Health and Social Care Committee

Good morning. Bore da. I'm Darren Hughes. I'm the director of the Welsh NHS Confederation.

Good morning. Matt Temby. I'm the director of planned and specialist care at Cardiff and Vale University Health Board.

Thank you.

Bore da. I'm Paul Mears, chief executive of Cwm Taf Morgannwg University Health Board.

Lovely. Thank you all for being with us today. So, Members have got a series of questions, but if I could perhaps just ask, to start with, initially, perhaps you could just talk a little bit about the waiting times data and tackling the backlog, and of course noting in particular that waiting times for over one year have increased. So, I suppose: how confident are you in the ability of health boards to manage their NHS waiting lists?

If it's okay, Chair, I'll just give a bit of an introduction and then hand over to my colleagues, who are far more expert in what's actually happening on the ground to tackle the waiting lists.

I think it's important to look back to the start of the pandemic, because what happened then is very much still affecting what's happening now in terms of providing care in the community, that the NHS needed to stop providing planned care, to pause for a period of time to deal with the pandemic. So, the waiting lists built up at that time. I think it's fair to say that, even before the pandemic, the NHS was working incredibly hard to provide timely care and was just about meeting demand. So, we're playing catch-up at the moment to get to pre-pandemic work rates and capacity. We're working incredibly hard. The biggest rate-limiting factor in dealing with the backlog is workforce and workforce availability, but also some of the structural changes that needed to happen pre pandemic, we're still working on. But I'll hand over to one of my colleagues to give you more detail on some of the things that are being done to meet the challenges on the ground.

That's fine. Just on the waiting lists, though, perhaps if you could just give a little bit more detail on that. And I suppose I'm asking as well: are you clear on what the Welsh Government's expectations and targets are? And the targets that were set and have been set, do you think they were reasonable targets and achievable targets?

They're incredibly ambitious, the targets, and I've pointed towards the workforce challenges, particularly in some specialty areas where there are particular challenges in clinician availability, so some of them are going to be incredibly difficult to meet. But my colleagues will give you a bit more detail on what's being done in those particular areas.

Yes, I'm happy for your colleagues to come in, but I suppose what I'm asking of others here today, and the other witnesses, is their view on the targets that have been set. Are they reasonable targets? Are they achievable targets? The targets set that have been missed, were they unreasonable targets in the first place? That's what I'm trying to grapple with.

I think that they're incredibly challenging is the answer I would give.

I'd agree. I think it's right to set ambitious targets. We have to set ourselves a process of continuous improvement after the pandemic to make sure that we can treat patients in a more timely fashion. It's right to have ambitious targets and extremely challenging to meet. I think there's—

If they're challenging to meet, though, were they the wrong targets in the first place? They've got to be challenging targets, but they've got to be achievable. I suppose I'm trying to understand—. This is your platform to say, 'Look, the targets that the Minister set were not achievable in the first place.' I'm just trying to get some understanding.

I probably wouldn't say that they're not achievable. I wouldn't go there. I think it's about us continually looking for different ways to work within the NHS to get the improvement. There are indications that we are continuously improving. The position for people waiting more than 104 weeks is improving. We're seeing that, certainly, in Cardiff and Vale. We are increasing both the numbers of out-patients and treatments that we're doing, in some instances above our pre-pandemic levels in terms of capacity. So, we are getting there, and it's not that they're not achievable; we just need to continually look for more ways to meet that capacity and drive the waiting times down.

Thank you. Paul Mears. I'm just checking with Paul, as we can't hear you at the moment, Paul, sorry. I think you've muted yourself. We can hear you now.

There we are—sorry. That was my fault.

We can hear you now. Go ahead, Paul.

Yes, I would concur with what Matt just said. I think, clearly, we need to be ambitious in what we're trying to achieve. The waiting times position is clearly not at all where we would want it to be for our patients, certainly in my health board and indeed across the NHS in Wales. I think the Minister rightly has been quite challenging in terms of setting pretty ambitious targets for us to achieve. I think what we have to just bear in mind is also, though, the risks around the delivery of those. Some of those are within the direct control of our own organisations, but it is very dependent on things like availability of workforce, which is a big—. I know we might come and talk in a bit more in detail about that later on, but the workforce pressure to deliver the targets we need to achieve is really quite challenging, at a time when the workforce, coming out of COVID, are already very tired, exhausted, slightly demoralised. There are all the other things that are going on around the workforce at the moment in terms of terms and conditions and those sorts of things. There's also the challenge, I think, of making sure that we are being as innovative as possible in how we approach some of these things. There are different ways that we can manage situations and patients on waiting lists.

We had some examples, certainly in my organisation, where, actually, people who were on waiting lists, when we offered them alternative options—so for example, people waiting for an orthopaedic procedure or chronic pain management—when we've offered them opportunities to go to alternatives to surgery or consultant-led interventions, such as physiotherapy or lifestyle and support, actually many of those patients have taken those opportunities up and have actually said to us afterwards, 'Well, actually, that's helped me manage the situation effectively, so I don't feel I need to be going through a surgical procedure.' So, I think it's about both being more efficient and delivering as much as we can do through our existing resources, but I think it's also about thinking creatively about different routes that we could be offering patients that mean they don't need to be treated in an acute hospital setting. There are many areas of work, particularly things like dermatology, where we have big pressures at the moment, where actually there are other options for patients that don't need to be about coming into a hospital setting to receive their treatment; they could be receiving that treatment in the community.

So, yes, the targets are ambitious. I think the risks associated with it are significant, but there is absolutely a willingness and a desire from all health boards, and certainly clinical teams, to try and get through this backlog as quickly as possible.

Fe wnaf i holi, os caf i, drwy gyfrwng y Gymraeg. Mae pwynt pwysig wedi cael ei nodi gan Paul yn fanna, dwi'n meddwl. Mae yna rai arbenigwyr clinigol wedi dweud wrthyf i fod y targedau amrwd yma hwyrach yn mynd yn y ffordd wrth ddarparu gofal go iawn, oherwydd bod angen, mewn gwirionedd, targedu'r bobl sydd angen gofal fwyaf, y rhai sydd mewn mwyaf o boen, yn hytrach nag edrych ar hyd a lled y rhestrau aros. Felly, pa more ddefnyddiol, ydych chi’n meddwl, ydy'r data amrwd sydd gennym ni am restrau aros? Ydyn ni'n gwneud y defnydd iawn o'r data yna, ac ydyn ni'n targedu’r bobl gywir pan fo hi'n dod i driniaeth?

Thank you. I'll come in. I think it's a really interesting question, and it comes to how we consider risk across the breadth of the waiting lists. So, through the pandemic, we switched to, when we had restricted capacity, very much a risk-based approach. So, you may be aware that the royal college set different levels in terms of which patients we should prioritise in terms of our treatment.

As we come out of the pandemic, I truly believe that the NHS in Wales needs to go through more resetting of how we approach and look at risk, because risk is developing for those people that are waiting a longer time. So, the raw data's really critical for us to reconsider how we're looking at our risk-based approach. We have to consider those that have the greatest clinical needs. So, if you're talking about your emergency streams or your urgent patients in terms of cancer delivery, we have to focus on those. But, equally, we need to get into the position of being able to accurately risk assess those people that are waiting the longest. So, that raw data, I think, is robust, it's helpful and it allows us to take a different approach in terms of our risk assessments. And they're the types of conversations we're having with clinicians now. Risk is not just about the clinical condition, because risk changes as the length of time goes on the waiting list. And we know that, in certain clinical conditions, the longer the waiting list persists, the more that risk will grow, and so we have to now make sure we continually assess those people at the end of the waiting list to look at the risk. And the clinicians are doing that now. So, they continually look at what is the risk of patients that are the urgent patients, the emergency patients, versus those long waiters, so that we can get the balance of use of our capacity right, both for improving the waiting times and managing those in clinical need. So, those conversations are ongoing, and I'm confident that the raw data helps us to do that in an appropriate way.

Diolch.

If I could just add to that, I suppose, the Welsh Government has got the five recovery targets. In your view, are those targets measuring the right priorities? Paul wants to come in as well. Shall I bring Paul in? Paul Mears.

So, waiting times are one way of measuring pathways, and, particularly for surgical patients going through a pathway, it is useful to be able to see the diagnostic phase, how quickly we can treat someone from their diagnostic tests through to then how quickly can we get them into procedure, to be operated on. So, that does give a focus for us within organisations, to make sure that we are keeping our eye on how quickly people are accessing different stages of their treatment, so the end-to-end time for that patient, from the point they're referred by the GP to the point they actually get into an operating theatre or get their treatment, is as short as possible.

Of course, as Matt's rightly said, we have to also then balance that with—. There's time-based prioritisation and then there's risk-based prioritisation, because some patients on the waiting list may end up waiting a bit longer because there are patients of more urgent need that need to be seen more quickly, just because their clinical presentation is more acute than somebody else. So, waiting lists are one way of managing performance, if you like, of elective care services, but I think they can't be the only way in which we do it. But they are commonly used across the NHS across the UK as the way in which performance is monitored for surgical specialties particularly.

But, just to be clear, the five recovery targets, are they measuring the right priorities? That was the question.

Yes—

Yes.

There's the diagnostic pathway target, which is clearly—. People need to get their diagnostic test done quickly to enable the decision to be made whether to proceed to treatment or not. There are the cancer performance targets, there are the waiting times for outpatient appointments, and then there are the treatment targets. And they are the right things to be measuring. But my point is that time isn't the only factor we need to be thinking about when we're considering waiting times.

No. Understood, absolutely. Jack Sargeant, you wanted to come in.

Yes, thanks, Russell, and it's just to pick up on that point. I think it's a good opportunity to do so, since we're talking about waiting times and the time-based approach and the risk-based approach. A very simple question: is that a standard approach across Wales? And do all health boards take that approach when they're looking at waiting lists?

Darren.

I'm just happy to come in, and it relates to Mabon's point and the Chair's point, really. At the moment, the headlines that we see in the newspapers are around waiting times, things we can count, so they're measuring activity. One of the things that goes on behind the scenes—and Matt's outlined that checking in with patients, ensuring they're getting support to stay well—is something that colleagues across the NHS have been calling for for some time, which is measurement based on clinical outcome, so what's best for the patient. At the moment, we're counting things and saying, 'Yes, we'll treat them within this time, this is the time it takes to treat them', but what we've been calling for—and it is more complicated to do, it is happening on the ground—is to look at measurement based on the outcome for the patient and those people. There is a balance, as we've said earlier, as the longer people are on the waiting list, often their condition gets worse and clinical need increases, but there is priority given to those in most need as well. It is a balance and a complicated picture.

And what's the Welsh Government's response to that call?

They think it's the right thing to do, I think, but coming up with a mechanism for doing it is the challenging bit.

Okay.

It is difficult information to gather, truth be told.

Yes, sure. I'm just going to pick up on a point as well. The health Minister has said that, in terms of tackling the NHS backlog and the slower than anticipated, I suppose, progress, health boards need to go faster and speed up the process, so I suppose I'm just trying to understand the extent of that, in your view. Is the slower pace of recovery due to delays in decision making at a local level or at a national level?

I might come in, if I can, Chair, there. I think we need to consider how we've come out of the pandemic and why we've got the certain pace that we have. So, we primarily focused on emergency and urgent care, as you'll be aware, through the pandemic, and, as we've come out of that, we've had to go through a process in NHS Wales of getting the priorities right. So, there's been a lot of focus over the last 12 months in Cardiff and Vale on emergency care to make sure that we get those processes right. Alongside that, we've done a lot of work on our cancer pathways, which is part of our planned care solution, and we're staging ourselves through to the remainder of planned care. So, we had to fix parts of the system, post pandemic, that were for emergency and urgent first. So, do we need to go faster, do we need to find ways to improve the way we're doing planned care? Yes, absolutely, but I think we're taking that approach that we start with the urgent and emergency patients, we get those pathways working better than they were before, we look for that continuous improvement, and now we start to introduce the same approach to planned care. So, I think it's right to challenge us, as organisations, to speed up and deliver more in that planned care arena, as they have done.

Yes. Thank you, Matthew. I suppose my final question on this section is—. The Government would say, the Minister would say, 'Look, we've invested considerably, we're putting money into diagnostic and surgical hubs'. Is it the case that the right support has been provided by the Welsh Government and that responsibility for missing the recovery targets sits with the health boards? Because that seems to be the suggestion from the Minister, so I'm just looking for your position and take on that.

I don't think there's a binary answer to that: does it sit with Government or does it sit with the health boards? I think it's a shared responsibility for all to play the maximum role that they can in it. Finance is an issue, which is related to workforce. We've seen those enormous challenges for NHS budgets relating to the simple things that are hurting people in their communities—the cost of electricity, the cost of heating, the cost of the consumables, goods that the NHS use every day—but also the limitations on workforce. I think if there were one area I'd suggest where the focus needs to be now, in terms of investment, it's in that workforce for the future, because there are things we're doing today to meet the waiting list, but, as you've probably heard me say lots of times, the rate-limiting factor in many cases is the availability of staff and clinical teams.

Well, with that, I'll come on to the next set of questions—Sarah Murphy.

Thank you very much, Chair. Thank you for being here today. Yes, that does follow on nicely, because I'm going to ask some questions now about workforce challenges. So, to start, could you tell the committee how satisfied you are with the actions being taken forward through the national workforce implementation plan, in terms of ensuring health boards have the right staff in the right place to address the backlog?

Who would like to take that? Paul.

Clearly, having a national plan, I think, is a really good step forward, because I think some of these challenges are outwith the direct oversight of individual health boards—it needs to be co-ordinated across the NHS in Wales. It's a common challenge across the whole of the NHS, across the UK—every day, you read newspaper articles, don't you, or online, about the challenges the workforce face in the NHS. So, some of this is definitely needing a co-ordinated approach across the whole of Government and the whole of the NHS.

There's lots of work being done by Health Education and Improvement Wales, who are the body across Wales who co-ordinate the training and development of professional staff across the NHS. There's a multipronged approach to this. We need to be recruiting more and training more people, but we also need to be retaining the people we've already got. And I think one of the biggest challenges we have at the moment is retaining staff, particularly staff, perhaps, who are coming towards the end of their careers, who are saying, 'Do you know what? Given all the pressures we've been through over the past few years, given the challenges still facing the NHS, I can actually go now; I can take my pension, and, actually, I am going to do that, or I'm going to reduce my hours, and I'm going to do part time rather than full time', which, absolutely, is understandable and it's within everyone's right to do that.

But clearly, for us in the service, what that presents are some real challenges then, in terms of how we fill those gaps. So, as quick as we're recruiting new, we're losing from within. So, I think the retention question needs to be of equal importance, if not more importance at the moment, because that's how we'll keep the people we've already got. Training and developing new staff, and growing the workforce for the future, is equally as important, but we won't see the dividends from that for another two, three, four, five years, because that's how long it takes to train qualified staff. So, I think there is something about how we retain the staff we've got. That's about how do we support staff, offer flexible opportunities to keep people, develop our own staff's career pathways.

But it's also about looking at the different models of workforce that we can use. I would say that we still, in some areas, have some quite traditional workforce approaches—doctors can do this, nurses can do that, physiotherapists can do this. There's a lot of movement now to thinking a bit more flexibly about how we create new types of roles. So, how do we develop people who are—. How do we make sure that people are operating—. The terminology that people use is 'operating at the top of their licence'—so, making sure that, where you've got a consultant orthopaedic surgeon, they're spending their time doing things that only they can do; where you've got nurses, they're spending the time doing things only they can do. And where possible, we grow and develop a workforce of support staff who can undertake tasks, with the right training and development, that means they're able to undertake things that, previously, would have been done by qualified professionals.

So, back to my point about needing a workforce plan—that requires you to need a national framework for some of those agendas, it requires national competency frameworks that are agreed, training programmes that are agreed. But I think probably the No. 1 challenge that any chief executive in the NHS at the moment would say is workforce. That's the biggest one. And that does drive the financial challenge, because where do we end up spending most of our money? At the moment, it's on temporary workforce costs and agency staff costs to fill the gaps, because we just can't find people to do the jobs.

Thank you so much. And if I can just ask a follow-up question before others come in as well, based on what you've said. The Minister has highlighted workforce challenges in anaesthesia, ophthalmology and urology. Is that the right focus for the investment? Should it be in specific specialities, or do you think it should be more broad?

I'm looking at other colleagues who want to come in—Darren or Matthew.

I can come in on that. I think the specialties you refer to are ones that we are also looking at on a regional basis. We have to consider workforce planning not just on a local health board basis, but how we can work across the region to support each other to deliver the best care for patients. The real trick with workforce planning, in my experience, is that it's not a static beast. So, we don't start today and create a national workforce plan and then we just deliver it in three to five years—it has to be a dynamic planning process, because things change in the NHS, and what we have as a challenge today won't be what we have as a challenge in a year or two years' time. So, I've no issue in terms of focusing on those particular specialties at the moment. Paul in Cwm Taf and we in Cardiff and Vale are both experiencing challenges in those specialties, so we see the benefit of that. But I think that regional workforce planning is equally important to consider.

Thank you. Did anybody else want to come in? Sorry, I couldn't see anyone.

If that's okay, just to reiterate the points about retention, retention, retention and staff well-being so that we are holding on to the hugely experienced and skilled workforce that we've got. And the other thing I think to be really aware of is the time lag in training lots of clinical professionals. So, if you start today, for many of them you're talking three, five or even 10 years before they're operating, as Paul said earlier, at the top of their licence. A national plan in terms of workforce development for the future is essential, and I mean from a UK perspective as well as from a Wales perspective, because in all parts of the UK, there's a relatively neutral flow of doctors and nurses—between Wales, England and Scotland. It's a whole-UK issue. And, as Matt has said, the workforce challenges would be slightly different in Hywel Dda in west Wales to what they would be in Aneurin Bevan in terms of workforce availability. You have to deliver services with the staff you've got in those areas.

There are national trends, as Paul alluded to. The age profile of some of the professionals in particular specialities where there are challenges—. For orthopaedic surgeons, a very, very large proportion of them are over 55, so it's highly likely that they're going to be retiring, certainly in the next 10 years, but highly likely in the next five. My take on it, having worked in health professional regulation previously, is we've probably underinvested in Wales, England, Scotland and Northern Ireland for all of my lifetime in these things. We've been increasingly reliant on international recruitment into many of the clinical professions. We're less favoured as a destination to work than perhaps we were five or 10 years ago; Brexit is one reason but it's not the only reason. I was talking to a colleague from India recently. Traditionally in Wales, in particular, we've been very reliant on Indian doctors and Indian GPs working in communities. There are places in the world they can go and work now for far better money than they're paid in the UK. As my friend said, Indian people are very much like Welsh people—very family orientated—and they can fly home for the weekend in a few hours for $150 instead of $1,000. Reliance on the world market leaves you very susceptible to changes across the world.

That's really helpful to hear. Thank you. I was just going to move on to drill down a little bit more into it, because all of you have mentioned improving staff retention and how focusing on well-being and reducing workplace pressures is key to this. But you have also mentioned, Paul, very helpfully developing those pathways, different models, flexible roles, flexible working. Are these actions that health boards can take immediately to try to improve working conditions for healthcare staff, Paul?

Who would like to take that? Paul.

There are things that we can do already today, and there's already work going on across health boards across Wales to look at how we can create new roles and delegate things that previously would have been done by doctors. We can develop nurse consultant roles and advanced nurse practitioners who can do things now. There are examples of nurses being able to undertake, for example, things like endoscopy procedures, which previously would have been done by doctors. So, there are already things that we can do today to encourage and support other professions to take on roles that were previously being done by medics.

There's nationally a programme of work going on led by the chief nursing officer to look at developing an enhanced nursing support role, so just underneath qualified professional level, which would also enable us to be able to delegate more things to support workers. In some ways, the challenge we have with the workforce forces that level of innovation and creative thinking, because just trying to do things the way we've always done them is not going to be how we're going to get ourselves out of the system.

I'd also just highlight that there are also opportunities for things like new technologies coming in and digital solutions. We're starting to see, for example, people being able to monitor remotely patients from home using new technology, which would previously have required people to come and see a professional face to face. So, a professional can now track and monitor patients remotely. Take the example of post-operative orthopaedic patients. We'd normally say, 'You need to come back in and see somebody after the procedure'. Well, actually, with remote monitoring you can say, 'You don't need to come back in, we'll keep an eye on you remotely and if after a week, everything is okay, we can discharge you and here's the phone number if you need to get back in contact with us—if you're worried, you can do that'.

So, it's about looking at the tasks that need to be done, which of those tasks could be done remotely, digitally, automated, what could be done by a different type of staff member, and therefore focusing the really precious qualified staff we have got on the things that only they can do.

Thank you. I'm aware that we're short on time and I just wanted to ask another question that kind of follows on from that, if that's okay. We have mentioned the retention, but also, as you said, the future workforce does depend on trainees as well. As a committee we actually visited the Glyntaff training campus, which was wonderful. The quality of training there is very good, and as you've mentioned, Paul, as well, even around the digital and what's coming down the line and innovation. But we did have a chance to talk to some of the trainees, and they were saying that, despite how excellent the teaching is there, nothing can quite prepare you for when you actually go on to your placement, and you're on a ward.

One of the things that they raised—and some of them did their placements during COVID as well—was that they found that, sometimes, especially when a patient passes away, the staff themselves are so rushed off their feet that they didn't quite have time to process it, and for some of them that was such a distressing experience that they considered whether or not to continue with the training. So it's just about the well-being and support, I suppose, around those training placements, when things that would never happen in the classroom are obviously going to happen on a ward.

And I do also want to add that some of the other issues that they raised would not be things that, I guess, you can really control. Sometimes they are sent to placements that are very, very far away, and the funding does play a part then as well in the training, too. But one of the things they did raise was that experience, sometimes, on wards. Paul.

You're absolutely right. I think we need to be really careful in terms of students. Because going back to my point about recruitment and retention, we don't want to put people off, and we need to watch things like the attrition rate through training to make sure that we're not losing people—that once they start their courses they drop off. For my organisation—I'm sure other organisations have the same—we have a really well-developed staff well-being service that supports people, so where there is perhaps a tragic issue or a death or a trauma case, perhaps, that people have had to deal with, we have psychology support that can go in and work with that team and facilitate a reflective session to talk through how the situation was managed and dealt with, could we have done anything better, but more importantly, how has it impacted on you. We offer individual, personal consultations and engagement with the well-being service if people feel they need that. I think it is really important that we put that in place. It's very difficult when we are so pressurised and everyone's so busy. It's almost like, 'Well, that's happened, and we've got to move on to the next thing that we've got to do'. So, we're really conscious of that, and our employee well-being service has been invested in as an organisation because we realise that—going back to the point about retention—we need to be supporting our staff to be happy and healthy and enjoy their work as much as possible, recognising that we work in an environment where things will go wrong, things do happen. But what support we put in place is really important to make sure that we provide that right pastoral support at difficult times for our staff.

Thank you. I'm just conscious of time—

Yes, of course. I'm happy, Chair. Thank you very much.

Thank you, Sarah. There are a couple of supplementary questions from Gareth and Jack. Did you want to come in with your question, Gareth?

Thanks, Chair. Just to come back on Paul's first comment about staff taking early retirement or taking their pensions, does that then create an opportunity and fluidity within the workforce system to then create opportunities for fellow staff members, particularly those who—? Because under the current system, if you're a band 4 nursing assistant or therapy assistant and you aspire to progress in your career, you potentially have to quit your job, go to university for three years, get into £27,000-worth of student debt, to then progress up the NHS pay scale. So, what do you think we can do better in terms of internalising some of the training systems within the workforce to help aspiring staff progress in their careers?

I think there's a huge opportunity. Just to take a local example from my patch, the University of South Wales is now offering part-time physiotherapy courses and part-time occupational therapy courses, so it does mean that, where we have staff that want to carry on working whilst they study, they are able to do that. We're working really flexibly now with USW to see what we can do to encourage more of our staff to take up those sorts of opportunities—and potentially staff who wouldn't traditionally have thought about themselves going into those careers, but who, over a number of years of working in a particular support role, realise that, actually, they do really like the physio world or they do really want to become an occupational therapist. So, having those part-time education opportunities is really important, because it enables people to carry on working whilst they're studying.

And what we're also really working hard on, and I know other health boards are doing the same, is looking at routes to employment. So, we know that one of the biggest determinants of good health for individuals is if they've got employment. So, in an organisation like mine, which serves some quite deprived communities, if we can try and support young people to go into careers in healthcare, that's a really good route in for a long-term, good job, that will hopefully set them up well for their life. So, we are working actively with schools, with colleges, with some of our more deprived communities, to look at particular groups of young people and how we can encourage them to take up a role as, say, a support worker or a healthcare support worker, but with a view that, over time, they could develop their skills and competencies internally, and, then, potentially take up opportunities with the university to go and train and become a qualified staff member, whether it's a nurse, a midwife, a physio or whatever. So, I think there's a huge amount we can do from within our own organisations in partnership with our universities and higher education providers.

Thank you, Paul. Jack, you've got a supplementary question.

Yes. Diolch, Cadeirydd. Quickly, an integral part of any plan is understanding the current situation of where we are. We've had evidence, not in this inquiry, but I think it was the gynaecological cancers inquiry that we're currently undertaking, to suggest that we don't understand where we are with the workforce. What are your views on that? Do we understand fully enough exactly where we are and where we need to be, or is there more work to be done?

I think there's a relatively good understanding of where we are now, in terms of the numbers of people in particular specialities, we can tell the numbers of people in training heading in that direction. I'd think an area where there's perhaps less certainty, which I've alluded to already, is particular specialities where the age profile is perhaps people approaching retirement, and there is that complex bit of it as well in some of these challenging areas, where we're having to re-design services so that we can do it with the workforce available. But, as I said, we need that long-term plan, we need to know where we want to get to, and, rightly, as you said, I think, we have a pretty good understanding of where we are, but the unforeseen is people leaving the workforce, which is—

There's some uncertainty.

Yes. Going back to the retention point, and things that Paul has alluded to already, in terms of supporting the workforce, and the other thing around retention and keeping things going forward is that, you know, recruiting from local communities. There's huge evidence to show that people tend to stay in their roles longer if they started their career locally and are given that opportunity to develop, and that has big knock-on positive effects for the communities more widely as well.

Thank you. Thank you, Darren. We've got quite a few areas to get through, so, I think, for each area—just to give Members an indication—we've probably got about less than 10 minutes to cover each section, so just to give some indication for that. Mabon ap Gwynfor.

Diolch, Cadeirydd. Diolch am eich tystiolaeth hyd yma. Ddaru chi gychwyn—y tystion yma—eich tystiolaeth drwy sôn am effaith COVID ar restrau aros, ond, wrth gwrs, ers hynny, mae'r Gweinidog wedi sôn bod gweithredu diwydiannol wedi cael effaith ar restrau aros. Felly, faint o lawdriniaethau a gafodd eu canslo o ganlyniad i weithredu diwydiannol?

I was within Cardiff looking after the management of the industrial action and we tracked individually, on each day of industrial action, the impact on both outpatients and treatments, and it was variable between the different days in terms of how many we lost, and that is down to what we've got planned for that day. In most instances, I don't think we've, actually, had to cancel anybody who was there for an urgent or a cancer operation. Some of the routine operations were cancelled. For example, on one day, I think, we lost 70-odd routine operations. But what was really positive is that we were able to set up the structures to make sure that our most urgent patients still received the care that they needed. I don't have the exact numbers for each day, but that gives you some indication, I guess, of the detailed process we went through.

Ac ydy hynna'n batrwm cyson? Sori, Darren. Dŷn ni wedi cael darlun bach fanna o un bwrdd iechyd; ydy hynna'n batrwm cyson dŷch chi'n meddwl, Darren, ar draws Cymru?

It's very difficult, and I don't have a figure in front of me that I could point to, that x number of procedures were cancelled. But obviously, it does have a very big knock-on effect, and, I think, it's a really good way of illustrating the interdependency of different professionals across the NHS. Lots of colleagues stepped in and did things they didn't normally do to enable emergency care, in particular, to be provided, but it's very challenging, and the industrial action we've seen across the UK this year is a good indicator that staff are under enormous pressure and not particularly happy with things. There's a role for the NHS as employers in that, but there's also a role for Governments to ensure that people are properly recognised for the work that they do financially.

Gaf i ddilyn i fyny? Os ydy'r gweithredu diwydiannol yng Nghymru wedi cael rhyw fath o effaith—dŷn ni ddim yn glir iawn, dydy o ddim yn berffaith glir, dŷch chi ddim yn sicr, mae'n amlwg, o hynny, o ran y niferoedd—. Ydy'r gweithredu diwydiannol dŷn ni ar fin ei weld yn Lloegr yn mynd i gael dylanwad ac effaith ar restrau aros efo ni yng Nghymru? Dŷn ni'n gwybod bod yna nifer fawr o gleifion o Gymru yn gorfod cael triniaeth mewn ysbytai yn Lloegr. Felly, pa effaith mae'r gweithredu diwydiannol yn mynd i gael ar restrau aros yng Nghymru?

To your first point in terms of clarity on impact, I don't have the numbers with me, but, absolutely, within all organisations, we have all of that data available. So, we are clear on the impact both on out-patients and treatments. In terms of the direct impact of industrial action in England, I couldn't draw on specific numbers today to say we know exactly how many people will be impacted on. There's good communication between organisations, so we'll have to watch that as it comes. But I think it's important to say that there has been an impact from industrial action, very variable through the different periods of time. My recollection is that the days that we had that were in the winter, so through December, were significantly more challenging for us because of the concurrent challenge of emergency care at that point in time. But in terms of specific numbers, I don't have a feel for that, and for those that will be impacted by the English industrial action.

I think that one of the obvious implications is that what happens in a particular profession in terms of pay negotiations in England will have a knock-on on that profession in Wales, and it may or may not result in industrial action in Wales, because, obviously, the workforce is fluid and works between the two. But also if the perception is that staff are being paid more favourably or treated better in one part of the UK, that's going to have an impact on staff well-being and staff morale in other parts of the UK. So, they are interlinked, for certain.

Ocê, diolch. Peth arall sydd wedi bod yn y penawdau dros y misoedd diwethaf ydy cyflwr stadau y gwasanaeth iechyd yng Nghymru, a dŷn ni wedi gweld adeiladu canolfannau iechyd newydd dros y blynyddoedd. Felly, pa effaith mae stad a seilwaith yr NHS yn ei gael ar ddarparu ac ehangu gofal sydd wedi cael ei gynllunio, yn enwedig o ran cyflwyno clinigau diagnosis cyflym a chymunedol? Dwi'n gweld Paul efo'i law i fyny.

Thank you. So, I would absolutely agree. We've talked a lot about the workforce, but, clearly, the workforce needs to have the facilities to be able to deliver services. I think this is an area where, particularly in the south-east of Wales, we are making some really positive progress. There's lots of work going on across the health boards in south-east Wales, as Matt's already alluded to, to look at how we can work in a more joined-up way across our organisations. That includes looking at facilities that we provide to our patients, so we are working together to bring in community diagnostic hubs across south-east Wales, so these will be facilities where we can see patients much more quickly, to have MRI scans, CT scans, ultrasound diagnostics, things like that, so a real drive to increase the capacity, because one of the challenges we have in terms of the elective backlog is that the diagnostic pathway for patients, often, is a bottleneck—getting people to scan quickly. The capacity in our scanners is constrained. We don't have enough scanners across Wales, so we are working to grow and develop the number of diagnostic centres across south-east Wales.

You'll know, I'm sure, that Welsh Government have also funded the purchase in my area of a facility in Llantrisant, which will be developed into a diagnostic and treatment centre, so, looking to grow and develop more capacity for diagnostics, but also endoscopy and also, potentially, surgical procedures as well. So, having dedicated stand-alone centres that can actually be protected space where high-volume specialties can get more patients treated more quickly, and we're looking to develop that as part of the wider south-east Wales regional work. So, it would be a facility that would be able to provide services not just for patients in my health board area but also for colleagues in Cardiff and Aneurin Bevan. So, you're absolutely right, the estate and the facilities and the capacity of some of our estates to cope with the volume of patients is a key determinant of success in our ability to bring down waiting times. But I think we have got some good plans across Wales to try and tackle that.

Diolch yn fawr iawn. Ac felly, yn dilyn hynny, pa gamau pellach ydych chi'n meddwl sydd angen ar fyrddau iechyd neu Lywodraeth Cymru, neu’r ddau ar y cyd, felly, i sicrhau bod yna fuddsoddiad cyfalaf yn cael ei ddefnyddio ar gyfer ail-lunio ystâd a seilwaith yr NHS, ond hefyd, fel dŷch chi, Paul, wedi sôn amdano, yn cynnwys yr elfen ddigidol hynny?

So, I think one of the challenges understandably—and this, again, is not just a Wales issue, this is an NHS UK-wide issue—is the availability of capital to support the estate developments that we all want to see. There are lots of services across Wales that are operating in the estate that are not fit for purpose, that are in poor quality.

Going back to the point about retention, one of the key things that people want to be able to do is work in an environment that's suitable for the job that it's fit and meant to do, and many of our facilities across Wales are not in a place where we would want them to be. There is investment going in in a number of areas to improve the estate, but the capital resource available to us is a real issue, and I think, potentially, is a barrier to some of the things we all want to achieve to improve the quality of services for our patients. And of course, the capital resource that we have available to us as health boards isn't just about buildings, as colleagues just mentioned, it's about the digital infrastructure that we need to support that as well, so it’s both buildings, but actually more importantly even, moving forward, I think it’s going to be about how we use capital to resource the digital infrastructure needed.

So, I think there are a number of pieces of work, and in fact, I’m doing a bit of work with other chief exec colleagues in the NHS, looking at the capital challenges we’re facing in the NHS and thinking, ‘Are there different ways we could access other sources of capital?’ We’re taking quite a bit of interest in some of the work that’s been done in Wales on the schools programme, to look at the model that’s been developed there to bring in different types of funding models for capital for schools. Could there be a read-across into the NHS for that? But also, more importantly, what does the infrastructure for the NHS in Wales need to look like for the next 10 years, and how are we going to resource that appropriately, because we all acknowledge that the capital restraints on the NHS are significant? The capital restraints on Government are significant, so maybe we need to be thinking a bit more creatively about how we can use different types of resources to support the really important investment that is needed in this area.

Diolch. Yn eich tystiolaeth chi, Paul, dŷch wedi sôn am bethau da dŷch chi'n eu gwneud yn eich bwrdd iechyd chi. Mae Matt yn y fan yma wedi sôn am bethau da sydd yn digwydd yn y bwrdd iechyd efo chi acw. Dwi'n sicr yn ymwybodol o bethau da sydd yn mynd ymlaen yn Betsi Cadwaladr, ac wedi clywed am Hywel Dda yn sôn am hyfforddi eu pobl eu hun. Mae yna arferion da mewn pocedi ar draws byrddau iechyd ar hyd a lled Cymru; pam, felly, eu bod nhw'n arferion da unigol, sydd ddim ond yn datblygu yn y byrddau iechyd yna, a sut fedrwn ni sicrhau bod yr arfer da yna'n cael ei rannu er mwyn i bawb ddysgu a datblygu’r arfer da yna? Beth sy'n atal hynny rhag digwydd?

We're just a little short of time, but if you can just—. Sorry to have to ask for shorter replies to questions.

Yes, sure. So, I'll point to some of the good work we're doing in the south-east Wales regional network. So, actually, we're doing a shared piece of work around community diagnostics that looks at how pathways should be developed, learning from England, so we've taken the King's Fund report and learned where community diagnostics went wrong, and we're actually working together on solutions, so that, if it's implemented in Cardiff or in Cwm Taf, we make sure that that learning is spread. So, we have the infrastructure now where we can start that regional sharing quite well, and we've had a lot of conversations with the NHS executive about taking good practice from individual health boards and making sure that that's shared through the performance management framework across Wales.

So, I'd point to those couple of examples where we are starting to make real inroads in terms of that shared learning going across organisations. And I think it's becoming more and more successful.

Okay.

I suppose Mabon's question was about not having those good examples, but how those good examples are shared, and what are the barriers to sharing.

So, I guess what I was saying is that they are the examples of sharing. So, the south-east Wales regional network, we work together, we develop pathways together, so that they can be implemented, irrespective of location, health board region. So, we're actually doing joint development work to allow good practice to be developed across the region.

Okay. Thank you. Understood, yes. Joyce Watson.

I'm going to come on to regional approaches, so we've already started. And, of course, if we're going to modernise, we can't have experts everywhere because of the numbers game—that's what we've been told; those are not my words. The plan acknowledges that the challenges we face are too large for individual health boards. You've given an example now of one area where that is working, but there is a movement, isn't there, of patients—particularly, you know, I've got the rural area—being transferred into another area to receive the treatment, according to those plans. So, can you provide us with an update on some localised capacity where that is happening?

If you don't mind, Chair, I'll just come in on the overview piece there. There's a lot more regional working and working between health boards than is visible to many people. I think, looking at the geography of Wales, that regional working is far simpler to achieve on behalf of patients in, say, South Wales West and South Wales East than perhaps it would be in Powys or North Wales. In the conversations we had before the meeting today, there were some really good examples that Matt will be able to give, and Paul, as they've been working on joint regional plans in their respective areas, so I'll hand over to colleagues, if that's okay.

Thanks, Darren. A really good example is the work going on with ophthalmology at the moment. We have a programme across three health boards, which are Cwm Taf, Aneurin Bevan and ourselves, looking at how we can have a shared waiting list and treat patients irrespective of borders. So, we have patients coming to Cardiff to receive their treatment within the Vanguard theatre that we have set up in Cardiff. But we'll have bilateral flows between organisations, so where it's better to do out-patients, for example, within Aneurin Bevan, some of our patients will travel. And what's important in that example is that the programme of work is actually making sure that we co-produce this with patients. So, I've seen some excellent examples of co-production where we sit with patient groups and we talk through how best to develop these services, to make sure that it's fit for the patient, fit for how they want to access health services as well. And we are starting to hear more and more examples of people who are happy to travel to get that treatment.

Of course, in some cases, it's not even a possibility to deliver it locally. You've given good examples of south-east Wales, but I don't represent that area; it's the only area I don't represent in Wales. So, how is that working in rural areas?

It is more challenging, but building on Matt's point around health boards looking after ophthalmology patients, there's lots going on, and particularly in rural areas where opticians on the high street are providing that follow-up care, post-operative care that ordinarily and historically would have involved a visit back to a hospital site, in rural areas and many miles away from patients' homes. So, there's a service redesign going on as well there, so not just the working between health boards, but the working between hospitals and community settings. I know there's a very large training programme going on of opticians across Wales to do that follow-up and monitoring post surgery, so there are ways of delivering care in the community, upskilling the workforce that we have—

That's if you've got your operation, though.

That's right.

So, what if you're waiting for your operation? That's what I'm, you know—.

Yes. There are multiple schemes and, again, I'll hand over to colleagues working on the front line, but to keep people well in their communities, it is a challenge. There's no doubt there are lots of pockets of good things going on, but there isn't a one size fits all for all conditions in all parts of Wales; they're very much condition specific, geography specific.

But there was a £170 million recovery fund, and £50 million of that was kept back to support delivery on an increased regional level. How much of that has been spent?

I couldn't give you an exact figure here today, but I can hand over to colleagues to talk to you about how it was spent in their areas, where they have that on-the-ground knowledge.

Okay. Paul.

Paul, you wanted to come in.

Yes, just on that point about the regional money that's been held back. So, just to be clear, last year, we had money from Welsh Government. Every health board had money from Welsh Government to help support the elective recovery. This year £50 million, as the Member has just said, has been held back to be supporting schemes that are working across regions. So, each region, and I can speak for the south-east, but I know similar things have happened in the north and south-west, have put forward plans for how they would use that money to support growing and developing more activity across the region. At the moment, that money hasn't yet been allocated back into health boards. We're waiting for agreement from Welsh Government. I think it's being looked at as part of the wider financial position of the NHS across Wales at the minute, but, obviously, that will be a key factor in making sure that we can carry on developing and working regionally to get more patients treated.

Just on the point about the travel and regional solutions, I absolutely agree, and, clearly, my region is nowhere near as rural and dispersed as some of the regions in Powys, west Wales and north Wales, but I think we should highlight that transport is one of those big factors that we do need to be careful of. Even in my region, if you're asking a person who lives in Merthyr to travel to Bridgend for an operation, that could be a really complex process if you've got to rely on public transport to get there. So, one of the things that we're considering looking at as part of our conversation with our communities is about what more we can be doing with community transport providers, with other local authority colleagues, to look at transport routes to key locations, so that where people do need to travel further for a procedure, a barrier cannot be that they can't access transport, because that will just perpetuate some of the inequalities that we're already seeing in some of our more rural areas. So, it is absolutely an area that I know many health board colleagues are focusing on, and colleagues in west Wales, I know, are looking at that similarly to the way that we are in the south-east.

I accept that, but I also accept that people will travel to access care if they're in extreme pain and they've been waiting for two years or more. I'm going to move on now, because you talked briefly about involving the independent sector in delivery, and you just gave an example of using treatment post eye care. Are there other areas where you're exploring work by partnering with the independent sector?

Yes, it's an important thing that we need to continue to look at in a number of areas. So, the community diagnostic centres that we've referred to are something that we are currently exploring, whether we could work with the independent sector. What's really interesting is that there are a lot more people now that are willing to look at an approach where they partner with NHS organisations and support us in transitioning to developing our own services. So, I think where we have particular constraints, it's important for us to explore that, and, as I said, community diagnostic centres are an example where we're doing that at the moment and exploring how we could work with the independent sector and then start to develop our own, I guess, critical mass to be able to continue that work.

Okay.

Thank you, Joyce. Gareth Davies.

Thank you very much, Chair. We've focused on it quite a lot already, but I want to just press a little bit more on the key reasons and differences for long waits across the different health boards. I understand, obviously, that health boards do have a degree of autonomy, but there are also national frameworks as well that underpin a lot of the operational, structural measures that health boards implement. So, in that case, what are the reasons for the differentials of data across different regions and health boards across Wales, and what can we do better to maybe negate some of those issues?

There's a myriad of reasons why you're going to have differences between individual health boards. We touched quite a lot earlier on workforce challenges, and, of course, the workforce challenges that we experience in Cardiff won't necessarily be the same as they experience in Hywel Dda, and that will be a determinant of some of the time that people wait, making sure that we've got the right workforce. Workforce is a big reason for it.

In terms of how do we move on from that, we're having some really positive conversations in this region, as I know they are in other regions, about how we share waiting lists. So, Paul and I have been discussing a single diagnostic waiting list, and we are working with the cataract list, which is shared across the three health boards. We are introducing this concept of that single waiting list, so we can try and negate some of those differences by working as regions.

But why is it different? Predominantly, it's workforce that drives the differences in the waiting times for different specialties.

And do you think there are also some socioeconomic factors in that as well? Because health inequalities were evident way before COVID-19, with people living in less deprived areas getting better access to planned care, and those in more deprived areas having more barriers in place to accessing some of those health provisions. So, what can we do better in that sense to make sure that as few people as possible slip through the net in terms of accessing good-quality NHS care?

Health inequalities are a massive, massive issue across Wales, and have been for my generation and the generation to come and the generation before. And I think the impact of COVID and how areas with high levels of deprivation were much more adversely affected by COVID yet again shone a light on some of those challenges.

I think, for me, if ever there was a case for a whole-Government approach to deal with some of these issues, reducing health inequalities is one of them. The economy has a big part, housing has a big part to play. We've talked about the transport issues and Paul cited getting to Merthyr. My family live in a village called Gilfach Goch, and to get from Gilfach Goch to Merthyr, which my grandfather had to do recently, when he had sepsis, is hugely difficult. Access to services, geographical challenges—which Joyce has touched on—are big, but health has a sort of handle on some of the levers for reducing health inequality, but one of the things we've been asking for with many voluntary sector bodies is that whole-Government approach, for every single bit of Government, from education, local government, transport and business, to think much more about what every bit of the public, private and voluntary sectors can do to reduce some of these health inequalities, as unfortunately in Wales, there is more inequality than many other parts of the UK.

And is there any comment from Paul, specifically, from an obviously executive level, of how that's managed in Cardiff and the Vale?

So, I'm from Cwm Taf Morgannwg.

Oh, sorry.

That's okay, don't worry. But absolutely, the point you make is really, really important, and it's not just about when people need treatment, making sure that we've got equal access, it's also how do we avoid some of these people actually needing treatment in the first place, because actually, we historically haven't focused enough on improving the health of the population, trying to tackle some of the long-standing health inequalities issues, the high rates of prevalence that we have of chronic disease. In my patch, if we can get better at detecting early-stage cancer, for example, and preventing lifestyle factors that will influence people getting cancer, it means hopefully that we all have a manageable number of people to treat for cancer in the long term. But at the moment, we're just seeing an inexorable rise in chronic disease, in lifestyle factors that will influence people's health outcomes.

So, I think there's something about how we make sure that we are—. As much, as health boards, as our priority has to be treating people when they need our care, which is what we're talking a lot about today, I'm really keen that my organisation's strategy is also to say, 'We need to be spending as much time, if not more time, focusing on why these people are needing care in the first place, and how do we try and work with communities, with primary care, GP colleagues, with the voluntary sector, with community groups, to try and encourage and support people to have happier lives.'

We see huge numbers of patients presenting with stage 4 cancer in A&E departments; that's just not acceptable. People should be getting the right care earlier, and be encouraged to go to see their GP or get support earlier, because their outcomes would be better if we caught that issue at an early stage. Once people are presenting with stage 4 cancer in an A&E department, quite frankly, it's too late. The likelihood of that person being able to be treated and cured is significantly lower than if we were able to catch it earlier. So, there is something about how we repurpose and reshift our focus as an NHS, and this is very much what the Minister was saying, I know, last week, around the seventy-fifth anniversary: we can't carry on just continually pouring more and more resources into the treatment end of the pathways. We've got to get better at really focusing on the upstream intervention, public health, population health prevention, so that we can start to try and tackle the root cause of some of the these real significant challenges.

And some of the biggest issues, from my perspective, is that we've had a sustained agenda of centralisation of health services across Wales, and maybe reinstating some of the community aspects of care, and you look at your cottage hospitals of years gone by and step-down facilities. Would some of those being incorporated into some of those rural communities—like Gilfach, as I think Darren was saying—and rural areas that may be not well connected to your likes of Merthyr or bigger towns and cities—? Would they act better in those cases, when you look at the geography of Wales? We've talked a lot about geographical issues, but would the reinstatement of some of those community settings indeed provide a bit more fluidity within the system and access to patients living in rural areas?

Pretty much everyone in Wales will be registered with a GP, so there's something about how do we try and capitalise on the opportunity that we have with GP colleagues, the work that's going on across GP cluster developments, so looking at groups of GPs coming together to provide more services locally. And then also we've got a plethora across Wales of community-based services, whether it's community hospitals, community clinics, various facilities where we could do more. One of the conversations we're having as an organisation is, 'What are we currently doing in our acute hospitals that could be done out in a community setting, that could be more local to the individual, that could be more accessible to them?'

I come back, also, to my earlier point about technology. We still have a mindset, in a lot of cases, where people have to go to a facility to see somebody face to face. For a lot of people, that's absolutely appropriate and that's what they need to do. But also, moving forward and looking to the next 10 or 20 years of the health service, we're going to be dealing with generations of people who are used to dealing with most of their services, on a day-to-day basis and in every other walk of life, in a digital world. So, what could we be doing also to provide digital opportunities? Because that does help us tackle some of the issues of rurality. Being able to engage and have a consultation with a consultant from your own home, rather than having to drive an hour and a half to get to see them in a hospital that isn't even local to you, is a much more convenient and accessible way of a patient being able to access it. So, what can we do to use technology?

I think it's a combination of existing facilities, new technologies, but also a mindset shift we have to make across the health service, and also with the population at large, about saying, 'Actually, services are going to be delivered in a different way in the future.'

That's the ambition, isn't it, but how do we make that a reality? That's the question, isn't it?

It's about people like me and my organisation starting to get our clinical teams working on that, working with colleagues in Government to look at making sure we're investing in things for the future. As much as keeping the show on the road today, we've got to be focusing on actually redesigning the service models for the future, to enable us to provide those sorts of services. Quite honestly, yes, there are real challenges in Wales, but we are a relatively small country that has the ability, potentially, to do something quite innovative and different in this space, and I think it gives us a real opportunity with the strength of what we have in our communities. We've got great engagement, we've got great support in voluntary sector groups, community groups. We've got a real infrastructure there that we need to be capitalising on to help our residents live happier and healthier lives, and hopefully encourage them to take different choices about how they live their lives, which hopefully will enable us to manage the long-term illness and disease burden in a better way moving forward.

Thank you, Chair.

Thanks, Gareth. Mabon, you didn't want to come in on this point anymore? No. That's fine. Joyce Watson.

I'm going to go on to challenging specialities. The Welsh Government identified seven specialities that are classed as being exceptionally challenging in terms of recovery targets to eliminate long waits. Was that decision to remove those challenging specialities from the recovery targets agreed with health boards?

I can't give you a definitive answer, but as far as I'm aware, they weren't. But I think the feedback from health boards was that they, in particular areas depending on the part of the country, would be most challenging because of team availability in those specialist areas.

Okay. That's interesting. That doesn't—

I said, 'As far as I'm aware.' I just didn't prepare for that one.

—tell us a lot, does it? In other words, the answer is that you don't know. Is that a fair comment?

As far as I'm aware.

Okay. So, in that case, how are the decisions being made about how to make best use of the funding available to each health board to tackle the backlog? For example, will the seven challenging specialities become now less of a priority for health boards, because they're not included in the targets? That's dermatology, ENT, general surgery, gynaecology, ophthalmology, trauma and orthopaedics, and urology.

I'll come in on that one. Absolutely not will they become less important.

That's what I was going to say too.

We're directly working at the moment on our plans for what we can do for improvement in year, and that includes the challenging specialties. We treat all of them with the same approach, the same process, the same governance, performance management, because, actually, the patients who are waiting for orthopaedics are equally as important as any other specialty—or ENT or anything. We just simply wouldn't go down a route of ignoring specialties—that's not how we manage the health boards.

And the same—?

Paul, did you want to come in?

Yes, just to echo what Matt said. Those specialties are probably getting more focus in my organisation that any others, because they are precisely the most challenging specialties and have the highest volumes of people waiting, and therefore we need to make sure that we're doing as much as we can to get those patients treated. Two of those areas, ophthalmology and orthopaedics, are two areas where we've prioritised work on a regional basis, to look at how we can capitalise on the total capacity available across the south-east. So, they are absolutely in our sights and very much being focused on as a priority.

Of course, there are other services that aren't in the recovery targets, and mental health, paediatrics and primary and community care are such services. So, how are the targets in those areas met?

Again, in the conversations we were having prior to today, those areas aren't as visible as a list of people waiting. But, undoubtedly, need in those areas did go up quite significantly during COVID, and because of some of the impacts on people through COVID. But again, I'll come to other colleagues to answer.

Again, whilst they might not be at the forefront of what's reported, there are measures that we need to meet in all of those areas. We have an equal focus across all of our clinical teams within the health board, whether it's mental health or primary and community care. We also know that there is a bridge between physical and mental health that we need to consider, and do consider, within health boards. So, whilst they might not be at the forefront of reporting, they are absolutely at the forefront of the health boards' approach, and we do watch all those different areas. And some of them do have primary measures as well. I'm sure you're aware that, in mental health, there are certain targets that we need to meet that are an indicator of how that service is working. So, yes, to reassure, they're treated with equal importance.

Thank you, Joyce. Just before I come on to Jack Sargeant, Paul, I know you gave us notice that you have to leave at about 10:45. By all means stay as long as you can, and we'll understand if you disappear off our screens, but thank you for joining us this morning. Jack Sargeant.

Diolch yn fawr, Cadeirydd. Let's go back to where we started today's session and the Chair's opening questions on the recovery targets. I think, 'The targets have to be realistic' were the words of the Chair, and, Paul and Matthew, you both said the targets are ambitious, and rightly so—they should be ambitious. I agree with the Chair, actually; they should be realistic and they have to be deliverable, and rightly ambitious. Do health boards have the capability to meet the targets in the Welsh Government's plan?

That's an awfully big question. It's about timing, isn't it? In essence, yes, we do. We have the workforce challenges that we need to work through, and we need to recognise those. We've rehearsed those well today. They provide constraints. But clearly, what's happening with the planning approach that we've got at the moment is there are short-term interventions that we can take as health boards. We talked about the spend on temporary staff to try and support us. But at the same time, we're looking at the sustainable solutions for healthcare in Wales as well and how do we create new ways of working to make sure that we are sustainable in planned care. For example, we're looking at introducing more protected elective surgical zones. Paul spoke about Llantrisant; we're looking in Cardiff at a similar type set-up in Llandough hospital, to see if we can do that. That would allow us to ensure that we get more sustainable delivery of planned care and get the balance between emergency and planned care right. So, yes, the capability's there. We have some workforce challenges we need to continue to work through, and we are currently in the planning phase of looking at what do sustainable solutions look like for the future.

I think we also need to consider the work that's going on for patients that are on our waiting lists. Because of course, how patients wait is just as important as how quickly they're treated. We've got examples of 'waiting well' programmes and 'live well' programmes. Touching on some of the comments we made earlier, we're making contact with people on waiting lists, we're helping them to make sure they've got the right prehabilitation before they come in to hospital. But equally, there are options there for people to take a different route to receiving healthcare. So, it's all of those different elements that will come together in a really complex puzzle, for us to have sustainable planned care. So, I think, to answer your question, yes, we have the capability, but there's a lot of work to do to get there.

Thanks for that. On the waiting well aspect, I think the committee agrees—we produced a report on exactly that subject. But there's work to be done. Given the fact the recovery targets have been missed twice before, are we confident we're going to meet the next one? Because I think the projections of the committee are that that's perhaps not going to happen, and, if not, what are the consequences for the health board? The Minister in her own words has said there'll be no excuses for health boards not to meet the target. What do the consequences look like? Where does that leave health boards if it's not achieved? Projections currently show we might get there at some point, but we're probably not going to get there the next time.

I think the assurance I can give you, having spoken to all of the health boards in preparation for today, is they'll be doing absolutely everything possible, leaving no stone unturned, to meet the targets. The consequences are, ultimately, for patients, that if the targets are not met, people will be on waiting lists longer. Everything that can be done is being done. But there are some longer-term systemic challenges, which were there before COVID, but have been causing more of a challenge since COVID, and have become more evident, particularly around workforce, where there is some accountability for not just the Welsh Government but for the UK Government as well, in that we need to be spending more on training and developing the workforce for the future, to help us deal with these challenges more effectively. But even more importantly than that is the spend and work around prevention, and improving people's well-being. Because if you look at the indicators, Public Health Wales have done some fantastic work—and worrying, actually, the outcome of their work in terms of healthy weights, in terms of healthy living. People are not living as healthily as they could be—all of us, across Wales, could be doing with more access to green spaces. There does need to be that focus on prevention. Otherwise, the numbers of people needing treatment are going to continually increase. It's the health inequality stuff that we've talked about. There's definitely a role for Government to be working more whole-system on some of these things.

Are the targets hampering some of that work?

I don't think they're hampering, but, again, I'd just refer back to my earlier point: in a way, they do impact on the work, but it's—. We've felt for some time, and have put the case, that it's more important to measure the positive outcome, rather than to measure activity, and at the moment it's a measure of activity. They're not islands. If you're on a waiting list for a long time, obviously your well-being is going to be negatively impacted. But we do need to be thinking about what's best for people, rather than how quickly we're doing the treatments.

Just one final question from me, Chair. With regard to the waiting times data that the Welsh Government has been publishing of recent times, do you agree that they should be publishing that data?

I think it's important to definitely publish the data, so that we all as taxpayers and individuals know how things are performing. But read some of the caveats around the data; all too often, we're saying, 'This is happening in England, this bit of the data's better in England'—but the data's often different—'this bit of the data is better in Wales'. The data there is to drive and the intention is to improve performance, obviously, which is a good thing. But I think it's definitely time now to be looking at how we're measuring performance.

Mabon.

Yn sydyn iawn, yn dilyn o gwestiwn Jack—a hwyrach y dylwn i fod wedi gofyn y cwestiwn yma ar y cychwyn—fedrwch chi esbonio i ni—? Mae yna lawer o sôn am dargedau; pwy sy'n gosod y targedau yna? Ydy hi'n broses o co-production, co-design, rhwng y Llywodraeth a'r byrddau iechyd a darparwyr? Faint o ddweud sydd gennych chi yng ngosod y targedau yna? Achos rydych chi wedi sôn eu bod nhw'n heriol, rydych chi'n sôn eu bod nhw'n anodd i'w cyrraedd, ond os y buaswn i'n chi, fuaswn ni ddim yn gosod targedau mor anodd â hynna i'w cyrraedd. Felly, pa mor top-down ydy o, a faint o ddweud sydd gennych chi yn y broses?

I'll come in. The most recent indications from the Minister of where we need to achieve this year are set by Welsh Government, absolutely—it comes from there—but we're involved in conversations with the NHS Wales Executive as part of the performance framework in terms of the challenging specialisms that we've talked about, the progress that we're making, what we are able to do. So, I think there's an understanding of where we are as organisations in setting the targets. So, yes, it's set by Welsh Government, but we do regularly meet with the NHS executive; they have a good, clear understanding of our improvement intentions, how far we can push, where we can achieve. So, I think, in a way, that does inform their thinking. But, again, I come back to that I still maintain that it's really important that those targets are ambitious, because it drives improvement. It's something that we really should be aspiring to as health boards.

Ond ydych chi'n mynd yn rhwystredig bod targedau yn cael eu gosod a bod eich llais chi, hwyrach, ddim yn cael ei glywed mor glir â hynny? Ydych chi'n teimlo y dylai fod mwy o rôl gennych chi fel byrddau iechyd a darparwyr iechyd wrth ddatblygu'r targedau yma?

Not particularly frustrated. I think we have opportunities to discuss that risk-based approach that I mentioned earlier, and we'll continue to do so. We share back with Welsh Government how our focus is about the urgent and emergency patients first and making sure that we get that risk base correct, and that's part of our planning approach. So, not particularly frustrated. I think our voices are being heard. We have to have something to aspire to as health boards in planned care, and I think the targets are going in the right direction, although we need to continue to consider that even though we've talked about the risk of people with greater health need, there's also a risk of those people waiting longer. An orthopaedic patient that waits too long will have worse health outcomes, and their risk increases the longer they wait. So, having waiting time targets that are based on time I think is okay because, actually, we have to consider the risk that comes with those patients as well. I guess it comes back to that earlier point.

Just a brief point on—. I agree with everything that Matt has said, but there is definitely a shared responsibility. It's up to colleagues across the NHS to do everything they possibly can to ensure they're delivering as effectively, as quickly, providing the best care, but there's also an accountability for Government in the resources they're able to provide to the NHS, and also the investment in the future, and a responsibility for ensuring that the best is done outside the NHS on the wider determinants of health across communities. We all know the huge effect that quality of housing has on people's health. Poor-quality housing leads to poor health, leads to people coming into the NHS. There is definitely—. Government are responsible, those delivering services are also responsible; it's definitely a shared accountability.

Yes. Thank you. As Jack pointed out in his questions—he quoted the Minister—there will be no excuses for health boards who miss the recovery targets. I'm hoping there's quite a bit left of the summer yet, but from your perspective as health boards, you start thinking about the winter, and there's not that long before we have to start getting to think about those winter pressures again, and no doubt that's in your thinking now. So, I wonder, with that in mind, how confident you are as health boards that you can maintain or even increase your capacity in terms of reducing the NHS waiting lists in that regard.

I think what's really important to consider with the seasonal variation is that we are bringing forward planning as health boards in terms of what comes in winter, so we are developing our winter plan at the moment; we have been for some time. And that allows us to look at what opportunities we have to make the system as sustainable as possible for emergency care in the winter, and the earlier that we plan on that, the greater opportunity that we have to minimise the impact on our planned care services. I also pointed earlier to the want for us to develop that protected elective surgical zone in such a way that patients could continue to be treated there, and that is not influenced by emergency care. That's something that's being discussed right across Wales in terms of how we do more and more of that.

And then, there's the governance that we've got around making sure we are watching very carefully our projections through to Christmas, through to the end of the financial year, and we, top to bottom in the organisation, shared with Welsh Government, are watching on a weekly basis what we’re doing in terms of how many treatments we’re managing, how quickly we’re getting to meet those targets, and what we need to do in future months. So, I think we have all of those elements in play to give us the best opportunity. Winter is always a challenging time in the NHS. I’ve done 20 of them now in Cardiff and this last one was the most challenging I’ve experienced, certainly. But we need to just continue the good work that we’ve done in terms of learning from winter to prepare for it as best we can.

Thank you for that clear answer. Jack was also asking you in terms of the Minister's 'no excuses'—health boards will have to meet the targets. And I think Jack did ask you about the consequences for health boards of not meeting the targets. He talked about the consequences for patients. Sorry, if you have answered this then please say if I've missed it, but what are the consequences in your minds for health boards if you miss those targets?

I think we need to recognise there's a performance framework in place right across Wales in terms of the individual health boards and where they are, the positions. You'll be aware that different health boards are at a different point in terms of that performance escalation. So, I think that's well rehearsed in terms of how performance is managed. I think it comes back to that our real focus has to be on continuous improvement of the waiting lists. Week on week, month on month, we need to make sure that we're doing better for our patients, and that's the focus that we've got in health boards.

And the way that Welsh Government manage performance, is that fair? Is there any area for improvement or change in that regime?

I think I'd point to some of the work that's been going on over recent months with the NHS executive. So, we have our regular performance meetings, which I go to with the executive, and that’s a helpful conversation going right through the four quadrants of delivery as an organisation—so, not just considering waiting time, but looking very much at the quality of our services and how we’re delivering, as well as workforce, as well as the targets. But what’s been really useful is the developing relationship with the NHS executive, and how we are co-producing plans. So, we are meeting regularly with the NHS executive and looking at where we have challenges, working with them to develop the plans for the future, so that actually the planning is really co-produced. So, pointing to, 'Are the targets co-produced?', I think what’s more important is that the planning is co-produced, and that we’re working closely with the NHS executive and getting their support and leadership in some of those challenging areas. I think that’s becoming more and more successful.

Okay, that's good to hear. And then, in terms of surgical hubs, Welsh health boards are looking to separate the planned and emergency care. Surgical hubs have been rolled out in England—and Scotland, I think—at a much quicker pace. What's your position on why Wales has been so slow in rolling out those surgical hubs?

I think it comes back to some of the challenges that Paul was pointing to previously. We've got to think differently about how we're using our estate, and I think that's where we've got to now. Within Paul's area they're looking at Llantrisant. Do we want to go quicker at developing these things? Absolutely. We have rehearsed that we've got workforce challenges. I think we've got a really good steer now as to how, certainly in Cardiff, we can develop the workforce in theatres, which allows us to move on and really have a look at how we can create those protected zones. We also need to look at how we finalise the reset post COVID. So, we had to move a lot of our services around between hospitals. They didn't all stay where they were traditionally held in hospitals, so there was a lot of movement, and that takes many months to get back to where we want it to be. We've a clear plan to do that, and that allows us to free up some of our own capacity to progress with these things. So, absolutely, we want to go quicker, but I think there's a lot of work in resetting the use of our own capacity.

Yes, and I think, just adding to that, I talked earlier about how difficult it is to compare that sort of data and descriptions. In Wales there's lots of joint activity, but we don't call them hubs. So, I don't think it's really fair to say, 'England have got hubs, they've gone faster.' In the brief conversation Paul and I had earlier, there are multiple examples between Cwm Taf Morgannwg and Cardiff of joint working, which you could describe as a hub by any other name. The cardiac services have been something that have been going on for a considerable period of time, where cardiac surgery and procedures are happening in Morriston, in the Swansea bay health board area, but patients are coming from Cwm Taf Morgannwg into it. So, we are doing those sorts of things, but don't quite describe them in the same way.

I just wanted to come back to a point briefly on shared accountability. One of the biggest challenges in delivering prime care is patient flow. Chair, you spoke briefly about winter, and one of the biggest challenges last year through the winter period was around patient discharge from our hospitals to enable planned care. There are some really good examples. I know that my colleague Paul has been speaking to Sarah Murphy recently in Bridgend, to give some good examples there of how health boards and local authorities are working together to ensure that this works much more effectively than it has in the past. But if there was an area where workforce is a challenge, a great example of a hugely challenging area is the social care workforce. Again, there is a shared responsibility there for local authorities, but also for Welsh Government, in ensuring that people are paid fairly in these roles. There is up to 40 per cent staff turnover in social care, which is hugely difficult. If Paul was here now—. At one point last year, over half of the Princess of Wales Hospital was taken up with patients who should have been discharged, but weren't able to be because of the challenges in social care. So, that's where there is a whole system—local government, Welsh Government, UK Government—responsibility for dealing with some of these things.

Thank you, Darren. Last week, we celebrated the birthday of the NHS, the seventy-fifth birthday, which gives us the opportunity as a committee to put on record our thanks to all those who work in the NHS and the wider healthcare professions, and thank them for all that they do. There was a lot of conversation last week from the Minister. The Minister spoke about the NHS not being able to do all that it does now in the future. What does that mean? What do you understand that to mean in practice for health boards?

We have talked today a lot about the challenges of treating people as quickly and as effectively as possible—people on waiting lists. We need to change. We need to stop people getting on to the waiting lists in the first place. At the moment, we are putting the fires out rather than stopping the fires from being lit. Again, there's that need for a conversation with the public that the NHS isn't sustainable in its current form, financially. The workforce isn't sustainable in its current form. We need to have that conversation and talk about how we are going to do things better in the future: the role of everybody in the public sector, the voluntary sector, the private sector and private individuals in ensuring that people are living as healthily as possible.

People are now living much longer than they did previously, but that ultimately leads to people having more longer term conditions, which again is an issue for the NHS. There are things to celebrate about people living longer, obviously, but challenges in providing care for people as, in Wales in particular, we have got an ageing population. Gareth and I have spoken about tourism in north Wales and the age profile of certain parts of Wales. We are an older population in Wales. For me, it's about getting into prevention, keeping people well, good houses, good jobs, being able to more easily live healthy lives, to stop them from coming into contact with the NHS.

Is there anything that you can add to that, Matthew, in terms of the Minister effectively saying that the NHS is going to have to do less? What does that mean, other than what Darren has outlined?

So, I think that I will probably build on what Darren said, rather than moving away from that. How do we get the population to interact with health in a different way? We have talked about inequity, and we need to recognise our collective responsibility for supporting those patients to understand their own health better. We really need to change that interaction with health, and there's a lot that we can do to do things differently, to do less.

So, I would point to some of the work that's going on in pathway redesign. So, we have done 400-plus pathways for our general practitioners to use, in terms of how people access our services in secondary care. Within that, we are able to provide good information about how patients can access other services. We know now that we have got physiotherapists working in primary care, helping people to approach their own health differently. We are interacting with leisure centres to try and make sure that people can get opportunities to become more well.

So, how do we do less? Well, we do different as well, and I think that what's really important for us to take from here is that we have a different responsibility for how we are going to interact in the future with our patients, so that they understand what their part to play is in their own health interactions.

I am going to push back, Chair, slightly on your suggestion that the NHS is going to do less. I don't think that any of us have said that. I think that it's going to do more, but do things differently and more effectively.

Yes. I may have been misquoting the Minister, but I thought that that's what the Minister said.

The Minister might have said that, but I don't think that any of my colleagues would have.

No. No problem. I may not have got the Minister right, actually, as well. Perhaps I got that wrong. Thank you. My very last question is: is it clear, are health boards clear, what the Welsh Government's expectations are of them?

I think so. I reflect often with colleagues in England that health board chairs and chief execs have much more interaction directly with the Minister than they would ever dream of, want or desire in England. The Minister does set clear expectations, and I can assure everyone that health boards, trusts and other NHS organisations across Wales do everything that they can to meet them, and also to feed back on whether they're realistic or not.

In short, yes, we are clear. What I know is that the conversations on planned care, for example, the conversations that the Minister is having with our chair, are the same as Nick Wood is having with us as an organisation, and we're all reporting the same data to our progress as an organisation. So, we're absolutely clear in terms of what we need to achieve, and I think that that's right the way through, from Government to the NHS exec, to the executives and then to the teams that work in the NHS.

Okay. Thank you, both. I appreciate your time this morning. We will send you a record of the proceedings so that you can check over that for your own accuracy. Anything that you want to add, then please do let us know. Because I'd imagine that one of the outcomes that we decide as a committee may be that we take up some issues with the Minister. So, if you have any other thoughts following this session, then by all means let us know. Thank you. Diolch yn fawr iawn.