Health and Social Care Committee

Croeso, bawb. Welcome back to the Health and Social Care Committee. I move to item 3. Item 3 is in regard to any substitutions and apologies this morning, or declarations of interest. We have apologies this morning from Joyce Watson, and if there are any declarations of interest, please say now. No.

In that case, I move to item 4. Item 4 is our session this morning in regard to follow-up with Betsi Cadwaladr University Health Board in terms of having an update in terms of the special measures intervention and any progress made. I'd like to welcome our two witnesses this morning, and perhaps ask them to introduce themselves for the public record. Dyfed.

Good morning. Dyfed Edwards. Interim chair of Betsi Cadwaladr University Health Board.

Good morning. I'm Carol Shillabeer.

I'm Carol Shillabeer and I'm the chief executive of Betsi Cadwaladr University Health Board. Thank you.

Thank you both for being with us today. Carol Shillabeer, if I could ask you the first question. Have you got the most difficult job in Wales?

Well, I think every public sector job is a really difficult one, but I'm delighted to be staying with Betsi Cadwaladr. There is lots of opportunity, and I hope that during our evidence session today we'll be able to share both the challenges but also the opportunities that lie ahead.

Yes, thank you, Carol. And, Dyfed, perhaps, or both of you, really, can you just give us a brief update of where we are in terms of the special measures intervention from your perspective?

Do you want to start, Carol?

Either of you.

Yes, if I make a start. Just to say that in terms of special measures, Members will recall that the Minister escalated the organisation at the end of February of this year. Three phases were described by the Welsh Government in terms of the expectation. The first nine months of that relate to stabilisation, so we're currently in the stabilisation phase. When I joined the organisation in early May, we drew together a special measures response plan, and stabilisation in three 90-day cycles. At the moment, we're just about to get to the end of cycle 2, at the end of November. We will be starting cycle 3 on 1 December. The board, next week, will receive the end of cycle 2 report and will approve the cycle 3 actions. We are then looking, from the beginning of the new financial year, so in April, to be moving into standardisation phase. This will be quite an important step, in terms of combining what has been the special measures work with our broader work, so our three-year plan, which Members will probably be familiar with—it's a requirement in the NHS.

The key thing that I want to say, really, is, clearly, the organisation has been in and out of special measures for a decade or so. And it's going to be really important that we make long-lasting, sustainable change. This change has got to be not just one that delivers an improvement that is sufficient to get out of special measures—that's not our first and foremost priority. This is about building an organisation that can be effective into the longer term.

And then the final thing just to say is that improvement isn't always in a straight line. There are days and weeks where we take one step forward, two steps back. But I think we are starting to see a stabilisation in the organisation, but I wouldn't want anyone to get too carried away that that means that things are going to change right away across the board very, very quickly. So, there is a lot to do and it's long term. But I think we've made the right start.

If I can just pause on the—. You've explained the cycles. So, there's the third cycle that's coming up, so if we pause on that for a moment, because I know another Member wants to ask a question on that going forward. But in terms of the first two 90-day cycles—so the second coming to a conclusion soon—were there any goals that were not being achieved in that period? And also if you could just talk to the main points and the main challenges in those first two cycles as well.

Yes, so a couple of things. I think, overall, progress has been good. There are some areas that we haven't been able to progress as quickly, so will roll into cycle 3, and we'll be very clear about where they are. Cycle 1 was a lot about gaining more insight, lots of reviews. So, in the submission that we gave to the committee, you'll see a whole table of all of the reviews that there were. A couple of those have yet to fully land with us. So, we haven't had the planning review, and some work on quality. But during cycle 2, we've had all of those reviews. We—

Sorry, what were the areas that weren't achieved, then, that were going to move to cycle 3? What were they?

So, we haven't, as yet, had the outcome of the mental health reviews—the review of reviews. That is near completion. We haven't yet had the planning review through. It is drafted, it is with Government, about to be issued to us. And our clinical governance systems review is a bit delayed, and the NHS executive is going to work with us on that.

So, they were supposed to be delivered by the end of cycle 2, but they're going to move into cycle 3. Is that right?

Yes. We'd anticipated that we would have received them, largely, in cycle 2. What's really important to say, though, is whilst all of these insights—. They've been very, very helpful, by the way; this was part of the intervention support. That's not to say we're not doing work on improving quality and improving planning. So, for example, in the planning, as a board, back in September, we have developed and approved an integrated planning framework, so we got on with those things. But if you were to look at the letter of our action plan, and our dates, you will see that some have not been fully completed. It was ambitious as well. I talk about the 90-day cycles. We put those in to drive a rapid change, and so they were ambitious, so I wasn't—

Were they too ambitious?

No, I don't think so. I think they were there to really push the commitment and really front-end quite a lot of immediate work. So, on the whole, important progress made, but a lot of this has been about measuring where we are, the insights, the discovery. We're now into the design of the new ways of working, and then we'll be into implementing those.

Okay. Gareth, you wanted to come in on this.

Thank you, Chair. I just wanted to dig in a little bit more about the cycles, and whether there's a reflection process based on the things that you've analysed during that cycle period. Is there a chance to go back, if things have maybe slipped through the net, in order to back feed some of those issues that may have come across during those cycles? Because, if you put a stop gap right at the end of that cycle, then you may be allowing a lot of things to slip through the net in that case. So, is there a review period to go back and look at some of those things again?

Yes, and we're literally just doing that now. So, there are a couple of things on that. So, as we came towards the end of cycle 1, the independent advisors, the intervention support, Government officials, and ourselves as a board all met to do that reflection, 'Where are we now at the end of cycle 1?' Cycle 2, we've been doing some reflection, and independent advisors' reflections are coming in through their reports. And then as we move through to cycle 3, particularly because we've got an eye on planning for next year, it will be, 'What did we say we would do in cycle 1? What happened? What happened in cycle 2?' Because these are themes that are carrying through. So, if it's culture, leadership and engagement, for example, these are things that are following through, so that we make sure—. And this is where the board and the independent members of the board in particular have come in. They wanted to see the thread and the evidence of impact, not just that we've done a review or we've held a meeting.

How deeply are those felt then throughout the organisation? Are those cycles felt by—? I don't want to stereotype, obviously. Is that from your cleaners and your porters right up to the executive team, so everybody in that organisation is aware of the cycle process and how they can feed into that process and how they can, individually as well, make sure that improvements are being made across the spectrum going into the future?

Can I just bring Mabon in as well at this point, and then I'll come to you, Dyfed, as well, to sum up both questions? Mabon.

I'll come in after the response. Thanks, Chair.

Okay, no problem at all. Dyfed, did you want to come in as well on the back of Gareth's question?

Gareth sort of prompted me just to say—. I'm tempted to say it's a process not an event, the whole special measures, where we've got to take the learning and align it with other work that we're doing and embed it, and that people get a sense of improvement across the organisation, as you say, in all areas, and people get a sense of what the ambition is. People understand what we're trying to achieve.

I think that does vary across different areas in the health board. It's quite interesting, as I go around and make visits and chat to people, many of them, on the ward floor, say, 'I'm just getting on with my job, actually. I'm doing it to the best of my ability.' What they look for is support, that we can get the right conditions for them to achieve what they want to achieve as members of staff. So, in that sense, that level of special measures is happening and people are getting on with their work at ward level, I think. But we are trying to ensure that people get a sense of, 'We're going in a new direction and we are seeking that improvement.'

Thank you, Gareth and Dyfed. Mabon.

Thank you. If I can just go back one step and build on the opening question that the Chair asked. Thank you very much to you both for coming in this morning. Just briefly, but very honestly, please, you've both come into this body from an external position, although you were aware of the history, could you just tell us, briefly, what your first impressions were of what was going on in Betsi Cadwaladr? What did you see, really, in terms of the problems, and what really struck you as the challenges in the first instance when you started out?

If I could start, because I think I arrived first on day one. Of course, I was aware of the history of the health board as a user of the services provided, I have family working in the service, and I'd been following the trials and tribulations of the health board over the years, of course. It was a mix of experiences, I would say. Possibly, it was an organisation seeking direction more than anything, with people who were looking for a change of culture, people who yearned to be appreciated, and people who yearned to see a culture of kindness and support.

I think that every organisation that aims at improvement will note that the culture is the main factor that has an impact across the board, wherever you are within that organisation, and I don't think this health board is any different in that regard. What's true to say about the health board, it's worth bearing in mind, is that you can multiply it by 10—one, because of its size, and two, because of its history—so, any issue is likely to be amplified and, in that regard, will take longer to tackle perhaps. But those, generally, were the impressions that I had in joining the health board at the early stage.

Thank you, Dyfed. It's probably a good time now to move on to the next cycle. So, I know that Sarah Murphy has got questions on that. Sarah Murphy.

Thank you very much. Thank you both for being here this morning. A lot of my questions, I think, have already been touched on, so I think I'll just move on, really, and just ask—because it is about plans going forward, which, of course, you've talked a lot about already—but I wanted to ask this specifically: how do you think financial challenges being faced by health boards in Wales will affect progress in making the improvements that you've set out?

Thanks very much for the question. If there weren't enough challenges already, adding in a really quite acute financial challenge has increased the significance of the changes that we will need to make. I've been really clear that we've got a lot of money. As a health board, the largest health board in Wales, we are spending currently just over £2 billion, which is a huge amount of public resource. How we spend that is going to be really, really important. The sense of being able to redirect and redesign our approaches to our investment is really important. It felt to me, just touching a little bit on the previous question, that new developments were requiring new money, rather than us thinking about how we can be flexible with the money that we've got.

That said, there are real, acute financial problems—in-year financial problems—that we are having to tackle, and that means that we've got to balance off the quality, our duty around planning for the longer term, our duty around financial break-even. We know that the rest of the public sector are really challenged as well, so the NHS has to take its responsibility seriously.

The one thing that I would say going forward is it's often when we're really challenged that we can be most creative about services and solutions. So, we've got to use this as something that is going to drive us to do things differently and better, rather than feeling completely constrained by it. But it's going to take a cultural shift as well as some of those other systems and processes.

Can I just come in on that as well quickly? That is, the need for all of us in the public sector and other sectors to build this financial discipline, which sometimes doesn't come easy because of demand on services, but it does, I think, force us now to think anew on our approach to finance. I often say that finance isn't about money, it's about performance. So, in a way, we're taking a look at performance and what we're achieving, and how do we then fit the finances to support that.

It may be of interest to you to know that there are some areas where we have had immediate improvement, for instance the use of agency staff, the use of interim staff. Those areas, we've seen quite clearly, there was an opportunity for us to depend less on agency and interims. We've done that; that's been a financial saving. It's also something the staff have welcomed and that staff were looking for at the same time. So, I think that's an example of getting a positive out of difficult circumstances, and the finance is driving us into areas that previously, perhaps, the board were reluctant to go into.

Thank you.

Very helpful. Thank you very much. That brings me on quite nicely, then, to my next question. Independent reviews in areas such as patient safety, the use and recruitment of interim staff, and contract procurement management have been undertaken. What are the expected outcomes of these reviews and what do you see as being your next steps, following them?

Shall I take that? Thanks very much for the question. So, there have been a number of reviews already completed, some are still to be finalised, as I explained. And I think, when we line up all of the reviews, they're giving us some really strong themes—probably not that surprising. So, a couple of the themes are about our use of data, intelligence and insight. So, do we know our services well enough, do we know what people think of them and our outcomes? Are we data driven?

Culture we've touched on. Culture is a big area for us to address, work on, together with people across the organisation. Some of the ways in which we've engaged patients, carers and communities. I think when an organisation is under the cosh, it's so easy to step back and not engage in those conversations, but we've got to be out there and be hearing the good, the bad and the ugly, all of those things that are sometimes very difficult to hear.

How we run the organisation, so the operating model, was a theme as well. We've got quite a bit of work to do to become a more effective organisation in our day-to-day running. And then, it's our planning ahead. We've talked about that we can't keep living the same year; we've got to lift our heads and try to plan—. We've got a duty to plan ahead, of course, but we've got to lift our heads and plan for the future.

So, they are the themes that are coming through. Some of our work is not just about, 'What did recommendation 2 say on page 44'? It's about addressing those core themes in the organisation.

That's very helpful. Thank you very much, and thank you, Chair.

Mabon, you wanted to come in on this.

Yes, very briefly. You mentioned there about reducing the number of agency staff, which is a very good thing. But is that true about locum doctors also, who are employed by surgeries that are managed? Because it seems to me that there might be a problem there specifically. And, following on from that, one complaint that we hear from the primary sector is that it's easy for people in the health board and people in the health sector to focus on hospitals and think that's where the problem is, that's where we need to put the money and change the culture, but, really, you need far more investment and possibly care in that primary care sector, in terms of GPs and the community. So, how do you divide those elements? What emphasis do you put on one at the expense of the other?

Carol can come in in just a moment, particularly on the issue of GPs, but what you referred to, Mabon, in terms of the primary sector, I agree with you 100 per cent. And I've described the health pyramid as being upturned; it needs to be turned on its head in reality. Most people, indeed, 90 per cent of people, access health services through primary care, but the emphasis in terms of resource and energy is focused on our major hospitals.

Now, the Government and the Minister are eager for us to diversify and turn to the primary sector and, indeed, the community sector too, so that we can create a healthier Wales, and that is the aim. Now, we can't do that overnight. As we speak, we have people waiting for treatment in hospitals, and people waiting very long periods. We must ensure that they are treated, of course. But we do have to shift the emphasis to enabling people to have a better connection with their health service, through those services that are local to them and in their communities, and they need to be confident that they can access those services. But also that they receive advice on their personal health journey, what I describe as a health journey, whereby we have a tendency to contact the health service when something major goes wrong, but we need to have better links to ensure that we can live healthier lives and that we can take care of some of our own health also, and accept that responsibility. I'll ask Carol to say a few words on the issue of locums and GPs.

Thanks very much. Diolch, Dyfed. So, I think that's absolutely right. I think it's fair to say that, across north Wales, there are particular pockets where recruitment is more challenging. We have got the development of the primary care academy and the intention around all of those portfolio roles. So, what I mean by that is where people want to do research, or want to do teaching, or want to do some work in a hospital. So, for example, in Ysbyty Glan Clwyd, we've got GPs doing particularly more hours at the front door of the hospital over this coming winter. So, that provides an interest for people, but we do need to have the sufficient core element of GPs, particularly, I think you were referring to. So, there is still quite a lot of work for us to do: what are, not just the financial incentives—and sometimes we can utilise some of those—but what's the package and what's the offer of working in north Wales?

There are a range of roles, of course, in primary care now. If we spin back 20 years, it would have largely been that you go and see your doctor; now you're seeing your physiotherapist, in some areas, you're seeing a social worker, which is fantastic, a mental health worker, a pharmacist, et cetera. So, that diversification is important. But what we do find is that that works well when you've got the sufficient number of GPs. We've got a number of managed practices, quite a large number, in north Wales, and we've been having some discussions about, well, how do we utilise the fact that they're managed practices, so to speak, so they're directly run by the health board, to develop further these different opportunities and these different roles. They're often managed practices because they've not been able to be sustained, so they're particularly vulnerable. It is absolutely key, and I think the conversation has got to look at the whole system and not just the secondary care system.

Thank you, Carol. Gareth Davies.

Thank you, Chair. I just want to dig in a little bit more into special measures and what it means. What does it mean? We talk a lot about special measures, publicly and in the press, and however that's portrayed, amongst politicians ourselves, and in the media, and the public view. But what would you say, what would be a statement from yourselves that could encompass special measures definitively in one remark, if you like?

Shall I just say something quickly, and then Carol will be able to say, I'm sure? I think I've taken it as a special focus for a period in time. So, it means that, from the Government perspective, we've got a specific programme, and we need to meet the needs of what's set out in that programme. But I'm always someone who likes to take an opportunity, and I think it is an opportunity for us to help almost reset the health board—not just refresh but reset. It's almost like creating a new health board. And in that sense, it's a great opportunity—a huge challenge, but it's an opportunity to say, 'This is what we want to achieve, this is what we want the health board to deliver for the people of the communities of our region.' So, it has got that feel to it.

And I think the balance we have to strike is being able to indicate to Government, yes, we've done this, we've done that and so on, in these various phases, but ensuring that there is continual improvement. I think that's the word. Carol probably picked up on that quite early when we met—it's improvement we're after, it's progress, and it's sustainable. So, I think it's that special focus, which is great. The challenge to us as a board is, grab hold of it, but make sure we use it to its best potential, and put it in the right context. So, it's that context of, yes, we're creating something much greater, over a longer period. This is probably a five to 10-year task, isn't it? It's not going to—

What, being in special measures?

Well, if it means being in special measures for five to 10 years, actually, I don't have a problem with that. If it means the Government are going to give us that focus, that's fine. I think that probably wouldn't be a healthy sign, but it's not an aim for us as a board to say, 'Right, on 17 March at 2 o'clock 2000-and-whatever we're going to get out of special measures.' That's not a consideration.

What are the measuring points, then, to coming out of special measures? Obviously, it's in a period of reform—you've identified that—but where's the end game? Where does that come to the point, and what's the qualifying criteria to say, 'Hey, look, we've achieved our goals, let's come out of special measures,' but doing it in a way that's safe, in a way that can be projected in a positive way to say, 'Look, this is where we've come from from the doldrums and this is where we are now'? What qualifies that school of thought, then?

And that's the sort of conversation we've had very, very recently with Government colleagues. Carol can expand on it, I'm sure.

Yes, and I just want to stress that the primary objective is not, 'We're going to get out of special measures.' The primary objective is we're going to build an organisation that's effective, we're going to be an organisation that's got a—

But can you do that with the existing structures in place, because, obviously, on the face of things, it's still Betsi Cadwaladr University Health Board, it's still under special measures from the Welsh Government. Is that achievable within the current structures to achieve a new system and a new health board within the existing parameters that you're obviously faced with?

And when you say about structures, do you mean configuration of the health board or the internal structures?

Yes, the internal structures, the naming of it, all the public connotations that have happened over many years. Is that achievable in its current context?

So, I think there's a macro and a bit of a micro on this for me. I see no real evidence that would lead me to believe that a reconfiguration of the health board in north Wales is essential, is required. It's a big health board, absolutely. The geography is huge, but we've been talking about what are the benefits and the advantages of being such a big health board, and really looking to draw those together. We have got fantastic expertise in the organisation; we're just not bringing it through and organising ourselves sufficiently well to capitalise on that.

In terms of internal structures, I think there will need to be some changes in the way in which we work, the way in which we operate. If I just take today, we've got a great announcement about the development in Llandudno General Hospital about the orthopaedic hub, and we're very grateful to them for the support. But that's come about because we've got our clinicians from the west, the centre and the east all working together, and I think that's the real benefit. So, when we think about things having to change in terms of structures, I'd like to see a lot more of that collaborative working across.

We'll need to work with other organisations as well. I was talking just yesterday with a colleague in the Clatterbridge Cancer Centre, for example. So, we'll need to take that broader perspective and not always be quite so inward looking.

Just on that point, something I've wanted to ask as well was in terms of communications because, obviously, the board is subject to things like press releases and things that come out to the public like the Healthcare Inspectorate Wales reports, things that we've seen into like vascular services and things like that. How robust is the board and the communications team to some negative stories that might challenge the public perception that it's just another story, it's just another negative press release, to identify that and the honesty and looking at that to say, 'We may have made a mistake or done wrong in that case', but on the other hand, turn that into something positive and say, 'In the long term, we are doing everything you're talking about today'? How does that permeate into the public view to make the health board look better in the public eye, noting all those problems that are going on and it's not just another nail in the coffin in the public view?

I'll just say a couple of things. I think Mabon asked the question earlier about what was it like when we first came. It felt as though the overall communication was very responsive to the latest difficult story, and there will be more, we know that, as we come through. So, I want to be very open about that. But we’re starting to change the way in which we work to be more about engagement, more about speaking, listening with communities. We were in a community meeting earlier this week. So, the health board is reaching out and is being much more open. That’s where we start to then build a different perspective about the health board, which may feel to many people as being very distant. I think we have got more work to do on sharing those good stories. We have got some fantastic research taking place in north Wales. So, that’s our challenge—to make sure people can see the good as well as the things that are very difficult. So, you talked about vascular, for example—we met with families relatively recently, and heard their experiences, and we’re hearing about the changes that have been put in place and the reviews are saying, ‘It is better, but there's more work to do.’ I think we’ve got to try and demonstrate much more that, where things go wrong, we learn and we make changes, and people can then feel and experience those changes. So, still quite a lot to do. We’re, again, only in stabilisation—

And just as a final question, if I may: obviously I've seen the change in direction since you took over as interim and now as permanent chief executive, and since you've come in as well, Dyfed, but where do you think that previous chief execs and chairs may have failed, and what are you doing differently to what was being done before? And I'm not trying to put you down a rabbit hole of personal things here, but just on a professional level, what is so different now to what wasn't the case between 2009 and 2023?

That's a very good question, and it’s a question quite a few people have asked, and I compare it with: why was Warren Gatland quite successful and Wayne Pivac wasn't with the Welsh rugby team? And I think all I can say is I’ve certainly taken the view when coming into the health board from a background of being in a local authority, for example, to put the health board in a place where we are open. So, we’re not trying to say, ‘Up with the drawbridge’, and we’re trying to hide everything—we’re going to do the opposite.

So, everything that we do as our business we try to do as much in the public domain as possible. You may note that one of the great things in board meetings is the chair's actions, where they’re reported to the board. There have been no chair’s actions since I have been in the chair of the health board, because everything has happened in public. That doesn’t mean to say there won’t be in the future, but that’s just an indication of trying to ensure that things are happening in the public domain, and, actually, turning to the public and saying, ‘You know, you’re not a nuisance—you’re actually a help. You are a resource.’ So, every patient experience should help us improve.

I’ve got an ambition, and I’m going to do it as part of my new year’s resolution, that a board meeting will receive patient experience and all the themes that we can capture—for instance, from correspondence we get from yourselves and others, from patient experience, from Audit Wales, from Healthcare Inspectorate Wales. We will put all that in the public domain and we will say, ‘Okay, this is what we’re learning from this. This is how we’re going to improve.’ So, that shift in emphasis is something I think we’re trying to do. What others have done in the past, well, I don’t know. But I’m hoping that is going to put us into a better place to go on that continual improvement journey.

Have you any points, Carol? It's obviously a big job.

Well, it is hard. I haven't picked over who did what, when. What I found is that people want to feel as though they belong to an organisation that is positive and moving forward. So, that's the approach that I've brought. We will have difficulties, we will have to make difficult decisions, but how we work, not just what we do, but how we do it, is going to be really important.

I think we've both tried to be visible. You know, there are challenges in a very busy in-tray as well as trying to get out, but making sure that we're visible people, that they feel they know us, they can approach us, and the same for our senior leaders and all leaders in the organisation—. So this is a relational job. This is about people and we've got to connect better to people.

In terms of doing things differently, because, obviously, you know, being a former employee of Betsi Cadwaladr, I think I worked under three or four chief executives in that time and I remember previous chief executive officers doing weekly newsletters to staff and being approachable and going around different hospitals, different wards, different departments, et cetera, but it ultimately ended in the same scenario of their time coming to an end and another CEO going about the job. So, in terms of how you see that role going forward, how do you think that can be done more effectively and in a way that permeates throughout the whole organisation across all of the north Wales region, so that everybody can feel that we're on a journey here from where we were and where we're trying to go now? So, how do you encompass that and get everybody on board to, you know—?

Two brief points on that. One is culture, leadership and engagement. So, at the board in September we approved the strategic intent around the work on culture, leadership and engagement. Everyone has to feel involved, that they've got a stake in their workplace. The other element for me is about standards, and we talk about standards a lot. So, there is something about supporting and nurturing and leading the organisation, and there’s something about being clear about the standards that we will strive to meet. And ‘the standard you walk past is the standard you accept’ is often used. So, we're going to be focusing relentlessly on the standards, whether that's the standards of governance and how we run the organisation, whether that's the standards of care, the standards of interaction with patients and communities—and that's why standardisation is the second part of special measures. So, there is a very clear edge and a clear expectation.

How do you do that? How do you do that? How do you, directly, as yourself as the CEO, go about achieving that? Obviously, it's great, the ambition's great, but how do you develop that cutting edge to do something differently that others may have not been successful at doing?

This feels like one of my interview questions, I must admit. [Laughter.] So, we've got to build a really strong leadership team and a strong board and we are on the way to that. There's more to do, a lot more to do, but we're on the way to that. Because, with the best will in the world, we are two people in amongst 19,000 staff. So, we have to do that through others, being very clear—there are things like performance frameworks, accountabilities, all of those things that we will put in place; that's what standards mean—being very clear about roles, expectations, performance. And, on the whole, people respond really well to that, the guide rails that say, 'This is what we need you to do', 'This is how we need you to behave', the culture, the engagement and the leadership, and you can actually go a very long way on those things. So, we have some tools in our toolkit.

And it's ultimately those that use the service that will be best placed to judge progress.

I want to just—. If any other Members have got questions on the special measures process, then please indicate. But I just want to dive into that a bit more, because some would say, 'Well, the special measures process didn't work last time.' So, I'm asking the question more broadly than just Betsi, actually. But is a special measures process—is it right? Why didn't it work last time?

Can I just make a general point and that's maybe on Government intervention? Many of us have had experience where Government have intervened. In local authority days, you know, you had social services or education with, quite often, Government seeing a need to intervene and put in a special team and so on. So, the danger for any Government, if I can say so, is that, when there's a problem, you throw everything at it. I think the challenge is to make it structured in a way that you can take it and embed it—that's the challenge—so then, when the support moves away, there is something left. That's the test, I think.

I don't think that's easy, because, clearly, Government are under pressure to make sure things improve in the short term, but, for us, particularly with the history of the health board, we know for sure that we've got to do something in a way that will ensure we progress. So, I think that's the general point—getting that balance right—and I think you've got to test that pretty early on.

You've made the points around the special measures process being there to be supportive and to offer that support et cetera, but I suppose I'm asking you, Carol, from your professional perspective, if you were the health Minister, what would you change about the special measures process? [Laughter.]

I've got one job; I don't need any more jobs.

What advice would you give to the Minister?

What would I change? Well, you know, it has been very interesting, because I went from an organisation that was in routine monitoring for a very long time, straight into special measures. So, the things that I was looking for from the process are clarity of expectation—'Where do you expect us to get to and by when?' So, I like clarity. The ability to shape and influence—

Have you had that, by the way?

Yes, I think pretty much so. The question earlier from another Member around, 'What will it take to get out of it?'—there is still some work going on, because we're in stabilisation, to be really clear about how do people measure Betsi Cadwaladr against every other health board, for example, so that you're not using different measures. In fairness, the Minister herself made that comment in one of our last meetings, about being very clear about that, so there's no ambiguity about, 'Well, actually, Betsi Cadwaladr has met that standard; so, therefore, that is fine', you know.

From your perspective, though, have you had—? This is going off on a tangent a bit, but have you had full clarity from the Minister and Welsh Government officials about what's expected of you?

Yes, we've got clarity about what's expected of us and we've got clarity around what we expect of ourselves as well, because the key thing for me, and it's really important, because I think, in the early days, people were, perhaps, in the media, saying, 'The Welsh Government is running the health board'—. The Welsh Government isn't running the health board; we're running the health board. So, I do see special measures as a partnership between the health board and the Government. So, they will do certain things that help us, but we've got to get on and do these things ourselves.

But, back to my question, I suppose: what would you, if anything, change about the special measures process, from your professional perspective?

Well, I've been in it for six months so far. I think the sense of being clear about the need to ensure that this is about long term, and not just about short term. Now, there are some real challenges in that, and both of those have got to be content bedfellows. What I really mean is that there's a lot of focus on making changes quickly, and I agree with that—we've got a lot of patients waiting a long time for their operations—but making sure that we're also focusing sufficiently on building for the long term. Now, I think that is coming through, but, in fairness, this organisation was not stable when we stepped in, so we are in that short-term stabilisation at the moment. I want the discussion to be focusing on the longer term, long-lasting change, as well as the short term.

Am I drawing out of that that one area of change for the special measures process is that it should be more focused on the long term than it is now, and it is too focused on the short term?

I think, Chair, it's probably more about pace and timing on that. It has been focused on stabilising the organisation, and what I'm saying—. I'm not saying it's about change; I'm saying that I hope and anticipate that we'll get a balance between the short term and building for the longer term.

But does the special measures process that's in place now—is that the right process? Is that fit for purpose?

I think it's been a very reasonable process. We've had a lot of support. We've had regular discussions and meetings. I've been able to raise issues with the director general at any time, so not just in these set pieces.

But all that was in place last time the board was in special measures and it didn't seem to be—it wasn't successful. So, that's why I'm trying to grapple—. It's not that I'm trying to catch anyone out, I'm genuinely looking at if there's a better way for the special measures process. What needs to be done differently? Dyfed, I think you wanted to come in.

Yes. I think one thing, on reflection, is to put all this work into a wider context, maybe a more long-term context. So, special measures could be seen as a phase, and then, working with Government, the health board could put a trajectory that goes beyond special measures, so you see the direction more long term. The matter of clarity—I think that's important—where you say what it is, but you also say what it isn't, because I think the perception of the public and, indeed, politicians and even some members of staff is, 'Oh, special measures means this.' Well, it doesn't. So, equally saying what it isn't about as well as saying what it is about. So, maybe that long-term framework, building something like that, and special measures as part of it, I think that would be a good thing to do.

I'll just bring Mabon in. Mabon.

Yes, thank you. This is a very interesting discussion. You've both mentioned one consistent theme—or two perhaps—which is the long term, how much time this is going to take, but, more than that, the culture and need to change the culture; that's something you've mentioned several times. But, thinking of the nature of special measures, and what's happened in Betsi Cadwaladr over the last few years, we've seen a huge churn in senior staff. We're perhaps on the tenth chief executive in 10 years. Finance officers and principal officers have come and gone. People have been appointed on short-term contracts. How is it possible to change that culture if we have that churn in senior staff? How can we set a culture for the long term? And, at the same time, how can you give us assurance that you're an organisation that learns lessons and that you've learnt from the past, so that we can move forward for the future, bearing in mind that churn in senior staff?

If I could start in responding to that, Mabon, if I may. And, yes, it is interesting in terms of staff turnover. If I could refer to the opposite issue, I was in Ysbyty Glan Clwyd last Friday thanking a member of staff who had served for over 50 years with the health board, which was quite astonishing. Staff, if I can use the term 'front-line staff', tend to be staff who are with us in the long term. Staff in other parts of the organisation have come and gone, and, if I may say, I think there has been a pattern of recruitment where people have been working remotely, often working from a very long distance away at times, and in temporary roles, and we have changed that. We have said that we do need to have people who are visible within the health board, and people who commit in the long term, so that we can build that team. So, generating that stability, as you've outlined, is crucial. It's impossible to change culture without that stability. My hope is that that signal of appointing a permanent chief executive now is something where everyone can see that the health board is serious about creating stability, and there will be similar appointments made, where we will carry out a review and decide which posts will be permanent—some of those senior roles. So, we do have to have that foundation if we are to change the culture. I agree 100 per cent.

Thank you. If I may come back on that, Chair, and I appreciate that answer, Dyfed. In the same way, can you confirm whether you've appointed each one of the independent members to the board? Because you haven't had them all appointed so far. You certainly haven't had a deputy chair. How has that affected your work as chair during the past few months? Has it been difficult for you? Has it been difficult to push the agenda forward without that whole team behind you? And what's the timetable for getting an established board in place?

To return to day one, I was appointed, or rather I was put in place, as chair, along with three other independent members for a period of time, and those were direct appointments by the Minister, of course. Then, gradually, the Government and ourselves have recruited more independent members. I'm pleased to say that the Minister recently announced two additional appointments as independent members and has confirmed Gareth Williams as vice-chair. The Government will also be recruiting further members over the winter months, with a view to confirming from March onwards, I hope. So we're not too far away, now, from being a full complement, if you like, and we are in a much better position than we were six months ago. It's true to say that we've operated without a vice-chair for nearly nine months, I believe.

Have there been any difficulties in recruiting?

None from the recent round. Indeed, I think we have been the most successful health board in Wales in terms of being able to recruit independent members. I think the panel that met to appoint the vice-chair and the two independent members recently would say that we've produced quite a lengthy shortlist on both occasions, and we could've appointed far more than were appointed, actually. So, I think we've done quite well and people can, hopefully, see the opportunity that, when joining a board, they can make a contribution to creating that success.

And what about the executive posts as well, then, in terms of what posts remain to be filled?

Carol, do you want to give detail on that? We've got the chief executive post filled now, so—

Yes, I noted that.

Which is quite an important marker when you're thinking about applying for a job; you want to know who you're going to work with. So, that was a very important step. We've got a number of posts that are currently covered by interim appointments, so we will be now progressing through—. We had a review of the executive portfolio, so I've got to consider that a little bit more in terms of what should the shape of the executive team look like, and then we'll be progressing with director appointments, where we're able to. We've already gone out for a director of corporate governance, given that the way in which we manage the organisation is really key. We will be advertising for a director of workforce and organisational development—that's a vacant post at the moment. And then we'll be progressing through other vacant posts. So, I'm anticipating that, over the coming few months, those steps will be taken. I'm really keen to get a full team in place.

When would you envisage that full team being in place in terms of permanent positions?

The vast majority of those I would like to have in for the end of the financial year, early into the new financial year. It does take quite a while, the appointments process.

Do you envisage any problems in terms of recruiting to those posts?

I'm hoping it's the same experience that Dyfed has had with independent members that I have, and that's that people see the opportunity to be part of building something important. It's important work, and there's lots of potential, and I hope that that will appeal to people—

I'm asking the question in the context of getting the right people in post, I suppose, because that's, obviously, quite key to this—

It's always good to have a number of people to choose from.

And that's been the experience of the recent past, where we've recruited to some key roles—that there has been keen interest, and we've been able to appoint really excellent people.

Before I come on to Jack for the next set of questions—just a quick answer on this—in terms of the special measures process, has there been, in your view, sufficient oversight, direction and support from the Welsh Government and the Welsh Government's intervention support team?

From my perspective, we've had really good support, and they've been keen to be constructive, I think, in the way they've managed that relationship with us. It's not easy, to be fair, where Welsh Government are holding us to account, but also know that they've got to be part of nurturing a new health board, going forward. So, getting that balance is not always easy, but I think we welcome the support and the relationships we have. Our approach as chair and chief executive has always been that we see any support as a resource, so we've got very open and positive relationships with Government, HIW, Audit Wales. We can see the positive they can bring in helping us create the health board we're trying to create.

The Welsh Government's got those two roles, as you say, so it's bringing that oversight, that support and that direction, but then, they've also got to bring challenge. So, are they bringing appropriate challenge?

I can tell you from the monthly meetings I have with the Minister that, yes, there is enough challenge, definitely. I think the Minister knows exactly what she's looking for and has a real focus, and rightly so. There's certainly enough challenge, yes.

Is that right, Carol, from your perspective?

Yes. There are two things that I would say. It is helpful for me that I've worked in Wales for some time, so I know how to navigate, and I know many of the people. Particularly, when you're looking for a bit of support, a bit of advice, some thinking, I generally know where to go. People are very willing to support, the Welsh Government officials, so that's really good.

In terms of challenge, absolutely, there's a lot of challenge on detailed operational delivery, and rightly so. There's a lot of challenge on financial governance and financial performance, rightly so. And, increasingly, I think, there's that nurturing support coming through on building an effective organisation, so it's not just about the numbers, it's about what's the context in which we're operating. So, I speak as I find, and I have found those relationships to be appropriate—

Is there any challenge that you were expecting that you haven't received from the Welsh Government? Have the Welsh Government challenged you in all the areas that you would expect to be challenged in?

Yes, I think so. While we're laying the foundations for a stronger organisation, I think there's an understanding that the organisation was not particularly stable as we came in. Those expectations will, understandably, increase, and therefore the challenge may well increase—

And have you been set any expectations that you think are unreasonable or an inappropriate challenge from the Government, in your view?

There's often a dialogue, I would say, Chair, around this. If I just take a specialty that's on my mind, there are some real workforce challenges in that specialty, and we can will the numbers of patients waiting to go down, but until we get some very tangible workforce changes, which we are working on, then those numbers will remain stubbornly high, or higher than we want them to be, and we have to be open in that dialogue and realistic. When we've had those conversations, they have been understood.

Thank you. Jack Sargeant.

Diolch, Gadeirydd. Bore da, bawb. We've discussed already this morning the culture of the organisation quite heavily, I think, but I do want to just touch back on that, because the history of the health board's culture is an issue. You've said that, previous leaders of the health board have said that. I think the previous leaders before them have said that. I'm looking at the Audit Wales report from the year 2019, the report in March 2022, 'Review of Quality Governance Arrangements'. Paragraph 25 says:

'We found that the Health Board is investing in quality improvement and is seeking to embed a positive culture and behaviours through its Stronger Together programme. But the Health Board needs to deploy its resources more effectively and ensure it demonstrates learning and impact from its activities.'

Dyfed, you said that on day one as cadeirydd of the health board you saw that people were looking for a culture of kindness and of support. We've spoken about the 90-day cycles, we spoke about stability being an important part of that journey, the fact that Carol is now appointed as chief executive rather than interim as being part of that journey. What's your assessment of the culture from day one to day whatever it is now? What's that next step in the journey to make sure the culture is where you want it to be and we all want it to be?

I think my take, Jack, is that people tell me that they sense things are different. That's the way people describe it, and I think that's based on the fact that we're engaging with people; we're engaging with people who work for the health board in all situations, and we're trying to get people to understand we're on their side. So, we are trying to be supportive, we're trying to be kind, we're trying to create the right conditions where people can succeed. I think something else I said on day one was that part of my job is to help create those conditions. The great thing about the health service I've seen over the years from my direct experience is the compassion. It's sometimes strange; you've got this huge compassionate service having difficulty being compassionate with ourselves at times. I think everything we try to do is based on trying to be kind to people, trying to be supportive of people and being clear about accountability and standards as well. People want that, people want to know, people want that direction.

So, the next phase—I think that's a good question to ask. We're creating this stability now. The test for me is will everything we're trying to do be able to penetrate to everywhere in the health board. That's a huge task. We were only addressing that yesterday when I was talking about the passion we have for our work and the passion for getting really good standards and being the best we can, but we can't do that by ourselves. We've got the potential of creating 19,000 leaders in this organisation, so that is going to be the test in the next phase. When I speak to people, if it's in the Maelor or if it's in Glan Clwyd or if it's in Deeside, people will get a sense of, 'We're part of this, we're part of building this, and we know what our contribution can be.'

Diolch yn fawr for that. On that particular point—I'm conscious of the Chair's time as well—engagement is key here. You said that, and I think, in fairness, we had that conversation, Dyfed, on day 10 of your appointment. Carol, I noticed, I think it was the day before the announcement of your chief executive role, you were in the Maelor, or certainly in one of the—. It was a press release that went out. That's good, and it's good to see visibility, but you're only two people of 19,000; you've got to create leaders throughout the organisation. But perhaps what's more important about being visible is what happens after that action has taken place. So, you wanted to be in public and being here demonstrates that. Have you any examples for us to hear today where—it might not be from your visits; it might be from some of your senior leadership team, who will have to do that—they've had those conversations with staff in the service, an action has happened following that, and there has been positive change?

Yes, I'm very happy to pick up a couple of those things. What we have to watch is that we just don't go around from service to service trying to wave that magic wand, you know. But the point is absolutely right. You're absolutely right. As you say, I was in the Maelor, and I went there because I wanted to understand what the challenges were for staff on the ground in terms of doing their job. Because our job's about making their jobs easier to do, and we were looking—. It was a post-take medical ward round—as you know, I'm a nurse, so, it's a little bit of time since I did that, but I was understanding the challenges for that multidisciplinary team. One of the things, for example, is, if they're looking at a patient record, they have to go into the X-ray bit and then the blood test bit and then this bit and this bit, and that's really clunky and they say, 'Well, that adds time and it adds a bit of frustration.' So, we were discussing with colleagues in Digital Health and Care Wales earlier this week, with our digital director in the health board, the work that we can do to improve electronic health records, for example, some very tangible things where staff will feel, 'Actually, we are being listened to and this progress is being made.' They're quite important things as well. You mentioned about learning and about how we change; there are some fundamental things that we need to put in place to help people to do their jobs easier and better, and that will be how we engage people as well.

There are a couple of things on culture, if I just may say. Values and behaviours—so, we can talk about what our values are, but do we act them out and live them every day? There's a lot of work in lots of sectors about this. Active bystanders—what do we see? What do we do when we see unprofessional behaviours? We have to tackle those things.

And then, finally, we've got a staff survey going on at the moment. It's the NHS Wales staff survey. We've had over 3,000 staff—. You don't always get a fantastic return, and we're seeing that number go up every day, but 3,000 colleagues have taken the time to tell us what they think and the important thing will be how we act and demonstrate we've acted on it.

So, just going back to the engagement and the experience in the Maelor with the electronic health records, that was a positive change—something's happened—but that's because you've been there and seen it. You can't be everywhere all of the time. What is the formal route for staff? If you hadn't gone there, that change wouldn't have happened, perhaps.

No, and I'll just be really clear to say that there was work already happening on this. So, when we think about the coroners, for example, the feedback we have from coroners is really valuable. And what they're saying is, 'We've seen patterns here of the electronic health records', so there was work going on. I think what Dyfed and I can do, particularly in our leadership roles, is drive the momentum on that and help to bring the people together who make it happen. Otherwise, it's on a bit of a wish list, potentially, you know.

Yes. Thank you.

We're over time, but I want to allow some time for Mabon, for any final questions he's got. But, Gareth, you wanted to come in with a quick one, as long as it's a quick one and a quick answer.

Yes, it was just a bit of an extension on some of the culture things. Jack was talking about the Maelor hospital; in terms of Glan Clwyd, I was reading recently the comments from Mair Dowell, who you probably know about from her time in Glan Clwyd. Historically, staff were darn proud to work in that place and there was a community feeling locally in Denbighshire, and they were really, really proud staff and they gave their all and there was a clear meritocracy within the system there to say, 'If you give your all, there will be—', you know, internal rewards for staff as well. So, in terms of—. I'm not saying turn back the clock and wind back 30 years or something, but how do we instil a bit of that pride back in, where staff feel burnt out now, they feel stretched and under-resourced, if you like—

I'm so sorry we're short of time, but ever such a quick answer to that, because I need to allow time for Mabon because we're over time. So, just a quick response to that.

It's a massive question, because, when you talk about the things that make people happy in their work, pay and conditions are not Nos. 1, 2 or 3, although they are very important to people at the moment, let me be clear about that, but it's about whether they feel involved in their work, whether their work is valued and whether they're recognised. That is what we're about. That's the change we want to bring.

Making a difference, that's what staff want to feel they can do.

Yes. So, Mabon, we've got about five minutes or so to answer questions from you.

Thank you, Chair. I just wanted to go after a few more detailed things, if possible—there are three main points, and I'll try to be brief. In terms of mental health, we know that the mental health services have been under the magnifying glass. Can we be confident that things are changing and improving, that mental health services are improving in north Wales? Specifically, one of the big problems we saw in the mental health units was the ligature points. And of course, promises were made over and over again that things would be improved and those fixed, but that didn't happen. Can we, as people who live in north Wales, now be confident that things are improving, that that specific problem has been solved, and that our loved ones can go to a mental health unit in north Wales and have the care that they need? That's the first point. I'll come to the second point later, but if we go after mental health first, please.

If I could start, Mabon, and then I'm sure Carol will want to expand upon my answer. But, in terms of mental health, just to highlight the importance of this area, it's an area that's becoming increasingly important for the majority of us, if truth be told, because we have lived through very challenging times, and we do turn to mental health services, particularly young people and those who have experienced the pandemic, and it is an area where we have had support from Government. There have been reviews. We're awaiting a further review—a review of the reviews is how it's being described. And we're expecting that before very long. And we have had excellent support from consultants, and we do have committed staff working in the area too. And as a result, the Government has acknowledged that there has been an improvement in our delivery on mental health and has noted the progress that has been made through special measures.

And, as part of that, we have had a review by the inspectorate conducted relatively recently, which has recognised that progress and the work that is happening, particularly around the ligature points that you referred to, which is always an area that needs to be addressed very carefully. Work has been ongoing there, and the reviews that are carried out by Healthcare Inspectorate Wales are a means for us to ensure that the systems are properly in place. I'll ask Carol if she has anything to add on that.

Thanks very much. There are a couple of things just to draw out. The two big issues that we see in relation to mental health relate to the environment and relate to the workforce. So, they're the biggies. In terms of ligature risks, I've now been personally walked around the three main acute units, and I can see quite a contrast in those environments. All of them will benefit from a redirection of discretionary capital investment, a decision that we took a couple of months ago, to ensure that ligature work remains a key priority for the capital resources we've got at our disposal; so, that's very important. The other thing to say is that the buildings themselves are in different states of modernisation, if you like, and the unit at Ysbyty Glan Clwyd, we've just recently got planning permission for a new unit and are working on a business case around that, because the environment of care is really, really important. It needs to be therapeutic and safe, and both of those are key.

On workforce, really important around having stable leadership, and I think we can see signs. Leaders in the mental health service have been there for some time. There are some other changes that are happening. And then, the big challenge, as with many other health organisations, is the workforce, the clinical workforce. Good progress, steady progress in terms of psychiatrists; we've got some very fruitful—we hope to be very fruitful, anyway—developments being worked on in relation to nurse staffing. So, that is probably one of our challenges, to make sure that we can attract and retain a workforce.

But I've spent particular time in mental health services over the last six months. I've been impressed by the motivation and commitment of staff. They really are striving to do a really great job for the people who use our services. I'm particularly impressed with the new '111 press 2' service; 24 hours a day, people can call that and they can get advice and support, and that was really very good. We went to the DAN 24/7 helplines, which we also run.

So, I think we're building now a much better platform. But I was asked this question a couple of months in, 'What did I think of mental health services?', and I wanted to reserve my judgment a little until I found out a bit more, and I think there'll be more to say when we have these reviews back through, so there will be more in terms of our status and where we're heading to.

Thank you. And finally—. That's good to hear, by the way, and it sounds at the moment like you're heading in the right direction, so, thank you for that, but it's a matter of time, really; time will tell. So, finally, vascular: that centralisation of vascular services hasn't really worked out, has it? There's recognition of that, and there's been significant attention given to vascular, but we're still seeing coroners noting that there are problems with that service. It's another one of those services where people who come under the care of Betsi Cadwaladr need assurance that this service is working in their favour, that no mistakes are going to be made and that things are improving. Is there recognition now, looking back, that mistakes have been made in moving those vascular services from Bangor, and also in not investing properly in this service in Bangor, and that the professor who was responsible for the service at the time had left? So, is there recognition of that in the first instance, and is there assurance now that we can see that service turning around and that we can get the best service when it comes to vascular services in north Wales?

Thank you, Mabon. I will make some general remarks on that. I think there is recognition that that change didn't happen in the most comprehensive and appropriate way possible. Now, was the decision the right one? Well, that was a matter for the board at that particular point. We are where we are. Recently, Healthcare Inspectorate Wales has looked at that service and has stated that it is now a service that has reached a point where it is good, but where there is still room for improvement. I think some of the lessons relate to, if you are going to institute change, then you do need to ensure that there's a strong foundation that you can land on in implementing that change, and I don't think that that was the case at the time. And the most important thing, of course, is who runs the service, the staff, of course, and that the staff are recruited in a timely manner and that we have the best possible staff in place. Now, was that the change that was needed at that point? I don't know. It was a decision taken by the previous board. I think our job is to seek to ensure that the public get the best possible vascular services. The clear aim in this area is that we do provide the best possible service, and with the support of others we can do that, I believe.

Thank you, both. Just a very quick final question, which I hope you can give a very short answer or a bullet point answer on, but what does success look like over the next six to 12 months—not long term; over the next six to 12 months—for you both?

For me, it will be a combination of two comments I've had recently, when I walk around my local community. One person from the farming community stopped me and said, 'When on earth am I going to have my hip operation—I've been waiting two years?' When such a person can stop me and say, 'Thank you very much, I have had my hip operation,' that would be part of the success.

You can do that in six to 12 months?

Well, exactly, yes—

I was thinking that that sounds a challenge.

But also, I was stopped as I was going into Ysbyty Gwynedd, into the office, the other day by someone who said, 'Thank you very much for all the service I've received with urology in the hospital—it's fantastic.' The combination of those two things sort of brings the whole thing home, doesn't it? It's when people can say, 'Yes, I'm getting timely treatment and it's the best treatment possible.' I think that's what success is for me. It's all about people's experience using this service.

Yes. Thank you, Dyfed. Carol.

We'll be more effective as an organisation. We'll have more effective leadership and engagement. We'll have more effective, clearer plans. We'll be performing better—continuous improvement. And we will be focusing on our learning, our development, our research, our training, and investing in our staff. Twelve months from now—I've worked it out; November 2024, date in the diary—I think that's what success will look like for me.

Okay, thank you, Carol. That's a clear answer. Thank you both for being with us for this public session today.

Just before we do close the meeting, I've just got to, under item 5, note—. There's one paper to note, a letter from the Finance Committee to committee Chairs regarding the Welsh Government's draft budget for 2024-25, if Members are happy to note that. Thank you, and our next meeting is on Wednesday, 6 December, so that brings our public session for today's meeting to a close. Diolch yn fawr iawn.