Cynulliad Cenedlaethol Cymru

Bore da. Croeso. Good morning, and welcome to this morning's meeting of the Public Accounts and Public Administration Committee in the Senedd, the Welsh Parliament. We've received apologies from two Members: Adam Price and Rhianon Passmore, and I welcome Carolyn Thomas, who's deputising for Rhianon Passmore. Do Members have any declarations of registrable interest they wish to declare, beyond what's already on the record? Thank you very much indeed.

Well, can I propose that, in accordance with Standing Order 17.42(ix), that the committee resolves to meet in private for item 3 of today's meeting? Are Members content? Thank you, Members. In which case, I'd be grateful if we could action that accordingly.

Bore da, croeso—good morning and welcome to our witnesses. I'd be grateful if you could state your names and roles for the record. 

Bore da, good morning.

I'm Carol Shillabeer and I'm the chief executive of Betsi Cadwaladr health board. Thank you.

Diolch yn fawr. We have a number of questions to get through, so I'd be grateful if both Members and witnesses could be as succinct as possible to enable us to cover as wide a range of the topics as we can. As convention has it, as Chair I'll begin with the first set of questions, and then pass over to colleagues to pick up from there.

So, given the changes in the board occurring over the last 12 months, which saw unprecedented resignation of all the independent members—. Obviously, you weren't involved at that time, so weren't privy to what actually happened at that point, but can you describe what impact that has had on the organisation?

Thank you. Do you wish to add to that?

Yes, just to say, from my point of view, I arrived a couple of months after the board changes. So, 3 May I arrived. I certainly felt that it was an organisation that was spinning somewhat, still in reactive mode to the things that were happening on, literally, a day-to-day basis, and it needed calming. We also needed to very quickly get in place the special measures response plan. So, they were my priorities as I came in in early May, just to provide that leadership to the executive to calm and steady the ship and to get a plan about how we were going to move forward.

Can I just ask very briefly, given that you came from a different health board not very far away, what lessons learned there were you able to apply by comparing what you were used to with what you were encountering?

I see it as a benefit that somebody came into Betsi Cadwaladr who'd been within the Welsh system, knew the way around Wales, so to speak, knew some of the key colleagues who had been working with and touching, if you like, the health board. That was very helpful for me. And there's a lot of that. You don't want—. When you're moving into an organisation that is spinning, you want to make sure you've got your anchors in place, and you know colleagues in Audit Wales and Welsh Government colleagues et cetera, so that was very helpful.

The other key thing was to provide some cover, in a way, to be able to deal with a lot of the challenge that was going on at the time. There was a lot of media profile, some of it was about individuals, and my job was to try to just calm that. So, I took a lot from being chief exec in Powys. I'd been there a long time. We'd moved from an organisation that, to some extent, wasn't always that stable a long time ago, to a place where it was stable. So, I knew what a stable organisation looked like. I knew what a good executive and senior management team looked like. So, I approached it in that way: start the work on building people's confidence in being able to move forward.

Thank you. Moving on, in your view, what progress has been achieved with the stabilisation phase of the special measures framework, what is still left to do, and when do you think this phase will be concluded?

Thank you. Just following on from the last question, really, I approached this in a way that was that we needed to get some rapid traction. So, a three 90-day cycle approach was taken, which would take us to the end of February. We're now in consolidation, and we will be publishing the whole progress of those three 90-day cycles. I wanted it to be ambitious, to show commitment and intent, but try to be realistic as well in terms of where the organisation was and still is. So, I think it is more stable—the work of Audit Wales has been very helpful to us in having that fresh-eyes look—but there is a lot to do. It's very important to get that message across. It's more stable, but there's a lot of building still to do in order to take the organisation to where I think it can get to, which is a highly effective organisation that can deal with all of the challenges in the NHS and broader public sector as effectively as possible. So, I think good progress—. It feels a different place to when I stepped in at the beginning of May. My eyes are wide open, our eyes are wide open—we talk about this a lot—about still the work to be done, and I do just want to share that this is the start, really, of the improvement. We're by no means where we need to be. 

Can I just add, Chair, briefly? I think that stabilisation phase was one where we needed to create the context where we can succeed, create the right conditions, make sure people are aware of the direction of the organisation—the new direction of the organisation—and, really, the sense of we're starting afresh with a new health board. So, that, really, was the context we were creating, and also trying to ensure that people could feel positive, that people could feel that we could succeed and that people could feel that they were going to be part of that success.

Okay. Thank you. To what extent do you believe that the special measures framework has been a positive driver of improvement in the health board and where do you believe it's had the greatest impact? 

I'll just make a general comment, first, and maybe Carol can speak about some of the details. I think the special measures framework exists because the organisation was placed in special measures by the Government, and I think there's a balance between respecting that and making sure we meet those needs, but also the ambition to develop the organisation and build the best possible health board for the people of north Wales. So, it's not only making sure we deliver on special measures, but also putting those building blocks in place to create that excellent organisation going forward, which is not just about ticking a box a week on Tuesday, shall we say, but it's over a longer period—five to 10 years—as I've described elsewhere. So, it's in that context I think we've taken special measures. It's been one of the tools in a box in many respects. 

So, if we're talking about five to 10 years—obviously, it's not in your gift to say when special measures will end, but, in your role as chair, when would you be content on that five to 10-year journey for special measures to move into the next phase? 

Five to 10 years I'd describe as a period to create the best possible health board. Now, I would think that special measures wouldn't be with us for all of that journey, and we're going to be in discussion with Government regarding what the attributes of the organisation should be in order not to be in special measures. So, 'I don't know', is the honest answer, 'how long it's going to be.' I think we've displayed that we've made good progress, and I think we can agree with the Government, 'Okay, what progress should we able to demonstrate before we don't have that special measures framework?' But it is interesting—we talk about that at a time when most health boards in Wales have some sort of intervention or another. So, whether the Government feels, 'Okay, we've got the highest level of intervention at the moment, we will tailor that accordingly and maybe have a different level of intervention', I don't know, but I imagine it would be that sort of path, wouldn't it, that the journey would take us on.

Okay. Thank you. Mike Hedges. 

Diolch, Cadeirydd. I'll start off with a couple of 'yes' or 'no' questions, actually. The first one is: as you know better than I do, a number of independent reviews have been undertaken as part of the escalation into special measures; some of the reviews have been made public via board papers. Is it your intention to make all the independent reviews available to the public, and if so, when? 

Well, I think, we've got to be clear that those independent reports were commissioned by the Government. So, it's up to Government, I think, to say if they want to put them on a certain date and say, 'They're all published.' As you mentioned, Mike, you can see those reports, because they've been included in other reports, but I agree it would be helpful to put them all together on a portal and say, 'This is where they're all published.' We are absolutely supportive of that, but I think it's Government, as the body that commissioned the reports, that has to come to that decision. 

And it's up to us, Cadeirydd, to ask the Government to do so, but perhaps that's something that can come out of this meeting. The second one is: in her oral statement two weeks ago, the Minister referred to independent advisors’ feedback and review findings making for 'uncomfortable reading' and identifying 'very serious issues'. Can you give assurance that urgent actions are under way to address the issues identified in those independent reviews?

Yes, I'm very happy to pick that up, so thank you very much. The range of the reviews has been very helpful to me, mainly because—. There is clearly so much going on that having people working in certain areas and giving their professional opinion means that we can build in the findings of those reviews into building a better organisation. So, they've been incredibly helpful. Some reviews have already led to action that's been completed. So, if we take the executive portfolio review, which was looking at the roles of the executive—that's been incredibly helpful to me as I build an executive team that will take us into the future. If I pull out another one—very high use of what I'd call interim agency staff, senior managers. I think something like 44 very senior roles were agency; it's down to one now. So, these reports have been incredibly useful.

But, of course, there have been findings in the reports that I would say, as the chief exec and accountable officer, are unacceptable to continue. So, one that is going through our governance at the moment is contract and procurement management. How we manage and we govern the organisation needs to be top-drawer, and it hasn't been, and some of that has been very public. So, there's quite a lot to do. So, when the Minister says 'uncomfortable reading', she's absolutely right in terms of that these aren't the sort of attributes that you would want to see in any health board in Wales, but we are making progress on them. 

A difficult question here: how confident are you that the health board has identified all the key issues that need to be addressed?

I'll just make a general comment, as the Chair, because I'm sure the chief exec will have a view also. We cannot give that assurance, honestly, for two reasons. One is that, as we progress things in the organisation, we are discovering different things, which we then take on board and tackle. But because of our experience, I guess, over the last 12 months, we imagine that there are other things that are yet to be uncovered. 

The unknown unknowns. 

Absolutely that. So, we can't give you a 100 per cent assurance, but what we can give you is, if you look at how we dealt with those issues over the past 12 months, we will have the same approach when we uncover what may lie in the future too.  

Can I say that I'm happier with that answer than the sort of glib answer we've had from some of your predecessors of, 'It's all under control'?  

No, I can't—. Well, I'd like to think that we have some control of the situation, but we can only control the present, not the future. 

Moving on, you've had intervention—this is probably for Carol. Have you had the support in this intervention that you've actually needed? It's easy to have an intervention and it's easy to tell people they're not doing very well or things are wrong. We're politicians, we're really good at that, as you know, Dyfed, but, actually, have they given you support as to how you can put it right? I've got an Estyn report back—an organisation that is incredibly good at telling you what's wrong, but not necessarily good at telling you how to put it right.

Perhaps I'll pick that up. Just to say there have been a range of independent advisers, and all have brought value to the organisation. So, I don't know what I'm going to say next to be anything different from that, but I think we've got particular value and contribution from the colleague that is supporting us on mental health, a particular value from the colleague who is supporting us in terms of citizen and patient care engagement, and we've had a range of support from the NHS executive at a more managerial level, rather than a completely independent adviser. So, all of that, on the whole, has been helpful.

One of the things for me is we've got to be able to build the capability and the capacity to identify issues early and to put in place the actions from within the health board. When I came, I was very interested in, 'Why has the health board been in and out of special measures over 10 years? Is it because it gets a to-do list when things are not going well and it tries to do the to-do list, or is it that, actually, we need to build the capability for long-lasting change?' That has to come from within, really. So, the independent advice, the support and intervention have been helpful, but we must be careful that we don't become too reliant on that, that we are building better capacity and capability. We have got some very good people, I just want to say, in the organisation, but the way in which we are organised, led and managed does still need quite a bit of work.

If I can just talk about the hospitals, you've got three major hospitals, haven't you, that are a long way apart, not in terms of miles, but in terms of the ability to travel between them. I want to declare as an interest my daughter lives in Bangor, and she knows exactly how far Wrexham is from Bangor, as you do, Dyfed. The question is: can you make it work? That is, the geographical constraints that people from Bala are in the same area as my friend Mabon in Corwen, and the same health board as Carolyn, who lives in Flintshire. I know it works in Swansea bay, because Neath Port Talbot—you know the area, Carol, don't you, very well. Neath Port Talbot, Singleton and Morriston, for I live in Morriston, are all a quarter of an hour or a 20-minute drive away, unless I'm going at 9 o'clock in the morning. Things are much more difficult there. Can it work?

It's interesting, isn't it, that this very small country called Wales, we then consider a region of it to be huge, which is a bit of an oxymoron, I think you'd call it. It is large, in the context of health boards, but it's not large in terms of being able to navigate it, I don't think. We've got to remember that there are different geographical dynamics across the health board, so the south of Gwynedd, for example, is very much to do with Hywel Dda health board, and getting provision from Wrexham Maelor rather than Ysbyty Gwynedd in Bangor, for example.

So, in terms of the geography, it can be done, not because our main hospitals are based along the A55 corridor, but because the great emphasis we want is in the community. That's where health improvement is going to take place. The main hospitals along the A55 corridor are a small part of our health provision. The greatest impact is in Bala, is in Corwen, is in Rhostyllen, is in Brymbo, is in wherever else. That's where we can have the greatest impact on improving health outcomes.

Sorry, we're not talking about finance yet; we will later on. Does that mean you'll be spending a greater proportion of your budget next year then you did this year on community? Because one of the problems we've had in health—and, sorry, people have heard me say it several times—is the continual movement of money out of primary care into secondary care as a percentage. I think it's probably gone down from something like 9 per cent to 6 per cent, 6.5 per cent, overall in Wales. Are you going to readjust that?

Well, first of all, I agree with the principle, and our planning, including our annual plan and our look forward over a three-year period, is putting far greater emphasis on primary and community. The pyramid is the wrong way round.

Yes.

And we need to make that shift into early intervention and about that health journey, as they describe it.

I agree with you entirely. But just to comment, because I've finished my questions, if you go and look at the health questions here, the questions on secondary care massively outweigh those on primary care, even though primary care sees 90, 95 per cent of patients.

Absolutely.

That's just a comment.

No, agreed. Yes.

Can I just tack on a supplementary there on the cross-border dimension? Because the north-east particularly, but the whole of the region to an extent, has relied on—or does rely on—Walton, for example, has relied on Gobowen, Alder Hey, Christie's and so on. And in the past, when there have been attempts to repatriate, the capacity or the expertise has not necessarily been there, and it's added to the statistics, which have added to the problems in presenting the health board's performance. So, how are you managing those cross-border relationships, given that, before your time, there were some issues at times in them, to ensure that you have embedded relationships, to ensure that patients get the best possible service, rather than just crisis commissioning?

Shall I pick that up first of all?

Yes, go on.

Yes, as you'd expect, coming from Powys, I get the cross-border, and to many extents, of course, health is a devolved matter and all of that, but the NHS is a community that works across borders. So, it was really good a couple of weeks ago; we—Dyfed and I and another colleague—went and met with our colleagues in the north-west, particularly in Clatterbridge, which offers a lot of cancer services for people in north Wales, and we went and visited the chair, chief exec and team at the Countess of Chester Hospital. That's important, because I don't think predominantly it's that we want to take all the activity out of there and bring it back to north Wales; we want to partner across borders, because we know that specialist centres—Clatterbridge, the Walton—have been highly valued by the people of north Wales, so I do want to say that. But there are things that we discuss that we think we could do to bring some of the care closer to home, but still working with those specialist centres, and we're meeting again, particularly with the colleagues in Clatterbridge, around a north Wales cancer plan, for example. We want people in our area to be able to access research trials and those sorts of opportunities. And when you connect to and you partner with centres of excellence, those opportunities become more real and more available. So, I think there's a big commitment to working across, but, equally, where we can, we should be providing those services as close to people's homes as possible. So, I think there's a partnership to be created along those lines.

I agree, and it was really good to have those conversations with the people in Clatterbridge and Chester. I'd previously been to Alder Hey and the Liverpool Heart and Chest Hospital as well, and I think there is something about recognising that great specialism that exists, particularly in the north-west of England, is something we can tap into. Historically, there have been great relationships. I'm thinking of my own family; my brother, about 60 years ago, was in Gobowen, in fact, having an operation when he was a young child. So, those relationships are historical, but I think what we can do more than we are at present is getting the knowledge and learning, having that transfer so that we can embed some of that in our own health board, and have an agreement where the specialist treatment is happening in one place, but the pre and after care can happen closer to home. And that's the sort of model we were discussing in Liverpool and we're hoping to develop, which will give the people in north Wales access to the best specialist care in whatever expertise they require. And people tell me on a very regular basis, 'I'm prepared to travel for the best, wherever it is.'

Thank you. Natasha Asghar.

Thank you so much, Chair. I'd just like to ask, noting recent recruitment activity, when does the board anticipate having a full complement of substantively appointed independent members in place? 

Well, we do have that now, Natasha. From 1 March, the Minister confirmed the appointment of four independent members, so the complement now is full and correct. And that's for the first time in 12 months that we've got the full complement of IMs. Other board members—. We have to remember that we are a unitary board, so, we also have executives on the board, and I think Carol has mentioned earlier that she's going through the process of appointing people to certain posts, and some of those posts will be board members too.

That's really refreshing to hear. So, in that instance, what action is now being taken to strengthen the office of the board secretary and to support sound corporate governance arrangements within the organisation itself?

Yes, and that's a really important question, and it's one that our colleagues in Audit Wales have highlighted of course. So, the good news is that we have a person beginning on 1 April in that role, director of corporate governance, Pam Wenger, who is really experienced in the Welsh NHS and is looking forward to joining us. And I know she's going to make a difference and will help us to address some of the issues that have been around governance and help us to develop our committees and ensure that we can get the board into a good place to fulfil its role.

Great. So, noting some of the other positive findings of the auditor general’s latest report on board effectiveness, what board development activities are under way or planned, in fact, to ensure that the dysfunctionality described in the auditor general’s report from February 2023 doesn't ever occur again?

Well, I think the most important thing is that we, hopefully, have established a spirit of unity—I've tried to do that from day one, both formally and informally—where people feel they have an equal voice, people feel they've got a contribution to make, and that, together, we can achieve something. So, I hope we've established that.

And in terms of the development of the board, we've got a series of sessions that we call board development actually, that we hold on a bi-monthly basis, but actually we are increasing those sessions because we have so much to discuss. They're happening also in sessions before our formal board session—the night before—so, we're really getting together on quite a frequent basis to develop the team, if you like. As you know, you can do that just as much in informal sessions as formal—equally important to get people feeling that they are part of that team we're trying to create.

Absolutely, and it sounds like you're certainly going in the right direction for it. So, I want to talk a little bit about building an effective executive team. So, I'd like to know: what did the review of executive portfolios identify and what is being done now as a response to that?

Yes, great. Thanks very much indeed. As I said earlier, it was very helpful to me for that piece of work to be done. There are a couple of things. We are guided by the regulations in Wales, so I can't go too far off script in terms of what the requirements are. So, we've held that very, very firmly. I've been very keen to try to balance the portfolios, where possible. One of the really substantial roles is that of chief operating officer. So, the regulations talk about having a role that covers primary, community, mental health, but also there are the hospitals, which the Member was talking about earlier. Now, that is a very large portfolio, so I've tried to remove things from there that don't need to be in that portfolio. 

The other element that we are modifying, I'm modifying, is the scope of the role of the executive finance director. Given the challenges that we have as a public sector organisation, an NHS organisation that has struggled to balance the books, that's a really key priority for me. And so we're just moving some of the other elements of that portfolio out. And then the really key element is to make sure that the clinical executive roles are of sufficient strength, if you like, that they're able to support the clinical leadership opportunity and challenge that we've got in the organisation. So, the director of therapies and health sciences, we've modified that role as well. We're already out to advert for the executive director of workforce and organisational development, and I can't stress enough how important that role is. I feel like doing a bit of advertising through this mechanism. But it is still out—please tell your friends. Because, for us, our workforce of 20,000 and our organisational development challenge and opportunity that we've got is really key. So, just trying to balance those portfolios through.

And then to match all of that—you talked about the development of the board—it's really about the development of the executive team as a team. It's been very important to me that we have properly facilitated, supported expert help and advice in our team development, and we've now had two development programme sessions, events—24-hour sessions, basically, they are. The last one of those just finished yesterday, actually. And it feels as though we're moving in the right direction. Now, I know there will be new colleagues to join, and there's always change in an executive team. So, every time somebody new joins, we're like a new team, and we'll take that into account. But we're moving in the right direction on that. It's been very, very helpful activity. 

I'm really happy to hear that, Carol. And you've practically led into my next question, but I do like to look into the future, as does the committee, so do you have any further plans or any further intentions to ensure, or perhaps any programmes going ahead that the team can, perhaps, take part in that will adapt and hopefully implement their collective skills and capacity to lead the improvements that are, ultimately, needed?

Yes, it was going to be very important that it wasn't a one-off away day. Often people talk about building rafts, or whatever; we haven't done any raft building. But it's a series, because we've got a lot to work on, and particularly about being a highly effective executive team. What does one of those look like? What are the attributes? Where should we spend our time? How do we develop and engage others? Because it is a big organisation, not just in geographical terms, and it's got a lot of challenges. An executive team of 10 people won't be able to make that change without having a whole host of others. So, we've got to really look at how we lead others. So, that will be some of the work that we're taking forward. And then working together as a unitary board team is really key. And as we have more people join us, we'll be moving into that team development on that bigger scale. 

Good. And do you feel that the board and its committee is happy with the assurances and information it's receiving from officers now?

Well, I'm not sure about this thing 'assurance'. It's a word that I discovered when I came into the NHS. I keep asking people, 'What do you mean by assurance?', and I keep getting different answers, actually, so—

I'll give you my definition; my definition is 'confidence', because that's what we need—

Right. Absolutely—

—in relation to this health board, and I think everyone will want the same. So, my definition is 'confidence'.

Yes. I think it's based on the question you ask, isn't it? It's in that individual situation where you are posing a question and wanting information, and then you feel that response is one that you can relate to and have that confidence. So, I would say, yes, that is the situation. It was quite interesting, wasn't it, the other day—I think there was a little bit of publicity to one of the reports in the committee that showed some of the negatives in terms of performance, and that was highlighted in the press. I saw that as a positive, actually. Because some of the officials, as you say, were ready and confident enough to be open about things that weren't going right, and that gave me confidence, that gave me assurance, that we have the right approach and we have the right context where people can be absolutely open, not just when things are going well, but when things are challenging, too. So, I think I can say that, yes. But it is to do with that individual question that is posed, and that you can respond with, 'Yes, I think that's the right response'.

Do you mind if I add to what Dyfed has said? I agree with all of that, but just to add one extra layer: for me, I think there's still more work to do on management reports, the analysis of the data, the deliberation of the options and scenarios to help us make the best decisions. When I responded earlier about leadership, management and governance developments, I think there's work still for us to do. I may be a bit old school, but I want to see it all laid out, all of the information that's necessary—not a book, but it needs to be analysed. And that will give me confidence, as the accountable officer, that people have really carefully looked at all of the options, they understand the position and they have weighed up the impacts of taking certain decisions. So, we've started—and our director of corporate governance will help us enormously in this—and we'll keep building.

Carol, that's really, really good to hear. If you look around the room, and I know I'm on screen, but I'm sure you can appreciate, all of us are old school in this room right now [Laughter.] When it comes down to it, I look forward to reading and seeing this and I'm sure the committee will as well. When do you hope to start implementing this? I know you're waiting for the corporate governance head to start, but roughly when do you think you'll be able to share and make us privy to the information that you're hoping to gather and put forward to us later?

I think we start in earnest when Pam starts. If Pam is watching, I hope she's having three shredded wheat—other cereals do exist. It's really good to have experienced people joining us. To be quite frank with you, we talked about confidence, and it does give me confidence that people actually want to come and work in an area that has been troubled, but they feel they've got something to offer, which is fantastic, and it will help us speed along. So, the work has started, but the pace will pick up once we've got that experienced colleague around the table helping us. And through this next six to 12 months, we should be able to see some tangible differences in the quality of reports, the analysis of the information and the understanding to help us make better decisions. So, that's the time frames that I'm working in.

Great. Is there now a scheme of delegation in place so that the health board has a clear local framework to hold the executive and other senior officers to account?

Yes. We've done quite a lot of work on a scheme of delegation, standing financial instructions and standing orders, because of some of the challenges that have been in the health board. Again, I think this is not a one-off event that we did on Tuesday afternoon, it's one that we keep revisiting. I am seeing positive signs of people understanding the governance more effectively, knowing where their decision making lies and doesn't lie, although there's a bit more work to do on that. So, I think that's been important work. The audit committee is now reviewing what we call compliance reports, so how are we sticking to those schemes of delegation and the SFIs and the standing orders, and where something happens that steps outside of them, why was that and what are we doing to put that right. That's been a new report that's been coming through over the last four or five months.

You speak about the last four or five months, but has there been sufficient accountability for previous and well-documented service failures in the health board itself?

Was there enough accountability previously? Sorry, did I hear that correctly?

Yes. Do you feel that there has been enough accountability for previous and well-documented service failures in the health board?

I think that's difficult for me to comment on, as I wasn't there at the time, but what I would say is that anybody in public office is accountable and should be accountable, and one would have hoped that the processes in the health board existed at the time to ensure there was accountability. I think the question to pose is did that happen, did people follow due process, or did they go outside the process, and I think we know what the answer to that is.

Thank you so much. Those are all my questions for now.

Could I just add something on that? I think my reading of the question was whether there has been sufficient accountability under yourselves for previous and well-documented service failures, if persons responsible are still in situ. It could be just a performance management issue, it could be a training issue, or it could be more serious. But it's where you're aware of problems that have occurred previously where those responsible are still employed by you.

I'll pick this up. There are a couple of things to say on this. One of the early things that we put in place—we approved it at the board in September 2023—was an integrated performance framework that has accountability lines in it, and we're implementing that framework, so we're strengthening internal accountability all of the time. In terms of the issues that have been identified that relate to governance, there are a number of those. There are people who are no longer in the organisation who may have been able to shed some light on some of those issues. The action I've taken, with the support of the audit committee and others, is to put in place very clear expectations—training, support. Over 400 of our senior colleagues have had training on procurement, for example. Put those things in place where you give people the guidance, give people the tools to do the job, give them support, and that will mean that if these things do happen again, we're having a slightly different conversation. People have embraced it, so I think we're on the right track, but if that helps to describe, perhaps, a change in the way in which we deal with performance and accountability, I hope that's helped at least answer the question as best I can.

As you know, a key role for the independent members of the board is to hold the chief executive and senior management to account through purposeful challenge and scrutiny. How confident are you now that the new IM team can feel completely confident and able to hold you to account through purposeful challenge and scrutiny?

I think purposeful challenge and scrutiny is a really good thing if you're an executive director and if you're an accountable officer. For me, personally, they are there to help me. What if I've developed a blind spot? What if I can't quite see in the rear-view mirror? I've got people there who are having a look at issues from all sorts of angles and then bringing those to my attention. That is great. Where do I think people are now? I think that it is strengthening all of the time, on a base that is a very positive base to start from. We have got people—independent members; there were only three, in fairness, and Dyfed, at the time—who have experience in other walks of public life, and that experience has been very helpful. There have been a number of people added into that. Some are new to the health service, but everyone has had some experience in the public sector, and that is adding to the complement of skills. 

In terms of clarity of understanding of the difference between roles of executive and independent members, we spent a bit of time in our June, I think it was, development session—it might have been May—just looking at that. When we're around the board table, we are equal members, and, then, we get into committees, and, actually, we're being held to account. I think the flexibility of those roles is really important to understand, and I think we've got a good understanding of that. And I say that because I've worked, for quite a while, in different boards, so I've got comparators to make.

Thank you. We'd better move on. Mike Hedges. 

We've been told that HR processes are still under way in respect of some senior members of the finance team. What action has been taken to address the problems with internal control identified through the auditor general's report and through Ernst & Young?

Thanks very much. I'll pick that up. Focusing on the financial control environment, I mentioned, in answer to a previous colleague's question, the work that has been undertaken in terms of standing financial instructions, standing orders and the scheme of delegation. That's been really important to do. There's been a lot of work on issues of single tender waivers, so where people will use procurement policy and do more direct awards. I had a lot of experience with that in my last organisation, and a lot of focus has been put onto that. That will improve procurement practice, but also reduce financial risks. So, those sorts of things have happened. 

And then, more effectively, there's the sense of getting underneath the real issues that were existing in the accounts of two years ago—I always have to watch I don't get my financial years mixed up. In terms of last year's accounts, which were the first big set of accounts, the work that took place between the health board finance team and the Audit Wales colleagues was really helpful. It was intensive, as you would imagine. It was challenging, because of the time frames and the amount of work, but important lessons came out. For me, we're about to end this financial year, and it will be a test of how well we have done this year. 

Thank you. From my experience in local government, there was a trick that one or two officers used to pull, and that was that they used to procure a very small number of items that only a limited number of people would bid for. Having done that procurement for that small number, they then wanted to extend the contract, because they'd already gone to procurement, to several hundred times the number they procured in the first place. I won't ask you, 'Do you have that happening in your organisation?', but do you have a means to stop it happening in the organisation?

Yes. Just to add to what I was saying before, one of the big reviews that has taken place is the procurement and contract management review, for that very purpose—let's understand, let's get underneath the bonnet of what's happening on procurement. And, absolutely, you can start with the small, less than £5,000, and then it adds and adds and adds. To make sure that we've got the mechanisms in place that would flag that—and actually, connecting procurement and finance systems together has been an important issue—and reduce the risk of that, there is an action plan in place to implement the changes that that report has highlighted. Good progress is being made. Then, there will be a follow-up review of that, to give me the assurance that any gates that were ajar, if you like, have been fully closed.

Thank you. When did the health board expect the issues with the suspended staff in the finance team to be finally resolved?

As soon as possible, is what we all want, and it's taken a long time and it's had a significant toll on people. So, as soon as we possibly can. The important thing is, given the seriousness of the issues that were discussed in the public domain, it is really important that those colleagues have a proper right to reply, and that the issues are considered very carefully and reviewed by independent and experienced colleagues. That process is under way, and I'm looking forward to getting to the point where we can see a resolution.

Ten years ago, approximately, I was on the Public Accounts Committee, and a number of people from Betsi Cadwaladr were here—that doesn't narrow the date down very much because Betsi Cadwaladr health board has almost had a standing invitation to the Public Accounts Committee over the last 14 years or so—but we had a senior member of staff there who said these words. I wrote them down, and I've embedded them on my memory:

'I was given my budget, but I didn't think it was enough, therefore I ignored it.' 

Can you assure me that that cannot happen now?

Can I make a general comment? We both come from a similar background in local government, and I've been involved in various organisations and various roles over the years, and I have to say, my experience of finance has been different in the health board. I think one of the things we're trying to do is not just address particular issues and specific issues that need addressing, but also changing the culture of the health board in terms of finance, and developing a financial discipline and an approach to finance that goes hand in hand with performance. I think all that is a different approach for the health board and it's something that really will serve us well, hopefully, for the future, but there has been a different culture to the one I've experienced in other organisations. 

I agree with you. I served six years on Swansea health board, as it then was. Yes, the laissez-faire attitude to finance that exists in health is one that neither you nor I would have allowed in local government. I think that's one of the things that you and Carol really have to address within the organisation because people do things in health, as you know—. Sorry, I'm almost having a conversation with you here. [Laughter.]

That's all right. [Laughter.] 

People do things in health, as you know, that in other parts of the public sector would not be allowed, and, really, what I'm asking is: has the maturity assessment on financial grip and control been completed, and have you actually got a system by which people can't just spend because they think it's a good idea and no-one is going to stop them?

So, can I pick up on that? I might be on slightly dodgy territory, trying to defend the health service, but let me just tell you this. Having spent eight years as a chief exec in Powys, seven of those years we had a financial break-even, so there is something about discipline, systems and processes. But, nonetheless, these are challenging times, and I know that Members will recognise that.

So, the financial maturity, yes, we've had that assessment. Our interim finance director has got a background of working with organisations that have been in financial special measures, and so brings that expertise into the organisation. So, he and I met with all of the executive and director-level budget holders to discuss the budgetary practice that we expect to see and we offered support to people to be able to achieve that. You may be aware that financial performance during this year has improved from an in-month high of a £5 million overspend run rate to a £6 million and £4 million underspend run rate, for the last two published months. So, a grip and control of finances is coming through, and people are getting used to a different way of working. We do have quite a way to go.

Thank you very much. Thank you. Diolch, Cadeirydd.

Thank you. Just one supplementary on this: although we understand that the findings of the Ernst & Young review can be relied upon, we also understand that you have identified issues with the procurement of that review. Can you share those concerns?

Yes, I can. Thank you very much for the question. One of the key things that happened when I joined the organisation is that people raised concerns with me. I've had a lot of people speak directly to me to raise these concerns, and one of the concerns, or more than one, related to the procurement and commissioning of the EY report. So, I asked for some high-level review to be undertaken, and that was done by the audit and assurance internal audit service, and they provided me with some high-level findings. Those findings are included in the briefing notes and are, hopefully, therefore helpful to not just this committee, but for others to see as well.

There were issues with the procurement of the EY report and, what we were just talking about, the normal procurement processes do not appear to have been followed. A direct award was made to the supplier, seemingly without the appropriate process being evidenced. The delegated limit for the sign-off of the contract was breached, and there was no record of a board decision or chair's action that the reviewer could find.

There are issues about retrospective requisitions, and there were issues of having a budgetary ceiling for this work as well. And then there were issues with the draft terms of reference and the role that the accountable officer—. The accountable officer had given some advice, and it was unclear as to whether that advice was taken.

I view these as serious matters as an accountable officer, and, therefore, I wrote to the NHS Wales chief executive and the director general of the health and social services group in relation to this. These are some of the findings that led to the key work on wider contracting and procurement management in the organisation. I'll stop there.

Thank you. I'm very conscious of time being against us. We took evidence last year from some of the former independent members, who made it clear that they had commissioned, in their view, the report and the investigation that led to the report, and that they had, at that stage, lacked confidence in a section of the executive—not the whole executive—which is what led them to take the action they took. Do you feel that might have had some bearing on this? Did you feel that an investigation was nonetheless required, but the process perhaps could have been addressed differently?

Well, we have the benefit of hindsight, of course, don't we, so it's tricky. I was certainly not there at the time, but when I look at the Audit Wales report on board effectiveness that was published in February 2023, clearly there had been issues. You know, it's unwise for me to enter the debate on where all of those issues were, but those issues were existing. In the work that I do, in terms of looking at the governance, there is certainly a period where I would say that normal governance wasn't being followed and, you know, there may have been a whole host of reasons for that.

Can I just add to that? Looking back at that period, as the chair now, I would reflect and think, 'How did that come about, what were the circumstances, what was the context? What was the culture of the organisation where that situation could arise in the first place?' So, there's a learning from that, I think, for us as the board, going forward, and myself as chair, and one where, if there were concerns by board members regarding officers, I would definitely approach my chief executive and say, 'Chief executive, I think we've got a problem, I'd like you to deal with it.' And the relationship I have, I'm very glad to say, with Carol as chief executive would allow that to happen, unquestionably. So, there is that route, but there is also the context where, hopefully, those relationships would be different now to what they were during that period.

Okay. I'd better move on. Natasha Asghar.

Thank you very much, Chair. Noting that the health board has received a significant additional in-year allocation—this may sound a little bit repetitive to what you answered earlier, Carol—what is the current forecast for the year-end position, and is the health board on track to achieve the year-end goal of control total, identified by the Welsh Government itself?

Thanks very much for the question. Just a quick summary: opened the year at £134 million deficit plan. The Welsh Government allocated £101 million in year. The remainder, therefore, at £33 million, would be the reset outturn position. There was quite a lot of risk around that, so I talked about £5 million in-month at its peak earlier in the year—back in May, June time, I think. But we have been able to really gain some traction on that in the last few months, so I'm much more confident that we can achieve that £33 million. But the control total is £20 million, set by the Government. That does feel a stretch, a significant stretch, for us; even though in-month performance is going in the right direction, the end of the year is going to come almost too quickly. So, I'm hoping that we can certainly improve on that £33 million position, but I'm guarding against too high an expectation as to reach the £20 million.

Our efforts are also very much focused on next year, working through the financial plan, as part of an integrated plan for next year. We've got very firmly set in our sights achievement of the control total on the way to getting the health board to a place where it can achieve its first financial duty of break-even. I think that, unless we take some really quite remarkable, perhaps, steps to get to a break-even for next year, that is going to be a challenge for the organisation.

Thank you for being so honest about it. I don't live anywhere near Betsi, but I do understand and accept that the position of other health boards is also challenging currently, as we speak. So, what are the particular factors behind the health board’s inability to perhaps spend within its means at the moment, for yourselves?

So, there are a couple of things that I've observed. I think that the health board has always had a challenge around having an integrated medium-term plan and a break-even plan. I think that some of the big issues have been really around workforce. And a Member alluded to this earlier, about how can you get the health board to work, trying to provide services on multiple sites, where, in other places, they would have consolidated them onto fewer sites. Now, these are the questions and the issues that we're going to have to tackle in terms of having services that are sustainable—that we're not holding up, if you like, by pushing a lot of money to try to hold them up. We're not ready for those conversations as an organisation yet, but we know that we're going to need to get ready for them. We've got a lot of money in the health board. We need to make sure we're spending it wisely, so there are definitely productivity gains—if I use quite businessy language, sorry—but the financial challenges, the service challenges may not be met fully just through productivity gains, and we are going to have to have a look at what and how we deliver services for the longer term.

Okay, fine. So, are there now clear processes and accountabilities for delivering savings across the organisation?

Yes, I'm really pleased to say that—well, I wasn't really pleased when I started—we had a savings target of £25 million, but the reality was less than £1 million when I started. We've now exceeded that—£25.3 million to £25.7 million of savings. The key issue for us is that they're non—. Too much of it is non-recurrent. We need to move to recurrent savings. That we will need to move over time on that basis. I think we can see real opportunity to become more efficient and effective and to reduce costs. We're about—. We established—. We're working up, for this coming year, what we call value and sustainability, and that is about value being a focus on outcomes, cost and experience of citizens. So, it's not, 'Do you want quality or do you want cost?' Actually, we've got a three-legged stool where we're balancing all of that. 

That will mean we've got a better chance of succeeding in terms of financial sustainability, and more of our colleagues—clinical and non-clinical—will, I hope, get on board with that shared endeavour. That will mean our performance and accountability is so much more straightforward, because people are very clear about what we need to achieve, we know how to do it, and then we're going to be monitoring our progress.  

Great. Thank you so much. Chair, that's my segment. Would you like me to continue or would you like me to pass on to another colleague? 

I think—. If you could continue with the next set of questions, and then we'll pass on to Carolyn Thomas. 

Shall I take clinical services, because they lead into question 8 as well? 

I've got you down for sections 8, 9 and 10. 

Okay. Well, I can do clinical services and roll it into 8, because they're very similar, if that's okay. 

Okay. Yes, thank you. 

It makes more sense, doesn't it, Natasha? 

Absolutely. 

I just want to ask you some questions on the fragile clinical services. So, in cycle 3 of the special measures framework, the Welsh Government expects the health board to have clear improvement plans for many services, including vascular, urology, ophthalmology, oncology, dermatology—a lot of services there. Why are so many services in such a fragile state, with risks to the quality and safety of patient care? And do you have a plan going forward on delivery of these services? 

So, thanks very much for the question. It's a very big question, why are so many services—

That's why I wanted to get it in before we finished. [Laughter.] 

Yes, I know. So, it's—. Because, to be quite frank, all the things that we talk about are actually patients, people in our communities. It's about services, isn't it? So, that feels very important. There are a couple of underlying themes in why are all these services challenged. I'll draw out just a couple. One is workforce. We have, rightly so, standards that we should be meeting in terms of workforce numbers, experience—all of those things—and we are not where we need to be with workforce, either in terms of having redesigned workforce or being able to recruit and retain the right skills. That has led to, often, temporary workforce, who are, I just want to say, fantastic, people step in and support, but it doesn't mean that you're often able to build services that are robust, being modernised and are ready for the future. So, that actually is one of the fundamental issues. 

Now, tied to that, really, is my response about both money and the size of the health board: what should we be providing where? Because, at the moment, some of the services, we're trying to—. We're spreading the jam too thin, really, and some of the external reviews that we've had are telling us this. So, if I was to take urology, for example, the external—. We’ve been using something called Getting It Right First Time—GIRFT—and the chap said to me, 'Carol, you’re trying to run too many rotas here. You're really spreading the jam too thin. You need to rethink.' Now, that service then connects to another service, which connects to another service, and so we will need to get into this broader configuration issue.

However, in the meantime, we have to make those immediate improvements, so, as part of the cycles 1, 2 and 3, the immediate actions have been to try to increase the capacity that’s available so fewer patients are waiting as long as they have been. The quality of services, the support to services, is increased. I talked about GIRFT—that has been very, very helpful, and very much embraced by our clinical teams, and increasing focus and support for leaders who are trying to move these services forward. So, all of those areas are our most challenged service areas—dermatology because of workforce, orthodontics because of workforce. Vascular is a story where it’s improving, and so Healthcare Inspectorate Wales have de-escalated that, and that’s that level of focus that’s been given to the leaders and the staff in that service. So, a lot—. I know time is short, but there’s a lot we could talk about in terms of getting under the bonnet of all of those, but we’re in the immediate; we’ve got to build for the longer term.

Can I just intercept there—a very, very short question? Because you mentioned—. Or, urology was in your question. We understand the royal college has now been in. When are they due to report?

So, the royal college has—. It was rather delayed, I'm afraid, but the royal college report is now in, it’s with us, and we’ve had the Getting It Right First Time review as well, because urology connects to general surgery et cetera. There is an improvement plan in place and we will be bringing through to the board the focus on certain areas. So, we’ll be publishing the reports and the action plans and the progress that we’re making in a number of areas, not just urology. 

Could I just mention, very briefly, because I think it's important, and I think Carolyn raised the question, 'Why are these services needing to be improved?' At the heart of it is quality and leadership. That's one of the reasons we've had support from one of the Government independent advisers and the team, and that's why we're developing a quality management system, where the culture of the organisation will have quality standards and improvement at the heart of it. I think that's one of the reasons we were in the situation we were. 

Are you looking at a plan now? I know previously there were plans of maybe having hub areas. You talked earlier about having more community provision, so is there a specific plan that you're thinking of?

I think orthopaedics is probably a good example of that, isn't it, Carol? If you want to go into detail on that.

Yes, orthopaedics. So, we have had the green light from Government and some funding, which is always very welcome, to develop a planned care hub in Llandudno hospital. That means that more patients who would have had their care in district general hospital can have it in that planned care hub, and we all know that what was happening was urgent, emergency care was displacing planned care, so people were waiting even longer. So, that's one example of what we can be doing. I think in a number of these specialties the opportunity is that more can be done in primary and community care. So long as we are supporting primary and community care to be able to do that, more can be done. So in dermatology, for example, teledermoscopy—you take photos and, actually, people can assess the photos as to whether the person needs to be seen in secondary care. These are the sorts of things that we'll be introducing. 

Okay, thank you. What's being done in response to the mental health unit's review—sorry, Chair—and the December 2023 prosecution by the Health and Safety Executive that resulted in the health board being fined £200,000?

Yes. Thanks very much for that. I think both Dyfed and I issued our apology to the family and people affected by that incident, which was highlighted particularly through the prosecution. Mental health is a really challenged specialty. I've had a lot of input into mental health services over the last 10 years in Wales, and it's going to be really important for us—it is very important for us as a board—that we see mental health services as part of all of the board's business. Just last week, we had a board development session, and about half of the day was spent on mental health; it was a very good session. Because we need to be able to create environments where there is a strong leadership, strong workforce, strong sense of standards and achievement and modernisation. The environment in mental health services in north Wales is poor. There are some great examples, actually: Heddfan in the Wrexham area is lovely, but that stands out as being a bit unusual here, and the environment does help or hinder care. This year, we spent money—changed the capital investment plan mid year to spend money on mental health environments. I've allocated £0.5 million for next year. So, these are some of the things—both the environment and the investment in staff—that will make the difference on quality.

Okay. Thank you.

Sorry, can I just intervene there? The Chair just needs to leave briefly. Natasha, are you okay to very temporarily just take the reins while Mark pops out for two minutes? 

Yes, absolutely. Can I just ask where we are with regard to the questions? Is Carolyn still going to continue?

Yes. I'll carry on, Natasha.

If that's okay.

It's easier for you to chair, then.

I'm not going anywhere, that's for sure. [Inaudible.]

You don't have any objection to that?

Absolutely not, no. Thank you. Okay. Just carrying on regarding clinical governance, patients experience and safety, so—. Let's see. Just regarding what arrangements do you have in place regarding the latest status of the review of clinical governance systems.

Yes. Shall I just build on Dyfed's points earlier about—? So, our big focus as a board—. We've done quite a lot on the governance front—there's more to do, of course—the corporate governance. Our big focus is on the quality of services and the quality of care and the experience that people have. And that experience is both as a citizen in receipt of care, but, actually, as a staff colleague who's providing that care. So, that's a really big focus for us. The development of our quality management system, which moves from just assurance and compliance and checking to planning services for quality, our quality improvement activity and our control quality activity, that coming together, I'm really pleased we're getting to grips with this at this stage. We're hoping that our work will get sufficiently progressed that, by May, at the board, we will presenting the outline quality management system—that's an approach, an organisational approach, for improving quality.

Sorry, can I just signal as well that the approach of the board is one where we want to hear directly what patient experience is? So, we've got an item at the board that we call citizens' experience, where we gather information that we get from various sources, be they directly from the public or through our patient experience team, or, indeed, from yourselves as MSs, and we put it out there in the public domain, saying, 'This is what people are telling us,' and the themes that develop and where we need to improve and where we need to get a renewed focus on. So, that, hopefully, is part of influencing our improvement going forward.

Okay. I just feel I should really—. I need to refer to the Public Services Ombudsman for Wales's and His Majesty's Coroners' concerns, which pointed to an inability of the health board to learn from service failures and to respond properly to complaints and incidents. So, really, I was seeking assurances that you can give the committee that these problems have been addressed now. It was such a public profile report, wasn't it, regarding that, and it raises concerns, then, doesn't it, for our residents, so—.

May I add a couple of specifics, just on that? So, we've got—. Because it's really important. We're doing the work on the building, and then there are some specifics to share with you. As a board, we discuss investigations and learning, because unless the organisation can learn, it will keep repeating the cycle over and over again. So, I've commissioned a programme of work, which is to review the investigations, the action planning and the learning of cases going back over the last few years up to about 2017. There are about 400 cases that we're having a look at, some of which won't need anything more than a desktop review, but some will need a more detailed review, and that is to ensure we have picked up the learning and that we can evidence that we have actually made the change in practice so we won't be seeing these things over and over again. 

I've met with both coroners, and one of them on more than one occasion, and I've heard the three big things that they talk about and we've had a discussion about, No. 1 being health records and information. We are just about to consider at a board meeting a strategic outline case for an electronic health record for north Wales. That would be transformational. I'm very, very keen to be able to progress that. The second one is the big issue of the experience of people in the urgent and emergency care pathway. We have over 300 people in hospital who are stuck. That means we're finding it hard to admit people. That is causing a challenge to clinical outcomes, and certainly clinical experience, and staff experience. And then the third thing is what I've talked about, which is about investigations and learning. They're the three big themes from the coroners, and actually also from the public services ombudsman, who I met with a month or two back now. So, there are some very tangible things that you'll be able to track our progress on.

There's a question here about the culture of an organisation, isn't there? When you get complaints, the danger is you become very defensive and you try and rebut them, whereas actually we should be seeing complaints—. In fact, I don't want to call them complaints, because it's such a negative term; I think it's something that should embed the learning of an organisation, what people's experience of the service is, and help us improve. That's the step we're trying to take. We've obviously got to meet all of the concerns of the coroner, but also get a culture where, when things go wrong, we can learn and embed the learning. I think that's the challenge.

I'm mindful of the time. I'm just going to go on to operational delivery, if that's okay, Chair. 

Before you do, can I just clarify? We're technically due to finish in two minutes, but we've got a few more questions, so can you stay for a little bit longer?

We're happy to do so.

That's great. In which case, yes, please, Carolyn.

Thank you. I am concerned about the fact you've got 300 stuck in beds at the moment. That pathway into social care is a sticking issue. Also, we talk about occupational therapy in the community as well—for recovery, it's really important. I'm really concerned about that, going forward, with the issues that public services are facing, other than the NHS and health. So, can you just respond to that quite quickly as well, if that's okay?

Yes. We're very concerned about it. I would say that our colleagues in local government are also very concerned about it. We've had a number of discussions. Actually, a common goal is to try to support people wherever possible in their own home or closer to home. This is not just a north Wales issue, this is a UK issue, for sure. I end up feeling quite strongly about this, because for some people they're spending way, way, way too long, a really important part of their lives, often when they don't have that much of their life left, in hospital. Somehow, whether it's policy, service, practice, we're going to have to try to improve this position, because sadly it isn't improving. Local government does not have the money to spend on this. The challenge for us is what more can we do to support people to move into the community. It may be back to the Member's question earlier about more community provision that is coming from the NHS rather than, perhaps, from social care. But I don't think we've got a proper system response yet that will deliver.

I'm just concerned about that partnership working when people are very defensive about budgets. That, as well, is an issue. Thank you. I better move on quick, I think.

Regarding operational delivery, we've got a number of patients waiting one year for their first outpatient appointment, some waiting over three years for treatment, a percentage of ambulance handover delays over four hours still, and a number of patients waiting over 12 hours in emergency departments. What progression are you making in improving access to services and patient experience now, specifically in those sorts of areas?

If I can very quickly say, in almost all of those areas that you cited, there is improvement. So, if I take the number of patients waiting over 52 weeks for a new outpatient appointment, that's gone down from 21,000 to 14,000 in 12 months. People waiting over 36 weeks for a new outpatient appointment is improving, down by about 6,500. Those waiting over 104 weeks—. And, in a way, we need to remind ourselves that 104 weeks is two years—this is a different currency to what we were talking about before the pandemic. But, again, there are improvements in that, improvements in people waiting over a year. If we look at ambulance handover delays, though, that is deteriorating, and it is connected to that previous discussion that we've had. We have got to find some different solutions to that. So, our general access on planned care is improving, although not quickly enough for all of our liking, I know. We talked about the planned care hub, we talked about some of the systems, trying to get them in place across the health board. But it is coming down, moving in the right direction. We just need to move that as swiftly as we can. 

Previously, you talked about the culture going forward. It's so important for the retention of staff as well, isn't it, and recruitment going forward. So, talking about the compassionate leadership initiative, what will that look like? What are you trying to do now to connect with staff to retain them? My concern is it's not just about the wages; it's the long working hours, the rotas. I talked to nurses on the front line and they said if they had consistent shifts that were daytime or just even night-time, that would help with childcare, or even a job share going forward, because of the hours—12-hour shifts, 14 hours if you include driving. So, those are just examples I hear. How are you progressing with that? What does that compassionate culture look like? 

I'll just make a general point. Yes, I can relate to what you've shared about people's experience. I know, because my family works in the NHS in north Wales, so I've lived with some of that. I think, firstly, the important thing is that people come to work feeling that they can make a difference and that they can make a contribution wherever that is in the health service in north Wales, and feel that they're supported in doing that, and that's the sort of culture we are trying to develop. I think we all recognise the NHS has been a different model in the past. It's been command and control, and now we're trying to change that, so it is going to take time. But it's about people feeling that they're supported, people feeling that they have an opportunity to develop in their roles.

I was speaking to colleagues, I was speaking to a group the other day, and union representatives, and asking them, 'What would your members say if I threw out this question?' I didn't tell the chief exec I was going to ask this question, by the way. But it was, 'What's the one thing that would make a difference? Nothing to do with finance, you can't have that, because we haven't got money. But what's the one thing that would make a difference?' I wondered what members would say. And what I was hearing was it's something to do with accountability and it's something to do with senior people then recognising that they can also give autonomy to people at various levels.

So, it's that sort of context that we are trying to create, where there is accountability on the one hand, but there's also autonomy for people to get on, to achieve and to feel that they're accomplishing something. I often say, as well—it's interesting, isn't it—that all our experience of the NHS, certainly my experience, has been one where there's huge compassion, but sometimes people aren't compassionate with each other within the NHS, because they're under so much pressure. So, we need people to be able to be supportive and compassionate and just take off some of that pressure to make that possible.

Part of that, though, is also celebrating the positives, which, unfortunately, doesn't always happen, and that will help, I think, your staff as well, and people wanting to come to use the service. Can I just ask you, has the health board received the 2023 NHS staff survey results, and what do they show, if so?

They're hot off the press, I think. Carol has got some of the details. I don't think they're in the public domain yet, but we can give you some insight, I'm sure.

This is such an important report for me, for us. I've often said it's a bit like a school report. We will be publishing this. We will put things into the public domain. But the single key score is the staff engagement score, and that was 73 per cent in 2020, and it's dropped by one percentage point to 72 per cent. When I look at other health boards, I think almost all, if not all, have had a percentage drop, some in different percentages, but the Betsi health board score is right in the middle of the pack. I thought that was very, very interesting, given everything that has happened. Actually, staff are still connected to their local team, their service, despite all of the challenges that are there. So, I was pleasantly surprised at that, which is a great sign, but must spur us on to deal with those things that we know will either maintain that score or even take it to a much higher score. The other one thing I was pleased about and then got shot down for was the response rate, because, actually, response rates generally are quite low in Wales. But we had the second highest response rate of the big health boards.

And what was it? Can you give it to me?

The response rate was something in the region of 21 per cent. The next health board was only one percentage point higher, and then another smaller health board was seven percentage points higher—

She means Powys when she says 'smaller health board', by the way. [Laughter.]

We worked very hard in Powys to make sure people knew that that staff survey was a valuable tool to us, and we're trying to get that message across in Betsi too. It's now what we do with this. We have got an organisational development steering group, which I'm chairing at the moment, and we've got a people and culture committee, which Dyfed is chairing at the moment. So, we're going to be taking this, we'll have conversations with people about the staff survey results.

And also getting staff opinion on a more regular basis. We don't want to depend on an annual survey, NHS wide, only. It's very informative, but we want to have touch points with staff where we can get regular feedback and regular information that can help us then in the work that we do.

That's probably about 4,000 results, then, 4,000 surveys returned, if you employ 20,000 people. You'll have to have an incentive.

Yes, and it's not just with the survey. I know that this, to some people, sounds strange, but it's for staff—say if you were a nurse on a ward, when do you get the time to do a staff survey? You do it in your own time. You shouldn't have to do that; you should be able to do training, surveys, the electronic staff record and all the rest of it in work time.

Chair, I think I've asked the questions that were mine to ask. I don't know if I've missed anything out.

I'll jump in on a small bit that merits attention. Can I just ask you one supplementary? You referred to—and I think Carolyn developed this with you—partnership working in the context of other statutory services, particularly local authorities and social services. What about partnership working with other providers, particularly third sector? Because you're aware, I think, that I chair things like the cross-party group on hospice and palliative care, on disability, on autism. I used to chair neurological conditions when it existed—[Inaudible.]—meeting in, so in that context with one local provider. To what extent are you now actively seeking to design and deliver services with those providers in the community that can help you fulfil your goal of more care and more preventative and early intervention work as well as post-operative or post-hospital step-down recovery work with those bodies?

Perhaps I'd just say that a really important partnership is the regional partnership board for north Wales, of which I think the meeting is tomorrow, coming up. So, that is a very key partnership where all of the parties come together.

In terms of the health board, though, you're absolutely right about the hospice sector and I've been on a visit recently to St David's Hospice, and we were having that very conversation—very, very keen to support more out-of-hospital care. We're very keen to see more out-of-hospital community care happening, so how do we take that to the next level and build on that? So, active discussions going on there.

The other real opportunity is health and housing actually have just established a health and housing steering group, which I'm chairing at the moment, because we think that there are opportunities for us to collaborate, work together, on some things such as how do we provide staff accommodation. Let's just start at that. Often, it seemed to be very basic, but if you can't find somewhere to live, then you're not going to come and work for us. So, it's those sorts of conversations, all the way through to conversation about what direct support can the housing sector provide in supporting people in the community. So, those conversations are very live and active.

But if I can just sort of have an umbrella comment, really, on the third sector: again, if I refer to my previous roles, my previous work, they bring so much value into the system that it would be foolish for us not to really invest both in terms of relationships and planning, but also actually invest in service delivery from that sector. We already put a lot of money in, but when times are tight, often there's a temptation to think, 'Oh, we can't quite afford that.' And we've got to sort of resist that temptation and ensure that we're modifying the services so they meet the need, but continue to invest in that sector, and I know it is something that Dyfed feels strongly about.

Very much so, because I think there's a resource there that we haven't used to its full potential, and I think what we're really keen to do is to plan services with those partners being part of the planning, not as an add-on and an afterthought at the end, but rather planning services and planning the way we deliver services with them at the centre. We have also got what we call a strategic reference group, which is a title for groups of people representing third sector and community groups coming together, and that's been revitalised recently, I must say, and with that objective of getting early communication and gathering views early on in the process, so that they can help inform us and we can take the knowledge they have from their sector to help shape our services.

Thank you, and jumping on, I think Carolyn referred to HM Coroners' reports—regulation 28 prevention of further deaths notice reports. I understand that at your board meeting on 25 January, a number of actions were discussed to strengthen responses to regulation 28 reports and also were told—privately, I have to say—that in private session at that meeting about regulation 28s, a paper, quote, basically acknowledged that the health board couldn't provide any evidence that they had implemented any of the regulation 28s for a number of years. So, obviously, that's looking backwards rather than forwards. But the number of regulation 28 prevention of further deaths notices in the health board since last April, April 2023, have been far in excess of those in other NHS bodies. Why is that? Why is there an apparent significant and worrying disparity? Does this indicate that the previous action taken in response to such notices has been inadequate?

So, perhaps I could start with—. So, I think there are different coroners in different parts of Wales, so I can't say particularly what's driving that. I can say with confidence that in discussions that I've had with the coroners, there has been, I think, a sense of seeing the same types of issues coming through and the growing linking of those issues to some pretty big system changes that are needed.

So, the majority of the regulation 28 notices are connected to a couple of the key themes. There are others that sit outside of that, and they're the themes that I mentioned earlier, really: the urgent emergency care system, and the fact that, at times, that system is failing people, certainly based on our experience, but also on outcome; the whole information connection issues, so having an electronic health record, not just because everyone can see all the information, but because it helps with work, it helps with workflow, it helps to reduce referrals that may go missing, for example. It may help with tests, where the results have not been reviewed.

So, these are quite important elements that will make a systematic difference to the quality of care in north Wales. And there is a legacy of lots of different systems across the different parts of the health board, and we need to bring those together. I think I've got a meeting with the coroners coming up, actually, and I'm looking forward to sharing with them the progress we are making, and how we will continue to try to demonstrate that in very tangible terms.

Chair, can I just ask—

Yes.

—because you're talking about the electronic health system, so what sort of time frame are you thinking of?

Can I first say that it is excruciatingly expensive, and that's possibly one of the challenges we'll have to navigate? In terms of some of the services, such as mental health, we're looking to take that forward, with Government support for this, in the next 18 months, so having it in in the next 18 to 24 months. A bigger, whole electronic health record would take about four or five years to fully implement.

One of the things we've got to think about, even when we start to think about infrastructure and how much that costs and the challenge with capital and all of that sort of thing, is that there are things that are now seen as, if you like, the basic tools for modern healthcare systems, and an electronic health record is one. Now, we have a particular focus and challenge because when we're recruiting people into north Wales—clinicians—if they've been working in the north-west, they're already on an electronic health record, so it feels like a very big backwards step for them.

And most other European countries too, and indeed worldwide.

The orthodontist mentioned that to me as an issue.

We've been shown figures suggesting that the regulation 28 notices, since April 2023, or since special measures were reintroduced, have approached over 60 per cent of the all-Wales figures just in Betsi. And obviously, a lot of those relate to matters before your time, but they also related to a failure to implement recommendations in a series of reports—Holden, Ockenden and others—which were picked up on by the coroners in their reports. So, what assurance can you provide us that lessons are being learned and that the actions you're taking should see Betsi's regulation 28 notices in the future falling more in line with the all-Wales average?

Well, as I said, I haven't done a study of why one area is higher than the other. There could be lots of factors there. I mentioned earlier the work that I've commissioned around the investigations and learning programme. So, over 400 cases will be reviewed to identify whether the issues were fully drawn out, whether the actions have been implemented and whether there's evidence of learning. Because you're absolutely right, all of those notices have come before that period, and so there's still a lot of learning. And I want to be absolutely sure that I can genuinely say to the public, to anyone who wants to listen, that the organisation has taken things from the past, has reviewed them and has put in place mechanisms to improve care, going forward. So, I am sure we will meet again and I'd be very pleased to update on the progress of that really important piece of work.

Before I conclude—and we're very nearly finished—two years ago, in March 2022, I wrote as Chair of this committee to your predecessors at the time, following a session we'd had with them, with a series of questions, one of which, and I'm quoting from the letter, stated that we were disappointed by the lack of ownership and responsibility taken by the executive of the problems at the board, and, referring to various reports, including the Holden, Ockenden, the Health and Social Care Advisory Service and previous reports from the Public Accounts Committee here, stated that we were also concerned about the ongoing presence of executives and managers at the health board who were implicated in the conclusions of these reports and about their ability to deliver the internal change required. Now, I don't propose to name those persons, but can you provide us with any assurances that the concern identified in that letter has since been addressed?

So, I think, throughout the whole evidence session this morning, what I've hoped to try to get across is that we've stabilised the organisation somewhat over the last nine months or so, but we've still got quite a lot of work to do ahead, as I said, I think, in response to Mike Hedges's question about leadership, management and governance. And things are moving forward, but there is still quite a lot of work to do—if I just take that very example of the regulation 28 notices, the need to go back, review, check, ensure that we've embedded, that we're owning those issues and that we're reducing the risk of repetition in the future. So, I think there's work to do still, but my sense—not just my sense, my sense and my experience is telling me that we are making progress.

We will inevitably, and properly, be judged on the progress that we make by the quality of the services that people receive, going forward, the experience of our staff. So, these are still early days, where we will be importantly judged and publicly judged on progress. And one of the final things, just before I hand over to Dyfed, is that we will be open and transparent about this. Dyfed mentioned earlier a report that went to the quality committee. We will put these things in the domain so that everyone can see what action we're taking, what responsibility we're taking and whether we're making progress.

I just wanted to say that we talked about compassionate leadership earlier and being supportive and encouraging of people, and together with that goes accountability. We're all accountable and whatever actions we take, we're accountable for. And if we get reports that indicate that somebody is accountable for something that has failed, then there's a process that people will be part of and held accountable for that. So, it's absolutely clear, I think, now, in terms of our performance and our improvement journey that at the heart of it are some of the things we've mentioned today—quality, compassionate leadership, support, but also accountability. 

Okay. Thank you. My final question, and I will shrink it all into one: following the assessment of progress at the start of the year, what, if any, refresh has there been of the special measures framework? What does the next phase of the framework after stabilisation, called 'standardisation', actually mean? In that context, what are your priorities for the 12 months, and what would success look like for you at the end of that period?

That's a great question.

That's a lot of questions.

Well done on condensing it all.

Yes, several questions.

So, maybe we'll start with the last bit, about success—if I may?

Certainly.

And you can dive in. This is about building a better organisation. It's about building a more effective, well-led, well-operated organisation. Because when we've got that, we will be improving care, we'll be reducing all those notices, you know, our staff will feel more confident et cetera. So, that's the prize, because that leads to, you know, the improvement of services for people in north Wales. How are we going to get there? We are moving what was the special measures response plan for this year and the annual plan into a single plan within a three-year context, and we've got five key objectives for that plan. They are similar, but broader than those special measures objectives. So, the discussions that we've had with Welsh Government is that they're expecting to see a number of things appear in our plan, and so they will be cross-referencing that and holding us to account. But we've started, which is the sort of theme, the foundational work now. I've talked, in the organisation, about getting match-fit, so there's still work to be done to get this organisation to be stronger, and the test will be, 'Are we reducing waiting times, are we increasing access and are we increasing the quality of the service that we provide?'

Yes. And the challenge is that all of this work helps us produce sustainable change so that we don't get into that revolving door again, but the organisation goes forward and makes progress. So, that improvement journey is a permanent thing—not necessarily in special measures, but continually improving in a sustainable way. That is our approach.

Okay. Well, thank you very much. Thanks for staying almost half an hour later than scheduled. A transcript of today's meeting will be published in draft form and shared with you for you to check for accuracy before the final version is published. So, that brings our session with you to a conclusion today. Again, thank you for being with us.

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