Cynulliad Cenedlaethol Cymru

Thank you very much. Thank you for your time today and for the opportunity to make a brief statement. I'm very grateful to be here today having been nominated as the preferred candidate to take on the role as chair of Swansea Bay University Health Board. I'm looking forward to your questions and your scrutiny.

I joined Swansea Bay over two years ago as vice-chair. I applied for this position because I believe it afforded an opportunity to influence care across an integrated system. I still believe that. As vice-chair, I had responsibility for primary, community, mental health and learning disability services, which helped me to understand better the opportunities we have in Swansea Bay to support many of our patients closer to home and avoid admission to hospital. At the same time, as chair of the performance and finance committee, I was acutely aware of the need to balance short-term imperatives, largely relating to the delivery of acute care, with the need to ensure robust plans for a long-term, sustainable future.

I have found my time as vice-chair very helpful over the last eight months as interim chair. I know the organisation and I've been an integral part of the developments that we are now building on: our organisational strategy; our work to develop an open culture further; and our strengthened governance arrangements.

As interim chair, in addition to strengthening my relationships within and establishing relationships outside the health board, I've enjoyed developing an overview of the whole system and its potential. I see the future of Swansea Bay as an organisation of motivated, enthusiastic people, who are proud to work for Swansea Bay University Health Board, and who continually drive improvements; a region where well-being, prevention and care closer to or at home is a given for everyone, whether supported by our organisation, other organisations or in partnership; a provider of nationally and internationally recognised specialist hospital-based services, whether for physical health or mental health; and an organisation that is embedded with our partners in the community we serve, working with the public, patients and carers, to ensure that what we do genuinely meets the needs of those we serve, both today and for future generations.

I fully recognise that delivering this vision has to take place alongside the imperative to improve performance and enable de-escalation from targeted intervention. I also recognise that the journey will not always be smooth and will take time. However, I do believe that the foundations have been laid and that we have a strong team, both executive and independent member.

It seems to me that the most important factor to consider before applying to chair an organisation like Swansea Bay is whether your vision and values chime with those of the organisation. Having got to know Swansea Bay over the last two-plus years, I know that this is an organisation I am proud to lead.

These are the reasons I applied when the substantive role was advertised and this is why I am both pleased to be the recommended candidate and excited about the future. Thank you.

Okay, thank you very much. My vision for the future involves—. We developed our strategy over a period just before 'A Healthier Wales' came out, and it was very much based around the imperative to deliver as much care and support close to home for our patients, and of course, that is entirely consistent with 'A Healthier Wales'.

As I said in my opening statement, as I went around the community services that we provide, whether they're mental health services or primary care or community services, it was abundantly clear that we already provide some amazing services for patients, but that, along with the whole of Wales, the whole of the United Kingdom, that wasn't at the core of our focus. And I think what 'A Healthier Wales' does is it puts that at the starting point, and that is where our strategy is also, and my vision for the service is. I have elderly parents. We don't want our vulnerable people going into hospital, unless it is absolutely necessary, but in order for that to be the case, we need to have a co-ordinated approach to providing that care much closer, whether it's in-home or close to home, and I think that is very much my vision. That needs to be in partnership, we can't do it alone; we need to be in partnership, not just with our local authority colleagues, but also with third sector and for other people who can do it, and we need to work out very carefully how and what is the best way to do that. 

I agree with your commentary there, but what I was wondering was if you perhaps just give us a view on how you think the financial split or the commitment split from the billions that go into the NHS should work out? Because, of course, hospital trusts still take the absolute lion's share; we're asking for changes in working practices; we're trying to keep people at home more and, of course, our community services still get far less as a proportion of the budget and we're asking them to do more and more. And again, social care has its own problems and again we have issues with the provision of social care—how do we fund social care long term and how do we fund it now? So, as the head of a trust that actually will get a substantial sum of money to run your function, really, it's just your overview on what you think needs to happen within community services and social care to bring them up to the kind of capacity levels that a trust would have.

Yes, absolutely right. We are doing some quite exciting things in Swansea Bay through the transformation fund, and that is very much about providing much more holistic care and signposting people. What is really important, though, is that we understand the impact that those changes have, because what you're talking about and what is the big question is: how do we change the way we fund from much more acute to much community? And that's not going to be easy, but the way in which it needs to be done is through very robust—. First of all, working on a clinical—everything needs to be clinically evidence based, but there needs to be a robust evidence mechanism for what impact things are having; if they are not an impact, then we need to be brave and stop them, but if they are having an impact then—. It is a business case, in a sense, it's a wide business case that looks at the impact on patients, the patient feedback, the staff feedback and the financial implications. But, yes, we have to be very focused about understanding the impact of the changes that we're making, and taking the necessary action as a result of that. 

The other thing I would say in terms of your comment about social care is that we are—the regional partnership boards are a very important mechanism there. It seems to me that, in the future, a lot of the way that we fund may be through joint funding or pooled funding, and indeed, over this winter, additional funds that went into the regional partnership board—. We were able to use the good relationships that we had but also the evidenced impacts that we were doing through hospital to home and other community-based initiatives to put that funding into the social care that was needed to support that, rather than necessarily into more acute clinical care. So, it is, as I said, it's a journey; it's not going to be smooth but we have to be evidence based in order to deliver the change that we all know is the right thing to do for our people.  

I don't think anyone would disagree with you that we need to be evidence based, but I know and I read somewhere in your curriculum vitae that you'd been a director of a primary, community and mental health portfolio, or silo, so, you've got a really key understanding of how the whole community services works. But my concern is with the fact that the drive to push everything into community services—which I do not disagree with; I think it's absolutely the way to go—just isn't being matched by the support that those community services need—financial support, which I appreciate that some of it has to come from Government rather than from the trust, but also, the communication, the cluster working and that whole sort of engagement. Because I know that sometimes, there's a real friction between the free-at-the-point-of-delivery NHS that you see in the hospitals and the free-at-the-point-of-delivery NHS that you see in community services, which, sometimes, are still seen as paid for, because GPs are not part of the big organisation—they're organisations within their own right. So, I was just interested in how you're managing those tensions and ensuring that health board staff, for example, like physiotherapists or occupational therapists, will be able to be housed, run and embedded within community services whilst still being trust employees, but, of course, being under the jurisdiction of the GP cluster to perform that vital sort of funding. 

I know that, throughout Wales, we've seen quite a lot of evidence that there's a real tension there between that sort of health board method of working and the GP method of working, so that's what I was just trying to explore a little bit.

Yes, I think that's right. The cultural approaches are very different, but I think we're quite fortunate in Swansea Bay, in that we have quite a strong primary care and community services delivery unit. And it's that interface between the health board approach, if you like, which is a large organisation, and the more small-business-like approach of GPs that needs to be married. It is about trust, and I think that's where clusters are very helpful, because the GPs work together and the cluster leads—we have ongoing monthly meetings with cluster leads—and that helps the understanding and the trust of what's being done, because it's just as important for the health board to understand and reflect. And this comes to something else that's very important in terms of an open culture—it's as important for us to understand the challenges that GPs are operating under as it is for them to understand our vision. So, that sort of two-way conversation is a very important part of that. And that's about the structures that we put in place to make sure that we, at the board, understand the issues that GPs are facing, as well as the issues that other areas are facing.

Some of the things that we've done—some of the things that I did as the vice-chair were introduce sessions where we did get GPs and physiotherapists to come to the board to explain the types of things that they're doing and the opportunities that they offer, but also the challenges that they are facing, so that the board had an understanding of that, but also we could appreciate some of the opportunities and reflect that in our plans.

Thank you.

Rhun.

Okay, thank you. I think there are a couple of things that I would say in response to that. First, on governance, when I first took over as interim chair, I did a number of, as you always do—looking at the way things operate. So, I spoke to executives and, indeed, to independent members. As a result of those conversations, I made a number of changes to committee membership and committee structure. We've been working on committee structure to make sure that what's very important is that the committees have the ability to scrutinise, and that depends upon the right information coming to the committee. So, that's about the structures underpinning the committee, but also the right people around the table who have the experience to bring to read those papers and to make the right challenges. 

I expanded and developed what was called the chair's advisory group. I introduced all-independent members for that. That provides an opportunity for committee chairs and members to exchange information across committees, so to triangulate, if you like. So, things that have come out in a workforce committee can be raised, and that then can be compared to what's coming out of perhaps a performance committee or a quality and safety committee. And that's been quite helpful. I've also invited the chief executive to those meetings, so, again, that provides an informal approach for the chief executive to develop relationships with the independent members, but also to sound out, so there's just this informal mechanism.

I've restructured board development sessions to really be board development sessions. There's always a tendency with a board development for executives to creep in with board meeting-type things, and to slip a paper in, because the timing works, and I'd be very firm on that: a board development is about board development, so it is about us understanding the context in which we're working. For example, last time, we—or, to look at best practice elsewhere, so for example, the last one we had somebody from Welsh Water talking about the water industry's approach to health and safety. So, again, that just lets the board, as well as scrutinising things, rise above and have to gather some perspective.

And finally, the board meetings: I took a conscious decision to take quite a brisk approach to board meetings. I limited the amount of discussion upfront from executives, because it is assumed that people have read the papers, and that allows us to have a much more fruitful and in-depth discussion of the papers without running out of time, and that's had a couple of consequences. Firstly, the board meetings are a bit shorter, which means that there is a higher energy level at the end; and, secondly, we do spend more time on those things, often at the end, and on strategic matters.

Those efforts, I think, have been recognised within the Welsh audit office's structured assessment. We were very pleased to see their assessment of improved governance and open leadership, so that is one part of evidence I would give you as an impact that I've had.

I think the other one was more operational, in a sense, but one of the things—and this is particularly around exiting targeted intervention—is we need both focus, and to make sure that our plans have actions that have milestones, and that we have an impact. And I think that the scrutiny, through the improved committees—our winter plan really did start to have that, and it has been an extremely difficult winter, but we have seen some tentative improvements in our performance as a result of both the plan and its very structured and action-orientated approach, with expected impacts of different actions, but also the extent to which I have ensured that despite—. The action plans often take a while to start impacting, and that's the point at which you have to hold your nerve, and not get distracted or try and put additional things in place, because, otherwise, the whole impact gets dissipated. So, I think those are the two areas that I would give you.

Thank you for that, and you clearly have a clear vision of the kind of structures and mechanisms that you believe are needed to move forward, and you've given us a hint at the kind of improvements that you believe are already taking place. You've also said that these things take time, but people will be impatient to exit targeted intervention. Do you have an idea in your mind of how long you expect it to take for those new structures to lead to exiting targeted intervention? And what do you believe will be the important signposts along the way, to show that you are moving towards that goal that you're hopefully heading towards?

As you would expect, I'm not going to put a timescale. I am, and the board is, as impatient as everybody else is to exit targeted intervention. It takes an awful lot of our time, so we are extremely keen. What I am equally keen on, though, is that we exit targeted intervention in a sustainable way, and I think that that requires us to focus. There are two areas on which we need to focus really strongly on over the next months. One of those is unscheduled care, because if we can address the flow issues around unscheduled care, that will help us in all the other areas of targeted intervention—certainly the performance areas, but also the financial performance. The financial performance as well—I think we are grateful to the external review from KPMG, because I think we were very disappointed by our financial performance at the end of this year—it is not where we wanted to be—and I think there are some understandable reasons for that, but there are also—. It also reflects our approach to financial governance, and we recognise that. So, in addition to the actions around unscheduled care, in our financial approach we need to reflect on the approach we take to financial budgeting and financial management to make sure that it is an all-health-board approach to financial—. It is not about—. I am a passionate believer that the most successful organisations financially are those that deliver high-quality services to good performance measures. So, our way out of targeted intervention is to focus on the quality and the performance of our services. In addition to that, though, there are some approaches to the way we do budgeting and hold people to account that we will be looking at through our response to the KPMG work. 

Okay, thank you. 

Angela. 

Just following on from Rhun's comments about structure and governance, how, as chair, will you be able to run—? How, as chair, will you ensure that, with the executive team, there's an honesty and an engagement that would not see us repeating the errors that we've seen in Cwm Taf Morgannwg University Health Board where, basically, executive members sat on vital reports that never made it through to the chair, and therefore we saw the great sadnesses that we've seen in maternity services? How will you run that check and balance? Because, again, at Cwm Taf it all seemed incredibly well until suddenly it all fell apart.

That is the thing that keeps a chair awake at night. Obviously, in the immediate aftermath of the publication of that report, we undertook a review of both our maternity services and our clinical governance structures, which gave us a degree of assurance. But the real answer to your question is about the development of an open culture, and that is something that we have been working on for a number of years, and that is something that both Tracy and I are absolutely passionate about. So, part of the answer to your question is about the governance structures to make sure that the—. Because, sometimes, if you don't have the right governance structures, things get held up for no conspiracy reasons at all—they just get stuck in the system. So, transparent governance structures are absolutely imperative, but so are the behaviours. It is about making sure—. We're doing a number of things to make sure that what we hear at board is consistent with what goes on at the ward level. So, part of that is about the well-being impacts we're putting on staff. Some of it—we have the guardian service. We're the only organisation in Wales—

Could you explain that, please? 

So, this is something about—. It's an internal process to facilitate whistleblowing. I don't like the word 'whistleblowing' because it suggests that something has gone wrong. I want people to tell me that things have gone wrong without having to whistleblow, and there needs to be a number of mechanisms for that. So, we have—. Part of those mechanisms are the incident reporting and the culture and the values within the organisation, which mean that people feel very comfortable raising problems with their superiors and knowing that that will have an impact. But part of it is also having a completely separate mechanism that allows people to go and say, 'I'm worried about this. I'm worried that my boss isn't listening.' In England—I've come from the English system—there is a national network, and I was used to having this when I was in England as a senior independent director, and I believed passionately in it. In Swansea Bay we've gone one step further because it isn't an internal structure; we've actually got an external organisation to provide that for us, which gives a degree of objectivity. When I became chair, I maintained the oversight of that because I think it's so important, and I meet every eight weeks with—. We've had two individuals that go around the organisation. They're just there, and anyone can come to them. They can come to them for any particular reason. Sometimes, it's just about the opportunity to say, 'How should I handle this?' And then they go back and they handle it through internal mechanisms, of which we have many.

But sometimes there are things that they want them to take forward. So, I think you need a number of different mechanisms because not every mechanism will work for every individual of our 12,000 staff. But in order to prevent—going back to your original question—things coming up at the board that we did not know about, because there will always be, in an organisation of this size and complexity—there will always be things happening, things will go wrong. What we need to know is that we know about them at the earliest possible stage so that we can put in support and address any issues. That is as much of a cultural thing, probably much more of a cultural thing, but you do need, also, the structures.

Thank you.

Okay. David Rees.

Thank you, Chair. Good morning.

Hi.

As you're aware, we have various operational issues as well as strategic issues. So, if I go on to those—you mentioned earlier this morning that you encourage the chief executive to attend meetings. One of my concerns, at any board, is the relationship between the chief executive, who has operational responsibilities, and the board that has governance responsibilities. It's very easy, if we're not careful, to allow those to get too cosy, and when, then, the accountability becomes difficult. Can you give assurances that the accountability will not become difficult? In other words, that there will not be this cosy relationship, that the board will still hold the chief executive to account for the responsibilities of the day-to-day operation of the board.

I'm not sure anybody that I've worked with around a board would accuse me of developing too cosy a relationship. One of the things that I think is most important in a board is a culture of supportive challenge. So, it must be supportive because executives are often under enormous pressure; they are juggling lots of different priorities. One of the knacks of an independent member, and a board, because all executives have a corporate director role as well around the board table, is to know when to challenge and when to say, 'They're under enough.' So, support is important, but without the challenge, then it becomes cosy.

I think we have—. Part of being able to do that supportive challenge is having a strong executive team, because if you don't have a strong executive team, then they need to be able to have the resilience. A strong executive will welcome the challenge because it is—in a sense, our role as independent members is to stress test what they're doing. They're there at the front line, they are looking at solutions and coming up with plans. We're not at the front line, so our benefit is to come at it from slightly different directions, to poke it a bit, and to say, 'Well, have you thought about this?' or, 'I'm not terribly confident that that is', and that we've got the relevant number of actions. 'Have we thought through what the impact of those actions might be?' So, it is, absolutely—and, basically, the majority of my job is to ensure that we get round the board table a culture that welcomes challenge, that independent members know to be supportive, and that the challenge is not personal. But without the challenge, it's not a board.

You've been interim chair, now, for nine months, so do you believe you're now in a position where the board is in that frame of mind and, therefore, they're able to be that critical challenge to the board and not be afraid of asking those questions and not be afraid to put those points to executives?

I do believe that, yes.

Okay. We're in targeted intervention in areas. You've identified you want to get out of those, but it's going to be a challenge, no question about it, particularly the financial aspects. How do you see the consideration of the board, because you're facing—? Well, take coronavirus out of this, which is on top of everything else you're doing. You were facing challenges before that, recruitment being one of the big issues—you talked about the need to deliver. How do you see the vision of how the board is going to attract recruitment into the areas you need? You have a major trauma network centre, you have two other district general hospitals, you have many GP practices, some that are managed by the board, as we know. How do you see, though, the board moving forward in actually recruiting the number of GPs, consultants, junior doctors, nurses, physios, radiographers—all those people—to ensure that you have the level of staffing required to deliver the services you are required to deliver?

As I put in my documents to the committee before, it is one of our key risks, along with all the other health boards in Wales and, indeed, across the UK and internationally. There are a number of areas in which we are concentrating. I think the first one is to make the organisation such that we reduce turnover and that we keep the good people we've got, because once we've trained people—so there is a part of trying to reduce the need for as much recruitment as possible. It's important to state that at the outset.

In terms of recruitment, there are a number of areas that we are pursuing locally, making Swansea Bay University Health Board and the region of Swansea an attractive place to come, and that's partly about the measures we're putting in to improve the well-being and open culture. If it is seen as a good organisation to work for, that helps us, and, of course, it's a wonderful place to work and live.

Other areas are: there is targeted recruitment that we undertake across Wales, so we've recently been to India and undertaken some recruitment there. There is also work under way both within our organisation and at a national level to look at the roles and the responsibilities, and perhaps changing some of the roles, along with the need to change for the transformation. We can adjust our need in that way. But, you're absolutely right. It is something that occupies a great deal of the time of our workforce committee and our executives.

Okay. Obviously, being from the area, I see a few things a little bit more on the ground, and I need to ensure that your vision is there. You have three district general hospitals, one of them being a major trauma network centre, and it's about using your resources effectively and efficiently. I've often met with you and with your predecessor to look at how we deliver those services, to ensure that the people are fully able to access services, as you say, on the doorstep, as close to home as possible. What's your vision for the hospitals? Because Neath Port Talbot clearly is there, Singleton and now Morriston. What's your vision for the hospitals? Because in the past we've seen bed closures as part of the strategic vision; we've seen hospitals, what we would now call the cottage-hospital-type concept, their closure as part of the strategic vision. The coronavirus comes and we need beds all of a sudden. What's your vision for the future, to look at how we're going to manage situations that come upon us unexpectedly, such as this pandemic?

If I separate the two, I think the coronavirus is going to challenge all of us in many ways. The strategy that we have developed does look, and there is still work under way to look at the particular roles of different sites and hospitals and so on—. But, for me, one of the key answers to your question is to ensure that we have as much flexibility as we can. Now that's not always possible, because you have certain specialties that have certain needs, and it's more difficult for that flexibility to take place. But one of the things that we can do is to look to make sure that, as we plan, we look at different scenarios and we provide within the cost of—you know, it costs to provide flexibility, but to the extent that that is possible, to futureproof, I always think it's a good idea to provide as much flexibility as possible.

If I move to coronavirus, this is something that none of us have seen, this magnitude of impact. I know that you wouldn't expect me to talk about any operational detail, but I know that there is an enormous amount of work going on at the four nations level, at the Welsh level and within our organisation, and there is a great deal of communication. There will be all sorts of scenarios being worked through. We've got a board meeting, as it happens, that I called for other reasons, but we will be discussing that at the board meeting, because as a board we need to know that we are as well prepared as it is possible to be within the parameters of what we can envisage at the moment. But to a certain extent, that comes back to that question of flexibility, and to a certain extent, that is what the NHS is good at doing, is responding to emergencies.

Okay. I won't ask you to answer any questions on this, on the flexibility, as you've made your point, but I'll just make a comment on flexibility—which I appreciate. It is important therefore, when you talk about flexibility, that we've ended up with a situation where utilisation of beds and capacity is in the 90s rather than the 80s, percentage wise, so we are seeing less flexibility in one sense because the occupation of beds is higher. So, I'll leave that one as a comment more than anything else. As chair, how do you envisage your position of engagement with the community?

It is very important. So, since I have been interim chair, as you know, I have reached out to a number of stakeholders, particularly in the local community. So I meet regularly with the local authority leads, we are looking at the best way to engage with Assembly Members, and I've met on a one-to-one basis or on a wider basis with Assembly Members. I have taken up the vice-chair role for the regional partnership board, because that is a key role for us, but I think there is also—. If you don't mind, I'm going to just—. Yes, here we go.

The community health council is another important contact, so I meet regularly, monthly, with the CHC chief executive and chair, and we do as an organisation work very closely with them. Looking forward, if we want to make the changes that we know we need to make, that is going to require a greater degree of ongoing engagement than I think has ever been required in the past, because we are looking to change the way services are delivered, and that means that we need to understand what people think of our services at the moment, which we have a reasonably good understanding of. We have good patient feedback that comes through, but more importantly, we need to work with the public in developing our vision and what that means for the services that they will require on the ground.

I think there are organisations that have done this. Hywel Dda did some very good engagement. I think there are some organisations in England that have done—. For me, this is not so much engagement as a wider aspect of communication. It is how we engage and communicate with our staff, with our stakeholders and with our public, and it needs to be, in a sense, a day-to-day, ongoing communication rather than as has historically happened, not just within our organisation, I think, but in general in the NHS, when we need to change something, then we engage, and I think that we need to move from that to a much more ongoing form of communication.

Thank you for that, because you talked about engagement and communication, and they are separate. I think they're separate things because you have communication, which is a one-way message, and there's engagement, which is a dialogue between the two. I'm very pleased you came, towards the end, to talk about the public, because the biggest stakeholder you've got is the public. 

Absolutely. 

I would therefore look forward to greater engagement—and I'm using the word 'engagement' this time—with the public to discuss those, so that we have those conversations and we have the ability to ensure that people both give their opinions on the service but also can help drive forward the structure of the services in the future. 

Yes. It's interesting about semantics, actually. I used the word 'communication'; for me, engagement is something you do formally when you want to make a change. For me, communication is two-way. So, we talk about communication within the organisation. Communication is not a one-way for me, but—

Not everyone will see it that way. 

No.

Okay. Lynne. 

Thank you, Chair. Good morning. 

Good morning.

I wanted to ask about a couple of areas that this committee has been very keen on. The first is the need for there to be a much more fundamental shift in the NHS towards prevention. This is an area that has caused a lot of frustration, really, in terms of the health boards because it doesn't always feel as if health boards are rising to the challenge. I know it's difficult, perhaps, to consider this at the moment in the middle of this pandemic but, longer term, how would you see your role as chair in terms of actually ensuring that we really do deliver on that commitment to prevention, rather than just paying lip service to it?

I totally agree with you. For me, the key to making change is to understand why it is you're doing it. So, without prevention, we haven't got a hope of making that transfer of care because there won't be enough resources. So, prevention has to be the first line of defence. I think if, as a health board, and as the public—. This is co-production, isn't it? If we understand the importance of prevention, then I think that that, by definition, means that it is at the front line, because it isn't just a thing we've got to do, it is the way in which we will have a chance of delivering the transformation that we want. 

The other thing I would say is, I'm a scientist by background, and I think that you do need to measure, because I think if you can measure—. Human beings, as a general rule, respond to feeling that they are making progress, and I think that one of the ways that you can do that is to look at the way in which you measure the way in which you are making progress on prevention, and I think that will need thought at a national level as well as a local level, but there are absolutely things that we can do to say, 'What are our milestones? How do we know we are making progress here?'

Okay. Thank you. Can I ask, then, about mental health, which is another area that the committee has been very focused on? In particular, we have argued very strongly that we would like to see parity between mental and physical health, and it feels often as if we are a very long way from that. What contribution do you think you could bring as chair to ensuring that there is a fundamental shift in that direction, really, because that in itself is a really key part of prevention if you look at the number of physical health problems that arise from people having mental health problems that they haven't been supported with. The cost is enormous.

Yes. I totally agree. That's something I feel very passionately about. I think there are two parts to that. Firstly, it's ensuring that the mental health services that we provide are as high profile as the physical health services that we provide, so that when people have a need for mental health services, it is timely—and we are fortunate in Swansea Bay, we do provide timely services—but that the importance of those services is recognised throughout the organisation and at the board, so that they are the highest quality services. I think we do do that. As a vice-chair, I encouraged a board development session where we looked at all our mental health services and I think that has raised the profile. There is more of that to do. So, that's part of the answer.

The other answer is that that understanding of mental health services and mental health needs needs to be throughout the entire organisation, because a lot of—. You know, people in mental health services have physical health problems; people with learning disabilities have physical health problems. And so, again, raising that visibility but also looking—. And again, it comes down to information as to what we're doing, what success we're having and monitoring that, but what I can do as chair is to bring both that passion and that spotlight through the way I run board meetings and through the agendas that I have. 

Okay, thank you. And just in response to, I think it was Angela earlier, you talked about the importance of regional partnership boards and I totally agree with that, but we know that there's a long way to go, really, in ensuring that they work in the way that we'd like to see them working. How would you ensure—? What particular contribution could you as chair bring to ensuring that the regional partnership boards work as effectively as we would like to see them work? 

Okay. So, we are quite fortunate in our region that the west Glamorgan regional partnership board predated the requirements, and so, there was already an element of quite positive working. This predated me, but the other thing that I am lucky to inherit is that there was quite a significant element of streamlining of the governance arrangements for the regional partnership board, which means that they are now extremely clear, and that helps. So, there was an older person's group, there's a children's group and a transformational work stream. 

For me, the RPB is my key partnership priority, obviously. I think part of the way that we will further improve the operation of the RPB is getting the right attendants, just like committees; it's making sure that we have right attendants both at executive and independent member level, and also that we have the right level of debate at the board about the regional partnership board so that we have expectations of the regional partnership board and what it is delivering on our behalf, if you like, but also that we understand what our contribution to that is and that we are confident that we scrutinise; that we are playing our role effectively in that. 

Finally, I would say that, by both of those mechanisms, in order for—. I think what I would like to see is further development. There is already a good relationship around the RPB table, but that supportive challenge is just as important in a partnership forum as it is in a health board. So, making sure that we have that within the confines—. It's a more tricky operation because you're dealing with partners, so you've got to build that trust. But if we really have that vision of the regional partnership board delivering for the region, as we do, we are going to need to have that supportive challenge around the partnership board to make sure that what we deliver as a result is as effective as it can possibly be, both in terms of the services that it delivers and the money that it uses. 

Thank you.

You were vice-chair when the boundary changes occurred and you're now interim chair. Clearly, there's going to be a challenge still with some of these service level agreements and other aspects, and perhaps service movements as a consequence of this. What's your vision for the future based upon the new boundary—the Swansea Bay footprint—and the relationship you have with Cwm Taf, particularly regarding the services currently provided at Princess of Wales Hospital for many, particularly my constituents?

Yes. Firstly, I do have to say that I think that the boundary change was handled on both parts by both health boards in an exemplary way, actually. It was a very major thing to do, and I think both health boards worked extremely hard. It was an enormous amount of work for both sets of executives, so what they delivered, both in doing it to time, but also in the detail of all the SLAs that you mention, I think that was a real achievement for both health boards.

In terms of looking forward, it does gives us a degree of regional focus, I think. So, we are Swansea Bay, Neath Port Talbot, and I think that is, in some ways, helpful, looking forward for us as a health board. We have very good relationships with Cwm Taf. Because I was vice-chair, I know the vice-chair of Cwm Taf and I now know the chair of Cwm Taf, and, at executive level, the relationships are very close, because, ultimately, these patients were our patients; a number of them still are our patients, and we want to make sure that that works. And I believe, on the ground, there has been very little impact of that boundary change, which is another tribute to the dedication with which it was achieved. 

Going forward, some of the SLAs, I'm sure, will, over time, move across, but it comes down to the—. This is part of the advantage of the collaborative system within Wales. We have collaborative relationships with a number of different health boards for different reasons. So, with Cwm Taf, it is very much around the boundary change, and we have a very clear remit to make sure that we make that work. There are other ways and areas in which we work, but there are other health boards with which we work in partnership in different areas. So, we are used to doing that, and I am very confident that that will continue to be a smooth transition. 

Because, obviously, there are pluses and minuses in that. Clearly, with the SLA you currently have a situation where the resources and the services are elsewhere, and they're already established. If you decided no longer to have the SLA, you'd have to establish those resources and services within Swansea Bay, which, again, looks at your estate and your flexibility and availability within the estate. So, clearly, there are going to be pluses and minuses whichever choice you make. 

Yes, but we have SLAs for other things, not just because of the boundary change. So, these are continual things we are considering. 

That's okay for the moment. We'll have our regular meetings, I'm sure, where we'll have these discussions. 

I'm sure we will. 

Obviously, we've been through your CV, and you have an impressive track record in financial markets and corporate governance and finance and governance before you came into the health sector. For me, my final question would be, if we step back away from Swansea Bay for a moment, I wondered what you felt that you yourself personally would be able to contribute to the overall governance and structure of NHS Wales. What can you add to the ministerial teams in terms of your past experiences? There's obviously a chair's forum that I understand meets on a fairly regular basis. Where do you think you would fit into all of that? What do you think that you would be able to bring to Wales?

Interesting question. Before I was interim chair, I was in the vice-chairs' forum, and as you rightly say, I now work with the chairs. I think, for me, the fact that it is a collaborative system is a real advantage, and I've learnt a great deal in terms of the benefits that that collaborative system can bring, both in terms of learning what other people do, and bringing that to your health board, and sharing things that you do. So, I think that that is one area.

And I would say that I've learnt a great deal so far. One of the things that I do have is—. My experience has given me a great degree of clarity of thinking, and I find that my best way through complexity is to work through what is my role, what are the roles of colleagues, and make sure that we keep to those roles, so that we effect the best change for the future. So, I think that, as I get more experienced within the Welsh system, I'm not afraid to challenge, and if I think that that is something that I can bring, I will absolutely do that. But, at the moment, I think it's an area that I'm still developing my thinking around, it's fair to say. 

And is there a key experience from your past work life that you think really helps you to have that insight going forward? Is it people skills, or getting structures right, or—?

I think the most—. Experience brings you all sorts of different skills, but one of the things that has always struck me as I've worked in the NHS—not just in Swansea Bay, and not just in Wales—but my FMCG experience, we never moved without knowing what customers thought. And I think that that experience is something that I do believe is of value. I think the other experience that I would say is the extent to which—I've worked across lots of different sectors, and I would argue that there are more similarities than there are differences across sectors. So I mentioned earlier, we had Welsh Water in talking about health and safety; there is an awful lot that the NHS can learn from other sectors, and I think that that is possibly something that I will be able to contribute.

Thank you.

No, just to thank you very much for your time, and to thank you.

Thank you.

Yes, certainly. I think we do have, actually, good data in some areas because of the initiatives that have been rolled out. But that differs from setting to setting at the moment. So, the ambition would be to make that consistent and have good-quality data from all the settings so that we can see the progress of the various initiatives. My colleague Nicky, actually, has previously worked in the community environment and may want to add some points specifically about the community, if that's all right.

Yes. I think the big thing is about the big roll-out in the community of tools like the national early warning score, and probably because it's so early on, we probably haven't got robust data monitoring across the patch at the moment—across the whole of Wales. But what we do need to do is to be looking at, particularly, cases, and reviewing together when somebody's been in primary care and secondary care—it's about working together and learning from that. Did we diagnose in a timely manner? Was the person treated in the right place at the right time by the right professionals? So, I think we do need to get more robust in our data and we need to have it in a live way so that nurses on the ground can review things very quickly and then make any changes quickly so that it makes improvement in care on a consistent basis.

Okay. I was going to ask: what does good data look like? I think that pretty much answers that. What does not-so-good data look like in the parts of Wales where perhaps more should be done?

Well, I think the introduction of the NEWS scoring system is critical here. I think what we were looking for was to make sure that that's accessible everywhere and that that information is the information that's transferred.

Yes. And I think the NEWS score, because it is now a recognised score, provides a language across all professionals. So, if a nurse rings the Welsh Ambulance Services NHS Trust, then everybody understands how critically ill that patient is. And I think there is more work to be done across Wales in terms of extending that NEWS score into other care settings like nursing homes, so that, again, staff and nurses have something that's very objective to be able to make—. Yes, clinical judgment is key, but you've also got an objective measure that you can share with other people to see how important it is that people get treated quickly, because that's the main issue with sepsis—it's that golden hour and getting people treated quickly. 

Angela.

Nicky, thanks for that. I just wanted to flesh out about how well you think NEWS scores has gone out in the community through nurses? Because the evidence we had from the Royal College of Physicians said that they felt that there was a level of confusion within out-of-hospital settings and that NEWS scores are unavailable for out-of-hospital use and, importantly, are a

'clinical judgement based on the understanding of the patient and their symptoms rather than the scoring systems.'

Well, they would say that, wouldn't they? I just wondered if you could perhaps—

Yes. We've got some real good exemplars of practice, particularly in Cardiff and Vale and Hywel Dda. We haven't maybe got the up-to-date picture across the whole of Wales, but with 1000 Lives Improvement and Improvement Cymru, now as it is, they've really tackled this and taken this forward, probably in the last six to eight months. So, it is quite new for the community. It is a drive across Wales—'once for Wales'—so it is quite new to the community. But certainly in the areas I was working, it was being rolled out; it was being integrated into the electronic patient record. It is something that we are advocating staff do on baseline assessments, on meeting the individual, because some people will have a NEWS score that would be of concern, but actually that's normal for them. So, we need to get a baseline, so that then we can see what the changes are.

So, it is being rolled out; equipment has been purchased in many areas to make sure that particularly district nurses have got the tools to be able to take the observations when they're in the patient's home. But there probably is more work to do to make sure it's truly embedded. With the staffing levels as well, it's an additional thing for people to do. It's absolutely right, it's evidence based and it's right for patients, but it's another thing to ask nurses to do on a regular basis in terms of baseline and things. So, all those—. We just have to really advocate for it, and I know all the nursing managers around Wales are really advocating that their staff start using this in the community, and looking at how we can work with our independent sector colleagues to then roll it out further. 

Given you say that there is growing discussion about sepsis amongst managers, what do you think is the overall level of awareness among primary care staff as a whole in recognising the signs, taking appropriate action?

I would say it is good, and within the last five years we've seen dramatic improvements in the level of professional awareness. I think what we need to do then is embed the behaviour changes, in terms of that assessment, and the access, as Nicky has said, to having the right equipment. But all of this comes on a wider baseline of safe staffing, of the appropriate levels of staffing in that setting as well, to make sure that the time is available to do these things and provide the best high-quality care. So, in terms of awareness, yes, good. There's a difference I suppose between awareness and exact knowledge and that's where we come probably linking on to the continuous professional development points that we've made in our evidence. 

And the concern that the time allowed for continuous professional development— 

Precisely, yes. So, we know that—. First of all, talking about the NHS, and I'll move on to talking outside the NHS, but within the NHS, we know that the levels compared with England are lower. We know there is a real problem with health boards allowing time for people to do even the most basic mandatory training. We know those levels are lower. We feel that that needs to be monitored by the Welsh Government more strongly and that needs to be more of a priority. Now, the important point as well to make is that the amount of CPD on offer, even the mandatory CPD on offer, is getting broader by the day, and rightly so, because as our knowledge increases, we want training in Welsh language awareness, we want training in dementia awareness, looking for vulnerable people like those with learning disabilities—all of the issues that the committee has previously looked at. So, what's important is that we prioritise what we're looking for, and we prioritise that perhaps in different areas according to the appropriateness of the service. But at the moment, generally, there is just an issue with access to that. Now, if we then start talking about outside the NHS, if we talk about, for example, care homes and about the importance of rolling that out to staff in the independent sector, then we're also talking about an even more difficult situation, very often, in terms of access to that.

There are some things we can do to be smarter. So, for example, if we have training programmes, it's about hosting those on websites that are accessible to everybody. For example, if you develop a training or awareness-raising module on a particular issue, why lock that in to, say, only students or lock that in to, say, only NHS staff? There's something about working smarter. But then there is also something about monitoring the uptake of that, because if you want to understand whether the monitoring is high, you need to have some kind of baseline. If you want to move from awareness to changing that behaviour, you do need some kind of education process. So, yes, that's a very important point, we think, we've made in the evidence.

Is the material there—is the teaching material there, given all of the constraints that you say? Is the material there on passing the relevant information on to nurses—is it available?

Yes, so there are a number of bespoke courses that are happening. I suppose there are different levels, aren't there? There's something about public awareness—about people recognising signs and symptoms—because it's a very difficult thing, sometimes, to diagnose, particularly if you've got people who are elderly, who may be confused or who may be having recurrent infections. It's about how we know that that's now gone from a very simple infection that can be treated simply to something like sepsis. So, there's something about raising awareness across the public. There's something about raising awareness to certain level across our social carers, because they will be caring for a lot of people at home, and they may be the only person who's going in to recognise signs and when to ask for help. Then, there are the more specialist areas. So, we need training for people like district nurses, your general nurses, so that they can recognise signs and know what to do, but then a more specialist avenue.

For the RCN, we have got our little 'Nursing Essentials' guide that we give to our members. That actually has a card on sepsis—what things to look out for and the six key elements that you use to treat people within the golden hour, where possible. It's also got the NEWS score on there, so that staff have got something that's easily picked up. I suppose it's about making sure that some of those basics are out there, because you can do training, but it's about retaining that and having something in your pocket or on the wall on a daily basis that you can then refer to, because not every area will see this all the time.

Diolch. Thank you.

Angela next.

Yes.

Partially asked and partially answered.

Yes. Sorry, can I just slightly—? Because of that comment that you made about 'not every area', I think you, rather than the Royal College of Physicians, made a comment about particularly triage in accident and emergency departments. You had concerns over that—was that you? It was the RCP—sorry. Well, anyway, what do you think about triage in A&E? [Laughter.]

We did mention the nurse staffing Act, and how that's then going to be rolled out across and what are the next areas that could be considered, because we know that paediatrics is pretty much ready to go. But is this something that, maybe, emergency departments—is it something that we need to consider? 

Over the last couple of years, certainly when I've been going into emergency departments, in my old role, we have got the trollies there. There is a very big emphasis now on sepsis. There's the sepsis trolley, so you've got everything to hand, like a resuscitation trolley, that you can take to the bedside. So, you've got everything to hand there. Emergency departments have ramped up, and they are very much prepared for this now. 

I think the safe staffing point is absolutely critical. When we're talking about tiny amounts of time, if you're adding in extra patients, then the medicine round and the assessment are all taking time. So, if you're even delaying the arrival of a registered nurse at somebody by 15 minutes, that becomes critical. In terms of taking observations, that's a critical, time-consuming issue. 

That is the actual connection—it's not just an abstract thing, it's a very real thing in the statistics—between the amount of staff, and the skill mix of the staff, that are available and the amount of patients and their acuity. That is exactly why we have been campaigning that safe staffing saves lives—it's as simple as that. So, we do need to look—as the extension of section 25B rolls on, we do need to look at introducing new work streams into doing the research, and accident and emergency would be an ideal candidate to introduce as a work stream where we can actually start doing the preparatory work for some of that guidance. So, we would make that point, because, if you're asking people to provide the highest quality care, you need the time to do it.

Yes, and I think your comment here about wards with lower nurse to patient ratios have a 26 per cent higher mortality rate, and that's just in the normal course of events—I think that's very powerful.

We talked about knowledge, nursing knowledge, and in triage. I just wondered, though, if you could talk about your view on when patients present in the community or out-of-hospital settings—so, it could be a care home—and they are given, usually, a telephone triage. What do you think we could do to improve the patient understanding or the system's understanding that perhaps those patients are unclassified, they're not really sure—it's not an obvious broken leg or a stroke—and that they're then monitored and called back, or that they're given enough information about the symptoms they have, that, if they think, 'Well, they said drink water and do whatever, but, hang on a minute, this is going on, this is going on', they come back in? Because, of course, a lot of the cases we've heard from people who've lost family and friends—it's because they were told, 'Go away, take a couple of paracetamol, lie down in a cool, dark room, let's see how you go', and then it's just a bit late.

And this is a real issue. I think, wherever you work in things like out-of-hours GP and triage and NHS Direct—you've got the triage tools within the systems that you're using to be able to steer you in a direction, and you can only work with the information that you're being given, unfortunately. So, you have to make sure that the prompts within that triage tool are sufficient enough to get underneath that information, so you've got clinicians then making clinical judgments. So, they may, quite rightly, with the information that's given to them at that time, say, 'Self care, paracetamol, rest, have fluids.' But what they always put in, in my experience, is that they would then talk to the individual about, 'If this happens, if your symptoms get worse, if your temperature goes up, if you're not happy, then please ring us back.' So, there's always that caveat, and they will talk to people about the kinds of things that they need to be looking out for.

Sorry, is this the ambulance service that do this, or—?

I'm particularly—. I've got particular experience of GP out-of-hours calls. So, when people ring the out-of-hours GP or NHS Direct to get that initial help, it's about them making sure that people are clear on what are the next steps, what are the things to watch out for. And there's very clear guidance that staff have, and also on the UK Sepsis site, that tells you exactly the kinds of things to look out for and what would be—as we would term in medical terms—a 'red flag', what would be the things that, actually, you would then say, 'I need an ambulance at this point.' But, certainly, they would give—. They call it 'worsening advice': if this happens, please give us a ring back.

And that might tie into public awareness as well, of course, because we can check that the software or—whatever form the triage tools are in, we can check that those are sophisticated enough to prompt people, but also, as well, in terms of the information coming the other way, that is obviously where public awareness is helpful.

Yes, and, of course, talking about diagnosis within the community, I thought your comments about the mandatory training—because you talked about care workers as well—. I just wondered about your view on what we could do to—basically, if we need to up our game in any way within the care sector, because a lot of care settings don't have a professional nurse on board.

This is a huge issue, and something that, as the Royal College of Nursing, we really want to focus on is provision of registered nursing advice and care and education and leadership in the care home sector. The fact is that, because of the—. Let me rephrase. It is important for patients, both who are receiving continuing healthcare—which is classified, in funding terms, as requiring nursing care—but also for the more general population, who may not be funded in that way, that they have access to that health advice. So, what's important is the ability of the workforce not only to be available for that advice, but also, perhaps more importantly, to be available to provide that education, that leadership, to the wider care workforce, and that's something, I think, that we could do a lot more of. The fact is, if you look at the make-up of that workforce in that sector—which we're only just beginning to understand, because Social Care Wales has only really just started, in the last couple of years, producing that information so we can start to see that population of that workforce—as you rightly point out, there's very limited presence of registered nurses in that field. So, that's about improving not only that, but also the connection then to the community nursing teams, the connection to GP out-of-hours, the connection to the wider system. So, there is, indeed, a lot of strategic work to do, I think, in terms of the availability of the education, education that's designed for that sector so that it makes sense to people on the ground and is relevant to them in terms of their lives, the staffing levels, which are, of course, absolutely critical. So, there are all sorts of things that we could do in that sector, I think, to improve—specifically to sepsis, but also there's a wider point in terms of the general health of that population.

I think there's also an element that we can work with the regulator around social care and nursing homes to look at, actually, when they're inspecting, what are the things that we're looking for and also how we can share training. So, we are moving to an arena at the moment where, if NHS is providing any training to staff, that's widely open to nursing homes as well. So, we need to be a bit smarter, as you said, around what we're offering and the different levels, because, for a care person who's going in to provide personal care or to get meals and things, it's about, 'What are the three things that you need to look out for?', and, 'How do you then escalate that?', 'Where do you go with that?' and the kind of language you need to use to get the response that you want. And that's a fairly—. That's not two, three days of training; that can be a small point. But it could be the regulators that help us unblock some of that as well.

This is going to sound like such a silly question, but are all nurses allowed to take blood? Take blood as in—. Well—.

If it's part of their role. I mean—

So, for example, I've come across nurses who haven't had stitch training, so they haven't been able to stitch a wound. And the reason why I want to ask that is that it goes back to the community. If you're out in the community—you make the comment about making sure you've got the right equipment, and I wondered if nurses, for example, had equipment—. We've talked about the new schools, but would it be useful for nurses to be able to have access without having to go through a GP, who may be already up to their eyeballs in other stuff—if they came across a patient in a care setting and thought, 'I'm not happy about that. I want to take blood, and I want to get it into the hospital', or, 'I want to get it to a CRP machine just to see if there is an issue', are they actually allowed to do that, or does that have to be through a medical hierarchy?

At the moment, it does need to be through a medical hierarchy, and not every nurse would necessarily have the skills to do it, because we tend to use, these days, phlebotomists or healthcare support workers, who are very proficient in getting blood. So, the nurses, particularly the registered nurses, don't always keep up their skills, because there are other people that are undertaking those. But I suppose, if you were very concerned about a patient, you'd ring into the GP. You may get that given to you verbally, 'Yes, please take that. I'll do the form for you. You can pick it up'. So, there is a process. And I suppose if you were gravely concerned and you wanted things like blood cultures done, which is in the six core bundle, then that person really needs to be in a place of safety. They need to be in a hospital to have that. 

But it does bring us back to—it's the point about skill mix, which is one of the points we have been trying to raise as the Royal College of Nursing for quite some time, which is, if you look just at the figures of nursing staff in the community or of registered nurses in the community teams, they have gone up, but, if you start looking underneath that then at the make-up of the teams and the skill mix that they have, you start to see a different picture. We are fortunate that the chief nursing officer's principles have been rolled out and they have some very, very important things in that about the standard that should be reached, but then the question is, first of all, is everybody reaching that standard—and we know from the committee's inquiry that we're not quite clear as to that picture of community nursing—so, are we reaching that standard, and then we need to roll out section 25B of the Nurse Staffing Levels (Wales) Act 2016 to make sure that that team is appropriate. Because if you don't have people with that more senior level experience in the team and if you don't have people, as you just rightly pointed out, with the really important phlebotomists, the care workers—if you don't have that right skill mix, that's when things like this start to impact on very specific significant issues like this. So, the more general point about the workforce principles shows up, then, in how this is implemented or not implemented.

I think there's been a lot of investment into communities, into cluster work, into locality working, and lots of teams like community resource teams have been added to the community to provide a really robust, holistic system, but I think sometimes where we've missed it is the core element of district nursing maybe hasn't seen the same, so I think that's something that we would be working on, really.

The other thing is about leaders within this, and have we got the right leaders within health boards, within areas? Do we need to look at new innovative roles like consultant nurses who can really take this forward, who can use the evidence? And there is evidence to suggest that consultant nurses provide better outcomes. If you've got a consultant nurse around a specific topic, there are better patient outcomes. So, there's something also about have we got the structure right in terms of our leaders, in terms of setting the scene, showing the evidence. Because that's what is really passionate about for nurses—is about looking at the evidence and how you can make a difference to those people you're caring for. So, it's about looking at that leadership across the patch.

And if you look at, I believe—. We're very proud of our Nurse of the Year, Eve Lightfoot, who is, I believe, either coming or has already been to give evidence on this topic. But if you look at the difference that she's made as a leader within her own health board in terms of behaviour change—

The Royal College of Nursing Nurse of the Year.

Absolutely. Yes, yes. And that's why, because you can see how those leaders can make a huge difference. But that does take a health board that can empower people to do that and find people who can do that. So, if you're looking to make a difference as a health board chief executive in a particular area, looking for those kinds of professional leaders that you can empower, which takes access to professional training, it takes access to allowing them to lead on certain issues, and specific posts like consultants' posts or specialist nursing posts that can really make a difference, because they can provide the professional education and develop the right kind of guidance, the protocols—. They can do all of that work to bring everybody on board in terms of that area, so that kind of way of approaching change through leaders does work.

I just have one very, very quick—which is a quite technical one and it's specifically about the evidence from the Royal Pharmaceutical Society, who told us that a significant contributor to sepsis hospital admissions is due to UTIs within the community, or community settings, and I just wondered if you had a view on that.

There are new guidelines out around the care of people with UTIs in the community and the use of certain drugs within the community, which will, hopefully, help take some of this forwards, that you're only treating the people who have got—. You treat using symptoms, rather than any other sort of form. There is very clear guidance about who you should treat, at what point you should treat, and with what, because, on the one hand, yes, we need to treat people, but, on the other hand, we have to watch out for resistance and things like that. So, there are new guidelines that, for the last year, I would imagine, have been implemented throughout.

Diolch, Cadeirydd. Can I just ask—[Inaudible.] The section 25B, which we know doesn't include A&E at this point in time: is there any consideration of district nursing within that, or is anyone looking at that at this point in time?

There is a work stream on community nursing, and it has reached the point where the CNO has issued principles around what the skill mix and make-up of community nursing teams look like, so that's all very welcome news. It is our view that now is the time—as the Royal College of Nursing, the time is now right for the Government to actually move, as it's already committed to doing with children's in-patient wards, to extend section 25B to community nursing. So, that's what we're calling for. So, we hope very much that that will be the next stage.

Because in your evidence, you also indicate that—. Obviously, one of the concerns is the discharge, and sometimes GPs are not—in your evidence, you're saying that GPs are not always made aware of incidents of sepsis during the acute or hospitalisation period. Would that be the same for district nurses, or would district nurses actually have that better information as regard to that? 

The whole discharge process—I mean, obviously I appreciate that committee's going to be coming on to look at that, which I think is very, very important—there are issues with that. I'll let my colleague answer that specific question about community in a moment, but I just wanted to add in as a general point that it is about the communication with the GP and the communication with the teams outside, whether that's a care home or community nursing. One of the other really relevant points—and I'm sorry to keep going back to this point, but it is the central point—is the level of staffing on the ward, because discharge planning is planning for the future, and as we know it should be done from the minute that the person actually enters the hospital environment, but when you are under pressure and the staffing is poor, it's one of the first things to suffer. So, actually, I do have to make the point. And if we're talking about improving that process, it's not just at the point of communication, it's at the point of the planning of, 'Who do I need to communicate with, and what?' So, I just wanted to make that general point, and then I'll get Nicky to answer the community point. 

So, not every patient who's going to be discharged from hospital will end up with the district nursing team, unless they have a specific need. The main communication on discharge, unless they are referred to a district nurse team, would be back to the GP. Most areas, I understand, are now doing electronic discharge, which is really positive in that patients had letters before and it was how could they get to the GP in time to give that in a timely manner. So, we are moving to a more e-discharge way, where you would hope that sepsis would be very clear on there. But, maybe what we do need to be looking at, as I sort of alluded to earlier, is, 'Are we sharing things like the national early warning score? What is the baseline for that individual?', so that we can say to the GP, 'This person's been in; yes, they had sepsis. This is the NEWS score', so that they've got some way of knowing if that patient's deteriorating again or not, and then they can link in with the district nursing to do that as well. Moving forward, we're hoping to have an electronic system across Wales that will join in the GP and the district nurses and the community teams, so we're hoping—that's being worked on at the moment, so, hopefully, communication will become more robust as we move forward.

But you would expect, if a patient is discharged and requires district nursing support, if they've had an incident of sepsis, you would expect them to be informed of that.

You would, yes. 

Okay. And do you have any evidence whether that is being done or not?

I think discharges, in general, the information that's being passed over can vary hugely. 

Okay, fair enough. Another aspect of this, since we're on discharge, is sometimes patients who have sepsis need to be informed as to perhaps what procedures—. There's no safety netting agenda. Where are we, do you think, on the safety netting, those indications to patients who have had sepsis in the acute setting who are being discharged but may need to be made aware of either who they talk to or who they should see or the symptoms that they may need to consider? As part of that, I know we've talked about this, but part of the discharge is—. What's the position on that and what's the RCN's view as to how that's going? 

I would say, and I'm making this as a general point rather than specific to sepsis, but, as a general point, the information given to patients varies quite widely.

Sepsis is no exception, then.

Sepsis is no exception to that. It varies quite widely and needs improvement, and that comes back to my point about the whole discharge process, which I appreciate the committee's going to look into in some depth. 

In that sense—. You've talked about it, I think, being in the public awareness agenda. In answering Rhun, you talked about the professional awareness agenda, but there is, obviously, the public awareness agenda. I think you've called for a greater public awareness agenda. Should the Government now be getting on with this and saying, 'Look, this is a condition that, like stroke many years ago, people were not fully aware of everything, we need to get this message out there'?

Yes, I think, generally speaking, public health messages and messages for people to be aware of need to be refreshed as our knowledge improves and as the needs of the community change. So, I think, yes, now the time is right to actually approach that. If you think about some of the big public health messages of the last five, 10 years, you can see there's been strong messages around heart disease, around cancer, around different areas where the public awareness needs to be raised, and we would agree that this is an area that does need to be looked at. Part of it, in a way, almost, is taking it back to your basic childhood in the school, lessons about just good health and keeping healthy.

Thinking back to something you said earlier, again, the care home settings, is there enough awareness in the care home settings for this when patients either may encounter symptoms and need to be hospitalised or when patients may come home? Is there enough awareness within all staff? Because everybody in the care home setting should be aware of this. Is there enough awareness, and do they need training?

I think there isn't and there needs to be more. It goes back to the answer I gave earlier, where I think the workforce in that whole sector is under huge pressure. They're very, very short staffed in that sector. And there are also real issues with the funding of that sector, and that impacts on access to training; it impacts on morale; it impacts on the quality of care, and all of those things are bearing down on that sector.

There are some fantastic examples of really good work, as well, where people have been able to use particular care homes as a sort of exemplar in a community of what can be done. So, the positivity is that things, I think, could be done there, but, yes, it would be fantastic to see more joined-up effort to do that. I think we've touched on some of that already in our evidence of how to take that forward.

We've talked very much about patients who either have had sepsis and the awareness of GPs when they come out. But, of course, we had two individuals here—one had sepsis and his wife was with us in an earlier part—who highlighted perhaps the failings, at the moment, to look at how we can care for sepsis survivors. What's the RCN's view as to, perhaps, these current standards of care for sepsis survivors?

I think we've touched on this in our written evidence. It's clearly an issue that needs to be addressed, and it's an issue that needs to be addressed, perhaps specifically and separately, from the issue of raising awareness. There are some resources that have been developed and, for example, we've we put in the work that's been done with Cardiff and the Vale last year around this. So, yes, I suppose in answer to your question, it's our perception, from talking to our members and from talking to people on the ground, that they would, if they do feel that they need more information about how to do this and about what services are available. As the Royal College of Nursing, we've highlighted issues at our congress, which is our UK gathering of members from across the UK. We've highlighted this with a special lecture and some materials ourselves, but definitely more needs to be done on this.

Can I ask a question, because we've talked to GPs about sepsis leads last week? On district nursing and community nursing, should there be a sepsis lead? Because what we had heard was that there are many facets of the survivors, whether it's mental health issues, physical issues or other conditions. Should there be an appointed sepsis lead within the community nursing team to ensure that there's someone a nurse can go to if they're having discussions with a patient and something's clicking in their heads saying, 'We need to do more with this patient'?

This might be going back to what my colleague Nicky was saying about the role of the specialist or consultant nurse, because when you have somebody like that in the health board, part of their role is the co-ordination across the health board, and also raising awareness among all the different settings and different professionals of what the most appropriate pathway is. So, where we've seen leadership work on areas like that around veterans, around particular groups who have particular needs, where—. So, one way of looking at it, rather than necessarily taking an approach at the micro level, is to actually take a more strategic approach and have a leadership, perhaps at a consultant specialist nurse level, to co-ordinate efforts. That might be one approach, but I mean, the important point here is that we would agree that something needs to be done. So, really, perhaps it’s just a case of getting the best experts in a room and suggesting the best way forward for that, because I’m sure that if we look at the work that's been done in Hywel Dda, if we look at the work that’s been done in Cardiff and the Vale and, I’m sure, other health boards as well, there are initiatives we can learn from to see which has actually succeeded the best. So, I would hesitate to say one model, I guess, is what I am getting at.

The models need to be looked at to see which one works best.

Yes, exactly. Something needs to be done. We've got some good models out there, so let's look at them, find out what works best and implement that properly.

It's also about having an infrastructure, because you can have those conversations with that individual and, hopefully, give them information, but if they need more than that, it's about what's the infrastructure then to be able to support them in a more intense way or in a longer term way. So, I suppose that's the other thing that we need to look at from here: are there services out there to help these individuals?

Okay.

Thank you very much, and thank you for welcoming me to the committee. There are some aspects of healthcare that we do data very well at. So, NHS England, for instance, know there are around 56 million people, and we can look at what activities happen, so 34 million antibiotic scripts are given per year. So, obviously, infection in itself is very common in the community. We can measure that 1.7 million people were admitted with suspected sepsis.

There are certain areas of the hospital where data is collected very thoroughly. So, for instance, in intensive care units—again, this is data from England—but 40,000 people are admitted to intensive care units with sepsis, and around 15,000 of these patients admitted to intensive care units die from sepsis.

Outside of that, data is unfortunately lacking, for a number of reasons. Firstly, we don't adequately code for presentation and the progress of patients through hospitals, but also, even aspects of patient care throughout their journey and any changes that happen are often not recorded. So, for instance, when a patient presents, they may be suspected of sepsis, but if the diagnosis changes or they die of other causes, that's often not recorded.

As an example, we're often very reliant on death certification, because that's a record of people dying. But even for that, sepsis may be recorded in a number of different ways. For example, if a patient has pneumonia, it may be recorded on the death certificate as pneumonia even if the patient fulfils sepsis criteria. 

There are a number of different strands there where you suggest there may be a need for improvement. How do we do that? Do we need a specific sepsis status strategy to bring all these different strands together and make sure that we do have the evidence that we need in order to plan services better?

To be honest, I think even that question might be a bit too far ahead, really, in terms of asking what we're trying to achieve with the care of sepsis. We rely very heavily now on the National Institute for Health and Care Institute guidelines published in 2016, which are reliant on NEWS scores, which I hear you were discussing before, on whether people have sepsis or not. We know people are screened as having sepsis, and a large majority of them turn out not to have sepsis, but will have been recorded as that and audited as that as well. I think before collecting data we actually need the research of identifying, 'Right, can we better identify these patients at an earlier stage?', obviously helping with management as well, and then track their progress through to find out, 'Right, are they getting the best care?' So, rather than data collection, from a medical point of view, what I'd like to look at is actually the research on, 'Right, are we targeting the right patients?'

Is there also an element here of the effect of the misunderstanding that you say in your evidence there is about sepsis, and the description, for example, by the NHS Confederation of sepsis as a syndrome, which is something that you disagree with. Is that a problem?

This really touches on the identification of sepsis, and I'll just run through this to make sure we're clear. Traditionally, back in 2001, sepsis was defined using what we call SIRS criteria, which was: does the patient have an inflammatory process? This was quite non-specific, and didn't really look at, 'Right, is this an effective process?'

More recent guidelines, 'Sepsis-3', rather than inflammation, looks at, 'Right, are someone's organs being damaged? Are there some problems with the lungs, kidneys and so forth?' Again, it's not very specific to infection. It's just saying, 'Is this a group of very unwell patients?' In terms of the confusion, what the screening process looks for is: are these very unwell patients who need urgent treatment, and do we think it's infection?

It's really that second part that we need better research and understanding on, because the concern of our members from the college is, if we're treating patients for sepsis who do not have sepsis and they have other diagnoses, they're obviously giving them inappropriate treatment, but we're also missing the underlying cause that they need the hospital care for.

There are some aspects—I noticed in the previous talk—of sepsis care that have evolved that are very positive for patients. Obviously, the NEWS score was mentioned, and even across our members' lifetime working, patients now get a very clear monitoring and understanding of how they are becoming unwell, and to what degree and how they should be escalated. Again, that's not specific to sepsis, but it does give us a good understanding of, 'Okay, where are our unwell patients and how quickly should we escalate it?'

For example, if you have a patient with low blood pressure, we know that if someone's blood pressure is low, that is sometimes associated with bad outcomes. They can sometimes die from that. Now, if we're measuring it day to day and it's going from 120 to 115 to 110, then we might just think, 'Oh, let's just wait', but that NEWS score gives us that click to go, 'Right, this is when we need to intervene. This is something that is of concern'. For a number of these patients, it may be sepsis underlying, but it starts that process.

NEWS brings us on to how well sepsis is identified in acute settings. You mentioned a couple of times that we begin treating people for sepsis and it may not be sepsis. Forgive me if this is a daft question: it's the other way around as well, isn't it? It's a matter of not identifying sepsis being one of the problems that we're facing here: thinking that we're trying to treat something else, but actually it's sepsis.

I think I'll illustrate this with a couple of examples. Every doctor working will have their stories, and unfortunately patients with sepsis and septic shock can get unwell quickly and get unwell quickly despite what you do.

My story is: I had a chap in his 20s—this was out in New Zealand—and he stepped on a sea urchin, which is very common. He came in and his foot was a bit red and, you're absolutely right, none of these scoring systems scored, but he just looked a bit unwell. There was obviously pressure in accident and emergency to discharge him, but we said, 'Let's just hold on a second.' Within a day, he'd had his leg amputated, he was on renal replacement therapy and it all escalated very quickly.

If I'm honest with you, the feeling among our members is that patients like that seem to be in the minority compared to the patients who are being overtreated by screening tools that seem to pick up too many people. 

I'll give you a quote from Sir David Oliver, who writes for The BMJ, and he's also a member of the college:

'Theres also a risk that, when pushed down the sepsis line by protocols and algorithms, doctors may rely less on their diagnostic acumen to identify the more varied problems behind acute presentation...Many clinicians share the same concerns about overdiagnosis, over-coding, overtreatment, and iatrogenic risk.'

Having stepped on a sea urchin, the story worries me, I must say. 

Have you got a sea urchin story?

Yes. [Laughter.]

Did you say it was a colleague in New Zealand?

It was a patient, when I was working out in—

Right, okay. You said he looked unwell, so it is the gut instinct of the individual, therefore, who saw the patient who said, 'There's something wrong here.' 

Yes. And we see that in evidence on a whole range of things, from heart attacks to other presentations where, when we introduced screening systems, actually, however many criteria you collect, often the gut feeling of the clinician, of the experienced doctor and nurse, either is as good or trumps it, time and time again, which is why as a college we fully support the NICE guidelines, but, obviously, like you said, there's wiggle room for that understanding. 

You can't get a gut instinct about something unless you're aware of that something, of course. I think there's a general agreement that there has been an increase in awareness of sepsis over the past, I think, five years or so, the Royal College of Nursing said earlier on. Are you comfortable that that level of awareness that can drive that kind of hunch in a physician is at an appropriate level now? Is there more that could be done through training, for example, to make sure that awareness level to think 'possibly sepsis' could be done?

If I'm honest, in hospital, we receive adequate training. No doctor ever says no to extra training, of course, but we're actually, in hospital, very used to dealing with sepsis. I didn't introduce my background but I'm a medical registrar. As I'm sure you know, the medical registrar looks after the hospital take and deals with the sick patients, leads the cardiac arrest and, out of hours, is the most senior doctor on site. You will not go through a shift without seeing a number of patients with sepsis. The advantages of that for the clinician is you get very rapid feedback of, over the hours you're dealing with a patient, or the days, what happens with the patient. 

So, from a feeling of what we can do to improve sepsis care, it doesn't feel like it's a training issue in hospital. I think we've got that covered. The issue that our members bring up is that of a capacity issue. Obviously, if we're running accident and emergency and acute medical units at full capacity and we're expected to give rapid, urgent care to greater numbers of patients coming in, then there's a disconnect. 

Yes, and is now a good time to talk about the current situation that we're in and that sepsis could be one of those things that—not will be ignored, but there'll be more constraints on you capacity wise because of what may happen within the NHS in the coming weeks?

It's worth pointing out—again, to contextualise the point I was making about identification—to make you aware that patients presenting with COVID-19 will have an increased respiratory rate, a cough, shortness of breath; they will screen positive for sepsis. So, as clinicians, we'll be forced down the line to give them antibiotics when we know it's a virus. We know that antibiotics will do harm to that patient. So, even in these patients who are presenting at the moment, a large number of them will screen as sepsis. But you're absolutely right, capacity is the issue that our members bring up time and time again in terms of how best we can serve these patients.

And without dwelling too much on this because that's not what we're here to talk about, achieving very quick diagnosis—positive or negative—of COVID-19 will be very important in order for you to then concentrate on, 'Is it sepsis? We'll treat it as such.' Is that fair to say?

I think it's fair to say. I think it might be a topic for another day in terms of that. But certainly what we're looking at now in the health service is how we create this extra capacity, really.

Can I just add that I'm working between two hospital sites at the moment and the response from health staff—of people cancelling their annual leave, study leave, people coming in who are long-term sick, people all teaming together—has been absolutely cracking to see? It makes me really proud to work with the team. 

I do take your point about the danger of over-prescribing antibiotics, and we know that one of the great dangers that's facing us in the future is antimicrobial resistance amongst the population of the world. But, of course, one of the comments that came—I think from the Royal College of Pharmacists, wasn't it? They were talking about ITUs and they said that, actually, a lot of sepsis cases in their experience from the community come from ITUs because they're not—

UTIs. 

Sorry, UTIs—because they're not being treated appropriately enough with antibiotics in the first place. There tends to be, 'Right, here's a day or three days' worth, go back', and then it carries on and carries on. In fact, a lot of sepsis that ends up being sepsis and death—and we will be meeting a person later who lost their child through exactly that—is because they're not getting enough of the antibiotics. So, I just wondered if you might have a comment on their evidence; it was their evidence they gave.

Unfortunately, I don't have data specifically on that. I can say that partly the public health guidance around the diagnosis of UTIs has changed recently. I don't know if you're aware but, traditionally, we got people to pee in a pot, we tested it and decided whether someone had a urinary tract infection. Nowadays, in patients over the age of 65, which is the majority of patients we see it in, actually, it's based purely on symptoms; they're what matters, you're not testing. It goes back to my point before: it relies purely on the clinical acumen of the treating clinician for urinary tract infections. 

You're absolutely right—as a panel, I'm sure you've been discussing all the causes of sepsis—urinary tract infections are a common cause of sepsis that we see, but another side to things is that they're often misdiagnosed as other things. People with urinary-type symptoms may have other diagnoses going on that we obviously don't want to miss. 

David Rees. 

This actually follows on from that question, in the sense of the resistance that we are all aware of and the desire not to over-prescribe antibiotics. But there's also the situation where, as you rightly point out, it attacks the sepsis; you prescribe those because on the occasions where it is sepsis it can actually save someone's life if it's done early enough.

What challenges are facing the profession? Because how much harm is—. We're talking about a situation of one day. How much harm would one day's worth of antibiotics being imposed on patients have  if it's not sepsis?

I disagree with your point about the early timing of antibiotics. As clinicians—. I'm sure you've discussed it, I heard it mentioned before about the golden hour and the importance of getting antibiotics in the first hour. Unfortunately, the evidence base for that is lacking. Those two systematic reviews—one in 2015 and one in 2019—both showed no specific benefit of early antibiotics. There are actually two studies that have shown that patients who've had early antibiotics had more harm than patients who didn't.

So, one of the aspects of sepsis care our members are asking for is, actually, taking a more sensible view. And you're absolutely right, if you have a profoundly unwell patient who clearly has an infection that needs treating, absolutely, we go down the route of delivering adequate sepsis care. However, for the majority of our patients where it's unclear, the benefit of taking a step back, giving a bit of time, doing appropriate investigations, is probably more appropriate.

I'll give you an example. Even though I'm an adult doctor, unfortunately, we had a five-week old child present to our hospital with meningitis, and I was the only—well, there were no paediatric doctors there. Now, this child, okay, it was the golden hour, but, if we'd treated them at 50 minutes, we'd have been remiss; this child, within 15 minutes, had got all the necessary treatment and investigations, and gone to an appropriate kind of place, really. The timing of these treatments has to depend on the patient, and we can't just group a number of patients and say, 'Right, everyone should be treated within the hour.' And that viewpoint is supported by the Sepsis Trust as well, now.

So, the position is, just for my clarification, we're in a situation where the recommendation is clinical consideration of a patient's condition will be the determining factor as to whether antibiotics should be given earlier or later, depending upon that individual patient's condition.

Absolutely. The point raised, which I completely agree with, is, with all these treatments, what you don't want to do is put it on the back burner and think, 'Oh, maybe we should do this' and look at handing it over to other staff members. You want to take responsibility, but what you want as a clinician is to have the time to take a measured approach to the patient's presentation to decide is this sepsis, and what are the right antibiotics. Unfortunately, the more immediate antibiotics we give tend to be the broader spectrum ones, and those are the ones we want to reserve for the patients who are most sick. 

Patient groups—again, as an example, patient groups that are particularly at risk of over treatment are patients with chronic respiratory disease. I don't know if this has been mentioned on the panel, but we have a group of patients with what's now termed COPD, chronic obstructive pulmonary disease; it used to be called emphysema or bronchitis. They present usually in winter when they get an exacerbation with shortness of breath, cough, coughing up sputum. It's usually called by a viral illness and the treatment is often steroids, and what we call nebulisers to open up airways. Giving those patients, who will score positive for sepsis, broad spectrum antibiotics will only lead to resistance and won't benefit them. Does that make sense?

I appreciate that, and I'm assuming, therefore, if those patients are admitted in a hospital setting, then medical records should be able to identify their history, and as such that would help you make your judgment as to what should be provided to them. 

You're right. You're correct; we're obviously aware of the patients with COPD and with other medical problems, but, obviously, you can have whatever background medical problems you like, you may still, the next time, have a pneumonia that needs urgent treatment. So, you're absolutely right, we focus our care looking at the background of the patient, but the patient in front of you and what's occurring is the most important thing. And, as clinicians, what's needed is sometimes that urgent treatment to make sure that a progressive syndrome, a progressive infection, isn't taking hold. But, sometimes, it's taking a step back and looking, 'Right, what is the correct treatment for this patient?' 

As well as making you afraid of sea urchins, I might also make you afraid of a coming wave of infections. It's scary, sometimes, looking at when we take blood cultures—so, sampling people's bloods, growing bugs—how much resistance is out there. And we have case reports now of patients who have infections, and the microbiologists has come back to us to say, 'We're running out of antibiotics to give them because of the level of resistance.' So, this something that's very prescient. 

In terms of antibiotic—. Oh, sorry.

No, no, carry on. 

In terms of antibiotic harms, there's a couple of other things worth mentioning. Obviously, a few years ago, the big drive was to reduce rates of MRSA and clostridium difficile, and antibiotic stewardship related to that. I unfortunately had a lady who was treated as pneumonia/sepsis, in retrospect probably was over treated. She had antibiotics, the next day developed clostridium difficile, and, because of the diarrhoea, fell in hospital and broke her hip. She was in hospital for three weeks because of that, and that was a very direct cause of the treatment of antibiotics, really.

And there's also evidence out about certain chemotherapy drugs now. If you've had antibiotics in the previous month, they don't work as well. So, we need to be very careful about which patients are getting antibiotics, because it will lead to harm. 

Did you want to come in?

I just wanted to clarify something, because, in your evidence, it says if sepsis 6 treatment is given to the patient within the first hour of the condition's presentation, it is estimated it can save up to 14,000 lives every year. I'm thinking I'm hearing you say that, actually, it should be held, just wait, pause, look before you—. So, is that before you start the sepsis 6, or is that because the sepsis 6 only applies to when you know for sure that that person's got sepsis? Because, hearing what you said, and reading the evidence, there's a slight confusion for us lay people here. And also, how does this tie in with the rapid response to acute illness learning set, and their drive on the whole 'treatment quickly' bit?

Excellent question. One of the problems with discussing this is sepsis is a heterogeneous kind of problem, really—there is a wide spectrum of people affected by sepsis. And, in terms of that figure, actually, the evidence on sepsis is changing, and a lot of the references I was looking at in preparation for today were published actually in the interim between providing our written evidence and here today. The representative from the Sepsis Trust has actually changed, and looking at, actually, if prompt treatment is given, that figure's now around 5,000 to 8,000—that's the suggestion. And these are when we're looking at our sickest patients. And these usually are younger patients who are presenting with infection who need prompt, rapid treatment.

Just to contextualise sepsis, out of patients who screened for sepsis, about three quarters are over the age of 75. Seventy per cent have what's called a 'do not resuscitate order'. So, it usually suggests that they're not for escalation of care—usually to intensive care, but certainly not to trying to restart their heart if it stops. So, for those patients, often this kind of measured view, and looking at, 'Right, what's the right thing for the patient?', is appropriate. And these patients—if we look at 52,000 people contracting sepsis per year, these patients are the majority of the other patients, who aren't the 5,000 to 8,000 where prompt treatment may help. In terms of that figure, though, if I'm honest, it's a best guess. Because we still don't have the evidence to prove exactly what's happened. Like I said, just specifically looking at the antibiotics, we don't have the evidence that early antibiotics helps, unfortunately.

So sepsis 6, then, perhaps shouldn't—. So, are you saying that sepsis 6, actually, is no longer—? Because it's very clear, isn't it? It's oxygen, cannula, bloods cultures, lactate, antibiotics, fluid resuscitate, fluid balance. So, you're saying we could take antibiotics out of that mix, or—.

So the—

So, is the sepsis 6 still a good protocol—I think that's probably what I'm asking—given what you've just said?

I think it's fair to say that we've come a long way in terms of the treatment of sepsis. And the Sepsis Trust has done fantastic work in terms of helping public awareness and helping develop protocols for the treatment of patients. For a large number of patients, sepsis 6 is a very useful tool, because it helps institute treatment and guides what sorts of measurements help. And it goes in line with the National Institute for Health and Care Excellence guidance that was published in 2016. For a large number of patients, and usually these are our patients with non-sepsis presentation—so that's screening for sepsis—or our frail elderly, then the sepsis 6 might not be the most appropriate approach.

There's another aspect—it was highlighted by one of our consultant physicians—about fluid resuscitation. So, that's just the giving of intravenous fluid. For some of our older, frail patients, when we give people fluid, it can sometimes go to their lungs, and instead of helping, it can harm. So, again, it's going back to that measured approach, the rapid assessment, and looking at the patient, saying, 'Right, what is the right care?' But, certainly, for the patients who will benefit from urgent treatment of sepsis, the sepsis 6 is a useful tool.

But one of the things we'd be pushing for as a college is more research into this area, specifically around these patients who we're talking about—our non-intensive-care patients, our patients coming in through the accident and emergencies and the emergency assessment units—of who are the best patients to get this urgent set of assessment and treatment.

Okay. Back to David.

In that sense, then, just going back to who those patients are, we've heard evidence that a large number of occurrences of sepsis occur in the community settings, rather than anywhere else. Is there anything that needs to change to help identify those types of possible cases, so that, when they come into the hospitals, you are fully aware of what is likely to be the case, because you've had some information beforehand? Is there anything we can do to improve the community settings, and the community awareness, so that it helps doctors who are treating and understanding what the conditions are?

If I'm honest with you, that's a very good question and I can't think of—

Perhaps you could write to us if you think of something.

Absolutely. One thing—. And obviously I can't comment particularly on our primary care colleagues. However, we are a referral service, we get referrals from primary care, and the primary care doctors I deal with are very, very good at identifying sick patients, and, again, not specifically relying on tools, but, when you're in a consultation with a patient, knowing very clearly if that patient's sick and needs to go into hospital or not.

Okay, a final question from me, and it's just, simply, it seems to me—[Inaudible.] If an individual has sepsis, and they overcome that and they're ready to leave, they'd be discharged. There's a very strong question that we've heard about the safety-netting aspect. There are concerns that there is not enough of it—awareness of who to speak to and who to approach, or what are the symptoms and what do you need to look out for. In your view, how can that be addressed? Is it greater awareness amongst professional staff? Is it a protocol that should be in place for any patient who has sepsis? How do we manage to ensure that safety-netting is done for all individuals so that they have an understanding, when they leave, if they feel something's going wrong, of who to talk to, who to get into contact with, and, 'By the way, this may be a symptom; don't panic about it because this is a natural part of your recovery.'

Again, an excellent question, and I go back to my point about sepsis being a heterogeneous condition in terms of the age of the patient, the comorbidity of the patient and the type of infection. What I'd look at focusing is, actually, on each individual infection, because it's very different. Obviously, if someone has a surgical-site infection, has had bowel surgery or joint surgery, then, in my experience, that follow-up and that patient advice is very good in terms of the patients being aware and clinicians informing them of complications. 

With regard to the more common infections we see, such as chest infections—to be honest, I don't know if we've got the research and the understanding ourselves of at what point the patient needs to worry. There are certain very clear signs, and most patients leaving hospital will be aware of those. But it's—obviously, the other side of things is, like you said, what patients don't need to worry, and we typically say that it takes about six weeks to recover from a pneumonia. You know, we wouldn't—. If you carry on having symptoms, so long as they're getting better, it's something the patient shouldn't be too concerned about. In my experience, that side of things I think we could do better at.

I'll give you an example: my father was in with prostate cancer, but he had sepsis when he was in. Yes, when he was discharged, they clearly gave him an indication as to treatment for prostate cancer and the way it goes, but there was no discussion as to could there be any knock-on impact of sepsis in that case. So, they dealt with one condition; they didn't deal with the other condition. So, should we be looking at making sure that, whatever conditions you experience during a hospitalisation, there is, on discharge, a notification as to how each one may be moving forward? I appreciate that individual patients will be different, and I appreciate that combinations of conditions could also be different, but should we be focusing on all conditions rather than just simply the main one you came in for?

Can I just clarify—? Sorry, you talked about your father. Was he receiving chemotherapy or specific oncological treatment?

No. He was in the early stage of diagnosis.

Okay. Because there are some areas of excellence and, certainly, around patients under oncology services, they are very—. And those who are receiving chemotherapy, I'm sure you're aware that, often, they have alert cards, phone numbers to call, paperwork around when to be concerned about receiving chemotherapy—what aspects of the treatment to be concerned about.

In answer your question, honestly, I think often the symptoms that people may get are quite vague and often it's instinctive to the patient of knowing that something's wrong. I referred to the NICE guidelines 2016—the largest change to that, to me, was actually the importance of the patient or the family being concerned that something's not quite right, and that's very prescient in the advice. What I would say, though, on the other side of things, is, through the emergency assessment unit in accident and emergency, we see people with infection without sepsis. For those patients, I'm very, very clear in terms of when you need to come back and where you need to come back to. I think, generally, our advice around those patients who—. Like I said, we have 34 million antibiotic scripts per year, but 1.7 million people are admitted with sepsis. So, it's only a minority of patients who are being treated for infections get sepsis. When a patient is discharged, we call it 'safety netting advice', 'Right, I want to see you if this happens' or, sometimes, my colleagues and I would book a routine appointment for a few days' time to check on how the patient's going anyway. 

Okay. Angela to round things off. 

Yes, I just wanted to talk about public awareness campaigns and what happens after sepsis. I thought you made a very interesting comment in here that you felt that the word 'sepsis' was clouding the issue slightly. I think you said,

'The public are familiar with terms such as blood poisoning,'

or pneumonia, and I just wondered if you could just perhaps give us an overview of your view on whether or not we need a public awareness campaign, which has been advocated by quite a lot of the witnesses who've come before us to give evidence. 

The public awareness has been very prominent. As you know, we've had Sepsis Awareness Month, presentations on Call the Midwife—sorry, I don't watch these programmes, so I'm just reading—[Laughter.]

Don't worry. [Laughter.]

There's something weird about doctors watching Casualty, I think. Call the Midwife and Casualty.

There was a paper, which I just wanted to highlight. I'm sure you've come across it: the Rush et al paper, published earlier this year, that looked at newspaper reporting. It looked at around 310 articles of patients who had died of sepsis and 140 of those were children dying of sepsis. Obviously, every child death is an absolute tragedy and, those of us who are parents, it's the stuff of nightmares, absolutely. But, unfortunately, it gives a very skewed view of the world where 45 per cent of the newspaper articles are around children dying, when the number of children who die of sepsis out of the population is probably certainly less than 1 per cent. 

The other thing that was highlighted by Rush is, and I'll quote here, 

'Descriptions of the health service's management of sepsis were almost universally critical...just six (4%) contained praise for the health service’s management of sepsis'.

Absolutely mistakes, omissions and errors occur, but we go to work to do a good job, and I mentioned the five-week-old with meningitis. Now, if a five-week-old child has meningitis, their chance of surviving is low. Now, thankfully, this child survived, but if the child would have died, it wasn't through lack of trying and we, as doctors, did everything we could. And it's very, very normal, as a family or as a patient, to be very angry if your family member or you come to harm. Often, it's not related to failings on behalf of the health service. I'm not saying that there are not failings, and certainly people carry with them examples of times when care could have been better, and I certainly do. But if we are looking at public awareness, what I'd like to focus on is firstly, giving an accurate view of the sepsis we deal with in hospital to make it a positive thing; to be aware that staff who go to work are going to work to do a good job; and to avoid this kind of critical look. But also we need to measure the anxiety levels.

So, one of our members told us of this case where, in their hospital, they had a big poster out, 'Sepsis'. The nurse in charge actually took it down in the waiting room, because she felt that it was creating such anxiety for the patients in the waiting room with a big poster saying, 'Could you be dying of sepsis?' when you're sat waiting to see a doctor, without much benefit. So, we need to be measuring right: if we are looking at public awareness, how are we measuring its benefit? Because a lot of our members have said, unfortunately, it creates excess anxiety and it's unclear what benefits are provided. 

Interesting comment that, and I've had quite a lot of representations now from people who didn't have sepsis, but they had a very traumatic event. So, I wonder if the incomprehension that the public have when they have a loved one who goes through sepsis is partly to do with the general incomprehension that anybody has when they have a very healthy person that suddenly, for whatever reason, gets very sick in an ununderstandable way. So, if someone you love is diagnosed with cancer, you have an understanding, you've got a plan, you've got lots of steps. If somebody's in a road traffic accident, that's a shock. It's that sudden, 'Oh, my god', because one minute they were completely all right. I just wonder if some of that commentary that you make is because one minute the baby or the child is right as rain, and then if they go into septic shock, it's just such a rapid escalation that people just simply can't process it.

I know when I've met families of people who've died from septic shock, it's been that horrible thing of—to be brutal—first of all you cut off one leg, then the other leg has to go, and then the arm, and then perhaps the nose, and then the person dies anyway. It's this sort of—. It's just such a shock, whereas other things, like perhaps having a heart attack, we understand better, we know more about it and you see a path. Does that make sense, what I'm trying to explain?

That makes perfect sense, and one thing that's often lacking is, we as clinicians, as doctors, nurses, healthcare assistants, we take this home with us as well. We have to look in the mirror at the end of the day and say, 'Did I do everything right? Was there anything we could have done to avoid that chap in his 20s losing his leg? Was there anything we could have done to avoid that person dying?' As I mentioned before, as clinicians, what we don't like is that feeling of helplessness, and sepsis and septic shock in its most extreme form often, unfortunately, despite whatever we do as a healthcare setting, there may not be a chance to save that person's life.

One thing you touched on before, which was a very valid point, was that when we're looking at follow-up for patients who have been through traumatic events, what I wouldn’t advocate is any specific interventions around sepsis. Looking at reducing variability between patients is actually—. If patients have been through a traumatic event—through whatever kind of means, whether it's sepsis or heart attack or road traffic accident—certainly that follow-up should be there. As a health service, we're very, very good at following people up from a rehabilitation point of view, from a social care point of view, and often from a medical point of view—monitoring ongoing care. But those who have had psychological damage from an acute medical problem—whether it's sepsis or something else—often, that's where we see the gaps. And we see that through discussions with patients who will recall back or tell me that on 3 March 1983 he had this happen, and this is what happened, and they have to carry that with them for the rest of their life.

The last point I make about public awareness is—. I'm sure you're aware, there was a paper published in The Lancet called 'Sepsis hysteria'. I'm sure you've come across it. As well as avoiding Casualty, I tend to avoid Twitter as well. I understand there was quite a lot of conflict between patient advocacy groups and clinicians who really, really work in different worlds because, obviously, it's tragic to have a family member die of sepsis, but as hospital doctors, we have to use evidence and have to look at our care of patients.

What seems to be lacking is, actually, going forward, why aren't we working together? Why aren't we co-producing these interventions? Why aren't we working with the patient groups and saying, 'Right, if this is how we're going to develop our sepsis services, why aren't we clinicians and patient advocacy groups and patients and carers co-producing this?'

I take some of that point as well. But when we come back to public awareness, the idea behind those who drive for a public awareness campaign is, because of the nebulous presentation at times of sepsis, to try to make the public more aware of what is going wrong.

I had a constituent who, a bit like David's father, had had a prostate exam or operation or whatever it was. His partner, who was a nurse, was actually away that night, and he went back home from the hospital, and within four hours he started feeling so bad. She happened to randomly phone him up—because they weren't going to speak because she was at an event—about half past 10 at night, and he was barely conscious. So, she got a friend to pick him up and took him to hospital, and it was sepsis. It had happened that quickly. But she knew about it because she was a nurse, so she knew about those things. Then you hear a lot of other cases where people actually didn’t, and it was then passed off as other things.

So, I think the idea behind a public awareness campaign is like we've got FAST for stroke, so you can identify and help to identify if somebody is having a stroke. It's not about trying to frighten people, it's about trying say, 'Look, if you have the—[Inaudible.]—and they won't go away, and this happens and that happens, then go back to say, "I know you've told me to go away and lie in a darkened room with some paracetamol, but, hey, guess what, it's two hours on and I feel really, really, bad now."'

I just wondered about your view on—. So, it's less about saying that it's your fault because that person died, it's more about giving the citizen the ability to keep knocking at a door and say, 'I'm just not quite right here, because you don't know me, because I've just been to A&E triage and you're really, really busy. You said it was fine, but you don't know me like my GP would.'

Yes, there are a couple of points related to that. Certainly, I'm obviously here to represent the members and, speaking to the members, overwhelmingly they feel that the current state is causing anxiety and panic among patients. I had a member who told me that they can be having a conversation with a patient and if the word 'sepsis' is used, the tone changes. Sometimes, unfortunately, it's not helpful because of that heightened level of anxiety, and it stops, often, the process going forward. National Institute for Health and Care Excellence guidelines suggest that we absolutely have to use the word 'sepsis' and talk about progress.

Health literacy is an issue across the UK, obviously. As clinicians, our favourite patients are the patients who are clued up and their families are clued up—who understand things. However, I would really strongly suggest that we need to be measuring what impact that has. Are we saving lives by a public awareness campaign, at the balance of the increased anxiety about things?

The tone of the newspaper articles—this was published by Rush—was, 'This is the silent killer, it can happen to your child at any time and when you go to see a doctor they don't care.' You know, it was that sort of terminology, which isn't helpful, because even though we're talking about 150 child deaths a year in the UK, which is an awful statistic and awful for any parent, it's not as common as the media would portray and, certainly, is a cause of sleepless nights for parents.

I just wanted to turn to another bit of your evidence that I found slightly surprising:

'Sepsis does not end at hospital discharge'.

I think we've had lots of evidence about that, but you say:

'There are support groups in place to help those who have been affected by sepsis.'

I'm the chair of the cross-party group on sepsis, and I have to say I have yet to meet a sepsis survivor who's been able to access any support groups. I just wondered if—. The Sepsis Trust run a couple in south-east Wales, but I just wondered if you could, perhaps, flesh out that comment.

As I understand it, they were referring to those groups. Other than fleshing that out, I'm afraid I don't know further. What I would go back to is, like I said, I think if we are looking at ongoing support for patients who have been through trauma through hospital, I think it would be wise to look at reducing variability and actually looking at our patients as a whole, rather than specifically picking out patient groups. Unfortunately, when we pick up specific patient groups, there are other patients who are left behind.

I do take that point. Sadly, we decided, given our current circumstances, to cancel the next cross-party group on sepsis—it was due next week—because a lot of our members are people who are, perhaps, a bit more compromised. But, we were going to have, and we will have, a presentation given to us by a person who gives a lot of lectures about just surviving intensive care units and high-dependency units.

Reading her presentation materials, it was quite interesting, because I really understood that, for example, if you have cancer, you're perhaps on a cancer pathway and you might have a Macmillan nurse with you, or whatever. So, the psychology behind it is also scooped up a bit, so you get that sort of longer term support. Hearts—you know, you'll then go to heart rehabilitation, where they'll talk about your mental state as well. But, if you've been to ICU for some sort of short, sharp thing and you come back out, that is such an appalling experience in your head that it's that whole group, so I can understand your commentary behind that.

Could you just give a very quick overview about just anything you have to say on hospital discharge and the communication between hospitals and GPs? A lot of GPs will say that they don't actually get the information that this is sepsis, so it might be that somebody went in and had pneumonia or something, but—.

So, you actually touch on a point on a wider issue, and that's around communication. Like I said, sepsis is a heterogeneous descriptor term. A lot of doctors would prefer, when speaking to patients, to talk about the underlying condition because that's usually more helpful. So, for instance, if a patient has a kidney stone that causes a blockage and there's a kidney infection and that causes sepsis, that actual process is much more useful when talking to patients because, actually, we need to be talking about our ongoing treatment, which is often a small operation and clearance of the stone or whatever. So, even between clinicians in hospital, different terminology may be used depending on the context and the seriousness of the situation, really.

Certainly, often, from hospital discharge, the communication will be the descriptor term of what the patient presented with and what the diagnosis was and the word 'sepsis' may not be used—not deliberately, but it's seen as more useful for doctor-to-doctor communication to talk about actually what's the underlying disease process and what's going to be done about it. Does that make sense?

Yes. I've just got one last question, if I may, and it was something that surprised me: that 40 per cent of sepsis survivors are rehospitalised within 90 days of discharge for potentially treatable conditions. I just wondered how you might think we could prevent that, or mitigate it. 

Re-presenting to hospital is an interesting topic for a number of reasons. There are a number of conditions where our readmission rates are very, very high: people who are frail; people who have come in with sepsis or infections; and people with conditions affecting the heart, usually heart failure. Despite a number of interventions and community support, the rates of readmission are often high.

Certainly, no doctor would ever argue with the fact that better community support would be beneficial. So, for instance, if I use heart failure as an example, we have specialist nurses who go out and will manage someone's ongoing care to try and, obviously, give the patient the best quality of life and life expectancy as well, but also to try and see, 'Right, if things are reaching ahead, can we do things to prevent that?' So, that's the area of heart failure.

In terms of sepsis, like I said, because of how wide-ranging it is in terms of patient age, characteristics and presentation, instituting something like that may be a bit difficult. That's a statistic. I'd also caution about what we're trying to achieve by reducing readmission rates. Obviously, if yourself or your family member have been discharged and they have to go back to hospital, that's a horrible process to go through. However, when we try and reduce readmission rates, often what happens is we just increase length of stay, because clinicians are so paranoid about discharging someone that they never actually get home, if that makes sense. 

So, going back to the point David Rees made, for patients particularly who are fairly on in their stay, I'll say, 'Look, we've got an infection, I think we're on top of it, here are some antibiotics, I'm on for the next three days and I want to see you if these symptoms come back.' If the patient then is appropriately discharged and then at home they get worse and they come back in, I don't know if we should see that as a failure in our current state.

Certainly, going back to the point about research, if we had better research to identify which are the patients who are likely to deteriorate and which ones are not, then we may have to rediscuss that. But for the moment, it's adequately assessing a patient, deciding that they're safe to go home, the patient themselves want to go home, clear safety-netting advice given, and then if they represent in two days' time, I'm often the same doctor that sees them, 'Hi, I'm back, things are worse', and then they get appropriate treatment. From our members' point of view, I don't know if that's seen as a failure. Does that answer your question?

Can I ask a question on that?

Final one now, then.

First of all, if the focus was that they were coming back in with conditions that could have been treated in the community or as an out-patient, I suppose this could be linked to the poor communication with a GP. In the sense that, on discharge, if someone's discharged after having been in with pneumonia, say, but they had sepsis whilst they were in, the GP understands the pneumonia agenda, but is unaware of the sepsis aspect.

The question, and perhaps the Chair could answer this one as well: if an individual is unaware of the patient actually having had sepsis when in hospital, they were discharged from an admission of pneumonia, would it change the way in which they were treated as an out-patient or in the community if they knew that sepsis was also a factor whilst they were in? Would they actually send somebody back in? This is a medical question I'm asking.

It's a question I can't answer. Obviously, what we want to avoid is using terminology that increases anxiety for clinicians and for patients that causes this bounce-back effect.

One aspect of patient care I unfortunately forgot to mention is about our community resource teams. I don't know if they've been mentioned. By chance, I happen to be working in the one in Torfaen at the moment, and supporting patients post sepsis—either with giving the antibiotics in the community, drip antibiotics in the community, or with assessment—is actually part of our job.

So, again, another case example: we had a lady with pneumonia who on Monday this week decided she didn't like hospital any more and wanted to get out and she had the capacity to do so, so I was in her home, having a good conversation with her, talking to her about, if things get worse, what she would like to do and her ongoing management.

So, what we're seeing a rise of, like I say, is—the Royal College of Physicians typically support it, it's hospital doctors who are our members—we're seeing more and more of doctors themselves going out into the community and seeing these patients, either de nouveau or after discharge, and a lot of those patients would have been treated for serious infections.

Okay. Angela, are you done?

Yes, I am. Thank you very much.

We're all done. Excellent. Excellent questions. End of questions. Thank you very much indeed for your attendance. Excellent paper beforehand. You'll receive a transcript of our conversations so you can make sure that the facts are right. You can't completely turn everything on its head, but you can at least make sure that they're factually correct. Thank you very much indeed for your attendance. Diolch yn fawr.

Thank you for inviting me.