually recognising some of the good practice across Wales. A couple of years ago, we changed the focus so that what they were starting to do was to establish more of the standardised templates and how we would describe individual services. We have—

Sorry, Chair, you mentioned insisting on those templates.

Indeed. Yes.

So what I'm saying then is: is that strong enough? Is there enough pace around that insistence around the templates, and is there more that can be done in that regard? 

First of all, I would say that, by coming out with the clinical support for these templates, it's getting more traction anyway within the system because it's seen not to be just an issuing from Welsh Government, it's seen as being sponsored by clinicians thinking about the best care and the services that they can provide for their patients. I think we have had to change our expectations so that we set clarity about wanting to make sure that the templates that are advocated and supported by the planned care programme are actually put in place. I think we have to still continue to see how we both incentivise it and also act to have penalties within the system. For example, as we've seen progress around referral-to-treatment more generally on both out-patients and in-patients and day cases, you'll have seen that, when organisations didn't hit the targets for which money was provided, actually money has been withdrawn within the system, which is sort of a financial penalty. We haven't quite got to that point on the follow-ups at this stage, but, again, if we were looking to align more money for it and we didn't get the outcomes that we would expect, which would include, 'Have you signed up to the template?', then yes, we would consider those types of approaches as well. 

So if I can just ask for clarity—sorry, Chair. In that regard, the £7 million that's going to come forward now, which has been announced, will there be any type of clawback attached to that because it's additional?

On the £3 million that we've put into eye care—the £7 million was for the eye care IT system—but for the £3 million that has been allocated, yes we'll be tracking through and evaluating the outcomes that were put in place by those community-based services. So, they will be measured in terms of whether the targets can be met that we've introduced this year, whether the community schemes have been put in place and actually whether they are achieving some of the activity and the throughput that was expected as well. So, we've not explicitly rehearsed that, because actually this is enabling money within the system on a non-recurrent basis, but the money has to be used for the purpose for which it's been allocated.

Thank you. On page 4 of your paper, at the bottom, you talk about the reduction of 20,000 over a year of the number of patients without a clinically agreed target review date, and you say that a large part of this improvement can be attributed to Cardiff and Vale University Local Health Board. When you look at Cardiff and Vale health board, as of December 2018, 312,000—nearly 313,000—appointments are waiting to be seen as a follow-up, out of a total population of 493,000. Not credible. When we discussed this with Cardiff and the Vale, they said that this represented about 200,000 individuals, because, obviously, some people have more than one complaint. But, even so, 200,000 people is 40 per cent of everybody in Cardiff and the Vale. That is not credible. 

Just on the table that we attached in our evidence paper and, again, equally, if you go back further on the data, you will have seen that the starting point for patients without a clinically agreed target review date was as high as 200,000. So, we have seen, as I said earlier, a 75 per cent of that level reduction since then.

Out-patients does work in this way. We have 3 million out-patient attendances a year, and we have a population of 3 million. The English system has 60 million out-patient attendances a year for a population of around 60 million, for example, so there's definitely something about challenging why is it that people are having to access this very traditional service. You're absolutely right, though, that these are not necessarily all individual patients; this is not the whole of the Cardiff population. These are individuals with multiple conditions and multiple referrals within the system. I think it just emphasises how significant the change could be if we could really bust this focus around an out-patient model that has been in place for 70 years, and really offer an alternative using technology, choices for people, community support and alternatives in place.

So, whilst the numbers are large, that reflects the norm around out-patients in general terms, but we can look at individual specialties, like following up for prostate cancer in urology, and know that there could be a very different approach about tracking, so that patients actually start to own when they think they need to referred in, rather than relying on the system to pick them up. So, they are very large numbers, I agree.


Okay. I'm just trying to tease out whether they're really credible numbers. It was the most surprising thing about your paper—that out-patients is where more people are seen than for any other. I always thought that 90 per cent of people were seen in primary care. Why are we sending people out off to hospitals when they could be seen in the community?  

In our hospital experience, out-patients is the setting where the most people will be seen. So, in Wales, 3.1 million out-patient attendances a year. The primary care focus, you're correct, is very different, so there is a higher number of patients being treated there. So, whilst we don't record every individual patient within primary care in the Welsh context, we evaluate that probably around 19 million primary care attendances take place, just to give you a little bit of a comparison. So, again, for a 3 million population, that shows you a much higher ratio of people who are accessing primary care, but it's in our traditional hospital services that it's the highest level of activity that occurs for out-patients.    

If I could just add in a specific point about the origin of the Cardiff figures, which are very high: I think there was an element of an IT system position. They had a different patient administration system to the other health boards that for some years, I think, was taking as a default code 'Follow-up?' if it wasn't clear from the clinical note what the outcome of the consultation was. So, I think quite a number of people were automatically defaulted onto the follow-up lists, and not necessarily—

Because obviously the reduction in those without a date begs whether we are now shovelling even more people on to having a follow-up appointment, regardless of whether or not they need a follow-up appointment.

I would respond in two ways. I think, first of all, as I said earlier, beyond just trying to track the follow-up waiting list, we had to get the data and the measurement right in order to be able to drive this on differently. I think, recalling Cardiff's individual figures, at one point they were describing over 800,000 follow-up out-patients on their list, which they've reduced to closer to 300,000 at this stage, and that does show that there were clearly some data errors and compliance within the system.

There is something about the way in which we track and monitor now. So, patient systems have been set up to require that the outcome for the patient to require a follow-up out-patient or not is a mandatory field. We've altered that guidance within the system as well to track it. But whatever we do on changing data around and however accurate the measurement is in the system, the real issue is: how can we provide alternative services to patients that don't mean that you need to come into a traditional hospital environment for an out-patient attendance?

We heard some compelling evidence from Aneurin Bevan that they did things completely differently, and were much more likely to see people in the community because people don't have cars to go to hospitals. And they left it to the patient, in many cases, to say whether or not they felt they needed an out-patient appointment. Cardiff and the Vale is the absolute outlier in this situation, so what is the Government doing to really drill down deep into what's going on here—the failure to do things differently? 

So, in part, you'll have seen the data change itself. I think, through the evidence session, the team who spoke to you were able to articulate what they have been trying to do and accepted the position that they were in. They articulated and described what they were going through to. We've had to ensure that people understand the profile of this, and whilst declaring new approaches to eye care measurement may do that from a very specific target aspect, we've tried to use our performance management mechanisms to deal with that.

I've just been going through the end-of-year reviews for organisations. I did the first four last week, which just take a look back over the last 12 months. Follow-up out-patients and our expectations and tracking the performance on that is part of it at this stage. I think this is where the planned care programme helps in part, because we've now got individuals taking a lead to not just implement for their own local health board system but actually to implement across Wales.

We've got these clear templates being agreed. I think Cardiff, in their evidence session, were agreeing and committing that they would look to implement those. I think they have got some examples of change themselves. But if Aneurin Bevan are able to introduce mechanisms of community support for audiology, for example, then there's no reason why other health boards can't be complying now. I do think that we've at least got the clinical statements from the lead clinicians who brokered that with their colleagues through the various boards, from ophthalmology through to ENT and neurology. 


But if ophthalmologists are refusing to refer people who've had cataract operations back to the community ophthalmologists, clearly there is a pretty substantive problem in the system. Because this is a conversation I've been having with Cardiff and the Vale for a while, and there are still consultants who refuse to do what is the clinical guidance. 

The release of the clinical guidance in the first place, to be clear on what we were measuring and checking was important for the first time, because that is at least owned. I would hope that colleagues would want to be part of the good characteristics of a high-performing department. The models that we're advocating have support, as we know, from stakeholders and from patients themselves, and we are seeing individual organisations making progress on that as well. Two of our organisations in Wales—this is even irrespective of Aneurin Bevan—had acted as pilot sites, which were Abertawe Bro Morgannwg and also Betsi Cadwaladr, to change around some of these pathways.

So, if it comes down to individuals refusing to comply with both best practice and expectations for the system, then ultimately that would need to be handled. But all of the evidence is there and I know it is supported by royal colleges as well, not least the Royal College of Ophthalmologists, who I happen coincidentally to be meeting on Friday. We can convert a lot of the volume around ophthalmology into the community support area. The change in the way we've managed glaucoma over the years really demonstrates that.

I think when we did our first assessment in Wales we thought that maybe around 3,500 glaucoma patients could be cared for in a community setting, but I think as we look back at 2018 on the provisional figures, we've seen that number go up to at least 22,000. So, it clearly shows that there's been scope even to build on our original analysis. [Inaudible.] From 3,500, as the projected and the modelled aspect, to 22,000. Feedback from the teams and the ophthalmology implementation board is that they think that number can increase further again, which would fit with your comments about the fact that all services across Wales need to improve.

But in this revised role for the national planned care programme, are they getting sufficient accurate data to be able to spot when consultants are simply refusing to implement the clinical guidelines?

I think the data pack that's available now is definitely more robust. I said earlier that I feel it was probably around February 2018 that there were some final figures from Hywel Dda where we felt we had a much more complete figure and information. The extent to which the planned care programme would dig into the detail of whether an individual clinician is complying or not, I think that's more a role for the individual health boards. That is a responsibility that they must do within their local reporting, but there are out-patient dashboards that are available for every specialty and also for every organisation. I know that every organisation has its own out-patient steering group and I've seen the detail of some of the papers that have gone there, which really do clarify the extent to which practice does need to be challenged and changed. Some of these are traditional views, some of them are opportunities to actually innovate for ourselves. 

Okay. So, the national planned care programme people, do they have teeth if they think that there's obviously a blatant disregard?

I think the teeth need to fit more with how performance management works, but I do think that the role of the planned care programme has now changed from what was its original reporting, supporting and awareness role. So, what we have tried to do through the regular meetings that happen across Wales, where the planned care programme leads will go and visit each of the individual organisations, is that they are expected to challenge and to highlight to the organisation where some of the practice is falling down, and they then feed into us as well. But they, I think, have adopted more of a challenge role now, which wasn't necessarily how we established them, but if it comes to, 'Is progress being made across the whole organisation?', that must feature as a discussion between Welsh Government and the individual organisation, hence why it's one of the areas that we're picking up in the year-end reviews. 

We are. What we wanted to do, again, is—. The best outcome for me is where it's not a performance management answer, it's where the system knows it's the right thing to do and we have clinical teams advocating on behalf of their patients. I do think we need to not lose that. 

In doctors, you do see a whole range of different personalities, from leaders to laggards, but they're all well motivated and they're trying to do the right thing, I think, for patients. Some are more conservative, I think, around change than others. In general, the best thing is to work with those that are most engaged first, and build on that strength and that success, so that, eventually, those traditional people who have been reluctant to change can recognise that they are now the outliers and they are now the ones out of kilter. That's a much more effective way of engaging them than just sort of hammering them and telling them, and really kind of offsiding them completely. I know it's difficult to countenance that.


But it does mean that other people are not getting initial appointments—because the sick ones genuinely do need to be seen.

You would expect there to be very robust conversations going on in those organisations, because this is a waste of a resource. The follow-up resource is very valuable and has to be used to best effect, and, if you know someone is not using it to best effect, I would expect those conversations to be had. The opportunity cost of taking that appointment away from somebody else who may need it more is really important.

Just a brief comment. I accept what you're saying, in terms of cultural change and the need to do this in the appropriate way, but, if we were talking about factory workers or, with respect, teachers, or any other profession, would we not be a little bit more intensive in terms of the approach that we're taking? Because we are talking about people's lives, we're talking about people's health and their longevity and surely we should be being a little bit more unafraid of being more proactive in that arena.

I think in the past we have gone down through some of those routes and arguably that is why we may have examples where we've not made the progress. I do think that making sure that we have a clinical consensus and things for people to aim for get you in a better place when you want it to be a more sustainable approach. It doesn't remove the performance management that we apply to organisations or how they have to pick up that practice, so I would accept that we need to make sure that we're focused on it. But clinical teams are not trying to remove the right outcome for patients—they are trying to deliver practice that is in line with what patient needs are and, of course, it's the clinical teams that actually make the determination about whether people should be put on the follow-up waiting list at all; that's part of their initial contact in there.

So, I wouldn't want to give the impression that this is about clinical teams refusing to take responsibility for patients within the system. I think it's a balance about how we have to have the best structure and systems in place, which are enabled by the organisations, alongside meeting with the clinicians about what their team and individual expectations are for patients. We train clinicians and consultants up to be individuals making agreements on behalf of patients, and what we need to create more so—and that has changed a lot, in my experience, over the last 29 years—is the movement to a much more of a multi-disciplinary model, where they're working as a—

And I accept all that, Chair, but I think you understand my point. Thank you.

Thank you, Chair. My question is regarding—a couple of questions: performance measures and performance improvement in your area and the NHS. The Welsh Government evidence paper identifies targets to improve out-patient performance and reduce the extent of wait and delays. Are you content that these are sufficiently challenging to address the extent of the backlog of delays in a timely way? And, given that the auditor general first identified the problem in this area in 2015/16, why is it now that the specific performance targets for follow-up out-patients are being introduced?

I think that our confidence in the broader range of data that was in place was a factor in when we have determined to establish the target. I think, as I've already conveyed—both at the all-Wales level and for individual organisations—we had to make sure that we are able to reliably draw out data, not just necessarily on the traditional follow-up waiting list, but the other measures and reinforcing about delays in the system. We have not had completeness, for example, about the outcome from clinic attendances for patients being put into the local IT systems.

I think, having got to a point where we judged around 13, 14 months ago the data being as accurate as needed, I think we felt it was just a different moment for articulating the targets. I was really struck that, if we're not careful, whilst we've wanted to make progress on broader waiting times, it would start to look as though we are prioritising one without expectations for the other. And I think we can be more confident that, even without the targets, over the last 12 months, we have at least seen the in-year position improve, and there's been some material reduction—not yet to an acceptable level, and I have to maintain that—but we did talk to the service—again, to clinical teams—about how challenging but also realistic could we make the targets look going forward. And, as you'll have seen from our evidence paper, we've outlined five targets that we're introducing within the system. I think they will be very challenging for the system to match. We didn't want them to fall short if we could really stretch the system, and we are expecting to see a material reduction in the size of the overall follow-up waiting list for Wales—because there will always still be a large number of patients who still need to be held on a waiting list—but in particular a reduction in the number of patients who are delayed, down to some quite low and insignificant levels—certainly, over the course of these next two to three years, to see a 50 per cent reduction in those delays and actually to see the out-patient waiting list for follow-ups, at least, potentially reduce by up to around 40 per cent or so.

So, I think if you look at the trend that we've had over the last three or four years, where it looked like these areas were just continuing to deteriorate, I think we've managed to step in and stabilise that now and actually see some improvement. And, hopefully, over the course of the next two years as the starting point, we will see some genuine delivery on those revised targets. So, I think they'll be hard to deliver, but I do think that the system should feel that we can step up and deliver those.


Thank you. Are you satisfied that the existing performance management regime is robust enough to drive improvement? What are the consequences of failing to meet the new targets that have been introduced?

The NHS in Wales will always be focusing on targets that are about the whole system and different settings and different services, and through all sorts of different perspectives, and we have to recognise that as health boards are looking to step up and deliver—of course, trusts will have different sorts of roles—there will always be some level of priority that we afford to different areas. I would say that, whilst we have been picking up follow-ups and measuring them within the overall system—and, in fact, some of the data we have available is probably in excess of other systems across the UK—the balance of the priority probably hasn't been strong enough historically, and that is in part why what we have done is make it a feature more of our quality and delivery meetings of the end-of-year and the mid-year annual reviews with organisations—I think that has helped to deliver some of the improvement that I've described over the last 12 months.

I think, on where do we go next with it, one always hopes that when you focus on it as a priority we'll see some change and response from within the system. I think we are seeing that in part by that renewed focus, but we also need to think about incentives and sanctions that apply within the system. We have got an incentives and sanctions framework. We have been applying certain rules within our system over the course of the last 18 months that actually demonstrate that, if we set up funding for example, if people don't achieve the outcomes then we'll actually look to remove that, because it's setting expectations. I would like to think that, in the arena of follow-ups, there is an opportunity for us to provide both an incentive and a penalty, and not to just have it as a penalty kind of mechanism. So, we may consider, as I said earlier, withdrawing some of the funding, if people haven't reached the outcomes, but I would rather do in part what we tried to achieve through the eye care measure support. It was: how do we just enable and facilitate the different services that are going to make the difference to patients? So, we will step things up again during 2019-20, but I'm at least pleased that having it much more explicitly within the performance management system has made a difference over the last 12 months.

Thank you. The committee is aware of the new eye care measures you earlier mentioned—you know, £7 million—and time is very crucial on that. The positive way Welsh Government has worked with stakeholders during its development and the approach to prioritise based on the clinical need—does the Welsh Government intend to adopt this approach for other specialties?

I think the eye care measure work is seen to be pretty innovative. I was actually sitting with the optometric and the royal college advisers from across the whole of the UK on Friday, and, in part, the reason we were hosting the meetings was because of various initiatives that we've done on eye care, which range from taking an approach to accessible standards, the eye care delivery plan, 'Together for Health', that was introduced, and particularly our approach around the eye care measures at this stage. It's come from a very difficult context. There was a criticism from patients about experiences, and also criticism from the RNIB, but I hope that one advantage that we have in Wales is we know each other, we're able to sit together and work on these areas, and we have now introduced measures that have been at least tracked in shadow form over the course of the last six or seven months. These do provide a focus on the experience of patients and the outcomes for patients, rather than perhaps our traditional waiting times measures.

The Royal College of Surgeons came here a year ago, and equally were saying that we seem to be quite innovative in this area at recognising that this would make a real difference for patients. I think we've already demonstrated the opportunity for us to look to change some measures anyway, so work that's been announced by the Minister around the cancer pathway, the single cancer pathway for Wales, was similarly dealt with by working with clinicians and stakeholders across Wales. We're doing some work around unscheduled care at the moment, working actually again with clinical teams and the Royal College of Emergency Medicine, and I think it's important that if we have an opportunity to have a better monitoring and measurement approach that makes an impact for patients we should be allowing ourselves to do that. So, clinically-informed measures and outcomes are certainly going to be important for us, and I'm sure, beyond those three or four examples, we'll have a few more over the course of the next 12 to 18 months. 


Okay, thank you. The BMA suggested that all consultants who manage a list should receive regular information on patients who do not yet have a follow-up appointment booked. Would this approach help improve the management of follow-up out-patients, and is there any reason why NHS bodies should not do this routinely?

Would you mind, sorry?

Well, I would support that. I think anything that we can do to engage the clinicians responsible for patient care in the whole pathway, in the whole system of care that they're offering their populations, the better. I think we need to recognise that clinical validation of people on a waiting list is quite a demanding task, that, actually, people have to have additional job plan sessions set aside to do that, and very often it's almost the same as doing the follow-up appointment in its own right. So, it is quite a demanding business, with such large numbers. But I do feel that, in the past, sometimes, doctors have felt that the capacity to deliver follow-up appointments has been kind of like a managerial responsibility, possibly because money comes through the RTT process, but, actually, I think it is a clinical responsibility. We have a defined resource and we have to make the best use of that. And the idea that we put people down for a follow-up when we know they can't receive it in a timely fashion doesn't seem right. So, I think the more we can get consultants to take responsibility for the whole system of care the better.

Sometimes, I think, in the past, we've probably—and this is a result of our training and education—prioritised safety for the individual sitting in front of us without necessarily realising we're also responsible for those that we can't see sitting in front of us—people waiting in the community for some other part of our service. And so we need to balance those responsibilities.

Thank you. And before I ask my final question, on page 18, there is a graph there, key performance data, which is—. Just under 1 million patients are on waiting lists by the look of this; one in three in our population. Is it because—

But they're not people, they're clinical pathways. 

Yes. Let me finish, please. What it is: I know some patients, they've got eye problems and then shoulder problems—

One patient—you know, a couple of constituents waiting for eye treatment, waiting for shoulder treatment and waiting for skin treatment. So, how do you measure for the waiting lists one individual waiting on three different areas of medical conditions? So, what's your indicator? Is it the individual or, actually, the condition or the health of the person?

These are around pathways rather than the individuals. So, I think the Cardiff ratio, they were suggesting that it would be about a third lower for the number of individual patients within the system, but, inevitably, with an ageing population, with people with a lot more, multiple, conditions, people won't just be going in to access one individual service; they'll be having more complex approaches to that. I think we can help to better organise some of that, but, certainly, the way that the waiting list is recorded is around counting it as a pathway, not as an individual patient. So, we could give you a rough calculation, but I would suggest it's probably about two thirds of that follow-up list that will be the individual patient numbers for Wales. 

All right. And my final question is, Chair: how is the Welsh Government strengthening and encouraging clinical engagement and accountability for follow-up out-patients, both at the national level and at health board level in Wales?

Well, I hope, in part—. As I've described our approach to this, it was a deliberate choice to set up the planned care programme as we initially wanted to get that into clinical ownership from the very start. That might, in itself, have added some delay, as we look back, but I think it's probably got us in a better place now with some of the understanding of the work that's been done. I think we've had to ensure that the responsibility, however, doesn't just lie with the planned care programme. There's certainly a role for medical directors to have their own oversight of this alongside other professionals, but I think they have a pretty key role in their professional oversight of clinicians. Chris acts as a conduit for that in his deputy chief medical officer role, because he attends the medical directors group. That's allowed us to have a particular focus on follow-ups. We've also asked for particular representation to happen from senior clinicians in our groups—so, all of the implementation groups, all led by consultants, all with representation from across Wales. The out-patient steering group actually has three assistant medical directors on it. In fact, it has a couple of the medical directors actually directly sitting there. So, I do think we've adjusted and adapted to some of the concerns that perhaps some of the representation wasn't quite linking back to the organisations, and we need to make sure that continues to be successful.

If I may, to return to your previous point about people being on multiple pathways, I think it is one respect in which we see, again, the NHS struggling, in a way, to transform to accommodate the rapidly rising number of very elderly people with multiple comorbidities. I think these clinic pathways were probably established for single-condition-type situations in the past, where, if you had a particular diagnosis you'd go and see the relevant specialist and they would retain you under their care. I think that is more difficult to sustain now with people having many different conditions being referred to many different clinics.

It is difficult, because it challenges the medical understanding of what is clinical excellence, based on evidence-based medicine, because the cardiologist will draw upon evidence that cardiac disease does better under a cardiologist and, if you've got diabetes, you'll do better under a diabetologist, et cetera. But perhaps we're needing—and 'A Healthier Wales' centres on this very much—a more holistic approach for the elderly, where perhaps we provide more overarching compassionate care, without necessarily all the different pathways having to exist in parallel. And that really is central, as I say, to our strategic direction in 'A Healthier Wales', which is about primary care-led care in the community, with support from specialists where needed, often using digital technology to enable monitoring remotely rather than people coming to hospital. That is the nature of the change that we need to see and the nature of the change we're seeing down some of these pathways.


Dr Jones, we can agree that we have a defined clinical resource and we need to make best use of it. When we saw the Royal National Institute of Blind People, we briefly explored the relationship between consultants' NHS work and private practice. There are clearly potential incentives in the system for particular clinicians to keep waiting lists high in order to encourage patients to go private or independent for particular conditions where there are extensive waiting lists. I've certainly had individuals bringing issues to me on that front, whether it's for hips or eyes or whatever. So, what measures are there within the system to prevent artificial inflation of waiting lists for benefit?

I can understand why you ask the question, but I don't think—. I would like to believe that our clinicians are not motivated by such self-serving ends. I do believe that people in the services are doing their best for patients and their care. Sometimes, we would like to see them do things a little bit differently and change more quickly, but I don't think there's any evidence that people are artificially inflating waiting lists for their own gain. I just would not—

Well, if they're having a conversation with the individual front of them and saying, 'However, I could see you in—

Well, they shouldn't be doing that. They shouldn't be soliciting for private practice. Clearly, though, if there are waiting time issues and people want to go privately, they do have that right to do so, and the consultants, through the consultant contract that was set up by Aneurin Bevan at the beginning, allows them to see patients privately in addition to their NHS practice, but I would hope that there is a complete separation of those two.

Okay. But they're supposed to be doing nine tenths of their work, if they're working full-time, in the NHS. So, how much policing of that goes on?

There's more policing of private practice than there used to be. All private practice now has to report its activity and outcomes through a legal requirement that was set up by the Competition and Markets Authority some years ago. So, local private hospitals are having to upload that type of information. A consultant's private practice also has to be included in their annual appraisal, which is required for their revalidation. So, that appraisal has to be based on their whole practice, wherever they work. So, a medical director of the health board will need to seek assurance about what that person is doing in the private sector and how competently and effectively they're doing that work. So, there is much more sight of private practice now than perhaps there was.

So, in the validation process, it would be obvious if somebody was spending less than nine tenths of their time in the national health service.

Yes. The job planning and the performance oversight of clinicians on a day-by-day basis should require them to be present for doing their NHS sessions, as laid out in their sessional job plan, agreed on an annual basis with them.

Thank you, Chair. Moving on to the issue of clinical reviews, we know that there are still many thousands of patients on follow-up waiting lists who don't have a date for clinical review. How much does that worry you?

Our own figures that we tabled demonstrate that we know that, whilst the numbers are improving, there's still an unacceptable level of patients without those reviews. I do expect those to improve with the targets that happen. Clearly, there is a worry when we don't know how patients' circumstances have changed and altered, and we have to make sure, therefore, that we continue to focus on this and improve it. Clearly, when patients have come in for their initial contact from a GP referral to their first new out-patient session, that gives clinicians the opportunity to individually review them at this stage. Having said that, some of the work that's been done across Wales to improve the figures shows that you can't make an assumption that every patient who is waiting longer than expected is a clinical concern. So, some of the work that Cardiff did, for example, demonstrated it was simply about some of their compliance with their systems, their data with the patient management system. I think the important thing is to make sure that we have a couple of things in place. Firstly, does every health board in Wales have a clinical review mechanism? Do we feel that that is assuring themselves of the progress that needs to be made, and is it clinically owned? But the second bit has been to ensure that there's been more of a focus—the planned care programme has helped some of this, but also other choices. There are more likely specialties where will be a greater risk to patients than others, so, areas like cardiology—your previous specialty, Chris, for example—or ophthalmology. We've particularly focused on those, knowing of course that, from our conversations with the RNIB on the eye care measures, that was one of their original concerns as well.

We're trying to do some of our own assessments that match that information, so we don't just leave it to organisations to tell us. So, there are other sources of information, but certainly there is a clear clinical review process in place by every organisation in Wales. I'd just like to think that organisations will still pause and learn, because Cardiff seem to have got themselves in a better place. That seems to be a very comprehensive system that they've introduced.


We clearly are concerned that there may be individuals out there who need to be seen and who aren't being seen. But I think one of the fundamental problems with these pathways is there are a lot of people who don't necessarily depend greatly on those follow-up appointments, and they're impeding, in a way, the access that the more critically needy have themselves to a timely appointment.

A piece of work has been done recently in Wales from the delivery and support unit with us looking at levels of harm for long waiters in clinic pathways. Their broad conclusion is that there's relatively little evidence of severe harm, generally, but there's quite a lot of evidence of low-level harm. So, people get very anxious waiting, and they don't know when they're going to be seen. Symptoms may get worse, so joint pains may get worse, and maybe that has an impact on their quality of life, which gets worse. But there's not that much evidence of severe harm.

Also, we have a serious incident reporting system. So, in the 'Putting Things Right' regulations, there are requirements for organisations to report serious incidents locally, or to Welsh Government, if there's moderate or severe harm, and those incidents can occur during healthcare and include those in the community. Now, I've had a look at the serious incidents reported to us in our category of delayed treatment. Delayed treatment can take a number of different forms. It could be potentially a delayed diagnosis in an emergency unit, or perhaps a delayed surveillance colonoscopy, or whatever. Over the last couple of years, we've had 44 patients in 2017-18 reported to us, and 29 over the last year. So, these are overestimates, in a way, of the risk due to long waiting for follow-up appointments. We can't guarantee that every patient with harm is being reported to us. We do encourage reporting very actively, but those still are very low levels. Of the 44 patients that were reported in 2017-18, 22 were from eye care, and of the 29 last year, 15 were from eye care. So, as a say, they're not an absolute measurement in their own right. The numbers don't imply severe harm. I think it is more an issue of a very poor patient experience. If you're told you should be seen, and you should be seen in six months, I think it does cause a degree of anxiety and loss of confidence in the system if you're not seen in a timely fashion, and, as I say, some people will suffer some change in their quality of life. But not all of these outcomes are amenable to treatment, either. So, I don't think it's necessarily so great a patient safety issue as one may feel it is, looking at the numbers, but clearly there may be individuals in there who do need those appointments.

Okay. Well, the Welsh Government has asked all NHS bodies to ensure by the end of December of this year all patients on their follow-up lists will have an agreed review date. How confident are you that that is actually going to come to fruition?

It does represent a step up of our expectations to improve this. So, whilst we take some of the improvement that we've seen over these recent months, it will allow us to maintain that momentum. I think this is a challenging target for the system, but, in our discussions with organisations across Wales, knowing some of the changes to services that we're introducing, and even specifics about supporting areas like eye care in very specific ways, we do think that we can make some progress on that. I can never be fully assured, but, at the moment, as part of their planning processes, health boards are telling us that they feel that they will be on target for those types of areas and we're just going to have to monitor and check that through the year.


Okay, thank you. Dr Chris Jones, you just talked to us about the issue of whether these delays are causing significant harm or not. If I can just go back and dig a little deeper there, with regard to the data around that, is that data reported both nationally and locally?

No. So, the data that's reported locally all goes into that national reporting and learning system. That is then reported nationally for England and Wales, but it's reported in categories. I'm not sure it would be reported at quite this level of specificity. The incidents reported to us, we know about those and we then follow up the investigation that's done for those incidents, because, in every case there is harm, it has to be fully investigated. We will then oversee the learning from that investigation and only close down that when we are content that the health board has taken appropriate action to prevent recurrence. But those are not in the public domain, to some extent because of the identifiable nature of each incident.

Okay, and those incidents with severe harm, they're referred to as 'never events', aren't they? I wanted to just as a question on that as my final question. Are you content with that definition of 'never events' as part of the all-Wales incidents reporting guidance and is it being adequately applied to harm that may result from delayed follow-up appointments? If I give you an example, as we've talked at length about ophthalmology, so, if a patient suffered irreversible sight loss as a result of a delayed follow-up appointment, would that be classed as a 'never event'?

No, it wouldn't be. A 'never event' is a specific definition and only applies to a minority of the serious incidents reported to us, even if those incidents are associated with severe harm. So, we share the list of definitions with England, and it is quite specific to situations that are agreed across England and Wales as being events that should not occur if you have proper safety systems. I don't think it would necessarily make any difference for individual instances of harm to be categorised in Wales as 'never events' because the process that follows a 'never event' is the same as for a serious incident.

Sorry, what did you mean when you said 'proper safety systems'?

These are systems like the surgical checklist in theatre. So, one 'never event' is wrong site surgery, and that should never happen if you've got proper checklists operating amongst operating theatre teams. Timely care isn't quite the same. It is clearly something that we need to deliver but it isn't a safety system issue as such. But, as I say, 'never events' are followed up and investigated fully, and the learning has to be implemented into improvement actions in the same way as for any other serious incident. So, I don't think we would necessarily need to change the categorisation of 'never events', although these are serious incidents when they happen and are a matter of great concern.

In the context of how we use those types of areas, the serious incident reporting mechanism and patient experience were both reasons for why we wanted to develop the new eye care measure in Wales. So, we were using the data that was around, and whilst we knew that the RNIB wanted to focus on it as a particular issue and they had examples of patient experience, our own data equally was flagging, so we had to issue clarified guidance to the system in Wales a couple of years or so ago, just to make sure that the eye care experience in particular was actually picked up within the system. And we did see an increase in the reporting then, because we were telling the system that we expected that to come through more consistently and regularly.

There seems to be really widespread acceptance that things need to change. The Royal College of Physicians is absolutely clear that too many people are being seen who don't need to be seen and, obviously, that then leaves other people who do need to be seen not being seen. One of the really simple examples of innovative practice we heard, from Aneurin Bevan, was that instead of hauling people with anxieties about skin complaints into a clinic, they employ a medical photographer to take photographs of the skin area that may or may not be a cause for concern, and that then leaves the appropriate clinician to examine the photograph and see whether there is something that requires a doctor to examine the patient. I mean, that's not something that seems to be that difficult for others to follow suit. So, my question, really, is—. My sense is that the Welsh Government is not pursuing change quickly enough and that we're continuing to waste resources hauling people into hospital who don't need to come into hospital, and that we're not learning from the best quickly enough.


Certainly, we do need to keep changing. Speaking openly, there's the default of 70 years of learnt NHS experience and perhaps the confidence arising from that, because patients do access our system and do find their way through the various pathways for different support. I think we need to allow ourselves to think quite differently. I said earlier that by engaging with the clinicians we're having clinicians actually spell out the kind of changes that can be introduced and we're making those more now about compliance than we are just about general good practice at this stage. I think that there are opportunities also to think ahead a little bit better on these. I've actually seen the change that's occurred from a very traditional hospital model for people to attend dermatology appointments, to having mechanisms whereby GPs have been able to use photographic equipment themselves, to pinpoint accuracy, to sending pictures, through to examples like the medical photographer as an alternative to a consultant who can then review that in a virtual clinic. I think there are other iterations to come here. The quality of mobile phones and the cameras associated with them these days—there are apps now emerging that will allow patients themselves to take their own pictures, for example, to a level of quality that will actually satisfy the individual clinicians. So, as much as trying to catch up the existing system that we've got, I also think that we've got to be much more agile about these expectations. 

We did a survey as part of the development of the out-patient vision for Wales that was about what patients thought about it, and while it is helpful to know that a large part of our population are up for changing the way that we operate in the system, I was quite surprised that I think it was something like 50 per cent of the public and patients who were asked the question who were uncomfortable about the idea of switching the traditional out-patient setting, through mechanisms like technology, Skype even, and telemedicine—50 per cent still saying that they wanted to revert to the more traditional experience that they've had. So, we also need to recognise that we're not just having to deal with clinicians who want to be more confident in these alternatives. We're also having to deal with patients who've learnt how to experience healthcare through a certain lens of experience. But I certainly would agree we need to increase the pace of these changes across Wales. Some of that is more standardisation. Some of it is more flexibility for innovation around services. And I think we are gathering that much better now, with some of the out-patient experience that we've got around the table, and I'll be looking to have better oversight of that nationally so that we can expect health boards to act differently as well.

We've been talking about prudent healthcare since Mark Drakeford was the health Minister, and that's a few years ago now. I agree we've got to take the patients with us, but what more—? It feels that we haven't really built up the momentum that we need to build up, because at the moment the resources are not being optimised for the patient outcomes.

On the prudent healthcare side, we've tried to make sure that there is a lens around the value and the outcome for patients that allows us to experience this. So, some of the initiatives that Aneurin Bevan were describing were their translation and interpretation, actually, of prudent healthcare as a system, as an alternative. I think that the shift that has happened in Wales to a greater focus and more consistently. Optometrist-led care in the community for eye care—I think, again, that absolutely satisfies prudent health care principles. The one thing I'm trying to do differently through the planned care group at the moment, rather than just describe to everybody 100 different things to go at, is, as I said earlier, every health board taking a lead for one area, which not only can they implement for themselves, they can actually help the implementation across Wales. That starts to address this issue of universalising and standardising the practice beyond just one individual organisation. So, I'll be hoping to see that as a different approach that we've established in our methodology this year.

I would like to think that we're at the beginning of seeing the tipping point in this regard. There is an awful lot of good work going on out there, in different parts of Wales, and the digital elements to support self-management are really crucial. The Royal College of Physicians' evidence, I think, alluded to the neurology consultation model that happens between Swansea and Bronglais hospital using teleneurology. That's been very successful for a number of years now. There's also the use of Skype in north Wales to assess frail elderly people for whom it would be a difficulty getting to hospital. The use of patient-related outcome measures based on the web, accessed through mobile devices, is avoiding the need for follow-up of orthopaedics in Cardiff to a considerable extent, and there are a number of commercially provided IT platforms that people can use on mobile phones that are enabling the follow-up of patients with prostate cancer because they can monitor their own PSA levels. In the renal unit in Swansea, people can monitor their own renal function as well. So, there are lots of examples, and I do feel that, actually, there is an emerging consensus around the use of a lot of this. It will take time for it all to spread, but there's an awful lot going on. It feels very different to me from how it felt just two, three or four years ago. 


Well, that's very encouraging. Dr Goodall, is it possible to give us a list—not at this moment—of what each health board is doing, what are the areas they're being asked to tackle? Because that would enable us to map how that good practice in area A—how quickly we can see it being rolled out.

I'd be really happy to give you a note on that that just outlines that perspective, and there'll be a couple of choices that we need to make at a more national level as well. So, I think, again, in your evidence, as I recall, you had various examples given of individual IT platforms, and DrDoctor and Patients Know Best are two examples of that. One of the other things that we're trying to do here is to make sure that these types of products can be made more available nationally rather than it just being a local innovation, and what that should lead to is clinicians just being able to start using these things anyway. They certainly seem to have had a very big impact in reducing a significant number of follow-ups. It just gives a confidence level, I think, between clinical teams and the patient, and there's a very direct relationship. But I'd be very happy to give you a note on some of those individual examples that have been led across Wales, and I hope that that will allow us to demonstrate that there is a more significant change happening rather than, again, just one good organisation doing good things. 

Okay. Well, a list rather than a narrative would be really helpful. 

Okay. Happy to do that.

Thank you. Briefly, if I can just backtrack, in regard to RNIB's evidence, they clearly stated that in terms of their patients they were much more at risk of acute risk in terms of the progression of eye disease and eye conditions. So, their view is that their patients clearly have expressed to them a reluctance to complain. So, in regard then to the serious incident reporting, do you feel that the new eye measure will go some way to mitigate for this lack of—anecdotal from their perspective, or perhaps not—reporting around their particular patients?

Well, certainly on the issue of patients not wishing to—. I'd hope that wouldn't be the case. I mean, it's really important that, if there is the wrong or unacceptable patient experience, people absolutely must ensure that the system understands that, whether that's with the clinical teams or more generally. But, yes, the whole premise of the development of the eye care measure work has been to very explicitly balance the ongoing need for us to still see new patients within the system, but to manage and mitigate the risk around patients who are on our follow-up lists. We have been monitoring and reviewing performance on these measures in shadow form. That comes with a few difficulties along the way over these recent months. We'll shortly be publishing the first set of the eye care measures. They will announce and demonstrate the baseline. So, it will show the level of the problem, and then we'll be expecting to see improvement on that across the whole of Wales but also organisation by organisation. So, clearly, when the figures come out, they're not going to show that everybody's fully complying. The whole point of having the measures is to demonstrate, actually, that this is a system that we need to put in a different place. But, yes, it was the absolute fundamental principle to focus on this category of patient and make sure that their clinical risks were being addressed. 

So, how will that be monitored in regard to—? Potentially, without sufficient framework and criteria, this could be used to just improve short-term services rather than transform services. How will you be monitoring that?

I referred earlier that when the money was allocated out for the eye care measures, the initial response of some of the organisations in Wales was very traditional, just to get the patient activity out of the system rather than change the service. I think the fact that—. And, again, this was with stakeholder advice around the table, including the RNIB. We evaluated them and we didn't feel that all of those bids were sufficient. So, we pushed them back into the system to demonstrate that it was genuinely about transforming the model and the experience to lead to better—

That's at the front end. So, in regard to the monitoring of that as it moves forward, how will that be—?

Well, we have the evidence through the outcomes that we're tracking. We also don't remove—even though we've got very specific eye care measures—any of the monitoring that we've put in place around the new targets in Wales. The out-patient dashboards locally within organisations—they've got their own out-patient steering group, and we will be getting feedback about the progress that we're making on this from the ophthalmology implementation board as well. That's the one that's led by the clinicians themselves. 

And that will come forward to this committee where appropriate.

Yes, indeed.

The Welsh Government is developing a national out-patients plan. When will this be completed and how do you see it driving improvement forward? 


We did some provisional work on out-patients linked to the planned care board—it was actually some work that Judith Paget was leading at the time as a lead chief executive. So, we have established already an out-patient vision for Wales; we included that in our evidence paper when we submitted it originally. I think Chris was right to make broader reference to 'A Healthier Wales' when we launched that last year; that was our more overarching category that sets the principles for how patients should be cared for in their individual settings. We do want the local organisations to have out-patient plans that demonstrate transformation and change, so they're producing those. And we're expecting the national out-patient plan to be available by the autumn so we can bring those issues together for Wales, and then, again, hopefully set some further expectations for the system.

Okay. Thank you. So, the national out-patient plan envisages the need for the development of appropriate IT systems, and I note your comments in terms of the eye measure earlier around this to help modernise out-patient services. So, how does that work in practice?

The core issue for us to get right is to make sure that the local patient management systems are able to collect and manage the patient through the system; they're not just data reporting areas, they are actually about the active management of patients through whatever pathway is being experienced. You'll have heard—

Can you explain to me what you mean by 'active management of patients'?

We don't have IT systems in there to just sort of say, 'It's the month end; how many patients do we have?' What we want to make sure is that patients are tracked as quickly as possible to whatever treatment and care that they need along the system.

And also, I said 'across pathways' because we have a number of experiences where the tradition would be just keep them in the hospital and wait for them to be seen, but there are alternative choices that can be made about tracking them across the out-patient system. So, getting the local patient administration systems—. The main model for Wales is the Myrddin system. Cardiff didn't actually have that system in place, so some of the—

The Myrddin system. Yes. It's the patient—

Myrddin—the tracking system for Wales. So, that's been the core focus of most of the organisations. There are, however, examples where we actually do need to introduce new systems. The development of the eye care measure also brought to the fore a discussion with our clinicians across Wales: was the existing system able to do that? And while it would've generally tracked some of the patients, it wouldn't have been specific enough. The missing part of the equation for us there was that wouldn't have reached out to the opticians and the optometrists who were working in the community. So, as I said earlier, the Minister announced £7 million to invest in an eye care system for Wales with a really strong endorsement from clinicians leading the programme about them needing this and it being an example of Wales capturing the pathway from optician right through to the hospital experience to actually speed up some of the delays.

In regard to that—. That's extremely welcomed. In regard to, for instance, the informatics system and the inquiry that's been ongoing within that, how do you reassure us that this new eye care measure will be successful in its vision and in its implementation?

I was being personally lobbied by the clinicians who developed the specification about wanting to see this. We've allowed this to be a very specialist area to introduce a system because we recognise that our existing hospital-based systems wouldn't have reached out to the optometry side. We know that there has been a lot of scrutiny from yourselves around the Public Affairs Committee table about our progress on informatics.

We have been able to introduce other community-based systems quickly. The pharmacy systems that we introduced in our community pharmacies across Wales—we were able to deliver those within 12 months to every single pharmacy across Wales. This will help us, I think, in terms of the similar approach to opticians at this stage.

I do think that we have already got the clinical evidence about the way in which optometrists work with eye care in a very different way. Coincidentally, I just happened to be having my latest eye care test myself on Saturday and the tradition of just looking at the sight test is no longer the experience. Alongside everybody else, you're having various clinical tests that are being done as part of your experience to refer on. So, I think we can rely on the fact that we do seem to have had an impact on our eye care pathway.

We're in the middle of the process at the moment. The tender went out on 1 March; the tenders close at the end of July. We're expecting the decision in September. The money has been already identified by the Minister, and I think with that good clinical support across the system, we should hope that that will really help the roll-out and the implementation—

So, it will be different because of the impetus, because of the buy-in, because of the—.

This has been very strongly articulated across all clinical groups involved in it—community and hospitals and across all of the ophthalmologists, as well, wanting it. I think it was the most assertive letter I've received in that respect of setting out the need for an individual system.

Okay. In regard to this year's round of the integrated medium-term plans, is there any evidence within them that health boards are now taking forward plans to modernise out-patient services and, obviously, the needed related actions attached to those?


I think there is evidence of them dealing with that. This was the first set of three-year plans that were set out after 'A Healthier Wales', so there's been a broader context about the kind of change and transformation that we've needed. I think some of the plans are better than others. You yourselves had evidence from Aneurin Bevan health board, who were very clear about what they want to deliver in their own area on behalf of their local community. I think there are a couple of the organisations that are probably struggling to articulate their vision in the strongest terms at this stage. All of the monitoring that we've described will allow us to track it, and, as part of our performance management and our feedback on the individual plans, we have been describing where we expect it to be a better description of what's happening around out-patients as well.

I'll come back to this, and I keep coming back to this—with regard to those local health boards that are struggling to articulate where they need to be, what is actually happening to reinforce that very strong articulation that you said was there around the eye care measure in other regards? What tools are you using to be able to have a consistency across those medium-term plans?

The tools are not specific to the three-year plans. We do feed back on those. It's the description that I've been giving you through the course of this afternoon's evidence session about using the mechanisms of the planned care programme, more challenging, the performance management approaches, the sharing of the good practice and making that more visible. It's the whole package of areas. But we do have a genuine opportunity to make a decision about whether we can actually sign off a plan or not. So, this year, out of our 11 organisations, seven actually had an approved plan and that meant that the majority of the health board organisations—we were seeing that they were going to be making some progress and traction on out-patients, but we have to monitor the outcomes as well.

Diolch. Hoffwn i droi nawr at strwythur y drefniadaeth ar gyfer gwella cenedlaethol, sef bwrdd y rhaglen genedlaethol ar gyfer gofal wedi'i gynllunio, ac wedyn y byrddau arbenigol oddi tano fe, ac, yn ogystal, y grŵp llywio cleifion allanol cenedlaethol, sydd hefyd yn adrodd i fwrdd y rhaglen genedlaethol ar gyfer gofal wedi'i gynllunio. Mi oedd yr archwilydd cyffredinol wedi cyflwyno ei ganfyddiadau cychwynnol—interim—i fwrdd y rhaglen genedlaethol ar gyfer gofal wedi'i gynllunio nôl yn 2016. A oedd y camau yr oedd y bwrdd wedi’u cymryd yn ganlyniad i’r adroddiad interim hynny yn ddigonol, yn eich tyb chi?

Thank you. I'd like to turn now to the structure of the arrangements for national improvement, namely the planned care programme board, and then the specialist boards underneath that, and, in addition, of course, the national out-patient steering group, which also reports to the planned care programme board. The auditor general had introduced his interim findings to the planned care programme board back in 2016. Were the steps that the board took as a result of that interim report sufficient, in your view?

Diolch. I think that the board, as I've outlined, had a particular purpose, so it was probably receiving an oversight, which was very much in the performance management arena when it was still more in the support and development role for Wales. So, I do think that clarifying the way in which we've had to ensure that whilst it's supported on a range of actions that are taking place, we've had to make sure that we've embedded the performance management approach within the system. I do think that, as always, working with clinical teams, there needs to be a confidence that when people are giving their own time to work on products and outcomes for Wales that can improve the patient experience—how seriously would that be taken? Would we get alongside clinicians? Would we actually be looking to implement and roll those out?

In retrospect, perhaps, could we have targeted some allocational funding alongside the role of the planned care programme? We've obviously tried to focus on this because they're not the only mechanism for reviewing follow-ups, they also look at treatments, operation sufficiency within the system in that way, and I wonder, in retrospect, whether we could've done more to allocate out those roles? I think that the links between the support mechanisms that they had, and perhaps some of the more senior professional views in Wales—I probably feel that, over the course of the last 18 months, we've more improved the reporting line of sight through to the medical directors. But, certainly, on their current work programme and what they've set out for this year, there's a whole series of, again, both innovative and compliance issues that are happening with the system under the various labels, ranging from ophthalmology to urology, and I do think that they've got some good momentum behind them at this stage. But I wouldn't want it to have articulated them as being the performance management system for Wales. I don't think that was the role that we necessarily allocated to them.

Ydych chi'n gallu rhoi enghreifftiau, a dweud y gwir, o'r gwelliannau penodol sydd wedi deillio o waith bwrdd y rhaglen genedlaethol neu'r byrddau arbenigol cysylltiedig, lle mae yna ymyriadau penodol wedi gwella perfformiad?

Can you, therefore, give us examples of the specific improvements that have emanated from the work of the national programme board or the associated specialty boards, where specific interventions have improved performance?


I think there have been a number of outcomes. I can't remove how they have really helped us as a group to get the local profile on out-patients in this way, which has really helped us with the formal reporting, in particular, of follow-up out-patients. So, a lot of the improvements that we've seen on the reporting side—some of that is connected to the original work that this group did. I think the establishment of the five clinically led specialty implementation boards that were bringing in the stakeholder engagement—that was working differently in Wales, and I think we've had a real strength about that and that carries on.

They've had to focus on a lot of support around balancing how you assess demand and capacity, of the number of patients that are treated within our system. They've acted as an advocate for us of not more of the same, traditionally, about alternative models of innovation, and I think that has led to some good examples. Where some of the community-based services are in place, I can directly link back to the work of the planned care programme board: the musculoskeletal model changes, the consistent aspect—hearing problems being assessed by audiology. These were emerging from some of those original areas.

One particular area, though, I think that they've really helped—. We've stepped into using patient-related outcome measures and patient-related experience measures—PROMs and PREMs—in Wales over the course of the last three years or so, and I think the big push for that actually came from the planned care programme board. Interestingly, it's really connected with some of the prudent healthcare work we've been doing when we're focusing on how we establish value for patients based on their experience, rather than, perhaps, some of our traditional measures in how we measure the NHS in Wales. I could add further to that: the learning events, the particular schemes supporting some of the IT developments as well, but I think there were a range of areas that they put in place at that time under a supporting and enabling mechanism that I think was that core, initial role.

Rŷch chi wedi cyfeirio yn eich papur tystiolaeth tuag at adolygiad o lywodraethiant a strwythur bwrdd y rhaglen gofal wedi'i gynllunio a'r grŵp llywio cleifion allanol. Ydych chi'n gallu dweud ychydig yn fwy am y rheswm am yr ad-drefnu yma a sut mae'n mynd i gyfrannu at wellhad pellach yng nghyfraniad y strwythurau hynny?

You have referred in your evidence paper to a review of the governance and underpinning structures of both the planned care programme board and the out-patient steering group. Can you tell us a little bit more about the reasons for this reorganisation and how it will contribute to the further improvement of the contribution of those structures?

I think that the reporting mechanism for how we would get the traction and momentum required in the system was not as visible and as explicit as we needed it to be, and I think we have tried to address that by Welsh Government taking the responsibility for the performance oversight, albeit still supported by the national planned care programme. We took seriously the original reflections criticising, perhaps, some of the establishment of the planned care programme, and there were improvements that were identified by the Wales Audit Office in their work. So, we have gone through a mechanism recently, because we thought we needed to build on what we had, rather than replace it, about revamping the terms of reference of the membership, having clearer engagement with the medical directors, bringing in the three assistant medical director leads onto the out-patient steering group. Every specialty board's been asked to look at its terms of reference to allow implementation; in particular, asking clinicians to lead on individual pieces of work that I've referred to. So, some of the examples on prostate cancer pathways are very much linked to individuals who knew that they could make a difference around that table. Some of the work on the patient outcome measurements—that's been led by one of our consultants in Cardiff, for example. And we've tried to set out a really clear programme for 2019-20 that we think, again, will mobilise these things and make them happen across Wales, and I'm very happy to share a note of some of the individual examples that are happening under the individual specialties.

Rŷch chi hefyd yn sôn yn eich tystiolaeth am y sifft yma o'r rôl mwy hwylusol dechreuol gan fwrdd y rhaglen ar gyfer gofal wedi'i gynllunio i rôl sydd yn fwy gweithredol, cyfarwyddol, yn dangos mwy o ymyrraeth uniongyrchol, mewn ffordd. Ydych chi'n gallu disgrifio sut mae'r sifft hynny yn mynd i weithio yn ymarferol a sut mae'r byrddau iechyd yn ymateb i'r newid yna yn y rôl?

You also make reference in your evidence to this shift from the more facilitative role, initially speaking, of the planned care programme board to a more directive role, and for it to show greater direct intervention. Can you describe how that shift is going to work in practice and also how the health boards are responding to that shift in the role?

Certainly, already—I'm just, over these next three weeks, going to be finishing off the end-of-year reviews for all 11 of our organisations in Wales. That's seven of the health boards. So, the performance management reporting of follow-ups is a very visible and explicit issue even in very high-level reviews. It's very clear, and I've already picked up on that with three health boards during the last week, so I know that there has been a change around the performance management side, which I think underpins some of the improving performance that we've at least seen over these recent months.

I think there is a dilemma. Again, speaking openly about the way in which we want the planned care programme to work, whilst I think its advantage in its inception has been the working alongside clinicians, enabling, I do think they have a role, probably three years on from the inception, to be more challenging on their local visits. I hope that is never to be over-critical, but I think they can clearly (a) provide very direct feedback on what other organisations in Wales are already implementing in best practice and share that experience, but, secondly, they can actually be very robust, I think, on some of their local demand and capacity assessments. So, what I like about their approach at the moment is, in performance management terms, they could only be focused on how we get the numbers down, and we could do it very traditionally. Their recent contacts with organisations are very much about ensuring that there is, for example, more evidence of community-based pathways in place that people are genuinely changing the services around, based on their analysis at this stage. So, I would say a bit more teeth to the planned care programme, but I think the predominant accountability exchange should be from Welsh Government through to the individual health boards, and obviously through to the chief executives and their teams.


Ar ganfas ehangach, mae 'Cymru Iachach' yn nodi'r bwriad i greu NHS executive, neu weithrediaeth y gwasanaeth iechyd genedlaethol, ac rŷch chi'n cyfeirio at hynny yn eich papur tystiolaeth. A allwch chi ddweud, yn y cyd-destun yma, sut mae'r endid newydd yma yn mynd i gyfrannu tuag at ysgogi mwy o welliant yng nghyswllt apwyntiadau dilynol i gleifion allanol? Pryd allwn ni ddisgwyl gweld mwy o gig ar esgyrn yr awgrym yma?

Looking more broadly, 'A Healthier Wales' sets out the intention for the creation of an NHS executive function, and your evidence paper refers to that. Can you tell us, in this context, how this new entity will be able to contribute towards driving further improvement in the context of follow-up out-patient appointments? When can we expect to see more meat on the bones of this suggestion?

We're at a point where the Minister will be receiving formal advice on the establishment mechanism for this. NHS Wales doesn't exist as an institution because it sits within Welsh Government in an oversight role. That's why I have a shared role as director general as well as the NHS Wales chief executive. We have to ensure that, as this mechanism lands, it is not of itself a different organisation, but it has the advantages about how it comes alongside organisations in Wales. So, the Minister will shortly be agreeing some formal advice and will be able to make a statement as appropriate on that.

I think the change that it brings, though—a couple of areas that I would reflect on. Firstly, that we have a chance to ensure that, whilst we always want there to be innovation, our system is moving more towards expectations and compliance and delivery, and in the spirit of the executive function starting to be much clearer on a range of areas, I hope, as we've been articulating this afternoon, because we're introducing targets here, we gave evidence, actually, to the Health, Social Care and Sport Committee around endoscopy, about screening thresholds, and we know that we'll be meeting those thresholds by the end of August because we've taken a much more directive approach as well. But the bit I think that we have still been missing has been our flexibility around the intervention and the support that is visibly available nationally out into organisations. So, we have some mechanisms already in place, like the financial delivery unit, and our delivery and support unit more generally, but a lot of the executive function was about bringing together areas that would allow us to look at improving performance, but at a quicker momentum. I'm hoping that that will allow not just me eyeballing organisations, but rather a capacity and support that is about making some of the changes that we've been describing through the course of this afternoon. But the Minister is just judging some formal advice coming up at this stage, and I'm sure he'll be making a statement on that very shortly.

Iawn. Jest i ymateb i hwnna, i ba raddau y mae creu gweithrediaeth y gwasanaeth iechyd genedlaethol yn arwyddocaol iawn, a dweud y gwir, yn hanes y gwasanaeth iechyd? Ac, i ryw raddau, gan ymateb i rai o'r cwestiynau a gawson ni gan Jenny Rathbone ynglŷn â chyflymder cofleidio'r modelau newydd fel gofal iechyd darbodus, os taw dyna yw 'prudent healthcare' yn Gymraeg, a'r sifft yn y model cyffredinol roeddech chi'n cyfeirio ato drwy'r prynhawn, a dweud y gwir—ydy creu'r weithrediaeth yma yn rhoi lifer, efallai, neu ganolbwynt neu gyfrwng ar gyfer y sifft model yma sydd ddim wedi bodoli hyd yma ar lefel genedlaethol?

Okay. Just to respond to that, to what extent is the creation of an executive for the NHS very significant in the history of the NHS? And, to some extent, responding to some of the questions we had from Jenny Rathbone as to the speed of embracing these new models such as prudent healthcare, and the shift in the general model that you've mentioned throughout the afternoon—is creating this executive providing a lever, perhaps, or some kind of focus or vehicle for this shift in model that hasn't existed so far at a national level?


Clearly, it's one of our responsibilities to enable that, to direct that at this stage, but yes, it is a step up, and historically so, to allow ourselves the capacity to get behind the change that we want to have happen as part of 'A Healthier Wales'. And, of course, the proposal around this distinction of an executive function in Wales was part of the parliamentary review recommendations, because they themselves felt that there needed to be a step up within the system in Wales if we were to deliver that kind of vision and outcome over the course of the next 10 years. So—

Is that quite a different thing to England, then—NHS England? I've not thought about this before. 

Yes. NHS England operates with NHS England as a separate, independent organisation, with its own sovereign decision-making mechanisms, and the Department of Health and Social Care is separate. Actually, our arrangements,  however, are consistent with what Scotland does, for example, where actually there is a shared role, because similarly the NHS in Scotland is hosted within the Scottish Government system and then there is a shared role at the top—

So the NHS here is almost like part of the Welsh Government.

Yes. We are overseen by Welsh Government and there are roles about it, but that is a different kind of mechanism. So, there will be, no doubt, advantages and disadvantages about that. Within the English system, just simply the scale and the size of it would be one of those reasons why that separation has occurred. But, it's interesting that Scotland, ourselves and even the Northern Ireland model is a shared model that is sitting within the kind of—

I should probably have known that, but I'd just never thought about it before. 

It's something I have to constantly think about because, clearly, I'm having to discharge two roles. There's a director general role, which is there supporting Government and Ministers, and then I have my NHS Wales chief executive role, which is the oversight of the system, and I have an accountable officer role that I delegate out to individual chief executives in Wales. So, it is a—

Dim rhagor o gwestiynau.

No further questions from me.

Great. Unless anyone's got any further questions—. Rhianon Passmore. 

Very briefly. In that regard, you mentioned the duality, or more so, of your role; do you feel that this model is appropriate, or do you not want to go there? Scottish model? English model?

Well, I think there is evidence—

There is evidence that the model can work either way, however the structures are. I've been liaising with colleagues in Scotland, and they've certainly just gone out to their own recruitment for a new chief executive up there. They've retained that. When I came into the role myself, it was retained here. The parliamentary review reflection was that that was less important as an issue. So, whilst it causes issues as to how you balance all of the priorities and the workload, I think with a 3 million population in a more intimate arrangement in Wales and with only 11 organisations, actually probably the role better works together than just introducing a person in a buffer role. Otherwise, it's just an additional person within the system. 

It can be very easy to get hung up on structures, can't it? And to spend all your energy changing those, when actually—

And I think it's about focusing on outcomes. 

Great. Well, we started bang on time and we've pretty much finished on time. So, great. Thank you for being with us today, Dr Chris Jones, Dr Andrew Goodall. It's been really helpful. We'll compile a transcript and send that to you for proofreading before it's published. But thanks for being with us today, it's been really helpful. 

Thank you. Diolch yn fawr. 

3. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o’r cyfarfod
3. Motion under Standing Order 17.42 to resolve to exclude the public from the meeting


bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).


that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

And I move under Standing Order 17.42 to resolve to meet in private for item 4 to discuss that session. 

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 15:03.

Motion agreed.

The public part of the meeting ended at 15:03.