National Assembly for Wales

Bore da. Croeso. Good morning and welcome to this morning's meeting of the Public Accounts and Public Administration Committee, here in the Senedd. This will be, I believe, the last meeting of this committee during this Senedd term. We have a couple of Members present remotely—so, welcome to Mike Hedges and Rhianon Passmore. The meeting, as always, will be held bilingually, with headsets providing simultaneous translation on channel 1 and sound amplification on channel 2. If you're joining online, via Zoom, you can press on the globe icon to access translation. We've had apologies from Adam Price and Tom Giffard. Do Members have any declarations of registrable or relevant interest? Thank you, Members.

We have a number of papers to note, the first being a letter received from Emma Williams, the director general of the education, culture and Welsh language group in the Welsh Government, to me as Chair, with follow-up information following our evidence session on 22 January. After that session, I wrote to Emma Williams to follow up on issues raised during the evidence session with us. We received a response from her on 27 February, which you've been copied on. This is in addition to information provided by the director general following the session on 30 January, which the committee noted at our meeting on 12 February. Could I start by inviting the auditor general—? No comments?

Nothing from me, no.

Members, do you have any comments, or are you content to note the letter? Content to note. Thank you.

The second paper to note is a letter received from the Permanent Secretary, Dr Andrew Goodall, to me as Chair, regarding the Welsh Government's legislative improvement plan. During our meeting on 4 February, as part of our scrutiny of the Welsh Government's accounts for 2024-25, Dr Goodall agreed to provide further details about the Welsh Government's legislative improvement plan and the ways in which the delivery and support of legislation can be improved. Dr Goodall subsequently wrote to us on 27 February, providing the information. I've written to Mike Hedges as Chair of the Legislation, Justice and Constitution Committee and shared a copy of this letter with him, because it raises matters of interest that fall within that committee's remit. I should declare I'm also currently a member of that committee. Again, auditor general, do you have any comments?

Nothing from me.

Members, do you have any comments, or are you content to note the letter?

Content.

Content. Thank you.

Our third paper to note is a response received from the Deputy First Minister and Cabinet Secretary for Climate Change and Rural Affairs to me as Chair, regarding the legislative consent motion on the Public Office (Accountability) Bill. Following our meeting on 26 February, as part of our scrutiny of the legislative consent memorandum and supplementary LCM on the Public Office (Accountability) Bill, I wrote to the Deputy First Minister and Cabinet Secretary for Climate Change and Rural Affairs. He responded on 17 March, and this letter was circulated to Members in a supplementary papers pack on Tuesday this week. The Chair of the LJC committee, Mike Hedges, has also received a copy in his capacity as Chair. The Plenary debate on this LCM is scheduled for next Tuesday, 24 March. Members, do you have any comments on this letter, or are you content to note? I don't know whether you hope to speak in that debate, but, obviously, participation would be welcome.

I will have to, Mark.

Sorry, Mike? You have to—

I will have to, as Chair of the LJC committee.

—as Chair. Yes. Thank you. In which case, I think we've covered the papers to note.

So, we'll go into a temporary closed session, and we will restart at 09:35, when our witnesses should be with us. Thank you.

Croeso. Welcome back to this morning's meeting of the Public Accounts and Public Administration Committee here in the Senedd. We've been joined by witnesses for an evidence session relating to NHS governance in Wales. Rather than my introducing you, I'd be grateful if you could state your names and roles for the record, in whichever order you choose to go.

My name's Jacqueline Totterdell. I'm the director general for health, social care and early years, and chief executive of NHS Wales. 

Bore da. Hywel Jones, director of finance for health, social care and early years group and NHS Wales. 

Good morning. Nick Wood, deputy chief executive of NHS Wales. 

Bore da. I'm Samia Edmonds. I'm the director of strategic planning for health, social care and early years. 

Thank you very much indeed. I remind everyone that the meeting is bilingual and, as you already know, the headsets provide simultaneous translation on channel 1 and sound amplification on channel 2. As convention has it, I will begin the questions as Chair and then bring in Members. Unfortunately, two Members had to give apologies, but we are quorate—we have two Members online, eager to get into their questions to you.

I'll start with a couple of general questions, if I may. What do you consider to be the main opportunities and challenges of your role—and this is to Jacqueline Totterdell—and what are your priorities for your time in post?

Thank you very much, Chair. Just by way of a quick briefing, I'm Jacqueline, and I've been here for six months in NHS Wales and in Government. I have 44 years NHS experience. My background is as a clinician and I still keep that in my heart. I've had three chief exec roles previously and, I have to say, I'm incredibly and very much enjoying the role here in Wales. I find it challenging and stimulating.

In terms of the challenges and, actually, the opportunities, I think there are huge opportunities here in Wales, and I see a lot of passion in those who are delivering services for improving care for the citizens that we serve. One of the areas that I would mark out as an area that I see and we have begun to work on is how we improve accountability through the NHS in Wales, and I'm happy to talk about that later, if that's the case. I'm very much around how do we engage and work with our teams in health and social care, and I'm very much about high support as well as high challenge in order to get the best for the citizens of Wales. I'm very clear and transparent and open with the people that I support and lead through Wales, as well as working with a really great team in the Welsh Government, and we've actually made some progress over the last few months, which I'm very pleased to see. So, I would say there's a lot of opportunity and there's a lot of good work that is also done in Wales, and I'm very pleased to be here.

And main priorities?

My main priority, I suppose, is several things. One is about fulfilling the programme for government. That has been, obviously, a main area, but it's also around making sure that we begin to put the foundations in to improve care across the whole of the spectrum for the citizens of Wales—so, beginning to put some of the planks in there, from prevention through to treatment and how we might improve what happens in communities. So, through our Community by Design programme, which is led by our chief medical officer, how are we improving what happens locally through to hospital care? Those are the areas that I've been working on and leading. Sorry, I probably haven't quite answered that question.

Thank you. Don't worry, but I would say, in order to remain quorate, we're going to have to bring this session to an end at about 10:45.

So, if I could be quicker. [Laughter.]

Well, if everyone, including Members, could be as succint as possible—

I'll be better.

In your introduction, you detailed that you're obviously standing on two stools and balancing. So, how are you striking that balance in your roles as both the director general for the health, social care and early years group, and your role as chief executive of NHS Wales?

I find them, actually, pretty well balanced. I think it's been a real opportunity to not just develop and support policies for Government, but also implement those throughout the NHS. So, I find doing both of those things a well-balanced way of working, and we're beginning to make some progress in terms of that. For me, I haven't found one more difficult than the other, and I've managed to keep the balance around both of those.

Okay. Thank you. Mike Hedges has some questions.

On NHS structure and governance, as the first question, if we look at the NHS in Wales and look at its structure, population size varies between Powys and Betsi Cadwaladr, area size varies between Betsi Cadwaladr and the compact areas in south Wales, do you think the structure is right?

The structure in terms of how we've structured the health boards?

The number of health boards and how they're put together, yes.

I think that there is some further tweaking that we need to do. I think that that will be a decision for the next Government. But, at the minute, my main priority has been actually getting the health boards as they're structured now to work as well as they can do across the constituencies that they serve.

My personal view—I don't expect you to comment on it—is I don't think Betsi Cadwaladr can ever work.

Do you consider the recent round of inaugural public accountability meetings to have achieved their aims?

The public accountability meetings were developed after the ministerial advisory group advice. To be honest, when we initially started them, I think we were slightly anxious about how they would go. But, having concluded all areas, health boards and trusts, I've concluded that, actually, they're a really good bit of transparency. This is about public accountability. Therefore, accounting to the public about the areas of the health boards that aren't going well, I think, has been successful. It's also given us an opportunity to look at how boards work when they're together to answer questions, and whether they actually understand the business that they're overseeing.

Thank you very much. Is the escalation and intervention framework working as intended? We've had escalation and intervention almost continually, for example, in Betsi Cadwaladr.

One of the areas that goes live on 1 April is a new accountability structure. It became quite obvious that it was very easy to get into escalation and not very clear or easy to get out of escalation. Neither was it clear what support we would give in order to support organisations to get out and keep out of escalation. So, we've now refined that across five domains, which are: quality, performance, finance and planning, people, and 'well led'. The 'well led' domain is one that we need to refine further, going forward, but it's certainly a lot clearer. We've done it with the health boards, and that will go live on 1 April. It will make a difference particularly for those organisations that find themselves in escalation level 4 or 5, where we will start with actually working with boards rather than just executives. There will be clear support, as we have put in Betsi Cadwaladr, to actually enable organisations to improve sustainably.

Can I just interject there, Mike, if I may? In that context, how are you incorporating performance management into those accountability structures, not to punish but to assist and help people both celebrate what they've done well but also to support them to work better in the areas where they need to improve?

We've developed it so that, if you begin to get into level 2 and 1, actually there's a bit more freedom for you, in terms of you don't have to see us as often. That gives people a bit more ownership and ability to have some freedoms in their health board. But, as we get into, particularly, levels 4 and 5, we will be asking organisations for a clear plan of action and trajectory for improvement, and then we will wrap support around them.

We've been working with NHS Wales Performance and Improvement, which is overseen by us in the Welsh Government and NHS Wales. We have a new managing director and we've restructured NHS Wales Performance and Improvement to add a bigger layer of targeted support to organisations. And in there, we have developed an intervention arm, where we have highly skilled individuals that we can call on, on a one-off basis or a two-off basis, to go into organisations and do some diagnostic work and support, particularly for executives and clinicians, around improving what they're doing, new ways of working and supporting leadership.

And that would include, presumably, the monitoring of and support for their internal performance management systems.

Yes, absolutely. That would all be part of the diagnostic about how they're working and how boards are overseeing and managing what's going on, as well as supporting what goes on on the front line. In Betsi Cadwaladr, we have individuals working across the emergency care pathway who are experts in that area to begin to improve what's happening for patients and for staff on the ground. The monthly meeting we will have with each health board, as I said, will include us monitoring what's happening, and then there will be people supporting them internally to do that through the organisation.

Thank you. Mike Hedges, please.

Carrying on with NHS Wales Performance and Improvement, when will we see success from it? This committee will exist in the next Senedd, so when will you come along and tell whoever's left on this committee how well it's working?

My view of NHS Wales Performance and Improvement is that there's a huge amount of work that they do that's really good already. Each one of my directors has an element working in NHS Wales Performance and Improvement. Hywel, the director of finance here, will tell you that quite a lot of his team work in NHS Wales Performance and Improvement, and they work alongside finance directors in the NHS.

Samia, who also oversees emergency planning—. We have a big emergency planning area there, which does a huge amount of good work around emergency planning. They've done a huge amount, as well—should we get on to talk about our elective programme—to improve elective flow and waiting times in the majority, if not all, of our organisations. They've been fundamental to doing that. And we've had the six goals programme across emergency care, which has had some success in improving emergency care and ambulance waiting times.

I'd say the area that we are beginning to work through more is about how we use our clinical teams in NHSPI to really work clinically across pathways across Wales. That's been one of the areas, as well as developing a new arm of that, which is the intervention arm.

How can primary care and secondary care work more closely together? We know that there are huge problems between primary care and secondary care. We also know that there are problems with delayed discharges and you have to work closely with local authorities. How is that work going inside the structure of primary and secondary care within the health boards and with local authorities from outside health boards?

The community by design work that I mentioned earlier is set up to look at how we begin to pull primary, community, secondary care and social care together in order to move patients to be looked at more in the community. That will mean more patients being looked after there, rather than in secondary care. But the second way is how we work on pathways, particularly for long-term conditions. One of the well-defined pathways we have, which is still work in progress, is around diabetes care. Diabetes care needs to start and finish in the community, rather than be wholly owned by an acute trust, so how do we work across pathways better? And how do we also enable, as part of this, clinicians who work in hospitals to outreach into the community to support GP decision making, particularly for those with a chronic disease? So there's quite a bit going on and quite a bit to do, but we need to change the dynamic where it's either the hospital, community or GP, so the patient, the citizen, feels that it's all working for them. One of the bits that will underpin that is having digital platforms that go across all of those boundaries, so they don't become boundaries, they just become part of a pathway.

Can I carry on with that? Because I've got a GP surgery in Swansea, and if you ring them up this morning at 9 o'clock or 08:30 and say, 'I need an emergency appointment with the doctor', all they'll say is, 'Go to the emergency department at Morriston Hospital.' How do you get primary care practitioners to start taking responsibility for dealing with patients, rather than saying, 'Go to emergency', which ends up getting filled?

I suspect that's something that is felt throughout the whole of the UK, and it's not an easy one to do, but I think that's about how do we support and work with GPs in a different way, and how do they have different pathways in order to utilise, rather than just sending patients to an emergency department. It's not my area that I know as much about. I might bring my colleague Nick in if he wants to say anything further on that, if that's okay, Chairman.

I think you highlight one of the biggest challenges. Clearly, GP access is—. We deal with, I think, about 1.6 million phone calls every year through GP services. How those patients are then triaged into respective appointments is really challenging, especially when, as you say, it's an emergency appointment and whether or not you can get that access. What we have done, clearly, in an out-of-hours scenario, is embed the NHS 111 platform, so that all people can access through a single number a primary care service. That's proved really successful in driving traffic to clinical support, and GPs remotely accessing people's care.

But at the front end, I think, on a regular day, at 8 or 9 o'clock in the morning, it's difficult. We need to increase the number of appointments available, which I know is being pushed, and there is further investment into primary care next year with one of the the key premises being to further increase access. The merging and co-locating of GP practices can also have a benefit of economy of scale, so that they provide more appointments, and trying to filter people into different clinical settings, whether that's the nurse-led clinics that I know a lot of GPs run, pharmacists that, again, are providing a lot of advice. So, I think we've got to have that rounded offer in the community and in primary care so that those emergency patients are seen by their primary care practitioner rather than, as you say, being directed.

I think the other thing that we try to do at the front door of emergency departments is implement urgent primary care centres, which, again, can pick up the excess demand from GPs in their local hospitals, so that at least then they're not having to go into, if you like, the ED queue, they're going into a primary care service.

Where it works well—. I've got a surgery in Swansea where it works incredibly well, and I've got another one that I won't name at the moment where I get a complaint a week about it. It's really how do you get consistency across primary care.

I think that is our challenge across the whole of the NHS, how we reduce unwarranted variation and improve standardisation. That's not just a challenge for general practice, it's a challenge throughout all of our clinical areas. So, that is our challenge to take on.

Finally from me, how effective is the overall structure of NHS Wales and the wider public service and partnership landscape it operates within, including regional partnership boards and public services boards?

The regional partnership boards are quite a new thing to me, but I have had a lot of the chief execs who've fed back to me that they find them helpful and engaging. It's something that they feel that they're part of. Of course, it's not just about health at the regional partnership boards, but that's, for me, as much of a view as I have in regard to those. Thank you.

I just wanted to flag it up. That's all from me, Mark. Over to you.

Can I bring in Rhianon Passmore, who has a question?

Very briefly, in terms of the thematic and very difficult issue around health board variance, this is an issue that when I started here we were talking about, and now today, we're still talking about it. I've only got to look at rehabilitative cardiac care to see the difference in, for instance, Aneurin Bevan health board and the massive difference that would make across Wales if it was applied equally. I know we're trying to be brief and we're on a timescale, but is there any thought as to where health boards can be better directed to use good practice as a standard?

As you say, variation across health boards in services in regions is a huge issue that has been forever with us, I think it's fair to say. I think what we tried to do through the planning round this year and the planning round for next year is set out a number of areas where we expected to see that variation either reduce or disappear. We set out 38 what we called 'enabling actions', which were predominantly clinical practice where we'd identified best practice and we expected all of the health boards to deliver those at pace and without variation. We could have probably chosen 150 to 200, but we wanted to centre on 38 reasonably large actions that could drive the system and reduce the variation.

A good example of that is to ensure that every health board emergency department has access services to a same‑day emergency care unit, or that every health board offers cataract treatment, seven or eight patients on a list. All of those we know are best practice that can be achieved within Wales. I think what we now need to do, now that we've started on that journey of embedding that best practice, is continue and refresh and renew those—. We've called them enabling actions, you can call them 'just do its', there's a whole number of phrases that you can term them. But start on that cultural journey of changing from a regional approach to a national approach to ensure that everybody gets access to the same services.

On the point you make about cardiac rehab services, in Wales, every health board has a different directory of services. That's fine for localism, but what we need that directory of services to have is at least 80 per cent of it as a national offer, so that if you're a patient who needs cardiac rehab—and there's a lot of people who do need cardiac rehab—then you can get that wherever you live, but there may be—

Sorry to interrupt you. That seems to be an easy hit. We've got the model in Aneurin Bevan health board, we know the difference that will make on mortality, and it just seems a really—. It's in plain sight. So, do you have enough teeth—? I know I'm going slightly off-piste here. But in terms of being able to direct health boards in terms of that standardisation in a sense of a national offer, do you have the tools that you need to be able to do that?

The levers and the tools that we've got are limited by the legislative framework and the way in which the accountability mechanism works in Wales. We try and use the levers that we've got. For example, this year, in terms of investment into our elective services, we've tailored that investment alongside a sort of check and challenge with health boards that says, 'We will invest in your services or your waiting times if, on the back of that, you deliver the enabling actions that we've set out in the plan for this year.' I think we can use those sorts of things.

I think there needs to be consideration given—. Both ministerial advisory group reports that were done in the last 18 months were clear that we need to improve the accountability mechanisms in Wales and look at the levers that we've got to direct health boards. Clearly, we can direct them, but it's the consequence or reward that we struggle with, I think, a little bit, to be fair.

But we've tried to address some of that with the new accountability framework and there is something for us about grit and keeping going.

Is that okay, Rhianon?

Yes, okay, it's fine, Chair. When I say 'it's fine', I would like more time to explore it, but it's not the time today.

Well, I'm going to start with following on from that theme, actually. You also mentioned diabetes. I'm in diet control remission from type 2 diabetes, because of the excellent advice I got from the diabetic dietician service in Betsi Cadwaladr University Health Board in Wrexham. And to their credit, they're a leader in that area, and I visited them long before I needed their service, so I was aware of that. But that's not replicated everywhere, and it's not accessible to everyone in the way that I was offered it. I hope it's not because of the job I've got, I hope it's because it's for everybody—access to all—but it was very, very good.

So, my question is on how we can spread that. And in contrast with a very close family member, who is in cardiac rehab and had surgery a month ago, the medical intervention has been good, both within north Wales and following referral to Liverpool Heart and Chest Hospital, but the rehab—it's, 'You're on your own.' So, if you're unable to read all the medication labels, understand the chemistry, adapt your diet to make sure you're not having things that could counterbalance or cause problems with the content of that medication and so on, know what is an appropriate level of exercise to take and so on, you're at greater risk of not recovering as you could. So, again, that's following on from Rhiannon's point about perhaps good practice not being spread in the way it could be, and that a little bit of investment can save a lot more down the road in those sorts of areas.

On beds, you've talked about the community, and you can't comment on the politics, but I heard the same answers from Ministers two decades ago. And often— politicians are guilty of this—we talk about the total number of beds rather than the different types of beds. We all know about hospital beds, but the community beds, whether those are community hospital beds, GP beds and so on—. And GPs tell me that they want the GP beds back in the numbers that used to exist, because not everybody can go straight from district general back to home, either because they're not yet in a physical condition to do so, or because the care, the joined-up care with social services, isn't available for all sorts of reasons. So, how do we address that gap in provision, not just symbolically—a few beds here, a few beds there—but as a programme to ensure that there are sufficient step-down beds to genuinely, sustainably, start tackling the delayed transfers of care and enable people to get back into their communities and then back into their own homes far more quickly.

And my final question relating to the previous sets of questions, again relating to community: a lot of the talk rightly here is on prevention and early intervention. As you know, the British Medical Association and the Royal College of General Practitioners have been campaigning for years, saying, 'Our share of the NHS cake, not the overall amount of money, but the share of the NHS cake, has fallen significantly, and there's so much more we would like to be doing with ourselves and our multidisciplinary teams in early prevention, intervention and rehab that we're prevented from doing.'

And finally on that theme, similarly, a whole range of third sector bodies, hospices—I've been chair of the cross-party group on hospice and palliative care—Macmillan Cancer Support, Cerebral Palsy Cymru, an autism charity that I'm a patron for that had to close last month, and many more, are having to withdraw services, which is putting further pressure on statutory NHS care. Again, I wonder if you have any thoughts on how we could better encourage health boards to commission smartly, which the Welsh Government states is what they want, to ensure that preventative intervention and improved rehab in the community reduces the number of people having to come back into hospital.

So, I mentioned the community by design work that has been led by our chief medical officer. That is entirely designed around how we keep people local. I have no view about whether we need more or fewer or different types of beds in the community, and I think we do need, going forward, to have a look about what we do have in Wales, because I'm not sure that we have, as a Welsh Government, a clear picture of everything that we've got and how well they are being utilised and used. And for us, going forward, we have the money we have and we have to use it appropriately and well, and we have to be efficient and effective. We know that there are opportunities for us to be more efficient and effective, and there are opportunities for us to do things very differently in people's own community. And how we do that, we've yet to work through with the health boards, which includes the general practice community et cetera, but that is the vehicle by which we need to explore how we do look after people either close to home or in their own home more than we are doing currently.

Okay. Without repeating what you said before, in terms of the good practice on diabetes among dieticians in Wrexham, good practice on certain cardiac rehab elsewhere, how can we genuinely embed that more widely and make it accessible to people closer to home? 

Well, I'd say that is the $64 million question, how do we really spread at scale and quickly, because that is the question, the theme, the golden thread through quite a few of the questions that you've asked us. And that is something where, as part of NHS Wales Performance and Improvement, we're using the Getting It Right First Time methodology that exists in England, which we're bringing over here, which actually benchmarks best practice and will allow us to look at all areas about whether individual teams or individuals are actually using best practice by which to treat patients, whether it be via a pathway or individual procedure. So, we've been very thoughtful about using more and more data to drive change, and we've certainly developed more data packs and data vaults for the boards to use in order to make changes to pathways and how clinicians are operating. So, I'd say it's work in progress, but it's absolutely part and parcel of what we're trying to do.

Rhianon Passmore.

I accept that, in terms of the massive challenges that there are and the many different areas, avenues and pathways that there are across Wales and across the UK in terms of mortality and conditions et cetera. But there are some things that we already know, and we already know that they work, and mortality is an issue. So, for instance, I'll go back to cardiac rehabilitation. We know what works. There is a small amount of upfront pump-priming needed to be able to replicate that across Wales. So, we know what works. My question is: how can we better translate that across Wales in terms of the importance of what we're doing and the challenges that you're faced with? There is no greater challenge, is there, than preventing preventable deaths. What would you say to that?

I suppose, without wanting to go back over what I've just said, it's to use data to drive change, engage clinicians differently across the board and try to move away from, in some areas, where we see, 'If it's not developed here, it's not a thing.' So, we have to move some of the culture to accepting that there are already well-defined, evidence-based ways of working that we need to adopt quickly. Nick mentioned levers, and our levers are limited other than: keep going, keep pushing and keep holding people to account for the delivery.

Chair, I'll just come in on some of that. Diabetes is a really good example. We've identified a number of what we call high-value pathways. Diabetes is one, which starts with the prevention element and goes right through to the treatment, and if we've missed on the prevention scale, how do we manage the treatment much more effectively. So, we have a value in health team that have identified eight to nine high-value pathways. They are clinically signed off. They are then expected to be scaled and spread across every health board. So, your experience in north Wales, in Wrexham Maelor, is a good one. We now expect to see that, and we monitor that monthly across each health board and each area. 

Some of that needs, as the other Member has referenced, some pump-priming, and we're limited on—. There are so many priorities, and the cake has to be divided in such a way that we meet the priorities that are set out. So, diabetes we've identified. Bone health is another that we've identified. At this point in time, cardiac rehab has not been identified as one of those to be pump-primed. But it's another one where the choice needs to be made as we move forward and shift the investment away from secondary care, into community and primary care. And we've got to—. That's a reasonably long journey, but it has started and needs to go at pace as we move forward.

There has been significant investment in GP clusters and in primary and community care to start to enhance the care that can be delivered and given on a cluster and local basis in that way. It's not enough, but it is starting to move in that direction. And I think we've got to shift, as 'A Healthier Wales' references, and all of the Government's policy and strategic direction, towards the prevention and first-contact agenda, and that's much wider than just the NHS. This has got to be a whole public service Government agenda, because the whole issue around diabetes and a lot of cardiac care starts with how well people live, and how well they look after themselves in their own homes et cetera, et cetera. So, it's got to come through as a whole-Government effort and not just as a health service issue. 

So, I think we're on a—. I hate the phrase, 'We're on a journey', but we are on a journey with that. It is not going fast enough. There are so many priorities, whether it be cardiac, whether it be diabetes, whether it be smoking prevention. All of those things fall into the same bucket, and it's how do we use the limited resources that we've got to drive the ones that we get most value out of. 

Now, our new chief medical officer is in the process of developing an outcomes framework that would drive these sorts of behaviours, because our—. We talked earlier about performance management, and we're very focused on performance management, on performance statistics—waiting times, access to ED, access to GP, the access measures. They are not health outcome measures. If we shift to a system of outcome measures, then the preventative piece, and the number of people whose life expectancy is reduced because of diabetes or cardiac conditions becomes the performance measure, rather than the focus on how long you wait for treatment.

So, I think she's very focused on utilising that to shift the emphasis into that prevention, early treatment, community treatment approach, which will then drive exactly what you've both just described in terms of consistency across the piece, in terms of whether it be access to a dietician, a cardiac rehab service, access to vaccines. There's a whole range of preventative measures that need to be really focused on.

Thank you. I think we're talking about low-cost measures to help people to help themselves—

Absolutely. 

—which would save a lot more down the road. 

Yes. 

In terms of GPs also, I won't name them and embarrass them, but my GP practice breaks all the rules. It's a single-partner practice, with their own small multidisciplinary team. Performance is phenomenal—the phone answered almost immediately, appointments quickly, treatment excellent and appropriate, in the experience of my family. So, as well as imposing structures—if you've got time to answer this now—I hope you would consider looking at where the better performance might be, and consider the models they're using, and whether those might be something that others could learn from, rather than just talking about clusters or large primary care centres, which tend to have worse performance than practices like my GP. That's a personal comment.

I suppose there's a bit here about—. There's a difference between process and behaviours, isn't there? And what you're describing is a GP who's on it. We can't always mitigate for those individuals who choose not to be as forward thinking and as energised as your general practitioner, and I suppose part of our bit as well is: how do we embody a culture where people want to be like that, rather than feel tired and burnt out, and how do we actually make a difference for front-line staff to enable them to feel energised to make a difference and a change?

I'm going to jump ahead. On to Velindre and the NHS Wales Shared Services Partnership. Where are you up to with the actions arising from a review of the NHS Wales Shared Services Partnership? And what assurances, if any, can you provide in relation to the governance and operational concerns identified?

May I pass over to Samia, if that's okay? Thank you.

Diolch yn fawr. So, just to provide a little bit of context, briefly, an independent review of shared services' governance and accountability arrangements was commissioned by Jacqueline's predecessor in April of last year. That was partly in response to some concerns that had been raised at the time, but it was also because, when we looked back, shared services had grown quite considerably in its function and scale over the 14 years that it had been in existence. So, it felt that it was right, proper and timely to undertake that independent review.

The purpose of the review was very much to look into the concerns that had been raised at the time, to ensure that there was clarity around the existing governance and accountability arrangements, and to look at any areas that need strengthening and updating. That review concluded in July last year. The independent reviewer found that the current arrangements are fundamentally sound, but there were a number of areas that needed updating and strengthening and, as a result, he made 21 recommendations. The Cabinet Secretary published the report and the Welsh Government's response to those recommendations in December.

Coming to your question, Chair, where we are now is that we've recently established a review implementation group. That includes representation from Welsh Government, shared services and Velindre, as well as partners from the wider NHS as well. We're looking, in the short term, at the priority actions that need to be implemented, and there is a commitment to implementing those within the first six months.

I think what I would like to reflect on is that there is really good collaboration between the partners. I'm seeing a lot of willingness and commitment to taking those recommendations forward. But I think my overarching reflection would be that we've been given an independent review that the arrangements are sound. We recognise, though, that there are areas there that we need to address, and we will look at updating the full accountability framework within the next six months. The concerns that have been raised have been looked into as part of that review, and also separately by officials, and I think many of the issues that arose have been clarified and confirmed by the review.

From the issues identified, to what extent have you questioned whether the wider model of hosting large functions within bodies, such as the NHS Wales Shared Services Partnership, need to be reconsidered?

So, there have been two recent reviews of the hosted-body model. There was also an independent review undertaken in 2022-23, which was an independent review of the national commissioning functions in Wales. That led to the establishment of the new NHS Wales joint commissioning committee. It was established on 1 April 2024. That's also a hosted body, hosted by Cwm Taf Morgannwg University Health Board. Then, of course, as you're aware, there was the more recent review into shared services, as hosted by Velindre.

Both of those reviews tracked back to 'A Healthier Wales' action, which committed to reviewing the hosted-body model, but also to making sure that we were strengthening and streamlining the NHS landscape. For both of those, there was also learning that we could take from the ministerial advisory group on accountability that was led by Ann Lloyd.

I think in terms of the shared services review, as I've mentioned, the reviewer was of the view that the current arrangements are fundamentally sound, but the application of those arrangements is fundamentally important, and what's required is a clear and transparent accountability framework, but also an environment in which there's trusted relationships to take those arrangements forward. I think what I would acknowledge is that, for hosted bodies, as with any partnership arrangements, there are inherent risks within that. So, it is vitally important that there is clear understanding of the accountability framework. The review implementation group that I mentioned has given its commitment to reviewing and updating that accountability framework within the next six months.

As part of the review, the independent reviewer did look at other options as opposed to hosted bodies, and we will keep those arrangements under review over the longer term, but the reviewer was fundamentally of the view that the current arrangements are fit for purpose, but do need some strengthening and updating. That would be far more preferable than any sort of significant or disruptive change in the system at this point in time, and that view also coincided with the review of the independent reviewer who looked at the national commissioning arrangements as well.

Okay. I probably don't have time to develop that further, but another question regarding Velindre. As you will know, the Welsh Government accepted a recommendation that it should work with Velindre and the shared services partnership to identify instances where correct governance procedures had not been followed in practice. Has that work now been completed, and if so, what did it find?

That work has been completed. The concerns that were raised were looked into at the time. Some of them were looked into by the review and some of them were looked into in parallel to the review. In each case, it was found that there was no wrongdoing as such, in the sense that the correct governance procedures had been followed. I think, again, my reflection would be that it wasn't so much about governance procedures; it was more about the fact that it was evident that there were different interpretations of those arrangements. That is why the review was so important, in terms of being able to confirm the arrangements that are in place, but also recognising where those need to be reviewed for the future as well.

This is my final question on Velindre, and whether or not I proceed with this will depend on your answer to the first question. I received a letter from the previous chief executive, which I shared with the committee. It was confidential. But are you aware of whether there are any current or expected legal proceedings? 

I think that would be a matter for Velindre. We haven't been notified of any procedures so far.

You haven't. And would you expect to be, if there were going to be?

Yes, we would, as part of the governance route, yes.

Okay. I will be careful what I say, but suffice to say, the individual concerned presented a version of events that was compelling. Are you able to share your understanding, or clarify your understanding, of why he was removed?

I'm not going to clarify that here, but enough to say that we have asked and received full assurances, both from the processes internal to Velindre and from their legal advice, that assure us that the processes undertaken were legal and correct.

And not just to say that the process to remove the person, but the validity of the concerns that person had raised prior to their removal, has that been considered or addressed? 

I don't think that—. Go on.

I would add that the concerns raised relating to the shared services partnership governance arrangements were all looked into at the time. There may be issues beyond that, outwith that scope, that wouldn't be for us to comment on. I think they would be issues for Velindre. 

The only thing I can comment on, which has been commented on in public previously, is that the previous chief exec's dismissal was nothing to do with the shared services arrangement.

Okay. Well, I better not say anything in case this develops—

Absolutely right.

—and it becomes sub judice. But that person will no doubt be aware of what you've just said and will consider their position accordingly. Can I bring Rhianon Passmore in, please?

Thank you very much. That went down a slightly different route to what I thought. In terms, then, of the NHS waiting time reductions that have occurred, I believe that they've been lowered considerably, by 28,000 in January, and there are some serious sustained reductions in those waiting times, which we're all very, very positive about. But why do you think there's been such a struggle to reduce those waiting times up until now? Does it have anything to do with the additional moneys that have been made available to Wales to be able to look at these types of issues, and what are the sustainable improvements that need to occur to keep that journey on track?

So, as you referenced, I think we've now seen eight months of a consistent reduction in both waiting times and the volume of patients that are on the waiting lists. It's the longest and most extensive reduction that we've seen probably since we started measuring waiting lists in this way. That's been driven by actions linked to, clearly, the investment of £120 million into the system this year, but those were very much focused on the front end of the pathway. So, throughout the COVID pandemic and the post-COVID recovery, we had not tackled the 250,000, 300,000 additions that had gone on to the first stage of the pathway.

At any one time, of those 790,000 that were waiting 12 months ago, over 50 per cent will have been at first out-patient stage. So, we set out a plan for this year to significantly reduce first stage, because only 25 per cent of those patients will go on to treatment. A further 25 per cent will probably have a diagnostic test, which will then inform other actions, but, in essence, 75 per cent do not need to be on that waiting list because we can deal with the action related to their referral quite quickly. We hadn't done that previously. That was the decision we took this year. We've delivered an extra 200,000 out-patients. The waiting time now for out-patients in most specialties is less than 16 weeks and is coming down rapidly, and is likely to be around about 12 weeks as we go into the sort of full spring/summer. That is a sustainable position as we go forward because we've dealt with the backlog. And our demand into the system is currently running at about 3 per cent per annum. Therefore, we have sufficient capacity to manage that input as well as the output at an out-patient stage. So, we should see the waits for out-patients being sustained as we go into the next financial year.

You'll also be aware that we've invested quite significantly in some specific treatments, whether that be cataracts or orthopaedics, endoscopy, et cetera. So, again, these were areas where we had very large backlogs and we've targeted the money to reduce those big backlogs. As of, I think it's the end of February, we will have delivered 37,000 cataracts this year in Wales compared to sort of circa 20,000 last year. So, there have been huge strides in the volume done. And what we've done on the back of that, by partnering with other organisations who provide cataract services, is give space and time to our health boards to embed the good practice of around seven to eight cataracts on a list, which I referenced earlier as one of the enabling actions. So, for example, in Llandough now, they are regularly treating seven or eight patients on a list; that's also true in Nevill Hall. So, that puts us, then, into a sustainable position with cataracts, as we've dealt with the backlog, and we've done the change at the same time to embed in the system.

So, if I can interrupt you, in terms of the time that we have, obviously this is a considerable improvement, and especially in terms of the doubling of the cataracts procedures. My question is—and I'm just underscoring this to understand—how important has that upfront investment been in clearing that backlog, bearing in mind that Wales has been receiving the same money in 2024 as in 2010? How important has that massive amount of investment been in regard to clearing that backlog, but also, in terms of what you just said, making that sustainable for the future? Because, obviously, there is a concern that without that huge investment year on year on year that can then regress. How would you respond to that?

So, I think it's been really important that the money has been invested, because it's allowed us to both insource and outsource additional capacity to allow our current clinicians to change practice, move to a more efficient system. Without the investment, we wouldn't have delivered the 200,000 out-patients or the extra cataracts. So, clearly, it's had a huge impact. You reference it as a huge investment. In the context of how much money we spend on elective care, it's a tiny proportion.

Yes, but this is investment, rather than sustainable working, so—that's my point.

Yes. So, I think it's been really useful. It's been really helpful in allowing us to shift the system. It's clearly reduced the backlog massively and had the impact that we intended. We are in a much more sustainable position. We now need to use the efficiency gains, the transformation, to drive forward the change and drive forward the sustainability of services, because we haven't got £120 million for next year. So, we need to use the benefits that we've gained to really continue to sustain and move the system forward, which we should be able to do.

If I can just interrupt there, if I may—sorry, Rhianon. A few years ago in Betsi—I've been on a waiting list for over three years—I was invited to an appointment on a Saturday morning. I saw a very good consultant, who'd come in from north-east England on the weekend, commissioned privately, although an NHS consultant, to help clear the waiting lists, and that was happening across the board. The growth in waiting times stalled. But then, when that was over, it started growing again. Early last month, a senior clinician in Betsi Cadwaladr told me that they were now bringing in NHS clinicians privately from all over the place to carry out evening and weekend surgeries to get the figures down. But you can see why politicians might be concerned that that may not be sustainable, given what's happened previously, once the £120 million's gone.

Yes, and I think it's a very valid point, because we've seen consistently, over the last however many years—four or five, longer than that—that we've invested money in, we've brought in private sector or other clinicians, we drive down the number, we aim for a target at the end of the year, and then, the following day, it starts to go back up again. So, I think that's—. I can understand why people would assume that would happen again.

What we've done this time, which is different, is focus on the transformation in the background, while that has been happening, so that—. Betsi has experienced this year—. I think it's 46,000 additional out-patients we will have completed in Betsi Cadwaladr. Their waiting list will come down to around about 170,000 from the 220,000 that it was previously. On the back of that, though, we've now got to the point where we've got a relatively clean waiting list—so, by that, I mean we're clear on how long people have waited, what they're on the waiting list for—and now they are transforming their out-patient services, their review services, the way in which they provide treatments, so that they can maintain that level of waiting list as we go forward. Clearly, if demand starts to rise rapidly, then that's going to be a real challenge. But demand currently is running somewhere between 2 per cent and 4 per cent—that is our projection for next year. That should leave us with a sustainable position.

Now, I don't know, demand may go back up again, but that should give them a sustainable platform from which to work and not have to move forward—. Clearly, there are areas—orthopaedic surgery, dermatology, general surgery—that remain challenged in Betsi Cadwaladr, and we need further work and further investment at a local level to deal with that. They are in receipt of quite considerable additional money, which is recurrent, to fund that recovery, so we would expect them to use that to bring down further their waits in those areas that are challenged. So, we—. The whole service will never be all sustainable; we've got to work through individual areas. We will always have challenges. But I think what we've done this year—. It's likely that we will see a 25 per cent reduction in the total waiting list in Wales. That's got to put us in a better position, going forward, from a sustainability perspective.

But I think, just to add to that, we've had a thread of standardisation. When we've looked at, say, follow-up rates in some of our health boards, they've gone right up. So, we need to get to best practice, because, actually, we need to reduce follow-up rates to allow more 'new's to come in. So, those are the bits that we need to embed in terms of best practice, and Betsi would be one of those areas.

Okay. I'd love to ask more, but there isn't time. Rhianon Passmore.

Thank you, Chair. Obviously, in terms of the waiting lists being at a six-year low, to an average of 18 weeks, that is encouraging, but, obviously, it's the sustainability moving forward that we've focused on.

So, in regard to your views on the state of urgent and emergency care in Wales, I can speak to the Grange hospital, in terms of the new SDEC unit, the new flow strategy, but what is your view on the ability across Wales for timely and safe care across our emergency departments?

So, first of all, I'd like to acknowledge that there have been concerns and issues across the emergency care pathway for patients. I'd also like to apologise to patients and their relatives for those that have had corridor care or have had poor care during their stay as an emergency patient. So, I wanted to say that first.

There's been quite a lot of work that we have done with health boards about how do we improve emergency care through our hospitals. But it has to start with how do we keep more people at home, particularly those who are frail, and, also, how do we actually improve the flow through hospital, and, actually, the discharge of patients in a timely and clear way that enables us to clear the emergency care department as well as release ambulances back on the road. We have had some success with reducing ambulance turnaround times; they've reduced quite dramatically over the course of the last six or eight months. But if I may just ask Nick to do a bit more of the detail about what we've actually done over the last few months and are planning to do in order to improve emergency care flow, because it's one of our biggest challenges.

I think there's—. There was an earlier question around integration and working with local authorities and how can we better improve, I suppose, the relationship with local authorities, but also that integrated care pathway. We know that we've got too many people who are delayed in hospital in terms of accessing whether it be social care, community care, and being transferred from district general hospitals. We also know that we've got processes within the acute hospital estate that are not responsive enough and are not effective enough in improving flow through the system. So, over the last six, eight months—part of that was around the winter plan for this year—we've focused on really embedding good patient flow systems within hospitals. Now, in some cases—. And we go back to the variation. That's worked really well in some places, but is yet to be fully embedded in other places. You're resident local to the Grange; we've seen some good progress in some areas in the Grange. Their SDEC model and the way in which they flow patients into that is really, really good, but their flow from the Grange back out into the community or into their local general hospitals—Nevill Hall or the Royal Gwent—has been really challenged over the last period of time. 

So, we're very clear we are having a non-variable patient flow system that NHS Wales Performance and Improvement will embed and oversee in the system. We're working with experts in this field, both from a Getting It Right First Time perspective, but also we've got two individuals who are currently working in two of the emergency departments in Betsi Cadwaladr to work with us on how we get really effective flow through the system. We will use all of that learning to inform how we embed that in each of the general hospitals up and down the country, so that we can maximise the impact of that.

And can I just ask in regard to flow, and, obviously, the ambulance service is critically important to that, but, in regard to that, are we not fighting a losing battle, even though there are improvements, if the social care situation remains, in a sense, at a standstill? How important is social care and the concept of intermediate rehabilitative care centres? How important would you suggest that that would be to patient flow, or is that not relevant?

I think it's totally relevant. I think it's a much wider construct than just, if you like, social care or integrated care. It's about that we have an increasingly ageing and frail population living at home, or living in supported accommodation or in care homes, that require support on an ongoing basis. We need to make sure that we have the wraparound support in the community to avoid them being conveyed into hospital or having to ring 999. There are a number of models around virtual wards, which meets the point that you were making earlier about community bed stock, that we need to get to the point where all of that frail, elderly population is looked after as part of a virtual ward, where we have very clear care plans, we have very clear intervention plans, for each patient that are aligned to the GP's care record and are provided by local community services. That would then significantly reduce the number of people that phoned for an ambulance and were conveyed on an ambulance inappropriately into an emergency department. They are the ones—. The data shows us they are the biggest users of the ambulance service and the ones that wait the longest, both outside a hospital on an ambulance to be admitted, but also the longest in an emergency department and the longest in a bed.

We're virtually out of time. 

Sorry. So, I think it's just how we wrap all of that around is the big question that we've got to answer in the next period to stop all of that—the flow issues, if you like.

Rhianon, given your time constraints, could I perhaps suggest you try and focus on questions 16, 18 and 21? 

I'll try and put some of these into one question, and perhaps if they could be taken one by each of our witnesses. So, in regard, then, to cancer services and the committee's report, and the differences expressed around roles and responsibilities between Welsh Government and NHS Wales Performance and Improvement and health boards, what, briefly, can you give this committee in terms of your assurances around the governance changes that are now being put in place?

The response to the cancer report from this committee I think has come back—was it yesterday or today—and I think we've accepted the majority of the recommendations. We have put in place the governance changes. The deputy chief medical officer now leads the cancer improvement network for Wales. It is a single team that responds to the recommendations both in their ministerial advisory group and previous committee reports. We have completely simplified the governance and oversight of cancer and are focused on delivering on the optimisation of pathways, the data response that I think the committee recommended. So, I think all of that has been put in place. We accept that there was confusion, there was challenge and we're now moving forward with that. We're also in the process of developing a response in terms of strategy around cancer and how we can really clearly identify a limited number of actions to really drive cancer performance and cancer outcomes in Wales. 

So, in terms of the driving of improvement in your last comment. In terms of variability in performance, we've talked about that across NHS bodies, and mechanisms in place to ensure that they are consistently adopted. Is there anything you want further to say on that in regard to where we've discussed this previously? Does anybody want to quickly add anything to what has already been said? 

I don't—

And this is about adoption of consistent pathways—

I think the report—

You have covered it.

Yes, we absolutely need to be pushing the adoption of those pathways, and I think one of the key elements of that, which we haven't perhaps talked about in this committee, is the diagnostic element and giving consistent access to GPs and first appointers into a rapid diagnostic, which we've absolutely accepted, but it's something that we really need to move on over the next few months. 

I have got further questions, Chair. I'm happy to ask any of them, but I know that there are further questions again. Do you want us to write to our witnesses, Chair, with this next set of questions? 

What I suggest, if you could be really succinct, if you merge, on your suggested question paper, 18 and 21 for a very brief answer, and we can follow up as necessary.

Yes, that's absolutely fine. So, in terms of the current in-year financial position, what is your overview assessment in terms of the prospects for the year-end outturn compared to last year? And do you believe that the national focus on value and sustainability through the all-Wales programme board is making that meaningful difference? And any possible example, if those two questions could be answered, would be very useful.

I'll come in on that, and I'll try and be brief, Chair, on two very big questions. 

I realise that. 

On the in-year position, as of February, the NHS is forecast at a deficit of £206 million. Within that, all non-health board organisations are forecast in financial balance. From a health board perspective, Cwm Taf is forecast to deliver in-year financial balance for the third year in a row, which should result, I anticipate, in the health board achieving its three-year retrospective duty. That £206 million deficit, therefore, is within the other six health boards.

You asked about comparison to last year. Our combined overspend in-year last year across NHS bodies was £124 million, and I think there's just probably a bit of context within that position that is helpful to set out briefly, because I'd categorise the health board slightly differently. Cwm Taf, as I've described, are delivering financial balance, and are on course to do so again, which is obviously positive. Hywel Dda are delivering incremental improvement. They delivered the target control total last year and are on course to do so again this year. Our challenge with the organisation is on the pace of the recovery plan to financial balance, and that's the nature of our interaction with them, because obviously they're a health board that's never been in financial balance.

Positively, both Aneurin Bevan and Betsi Cadwaladr submitted balanced financial plans this year, having met their target control total last year. Unfortunately, in-year they've been unable to deliver those plans, which I think is a particular set of challenges. And then Swansea bay, Cardiff and Powys health boards have seen a deterioration in their position over the last year, and have deteriorated further this financial year, so represent probably the greatest challenge to us. It's a challenging position. Some of that's a consequence of system pressures, some of that's a consequence of individual organisational challenges. Shall we move to value and sustainability?

Yes. So, in terms of the all-Wales programme board focus on value and sustainability, has that made any difference?

'Yes' is the answer. As on offer, Chair, because I'd like to come back with an example, I'm happy to write to the committee just setting out some of the function and programme and an explainer of what the programme has achieved. Succinctly, it's organised around the six main areas where we consume our resources, with a focus on actions that we can take to appropriately reduce costs and improve efficiency and productivity, whilst also utilising resources more effectively.

If I could give two examples briefly? If you take an area like workforce, through some of the actions put in place, our locum and agency bill in Wales has come down from £325 million in previous years to a forecast of £126 million this year, and there's a huge amount of great work in areas like medicines management. I think our reflection—and the conversations Jacqueline and I have had since Jacqueline has come in—is there is always work to do in terms of improving how we are taking that forward, so we are considering again with chief executives how we move that up a couple of gears going into next year.

Just as another example, I'd like to briefly go back, Chair, to your experience on diabetes care, because at the heart of that is allocative value, which is really what we're taking forward through that group as well. From a finance lens, the resource environment is really challenging, as I've described. We've got a huge amount of work on identifying, as Nick described, the high and low-value interventions across pathways. NHSPI have developed a phenomenal data tool around diabetes, and we've got a clear pathway map around what high-value and low-value interventions look like. The challenge for us then becomes how we look at what we spend on diabetes as a whole and redistribute that resource. So, taking resource out of potentially low-value medicines, where efficacy isn't as evidenced, into more high-value interventions, such as your dietetic experience. Again, that's part of the work that the group is taking forward through clinical and financial partnerships.

It might help if kind-hearted people stopped handing out jammie dodgers and chocolates on the acute cardiac unit to diabetics, but that's another comment for another day.

It's fine if you can't answer this question in any detail, but are you reconsidering the shape and structure of NHS Wales? If so, could you write to us explaining that?

Yes, we can write to you, although I think the shape and structure of NHS Wales will need to be led by a new Government, obviously.

Thank you. Yes. Mike, do you want to take a final question, just summarising?

Yes, very briefly, why aren't you making more use of artificial intelligence to drive efficiency in health?

I will try and be succinct, because this is a whole issue around digital. We've put in quite a lot of systems already into Wales in terms of some foundation blocks. We now need a bigger strategy across how we connect all of Wales up digitally, and that will need to include AI. As someone who has used AI in an ED previously, and it saved a huge amount of clinician and admin time and it also helped patients, I know how valuable it can be.

Can I just tell you, a very easy win is to not send letters to patients, which quite often arrive after the appointment, but contact them by text or e-mail, if they're prepared to accept those?

I would say the NHS app, whilst it's done some good things, has further to go, and that will need to be one of them.

Which obviously isn't AI. And in regard to this—sorry, Chair, I know that time is limited—we know that there are huge benefits, especially across clinical settings, as Mike has referred to, in terms of AI, but there are also still very many concerns in terms of data development and large language models. In terms of the regulatory processes around that and patient confidentiality, I do believe sometimes it's not always the best thing to go rushing into a new nanosphere without understanding all of the issues that are behind it. So, from a personal perspective, I would also urge caution in terms of that as well.

I'd agree with you. ChatGPT—once you put patient data in there, you've lost it. So, I'm absolutely clear that, in doing this—I think as a UK, actually—we need to put safeguards into healthcare around data protection in using AI.

Okay, thank you. We've still gone over 10 minutes, the target time, but we're still within the original time, so we'll have to bring it to an end at this point. Thank you all very much for attending and answering our questions.

Thank you very much for having us. 

As always, a copy of the transcript of this meeting will be sent to you to check for accuracy before being published. Otherwise, may your day go well.

Thank you, and you. Thank you very much. 

Members, I propose that, in accordance with Standing Order 17.42(vi) and (ix), the committee resolves to meet in private for the remainder of today's meeting. Are Members content? 

Content.

Thank you. I'd be grateful if we could go into private session.