National Assembly for Wales

Bore da a chroeso. Good morning and welcome to today's meeting of the Public Accounts and Public Administration Committee. Welcome to Members, guests, clerks and Audit Wales. For those in the room, please note that headsets are available for translation and can be used for sound amplification if needed. Please could I ask everybody to switch off their mobile phones or put them into silent mode? In the event of a fire alarm, everyone should follow the directions from the ushers. We have had apologies for absence from Rhianon Passmore, and unfortunately Plaid Cymru could not be represented today. Do Members wish to declare any registrable interests at this point that aren't already on the official record? Thank you. 

We have a couple of papers to note. The committee has received a copy of the response from the director general of the climate change and rural affairs group to the Auditor General for Wales reports on public sector readiness for net-zero carbon by 2030. The committee has previously considered the reports at its meeting on 22 September this year. We noted that the findings in the auditor general's reports were also relevant to other committees in the context of the Welsh Government's programme for government commitment to embed the response to climate change in everything it does. We agreed to consult with the Senedd Climate Change, Environment and Infrastructure Committee on the relevance of the auditor general's reports to its own forward work programme. It is noted that the Climate Change, Environment and Infrastructure Committee will be undertaking a short piece of work on progress made towards decarbonising the public sector, which will build on the auditor general's recent report. We also noted the opportunity for us to consider these findings during scrutiny of the Welsh Government's consolidated accounts 2021-22, which we anticipate or hope to undertake early in 2023. And any statement about the Welsh Government's leadership of the net-zero agenda or its own net-zero performance could be accommodated then. Could I please invite the auditor general to comment?

Thank you, Chair. We didn't actually make specific recommendations in our report on net zero, but we did encourage the Welsh Government to respond in some way, so I'm really pleased to see the letter today. As you said, Chair, the Climate Change, Environment and Infrastructure Committee has picked up on our work and is undertaking its own inquiry, and we'll be briefing the committee later this month. And, finally, just to make the committee aware, this is an area that I'm determined to maintain a focus on through our wider work programme. We're currently discussing with the other UK audit bodies the development of a joint report giving an overview of the policy and delivery environment for net zero across the four nations. We'll also be publishing a short report on flood risk management next month.

Thank you. Members, do you have any comments or questions, or are you just happy to note what we've heard and proceed on that basis?

Note it, and we'll come back to it, I'm sure, in the near future.

Agreed.

Thank you very much indeed. 

The second item, I'm trying to find here—

It's the letter from the Welsh Government on the public bodies unit.

Oh, here we are, yes. The Permanent Secretary has written to the committee with details on the register of devolved public bodies in Wales, updated on 30 June this year, following a review of the public bodies unit. The letter also provides further details on progress in delivering public appointments and the diversity strategy for public appointments, and an update on the timetable for tailored reviews, including the tailored review of National Museum Wales. This committee is due to start an inquiry into public appointments later this month, and that will include scrutiny of the effectiveness of the Welsh Government's approaches to encouraging and increasing the diversity of candidates for public appointments. This will include consideration of its diversity strategy for public appointments and the details contained in letter will be relevant to that work. Members may wish to note from the letter that the draft for the programme of tailored review will be completed by the end of November. Members, do you wish to ask that a copy of the programme be shared with the committee?

Yes.

Yes, please, Chair.

Thank you.

Two yeses.

Two yeses. Unanimous.

You may also wish to note the time frames for the tailored review of National Museum Wales. Do you wish to ask that the progress report, focusing on progress and confirming the themes for the agreed remit, and the further interim report, as referred to in the letter, be shared with us, albeit on a confidential basis if required?

Yes.

Okay with you, Natasha?

Yes it is—it's okay with me. My apologies, the speaker was being a bit slow. 

Great. Thank you very much indeed. Again, does the auditor general wish to comment?

I support the committee's decision in both those areas, Chair. I think the timetable for the tailored review of the museum is now looking as though it's slightly longer than originally anticipated by the committee, so it's absolutely the correct thing to do to keep yourselves informed of that, and also to obtain a wider timetable for the whole programme of tailored reviews, as you've said. Just one point of detail: I think, back in April, the committee were told that there were 52 bodies, potentially, subject to a tailored review, but the diagram that's been provided by the Government shows fewer bodies than that, so you may want to get clarification of the coverage.

Thank you. Are Members otherwise content to note the letter, but following on that comment to seek clarification of the coverage?

Yes.

Yes, content.

Thank you very much indeed.

This brings us to item 3 on our agenda today, which is an evidence session with the North Wales Community Health Council regarding our governance review of Betsi Cadwaladr University Health Board follow-up. I welcome, therefore, our witnesses, who are sat opposite me physically in the committee room, which is a nice change. I think you're our first physical witnesses since the last lockdown. Most people have taken part remotely, so thanks for coming down. For the record, could you, please, state your names and roles?

My name is Geoff Ryall-Harvey. I'm the chief officer of North Wales Community Health Council.

I'm Carol Williams. I'm the deputy chief officer of North Wales Community Health Council.

Diolch a chroeso. Thank you and welcome. I'll start the questions. We've got a series of questions for you. There's quite a lot of ground to cover, as you know, so I'd be grateful if everybody could be as succinct as possible, both Members and witnesses. 

So, we may begin. How confident is the community health council that the Welsh Government's decision to de-escalate the health board from special measures in November 2020 was the right one? What is your view on whether the health board can sustain the improvements that contributed to the decision to de-escalate, based on your current understanding?

I think that's quite a complex question. We were certainly happy to see special measures removed for certain issues. We would have liked, I think, to have seen special measures kept for vascular services and for mental health services. That wasn't to be, so we are working with the health board on the targeted intervention in those areas particularly, but right across the board. 

When we get into this later, we will be telling you that progress is slow, probably unacceptably slow, and we'll tell you why we believe that is. But it is progress nonetheless. I think that we need to be more confident that the role of the Welsh Government is not just scrutiny, but also playing its part in sharing responsibility and assisting Betsi Cadwaladr to come out of targeted intervention. Some of these issues are greater than Betsi Cadwaladr alone can deal with. I'm thinking in particular around vascular services. 

Thank you. And without going into the issues that you're going to highlight later, since de-escalation from special measures—although, clearly, there's still targeted intervention—there have been a series of reports, either old reports released or new reports by regulation inspection bodies. Have the findings in those reports and the recommendations from them, past and more recent, influenced your view of the validity of de-escalation?

Some of those reports are historic, some of them are not, particularly around vascular services. I think had the CHC's recommendation that the vascular services in north Wales have an ever closer relationship with the vascular network in Liverpool been acted on, that would have perhaps prevented some of the problems. There are still things coming up from many years ago. We await, in the new year, inquests in relation to Tawel Fan deaths in 2012. And all of these have an impact on the board's reputation and the work it needs to do to recover. Progress is slow, I'm afraid. 

Thank you. Can I pass over to Natasha to pick up the questions?

Thank you so much, Chair. Good morning, everyone. The TIF—the targeted intervention framework—agreed by the health board with the Welsh Government actually sets out a very wide-ranging and significant number of challenges. I'd like to know what are the key and most immediate priorities for delivery for you. Where is the health board not making progress at the expected pace?

I think there are three. There's vascular, there's the emergency departments and there's mental health. In terms of emergency departments, we have seen that there's a recovery manager been brought in. There is a very clear programme to resolve the issues, particularly at Ysbyty Glan Clwyd. You won't need me to remind you that those ED reports by Healthcare Inspectorate Wales were some of the worst that HIW has ever issued. Leadership and governance is a big part of the framework, and the recent loss of the chief executive has not played into that, let's say. We are seeing work around these issues. There is a new management structure that's meant to address some of the issues of Betsi Cadwaladr being so large. It devolves decision making and responsibilities down to the three east, west and central areas. Vascular—I'm afraid that the progress is still very, very slow, and key elements of it are not being progressed. So, the diabetic foot service, which is massively important in terms of feeding into vascular surgery—. There just doesn't seem to be the drive. Our vice chair is a very eminent retired surgeon, not a vascular surgeon, but a surgeon nonetheless, and I have to say that he has been one of the major driving forces behind what has been achieved so far. I don't know why this is. We are working with Nick Lyons, the medical director, and Gill Harris, the interim chief executive, to ensure that improvements on vascular get the resources and the priority that they need. 

Can I just ask you to elaborate? You've mentioned a few times about vascular services. Is it the staffing that's an issue? Is it the equipment that's a problem? What exactly is the concern—[Inaudible.]—of vascular services?

It's not the equipment. There is a relatively new, state-of-the-art vascular theatre. The issues are the staffing and the changes. In 2019, it went over to a model of hub and spoke, with the centre of excellence at Glan Clwyd in the middle. That change was not well managed. It's a system of providing vascular services that works elsewhere around the world. It works very well in the highlands and islands. It works very well in Cornwall and the Scillies, which have equal issues of transport and distance in relation to north Wales. Part of the problem was that they could not get the quality of staff, and they still cannot get the quality of staff. Then that becomes a downward spiral, and people don't want to work there. We believe that the involvement of the Liverpool vascular network is a tremendously positive step forward. I can't see that there will ever be a return to an independent north Wales vascular services. I think that there will always have to be that link to Liverpool, and it's a good thing.

Thank you. Natasha.

Okay. Thank you so much for that. You mentioned in your answer that you just gave about leadership and governance as well playing a big part. Is it possible that the reason why a lot of people don't want to work there is based on the reputation and the unfortunate circumstances that have happened so far in this particular area? I mean, I'm all for working together with England and I'm a huge believer in joined-up working, but we do have a number of health boards in Wales—. I know that this one isn't mine, personally—I'm more south Wales based—but ultimately, I would want to have a sufficient health service in north Wales as well, as I would in other parts of Wales. So, when you mention leadership and governance, what changes specifically are the leadership and governance teams going to be bringing in to ensure that that actually does happen now?

I think it's leadership at all levels. Because of the recent unexpected departure of the chief executive, people tend to concentrate on that, but clinical leadership is also hugely important. And if you look at areas in Betsi Cadwaladr where they do have good leadership, that would be things like learning disabilities, it would be services like biomechanical engineering, it would be pathology. They have no difficulty at all in recruiting really good-quality people. But, in areas like vascular, where the service has a dreadful reputation, people don't want to go there. We may see some improvements, I think, around clinical leadership with the new medical school in Bangor. I think that's a great step forward and that will enhance recruitment and retention. And things like the surgical robot, which is now up and running at Bangor, that will attract people. Young surgeons don't want to go somewhere where they can't work on this sort of equipment, and the CHC have pushed for this for nearly 10 years, because we see it as a real aid to recruitment and retention. And without it, it becomes ever more difficult. 

We see recruitment and retention as the biggest challenge facing Betsi Cadwaladr—bigger than any financial challenge. Being able to get the staff to provide good-quality services is vitally important. As a CHC, we don't have a great deal of overview on finance. We leave that to the people who know what they're doing. Our belief is that finances come a long way second to quality services for patients. 

We have found that the leadership over the last two to three years has been particularly open and transparent when it comes to talking to the community health council, and we have worked regularly with them throughout the pandemic and thereafter. There is a new operating model in place now, and we haven't really seen how that's going to impact on services. But, we are hopeful that things are going in the right direction. 

Yes. Your own 2019 report was, I think, fairly upbeat about changes that were happening. Unfortunately, we had the pandemic, and that work was diverted into responding to the pandemic. And we believe that Betsi Cadwaladr did very well in the pandemic. There were some outstanding achievements, and we'd like to see those translated into giving people the health service in north Wales that they deserve. 

Thank you.

Frankly, I couldn't agree with you more. I think a lot of my colleagues will be in the same boat as well; we all want to see the services thrive, especially for the residents of north Wales. So, my next question is: the process of self-assessment is—. I'd like to know how reliable, actually, is the process of self-assessment that the maturity matrix actually relies on.

We've been kept up to date with that process. They're building the information systems that will allow them to do that, and it's only very recently that they were able to sign that off as being fit for purpose. They are saying now that the outcomes are not at the level required, and I would agree with that. In terms of the Ysbyty Glan Clwyd maturity matrix regarding emergency department services, that's only relatively recently started. It started in July of this year. We are seeing some changes: a turnaround manager has been brought in with really good experience from NHS Improvement in England. We have visited there. I think one of the issues that we have that will make it more difficult to achieve the required results is that there are huge numbers of agency and temporary staff in ED. We visit on an unannounced basis, and we talk to staff. We've started that recently, following a gap of two years, because we weren't visiting due to COVID. And we're seeing that right across the health board, but particularly in ED and particularly in mental health. And I spoke to the Betsi Cadwaladr chairman recently about this. He also makes his own unannounced visits, and he said that this was something that concerned him—the levels of agency staff. And the problem there is that they don't have knowledge of the systems, and if you look at the HIW report into ED at Glan Clwyd, informatics and logging people in and knowing where they were in the hospital, and co-ordinating their care with in-patient stays was absolutely vital, and when you've got people who are coming along on an agency basis, and they might be working in a ward one week and in ED another and mental health another, it's not conducive.

I think there's a lot of work being undertaken, but what's difficult to gauge is the actual impact of that; what the outcomes are, and as Geoff mentioned, obviously, COVID has skewed people's view on health services. So, that's the hard bit for us is understanding that the—

Yes. I think what is interesting and positive is that, this time around, Betsi Cadwaladr are saying that they need to engage with patients so that they can assess the outcomes of this maturity matrix work, and as you can imagine, we're all for that.

Thank you. Many of the issues that you've highlighted we're going to seek to develop in our further questions on specific matters. But Natasha, do you have any further questions?

I do. Thank you so much, Chair. I just wanted to reiterate—I completely want to make something really clear to you both. I know I'm not there in person today, but I'm sure that my other colleagues do as well; we appreciate and sympathise with every health board for what they've all gone through during COVID, but the issues with Betsi have been there since well before COVID even began. So, the worry that we all have is that we want this health board to strive and thrive just as much as the others are across Wales, but we need to see the actual proof in the pudding as well.

Speaking of previous issues, previous reports have actually talked about the importance of closing the gap between boards and wards, so what is the CHC's view on health boards' progress to improve leadership now, throughout the organisation from top to bottom, including clinical leaders and middle management as well?

One of the things that's encouraging is that the independent members are more willing to present a challenge to the executive team. This was something that was picked up by the Welsh audit office and HIW in the various reports they did. I think it would be fair to say that some members of the executive team are struggling with that challenging environment, and that executive team continues to lack the cohesion that you would expect, and I think that that is evidenced quite clearly in the very slow progress on key issues. And I think that's something that the executives should expect to happen; this is the role of independent members, it's the role of the chair. What the Welsh audit office has pointed out in the past is that, for too long, the Betsi board acted as a support mechanism for the executive team. That's not their role at all. We saw, with the new chief executive, the one who's just gone, a greater commitment to openness, a greater wish to engage with patients and the public. We believe that that will continue. I think it's absolutely vital that it does. Reputation, I think, is a great Achilles' heel for Betsi Cadwaladr at the minute. They pulled some of that back in the pandemic because of the work they did. Unfortunately, because there is this commitment to openness now and they are releasing adverse reports in a way that they did not before and there is some clearing of the decks of historic problems—and new problems coming up, let's be absolutely honest about that—it makes it difficult. But, in terms of the board, I think we're seeing the board acting in the way it should more than it ever has done in the past.

Thank you.

Okay, thank you for that. As you mentioned, there are difficulties; I can appreciate that. I know my colleagues in the room will appreciate that as well. There has always been a consistent theme in reports relating to the health board over the years about there being a need for a clear and realistic vision of services for the population. So, I would like to know from you now—. You mentioned about the board a few times in your previous answer. Has the health board now agreed a clear, concise and specific clinical strategy and have you got it in place now?

I'd say that they are working on that. There are a number of elements to that, and there are a number of challenges. Obviously, the massive one is waiting times; 36- and 52-week waiters are about 10 times what they were before the pandemic, but that's the same right across Wales. We see a number of initiatives like rapid treatment and diagnostic centres as being a potential solution to that. Interestingly, those are private-public partnership, and I think that is really the way forward, given that Welsh Government capital investment for the NHS has gone from £350 million to £250 million.

One of the things that have been affected by that, which the North Wales Member will know, is the Royal Alex. That was a scheme, a £40 million scheme, of upgrade and investment that not only would provide better services to patients, but was also part of the regeneration of Rhyl. People tend to forget the huge part of the Welsh economy that the NHS puts forward. That has been lost. Welsh Government have suggested that the health board go to the regional partnership board for the money. I've never heard of that, and I asked my colleagues in other CHCs if they'd ever heard of regional partnership boards funding major NHS investments, and they hadn't either. So, that is a huge challenge. They have failing estate, they need to make investments to produce a modern health service that meets people's needs now and takes advantage of technological developments and takes advantage of better ways of treating and caring for people in the community. Now's not the time to starve it of investment, but I know that there is less money available, so—.

We've heard also about the estate strategy, which I think is going to be signed off around December time. It does feel more joined up, but the consistent message that we're getting is that capital funding is just not there and that there will be a reduction.

What would be devastating is if the money for the redevelopment of the Ablett unit, which people may know from Tawel Fan and other such horrors—if the funding's lost for that. We understand, at the moment, it's secure, but the Royal Alex funding was secure last year. Really, that would be a huge issue. Without a modern facility, we will have more and more of the sorts of things we've heard about. Mark will know that there were two deaths associated with the poor quality of ward layout—not fit for purpose, not fit for modern care. Some of it wasn't even anti-ligatured, which I find, in this day and age, to be just unbelievable.

We'll come to mental health shortly. I would point out that I think the coroner has withdrawn reports from public circulation pending their determination of those cases, but I'm aware from media reports and discussions with yourselves and others that, I think, one was a suicide and one was a failed suicide that led to a heart attack—

Yes.

—because of the issue you highlight, so—. Anyway, sorry, I interrupted you.

Yes, so, there will need to be investment to change the pattern of healthcare in north Wales to make it fit for purpose, to make it economically viable, to make it economically efficient, but, more importantly, to provide the quality of service. I think that Betsi Cadwaladr are seeing private-public partnership as the way forward. They're being supported in that by Welsh Government, and perhaps it's something where we will see change. The regional treatment centres, as I've mentioned, are to be subject to a private-public partnership. One of the things that we've asked for assurances on is that the Welsh experience of PPP will learn everything that was learned from the failures in England, and I'm sure it will. We sat on the project boards, we've been included in that, and have been quite impressed with what we've seen.

What we have stressed, though, is there is a strong need for greater engagement, so that patients and the public are behind or understand the reasons behind these plans, because they could actually have far-reaching changes to the way that services are structured and delivered in north Wales. So, now is the time to start engaging with patients about those proposals.

Yes.

I appreciate you just mentioned that you want to engage with patients, and that's absolutely fantastic. We've had many a meeting with different health boards since the Senedd was formed in this particular term, and the one thing that they've always emphasised is how important it is to engage with staff who are front-facing as well. So, how much engagement are you actually having with the staff, the front-line staff who are facing these patients, who are having to answer those questions on a daily basis, to ensure that they are also part of that change that you so desperately need to have in order to restore that confidence that the public and we as politicians and everyone needs to have in the health board?

The CHC is patient-facing rather than staff-; we do engage with staff because, although we don't have a duty to do that, our experience is that it needs to start from there, that you need to have staff on board. One of the reasons for the huge failures around vascular was that staff weren't engaged with beforehand and it was just landed on them. We've been at pains to point out in the process around the regional treatment centres— sorry, the rapid treatment centres—that staff are on board with it, and we've actually had detailed discussions with staff, with the clinical leads, to ensure that they're doing that. We don't want to be three quarters of the way into this project and find that the staff know nothing about it. So, that is really important.

For us, we have a rolling programme of engagement with patients on particular issues. We did one around vascular and I think it's fair to say that that was the trigger for the invited review by the Royal College of Surgeons, which was so damning. We've done one around mental health services, and that has been quite influential with the senior management. The problem with that, though, is that there has been a massive churn in senior management in mental health. We did one around speech therapy. That was really useful. It wasn't specifically about service change, it was about how the service fitted people's needs, and there have been changes around that. We're currently doing one around menopause, and that's a real eye-opener, I'm afraid.

Pre pandemic, the community health council in north Wales was undertaking somewhere in the region of 500 visits to NHS settings across the region—

Every year.

—and we would meet staff on a regular basis, and we'd be able to engage with staff. Obviously, because of the pandemic, we've not had that ability to have that face-to-face discussion with them, and, sadly, after 1 April, that right to visit will—

There will be no organisation with the right to enter and view NHS premises.

—no longer be there. But we do have staff come to us on a regular basis.

Thank you so much for that. My final question now. My mother's a doctor and, obviously, she and my father have a lot of friends who are consultants across various health boards across Wales. And one of the issues that they have, and they've raised with me, is that CHCs, for them, they feel is a very bureaucratic process, they don't feel the need for it, and they actually feel that, without them, more money could be spent on staff, on nurses, on more doctors, on more salaries for those that we, obviously, desperately need. So, I want to ask you now—both of you, please—whether you feel that the current health board structure actually works, and would it not be better to split it up into areas where they're actually providing different avenues or various forms of services for the patients that need them the most.

I presume when you said 'CHCs' you meant health boards. Yes. Because CHCs have a budget of about 1 per cent of 1 per cent of the NHS. I think there are a lot of governance issues. I think it would be—. It is necessary to have a board. I think the Chinese found this out about 3,000 years ago; it was necessary to have a civil service and an oversight. It's not a popular opinion, but I actually think that the current Betsi board is really working towards making the changes that are needed. I don't think they're doing it fast enough, but there are limiting issues around that. I don't see another way of doing it, really. I don't think you could have—. If it was all taken centrally, then what you would have is a local health service that wasn't sensitive to needs.

There are some health boards, like Hywel Dda, who are very well thought of, by some people, and have the confidence of Welsh Government and the confidence of the various regulatory agencies. I just don't think there's another way to do it. When you let doctors do it, you end up with a whole different set of problems that are not necessarily any better.

Wouldn't they know better, being the ones seeing the patients on a day-to-day basis?

This is why we have a medical director and a director of nursing. And in Betsi Cadwaladr, the interim chief executive is a nurse. I think what it points out is not the failure of the system we've got now, but the failure to involve clinicians in decision making. And you kind of don't want those doctors dealing with the million and one problems around finances and admin. You want to engage with them properly, find out what they need, find out what they want—which is, by the way, not what patients always want either—and then deliver it to them. 

But surely wouldn't doctors know best, because they're the ones that the patients are waiting in line to see for so, so long? And wouldn't they be the ones who—? Potentially, okay, I understand that not every doctor's a fully-fledged accountant, but when it comes down those actual decisions that need to be, to perhaps benefit the health service, wouldn't they be of some use and value to be able to help work together to create a better system?

I think that's what the Betsi new operational management system is trying to do; it's trying to give more responsibility around decision making and more influence to clinicians. I think that's the way forward, and that can be done without legislation. To change that whole system would be a massive project and it would lead to years of chaos. I think the better way is to listen to patients and doctors, and those views often vary, differ, quite substantially. What's interesting is that when you have a doctor who's been a patient, particularly in his own speciality, and then they sort of have a bit of an epiphany and—[Laughter.]. I can see that the Chair has come across that experience before. But, definitely, involving clinicians more. I would hope that any forward-thinking health board would do that. The consequences of riding roughshod over clinicians' views are quite clearly demonstrated in a number of areas in Betsi Cadwaladr. I think the vascular one should be written up as a text book, an academic exercise in how not to do things. 

I think the last thing that north Wales needs is another health organisation restructure. Splitting the health board is not the way. There are new health communities now, and, as Geoff has mentioned, it does feel more joined up. I think people forget why the health board was created in the first place. It was to try and get some sort of equality in service provision across the region, and I don't know whether patients will be engaged and supportive of another restructure. 

Thank you. 

Thank you, Chair. 

Thank you very much indeed. Mike Hedges will develop the theme of vascular services. 

Yes. Before I move on to that, I used to serve on a health board, and I'll tell you the best way to not get reappointed to a health board is to challenge the executive and the chair. I think that perhaps what you need to see is those who are doing the most challenging—whether they actually get reappointed, because my expectation is that they will not. If you look at a health board, just to  break it down to three simple sections: central services, hospitals or secondary care and primary care. Now, central services can be provided anywhere. In fact, in France, payroll for teachers is done in one place for the whole of France. That doesn't matter. Primary care is very much done in clusters. So it's the secondary care that we're moving on.

Now, the question I'm asking, and you talked about a hub-and-spoke model earlier—. I come from the Swansea Bay University Health Board area. The question I'm asking you is this: is it possible to have a service in Ysbyty Gwynedd to cover the whole of north Wales and a service in Glan Clwyd to cover the whole of north Wales? Or is there more of a need for certainly services to be run centrally? If you have only one A&E—we've only got an A&E in Swansea and Morriston—but one A&E in north Wales, you're talking about people having an hour, an hour and a half journey to get there. You said that restructuring is not the answer; I would say that when the structure isn't working, perhaps you need to look at how you can fine tune it. My personal view is that the hospitals ought to be split up into either two or three different things, so they could actually work together. Is there more of a role for involving Chester and Liverpool hospitals, which are just over the border, which goes against the political view of the Senedd, but is actually, in terms of patients, much more useful than moving from where Mark lives across to Ysbyty Gwynedd, when he can get to Liverpool and Chester quicker? 

We often have a concern that people can't go across the border to the hospital that they consider theirs. So, if you live in Deeside, Flint, Holywell or Connah's Quay, your local hospital is the Countess of Chester Hospital; that hospital was built for residents of Deeside. It could not operate in its current form without Welsh patients, regardless of what the former chairman had said from time to time. Welsh patients allowed it to be the hospital that it is.

One of the issues that we have in north Wales is distance, as you've pointed out. We've got three district general hospitals. Nowadays, many aspects of care can only be done when you have specific populations. The population in north Wales is 760,000. There are plenty of services—complex services—that, really, you don't start to have a specialty centre until you've got 1.5 million people. So, people do go to the Countess of Chester, some for fairly ordinary treatment, but a lot of people in north Wales will go to Clatterbridge Hospital for cancer care; and, of course, for complex paediatric care, everyone in north Wales would look towards Alder Hey Children's Hospital.

Those flows across the border are natural. Nye Bevan said that the greatest asset to the NHS in Wales was the NHS in England. For people in north Wales, transport from Llandudno—it's just as easy to get to Clatterbridge as it is to get to Ysbyty Gwynedd. So, that's the fact: there will always need to be cross-border travel in north Wales. It's natural; that's how the system has developed. I understand people who think that NHS Wales should be totally self-contained, but, unfortunately, it can't work that way, because you can't get accreditation for certain services in relation to population size.

In relation to vascular services, that hub-and-spoke model that was proposed would see, as it was set out, people with fairly low-level vascular issues being treated where they'd always been treated. So, if you always went to Bangor, that's where you'd carry on. Similarly, if you lived in Wrexham, you'd go to Wrexham. The centre of excellence at Glan Clwyd was intended for really complex and difficult things like aortic aneurysm. Unfortunately, when they recruited the staff to that, they didn't get the quality of staff that they needed, by any measure. So, services were not as good as they'd been prior to reorganisation. There were issues like—there was a very well developed and mature relationship between primary care, district nursing, the vascular wards and the vascular surgeons in Bangor, and people could get back into the service very quickly. So, typically, if a diabetic had problems with feet, which, as you probably know, is where it manifests itself most seriously, they could easily get—the district nurse could refer straight to the surgeon or they could send them straight to the—. All of that disappeared, so people were getting a far poorer service.

When we did our safe space events around vascular, we had hundreds of people attending those meetings. Once we'd done that—once we'd engaged with people and told their stories—it was very clear to the Betsi Cadwaladr senior management team that it could not continue as it was. They brought in the Royal College of Surgeons. There is a view in north Wales that it should all go back as it was. I don't think it can now, and you would still be left with the issue that, for certain items of complex surgery, you need to have a centre of excellence, you need to have the equipment. Now, for a period, people were taken to Liverpool because it couldn't be done safely in Glan Clwyd. That is changing, and they're doing more operations in Glan Clwyd, but they're doing them with the support of the Liverpool vascular network. Sometimes it's a physical presence, sometimes it's being on a call, sometimes it's digitally.

So, to come back to your question, I think there are a unique set of problems presented by the layout of north Wales, and the distances and the poor public transport—even the A55 is a reason, and the bridges we've just seen—. I don't think we can reduce the number of hospitals in north Wales. That would be absolute madness. But they do need to work closer together. There is to be an invited review on urology services, which is another service that has many challenges, and it would be interesting to see how they work that out.

I was just going to say, Hywel Dda has a hub-and-spoke model from Morriston for renal services, which works incredibly well. Hywel Dda uses Swansea Bay University Health Board/Morriston Hospital as their place to go for a whole range of services. And although they've got an eye centre in Bronglais, people certainly in the eastern part of Dyfed look very much to go to Singleton rather than to go to Bronglais, where they often then get referred on to Singleton. I'm a big fan of the hub-and-spoke model. Two questions, really, on vascular services: is the current model deliverable? And the second one is, if you have to have digital and other support, why can't you have that from one of the other health boards in Wales?

It's clearly not deliverable as it is, which is why there's all the work going on. But neither is going back to what was there before possible. Could it be delivered from another Welsh health board? 

Not the digital and online, I mean the physical—

Yes, I understand what you mean, and you can go further than that once you're using something like a surgical robot, and the surgery can be done. I think the relationships are there with Liverpool. They've always been there, and there is a flow of staff between. Actually, we've just spent five hours getting down to Cardiff from north Wales, and there will be times where you actually have to have an exchange of staff, and that's easier. But the relationships are there naturally from Liverpool. It wouldn't be impossible to do it from elsewhere, but it would probably have to be somewhere of equal standing to Liverpool because of the assistance that's needed. So that would, I guess—I don't know; it might be Cardiff, it might be Swansea. It's probably Cardiff, isn't it?

It's going to be one of those two, depending on the service. I'm not an expert on vascular services. It would be one of those two. If it was renal, it would probably be Swansea. 

And one of the issues about hub and spoke is that people don't mind travelling for serious and complex treatment. What they don't like, then, is all the out-patient follow-up. But the digital thing means that it can be done locally.

I was going to say that, where I live in south Wales, in Swansea, people always, for heart, used to go up to London. It's a recent phenomenon that the provision is in Swansea and Cardiff. It used to be always up to London. So, that's me on vascular done, Mark. 

Sorry—on that travel to London, Betsi Cadwaladr has used a lot of the waiting list money. Some of it has been used to buy 400 cataract operations a month on the Wirral, but some of it, for prostate, people are sent down to London, and then they're followed up digitally, et cetera, here. And we did initially get people thinking, 'Well, I've got this prostate problem. I've been sent to a major London teaching hospital. Is there something you're not telling me? Is my condition so serious I can only be treated in London?', and it wasn't that at all. It was just that there were some good deals in London.

Thank you. 

Thank you. If I could just, before I move on, pick up on a couple of things you've referred to. You've just referred to hub and spoke and neurosciences, the impending review. 

Urology.

Neurology, sorry. Well, neurological conditions. 

Urological, yes. Waterworks.

There was a 2009 north Wales review. They called it the neurosciences review, but it covered neurological conditions, which followed the Steers report. That had followed outcry in north Wales when it was proposed that elective neurosurgery should be transferred to Swansea or Cardiff, rather than staying local at Walton. So, following Steers, following the north Wales review in 2009, a hub-and-spoke model was introduced, theoretically, but we are where we are. So, just a thought that this is a bit like groundhog day in that example. I was then chairing the cross-party group on neurological conditions, and we had oversight of this, and we were working with Betsi Cadwaladr University Health Board on this. But, just an observation that we might need to revisit some of the historic stuff in order to see what worked well.

As you know, people in north Wales have had great confidence in Walton. It has a very good reputation. The transport services are good, and we've been to Walton and other Liverpool hospitals where they have signage in Welsh, they have members of staff who can speak Welsh. So, it just suits people better, and either by car or by public transport, it's easy to get to Liverpool, but not to get to Cardiff. It would be very, very unpopular to—

In that context, you've referred a lot there to cross-border interdependency, and you quite rightly used the words 'health economy'. In that region, it's always been historically across border, for the reasons you describe. But there are tensions and we should comment on those. So, Walton, periodically—we know because it's gone public—have had funding disputes with Welsh Government. I got an e-mail this week from a long-standing Clatterbridge patient who's been told that because of decisions made in Wales, she's now got to go to north Wales for her treatment, having always gone to the centre of excellence in Clatterbridge.

Several years ago, I was invited to meet the chief exec and north Wales board members from Countess of Chester Hospital, concerned that services that had always traditionally been provided in the area you describe, in north-east Wales, were being repatriated to hospitals in north Wales that didn't have the capacity or expertise to deal with them.

So, there are historic and current problems where the differential systems, and the desire amongst some to spend what some refer to as the Welsh NHS pound within Wales regardless, can lead to these pressures. So, how effectively is that historic and current cross-border model working, given those tensions, and what do we need to do about it? 

The Countess of Chester—. The bigger problems were when Sir Duncan Nichol was chair, and the Countess of Chester is in some fairly big financial difficulties. And I think he—. There was a dispute around tariffs and what you charge per operation. I think that was highly political. It was damaging for everyone concerned, and I think it's significant that we haven't seen that sort of public falling out in recent years.

Normally, things go very well. So, you'll know that for years and years complex orthopaedic surgery has been done at Gobowen, which is in England—people think it's not, but it is. There is flow the other way. Paediatric cochlear implants—the thing that goes directly into the hearing—

My daughter has one.

Well, that now—. Previously, children went to Manchester and had it done there. The audiology people at Betsi have worked quite closely with Manchester, and they've developed their own service locally, so children won't have to go to Manchester now, and they get all their follow-up and all the support locally. But that's been done with the co-operation of people in Manchester. So, they've not had a falling out; there are still other implants being done in Manchester. There are good working relationships, and because, in the north-west of England, people do go and work in north Wales, people from north Wales go and work in England, and I think that's not well understood in Cardiff. I understand the drive to spend the Welsh NHS pound in Wales, but if that means people from north Wales always travelling to Cardiff and Swansea, it's not right.

There was recently the resignation of some oncologists in north Wales, and we heard that patients were sent to Clatterbridge so that there wasn't a delay in the services at all. And, again, that worked well.

And people actually like being transferred to Clatterbridge—it has a world reputation.

An example I gave was a Clatterbridge patient from north Wales, who has been going to Clatterbridge for years, who's now been told she's got to come to north Wales. This week.

We would take that up on her behalf.

In terms of Countess, it was years before the incident you referred to, when they asked to meet me, and when I've conferred with them since, they've said they've had to redesign their business model now, so they've got more work contracts with referral bodies in England, to make up the provision that previously was made for referrals from north Wales.

I think this is one of the post-pandemic issues. Everybody has got long, long waiting times, and any hospital with spare capacity can sell that capacity now. So, areas where we'd had flows to the Countess of Chester, they've now filled up their capacity. They can get that—. That is one of the reasons, for example, that prostate patients are being sent to London, because that's where it is.

I think the concern was that the only reason they have that capacity was because, previously, it was filled from north Wales.

Yes, that's right, that's right. And the only reason it is the hospital it is is because of patients from north Wales. So, it annoys me when they claim that Welsh patients are a drain. Although, as I've said, since Sir Duncan Nichol has moved on, you don't hear that as much.

It was many years before that they asked to meet me.

Anyhow, to move on to mental health services, you made some reference earlier to Tawel Fan, and it's almost a decade since the incidents in Tawel Fan—it's actually 13 years since constituents and staff contacted me and others with concerns around those services. We know that this committee's predecessor, the Public Accounts Committee, received a limited summary of the Robin Holden report in 2015. More recently, the health board has been forced to publish the Holden report entirely because of a complaint to the Information Commissioner and then the enforcement of that. Welsh Government Ministers, following that, initially stated that the issues were historical, although they've since indicated or acknowledged that the central issue of providing a safe space for older and vulnerable people, which I think you touched on earlier, has still not been dealt with. And we know there are allegations, for example, that, early in the process, the then interim chief executive appointed one of the senior people against whom the allegations had been made by 42 staff to conduct the inquiry into this. So, moving on to almost a decade later, are improvements moving at a satisfactory pace?

No. And many of the issues highlighted in the Holden report are still in existence, as are many of the issues highlighted in both Ockenden reports, and the Health and Social Care Advisory Service report, and the Flynn and Eley report. We could give you a list of reports, independent reports. 'No, they haven't' is the short answer, and the incidents are still happening. So, although we still have these historic incidents around, we have incidents that happened last year, this year. We had a report of abuse of older patients with dementia in Morfa ward in Llandudno General Hospital last year. Action was taken on that, and staff training, and people were appointed to change the culture. But then we had a dreadful incident at Morris ward in Wrexham Maelor, which is—. I don't want to say too much about that, because it's with the Crown Prosecution Service, but a dreadful, awful incident of abuse of people with mental health. And in the past few weeks, staff have been suspended around incidents at Cefni and Bryn Hesketh, so those things are all still ongoing; they're all still a problem.

Progress is really slow. There has been, as I mentioned earlier, a churn of management at the highest level in the mental health and learning disabilities directorate. We did have two really good appointments: an interim director of nursing and an interim director, a management director of the unit. One of those has left following illness; the other has had family illnesses and has only just returned, so again delaying the pace of progress. There is a management review being undertaken of that directorate, and we very, very much welcome that. There need to be changes in that directorate. It's not responding as we would hope. I've been concerned that, over the past 12 or 18 months, I've started to hear people saying, 'Tawel Fan was overblown; it wasn't really the issue that everybody made it out to be', and I think that's disgraceful.

We've heard about the four-stage improvement plan as well, as part of targeted intervention, and we've, as a community health council, noted that there may well be service changes as a result of that, and we're still awaiting the service-change protocol in relation to how the health board's engaging and communicating those plans to patients, and we've not heard; we've been pushing for that for some time. But we were encouraged that things were moving in the right direction. 

We were.

As Geoff mentioned, there has been this churn in management, and there are still huge vacancies on a nursing level—

Two-hundred nursing vacancies, 50 psychiatry vacancies, and those are filled with agency, with bank, with people who are not there long enough to develop the relationships and the skills and the experience that they need. One of our priorities for our return to visiting was to visit psychiatric wards, and we did a round of visits—visited every psychiatric establishment on an announced basis —and spoke to the staff and re-established our relationship with the senior nursing side of things. And then we did an unannounced round, and we were shocked by the number of agency staff. It was common to find one permanent member of staff and then everybody else agency. 

Well, I think we've captured your comment earlier about concern that your successor body, the citizens voice, at this stage doesn't have powers to make unannounced visits—clearly, that's a critical point. We know that last year's HIW reports indicated that the majority of the Holden recommendations either haven't been implemented or whatever had been done had failed to bed down, so the problems are recurring. If we're to move from a culture of a decade of delay and denial to openness and transparency, what positive action would you propose would need to be done to start tackling those issues in the short to medium term?

I think a lot of that is contained in the targeted intervention maturity matrix. But engaging with patients and staff. There are consistently problems at Bryn Hesketh, and you will know that every so often there is a letter from the staff who are appointed at that time to the Minister or an open public letter about their concerns around patient safety. This was what happened with Holden. And then those staff are dispersed and you get a new bunch of staff, and it's not very long before you have another similar group letter. So, there is something there that's not right, and if it's different staff but the same management, well, you know, if it walks like a duck and quacks like a duck—.

Well, I was going to save that until later. How do you respond to a comment in an e-mail I received from an informed person this week that we're asking the same people responsible for the problem to now be the solution?

Yes, I agree, which was why we welcomed the management review; it's why we welcomed the arrival of the interim director of nursing, the chap who has now left due to illness. We've been banging on for years about how it wasn't fit for purpose and there were all these problems. Within two weeks of him arriving, he did a report—I think I sent it to you at one point, Chairman—of his impressions on coming in, and it said everything that we've been saying for years. I would very much like to be able to come to a committee like this and speak positively about mental health services. There are some very good staff working there; I attended the Betsi staff awards, and there were a number of awards given to mental health nursing staff and support staff, and just tremendous work going on. They need to be supported; that needs to be the norm, not the exception. 

Thank you. We'll have to move on, because we're already over time, but I would just comment, outside mental health, my own family has had very positive experiences of audiology and oncology, so it's not all negative. It's where—. We focus on the glaring issues, which still appear to be outstanding. So, could I please invite Mike Hedges to come back in and develop questions on one of those glaring issues?

Well, I was going to talk about finance, which I've got down here, but I'll talk about emergency services.

By all means, yes. 

On finance, I was going to say, Betsi Cadwaladr has had lots of money given to them; they keep on having lots of money given to them. You've just told us why they can't break even, but they keep on filling the place with very expensive agency staff, which inevitably means that you're not going to be able to set your budget. Do you think they can achieve financial balance and have an approved three-year plan in anything resembling the near future? At a public accounts committee I attended about nine years ago, somebody from Betsi Cadwaladr came along and said, 'Well, they gave me my budget. I didn't think it was enough, so I ignored it.'

I do have some sympathy with that. CHC is not set up to look at finances; it's not really our role. We're interested in finances in relation to how it impacts on patient care. As I mentioned earlier, our greatest concern at the minute is capital and the availability of it. Our view as a CHC is that the most important thing is quality of care, and that needs to be got right ahead of finances. I think people might say, 'Well, that's not a very responsible attitude for the CHC.' We're not here to look at finances. That's not our job. There are other people who are better placed and have the skills to do it. I don't have the skills to do it. Having said that, I don't think that they're going to be ready to break even, or even have a three-year plan to break even, any time soon.

One of the issues is how finances are allocated, and I remember writing to the previous health Minister, Vaughan Gething, and saying, 'I don't think that the formula works very well for the people of north Wales and, if we took these other things into account, we would have much more.' And he told me that the formula was infallible and produced the right results on every occasion. And then, a couple of months later, he tweaked the formula for Hywel Dda. So, I don't know. Finances are beyond me. My job is to look at the quality of care, is to act as a voice for the patients, and I'm afraid I will agree with the Betsi Cadwaladr guy that we always need more money.

I'll just say that money can be spent well or badly.

It can, yes.

And I think that employing a whole area full of agency staff is not spending the money well. But can I just ask you my last question, because Mark is going to shout at me in a minute? The emergency department at Ysbyty Glan Clwyd—is it improving?

Slowly, yes. I think the pace of change is picking up. We are going to visit. But, again, staff. They've got the SDEC, which is the same day emergency care service, which takes referrals direct from GPs. That's a good initiative, but it needs to be used properly, not just as a big waiting area. But, yes, we are seeing those improvements. They've brought in somebody who is skilled at doing that, which is a good thing. If they could be spending money on directly employed staff rather than agency, that would be a lot better.

Thank you, that's me.

Thank you. I think, Natasha, you might have had some finance questions as well.

My apologies, Chair, I don't think I did according to the—. Oh, my apologies, sorry. I'm so, so sorry. In relation to—. I do apologise. I just wanted to know if you're going to be able to achieve the financial plans that you actually have in place, moving forward.

Well, it's not them; it's their board. This is the patients' watchdog.

Oh, my apologies, Chair, I don't believe I've got that section in front of me. Bear with me. I'm so sorry. I'm badly organised.

But the answer to that is: not straight away. 

[Laughter.] Okay, that's a good start. Chair, I do apologise, I can't find that particular area in front of me.

Don't worry, Mike's raised a few points around finance, but you'd indicated earlier you might want to raise questions on this matter.

Okay. My sincerest apologies, Chair. No, I won't be pushing it any further. I believe they've answered the question that I had in mind.

Okay. Well, that brings us to our last couple of questions around a matter you've already touched on, which is senior leadership and succession planning. As you indicated, there have been significant management and senior management turnover. The previous Public Accounts Committee identified concerns around senior leadership in the health board all those years ago. To what extent, given, particularly, recent changes at the very top, do you consider the health board is now in a position and has the capacity to undertake its role effectively? And what do you believe should be the top priority for action if the community health council had an opportunity to make such a suggestion to an incoming new chief executive?

As I've said earlier, I think that the board are now playing a stronger role in holding the executive team to account, rather than being a support system for the executive team. I think that's much more appropriate. 

Things were going certainly in the right direction under Jo Whitehead. I'm confident that the interim arrangements will continue that. If I had—. I think our greatest wish is an improvement of engagement, and not just information giving, which it has tended to be, but really listening to people, really engaging them with a debate. People aren't stupid. They know that there are finite resources to healthcare, and, whilst they might not like that, they would be in a better position to understand it and to enter into a debate about what the priorities really are. 

And there is a new strategy in place now to bring communication and engagement—

There is, yes. I think that has—. The framework for targeted intervention says that, without public engagement around the actions and the outcomes, they can't really fulfil the maturity matrix. And if we think back to why they were taken into special measures, one of the reasons, one of the key reasons, was that the health Minister, now the First Minister, felt that engagement was not adequate—the engagement with the local population was not adequate. 

Thank you. And my very final question, then: what, if any, role, given everything you've said, do you believe that the Welsh Government itself, the Permanent Secretary, the director of propriety and ethics in the Permanent Secretary's group, and the director general of the health and social services group and chief executive of NHS Wales should have to work together to put things right with the health board?

We have heard from the Minister herself that operational issues are for Betsi Cadwaladr and not for Welsh Government. And we totally accept that; that is right and proper. But the services are provided in the Minister's name, and Betsi Cadwaladr has been failing on a number of fronts—not all, but a considerable number of fronts—for many years. And we believe that the solution to those problems are beyond Betsi Cadwaladr themselves, and that Welsh Government really needs to be providing as much assistance as possible in every respect. 

When they were in special measures, I really don't understand what that was about. If you go into special measures in England, you are provided with a huge amount of support, and then if, after about 12 or 18 months, that's not working, something else happens. But we saw people come up, individuals come up, for a few months after the announcement of special measures, and that was it really. Special measures meant nothing at all, really. Nothing changed. The problems that we see now were there then. So, I think it needs to be a truly partnership approach. And that's not just telling them where they're going wrong. If you speak to Mark Polin, he will tell you where they're going wrong. Similarly, the chief executive and the medical director, they know where they're going wrong. They need assistance on that. 

We were very surprised that they were taken out of special measures in respect of mental health. 

We were. I think it was fair to take them out of special measures on other things, but not mental health, and not vascular services. 

Okay. Well, thank you very much. Members, do you have any further questions? No. Well, we've run 20 minutes over, but thanks for staying with us, and thanks for being with us—

It's been a pleasure, Chair. 

—not remotely, but in person. So, you have set a new record. A transcript of today's meeting will be published in draft form. It will be circulated to you for you to check for accuracy before being published in the final version.

So, I hope your home journey doesn't take quite as long as your journey down here, but—

No, it should be—. It's a better time of day. 

Yes. I've got mine tonight, so—. Well, thanks for being with us.

I'm very surprised nobody asked us about the air ambulance.

If you wish to comment—.

No. [Laughter.]

I think another committee, the health one, is giving consideration to that, so it wasn't one of our priorities, given the work programme we already have on the board.

Thank you. Thank you, all.

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