Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd
Health, Social Care and Sport Committee - Fifth Senedd11/07/2019
Aelodau'r Pwyllgor a oedd yn bresennol
Committee Members in Attendance
|Angela Burns AM|
|Dai Lloyd AM||Cadeirydd y Pwyllgor|
|Darren Millar AM||dirprwyo ar ran Angela Burns yn ystod y bore|
|substitute for Angela Burns for the morning|
|David Rees AM|
|Helen Mary Jones AM|
|Jayne Bryant AM|
|Lynne Neagle AM|
Y rhai eraill a oedd yn bresennol
Others in Attendance
|Ann Lloyd||Bwrdd Iechyd Prifysgol Aneurin Bevan|
|Aneurin Bevan University Health Board|
|Glyn Jones||Bwrdd Iechyd Prifysgol Aneurin Bevan|
|Aneurin Bevan University Health Board|
|Janet Davies||Llywodraeth Cymru|
|Judith Paget||Bwrdd Iechyd Prifysgol Aneurin Bevan|
|Aneurin Bevan University Health Board|
|Martine Price||Bwrdd Iechyd Prifysgol Aneurin Bevan|
|Aneurin Bevan University Health Board|
|Sapna Lewis||Llywodraeth Cymru|
|Sioned Rees||Llywodraeth Cymru|
|Vaughan Gething AM||Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol|
|Minister for Health and Social Services|
Swyddogion y Senedd a oedd yn bresennol
Senedd Officials in Attendance
|Claire Morris||Ail Glerc|
|Tanwen Summers||Dirprwy Glerc|
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 rhan gyhoeddus y cyfarfod am 11:10.
The public part of the meeting began at 11:10.
Bore da i chi i gyd a chroeso i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd. Dan yr eitem gyntaf, y cyflwyniadau, ymddiheuriadau, dirprwyon a datgan buddiannau, allaf i estyn croeso i’m cyd-aelodau o’r pwyllgor y bore yma a bellach egluro bod y cyfarfod yma, yn naturiol, yn ddwyieithog? Gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o’r Gymraeg i’r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2. Dŷn ni ddim yn disgwyl larwm tân i ganu fel ymarfer y bore yma, felly dylid dilyn cyfarwyddiadau’r tywyswyr os bydd larwm tân yn canu. Fel dwi wedi cyfeirio eisoes, mae’r meicroffonau’n gweithio’n awtomatig; nid oes angen eu cyffwrdd o gwbl.
Rŷn ni wedi derbyn ymddiheuriad gan Angela Burns am sesiwn y bore yma a bydd Darren Millar yn dirprwyo ar ei rhan y bore yma. Mae Angela Burns yn bresennol yn sesiwn o’r pwyllgor yma'r prynhawn yma.
Good morning, everyone, and welcome to the latest meeting of the Health, Social Care and Sport Committee here in the Senedd. The first item is the introductions, apologies, substitutions and declarations of interest. Can I welcome my fellow members of the committee this morning and can I further explain that this meeting will be bilingual, of course? You can use the headphones to hear the interpretation from Welsh to English on channel 1 or to hear contributions amplified on channel 2. We don't expect a fire alarm today as a drill, so, if one does sound, you should follow the ushers' instructions. As I've referred to previously, the microphones work automatically, so you don't need to touch them at all.
We have received apologies from Angela Burns for the meeting this morning, and Darren Millar will be substituting on her behalf this morning. Angela Burns is present in this committee meeting this afternoon.
Felly, gyda chymaint â hynny o ragymadrodd, dŷn ni’n symud ymlaen at eitem 3 a chraffu cyffredinol, sef sesiwn dystiolaeth gyda Bwrdd Iechyd Prifysgol Aneurin Bevan. Dyma’r chweched yn ein cyfres o sesiynau craffu cyffredinol gyda phob bwrdd iechyd lleol yma yng Nghymru. Tro Bwrdd Iechyd Prifysgol Aneurin Bevan yw hi'r bore yma, felly, i’r perwyl yna, dwi’n falch iawn o groesawu Ann Lloyd, cadeirydd, Judith Paget, prif weithredwr, Glyn Jones, cyfarwyddwr cyllid a pherfformiad, a Martine Price, cyfarwyddwr nyrsio dros dro. Yn ôl ein harfer, dŷn ni wedi darllen y dystiolaeth ysgrifenedig. Awn ni’n syth mewn i gwestiynau yn ein modd traddodiadol, ac mae’r cwestiynau cyntaf gan Lynne Neagle.
So, with that much of an introduction, we move on to item 3, which is the general scrutiny, and an evidence session with Aneurin Bevan University Health Board. This is the sixth in our series of general scrutiny sessions with every local health board here in Wales. This time, it's Aneurin Bevan's turn. So, to that effect, I'm very pleased to welcome Ann Lloyd, who is the chair, Judith Paget, who is chief executive, Glyn Jones, director of finance and performance, and Martine Price, who is interim director of nursing. As usual, we will confirm that we've read your written evidence. We'll go straight into questions, as usual, and the first questions are from Lynne Neagle.
Thank you, Chair. Good morning, everyone. If I can just start about financial performance and ask you how you describe the health board's reported outturn for 2018-19 and what the underlying deficit is for this financial year.
Yes, certainly, if you'd like me to pick up and answer that question. So, the outturn for the last financial year was a small surplus on a revenue budget and, similarly, on our capital budget. It meant that, taking the three-year rolling duty that we're actually measured against, that we met the statutory financial duties for last year, which was very pleasing, I think, given the range of challenges that we actually face as a health board.
In terms of the underlying position, that's something that we've focused on quite significantly over the last few years. Given the way that some of our services are changing and the way that we've resourced them, we have had to actually manage what was a fairly large underlying position a couple of years ago where if I—. Just to say that, 2018-19, when we went into that financial year, our underlying position was around about £19 million. On a budget of £1.2 billion, I guess you could say that's fairly immaterial, but, actually, when you're trying to manage a number of risks around service workforce and financial risk, that is still quite sizeable when you're trying to manage that in-year.
I think, through a combination of hard work around delivering robust savings through the organisation, focusing on efficiencies and looking at where we could contain some of our costs, we are now in a position where we go into this financial year with an underlying position of around about £11 million. Our aim over the next integrated medium-term plan cycle is to try and get that underlying deficit position down to around about £4 million to £5 million. We'd like to go further if we can, but, clearly, we have to balance service workforce priorities with making those recurrent financial improvements.
Okay. Thank you. And, in the structured assessment report 2017, undertaken by the Auditor General for Wales, he noted that the risk was that future savings or funding for Welsh Government may not be sufficient to recover that underlying deficit without wider transformational change. Can you just give us a flavour of what kind of transformation the health board is putting in place to ensure that's delivered?
Yes, certainly. Obviously, we have our Clinical Futures programme, which we may talk about later. The approach that we take to efficiencies and savings is very much one of an integrated approach. So, we look at savings and how we can improve efficiency and productivity alongside developing our service and workforce plans. So, I think it's important to say that we very much do that in an integrated way, making sure that any savings that we identify don't adversely impact on quality and safety of care.
Our approach broadly takes two broad themes. One is around what we would call 'operational efficiency', so where perhaps we can get a better deal around renegotiating a contract for particular medical supplies; that would be a very operational type of efficiency improvement. The area that we're focusing more on now, and have done over the last couple of years, is a value-based approach to delivering healthcare, which quite simply is looking at how we can improve outcomes for patients and, in doing so, reallocate resources in a more appropriate and more effective way. So, it's what we call 'allocative value', in the sense that we try and allocate resources in the most appropriate areas, but it is very much based on improving outcomes for patients.
So, part of the system that we've developed in the health board is around collecting outcomes across pathways for different patients. And what that allows us to do is look at how we can redesign some of those pathways to make better use of resources. And we've got some examples where that's already driving improved efficiency. And it means we can make better use of the resources that we've got. I think, in terms of the longer term strategy, that's really where we have to go. We need to scale it up and we need to embed that more across the organisation. But that's our strategic approach.
Can I just add something, if that's possible? I think, in terms of the transformation programme, clearly, for the health board, the Clinical Futures programme is our transformation programme. People often associate that with the opening of a new hospital, but it is much broader than that, and the transformation extends across our health and care system, including substantial work that we're doing with our local authorities and other partners around changing the way primary care is delivered, changing the way we support children and young people, changing the way we think about supporting people to live well in their communities, thinking differently about how we support people when they need to leave hospital. So, the programme itself is fairly substantial. Clearly, there are elements of that that we might pick up at various points this morning.
Yes. Okay. Thank you. So, an increased proportion of the health board's savings were delivered through non-recurrent schemes in 2017-18 and 2018-19, when compared to the previous three years. Can you just explain why that was?
I think in some respects it's to do with the way that we've categorised some of those savings. So, one of the areas where we've made fairly significant gains financially has been around prescribing savings, both in primary care and in secondary care—probably more so in primary care. The nature of the way that prescribing works, particularly in primary care and around the way that the pricing regulations scheme works, means that we've probably taken a slightly more prudent view about whether some of those savings will be delivered recurrently. So, we have benefited from some changes in drug tariffs, and we've tended to report those as generally non-recurrent savings unless we are absolutely sure that they will continue to come through recurrently. So, I think that's probably why it's coming through as a greater proportion of non-recurrent savings.
And in terms of cost-avoidance schemes, do any of those involve a reduction in activity, and what is the impact of anything like that, then?
It wouldn't be a reduction in activity, no. It's more about how we can do things more efficiently and more effectively, and this is really why we're pushing forward our value-based approach, because that's absolutely the right thing to do. It's about improving the outcomes that matter to patients and, in doing that, enabling you to redesign your services. Part of the transformation programme is about doing that. It allows you to reallocate resources, which is not straightforward, but, actually, it involves everybody in the design and delivery of those services. There's a lot of international evidence behind this approach. Long term, it is probably the way of making sure that health systems are financially sustainable.
Okay. Thank you. Finally, on the finances, have you developed plans to deliver the £15.1 million saving target and what proportion of that relates to recurrent schemes?
Some of those schemes, given the time frame, will still be fairly embryonic in terms of we know where the opportunities are, but it will involve some changes in our workforce and changes in the way that we deliver services, and we know that, over the next three-year period, our Clinical Futures programme will substantially change the way we deliver services. So, some of that is about, timing wise, we know when those savings will be delivered. It's making sure that we put everything in place to make it happen. And I guess the largest part of that is the workforce change, really, so we're doing a lot around change management with our workforce to make sure that that becomes a reality.
Okay. Thank you. And if I could come on to ask about the Grange university hospital—I feel as though there should be a klaxon whenever I say that in this committee, really. [Laughter.] Obviously, it's on schedule, but can I just ask about workforce plans and what assurances you can give the committee that the health board is on target to have the workforce in place in all specialities by the time it opens?
Absolutely. We've just completed a fairly extensive review of all the service models affected by the opening of the Grange university hospital. There are about 47 of those. Alongside the refresh of those service models, we've updated all of the workforce plans associated with that. So, we're quite clear about what workforce we'll need and when we'll need it. Some of that workforce recruitment started two years ago—so, for things like emergency nurse practitioners, we started training our own emergency department nurses in additional skills. Last year, we started our recruitment for radiographers and we've got another schedule—in fact one of the last things I did before I left the office this morning was read through a schedule of the key appointments for this year.
Clearly, I can't give a guarantee, because for some, we are testing the market, but the reason why we are going early is if there is any concern about our ability to recruit a certain type of workforce that we need, then we've got time to rethink and think differently about whether or not we can flex that. So far, we've been very successful. So, we've recruited 10 staff grade doctors, we've recruited radiographers, we've recruited ENPs for our minor injuries unit that we're developing and we haven't had any difficulty recruiting. But that isn't to say that we might get to a certain type of professional group or area where we might have some problems in the future. But we are trying to be really careful about making sure that we give ourselves plenty of time, to not rush it in the last six months before the hospital opens and risk anything happening that might affect that.
Okay. Thank you. Just finally from me on this, it's great for my constituents, obviously, because it's very local, but you are serving a wide area, as far up as south Powys. What's going on in terms of the public transport plans to ensure that patients and visitors can access the hospital easily?
The transport planning has started in earnest. Public transport providers said that—. We did try and talk to them a little while ago and they said it was too early to have the conversations, so we've now commenced that work in earnest. The first draft of our travel plan has been signed off by our Clinical Futures programme board and conversations are happening across the network, really, in terms of opportunities. We do have issues in the here and now in terms of public transport, so we're trying to have discussions about current movement of staff and patients around our system as well as what that might look like for the future.
We've done some particular work with the five local authorities. Clearly, the city region deal has got a large element of focus on transport and networks of how we move people around south-east Wales, and so one of the local authority chief execs has offered to be our link person in terms of taking that work forward. So, it's proactive and active. It's not complete, but we're getting good engagement from the transport providers in that conversation.
Okay. Thank you.
The Member for the Royal Gwent Hospital—Jayne.
And St Woolos and St Cadoc's—not just one.
And associated hospitals.
And other hospitals that may be available. [Laughter.]
Exactly. Thank you. Just following on from Lynne on the transport plans, obviously the Royal Gwent Hospital will still be seeing large amounts of people coming in on a daily basis, and there are still issues around transport, how to get people around, whether that's staff and patients visiting—perhaps more people will be visiting the Royal Gwent. Are you looking at that in the transport plans as well?
Yes, certainly. We're looking at the movement of people across the whole system, really, because although we're opening a new hospital, the movement of staff and patients is critical. Some staff, and particularly some of our senior medical staff, will work on more than one site, so it's making sure that they can get back and forth. Clearly, other staff will be just located on a single site. Obviously, we need to get our staff to work and home in a sensible way, and you will know some of the issues we've got in Newport at the moment around the Royal Gwent in terms of car parking and other space availability. So, we're trying to take a whole-Gwent approach and think a little bit differently as well—so, looking at things like do we need to provide a park and ride. Newport city transport are already in very active conversations with us about routeing buses from Newport up to the Grange and back, and those conversations are well advanced and very positive.
That's good to hear. Just around the rest of the hospitals, and how they will work with the new hospital opening at the Grange, perhaps you could explain about the levels of accident and emergency services, or what will exist at the Gwent in terms of minor injuries.
Sure. So, the main emergency department and trauma unit for the Gwent area, if I can use that term, will be at the Grange university hospital, and at the Royal Gwent, Nevill Hall and, as it is already, at Ysbyty Ystrad Fawr, there will be a 24/7 nurse-led minor injuries unit on those three sites, hence our need to recruit early in terms of increasing the number of emergency nurse practitioners that we'll need for those areas. So that's how the service will be provided and designed when the Grange opens.
You were talking about some of the positives around recruiting for the Grange hospital; how will that impact on, say, the Royal Gwent and Nevill Hall? Do you see that it will become even harder to recruit for those positions?
I don't believe so. Certainly, we've run a similar model to what will operate at the Royal Gwent and Nevill Hall at Ysbyty Ystrad Fawr since that hospital opened in 2011. We haven't had any issues in terms of the recruitment of ENPs or other staff there. We have occasionally run into some difficulties around the availability of middle-grade doctors in medicine, but we've resolved some of those issues as well. So, that hospital was designed as a sort of pathfinder, really, to test the model, test the relationship between that hospital and the specialist and critical care elements that are currently provided at the Royal Gwent, obviously, and to make sure that we could manage services, that staff got used to working between two sites, and also the issues around if patients need to be moved from the Royal Gwent to Ystrad Mynach or vice versa—that we know how we can manage safe systems of patient transport where we need to as well.
So there are no concerns, really, around sustainability in the Royal Gwent or Nevill Hall.
Not in the new model, no—not that we're aware of, anyway—and our risk assessment is not showing any particular concerns at the moment.
And you'll look at St Woolos in the future.
Yes. The future of St Woolos—. You will know that we've just done a complete review of our estate across the whole of our health board area, and that's showing up some areas where there is the potential—. Some of our estate is very aged, St Woolos being one of those, although parts of it are very actively used and are in better condition. So, we're just giving some thought at the moment about when wards and departments move out of the Royal Gwent up to the Grange university hospital when that opens. Clearly we will have vacant space in the Royal Gwent. Whether or not we move any of those services down—. How many of those services can move down to the Royal Gwent and make use of that space—there's a decision yet to be made on some of those areas.
David, you've got a supplementary here.
Yes, just a quick one. You mentioned the nurse-led minor injuries unit. I've got one at Neath Port Talbot Hospital in my constituency, which obviously works very well, although it has reduced its hours because of demand. But one of the problems we've also had was the doctor recruitment—middle-grade doctors, as you've identified yourself. Are you confident that you have resolved the problem of that? Because if you lose that grade of doctor, your mental assessment unit is going to take a hit, which means, therefore, problematic changes in the services provided? So, are you confident that, in your plans, you will be able to continually ensure that that grade of doctor will be there, so your MAUs will not be affected by this?
So, the work that we've done so far suggests that we can. We've had—. Clearly, our clinical teams have been very carefully assessing the availability of medical staff, and also the hours of operation that we can commit to in terms of some of the—I call them 'peripheral hospitals', so local general hospitals, in our design. And part of the reason why we've gone early on the recruitment of the 10 staff grades is to give us the opportunity to get people in, get them settled into the organisation, get them to start working, undertaking shifts and filling rosters now, so that when we move into the Grange, they will be working in those three other hospitals, to give us a level of surety, really, that we've been able to recruit.
Whether I can guarantee that we will never have problems in the future, it's difficult to predict. But, certainly, the clinical staff, Health Education and Improvement Wales, and others that we've consulted with so far have said that the model looks realistic, looks sustainable, and that's what we've started to recruit to.
Ocê. Symud ymlaen i faterion yn ymwneud efo gofal sylfaenol—Helen Mary Jones.
Okay. Moving on to issues regarding primary care—Helen Mary Jones.
Thank you, Chair. Good morning.
In your paper, you talk about this integrated well-being network model. So, can you tell us a little bit more about what that model is, how it's going to work, about the timescales for implementing it across the area, and about how you anticipate that using this model will reduce the impact on acute services and make primary care more sustainable?
So, our transformation programme has got a number of elements and they're sort of interrelated. So, the integrated well-being network sits closely alongside the transformation of primary care in terms of changing the model in which primary care is delivered. So, the integrated well-being networks are associated with trying to develop a compassionate community approach to well-being and supporting individuals with a place-based approach to care delivery, and also thinking about prevention, self-management. So, they're a network that involves all the key stakeholders, as you might imagine, so clearly well linked into the local authorities and the third sector, volunteering—the whole network of groups that might be available in the community. We've appointed community connectors to act as that sort of link approach, and they're already recruited. And the networks have started to develop. And in terms of our transformation programme, we are well advanced with the recruitment, and, actually, they've started to work in a number of areas to build those links. They were launched in April. Clearly, there'll be a little lead-in time in terms of them working effectively because they've got to create those opportunities for joint working, but they are well advanced, and the feedback that we're getting from those where they've already started—and those connectors are already connecting on the ground, as it were—is very positive.
Alongside that, we're also investing a significant amount of resource, through the transformation programme, to change the models in primary care, and to think differently about how we recruit and resource primary care for the future, but also how the changes might impact on some of that flow.
We've done some particular work in our managed practices. We directly manage three GP practices in our area. And while there's a financial premium to running managed practices, it has given us the opportunity to change the model of care, to bring in new workforce to contribute to the delivery of primary care. And we're also tracking the impact it has on referrals, people going to the emergency department, people going as emergency medical admissions, and then a whole range of indicators that would help us over time indicate that that model will change the way in which the flows into secondary care or acute services change. And we've started collecting that data now.
So, it's a bit early to say yet, but you are measuring it.
Yes, we absolutely are measuring. The first information I saw, which was about four weeks ago, was indicating some very positive trends. Not all the work is being done. We’ve got a rolling programme in the managed practices and certainly the early adopters—we’ve started to see some of the changes coming through in the data.
That's really interesting. Could you tell us a bit more about some of these new workforce models that you're trying out in the managed GP practices? And I should declare an interest—I'm a bit of a fan of managed GP practices. [Laughter.] I think we can get too hung-up about wanting them all to be independent. So, tell us a bit more about those workforce models and how transferrable those might be, then, into those GP practices that have got independent contractor status?
Yes, so we've got four managed practices: one in Caerphilly county borough and three in Blaenau Gwent. I'll pick the one, because the one is the largest practice, and that's Bryntirion Surgery in Bargoed. In that surgery, clearly, we have GPs, but we also have other practitioners who are contributing to the primary care team. So, we have physios, we have a pharmacist, we have an occupational therapist, we have a mental health practitioner, and we have a paramedic, who's supporting with home visits. I'm trying to remember whether I've missed anybody.
A physician associate.
A physician associate as well. They've looked at the workload of the practice and determined what is appropriate to be seen by which individual. Clearly, only patients who need to be seen by the doctor are seen by the doctor, and that system is working very well. We are now taking that learning from that to our other managed practices, but we're already seeing some of those opportunities being adopted by non-managed practices as well. So, a lot of them have started to appoint pharmacists. We're already getting interest in physiotherapy, and so, I think, having some demonstrator projects in your health board that you could then share with non-managed practices is a really positive thing, and the GMS practice is very receptive to thinking differently about how they deliver care as well.
Darren's got a supplementary at this point. We'll come back to you then, Helen Mary.
Just on this issue of managed practices. We've got a lot of these managed practices, of course, in north Wales as well, and I can see very much that there has been an investment in diversifying the workforce in those practices in order to perhaps better suit the patient. But in my experience, the patients sometimes struggle with the concept of not being able to see the doctor, and we need to change that mindset, obviously, so that they can see the best person to suit their particular need that's presenting. Have you done any work on patient satisfaction rates in the practices that are managed? And you mentioned the financial premium, because there is an extra cost, obviously, to providing extra members of staff and therapists that wouldn't otherwise be there—what is that premium and how difficult might it be for the GP contracted practices to actually diversify their workforce in the same way, given the extra costs?
So, yes, in each of the managed practices, they're all at different stages of development. I think one of the things that we learnt very early on, even when the practices were struggling with sustainability, and there was a risk that they would become managed practices—we had to do a lot of work with the practice patient population to try and explain what this actually meant and that there was nothing to fear from it and possibly some things to gain from a different way of delivering services.
We run patient participation groups in Bryntirion and in the surgery in Brynmawr, and they are very active in engaging with us. We also have worked quite closely with the local elected members, the local councillors in those areas as well, in terms of facilitating community meetings, meeting patients in the practice and generally getting feedback. There have been some quite difficult moments, so I can't pretend that it's been an easy journey, but, actually, now that people have gone through the adjustment, have adjusted to the fact that they are seeing different people and are able to get to be seen quickly, that has been a real consideration for people, so being able to be seen by somebody and having a conversation. Certainly, some of the feedback we've had around the ability to sit down with a pharmacist who's got more time to explain to people about their medicines and give them more time has been extremely positive, as have the paramedics going into care homes and doing visits as well.
So, yes, positive—it requires a lot of investment of time, and I think that's good, and we've learnt something different every time we've done it, and patients do adjust to the new model. We are doing patient information leaflets. I saw one last week for our surgery in Brynmawr where they've set down what the roles of each of the different practitioners are, when patients might see them and the sorts of things that they could see them for.
In terms of the financial premium, the additional cost of running our four managed practices is about £1.3 million at the moment, but most of that relates to locum costs for doctors. They became managed practices because we didn't have GPs under a GMS contract. So, we are heavily reliant on locum doctors in the practices, so half of that £1.3 million relates to locum costs. Clearly, if we didn't have locum doctors and we had substantive doctors, that cost would go. In terms of the rest of the model, though—
Can I just ask—? In terms of percentage of what would have been paid under a GMS contract, how much is £1.6 million?
Off the top of my head, I don't know.
Is it a 10 per cent premium, a 20 per cent premium or—?
The premium will probably be quite a lot higher, actually, because of the nature of the agency locum that we're bringing in.
But if you exclude the locum and assume that you eventually get some employed GPs, what would that be—you'd still be paying a premium, yes?
But what percentage would that be? I think that would be interesting.
Of the whole cost, do you mean?
I haven't got that, but we can get that to you. I just haven't brought it with me today.
That would be interesting, just to compare the models in different parts of Wales.
If we had substantive GPs, the cost at the moment for the four practices would be about £600,000, but, clearly, when we go into practices there's usually quite a lot of work to do in terms of putting systems in, changing the way the practice is managed, and quite a lot of support to provide to staff. So, that wouldn't be the cost of running the model in a GMS practice, that's just a cost of actually moving practices who've gone through sustainability into the health board. In terms of the model, I think it's genuinely doable. What practices need to do is to just think through how many GPs they need to run their practice population and what other contributions other staff can make to that.
Certainly, we've been doing a little bit of work, which is just in its early stages at the moment, to look at—if you ran all the practice data through a system, it tells you, by case mix, the sorts of patients who need to see a doctor, the sorts of patients who could be seen by an advanced nurse practitioner, the sorts of patients who could be seen by a physio. So, we're just doing quite a detailed piece of workforce planning at the moment, which will help all the practices to think that through.
Okay, back to Helen Mary.
Thank you. You'll know, of course, that in May this year the audit office report said that the current performance indicators don't easily allow oversight of all areas of primary care, and that there's more scope for more board level focus on primary care. Can you tell us a bit about how your health board obtains assurance about the quality of your primary care services?
Do you want to say anything, and I'll come in as well?
In a variety of ways, as you will recognise. We have a suite of scrutiny committees that report to the board. At the moment, the quality of primary care goes through the quality committee, but we also have a public partnerships and development committee, and, again, the quality and the approach to primary care will be discussed at that committee in terms of the future strategy for it, the difficulties that are being encountered within it, and, again, we will be looking at the outcomes.
I would agree that we need to focus further on the very different models of care that we have and are developing now to ensure we are measuring the right things, and not just sticking to the suite of measurements that we've got at the moment, which might not be entirely indicative of how well we're serving the population. The board itself pays great attention to what's happening in primary care, and particularly the quality and the outcomes. We have visits to the managed practices so that we can talk to the staff to make sure that we are assured that they are managing. And I think, with the managed practices, our next campaign basically will be with the deanery, to try and get the trainees in there to see how these new models are developing, what can those trainees learn, and how interested they would be in practising in those sorts of practices in these fairly deprived areas for the future, to get some enthusiasm behind it. So, I have found our board—. And I'm relatively new to the board, but I have found our board is very, very good at scrutinising the outcome for people, and therefore to get assurance on that range of services.
That's helpful. Thank you. And just finally on primary care, does the health board expect to see a greater increase in the proportion of your spend on primary and community care this year and beyond, and, if so, what is the expected increase?
I'll bring Glyn in, because we've just done a fairly extensive piece of work to look at how resources are shifting between primary and secondary care in our health board. So, I'll bring him in. He can explain a little bit about that.
The work that we're doing is actually looking at where and how it's appropriate to shift resources from what we would term as hospital services and out-of-hospital services, so I would say it's probably a bit broader than the traditional view of primary care. Obviously, our strategy of care closer to home means that we actively want to move resources in that way. The plan is to do that, so the transformation fund that we have, areas like the integrated care fund, are focused on developing services that are out of hospital. They're not necessarily just the traditional primary care services. So, our aim, actually, is to achieve that shift. I think, in reality, what we're finding at the moment is, whilst we are making some of that shift, we are still seeing that we're having to put resource into making sure we meet a lot of the access-time targets, which are generally secondary care focused still. I mean, obviously, there is a shift in some of the performance targets to look at the whole system, but there is still quite a strong focus on making sure people have good access to secondary care hospital services. So, naturally, we have to make sure that we resource that properly as well.
That's very helpful, thank you. If I can turn now to some issues around scrutiny, and particularly handling of concerns and of patient safety incidents, what assurances can you provide as a health board about your internal governance and reporting arrangements, and how sure can you be that, if there was a significant issue in any particular service area, the board would be aware of that issue and would be scrutinising how that issue would be addressed?
Okay. Shall I bring Martine in first, and we might all contribute to this as well? Thank you.
So, you particularly talked about concerns and SIs, and then overall in terms of our assurance processes. As Ann has said, we have very robust clinical governance arrangements in the health board that are well established, and we have—. That starts, obviously, at a clinical level, in terms of the culture is very important, and I'm sure we'll talk more about that, but, in terms of staff being able to raise concerns and reporting incidents, through the Datix reporting system we are a high reporter in terms of actually staff using that system—so, I think very important at that level. At divisional level, every division has their quality and patient safety committee, and that then feeds through to our board committees. We have an assurance framework for quality and patient safety that picks up all the key areas that relate to quality and safety. It's very wide-ranging, as I know you will know—all aspects, in terms of that can cover off health and safety as well as risk management, as well as key topics of safety in terms of, for example, deteriorating patients. So, that broad range of having key committees, but actually, then, on how that work is fed up through, we have an operational quality and patient safety committee. That receives reports and has a programme of work. That then feeds through to our quality and patient safety committee, which is chaired by an independent member, and on to the board. So, that gives a very high-level summary. I'm very happy to talk more specifically around concerns and incidents, if that's helpful.
I've got a question—I'll come onto that specifically in a minute, if I may.
Okay. Thank you.
The board is well sighted on areas of concern, because not only do we get the assurance through the quality and patient safety committee, but also, where there are issues of potential sustainability of services, the board has been conducting board development sessions, where the full board will understand precisely what the issues are and can receive assurance that they are being well managed, that the right action is being taken. For example, I'd only shortly started and there were concerns about the sustainability of some of the older persons' mental health services, which were thoroughly, thoroughly discussed by the whole board so that they could ask any question they wished to gain any assurance before they had to sit down in public and decide what did we then do about these services, how we would consult on them, who did we have to listen to, what were the alternatives.
So, I'm very keen that, before any service change is undertaken, the board, many of whom have not been associated with the health service, really have a thorough understanding of the issues, the action that's being taken, what assurance they can receive that the situation is being managed properly and effectively, because the last thing that any of us want is to oversee a service that is not sustainable or the outcomes of which are not appropriate for us or wouldn't meet our standards. So, they are very, very critically keen on ensuring that they understand what the services are and that the QPS undertakes the routine scrutiny anyway and will do deep dives on any area that is showing up in concerns—they will do immediately a deep dive into that so that they can reassure the board that the right action is being taken.
If I could just add—
I think even with good governance and processes, it is absolutely fundamental—and we work quite hard on this as a whole organisation—that we create a culture where we encourage staff to say when things are not right. So, I think we've tried to foster a culture where people feel able to come forward and will come forward. We give a variety of opportunities for people to voice concerns or to give feedback, because I think you can put in lots of mechanisms, but, actually, if people don't feel able to—. I think people's ability to do that comes from two things: (1) if they've raised it before and somebody's done something about it; and, secondly, when people have raised a concern, the response hasn't been, 'Well, how did that happen?', it's been more thinking about, 'So, what can we do to learn from that and how can we move forward?' So, setting the tone and culture of the organisation where people feel encouraged to and are able to and supported to voice concerns is really important.
Can you tell me a little bit more about actually how that happens? Because I completely concur with what you said—it's not just about saying that you want people to raise concerns; you have to, when they raise concerns, do all of that. So, could you just very briefly touch on what some of those mechanisms are?
Okay. So, there'll be—. So, visits—so, the execs and other members of the team will be visiting areas on a regular basis. And sometimes with independent members—sometimes not—we do specific visits that look at patient safety. So, we have a particular visiting programme, where we visit purely looking at things through the lens of patient safety and talk to staff around that. We operate an 'ask the chief executive', so all members of staff can actually send an e-mail or send in a question or an issue that they'll get a response to, and that's very well used by the staff in our organisation. I do drop-in sessions. So, I go and sit in various of our hospitals or clinics or buildings, tell staff I'm coming and just invite them to come and talk to me, basically, and they do. We do shadowing: so, the execs will send a note out four or five times a year saying, 'Would you like one of our exec directors to come and spend a half day or day with you and your teams?', and the take-up of that is always phenomenal. We sort out who goes where, but that's really good, and we always do a write-up and put it on our intranet site of what we've seen and heard when we've been about.
And, in relation to our Clinical Futures programme, we have now got 500 members of staff who have now put themselves forward as champions to help us and help their colleagues through the change programme that's now being developed. We also get feedback from things like the staff survey about whether people feel engaged in the organisation, and we always get very high scores on that.
I would also say that going out and visiting places isn't enough. You've got to go out and visit with a sense of being vigilant, caring about what people say to you, engaging with people in a way that it's not just a tick-box visit, that you're actually going because you really do care about what people want to tell you about their services.
That's really helpful. So, if I can move, then, from staff to patients: can you tell us a bit about how you would support patients when they raise concerns, whether you think that those systems are adequate and robust and how you're performing against the 30-day target for responding to patient concerns? I happen to think 30 days is a ridiculously long time, myself, but—.
Right, well, you'll be aware that our performance has not been good in relation to responding to concerns in the 30 days. We did, at the end of last year, start some quite fundamental improvement work in relation to concerns and, then, unfortunately, we had completely unexpected events with our Putting Things Right team, which led to—. Actually, we had very poor performance during the first quarter—so, January, February and March—which we do not accept. I think in terms of, actually, how we respond to concerns, how we hold patients and families during that time is absolutely fundamental and very important. And that sits with our whole work that we do around patient experience; it is a key component of that. So, in terms of that performance specifically, we have got a very robust improvement plan in place, and we've actually been working with our—. We have what we call ABCi in the organisation that are our improvement team, so really looking at that pathway of managing a concern and how you hold that person during that time to improve that. So, that plan was scrutinised and signed off by our quality and patient safety committee in February.
In addition to that, we have put additional resource into our team—we did that straight away—into our PTR team. We've also appointed two—so, two new appointments of key leadership roles in terms of taking this work forward. We also undertook work as part of that improvement plan—a thematic review, and that included the ombudsman as well, really understanding our position, and I'm very aware that complaint handling was a key theme for us.
Each division, as well, has a very specific plan because, when we've gone into the detail and really understood at divisional level, the divisions are in different places in relation to that. I think, to highlight, we do have some very good practice in terms of our concerns handling, and our maternity service is an exemplar in that area, which we have drawn on for the other divisions. And they have consistently maintained performance above 70 per cent in relation to responding to the concerns raised. So, I think that overall response rate that we've had—actually, there has been variation in divisions. It has been scheduled care that really has had to significantly improve.
So, we have seen improvement in quarter 2 in terms of closing concerns within the 30 days, but also in terms of the total volume of the concerns that we're closing. We have absolute transparency around the number of live concerns that we have. I know, on a very regular basis, how many are exceeding the 30 days, exceeding three months, and, if you look beyond 12 months, we have three concerns that go beyond 12 months, and that's for very good reasons. So, we are very transparent about that.
It isn't just about the performance, though; it's absolutely about the quality of the response and how, as I say, you hold that person during that time. So we've been working very much on the quality of the response, looking to offer more meetings. So, in terms of the support, there is still more we can do, absolutely, in terms of how we support people, so we are offering more meetings, obviously we offer advocacy and support, and how we improve our communication around if there are any delays, why is that, and explain that in a very proactive way with people, because every day is a long day when you're waiting for that response. We're taking immediate action on those concerns where there is action that we can take at the time to improve the care for that person. So, we're very aware if a concern comes in and we can do something, to actually get on and do that. But that doesn't take away from the fact that we do know our reality in relation to our current position and performance and the need to improve.
I'm very grateful to you for what I think is a very refreshingly honest and open answer, and I think that's an exemplar. Just a last point on the handling of concerns and safety. We have had chief executives and chairs sitting in front of us and telling us that there were terrible things going on in parts of their service and they just didn't know. Now, that is obviously a real concern. Can I just seek your assurances that you believe you've got it sufficient that if—you can never, not in an organisation that size, you can never guarantee that problems won't arise, but are you clear in your own minds that if they did, you as an executive team and you as a board would know that and be able to act?
Absolutely. I've gone back to culture before. One of the things that I think exemplifies our organisation is that if somebody points something out to us as a concern, we take that very seriously and we do something to respond to it. We don't pretend it doesn't exist, we absolutely are upfront about it and we want to be seen and we want to respond to those concerns, so absolutely. In a large organisation, things won't be perfect in every place—
No, of course not.
—so the most important thing is that we are vigilant all the time to where things might be going a little bit wobbly or where we might need to put a little bit more effort or support in, or a little bit more training. And I feel, from an exec point of view, and Ann will say from the chair's point of view, from an exec point of view, we are very responsive to those when we spot them.
I think from a chair's point of view, I am assured. You're absolutely right, there will always be pockets within any large organisation where something's not going as well as you want, and I think that we have a number of mechanisms to track those and try and improve them.
But, going through the organisation as I do—and people don't pick where I go, I choose where I go—I have always found the staff very honest. They'll tell you what's wrong, they'll tell you what they're proud of and they'll tell you what they're going to be doing about things, and where they need help, they will ask for help. And I've found that universally true and I have now just had a new vice-chairman, who is telling me exactly the same thing.
I also know that if the slightest thing sounds like it's not going as we would wish it to go, Judith comes into my office and tells me about it, so that I feel assured that there is nothing going to hit me. You can never know everything, but I think there is a culture, certainly within the executive and the board, that they do not want to run unsustainable, poor-quality services and they will do everything they can to ensure that the staff are enabled to improve and are given the help and support that they need to ensure that the services are of good quality. And I have confidence in the chair of the quality and patient safety committee and the people on that committee that they are astute enough and experienced enough to know that the data is not as it should be, and we go through this very meticulously.
Thank you. I'm really grateful for that. A final question from me, specifically about maternity services. You touched on a good response to patient concerns in maternity service, which is really encouraging. Obviously, the Minister wrote to all the health boards after what happened in Cwm Taf to ask for assurances about quality, safety, sustainability. Can you just briefly touch on that for us, and how you responded to the Minister, and how can we be assured that your services are all of those things—safe and good quality?
So, for our maternity services, we do have robust, very well-established clinical governance arrangements that are transparent, as I say, from the clinical areas up to the board. Obviously, we provided the assurance to Welsh Government, and I think a really salutary lesson in terms of really looking and really testing that. In our response, there were areas that we highlighted that we still need to work on and improve on, so in terms of—. So, we knew that, and tested that. We have, as I say, very clear clinical governance arrangements in place. We have staff feedback as well, as we've alluded to, but also specifically within maternity services in terms of how we listen to staff.
The governance arrangements within the division itself, within maternity, are very much multidisciplinary. So if you looked at the minutes and the notes of the risk meetings, the governance meetings, you would see that they are multidisciplinary, you would see that there are doctors, midwives, managers, other staff there at those meetings. They have a whole day a month that is their divisional governance day and learning day—very important in terms of the learning that they have in place.
We have a well-established maternity services board that's chaired by the director of nursing. We have CHC representation on all our key committees. We obviously have a maternity services liaison committee that has a lay chair. That's recently been revamped, that committee, in terms of how it's working. It's been refreshed in terms of how that's going forward. We then report directly up to the quality and patient safety committee, which, as I'm sure you can imagine, has had many reports in relation to maternity services, scrutinising the outcome data as well as the data around feedback.
A key area relates to how we gain feedback from women and families who use the service, and we have again a very well-established huge amount of work in this area. We do use social media a lot; it is the medium that the women want to engage with. That is extremely active. We have a Facebook page that is open. All of the feedback that we have from women who use our service is open and transparent, and we have in the last couple of months—I have got the figure; it was over 1,000 comments posted onto that site. We have had a negative comment as well, which is very immediately picked up and responded to, but that is on there, and that is open and transparent. So any concerns that we have, there is an immediate point of contact and someone who holds that person. So, very open in that respect, and we have actually done some national work around collecting feedback from women and recently published two books in relation to that which are used for learning. So, I think that creates that culture.
Also, to touch on leadership, it's absolutely fundamental, so we have put in additional investment in terms of clinical leadership, in terms of the sessional time for midwives and doctors, in terms of being able to be visible and have the time in terms of incidents and reviewing. Those key people are all trained in improvement methodology as well, because that's very important, that you create that environment of continuously learning and improving.
So, that's briefly the governance arrangements. I think in terms of our risks and our top risks as we stand at the moment, that relates to medical sustainability and that's at Nevill Hall Hospital. As I say, that's very open and transparent. We have, as well as myself and the medical director, another executive director who is directly supporting that work, where we look to mitigate the risk, and we have taken actions around our services at the moment at Nevill Hall and the Royal Gwent to manage and mitigate that risk. We have very well-established locum consultants and we have just been out to advert as well for consultants. We actually had 16 applicants, so we're very hopeful. I think that is our greatest challenge, but to reassure you around the governance arrangements that we have, overlaid onto that, when you're managing the risks, you look at how you're mitigating those risks and also how regularly you are reviewing that, and there is a weekly executive review in relation to the sustainability of these services. It is very much on the executive agenda.
That's really helpful. Thank you very much.
Darren, you've got a supplementary on this point.
Just in relation to the governance arrangements, as you say, it's important that the whole NHS learns from the sorts of reports we saw at Cwm Taf, in a similar way that we tried to from the Tawel Fan situation in north Wales, that, I know, Ann, you had some follow-up with in Betsi. There are some external reference points here. I haven't heard you mention the importance of Healthcare Inspectorate Wales or the community health councils to your quality assurance framework. Do you want to just explain how they work and fit in with your governance arrangements?
I have mentioned the community health councils—
You touched just briefly on it.
Actually, they are very active and they do sit on our key committees, in maternity, but also in relation to our quality and patient safety committees. And, obviously, in terms of the reports that we have from the community health councils, that is extremely important to us, and also in relation to all external assurance. So, HIW is extremely important to that. Our assurance framework, and this is why I probably should have explained that more fully, our assurance framework is very clear around levels of assurance, but also where assurance is gained from. And that is a number of sources. So, you have your external assurance, which is absolutely HIW, royal college reviews, the CHC, but also peer reviews. So, that external assurance is very important and part of that whole framework that we have around our assurance mechanisms, and obviously processes around audit as well, internal audits. So, there are many sources of assurance that then go, in terms of that triangulation, in terms of understanding our position.
And to what extent does the Welsh Government help guide your assurance framework, or were you allowed to just develop it yourselves? Do you have a suite of measures that the Welsh Government says, 'This is what you should use. This is how a quality and safety committee should be established'?
So, there are key frameworks, obviously, around which we place our assurance framework, and key strategies that relate to quality as well that form that framework. So, we've just had the launch of the maternity strategy. So, in terms of aligning that to our strategy and framework. If you look, we've done a huge amount of work around patient experience and our framework for that, that aligns to the national framework for patient experience around reporting. So, yes, absolutely, in terms of aligning to that.
Is there too much from the Welsh Government, or not enough? That's what I'm trying to get at really.
Or is it just right?
Or is it just right? [Laughter.] Have they hit the sweet spot?
Clearly, we're an organisation with an approved IMTP and in routine monitoring in terms of the escalation framework. So, in that sense, I think it's fine. I think the governance and assurance framework that we have in the organisation is our governance and assurance framework, but, clearly, board secretaries, and others across Wales, we're working together to make sure that there are some similarities in in. But it is our assurance framework, yes.
And just one final question. The role of independent members is obviously very important, and perhaps I can direct this to you, Ann. Obviously, the attendance of independent members has been an issue in some boards, and the engagement, the lack of engagement, shall we say, from some independent members. What assurance can you give us in terms of the engagement of your independent members on the board? You mentioned that you had board development sessions. Is that 100 per cent attendance? Are there some members who rarely turn up?
No, I'm not beset by that problem. Most of my independent members are as new as I am. And, therefore, we've—. Which has been good in one way because we've learnt together. I find that they give more than their time, because there are lots and lots of things that go below the radar that the independent members have to do, like appointments panels and things like that. But they do turn up. They ask intelligent questions. They ask the right questions, I think, because I will always have a list of questions; if nobody's asked them, I will ask them. But that doesn't happen too often. And they all bring their own individual skills and experience. And, I think they are really starting to mould themselves, so that, as a team, we've put in quite an extensive board development programme, as you would expect with a group of new independent members, most of whom have never had any contact with the health service or social care. And I appraise them on a regular basis and they turn up.
Mae'n amser i symud ymlaen i gysidro lefelau staff nyrsio—David Rees.
Time to move on to consider nursing staff levels—David Rees.
Good morning—or afternoon it is now. The Nurse Staffing Levels (Wales) Act 2016—in your written submission, you highlight:
'The Health Board is clear that the continuing risk to compliance relates to registered nurse vacancies and the challenges of recruitment.'
I suppose the question is: how many vacancies do you have, what are the challenges you see, and what are you doing about it?
Okay, I think that's a question for Martine. Thank you.
It is a significant challenge. As we stand at the moment, we have 350 registered nurse vacancies. That is across the whole of the health board. We have particular areas, obviously, that have higher numbers. I think our particular hotspots, if you like, relate to unscheduled care, where we have higher numbers, and then scheduled care—that is where our highest number of registered nurse vacancies are.
In relation to the picture going forward, obviously we look very carefully at our turnover rates as well. Our turnover rate for 2017-18 was 10 per cent. It's now at 9 per cent. So, I think what we're seeing is that our vacancies have hit that peak of 350. We're starting to see—we did have a number of retirements, looking at our workforce plan, and obviously we do everything we can to retain those nurses, offering them options to retire and return, and some of that has been successful as well.
Fundamental to the vacancies, the key area is recruitment. I think we have got a significant focus on recruitment. In fact, the executive board received a further paper on nurse recruitment on Monday, in terms of where we are and the actions that we're taking in relation to that. So, we have a very robust recruitment strategy.
Also, fundamental to that is maximising the commissioned student numbers that come out through the streamlining process, and we have 128 students that we have secured through that process. Obviously, many of those have yet to start. For us, obviously, it's critical in terms of our workforce plan for any health board, but as we've discussed with Clinical Futures as well, it's absolutely fundamental. We will start to see—. We've looked in terms of some of our predictions that, by 2020, actually we will start to be getting into a—. I'm not saying—. We'll still have a difficultly with recruitment, but we will start to see the benefit then of some of the longer term in terms of the commissions.
In terms of the here and now, we're really focusing in every area that we can with recruitment—return to practice. We're encouraging that. We've done a very innovative programme in the health board around offering opportunities to nurses that have trained overseas but who live locally with us that have not been supported, for many reasons, to obtain their registration with the Nursing and Midwifery Council. We're offering them what is quite an intensive programme, to go through to achieve their NMC. We have 27 people going through that programme at the moment, and eight now have got their registration. These are people that are living locally, so they're going to stay working with us.
We've also maximised every opportunity we can through the flexible route for training. So, this is healthcare support workers in our organisation, giving them an opportunity to become a registered nurse. So, we have got 23 healthcare support workers that are taking that programme forward, with the University of South Wales, but also through the Open University, and working with HEIW to gain more places. We have many people that want to take that route.
Working alongside 'Train. Work. Live.', we have been working on recruitment strategies, looking at the borders. We've been successful recently and recruited nine registered nurses from the Hereford/Bristol area. So, I think it's a very multifaceted recruitment strategy, which we continue to review, hence the further paper to the board on Monday, because we are looking at going overseas again. We're really learning lessons, but actually we want to take every opportunity that we can.
Fundamental to this is actually the experience that those nurses have, and we've invested in our practice development, and we have what we call the 'journey of excellence', which is our programme for when a nurse has gone through that preceptorship—that support for them. But I have to say it is very challenging with that number of registered nurse vacancies that we have. That remains a challenge, so recruitment is our key focus. Retention is our key focus in how we hold and support nurses, but also, as we've touched on with Clinical Futures, it's about new models as well. So, we are looking at how we maximise the whole workforce—our healthcare support worker workforce. We've got some new roles that we introduced in primary care, where we have complex packages of care, where we have band 4s, with appropriate training working in those areas. We have rehabilitation assistants in our orthopaedic wards. So, we are looking at different models. We've touched on the physician associates—we have six. We're just going through the process of appointing a further 11. So, where it's appropriate, we are looking at how the whole workforce can work together, but it is a significant challenge for us.
Okay. On the—[Inaudible.]—vacancies, you said your hotspots were unscheduled care and scheduled care, and, of course, the nurse staffing Act focuses very much on adult medical acute, and I would think that would come under the scheduled care agenda.
So, is there a knock-on effect on other areas as a consequence of shortages in those areas?
The staffing Act applies to all areas in the health board, in relation to the 25A, which is the overarching duty in terms of safe care and sufficient nurses: 25B very specifically relates to medical and surgical wards. So, we obviously ensure that we have safe staffing across all areas where we provide and commission care as well, specifically with regard to medical and surgical wards that fit under that section of the Act. We have 29 wards that apply to that part of the Act, where we actually regularly review those establishments. We took a paper to the board in May in relation to following the calculation around the needs of those patients and actually the numbers of registered nurses that we need to care for those patients. And we have agreed investment in areas where we've—. Just for an example, in orthopaedics, where we have seen an increase in activity, then that has obviously meant that we've needed an increase in nurses to care for those patients. So, yes.
It sounds as if you're looking at that matter, because, we all know, as you say, the Act actually refers to particular wards, and there is a strong possibility it will be extended to other areas—mental health, paediatrics, maybe maternity, A&E. They still do come into this, in some way or another. So, clearly it's a big challenge for you.
Okay, can I move on to, then, health and well-being? You've talked about some of the training and developmental areas. I noticed in your evidence you talked about the employee experience framework, looking at the health and well-being of individuals. Can you just give a brief description as to how that works to ensure that, whilst the pressures there are being faced—because, clearly, there are a lot of shortages; they're going to be facing pressures—you are also ensuring the health and well-being of your workforce?
Absolutely, and I think a couple of times during the session this morning we've mentioned about creating culture, and clearly looking after the well-being of your staff is part of that offer. We approach this through a number of things, and it's an absolutely fundamental part of the way we work. So, clearly, there's training, so we offer training modules on well-being for managers and supervisors. We have a very well established 'leading people' programme, which is about how managers and supervisors and other leaders in the organisation create a positive culture of well-being and support for staff who work in the organisation. We have a commitment as a board to offer 'making every contact count' training to 10 per cent of our workforce every year, which we do, which is very much focused on well-being, so it's on their well-being and also the advice they can offer patients that they come into contact with, about looking after their own well-being as well. And we offer bespoke training resource to particular departments who go through the employee experience framework and ask for particular support. So, whether that be in ophthalmology or cardiology or other areas, we will go in and provide bespoke training for staff. So, training is a significant part of that.
Then we've got an internal well-being offer and an external well-being offer. So, internally, we actively encourage staff to take time away from their busy front-line roles and take the opportunity to talk to colleagues about how they're feeling. So, we encourage people to do compassion circles—so six or 10 people from an individual ward taking time to talk about things that might have gone on on the ward. We offer Schwartz Rounds in the Royal Gwent, Nevill Hall and Ysbyty Ystrad Fawr, and Martine was telling me that she went to one of those to sit in quite recently, so she can offer some first-hand experience. But that's where the clinical team, over a lunch period, an hour or so, go and talk about particular issues that they are coming across. I think the one you went to was about where staff had got things wrong, so they were sharing—'In hindsight, we got it wrong, but this is what we did and this is how it made us feel', and those sorts of things.
We offer counselling, we offer a confidential contact service. We've got our own full-time consultant psychologist and three counsellors and admin staff who work in the organisation, and they see individuals but they can also be deployed. So, during the winter, they spent a little bit more time in the emergency department and emergency assessment areas than they might do the rest of the time. We've got a volunteering listening service and we offer things like 'chill out in the chapel', where our chaplains open up the chapels and provide tea and coffee and music and, sometimes, a little bit of massage and things like that—they don't do the massage themselves, but they get people in to do the massage. [Laughter.] And we offer financial well-being and health promotion. So, we've recently launched clinics around supporting staff through the menopause, which have been, absolutely, so well received. And then—
It sounds as if you've got a lot of schemes in place—
We have got lots of things happening, yes, and we've got more. And we've got external things as well.
One question I want to ask is: of those individuals who have retired—you talked about some of the ones where you offered them, possibly, retire and return and so on. I know many people who retire from the health sector who simply retire and they've had enough of the stress and strain, and therefore their well-being—. My wife is a recently retired health professional, and one of the things she says to me is, 'I sleep at night.' How are you talking to those individuals to look at what you can learn from what they're saying to ensure that other people aren't going to say, 'I've had enough. I'm going'?
Specifically around retirement and people that have that option, over 18 months ago, to inform our work, we actually did a survey of—this was particularly of registered nurses, but nurses that actually were coming up to have that opportunity that they could be considering retirement, we did quite a wide-ranging survey to ask them, actually, what they were looking to do, what they would like, whether there was anything that would help them maybe to stay in work, and actively sought feedback from them in seminars as well, to inform the work, then, that we wanted to take forward.
Part of that offer, then, in terms of retire and return is a step-down and, actually, 'Would you like to work somewhere else? Is there another area?' Some of the areas, obviously, that people work in are very intense and very pressured and actually they'd welcome the opportunity to maybe go and work in a different environment. Hours of work—we're looking at that, not just for people who are retiring and returning but, actually, more flexibly in terms of the hours that we're offering people. So, I think, yes, absolutely, that conversation in understanding the intensity of work for all our staff in those areas and, actually, how we can support that—. There is no doubt it is many of those things, but also it is about that opportunity for that training, that practice development. Many of our nurses' away days do now incorporate sessions around resilience and well-being aspects to them as well.
Ocê, iechyd meddwl—
Okay, mental health—
That leads us nicely on—Lynne.
Thank you, Chair. Your evidence paper says that you are meeting all your targets for both adults and children. Is that going to be sustainable in the long term?
Yes, I checked before I came in today what the current position is as well. So, yes, emergency and urgent were 100 per cent compliant—the children have been for two years, and there's nothing to suggest that we won't continue to be. So, everybody is seen within the same day or next day. In terms of routine appointments, actually, our performance has improved in the last two months. So, we're now 100 per cent compliant in the last two months; all youngsters are seen within four weeks. And the last year, we were compliant with the target. So, it was at 80 per cent last year, we're now at 100 per cent. The current actual wait is three weeks for routine appointments.
On neurodevelopmental, we've hit a little bit of an issue because of an increase in referrals. So, we're currently at 73 per cent on neurodevelopmental—the ISCAN—but we've got a plan in place to get back to target compliance by September. And the blip relates to a huge increase in referrals coming from education. So, we're just managing those through at the moment. In adult—I think Glyn's got most of the adult figures.
Yes. Again, in terms of adult access to assessment and treatment, we're meeting the target. We know that with some of the children and young people access isn't quite as good, but there are a number of things that we're planning to put in place over the next month or so to improve access times there as well. So, we've recently appointed five children and young persons practitioners. Four of those came into post during June, one is due to come into post in July. So, again, in terms of increasing the capacity of that service, we should see an improvement in access times.
You're talking about primary mental health—
Yes. Sorry. The local primary mental health as opposed to CAMHS.
Okay. Your IMTP refers to the work that the health board is doing to develop a more integrated mental health and well-being service for children and young people, known to me as the iceberg model, which I am extremely enthusiastic about. I wondered if you could—obviously you can't go into it in detail—just say a little bit for the committee about what that is and the timescales for taking it forward. And I also wondered if you wanted to comment on the Gwent attachment and trauma service, which is very much linked to that and which is doing an absolutely brilliant job.
Thank you. The iceberg model, now known as SPACE, has been in place for three months. It is a bringing together of all those people who might have an interest in the mental health and well-being of children and young people. All the referrals go there. They have a multidisciplinary team discussion about the best course and options available to that individual, and the individual is supported then in terms of care. It's addressing one of the weaknesses of our previous system, where youngsters were being referred into specialist CAMHS, were told that they weren't meeting the threshold for specialist CAMHS and then getting sent back. And in some cases, being bounced around the system is the best way I can describe it—I'll probably get told off for describing it like that, but that is the best way I can describe it. So, this is avoiding that.
The first three months' feedback is incredibly positive. The feedback from GPs, from neighbourhood care networks, from all of the stakeholders involved, is really positive. We're already seeing an impact in the number of referrals going through to specialist CAMHS. So, the number of children getting specialist CAMHS support has not been reducing, but the number of people being inappropriately referred into specialist CAMHS—we're already seeing that happen. In relation to the local primary mental health services, also, the teams are looking to do a little bit more work, as Glyn has said, to try and make sure that we use the experience we've now got, and the systems we've now got, to address some of the issues we've got in that for children and young people as well. So, we're having positive feedback and I think we'll go from strength to strength. So, after three months it's really good news.
And the attachment and trauma team—because, obviously, this is the only health board that has an attachment and trauma team.
Absolutely. Yes, it is. Again, it very positively evaluates. It's a different approach to how you engage around children and young people's well-being and, actually, again, the feedback from patients, service users, parents and the whole system is very positive in terms of the difference that is making.
Hapus? Dwi'n credu ein bod ni wedi dod i ddiwedd y cwestiynau achos rŷm ni ar ddiwedd y sesiwn, os nad oes yna unrhyw gwestiwn pwysig y mae rhywun eisiau ei ofyn nawr. Mae yna gwpl o gwestiynau ar ôl, ond byddai'n cymryd gormod o amser i chi eu hateb nhw'n gyflawn, felly fe wnawn ni ysgrifennu atoch chi ymlaen llaw. Felly, allaf i gyhoeddi ein diolchiadau ichi am fod yma y bore yma ac am eich tystiolaeth ysgrifenedig, a hefyd am ateb y cwestiynau mewn ffordd mor raenus ac aeddfed y bore yma? Diolch yn fawr iawn. Gallaf i gadarnhau, hefyd, y byddwch chi yn derbyn trawsgrifiad o'r trafodaethau yma er mwyn ichi gallu gwirio eu bod nhw'n ffeithiol gywir ar ddiwedd y dydd. Ond hefyd, i gadarnhau, mi fyddwn ni'n ysgrifennu atoch chi, achos mae yna gwpl o gwestiynau ar ôl hefyd. Felly, diolch yn fawr iawn ichi.
Happy? I think we've come to the end of the questions because we're at the end of the session, unless there's an important question that somebody wants to ask now. There are a couple of questions left, but it would take too long for you to answer them wholly, so we'll write to you with those. So, may I announce to everyone our thanks to you for being here this morning and also for your written evidence, and for responding to the questions so well? Thank you very much. I can confirm as well that you will receive a transcript of the proceedings so that you can check them for factual accuracy at the end of the day. But also, to confirm, we will write to you, because there are a couple of questions left that we need answers to. Thank you very much.
Thank you. Diolch yn fawr.
I'm cyd-Aelodau, gallaf ddweud ein bod ni nawr yn mynd i dorri am egwyl tan 13:15. Yn y cyfamser, bydd rhai ohonom ni'n cyfarfod efo Gweinidog iechyd Gwlad y Basg yn yr ystafell ar draws y ffordd, ac mae croeso i bob Aelod o'r pwyllgor yma hefyd i fod yn bresennol am y digwyddiad hwnnw. Felly, diolch yn fawr iawn i chi.
To my fellow Members, I can tell you that we're now going to have a break until 13:15. In the meantime, some of us will be meeting with the health Minister of the Basque Country in the room across from here, and all Members are welcome to be present for that event. Thank you very much.
Gohiriwyd y cyfarfod rhwng 12:36 ac 13:15.
The meeting adjourned between 12:36 and 13:15.
Croeso nôl i bawb i sesiwn y prynhawn o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yn y Senedd. Rydym ni wedi cyrraedd eitem 4 rŵan ar y Bil Iechyd a Gofal Cymdeithasol (Ansawdd ac Ymgysylltu) (Cymru). Dyma sesiwn dystiolaeth gyda'r Gweinidog Iechyd a Gwasanaethau Cymdeithasol. Cyn inni ddechrau, dwi'n credu bod angen i Jayne Bryant ddatgan buddiant. Jayne.
Welcome back, everyone, to the afternoon session of the Health, Social Care and Sport Committee here in the Senedd. We have reached item 4, on the Health and Social Care (Quality and Engagement) (Wales) Bill. This is the evidence session with the Minister for Health and Social Services. Before we start, I believe Jayne Bryant has an interest to declare. Jayne.
Diolch, Chair. My mother is a member of Aneurin Bevan Community Health Council.
Diolch yn fawr, Jayne. Dwi'n siŵr y bydd hwnna yn cael ei nodi. Felly, dyma sesiwn dystiolaeth gyntaf y pwyllgor yma ar Fil y Llywodraeth, a bydd y pwyllgor yn clywed rhagor o dystiolaeth lafar ar ddechrau tymor y hydref. Ond rydym ni'n dechrau bant brynhawn yma i graffu ar y Bil Iechyd a Gofal Cymdeithasol (Ansawdd ac Ymgysylltu) (Cymru). Dyma sesiwn dystiolaeth gyda'r Gweinidog, ac i'r perwyl yna, dwi'n falch iawn o groesawu Vaughan Gething, y Gweinidog Iechyd a Gwasanaethau Cymdeithasol, ac yn ogystal Sioned Rees, uwch-swyddog cyfrifol am y Bil, Janet Davies, dirprwy gyfarwyddwr y grŵp iechyd a gwasanaethau cymdeithasol, a hefyd Sapna Lewis o'r gwasanaeth cyfreithiol. Croeso i bawb. Rydych chi'n gwybod fel mae'r system yn rhedeg yn y lle yma erbyn rŵan. Mae'r meicroffonau yn gweithio yn awtomatig. Nid oes angen eu cyffwrdd o gwbl. Awn ni yn syth i gwestiynu gan fod Aelodau wedi darllen manylion y Bil yma mewn manylder anghredadwy eisoes. David Rees i ddechrau.
Thank you very much, Jayne. I'm sure that will have been noted. So, this is the first evidence session for this committee on the Government's Bill, and we'll be hearing a lot more oral evidence on this at the start of the autumn term, but we start out this afternoon with scrutiny of the Health and Social Care (Quality and Engagement) (Wales) Bill. This is an evidence session with the Minister, and to that end, I'm pleased to welcome Vaughan Gething, Minister for Health and Social Services, Sioned Rees, senior responsible officer for the Bill, Janet Davies, deputy director of the health and social services group, and also Sapna Lewis from legal services. Welcome to all. You know how the system works in this place by now. The microphones work automatically. They don't need to be touched at all. We will go straight to questioning as Members have already read the detail of this Bill in unbelievable detail. David Rees to begin.
Diolch, Gadeirydd. Good afternoon, Minister.
I suppose the first and simple question is: why do we need the Bill? Because surely a duty of candour and a duty of quality—these are things you'd expect to actually be in place, and not have to put legislation in for it. So why do we actually need to legislate? Why do you think it's important that we bring this Bill forward?
I'm happy to address that at the start. So, on the duty of quality first, we set out again in correspondence we sent to the committee to try to be helpful—and that actually came from questions with the Finance Committee—some of the understanding about the wider duty of quality, because at the moment it doesn't apply to Welsh Ministers and the duty of quality has not been interpreted in a really broad way, so we want to have a broader impact from the duty about the way that organisations make decisions, and about quality needing to be a central consideration. So we've made progress, but actually I think it is entirely proper to say that actually this broader duty will make an even bigger difference. Welsh Ministers would also have to provide an annual quality report on how quality has been a part of our decisions as well as health boards too, so that would build on the current quality statement, which broadly describes where quality is within the system, but it doesn't really require health organisations to set out how they're taking quality into account in their choices and how quality is at the heart of the decision making to improve quality outcomes.
On the duty of candour, we see in other parts of the United Kingdom they've introduced a duty of candour. People in this room and outside will recall the Francis report, and how that led to calls for a duty of candour. The way that we're looking to introduce a duty of candour is different to the structure in England. We may be able to get into the detail of that later, but again, the duty of candour is an organisational duty, because registered healthcare professionals have duties, but actually the organisation at present doesn't, and we think it will support a change in culture, and a change in culture and behaviour that we would all want to see regardless of our route to being elected here. I think everyone would want to see a continuing shift in culture in the service, so that people are better supported and the organisations themselves have a duty to advance that.
On the creation of a citizen voice body, we can't create a new citizen voice body without primary legislation, because we can't shift the mission of community health councils to simply cover social care unless we change primary legislation. So, it isn't possible to do that without this Bill moving forward. But we're still looking at other areas that were in the White Paper, where we've had to think again about whether there's the space to do that within the one piece of legislation, and think about how we can make better use of our powers. So, we have thought about areas where we can make progress within our current powers, and this represents where we think primary legislation will make the difference and is necessary.
Okay. We'll go through each of these, I'm sure, this afternoon. But I suppose, in a sense, what I'm trying to work out is—ignore the citizen's voice, because you've just said you'd need primary legislation, which we do understand. But the other two are things I would expect from the service. Is it a sign of a failing system now that we have to put legislation in place to actually make them do it?
No, I think it's a sign that—. We have made real progress. But if you look again, go back to the parliamentary review and then look at 'A Healthier Wales' and the message we had in the parliamentary review about the quadruple aim, quality improvement is a central part of that as well. And so we've needed to think about not just repurposing our quality improvement function—. So, if we just said, 'We're relaunching 1000 Lives, we're changing the name and giving it a slightly different mission', I don't think that would actually be enough to meet the aim and objectives set for us in the parliamentary review and the response we set out in 'A Healthier Wales.'
So, it is looking at how we introduce a duty across the whole system, and, like I said, at the moment, there's no duty on Welsh Ministers in terms of quality improvement. Now, I actually think that Welsh Ministers having to set out a report on the advancement or otherwise of quality improvement each year would be a really helpful thing, and it would undoubtedly be something this committee, and/or successor committees, would be interested in. You can expect there to be deliberately increased scrutiny on quality improvement and in the choices that Ministers make—indeed, the same point for health organisations as well. So, the duty at present, the current quality duty, is interpreted rather more narrowly. The deliberately broader duty, I think, will have a deliberately broader impact. And I don't think you can do that without changing primary legislation.
Okay. Well, your legislation highlights four areas; three you've already talked about. The White Paper covered more. Do you want to perhaps explain why you've picked these areas and not some of the others, such as health board membership and composition, or the role of the board secretaries, for example? So, why these areas and not others?
We did think about the size and scale of the Bill and whether we need to do more thinking about what we can do within our current powers. And so we decided not to take forward those changes to health board membership. Apart from anything else, I think it's sensible to look at the whole system change we're delivering. So, for example, once we have created an NHS Wales executive, and we've got different pieces of our system and architecture, we can consider then what we think we'll need to do, if we need to do anything, about the composition of boards as well, but also the current powers that we have around the way in which boards are composed.
And the same with the reformed inspectorates. There's actually some more work to be done on that, I think. So, whilst we want to think about how those inspectorates work together, and there are points about their relationship that we can, of course, improve, and there's a commitment to improve between those inspectorates without primary legislation, I do think we should think again about the legislative framework we currently have, what's within our powers, and then consider the case for is there a case for having a single inspectorate across health and social care, and, if so, how do we do that. And I don't think we're there yet. And I think it would be—. That would be quite a significant change. And if you think about an area that health has an interest in, about our early years provision, we've previously had a report that, I think, Helen Mary sat on, that recommended significant change to early years education and childcare. And, if you were talking about Estyn's functions and Care Inspectorate Wales's functions as they currently overlap in our early years and childcare landscape, we'd have to think about, if we were going to create a single regulator for health and social care, what the interplay with Estyn would be. We'd also have to think about whether we'd want a third regulator for early years and childcare as well.
Now, I was in Government at the time that early years report was provided, and I wasn't persuaded then that either there was the legislative time to do that or that, actually, I agreed that it was the right answer. So, I don't think it's a simple, 'Yes, we should do it; it's obvious and let's get on with the legislation.' I think we'd also want to come back with not just some more feedback on what is already taking place, but then I think we probably would want to consult again before going ahead with anything like that, whether that's in a White Paper or a draft Bill, to again regather views, because that would be a pretty significant change in and of itself.
In that sense—you published the responses back in February, and you indicated that you were going to undertake further policy development in some of the areas that are not in the Bill. When will we see that detail or the publication of any of those further analyses, further developments? And could you be in a situation where, if this Bill—and it is a question of 'if', because, you know—is allowed to proceed, you would be looking to bring some amendments in that may cover some of those areas, because there'll be consequences of those on your work?
I think it’s a fair question and what I think might be helpful is if—. Rather than running through a couple of areas now—we’ve run through a couple already—it might be helpful to set out how we’re looking to address the areas that are not in the Bill but were in the White Paper, because there’ll be differing timescales around different pieces of work and they'll be dependent—. So, for example, the point on inspections—we’re doing some work already and I wouldn’t want to necessarily say that there is a time frame to definitively decide, because it actually needs to be that we’ve got the right answer rather than, 'We must have an answer by a certain point in time.’
The same thing on service change. We think we’ve got current powers to reframe that. We’ll need to reframe guidance around service change, should the Bill go ahead and become an Act and the new citizen voice body be created. So, I don’t think it’ll just be as simple as, to use someone’s example, 'Just Tipp-Ex things out and write in the name of the new citizen voice body where CHCs were.' I think we’d want to take the opportunity to look at the guidance we have. And, again, we’ve got duties about quality and candour in there as well. I think we’ll want to think about when—if, in the case of service change—to be clear that duty of quality requires you to set out how any formal service change will advance quality and quality improvement in the delivery of services. But we can do that within our existing powers.
I hope that’s helpful, Chair. We can—I’m sure there’ll be other things where you’ll want me to follow up afterwards, if we could write and set that out. That’s not within the Bill now, but that further policy work—. Because that may affect choices that you, as a committee, want to make.
We're going into summer recess, obviously, and it would be nice to have that by the time we come back so we go into some of the—. In the sessions with evidence givers, it would be helpful.
Okay, let's go on to the duty of quality, because it's one of those three areas. I suppose—. I've read—the Bill states that 'quality' includes, but is not limited to—. The definition of 'quality' is very difficult sometimes. Do those actually define 'quality', I suppose? Because, if you're talking about a duty of quality, people need to understand exactly what it means. What is the duty? What am I expected to do? Do you have a fairly clear, definitive definition that could stand up in court—because this is legislation—where someone can say, 'You have not delivered that'?
I don’t think we do, honestly, in quite that lens about can someone stand up in court and say, ‘This is the duty of quality’, because quality improvement, of course, is not something you define at a fixed point in time, because the service would always want to be changing and moving on in the light of either current pressures and challenges, but also opportunities as well. So, I don’t think I’d want to necessarily set out a definitive duty of quality on the face of the Bill in the strict terms that you suggest, but, in the correspondence that we sent to the committee, we set out areas about planning, improvement and control and the new provision about the wider population-level impact of a duty of quality as well. So, we tried to set out the thinking from the parliamentary review and the challenge and how this Bill with a duty is a direct response to that.
I think, actually, people will scrutinise and judge how far we’re moving as a system, because we’re going to have annual opportunities at health board level, but at national level—and whoever is the Minister, if this Bill is implemented, they can expect to face questions, both in the Chamber and here, about, ‘Well, how far have you got—[Inaudible.]—your own choices?', and, indeed, questions about the wider system. And I do think that that will make a difference from the point of view about the culture and the way that decisions are made and having to think, before getting to the point of decision making, how does this potential choice in front of us, or the proposal to shift what we’re doing, how does it advance quality improvement, how does it advance the quality of care and quality of outcomes in the way that we’re trying to run and deliver the service.
Okay. Because we understand that the duty of quality already exists, in a sense, under the 2003 Act, and, as you highlight, I think it's in a narrow definition. So, how does this broaden out that definition?
The duty reflects that all parts of the system can contribute to improvement and outcomes. It's about trying to get them to think differently from the narrow way that it currently is applied. If you look at the current annual quality statements, as I said earlier, they're broadly examples of where quality has been improved, as opposed to how as an organisation turned its mind to quality improvement in a range of its different choices. It's not quite set out in that same, broad way. So, I do think the organisational duty will help to make that difference. That's again what we've tried to set out in the correspondence to the committee, about how quality is currently within our system and how we think the new duty will make a difference.
I suppose, moving on to the framework, it is—. Will the public see a difference as a consequence of this? What will the expectations be? Because people out there hear a Bill is going forward, a Bill on quality and engagement and placing duties upon them; I just want to know how you see the people actually understanding what this Bill will deliver for them.
I actually think that there'll be the scrutiny that comes from each of the annual reports about the understanding of, on an annual basis, what does that mean, but, equally, if you're going through a service change conversation about why does a service need to change, the organisation will need to set out very clearly at the heart of that how and why will this improve the quality of service, how and why will it make a difference to outcomes.
That would not just be within a narrow health board area, because, for example, if you think about cancer services, for example, a range of those services are already provided by one health board for a wider range of areas. So, Swansea Bay provide services not just for the local population of Swansea Bay, but certainly for west Wales as well. So, Hywel Dda would need to set out what they're doing and how they're working with Swansea Bay, and, equally, when Swansea Bay are talking about how they're delivering their duty of quality they need to think about the service they're providing and who they're providing it for.
So, I think, actually, you will see a broader reflection and you'll need to see, 'Well, is this just about my local responsibilities within a geographic area, or is it more about my responsibility for people who live in an area?' And to secure quality improvement will often be about how you have services delivered in a different way. Again, that's one of the central challenges from the parliamentary review. There's, on the one hand, more care closer to home, which everyone says, 'I'm signed up to that.' The more difficult part is then what the parliamentary review said about the secure and improvement in quality and outcomes. Some specialist services will need to be delivered on a smaller footprint, with fewer centres delivering better care and a more robust and sustainable way of doing so. Actually, the organisation will require people to turn their mind to that, but also set out how they're doing that as well. I think that will actually lead to a better informed conversation within organisations but also with the public as well.
Okay, so we've got a situation, if I'm understanding this, where we're going to get greater public awareness and transparency as to how health boards will address the issue of delivering quality care and outcomes, and the processes they will be needing to put into place, and they will have a requirement to produce a report on all those things. How will we sanction someone who doesn't do that? Because I understand there are no sanctions in the Bill.
No. We don't have current sanctions for the current duty of quality. The new system takes a different approach in terms of sanctions and the use of money. This is still about scrutiny and accountability. So, that duty on the organisation isn't just in one part of the organisation—so, the executive leadership and the board leadership, and there are independent members there, fixed by the duty as well. And actually being required to report on that and the obvious scrutiny that will come—so, not just within this place but within local populations as well—. So, I actually think that having to set out how you've met the duty or not will help to clarify how functions are being exercised, and those functions are actually about not just delivering a service but how you want to improve the quality of the service that is delivered as well.
I don't want to go down the route of saying there is an A=B sort of scenario about that, that therefore means there is a sanction, because the easiest way to do that is about activity or about money, and I don't think that approach really delivers everything you'd want it to across the border.
Okay, but if you're putting that legislation in to give someone a duty and they're not delivering that duty, I just want to know what we can do about it, because there should be some sort of sanction, or some form of comeback on this.
So, if there's not—. And it will affect the way that organisations are treated in not just scrutiny, but in what that means in terms of direct engagement with me and officials. For example, if an organisation has not made sufficient progress and there is not confidence they're going to meet their duty, it will obviously have an impact on escalation and intervention. I know we regularly talk about this in here and in the Chamber, but the escalation framework does make a difference about how people behave. It does make a difference to organisations about where they are and what they can do, and, equally, we want to see that set out in the medium-term plans that organisations provide as well, so you can expect to see how the duty will be achieved in that. You can then expect to see reporting against how much progress has been made, and what is likely to happen in the future. So, our scrutiny and oversight and the escalation and intervention process sets out how we intervene, and, if you like, how we apply sanctions and intervention in organisations currently. I'm not proposing to fundamentally change the landscape of that in this Bill by having a separate system, because I don't think that in itself is going to be helpful, but we'll certainly have much greater transparency and scrutiny over the way in which organisations meet their duties on quality.
The NHS Confed, to date—and we will, I'm sure, explore with them in more detail during our sessions in expanding the Bill—have initially given indication that in fact we shouldn't be focusing on the duty in this Bill, but we should be focusing on ensuring the quality and the standards are equivalent across health and social care sectors. Comments on that, initially.
Well, look, social care already have quality duties in the legislation we've already passed, and part of our challenge, which this Bill—and others—addresses, as we deliberately design and deliver a system that is more integrated across health and social care, is: how do we have equivalent duties in the way that different providers and commissioners behave, and how do we make sure we've got a citizen voice body wrapped around that that is fit for purpose across the whole sector? So, I think this is actually about bringing our healthcare part of the system into a place where we've already got to in terms of the duties around social care in any event, and some of what we are doing is not just about catch-up but it's about making that system fit for purpose.
Before we go on—Angela, on this point. I'll come back to you, then, David.
Well, really, it's basically on David's whole line of questioning, because I find the reasoning behind this really hard, actually, to get my head around, because it seems to be a paper tiger. You're going to put a duty, legally, and as an ex-lawyer or a 'lawyer in remission', as I think you like to describe yourself—. As an ex-lawyer, you know that if you put something in a Bill and it's on one side of the scale, you usually want something on the other side of the scale, and this business about not having sanctions—I just wondered if you would or have looked at other countries to see how they implement a duty of candour, because it is a moveable feast. I was always taught that the basis of law tends to be what's fair and reasonable, and when judgments are being made it's the fair and reasonable that sort of does the swaying, but if you've got nothing to measure your duty of quality against, if you've got nothing to say on what is a quality benchmark, then how can you measure it? And, how can you either say, 'Well done' or 'You're doing a dreadful job', and if somebody's constantly doing a dreadful job, how can you say, 'This is your punishment until you get it right'?
Well, it's about securing improved outcomes, and we've got a range of measures about what outcomes get delivered within our healthcare system. We have a range of things that are actually about activity and not really about outcomes, but we measure activity lots, and I think this will help about understanding what quality and outcomes and experience are. And not only that, but we have a range of intervention measures that we take, and our escalation framework—it really does make a difference for the way that organisations behave and deliver services, and you'd have to see how the duty is set out in those choices that are made about the future. So, if you take a hypothetical example of if you want to change the way that stroke services are delivered, well you'd need to be able to set out what we currently have, what our current outcomes are and why making changes in the system would help to deliver improved outcomes, to improve the quality of the service that is being delivered and what that should mean in terms of the experience of the patient and what you then need to do to move it on. I think that would actually be a helpful way to describe shifting the way that you want to deliver a service. Because, otherwise, you can just get stuck into organisational boundaries rather than the service and the people who rely on that service and take part in it either as staff or citizens. So, actually I do think that the broadening duty will help.
And our current duty doesn't have a sanction attached to it. It's certainly not the case that every statutory duty has a sanction and, sadly, not every single legal duty you would say is fair and reasonable. I don't want to get into examples or we'll end up sidetracking ourselves—
Okay, well here's one example: how would the duty of quality have helped alleviate or prevent something like Cwm Taf or Tawel Fan? How would that—? And have you tested the principle against real-life scenarios to see—? Because you talk about outcomes. Would it have made a difference to the outcome, and, if so, can you share that with us?
Yes, it really should've made a difference. So, for example, the duty of candour and the duty of quality should both have made a difference in maternity services in the way in which challenges were highlighted, the way in which there was an organisational duty to address them and the way in which they should then have been able to set out, in response to concerns that have been raised: 'Here's the current view on quality, this is what we're currently doing to improve that, and to secure improvement, this is what we're doing.' To set out in those terms how you secure quality improvement I think will make a difference.
But the introduction of a duty on day one doesn't change overnight the way an organisation works. You know this from your own time outside the Assembly. If you introduced new rules in the business you used to run, well, it doesn't mean that everything happens from that point. You have to take people with you, you then have to come back to, 'This is what we're doing, this is why', and then you say, 'Look, this is how we're going to measure how that improvement actually makes a difference to the way in which we're running our particular organisation.' It's no different in the healthcare system, to understand when the duty's introduced and then to test and be able to understand, 'Are we making a shift in culture, in performance, in outcomes, in what we value within our system?' Because this isn't about saying the system is awful and will fall over, but it is about saying, 'If we want to continue to move on with quality improvement, is the current duty in the optimal place to allow us to do that?' And if it isn't, then we need to change the law, because it's a statutory duty on the face of the legislation.
So, that's why we're taking a step to broaden the duty, because we do think it'll help, we do think it'll make a difference, and you're going to see that in the scrutiny, both annually for organisations, annually for Ministers, but also we've committed, for three years post delivery of the Act and implementing changes, to actually review the impact it's had. And that will be available for this or a successor committee to undertake that post-legislative scrutiny about what difference it has made. Has it made a difference to the culture? Has it made a difference to the way organisations and individuals behave? And then to test whether the change has made a difference. Because, otherwise, if you say they must be absolutely certain in a mathematical sense, well, actually, we wouldn't pass lots of legislation. We wouldn't have passed the organ donation legislation on that test.
But have you got any assessments that you can share with us as to your thinking behind this in terms of examples or workings out that you might have done? Because it just seems to me to be a random sort of, 'Let's pop this in.' There doesn't seem to be a finite, measurable gain, and I just wondered, when you did all your workings on why you should move forward with this, what you looked at or what assumptions you made or how you sort of—I don't know, how you got to the process of deciding that, actually, you thought you might need to do this.
Janet may be able to help with some of the evidence we've considered, but, equally, some of the people who took part in the—[Inaudible.]—Don Berwick's work in this area, I think, is useful.
Yes, so there's quite a bit of evidence around how to embed quality improvement at an organisational level, and I'm sure you all will have heard of Don Berwick in the Institute for Healthcare Improvement in the States, and obviously he's a lead expert in this area. His mantra is that not all change is improvement, but all improvement means change. Fundamentally, in organisations, you'll see lots of change going on at a micro level and teams and so on, but often it's very difficult for it to get built up and drive organisational change and to get that shared practice and transformational change across the system. What he says in some of his research is that organisations themselves and the boards of organisations are fundamentally often the barrier to doing that. So, what this tries to do is to try to help remove some of those barriers to actually enable staff to work within a culture where the organisation embraces improvement and has an evidence base and a capacity and capability around driving improvement, which is what we've been trying to do for many years in terms of trying to drive capacity through 1000 Lives Improvement work and so on.
And similarly, the Health Foundation, another lead body in this area, says similar things: to drive quality improvement at organisational level, the leadership and governance in the organisation is fundamental. So, as the Minister said, what we really want is: we want to change the way organisations think and behave; we want them to really actively consider the decisions they make around the use of resources, both in people and in financial terms to make sure they're absolutely focused on driving quality improvement. I should say quality improvement's not finite; quality improvement is continuous. Things change: drugs, technologies and so forth; you have to keep them under review.
You have to be really clear about the milestones you're trying to achieve, the outcomes you're trying to work towards, and how you can demonstrate that you're going in the right direction: you keep it under review, you might change tack if something comes online—a new drug or whatever—but, ultimately, you have to have a real clear focus of where you're trying to head, looking across the pathway as well, not just in the microsystem that goes on in an organisation.
So, I think there's a fair bit of evidence base we've looked at to try and look at how we really get organisations to behave differently. And this is why, I think, changing the duty, broadening the duty, to put it right up in the NHS Act, makes it very, very clear that what we want, without no doubt whatsoever, is for our NHS organisations to be quality-driven organisations. And picking up the whole definition of 'quality': what we've based on is the internationally recognised definition of quality from the former Institute of Medicine in the States, which has got six domains where you're talking about the safety of care, the effectiveness of care—so, the clinical effectiveness—the experience people have, but also you have to look at that alongside efficiency, the timeliness of care, and also the equity of care as well. So, this is an opportunity to really start to get equity onto the agenda so that service is provided not as a one-size-fits-all—you're looking at your local populations and you're really trying to drive that equitable service. So, you're putting things in place that will improve quality for that population in that place. It has to have a real evidence base, linked to population needs assessment, working with your partners and across boundaries as well. And we need to get organisations working with others and not in their silo trenches. So, that's where we've been coming from.
And you see that this duty is going to be the catalyst, or the driver, that will really push them over the hill on that one.
Absolutely, yes. We're seeing this as a key lever to actually drive this change. But, again, as I say, it's going to take some time; it won't happen overnight. We need to do lots of work with organisations to talk about it, to work up guidance, case examples. And through the period, we have had a lot of conversations with peer groups, with organisations, and there is a real appetite to work in this way and to work with us to look at how we really deliver this duty in practice.
I think the point about health equity is important, actually, because, to be fair, I think I glossed over this in one of the questions Dai asked about what difference it would make. If you think about all of our screening programmes, in almost all of them, there is a variance in socioeconomic take-up. And, actually, in delivering that screening programme in the future, the duty of quality at an organisational level would say not just, 'What are we doing? Are we hitting the overall target or measure that we want to achieve?, but then, 'How do we address the fact that there's an inequality within that?' Because, actually, that will drive quality improvement, because if we get take-up on an evidence-based screening programme and we improve it for groups of people who we know are less likely to take up the screening opportunities, more likely to present later, it will actually make a real difference in not just hitting measures within the screening programme, but a real difference in outcomes and experience of healthcare and what that means. So, that's perhaps a good example of how the new duty will highlight, 'What are we doing?' and to have clarity in what's being done. The Organisation for Economic Co-operation and Development made similar comments in their review of quality a few years ago as well.
And especially with the OECD review—health boards haven't taken the advantage of being population-based health boards and it's how we can improve that, and we're seeing this duty supporting that. And the reason we were looking at it from a broader perspective as well is that quality should be discussed at every committee of the board, not just the quality and safety committee; it should be going to the finance and performance committee, it should be driving and influencing decisions that people are making, health boards are making, with regard to saving plans and finance plans as well. And that's why we've looked at it. So, that's been driven from experiences that we've had in Wales and elsewhere.
And it's got to be real. So, it can't just be that you say, 'Have you considered quality?' and tick the box and say 'yes'. You've got to be able to demonstrate how you have considered that and how that has influenced the decision you're making, rather than, 'We'll agree the decision we're making and then we'll track back and agree how it improves quality.'
Just a final point, thank you, Chair. I think the answer from Janet was very helpful, to be honest. It gave a little bit more definition and more detail as to where your thinking is. And you all mentioned—the Minister and others have mentioned—outcomes, and clearly that's going to be the driving factor and I would hope that, somewhere, maybe a bit down the line, you'll be looking at how you can make sure that reference is there as well within the paperwork to ensure that it's not just about the process, it's actually about the end product, which is the outcome for the patient, to ensure that. And you've mentioned that several times already, so I won't pursue that.
Ocê. Symudwn ni ymlaen, felly, i'r ddyletswydd nesaf—y ddyletswydd gonestrwydd. Helen Mary Jones.
Okay. We'll move on, therefore, to the next duty, which is the duty of candour. Helen Mary Jones.
Thank you, Chair. Looking at the duty of candour—and some of these questions will potentially mirror some of the questions that David Rees has already asked—Minister, you told Plenary last week that the duty of candour will mean that all staff, including managers, will be subject to the duty, but the explanatory memorandum states that provisions will place a duty on NHS bodies at an organisational level and not onto individual healthcare staff. So, can you clarify a bit more about who will be bound by this duty? Who is in the frame?
Well, it's the organisation. The people with responsibility for running the organisation are obviously making those choices, aren't they? So, if you are an executive director, whether you're a healthcare professional or not, you're part of running and deciding in that organisation; you're bound by the duty. There's a difference in the way that, in England—and, again, it might help the committee, because of the way that the duty of candour has been introduced, to set out how it's introduced differently in other parts of the UK and how we're starting to do it here—. They have a person who is responsible for the duty. Now, I don't think that's what we'd want to do, because if that person is the chief exec or the finance director, actually that may mean that they're in the frame on the one hand, but I don't think it necessarily helps in the sense of the whole organisation understanding, 'This is our responsibility too, and how do we support people who are raising issues of concern?' And, equally, 'If I'm that senior manager, how do I reflect on what the duty means as well?' Again, there's plenty of evidence about how we think this could work and why it's an organisational duty and not an individual one.
So, in effect, the duty is on the organisation, but in order for the organisation to discharge its duty, they'll have to have a comprehensive policy in place for how that duty's discharged. So, what it means is that every single person employed by that organisation will therefore be under the duty. So, the Bill is not framed in terms of the duty being on an individual, because the duty is on the organisation to have the policies and procedures in place to ensure that all its staff, whether it's the porter, the chief exec or anybody—and then how that obviously complements some staff already under a professional duty, especially for health professionals. And what we think, and from the evidence that we've seen, particularly from people from a professional standards authority, by creating an organisational duty, it helps to create the conditions for those professionals to discharge their duty as well, because what we want to see, in having those policies in place, is that organisations set out very clearly how they will support individuals to raise concerns, so that it's a much more conducive environment for staff to feel comfortable in raising concerns and having them dealt with.
I suppose my concern is that if you've got an organisation that isn't healthy, it's not going to help the individuals if they feel that they want to exercise their duty of candour. But, just to explore that a little bit further, then, I do completely take the Minister's point that having one individual whose job it is to do the duty of candour is like having the one individual whose job it is to do equality in an organisation, and that can mean that everybody else goes, 'That's their job and we're not going to do it'. So, that's a valid point, I think.
The social care duty of candour is obviously much more specific than the one proposed in this Bill. The Francis report and the Keith Evans review both recommended a legal duty on individuals and organisations. Would you consider, depending on the evidence that comes forward, if this proceeds, looking again at whether you need an individual duty as well as an organisational one, taking on board the points that Ms Davies has made, because obviously the organisation should have that policy?
We're looking to achieve a system shift and improvement and we want to have a whole organisation responsible, and to make sure that this isn't used in a way, in terms of, 'You have failed', as opposed to an organisation has not delivered. But there's always a risk, when you look at where things have gone wrong, when things really go wrong and organisations don't appear to learn, it's often because individuals are told, 'It was your responsibility.' I am a lawyer in remission, but I remember running cases for healthcare regulatory bodies and for individuals. There were times when I thought, 'Actually, I'm representing this person, but am I entirely comfortable with it?' But there were other times when I thought, 'This person has not been perfect, but this isn't all about them, and where is the organisational learning and responsibility?' Actually, the individual regulation system is important to make sure that individual healthcare professionals have got duties and boundaries about how they're supposed to behave, but I think you want to reflect something that is about the whole organisation's duties, because, again, where things have gone wrong, often, people within the organisation have said, 'Something is wrong here,' but it's about the whole organisation not responding to that.
Look, if there is compelling evidence that framing it on individuals could make a difference, I'd have to consider that, because we are going have some regulations and guidance to underpin this as well. But, on the face of the Bill, I'd be anxious about wanting to say there must be an individual duty for named people. I'm open-minded, but I'd need to be persuaded that something on the face of the Bill would make the difference, rather than framing it as how organisations respond.
I suppose just a comment, more than a question—. Of course, I can see what you're saying about how this could lead to an individual being blamed, but the other side of that is that it can empower an individual, because an individual can say to their manager, who is saying, 'Let's just park this,' 'No, I've got my own individual legal duty of candour that means I have to speak out.' Now, of course, you're quite right, Minister, to say that—or I think it may have been one of your colleagues—clinical staff are covered to a certain extent with those duties and responsibilities through their professional bodies, but we don't have anything equivalent for other staff. But let's just see if—. I'm encouraged to hear you say that if the evidence does come through clearly, you would take a look at that.
If we can turn to sanctions, then, and I'm probably the last member of this committee who's going to encourage you to do anything the same way as it's done in England as an automatic, knee-jerk reaction, but there's the organisational duty of candour, there's a general duty on health and care providers and there are sanctions. Again, we don't have any sanctions in this Bill, and I've heard what you said to David Rees and Angela Burns, but, in the end, I'm struggling to see—coming back to what we're discussing today, which is, in a sense, is there a need for law or whether this could be achieved in other ways—if there isn't a sanction, why we need a law, why it isn't just done through policy direction or whatever other—. If there's a law and nobody gets into trouble if the law is broken—and I'm not a lawyer in remission—I'm left with the question of why we need to do this by law. Could we not achieve this through the other ways in which you have of directing health organisations?
I don't think clarifying and introducing a duty of candour that comes in a circular is actually going to have the impact that we want. I don't think it's going to be visible, either publicly or within an organisation, and the cultural shift that we would all want to see continue—. Because we are in a different place to 10 and 20 years ago, so let's not pretend we've made no progress. But, to make further progress, I think a duty of candour will be helpful. You don't need to look at England; you can look at other parts of the UK where a duty has been introduced, and, again, there's been deliberate learning taken from Scotland and England on the introduction of their duties. I don't think it is as simple as, 'Does anyone get in trouble if the legal duty is not complied with?', because we're setting it at an organisational level, and, actually, if you are around the executive table or a board member and your organisation is failing to meet its duty of candour in the way the organisation could and should behave, then that should change the way the organisation behaves. Equally, if there is a failure to recognise that and act upon it, then, actually, of course, within our system and the way we've talked about the way organisations behave, we've got a range of ways to intervene in doing that.
But I am interested in how we have organisational behaviour change and shifting the culture, because, actually, that's often the area of greatest gain. You can't describe what it is, but you can often describe when something doesn't work, and, again, I've represented people in workplaces where you can do that, and so you can recognise when things have gone wrong or are going wrong. This is about trying to make sure that people recognise what it is that's going wrong and what we do about it. So, that's why the duty that is about the reporting levels will matter as well. And, again, I think your colleague committee tried not to go too far into policy matters; they couldn't really help themselves on the Finance Committee. But, again, in terms of having the guidance to underpin this, virtually everybody representing staff within a service are interested in part at looking at how you design a duty of candour that makes a difference and makes sense, because they all want it to work for their members as well as the service that their membership works in. So, I think there's not just lots of goodwill, but lots of interest in how we make this work. And, again, it's the deliberate point about not just the Government learning from what's happened in England and Scotland, but actually how our whole system gets—[Inaudible.]—be part of determining what the future looks like. That's part of the reason why the detail about that will need to come in regulations and/or guidance, because we want to have that richer conversation with the wider service.
Okay. So, talking about those who represent some parts of the people who work in the service, there are those, including the NHS Confederation, that believe, as well as a formal candour procedure, staff need an independent authority to turn to if they feel their concerns are not being listened to or acted upon. Is that something that you would consider? If you've got somebody who's working within an organisation where they feel that the duty of candour is not being fulfilled at an organisational level, do they need somewhere else to go if they're not succeeding in getting that raised through—?
We are thinking seriously about, for example, 'freedom to speak up' guardians, and how they have worked. We've got some deliberate work that's being done on reviewing that, and, again, across the healthcare system, people are interested in the review that is being undertaken. So, I'm not saying that nothing needs to change, but there's a challenge about whether you have a person or a body for people to go to, as well of course as people's either professional or trade union bodies, where people can be supported in making complaints or raising concerns as well. So, this isn't a case of, 'No, nothing needs to happen', but it is about what evidence is there for the system that's been introduced across our border, on how successful it has been, how successful the different approaches taken in different health boards have been. For example, the chair of Cardiff and Vale, soon to be the chair in Hywel Dda, which we have direct interest in through a couple of Members in this room, has an approach that's called the safety valve, where people can come to her to raise concerns and she can describe for you how, as an organisation, she's then taken an interest, as the chair, in what's happening, and that has led to a shift in the way that care is being delivered. So, there are different things to look at and to learn from, for the detail of what we'll want to do, and what we actually need to do on the face of the Bill, what we can do outside the Bill, and what we'll want to try and address in guidance and regulations.