Cynulliad Cenedlaethol Cymru

Diolch, Gadeirydd. Good morning. Thank you for the submission of your written evidence, but in that, you actually identify that you're talking about some collaborative working and the transforming cancer services programme. You highlighted the fact you're going to change the clinical model in the approach that you're going to take forward—for the patient benefit, you highlight. Perhaps you can just explain how that model will work and how patients will see those benefits.

Sure. I'll kick off with that. We've been working on the programme for about three years now in terms of taking it forward with patients, our colleagues and stakeholders in the third sector and with our colleagues in health boards who commission our services. We're working on a model that meets the challenges of the future. So, we're looking to take care as close to people's homes as we can, and that's the underlying principle in the work we do. I'm sure Jazz and others will come on to how we manage to do that safely. So, the model is making sure we're sustainable in the future and actually we can deliver care as close to home as we can.

Our current model is about 40-odd per cent close to home; we want to push that up over 50 to 60 per cent. And that will help us and it will help our patients as well, so there'll be less travelling, less impact for poorly people having to attend our centre. So, that's the underlying ethos. We've worked with our patients in designing that and coming up with what that model will look like in the future. It will be based around centres in each of the health board areas, but also providing care at home, building on what we currently do because we already have some models of care that actually are delivered at home.

So, does that model of care closer to home obviously then require—? I think if I mention the satellite-type hubs being placed around—are they in place at this point in time or are they yet to be put into position?

We work out of all of the health boards currently in a multitude of sites. What we're looking for is to bring those together to have one improved site to access our services in the local catchment areas.

Okay. Because I'm just wondering where the funding comes from for some of those infrastructure projects. Is it coming from the health boards or is it coming from your own trust?

That will come from Welsh Government through public capital.

Obviously, you also highlight that included in one of the projects is the new Velindre cancer centre. Where are we with that? What kind of stage are we at? Because that's going to be a major element of delivery.

Yes. It's clearly a key element. In terms of infrastructure, it's the biggest part. We are completing the business cases at the moment with Government colleagues. We are completing a development agreement with Asda, which is providing the access through their car park at Coryton, which will deliver benefits for the Whitchurch community in particular, in terms of taking a lot of our travelling patients and staff out of Whitchurch. Those things are coming together and we're aiming to close those as quickly as we can. The aim at the moment is that the hospital will open in 2024.

And what's the funding model you're looking at?

It'll be delivered using the mutual investment model.

And you think that's the best way forward.

We're just delighted to be provided with the ability to deliver the centre, to be honest. That's what we wanted. It's why we delivered the strategic case in the beginning. I think it's needed in Wales, certainly in south-east Wales, and it will certainly improve the benefit that patients can get from visiting us at the building that we've got at the moment and to meet future demand, which is going to go up 2 per cent a year.

Obviously, that new centre, when—and I say 'when'—it is actually developed and established will be focused on south-east Wales, but will you keep on specialisation, because clearly there are patients from all over Wales who come to Velindre?

Yes, we will. That nature of the organisation won't change. What we are doing is working more closely with the centre in the south-west. We're building—. Carl can maybe talk about some of the links that we're creating to actually work more together as a service in south Wales, as I think that would benefit everybody as well. I've been talking to the chief executive of Swansea Bay about exactly that.

So, there's a programme to actually create a wider linked network between you and other—?

Yes. Thanks, Steve. So, the programme consists of seven projects. Some are buildings. More importantly, it's about service change and transformation. There are two phases. Phase 1 is non-surgical oncology—the bit that we do—so the last end of the pathway, the tertiary bit. Phase 2 is actually the whole of the south-east Wales system, and we are in conversations currently with health boards to understand because we all know that, whilst, if we continue to get patients coming at stage 3 or 4, you can only do so much in terms of improving the outcome as opposed to the game changers that are way up front in terms of public health, prevention, early diagnosis and protection. So, that is part of the conversation we're having with the health boards, and the chief execs, through Steve's good office, have agreed to set up a commissioning leadership group, which has started looking at a programme across the whole of south-east Wales, which starts to pick up those issues.

Just picking up a couple of other points, which are really important, actually, and your question around what we are doing. Well, I think what we're trying to do is improve cancer in Wales, and there are a number of benefits identified within the programme business case and across all of the business cases. So, for example, we would expect to see more patients surviving cancer, more patients having a better quality of life, more patients having reduced pain and anxiety, more patients presenting at the general practitioner surgery rather than at the accident and emergency department. So, at the minute, about 35 per cent of patients present in A&E for the first time with a cancer. So, clearly, the system hasn't performed as it might, and there's a whole range of things we've set out in our business case to say, 'We will know we've got there because these things will either have been reduced or removed or the patient will have a better outcome and a better experience.'

So, it's a very detailed business case at the programme level, and then each of those projects deliver a part of it. Again, I think Steve's point was really important earlier, whereby the approach that we've taken also adheres to the direction of travel in 'A Healthier Wales' in terms of care at home, care close to home, and only travel where required for really highly specialised services. And we are also very keen to make sure that that ties in with the Well-being of Future Generations (Wales) Act 2015 about us being cohesive, prosperous and making sure that people get back to work as soon as possible to contribute to the economy. So, we try to have a really, really simple approach to a very complex programme and problem in Wales.

We've started the work, and some of those benefits are already in the system. As Steve said, we do provide services close to home currently. What we want to do is do more, go faster and use some of the things available to us that aren't currently, so automation, artificial intelligence, workforce capacity gaps. So, that's the general flavour of the programme and, again, we can certainly provide you with quite a lot of information. As you can imagine, business cases run to hundreds and hundreds of pages, but we are trying to keep it simple so that people understand what we're trying to do and they can help us to make it better.

Okay, thank you. Workforce issues—I know others will raise that point. I'd love to jump in there, but I'll wait. But in relation to you trying to—. You talked about the fact that part of your model is also spreading out to try and hit the early stages—stage 1 and stage 2, rather than stages 3 and 4—and there are models that work. I think Royal Glamorgan Hospital and Neath Port Talbot have got the sort of turn-up, one-day service, in one sense. Are you working closely with those types of projects to see how they can work and benefit, so that we do tackle those early interventions?

Yes, absolutely. I think, just to follow on from the previous conversation, I think what's important to mention here is that the whole programme has patients at the centre—that we have really listened to what our patients have been telling us in order to plan this transformation. It really comes from their views, which is key; it's about the service that is fit for them and fit for the future. And, of course, this is on the background of an increased demand on us in terms of cancer diagnoses. And to do this, it's a huge piece of work not to be underestimated. This work has started. We have got a patient leadership group in Velindre, and this is a cohort of people who've been trained. There's a cohort of 10 people who have gone through this leadership programme in collaboration with Public Health Wales, and the King's Fund is also involved, and they have—. So, they are individuals who now sit on our trust committees and are contributing and quite openly telling us what we need to do.

When you think about trying to move this care closer to home, it is also about various aspects including self-management, understanding what the diagnosis is about and communicating also with primary care. I think in our submission we've talked a little bit about a primary care initiative, because we need to speak to our GPs, get them on board and educate them about oncology, so that they can also support our patients in the community. So, I think that's just to give some perspective as to where we've come from.

With the early diagnosis programme—I mean, that's hugely exciting. That could be the most significant intervention in terms of improving outcomes for cancer in Wales, so we really do need to consider that seriously. We, obviously, in Velindre, are perhaps at a slightly different point in that pathway, but we do have a role to play, we do have radiology services in-house—there is certainly an opportunity there that we are looking at, and we're working very closely with the Wales cancer network involved in the single cancer pathway to look at our opportunities there. We need to be prepared for what an earlier diagnosis might mean for our cancer referral numbers. There might be an initial blip of an increase—how would we handle that? So, we need to plan for these things, but, ultimately, the goal is to improve outcomes, which we're absolutely on board with.

We appreciate that goal and I think we all support that goal. The question, I suppose, we want to ask is: are you in a position to achieve that goal, for example financially—funding? Are you able to ensure that your budgets are in place to actually achieve that goal? Because, as you've highlighted, there may be a blip increase and that's going to add extra costs and pressures on your budgets. So, are you in a position to say that the budgets actually can deliver your ambition?

I think the work that we're doing, our demand capacity planning as part of the implementation of the single cancer pathway, will tease that out. I think we all need to collectively work out what that means and how we handle it. We're focusing at the moment on the diagnostic end, which isn't a part we play a huge part in, but, certainly, it will have an impact, and we're on the second or third round of actually working and modelling the demand capacity issues so that the system is in a position to respond and we will work with our commissioners in terms of being able to do that.

Okay, because one of the challenges in your integrated medium-term planning is actually an ageing population and increasing demand. So, you've already identified those challenges, in a sense, in your IMTP. Has the Welsh Government come back to you and said, 'Okay, we'll actually agree with this', and have you had discussions with the Welsh Government about budgets?

Yes, and as a system, we're working with—. We work with the cancer network and we're co-ordinating this work in determining what the system needs to be able to implement it. So, it's not just us—the whole system needs to be in a position to respond. So, that dialogue is happening, it's being co-ordinated by the cancer network, and we're part of that dialogue that's going on.

Yes. And just to give you some assurance, in terms of before we continue down the path of the programme, clearly, the programme business case sets out the high-level programme. So, that's got to, basically, at the very start of the journey, justify, identify all the costs, and cost all the benefits and the disbenefits. So, essentially, we've got to justify at a very early stage that the benefits will outweigh the costs if our assumptions come to pass. Now, clearly, they're assumptions, but we've done that, and I think the central argument in our case is quite a simple one in many respects, in that if we continue to run the system we currently run in the way in which we run it, and demand continues to rise, as we expect it to, it's going to cost X, and the quality and survival rates will remain roughly the same. If we introduce a new way of working, with a new system where patients and carers and families are at the centre of that design and delivery, we believe quality will improve, survival will improve, experience will become better, and the relative investment will be reduced. So, that's the basic central thread of our programme business case. So, we believe by doing it in a different way, we can get a better result for a more effective use of public money. 

And that includes—. Obviously, we've talked about the cancer transformation programme, but you also do the blood health plan and the blood supply chain 2020. Where are we with those? I'm assuming, again, that the budgets can be shared out or distributed to ensure that they are also deliverable at the same time you're trying to do this transformation on your cancer services. 

Yes, we've got a robust financial plan in place to support that. Clearly, once we identify areas, we will have to have discussions about investment if needed, but we'll need to be clear about what the benefits of those are. We've got the plan in place; we're working closely with colleagues. Cath, who up until recently was the director of the blood service, can take us through some of that in a bit more detail.  

Yes, I'm more than happy to. So, there's two elements to this, really. The Welsh Blood Service has a role in producing the blood, in collecting the blood from our generous donors, and in processing that and distributing it to hospitals. But we also have maybe a lesser known role, which is in working in collaboration with the health boards to make sure that we're looking at the effective use of blood in that clinical environment. And in doing that, in 2015, we started having a sort of renewed conversation with the health boards to create the blood health plan for Wales, which was then disseminated via a Welsh health circular, and we're now in the implementation phase. So, to ensure that we're working effectively and collaboratively with the health boards, we have a national oversight committee that's chaired by one of the consultant haematologists from Aneurin Bevan health board, and there is a work plan, and that work plan is covering five different areas at the moment. 

So, we're working with the health boards to look at the use of O negative blood, to look at the use of platelets, and to look at a number of different conditions that can arise as a result of transfusion. And in terms of taking us to a very different area really, in terms of that prevention agenda, we are working on the incidence of anaemia in the Welsh population, and what that might mean and the way in which we tackle that, to ensure that patients are coming in well enough to have their procedure, potentially without that need of a blood transfusion. So, it is very progressive, and we are working on, as I said, a number of projects. So, we're about 15 months in to some of those projects and they're already starting to reap rewards, so we're starting to have some very different conversations with the health board staff about how they use, for example, O negative blood in major trauma, and the major trauma protocol, and actually how we can make sure that we reduce waste through that protocol. 

But one of the other important things that we're looking at with the health boards is how we mine and share data to enable us to really have a very much more granular understanding of what happens to the blood once it leaves us. Because if we're able to map that against the population demographic and around incidence of disease and interventions, then we're going to be able to better plan our service for the future.

As you said, we know we've got an ageing population. We also know that the number of new donors coming forward globally has reduced by about 30 per cent in the last 10 years, and 40 per cent in terms of young donors coming forward. So, we know that we've got a challenge to make sure that we continue to have that adequate blood supply for our population in Wales, and I'll come back to that in a second. But what we're doing at the moment is we're working with the health boards to look at that more granular data to enable us to better understand the utilisation and to map that against where the health service is heading for in the future, to enable us to have a more accurate level of planning for the future. So, that's a piece of work that's still at the early days of exploring maybe who has what data and where, but we're hoping that, over the next couple of years, that will really reinforce our planning process. 

I'm assuming from the last point of your answer that you are having discussions with Public Health Wales to look at campaigns to promote greater blood donation. Because if you say there's a definite drop in donors, particularly from a younger age group, we have to do some form of campaign and public awareness. So are you in those discussions with Public Health Wales?

We don't actually do it with Public Health Wales; we do that ourselves. So, within the Welsh Blood Service, we have a team of people who are actively engaged in donor recruitment, and we have a whole range of campaigns. Some of them we run locally. I don't know if you might have seen that, in the last 18 months, we've made some very great strides in terms of using organisations and their social media to get some of our messages through people's networks. So, we've subtly changed our model, from going out and our staff ourselves going to businesses to ask their staff to donate, to going to businesses and organisations, rugby clubs, mothers organisations, parent organisations, youth clubs for younger people, and asking them will they help us distribute our message through their social media networks. And we've found that this has given us a big increase in the number of new donors that we're able to recruit.

We also participate in global activity. So, for example, over the last couple of years, we've participated in a global initiative, which is called the Missing Type campaign. And, in fact, we engaged with Welsh Assembly and Welsh Government colleagues. It was to get organisations to highlight the potential for not having enough blood, by removing the letters A, B, and O from their names, and using social media as well to highlight our plight. We also have an awful lot of support from the media in Wales. And in fact, ITV came and helped us highlight the need for platelet donors, and we had an item on the news with them last week, and the BBC have also covered issues with us in the past. So, we have a very active campaign, and we're always trying to come up with new initiatives and ideas to do that.

And then, addressing the decrease in young donors, we know that life is getting busy, we know that there's an awful lot more for young people to do—you know, that society is changing. And so we are currently engaged with Cardiff Metropolitan University to look at a programme of research with young donors, to really get a better understanding of their perspective of what blood donation means, what it is and the benefits, to really make sure that we're able to fine tune our recruitment campaigns and our service delivery model to meet the needs of those younger people.

Okay. That was quite thorough. Thank you for that. Your IMTP highlights all these points, but also includes a reference to the fact that the current commissioning arrangements are no longer sufficient. There are wholesale differences there, and, with commissioning changes possibly on the line, quite dramatic wholesale changes. Where are we with the commissioning arrangements, and will they be sustainable for the medium term? Because, clearly, the programmes you've identified are ongoing programmes. 

Carl mentioned earlier the arrangements that we're putting in place and establishing with the health boards for the cancer service, and I think they will take us into new territory, and I think will strengthen our engagement, actually. We've got strong contracting arrangements with health boards, and what we want to do is improve our commissioning with them. The work on the Transforming Cancer Services model has helped to that end; we need to build on that as we take that work forward. We want to develop the delivery models underneath the model we talked about earlier, and we need to do that with health boards. Our engagement is improving, has improved, and it can get better as well. Certainly, the conversations I'm having with my chief exec colleagues is about doing that. And we've got sign-up from them to actually take a lead on this commissioning group, which I think will be a positive thing as well. So, I think it's a big move forward.

In terms of the blood service, we're changing the way we engage with the blood plan. I think it will only improve our supply and delivery and collection by understanding how things flow better. And I think our connections there have improved a lot over the last 12 or 18 months, and they will continue to improve in the future, on the basis that we're all now sitting down and working through the blood plan.

So, you're in a situation where you have developed strong networks, strong relationships, and the commissioning is an ongoing process with room for improvement.

Yes. That's where we are. 

Before we leave the blood transfusion service, can I just ask, in terms of when you've got a clinic randomly somewhere in Wales, is it possible for people who know about that clinic just to turn up and have their blood taken there and then or is it a situation where it's appointments only?

So, we try and do both. We used to just have walk-in clinics, but then we used to find that a lot of people would turn up all at the same time and we'd then end up with quite long queues, which could be quite frustrating for donors. So, based on some partnership work that we did with donors a number of years ago, we introduced an appointments system. But what we try to do is to keep a balance of having appointments available, but also having walk-in slots. Trying to maintain the balance that you allocate to the two is quite challenging. We consider it to be a bit of a dark art, actually, because it's difficult to draw a particular line somewhere. So, we always try and work hard to accommodate our donors wherever we can. But, absolutely, we’re happy for people to turn up and make a donation if they’re eligible to and if it’s safe for them to do so. But we’re also happy for people to turn up just to come and have a look—if that's somebody who would like to find out a bit more about blood donation.

Okay. Jayne Bryant is next.

Thank you, Chair. I think Carl's already touched on 'A Healthier Wales', but can you outline how you're responding to the challenges in 'A Healthier Wales'?

Yes, of course. I think the first thing to say is that we really welcome 'A Healthier Wales' because it’s very consistent with Welsh Government health policy for the last 10 to 20 years, which is really reassuring. In terms of our organisation, I think, we’re also a very ambitious organisation and to date, we’re certainly not complacent, but we’re relatively successful. So, I think what we’re trying to do is—. First of all, our challenge is to be the best at what we do in Europe and the world. So, in our two core services for cancer and for Welsh blood and transplantation, the advantage we have is that we know what the best looks like because we have comparators out there that are tangible and we know what the outcome measure and the outputs are.

So, our first response to 'A Healthier Wales' is to actually take the service models we’ve just described in terms of blood and cancer and fully implement them and yield the benefits we expect to occur. So, that gives everybody a huge step forward in terms of the availability of that service and accessing that service, the service they receive in terms of the treatment, the care and the experience, and ultimately the benefits. So, that’s our phase 1, as you’ll see outlined in our IMTP. And that’s not to underestimate the challenge that that presents, but also the huge opportunity. Phase 2 for us, which is what we’re discussing at the moment with colleagues around Wales and also the board, is how can we as an organisation add value. How do we reincarnate ourselves as something different? So, are we always going to be providing Velindre Cancer Centre, tertiary and blood, or are there things we can do further upstream for Wales plc?

To go back to Steve’s point about commissioning, really, what we’re looking to do is commission for outcomes in health, but also in the wider determinants. So, what’s our contribution to social inclusion? What’s our contribution to a highly productive, resilient community? So, we’re into that space, really, to say what can we do more upstream, which might not be us doing it, but we are partnering and supporting. So, for example, in public health, we have a really unique set of brands that are well known, well trusted and respected: blood and cancer. What can we do then to get moments where we make every contact count? For example, when somebody comes in to donate blood, if they are happy to receive the information, we’ll talk about lifestyle issues, smoking, smoking cessation, obesity and healthy living.

So, there is a range of things that we’re looking to do that is in accordance with the direction of travel of 'A Healthier Wales' and moving from right to left—so, doing as much as we can for my mum at home, because that’s where my mum is best placed and she values that more than coming somewhere else for her treatment or care, and then secondly, being a bit more creative and thinking about what other value can we add, both in the healthcare system and also the wider public services. We're particularly interested in how we start to become a really, really helpful partner in regional partnership boards and public service boards and getting into that space, really. So, not just doing what we’ve always done; we want to keep evolving and keep improving and adding value in different places. And we’ve got a range of activities that we’re taking forward within our IMTP over the next few years, which start to set out not a different direction of travel, but a broader direction of travel for our organisation.

Just a couple of things there. I'm meeting the chair and chief exec of Public Health Wales I think next month to build on some of these conversations. Primary care is a key area for me. I think we can contribute in primary care probably more than we do at the moment. We've got to work out what that is and build up a proposition, because I think we can support, certainly, clusters in terms of the way they work, and we've already got an initiative that we're running with Macmillan—so, embracing some of the 'A Healthier Wales' stuff. 

The other thing I'd say is that we're collaborative by nature as an organisation. You can't survive as a stand-alone centre unless you do collaborate. So, it's in our ethos; it's in our blood to actually look for partners to work with. We work across the third sector, in terms of supporting our patients on their journey through their illness. It's in us, so we're building on that, and that's not just with healthcare, that's with higher education and other sectors as well. And what we'll be doing is building up our interest in working in commercial partnerships as well. 

Great. Sorry, did you—?

I was just going to mention the use of innovation in the space, which we are certainly excited about, and we are looking at how we can innovate digitally, support our patients and our donors through this journey. The concept of being cognitive by design in our very approach to the system that we're trying to set up and the opportunity to do that with the new hospital and the transformation programme, so—.

I was going to come on to that in a minute, but I was just going to ask you: in your written evidence you refer to a programme of engagement and education oncology for primary care professionals. What does that programme involve? 

Yes, I'll take that. This is an initiative that we have started in-house. As I said, it came, really, from the fact that we don't seem to know our GPs like we used to. We don't meet them, and, actually, we really should have a better relationship. So, it came from a position of, actually, 'We don't interact with them: how about having a hosting and engagement event?', which we did of an evening, with some talks around common cancers, a little bit of food and a relaxed atmosphere. Prior to that, we'd actually sent out a questionnaire to find out if people were interested, and we had a very good response to that, suggesting that, actually, yes, there were people who were interested to come and find out about cancer and be educated and meet us. So, we were oversubscribed for that first engagement event and we have since continued to host those every six months.

But part of the work that we've done in parallel with that has been to assess, again through feedback, where the gaps are—where do GPs feel that their knowledge is lacking? It's difficult to keep up with changes and advancements in cancer care. We ourselves find it difficult. So, we recognise that, actually, there was a need for something more structured and formal around a course for education to improve knowledge around oncology. So, we have developed, with Cardiff University, a short course in primary care oncology called community oncology, because it's also for anyone working in the community—therapists, nurses—and we've had our first event in March this year, which again was oversubscribed. I was at it and did the introduction talk and it was just a great place to be. There was a real enthusiasm in the room from people of all health professional backgrounds in the community wanting to know about the work we do, wanting to know about cancer, and we will be rolling that—. We're just now looking at the analysis. The feedback has been excellent. We're planning what we will do with that. 

I should say that part of the focus for doing this work has come from the Macmillan framework for cancer programme, and we have a GP in-house who has worked alongside us to help with this. And, of course, we've been also liaising with our local medical committee, which I attend, and recently did give an update on the work there. So, we've started small, but we do have ambition around this, which we are planning. 

And there are ways to measure it and evaluate it.

Absolutely, and we would be able to share that when we have that. 

Okay. Yes, that would be great, thank you. And just going back to the bit about innovation, you said that high-quality research development and innovation is a strategic priority for the trust. What are the main areas of work that are under way or planned in the area, and what benefits do you think that could give the patients of Wales? 

Where do we start with that one? 

I'll start off. We've given you an example here, which is particularly exciting, actually: the area of artificial intelligence can provide for patients and for us a very different experience in the future for the better, and I think it's an ability to actually keep in touch with parents 24/7, if we can build trust in that sort of model. So, we're taking that forward closely with patients. We've got a patient group right in the middle of designing RiTTA—real-time information technology towards activation—who is named after one of our receptionists, because we started with, 'So, what questions do you get asked?' It's a really engaged programme. We've got support from industry, in terms of delivering it, which has been really exciting—they're excited about it as well. We're keeping the intellectual property, which is an important part, from our point of view, to make sure we keep the benefit for the service going forward. But it can change our interaction with patients fundamentally. We're starting small, again, with RiTTA in some key areas, just to understand how it works. What it'll do for us, as an organisation, is change our view of what the future might look like. So, one of my challenges for the organisation is, 'What will the service look like?'—not the locations about where we'll deliver it, but what will it look like in five or six years' time, and how do we embrace technologies and other things, and engage with patients and staff about designing what that model will look like?

Then, embracing innovation as part of the organisation, we've employed some people to actually work on innovation with us. We've got some very challenging, exciting people around who Jazz manages and leads, and they put that challenge into the organisation to benefit patients. We're not doing it just for ourselves—what we're doing is broader than that. So, we've got people involved in Bevan Fellows, sharing skills from that point of view. We bring in from other services as well.

How has achieving university status made a difference to the trust?

I think on one level it changes the view of the outside world. It's all part of where the organisation wants to be in the future. But it fundamentally builds on the relationships and the work that we were doing before. So, we've got a lot of cross-working with the university sector, not just Cardiff but others as well. We want to broaden that, both in terms of research and education. Jazz has already talked about the educational work around primary community care. We've also got learning programmes around other things. We want to link in the blood service with that. It's not been a huge feature in the blood service, in terms of research, but since Cath's been there—about four years—we've started to build a research base for the blood service as well, using our scientists.

So, I think there's something about using the university status to actually put that leadership in and bring people in to actually join with that. We already have an arrangement with Cardiff University—I meet with them about twice a year to actually set, 'What is our unique selling point as Cardiff? What do we want to focus on? How do you want to take things forward?' So, it's adding to momentum, it's not starting a journey, but I think it's really helpful in so many layers. Also, in terms of recruitment and retention of staff—I know we'll come on to that later—it actually says something about the organisation and where it wants to be.

Just a couple of things—I think, reputationally, it's really important for us. It's about our kind of external-facing position, really, to our commercial partners and academic partners externally. What we've done, in the process of actually achieving that university status, is we've had to take a good look at ourselves and actually develop areas of priorities and a kind of strategic approach about moving forward, which also includes actually writing a strategy for research, development and innovation, which is under way. So, I think it's helped us create that clarity of thought and process. A lot of good stuff is happening.

Could I just add something very quickly? It's also wider than you might anticipate, because you might expect, as a health organisation, for us to focus on health research, but, in fact, within the Welsh Blood Service we're an enormous logistical operation, and we've been working with the School of Mathematics in Cardiff to look at some of the organisational logistics research areas—I'm working with them on a PhD at the moment. So, our aspirations are wider than what you might expect, just as a health organisation.

Okay, great, thank you. Just finally from me: in the written evidence you've provided, you refer to a system leadership role. Perhaps you could expand a bit on that and what it means.

I think Carl's already touched on—

Yes. Is there anything you'd like to add to that?

Well, I just think it's about looking around the world at what models seem to deliver the best results. I think if you look in Wales, we're a country of roughly 3 million people—all of the external folk who come and look at us say we're roughly the perfect size to do something very special. We've then looked across the world, with our health board colleagues and others, to see what works well. It seems that there's a number of interesting models, certainly in Canada and also, actually, in England, at the moment, with the vanguard systems in Manchester—Christie—and Birmingham, which largely talk about a system, a whole system that has got lots of component parts all working to a common aim and a common purpose and a shared set of outcomes, where we share resource and we share capacity, and we do that in a collaborative way.

Most of the ingredients are in Wales, but I think what we're looking to do is perhaps work with colleagues and somebody to lead on their behalf, with the mandate to actually start to put in place those things. We talked a bit earlier, didn't we, around a programme for cancer as a good example, which would include public health? So, how can I maintain—? My young daughter's 10: how can I keep her healthy and so on and so forth—prevention, diagnosis? Well, wouldn't that be really exciting and would it deliver the best results if an organisation, on behalf of others, was almost the gatekeeper to start to help design the system and make sure all the standards are in the system, that we have the right plan that connects—? If, for example, we have a capacity shortage for radiotherapy down in Swansea, wouldn't patients come across to Cardiff for their treatment? At the moment, some of those things are in place, not all.

So, that's the conversation we're currently having, certainly at chief exec level and at Government level. And, again, it ties in with one of the key ambitions of 'A Healthier Wales', which says: new models of care that are scalable. So, at the minute, we're talking about south-east Wales, but you could have a model that talks about south Wales, and then, potentially, you might want to do something in north Wales that may look into England, as it does currently, because of the logistics. But we are trying to say: one system, one common purpose, one set of shared outcomes, one plan. Now, that's really what system leadership is about: it's about collaboration, cohesion, integration and success. At the minute, we're nearly there, but not quite. But our push—and it might not be us leading it, we're not at all conceited about this, we're just saying: we've got an interest, have others, how do we move that forward? And the same for blood, albeit that blood is in a slightly different place, because we have a national service.

Just one more thing I was going to pick up on the blood service—from the blood service point of view, it's about the wider geographic impact, and I think our footprint on the European stage and within the UK is changing. People are coming to us to see how we're doing things, which has been a big thing over the last few years, and it's really good for the staff working down there to see that as well. And it's changed how we're viewed, because there's quite a close European group involved in blood services. Leadership comes in many ways, I suppose, and I think it's not just about Wales. 

Can I add another example to that, just to echo what Steve says? The Welsh Blood Service is now being recognised globally as one of the leaders in terms of where we are, particularly in terms of the work we've been doing to engage donors. But there's another area where we've used our specialism to have a leadership role for Wales, and that was recognising the expertise that our staff have in handling cells. We were asked by Welsh Government to lead a piece of work to develop the statement of intent for advanced therapies for cell and gene therapies for Wales, and that was recently launched by the Cabinet Secretary as part of the precision medicine initiative. And so we've taken a leadership role in that for the last few years, and we're delighted now to have been tasked with setting up the implementation programme, and we were also able to bring the best part of a couple of million pounds of Innovate UK funding to Wales to establish an advanced therapy treatment centre in collaboration with the University Hospital of Wales and Swansea Bay. So, that, I think, is another prime example of our expertise being recognised and our track record in delivery in being asked to take forward some of these initiatives. 

Thanks, Chair. How would you describe your overall performance, and how would you rate cancer services in Wales as a whole?

Our overall performance has been consistently very high over several years. We meet demand. Our quality indicators have good standards underpinning that as well. Our patient experience responses are very, very good. Now, that doesn't mean we take that for granted. I particularly read every patient concern letter and sign every patient concern letter before it goes out so that I'm sighted on some of those aspects as well. But performance has generally been very good, or better, for many years, both in the cancer service and in the blood service, and we deal with underlying issues. 

In terms of the cancer service in Wales—I'm not sighted on services elsewhere—one of the benefits of Carl's description about how we could work in the future would be we would be more joined-up with what goes on elsewhere. Clinically, we do link up. I think our clinicians are very linked across the sites, and Jazz in particular works with Cwm Taf in her area, so our clinicians are linked through multidisciplinary teams across the piece.

Okay. You mentioned concerns, and we had a discussion last week in this committee about viewing concerns as a gift, really, and something that can really benefit an organisation. Do you get lots of concerns raised with you? Can you tell us a bit more about—?

Well, across the service we get on average—I was looking at the numbers yesterday—between 80 and 100 a year, between the two services. In volume terms, we probably get more from the blood service, and Cath might want to explain why that would be. Thirty to 40 in the cancer centre a year. Clearly, I certainly see them as a learning experience, and for somebody to go through what is generally a very emotional position as well is really important. So, I read both what they send in and what we're sending out, so that I can get a picture of what's happening and actually make sure we get the tone right on how we're engaging.

We've got a very good team—it's not a big team—who actually keep closely in touch with the people who have actually put the letters in in the first place, or the e-mails or however they engage. And I engage with them as well through our nurse director and I meet with the team to see how that's working. So, I think it's a really important part of what we do. We don't just take the fact that from the patient experience point of view, we get 90 per cent, nine out of 10 for the cancer service; we get 95 per cent or more satisfaction for the blood service. It's about understanding the whole picture. I've got the patient liaison group most months to actually get a sense of how they feel about what we're doing, and certainly, the rest of the board—the independent members and the chair—meet with patients individually, in out-patients and elsewhere. So we do engage to find out what people feel about what's happening. It's not perfect—it's never going to be. There always will be issues, but it's how we deal with them and how we learn from them.

Okay.

I was going to say, actually, I was looking back, in preparation for this, at the very point that you raise about how we've used those concerns to improve our pathways and, actually, there's a kind of rich list of pointers that have come out of them that actually help us shape our organisation. There are simple things like the text messaging for donors, an online booking system, but also about treatment choice—people want choice—and how we are considering that in our pathways. Record keeping, communication, we hear about that. But in one case, actually, we changed the nasogastric tube that we use on the wards because there was a better product that somebody had had in the health board, and that led to a change clinically. That's a really positive thing. So there is something there about using that opportunity I would say.

Okay.

Just in terms of service concerns for the Welsh Blood Service, obviously we're dealing with donors and not with patients, but we use the same NHS system that is used for patients who raise an issue. So, we proactively put feedback cards on the tea table when donors are having their biscuit and a cup of tea at the end of the donation, and we actively encourage them to fill those in. Every single one of those is read and every single issue is logged. If there's anything that's not positive, then we pick that up. All of the positive comments are then fed back to our staff, because it's really important for our staff that they receive that positive feedback from donors. So, what we then do is we have a service improvement loop, and they're reviewed by the senior management team and the operational management team, and collection is on a monthly basis. And then any that we're not able to deal with immediately then get fed back in. But as well as those cards, we also proactively send out an e-mail every month to anyone who's made a blood donation in that month, and again, the feedback through that e-mail system is again trawled, trended and there's an action plan set up. And then any that we can't deal with within that 48-hour period immediately then become a formal concern. Although, actually, what it is quite often is just user feedback as opposed to somebody making a complaint. We just take very seriously any information that we can get and make sure we use it.

Okay. Thank you.

Angela's got a point before we move on.

I just wanted to pick up on the response that you gave to Lynne about—. You said that you weren't really sighted on performance in other cancer services outside of Wales. So I just wanted to ask: what benchmarking processes do you have in place? Do you benchmark yourself with the best of the best? Because that, surely, is how you can really measure performance.

Yes, we benchmark with many centres across the UK, and if we can, elsewhere. It's a bit of an art rather than a science sometimes, but actually we've done a lot of work building up our benchmarking over the last three or four years as we've taken the transforming cancer services project forward. We've improved that. Carl's led on some of that work, so he might want to take you through that.

Yes, we have. It's really important both in terms of the effectiveness of our service, but also other aspects. We've certainly developed some good relationships and benchmarking data with centres that are perceived to be high-performing in the UK. So, we benchmark with Clatterbridge, Christie, the Royal Marsden, Leeds and Beatson, and we're also looking further afield, so places like the Peter MacCallum Cancer Centre in Western Australia.

I think the one problem we've stumbled across is because we're not a secondary care organisation—if you take Dr Foster, CHKS, all of those sorts of benchmarking systems are largely focused on secondary care—there is not a wealth of readily available information or benchmarking clubs specific to specialist services, so we are trying to almost develop a market. So we have done it ourselves, but we would have found it far easier if we could have found a provider that would run a benchmarking club similar to the ones that are available for secondary care. I guess it's similar for areas such as mental health, primary care. We're struggling with the same sorts of issues, because there's always been a focus on secondary care.

Then Cath might want to say that, for the blood service, there's the European Blood Alliance, which is a European benchmarking club, so we are literally talking about the best in Europe.

So we have made some progress. There is a bit to go; some of that is within our control, some is not. I think that the important part really is: how are we doing? And actually we're doing not too badly. Most of the benchmarking information we have at the moment is that our quality of delivery is high, and the other thing we get asked is, 'Yes, but how much is it costing?' and our unit cost is within, I think, a fairly low quartile as well. So, on both aspects we're going fairly well.

Can I just flip the question the other way and ask if others are coming to you for experience and guidance in developing elsewhere?

Yes, absolutely. I think that's part of the journey, isn't it? We've learnt a lot from others, and they're learning from us. And it's really interesting when you start looking at different models of delivery. So, when we went to the Christie and the Marsden, they're providing a very similar model to ours, with a home outreach specialist service, but we went up to Scotland and it was all centralised, and it's, 'Oh, can we come and have a look at how you—?' It's just the question why, isn't it? Why is it different? What are the benefits, what are the advantages and disadvantages? So we've really got quite a rich network of information, and more importantly peers all trying to get to the same place, which is delivering the best possible outcomes for patients. It's been really helpful. It's quite time consuming, just because we don't have that data set readily available at the moment.

Thank you.

Okay, back to Lynne.

Is the trust meeting waiting-times targets?

In terms of the waiting-times targets you see published, we're not part of that system. We have set targets that we work with in terms of chemotherapy and radiotherapy. We've generally met all of them. The last few months there's been a significant increase in demand for radiotherapy, particularly in prostate, and we're adjusting to that at the moment. So we've had a few months where it's not been as good, but we're still focusing on addressing the clinical need of the patients that come through, and Jazz might want to pick up on that, to make sure that patients don't come to any harm as a result.

We engage fully with the patients through that process as well. We're adjusting to it, we're putting plans in place to be able to get it back to where we want to, but we did have that unexpected—. Actually, it's not unique to us. Again, we've spoken to the cancer centres and the cancer network about it and it's happened across the whole of the UK, so everybody's having to adjust to what has been about a 9 per cent increase. Jazz, do you want to—?

There is this increase that we've seen in referrals from prostate cancer and we're working with the health boards to get their data and understand if this is equal across the health boards. We think there may be three things that are contributing to it. One is a change in the prostate-specific antigen measurement, which is based on a National Institute for Health and Care Excellence recommendation, so we've slightly lowered the threshold of how we record that. That may well be contributing. There is the kind of Turnbull and Stephen Fry effect, social media effect, that we may have already been aware of. And the third thing is also the use of multiplanar MRI imaging, so a diagnostic improvement that is leading to earlier detection of prostate cancer. So, all good things. We're trying to, again, shift the pathway so that we're detecting things earlier, but sometimes these things just all happen at the same time. We are looking at what the implication of this is. It may be that there is this initial rise and then it will calm down and, obviously, clinical prioritisation is absolutely key so that we don't in the process cause harm to patients, and we have a very robust process in place to look at that.

I wanted to come in on some of the issues that you touch on in your paper about workforce issues. And if we start with the staff survey, you say that you've had some positive results, but there's also been some negative movement in scores, particularly around stress at work, harassment, bullying and abuse. So, could you talk to us a little bit about that and how you expect to improve those areas of concern? 

Yes. Underpinning this, there's a lot of change going on in the organisation, and we recognise that. So, before we started some of this change, we put in place some mechanisms to actually support staff through that process, but one of the underlying things is: how do we connect with staff to actually make sure it doesn't become a lonely place to be on the journey through change? It's been a big drive for, certainly, Cath and I, working together in terms of making sure people feel connected and not disengaged. And certainly, we've done a huge amount with the blood service, which started a change agenda probably earlier than the cancer centre, and that's been of real benefit, actually. For an organisation that's gone through a huge amount of transformation and change, they're very engaged as an organisation.

So, it's about culture and behaviours, but alongside that we've given training to managers about how to manage change, we've put mechanisms in place for people spotting well-being issues, and we've got mental health first aiders in place, which we've trained over the last few years. We've also got support mechanisms out there that members of staff can engage with themselves, which is wide-ranging, from counselling to financial support.

So, we've got a lot of things in place, but if you haven't got the culture that goes with it as well, it doesn't come together. Our focus is on bringing the two together. Certainly, at the board, we talk a lot about what that's measuring and we'll have another survey fairly soon to make sure we're getting there. I'm engaged with the trade unions; I get personal feedback from them as well—and I know Cath does—in terms of how they feel about what we're doing, and that's an open door. So, if they've got concerns—and I know they will, because I've had relationships with them for many years—they'll come and speak to me, and we meet as a local partnership forum as well.

So, it's not one thing in terms of dealing with it; it's about making sure people feel they're in a supportive culture, even though we've gone through all of the change, and we get the communication right to make sure people understand why we're going there. 

Just if I press a little bit on that, if you've got the scores going in the wrong direction around really serious stuff like harassment and bullying, does that say anything to you about what sound like very sensible measures that you've just been talking about? Is there more that you need to do? Because nobody wants to be—. I take what you say about change, and I was going to ask about that, and you've already addressed that, but being concerned about change doesn't mean that you're going to be reporting harassment and bullying. It might mean that you were reporting stress at work, but it doesn't mean to say you're going to report—

No, it's part of the picture. We've done some work and we had a board session about two months ago. As a board, we're very conscious of that area. It was something that was new for us; it wasn't an area where there was a particular issue in the past. I hope people feel more comfortable with reporting it now, and actually saying it. But as a board, we've actually done some work with our organisational development colleagues about assessing whether there's an underlying issue. We don't believe there is, but we will continue to engage with staff on that, and we will continue to push the services that we've put in place and the mechanisms. We've got a 'my voice' facility on the intranet, where people can raise concerns anonymously if they want to, or they can put their name to them. We are really interested in the Swansea bay guardian system they've put in place as well. We're exploring that. So, the more ability people have got to flag up—. I certainly go out and I'm visible in the organisation, and I know the team are. I engage with staff on a regular basis, on a one-to-one, and elsewhere. I believe we've got the sort of relationships that people will say—.

I think it certainly is an area of concern coming from that staff survey. There's no question about that. We have been working our way through where we need to focus particularly. There are a couple of initiatives that we have done in addition to what Steve's already mentioned. There are in-house mediators. We've got six people who are trained and actually accessible. Because some of this is around communication, lines of working and general engagement. Have we got everybody  on board with things that we're trying to do? Certainly, in the medical staff, I've been very aware of that. We had a medical engagement conference, where I brought Steve and the chair into the room for panel questions, allowing people to perhaps ask and raise concerns openly, but actually understand what we're trying to do as an organisation and try and get them along with us on the journey. 

The other thing I was going to just mention was something that we've just initiated—a mindfulness app, which is really for patients as well as staff. In the first week that it was launched, which was just recently, I think there were 286 downloads. I've yet to use it, but what we're trying to also say is that it's okay to talk about these things. It's okay. People are feeling more stressed and we need to understand that and have conversations about it, and actually provide tools to support people as well. 

Would those mechanisms that you're describing—and thinking of some of the things that we've seen in other health organisations in Wales recently—would the mechanisms that you're describing allow you to identify if there was a particular area of concern in a particular part of the service? You mentioned that there's some capacity for anonymous reporting, for example, but would that work in a way that would highlight for senior management, potentially for the trust board, if you were thinking, 'I don't like what I'm hearing from this'?

Yes, and partly from the staff survey as well, because as long as it's a big enough group you can focus on the particular areas. And we have done that and we've picked out the teams. Cath can go through some of the work we've done in the blood service around that. It's about identifying the areas and focusing on—. As well as having an environment and a culture and mechanisms to support people, it's about identifying, when things come through, that actually we work on those areas as well. Do you want to pick up some of the work we did?

Yes, I think part of this—. We are at a time of unprecedented change. We've highlighted a number of programmes of work that we've got ongoing. Things like our change programme in the cancer centre will naturally increase, both in terms of the increase in demand we've got and as we move towards the new models that we aspire to. So, I think we're really keenly focused on how we actually do our change and how we do our business.

Back last year, we brought a number of staff together from various levels across the organisation to have a number of think tanks to really start to give us some feedback on how they thought we could do things better, how they thought we could draw upon expertise from other organisations outside health to start to run our change in a different way, the approach we take to PADRs, the approach we take to communicating with our staff. So, we've been trying to draw on the best experience we can from outside, and so we're still in quite the early days of exploring some of that. We're trying it. Some of it works. Some of it doesn't work. But we're very keen to have feedback from our staff.

I think key to this has been the staff engagement programme that we've had alongside our service improvement programme. We work very closely with the unions. They have been absolutely alongside us in terms of shaping our programme in terms of testing our staff support and testing our intervention, and we have extremely positive feedback from them in the way in which we're running it, but it's something again we're trying to fine tune. What we're hoping to do is to take some of the positives that we've drawn from the Welsh Blood Service service improvement programmes and actually apply those to the cancer centre. Key to that is the information that we're able to give our staff. I think one of the things that we've learnt is the fact that we set up a programme of work and we go away and work on it, and sometimes the timescales within which we're able to deliver define pieces of work, move or flex, and one of the key things we've learnt is that it's really important to keep our staff appraised of where things are, even if there's no news, just to tell them that there's no news and when there will be news. So, as I said, some of those things that we've learnt, we will be applying in the change programmes within the cancer centre.

Just to come back to your question around information as well, we've developed our business intelligence capability and, importantly, the ability to be able to be more sophisticated in answering some of the questions you pose. So, what we are doing now is triangulating the data. So, for example, if there's a hotspot, we look at service performance, we look at personal appraisal development reviews—is it a sickness issue? So, rather than just taking a one-dimensional view of an area, if all those things start to correlate then you know there is an issue. And I guess the other thing, which is a slight advantage for us but doesn't at all negate our need to do really positive things, is that we are a relatively small organisation, so most of us are able to walk the floor. We've got a couple of major sites. I think the challenge for us, really, is in the outreach facilities within the health boards that we run and, obviously, for the blood service because it's a large mobile service. But as an organisation, we are able to walk the floor very often. We're all very visible, as are the board. That doesn't at all solve the problem, but at least we're able to listen, and I think listening and observing is probably the key to many of these issues, because you get the feel, don't you, whether there's an issue, and that's then usually substantiated by the data or otherwise.

Just going back to your triangulation point, we were discussing it at our planning performance committee a couple of weeks ago. We're going to have that sort of triangulation, so we're going to focus on an area and we're going to model this up to actually—. As opposed to having a blanket set on performance, we'll focus on one area, drill down into it, and bring all that data for that area together, rather than just looking at the trust as a whole. I think that will start to triangulate. How, as a board, we prioritise which areas we look at is something we'll need to evolve, but actually we're going to implement a system of doing exactly that. The board does get all that information. I give an example of the deanery visits. When we get feedback from the deanery, those reports go to the quality and safety committee, we have a discussion about it, and, when there are issues, they appear on the risk register and we deal with them. A few years back, we did have a few issues with that with one cohort. We dealt with the issue and our reports now from the deanery are excellent. So, they come up in the organisation, and what we're going to do is improve them when we triangulate some of this around particular areas.

That's helpful, thank you. You mentioned sickness absence, and in your paper you talk about a new managing attendance at work policy. So, where is the trust with sickness absence now, and are you able to meet the targets that Welsh Government have set around sickness absence in the service generally?

We're slightly above our sickness target, and we're certainly not complacent about that, because we know that stress and anxiety, not always for work-related issues, is the highest—. So, again, it's why we put these well-being things in place to support our staff. We're conscious of it. We monitor it constantly. We're looking for trends. We target. We've also put things in place to support managers in terms of handling that, because it's sometimes quite difficult for managers who haven't had experience to do that. Again, our workforce department focus on areas that are reporting, that are showing, trend. And then what we do is try and have that wraparound, so we actually engage with staff. I think there is a bit of a trite phrase I think I probably came up with a while back, which is 'Doing things with people not to people,' and it's become a bit of a mantra for us all, really, that there's a different way of doing these things. It brings people into change rather than it's done to them. It's not meant to be as trite as that, but it's actually quite powerful to use some of those phrases, and if people believe that's where we are, and this is where we've got to, it's quite powerful.

That's helpful. Just to step slightly away from some of the welfare issues now, are your current staffing levels sufficient to do what you need to do, and do you have to make much use of agency staff?

To the second bit, we don't use agency staff much. What we do is use it to flex up and down our radiotherapy capacity when we need to, because it does have peaks and troughs in the year, and I mentioned earlier we've had a big increase in demand. Whilst we adjust for that, we use agency staff, but predominantly that's the area in the trust that we use it for. We don't use agency to any significant extent anywhere else.

In terms of having enough staff, Jaz might want to comment on this from a clinical point of view. Staffing is not generally a significant issue for us. We recruit successfully. It's partly about some of the things we've talked about previously, about where we position the organisation and the picture of the organisation that we give to the outside world, which is why university status was really important to us, because it's about attracting people from elsewhere. We don't always get a big field, but we've been really successful over the last six months in recruiting consultant staff. You will have seen some of the press reports about consultant oncology shortages. Now, we might only have one person, but they've been actually excellent candidates and we've been very able to appoint to these roles. But there's pressure on the service with that level of 9 per cent demand in any one time. It creates pressures. What we need to understand is where that's a constant we are going to have to live with, and then we'll have to adjust, work through those expectations to go there.

Can I just add to that? We are managing at the moment, I'd say, is probably my assessment, but we've also got a very clear vision for the future. So, one of the things that we're doing at the moment is to really look very closely at our staff, our skill mix and how we maximise the potential from enhanced roles and from maximising the potential that other members of staff within the health service have, as well as our medical colleagues. So, that's an active programme that is supported by our clinical team and a proactive programme we've got at the moment. So, for example, within the Welsh Blood Service in the last 12 months, we've just started a trainee on a consultant scientist post that will enable them, at some stage in the future, when she's fully qualified, to be able to take some delegated tasks from our consultant haematologist, who would not have been there before.

But we need to be thinking, really, quite far ahead because that training programme takes about seven years when you've got somebody who's doing it in the workplace. So, we're having to be forward thinking and we're having to really think hard and challenge ourselves in terms of how we best use the resources that we have and employ that in the whole staff mix. But we are taking that holistic approach with Jaz and the team.

Before you come in, if I can get back to something I said earlier about having a target operating model for the future—either five or seven years—it gives us a future state to think about how we're going to get to that, how we're going to support it and how it's going to change what we need in place. Because then it fits in with the sort of training, the length of training that's needed to get people there. That doesn't mean we'll wait for seven years to implement; we phase it in and we transition it. Once we've got that target operating model, which we're starting to work on, we'll then have a process of transition to that over that period.

And if I could possibly add, then, back to your question earlier about system leadership, resilience across Wales and one level of quality, we are looking forward, as has been said, about how we use—. Because even if we had all the money in the world, I think what we're saying is the workforce simply won't be there in the way you provide a service; we're looking at artificial intelligence and so forth.

But we've also made a joint—. Well, we've agreed a joint endeavour and a joint bid between ourselves, Betsi Cadwaladr LHB in the north and Swansea bay in the south-west to a single cancer pathway fund, via the cancer network, for some support to come up with a non-clinical oncology workforce model that is fit for the future. We're still waiting to hear about that. So, the work has to be done, but it just again goes, 'We've got a need, but that would be daft to be done in isolation.' So, what we're looking to do is a national piece of work that also, then, speaks to primary care, diagnostics, and so on and so forth. So, it's just trying to demonstrate that we are trying to do these things in a strategic way.

David's got a question.

A very quick one. You just talked about your programme earlier. When we started off, you told me about your transformation programme, where you're looking at changing a couple of models to be more closer to home, which includes spokes and hubs outside. Now, are you going to be confident that the resources in those areas will be sufficiently available to you to actually deliver that model?

Yes. What patients tell us, and the evidence is that most people are able to provide most of the care and support they need right now. So, if you take chemotherapy, 10 years ago you'd have to come to a chair and sit down; now you can literally take it orally. And as things progress in terms of reduction in toxicity and things become safer, far more will be done at home. If you take dementia as an example right now, you can wire up a house that ensures that movement shows the person's got up in the morning, you can make sure the kettle's been on, so they've had their cup of coffee, you can have their lunch monitored. So, through telemedicine and telehealth, lots of the things that we are doing today in physical places will be done by somebody who wants to live independently at home. So, I think, back to where we started, our case is presuming that lots more of that will go to the left. We will then provide a different level of care and support, notwithstanding the fact that, when people do come into a place, they will have to have the right facilities, clinical and other care to meet their needs. But the whole direction of travel is actually providing patients with the support they need to live far more independently, having made a choice about what care and support, or not, they wish to receive. So, I think what we are saying is that that is the way forward, And that will be tested, because, clearly, there will be some gaps in the short and medium term, but I think we are as confident as we can be in what we see at the minute. The workforce will be able to cater for that with the support of automation, artificial intelligence. If you look at Japan at the moment, they've got a huge problem with social care—

I'm just interested in the confidence.

Well, as confident as we can be—

I'm happy you've got confidence, but, in my area, we have concerns over district nursing and community nursing, so—. But I'll leave it there.

We'll revert to Helen Mary.

Yes. So, you've touched on what I want to ask now in a number of answers to myself and to Lynne and others, but I just want you to pull some of that together and outline for us what processes the trust has in place for handling concerns from staff and from patients. Are you confident that you provide adequate support for people when they raise concerns, whether that's a patient or a family member or whether that's a member of staff? And I think Mr Ham did begin to touch on this in terms of how those processes are monitored and how the board gets sight of the issues that come up through those processes. So, you've mentioned it in a number of different ways, but this is just an opportunity to pull that together so that we can get a clear picture.

And briefly. We need some agility now, otherwise you're going to be here all day, so—. It's your own time you're taking up. [Laughter.]

He does this to us as well; it's not just you. 

That's fine. I'll pull it all together quite quickly. We've got a relatively small team in both services and they do support whoever raises a concern. They keep closely in touch with them and I believe that they're very supportive; they're the type of person you'd want to have engaging with you, which I think is really important. They also support our staff in going through it, because the best way of getting the best outcome in this is to get people in a comfortable space. We bring people together if they want to, so we make different offers to different people, depending on where they are. So, we support our staff going through that as well. From a board point of view, it comes up through our quality and safety committee. We report on the concerns and the good and bad in terms of patient experience that we get, and the board is sighted on those things.

The learning we take forward through various places. Certainly, in the cancer centre, we've got a thing called a serious clinical incidents forum, where we bring clinicians together to understand what issues have been raised, what incidents and concerns have been raised, to actually work through those issues and get the learning in place. And Cath mentioned earlier about how the team in the blood service also engages. So, the board has sight, we've got mechanisms in place to get the learning in place where it needs to be in place, and we've got a team of people. It could be bigger, but, actually, I know that, given the volumes that we've got, and I talked about those earlier, we do keep in touch with people, and I think that's really important when people are going through it. We're clear in communicating where we are with their concerns as well.

And then just finally, Chair—so, you would be confident that it wouldn't be possible within the trust for a particular part of that trust to develop a difficult or a toxic or a damaging culture around concerns, because the board would—. I'm taking it from what you're saying that the board would see if those sorts of trends were beginning to develop and would be able to do something about it.

We've done a lot of work on the culture over the last number of years to actually make sure that that doesn't happen. We're sighted, we're visible, we engage with people. There are a multitude of ways we make sure that happens.

Yes. That's helpful, thank you.

Yes, a couple of financial questions. You describe your own financial performance as robust. I just wondered if you can give, for 2018-19, just a general overview as to why you say it is robust, but what are the main challenges you think that you have to face up to.

I'll start off, kick off with that. In terms of 2018-19, we've made a small surplus and that's a consistent thing that we do every year. The challenges and improvements we've put in place—during the last year, we've invested and taken the service forward, we've worked closely with our health board colleagues around making sure that, when service increases, we get support financially to take those forward. We've been really tight and close on savings programmes and we've delivered against them—not all of them, but what we did was readjust very quickly to actually bring other things on board, and we got there at the end of the year and dealt with all the in-year issues as well—so, tight management, a clear focus on what we want to achieve.

And one of the real benefits of finishing off the integrated medium term plan process earlier this year has been that we're even further ahead on that. So, for 2019-20, it meant that we were really on it before the end of the last financial year in terms of the new year and, again, it'll be brought forward to December this year, which, again, will put us in a really good place to be on top of our financial position. The pressures are about demand, particularly, and how do you generate change in the middle of it, but we're pretty innovative, we're agile as an organisation, and we make both happen. 

You say that the medium-term plan for 2018-19 to 2020-21 is going to be difficult to sustain; what are the main difficulties in sustaining that?

Well, a couple of key issues. We're talking about staffing and making sure we stay on top of the staffing. So, we've done a lot of work in terms of making sure that we're an attractive organisation to come to. And, in many dimensions, we do that, whether it's around innovation, the university status, how we engage with the outside world, the collaborations. We want to make ourselves—. So, workforce is clearly a key issue for everybody. We're not out of that space that everybody else is in. Demand is the other thing. We talked earlier about radiotherapy demand. We need to meet that, and that may well be a blip or it might be an ongoing process, but we will need to keep a close eye on how we resource that and work with our health board partners in terms of keeping that on track. 

Sure. The auditor general has obviously reported and commented and identified the need for realistic, sustainable savings going forward, and I'm just wondering how you are achieving that and the problems that you might face in achieving those.

Well, I think—I think we're in a good place on that. Our savings programme for this year is already tight, as I mentioned earlier. We know what we're doing. The majority of it is recurring in nature. We've got a direction of travel. We look at it over more than one year, which is always a benefit, because you can utilise your money in a slightly different way when you do that. It will always be a challenge, because there will always be more pressures, but I think we handle it, as an organisation, well. We work really closely as a team and with the senior managers about how we action that, and we understand the space that it gives you if you're not dealing with that in-year, which is the benefit, really, of the IMTP deadlines coming forward—that we're now in an even better place than we were last year in terms of having the freedom to think about this year and not about how you establish some of these things. 

It ties in to where we started earlier in both the blood and the cancer service. I think the term is 'allocative efficiency', so efficiency productivity gains. That'll take you so far, won't it, and then the cupboard runs a bit bare. I guess where we're at, we're looking for different ways of delivering the service. So, the models—the models of care that Cath alluded to and the cancer service. So, just as an example, in the cancer service at the moment, if we're delivering chemotherapy, we probably deliver from roughly about 16 different locations around south-east Wales. That's got variable quality, because some of them are open longer than others, some have better facilities. So, if we change the model of care, that is, some patients having more at home, almost self-managing, some patients coming to a smaller number of settings that have longer opening hours during the day and longer during the week, we believe we can improve the quality of care, but also actually take that level of unit cost down a bit further. 

So, I think—traditional efficiency gains will take us so far, and we're not too far away from yielding all of those. We are now looking into transformation, which is about artificial intelligence, automation, taking out those low-value activities that can be done a bit cheaper by something else, whether it be a chat bot or so on and so forth, so allowing our highly skilled workforce to really focus on the additional value-added bits that perhaps we wouldn't have done in the past. So, that's where we're really, really keen to explore, because that really takes you to a position of sustainability. Continuing to top-slice year on year, we all know probably won't get us there. So, that's really where our focus is—getting the core service stable, benchmarked, so we know we're in the upper quartile, so we can demonstrate to our commissioners that the funding has been well spent, then how do we take the next step into transformation, so we know that quality is high, cost is where it should be, and we've got a workforce that is sustainable for the future going forward. So, that's where Steve is really trying to take the board to.

You do refer in the report, in your plan, to the increasing difficulty of maintaining the level of service and the need for further financial support. And, if I understand this correctly, you're also dependent partly on dipping into reserves as well, and the issue of the sustainability of that becomes an issue. If I've got the figures right, it was 2018-19, £306,000, and 2019-20, £507,000. I'm just wondering if you could explain how that operates within the robust financial performance. 

We're not unique in terms of any other organisation holding a reserve for the year. So, that is how we deploy that in-year to get us through the year. Pressures come up. Some of them we'll need to fund. We might get something like a breakdown on a radiotherapy machine and they can be quite pricey. So, we will deal with those from reserves, so I think that's—.

So, there are plans in for the replacement of reserves, for the maintenance, or are reserves being depleted to make up for deficits?

No, we keep a level of reserves and then we deal with it through the next year's plans. 

One of the issues that arises, of course, is the engagement of staff in the whole process of sustainable savings, innovations and so on. How has that worked out? Have you got any examples of achievements that have been raised there?

I think that is a challenge, and I think part of this is actually the culture that we've got to change. We've all got to buy into this together. One thing that—. We are engaging with the value-based healthcare programme in Wales, and there's also a parallel conversation around value-based research and what does that looks like. So, we're learning; I think it's a learning curve for us. One of the things we have done, and I'm responsible for this, is nominating our operational finance lead and the clinical director to participate in a national programme, where we're bringing finance and clinical management together, to understand what value-based healthcare means and actually set up a project, and this is happening across the health boards. It's an initiative that's actually, I think, just recently won an award somewhere as well. So, that's one way of just getting the people who are really in charge of the budgets to be engaged, and, hopefully, then cascade that information across to the rest of the us. So, that's one initiative. 

The other things that we're looking at is really what does value-based healthcare mean, and it is linked to outcomes and understanding what those outcomes are and looking at what we're spending—are we getting what we want for that money or that efficiency? So, in parallel with that, we alluded to the fact that we've got a knowledge, expertise and science PhD student who is doing mathematical modelling against a lung cancer pathway, and there's some fantastic work coming out of that, which could look at actually lots of repetition, lots of steps that are unnecessary and how we can remove those. But approaching it from a kind of scientific, mathematical way is quite interesting, and then you can plug in the artificial intelligence and other things that might help. So, those are some examples I can think of. 

I'm sure Cath could go into detail about some of this—I'm not sure—but, about time, I'm just conscious, Chair, about the time. But what we—. Certainly, the engagement we've got with staff on the ground is about where the service is going. So, it's not that we come up with savings plans that tell them, 'You have to do these.' We actually engage with staff through the service about where do we want to take the service to so we end up with a better quality service and efficiencies that come through as a consequence, and that's been a model that we've been working with now for about three, four years, in the blood service, and it's starting to come through in the cancer service as well, which give us a far better sustainable position that people understand, they're involved with. So, it's a model of a way of working, I suppose, that we're quite a way down, so it's everybody's organisation, not just ours. 

Sustainability can be a euphemism for all sorts of things. How do you actually then distinguish between them when you say, obviously, that without further financial support, it might be difficult to maintain services? So, clearly there's a major financial pressure, and of course achieving savings can often be a euphemism for cuts in services. Is that a road you've had to go down in areas, or how do you avoid going down that road?

No, in fact, we've developed our service over the last—. Well, we continue to. I've been there nine years. We've developed the service all of the way through that, and we continue to develop it through that process. It's about the balance you have in the organisation and how you have those conversations about where we want to go. So, people can see progress as well as the fact that we have got financial pressures, because everybody has those, but it's how we engage in those discussions that's been really important.

Sorry to keep going back to the programme. A good example is our clinicians working across the health boards identified that too many patients were being admitted to A&E, and so on and so forth, and on weekends some patients fell through the gaps of service availability. So, with colleagues across the health boards introducing an acute oncology service, which is trying to catch people when they fall, that directs them straight into the right place as urgently as possible. And then, internally, our clinicians and our health professionals identified the need for a rapid assessment unit. So, a business case was put forward and the benefits seemed to outweigh the costs. The results are really, really impressive in that we've now got fewer people coming in for follow-ups, so doing that via telephone and Skype, and we've got fewer people being admitted to a bed and a reduction in the length of stay in that bed as well. People don't want to be in hospital. They want to be home with their families. It's better quality of care, there's less chance of them catching an infection, and so on and so forth. So all that has actually delivered improved quality of care and reduced the cost, which, for us, is sustainability. So, I think that's really what we're focusing on, not, as you were rightly suggesting, just giving everybody a 4 per cent reduction in their budget every year, because the tin runs dry, doesn't it? 

Lynne, you've got our final question.

Yes, Brexit. There's been lots of coverage of the risks to the NHS. Some of the most alarming coverage has been in relation to cancer services, actually in terms of whether it will affect radiotherapy and important chemotherapy drugs. What assessment have you made of the risks to patients?

I'll hand over to our senior responsible officer on Brexit.

I thought we weren't going to talk about Brexit. [Laughter.]

Can't avoid it.

Absolutely. Like everybody else, we've been planning for that for some time. I would say we've already got really strong existing business continuity arrangements in place which cover a whole range of scenarios. But, clearly, Brexit was of such significance that we did set up a Brexit group within the organisation that links into the national SRO group, which I sit on, and Alan Prosser who is our key driver in this back in the organisation.

So, in terms of the key areas—consumables, supply chain, workforce shortages, research and development, and international services—we're involved in all. On consumables we're fine. So, blood bags, and so on and so forth. As you say, with supply medicines and particularly around isotopes, as you're probably well aware, that was a position that was being managed by Welsh Government with the UK Government, so we have fed into that process. In terms of drugs, our chief pharmacist works with the chief pharmacist of Welsh Government as part of that group. We are aware there's a list of drugs that may not be available for various reasons. There are replacements available and we've worked through that, all the way through all the algorithms, so our clinicians know exactly what they would do in a circumstance where there was a shortage of that particular drug. And similarly, around radioisotopes, we know there's a half-life decay, so we can't store radioisotopes. So, we're working with Welsh Government and, nationally, they would be available. We've also been having conversations with our colleagues down in Swansea bay, because they're the closest radiotherapy centre to us, to say 'What if?', 'What if, in this circumstance, this was available and this wasn't and we had this cohort of patients, which would be treated in what order?' So, we have all those protocols in place.

We've done the work on a range of other issues. The good news for us in terms of workforce shortages, they aren't really impactful upon us. So, in answer to your question: it's a worry. We've done all the planning we can at this moment in time. We are still continuing to plan and to ask other questions. But as we stand at the minute, we have plans in place that we think are as robust as they can be. We hope they don't have to be tested.   

So, it sounds to me like you're saying that if we crash out on 31 October, then you can't guarantee that patient care is not going to be affected, can you?

We have plans in place to manage all patients safely and effectively. I guess, until we understand what that crashing out looks like—. We are relying, of course, on the Welsh Government, and there is then an escalation framework, which takes us up to UK level. It's difficult for me to give a guarantee, because I don't think I'm best placed to do that, and I wouldn't want to give the committee any false sense of something—I'd be speculating. But, all I can say is we've planned this in fine detail. We think we've got really good plans in place. They're yet to be tested, and things will come out as this thing goes forward, but I don't know, Steve, if you wanted to—

The important thing, from our point of view, is that we know how we will react not just as an organisation but the people on the ground—so, the chief pharmacist has done all of the assessments of how we'd swap things around to make sure we had continuity. We know our own risks, we're geared up clinically to be able to deal with them. So, you don't know what's actually going to come, but we've planned for this in a level of detail that assures me that we know how to respond, with patient safety at the heart of it from our point of view.

A very quick one from David.

On this point, in your paper you say you've put your 'no deal' Brexit preparations on hold. Are you reviewing that because you are going to a different period of time? In October, workload pressures may be different. Are you going to be reviewing that at this point? 

Yes, we are.

Yes, absolutely. So, what we have done, as of last week, we've essentially—. We've got our normal business continuity arrangements and we've now restarted our Brexit group as well, because, like everybody else, we were watching the tv to find out what's happening 200 miles up the road there and those things were fluid. So, as of the situation, we've restarted the Brexit group. That will feed now through into our normal business continuity arrangements and back through into Government.

I've got a point to make on the paper to note on suicide prevention. I'm happy to do that when we go into private.

Thank you.

Likewise, I think we need to have some thoughts about how we respond to the letter from the University of Wales, because it does make some quite important points, but, again, better done, I think—