Cynulliad Cenedlaethol Cymru
The National Assembly for Wales

Y Pwyllgor Cyfrifon Cyhoeddus
The Public Accounts Committee

 

Dydd Mawrth, 9 Rhagfyr 2014

Tuesday, 9 December 2014

 

Cynnwys
Contents

 

           

Cyflwyniadau, Ymddiheuriadau a Dirprwyon
Introductions, Apologies and Substitutions

 

Papurau i’w Nodi
Papers to Note

 

Gwasanaeth Awyr oddi mewn i Gymru—Caerdydd i Ynys Môn
Intra-Wales—Cardiff to Anglesey—Air Service

 

Cynnig o dan Reol Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd o’r Cyfarfod

Motion under Standing Order 17.42 to Resolve to Exclude the Public from the Meeting

 

Llywodraethu’r GIG: Tystiolaeth gan Gomisiynydd Pobl Hŷn Cymru

NHS Governance: Evidence from Older People’s Commissioner for Wales

 

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd.

 

The proceedings are recorded in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included.

 

Aelodau’r pwyllgor yn bresennol
Committee members in attendance

 

William Graham

Ceidwadwyr Cymreig
Welsh Conservatives

Mike Hedges

Llafur
Labour

Alun Ffred Jones

Plaid Cymru
The Party of Wales

Sandy Mewies

Llafur
Labour

Darren Millar

Ceidwadwyr Cymreig (Cadeirydd y Pwyllgor)
Welsh Conservatives (Committee Chair)

Julie Morgan

Llafur
Labour

Jenny Rathbone

Llafur
Labour

Aled Roberts

Democratiaid Rhyddfrydol Cymru
Welsh Liberal Democrats

 

Eraill yn bresennol
Others in attendance

 

Matthew Mortlock

Swyddfa Archwilio Cymru
Wales Audit Office

Sarah Rochira

Comisiynydd Pobl Hŷn Cymru
Commissioner for Older People in Wales

Dave Thomas

Swyddfa Archwilio Cymru
Wales Audit Office

Huw Vaughan Thomas

Archwilydd Cyffredinol Cymru
Auditor General for Wales

 

Swyddogion Cynulliad Cenedlaethol Cymru yn bresennol
National Assembly for Wales officials in attendance

 

Leanne Hatcher

Dirprwy Glerc
Deputy Clerk

Michael Kay

Clerc
Clerk

Meriel Singleton

Clerc
Clerk

 

Dechreuodd y cyfarfod am 09:00.

The meeting began at 09:00.

 

Cyflwyniadau, Ymddiheuriadau a Dirprwyon
Introductions, Apologies and Substitutions

 

[1]               Darren Millar: Good morning, everybody, and welcome to today’s meeting of the Public Accounts Committee. I will just make a few housekeeping notices. I remind Members, and witnesses later on in the meeting, that the National Assembly for Wales is a bilingual institution and that we should feel free to contribute to today’s proceedings in either English or Welsh as we see fit. There are, of course, headsets available for translation and sound amplification. I encourage Members to switch off their mobile phones, or to switch them to silent mode, as they can interfere with the broadcasting equipment. I remind people that, in the event of a fire alarm, we should follow the instructions of the ushers. We have not received any apologies for absence this morning, so we will go straight into item 2 on our agenda.

 

Papurau i’w Nodi
Papers to Note

 

[2]               Darren Millar: We have a number of papers to note. We have the minutes of our meeting held on 25 November.

 

[3]               Alun Ffred Jones: Cyfeiriaf at y nodyn ynglŷn â gwaith sydd wedi cael ei gynllunio. Mae gennym, o bosibl, ymchwiliad pwyllgor i’r rhwydwaith priffyrdd yng Nghymru. Pan oeddem yn yr Alban gyda’r Pwyllgor Cyllid, ac yn trafod pethau roedd y pwyllgorau wedi’u gwneud yn y fan honno, soniwyd am gynllun—rwy’n meddwl mai pont newydd dros y Firth oedd y cynllun—lle’r oedd y Llywodraeth wedi rhoi amcan bris a oedd yn eithriadol o uchel. Cynhaliwyd ymchwiliad i’r costau hynny a daethpwyd i’r canlyniad bod y costau yn hollol afresymol, a bod ffordd arall—. Nid cynllun arall, ond bod y costau eu hunain yn anghywir. Meddwl roeddwn i, yn wyneb y drafodaeth sydd wedi bod ynglŷn â’r M4, a’r costau rhyfedd rydym wedi clywed amdanynt—rydym wedi clywed am £1 biliwn a rhywbeth sydd yn nes at £600 miliwn—a fyddai hynny, o bosibl, yn destun ymchwiliad i ni. Ymchwiliad i’r costau, nid i’r cynllun—costau arfaethedig llwybr y draffordd newydd. Os ydych eisiau cynnwys costau’r llwybr glas hefyd, mater arall yw hynny, ond byddai’n gyfle i ni gael gafael ar ryw fath o wybodaeth ynglŷn â hynny. Rwy’n taflu hynny i mewn fel posibilrwydd i’w drafod eto efallai.

 

Alun Ffred Jones: I refer to this note on the forward work programme. We have a possible committee inquiry into the trunk road network in Wales. When we were in Scotland with the Finance Committee, discussing things that committees had done there, a scheme was mentioned—I think that it was a new bridge over the Firth—where the Government had produced an estimate that was exceptionally high. An inquiry was held into the costs, which came to the conclusion that they were completely unreasonable, and that there was another way—. Not another scheme, but that the costs themselves were wrong. I was thinking, in light of the debate about the M4, and the strange costs that have been mentioned—we have heard about £1 billion and something nearer to £600 million—whether that could possibly be the subject of an inquiry for us. An inquiry into the costs, not the scheme—the proposed costs of the new motorway route. If you want to include the costs for the blue route as well, that is another issue, but it would be an opportunity for us to get hold of some information on that. I am just throwing that in as a possibility to be discussed again perhaps.

[4]               Darren Millar: Okay. Are other Members happy with that?

 

[5]               William Graham: Chair, should we not wait until the public inquiry, to see which route is actually chosen, before we waste time?

 

[6]               Sandy Mewies: I agree with William—[Inaudible.]

 

[7]               Alun Ffred Jones: Nid wyf eisiau ailagor y drafodaeth ynglŷn â’r gwahanol lwybrau ac yn y blaen—mae unrhyw un o’r llwybrau yna yn debyg iawn i’w gilydd. Nid wyf yn meddwl bod llawer o wahaniaeth yn y costau sy’n ymwneud â’r rheini. Felly, byddai’n ymchwiliad ar y costau arfaethedig yn unig—sut mae’r Llywodraeth wedi cyrraedd at y costau hynny, a sut maen nhw’n cymharu â chostau cynlluniau tebyg. Nid yw’n ddim byd mwy na hynny. Ond gan ei fod yn gynllun mor enfawr, byddwn yn tybio bod trio sicrhau rhyw sicrwydd ynglŷn â’r costau o werth i’r drafodaeth yn nes ymlaen.

 

Alun Ffred Jones: I do not want to reopen the debate about the different routes and so on—all those routes are very similar. I do not believe that there is much difference in terms of the costs that are involved with those. So, it would be an inquiry just on the proposed costs—how the Government has arrived at those costs, and how they compare with the costs of similar schemes. It is no more than that. However, given that this is such a huge scheme, I would presume that trying to have some sort of certainty about the costs would be of value to the discussion later on. 

[8]               Darren Millar: Sandy, do you want to come in? I will bring you in then, Julie.

 

[9]               Sandy Mewies: I understand the point up to a point, but I was going to make—not the same point, but one a bit like it, on the trunk road network. You might remember that, some years ago—it feels like years ago, but it might have been last year; I do not know—we looked at how public sector contracts were let out to tender, then they were delayed and the actual results were much higher. I think that there is a value in doing that. I wondered if somehow we could look back at other schemes. Maybe we cannot. However, I do think that, with the M4, the odds are that there will be a public inquiry, and of course, whatever the costs are, a lot will depend on when the job is finished.

 

[10]           Darren Millar: There is a cost to delay, is there not—

 

[11]           Sandy Mewies: There is a cost to delay, so for those reasons—. I have made this point before to you about the work programme. We have a very busy work programme at the moment and I think that we should concentrate on that at this stage.

 

[12]           Julie Morgan: Would we have enough information to do this? I do accept Alun Ffred’s point that it is one of the major schemes that we are going to commit money to. We also have the issue of the borrowing powers and using them for the first time and how much of that has been determined by the Westminster Government, which I find of interest. I am still not sure how all of that works out. I think that it would be useful if we could uncover some of those sorts of issues, but I just wonder whether we would have the information available to tap into.

 

[13]           Darren Millar: One thing that we decided we wanted to do as part of our new ways of working was more ex ante scrutiny—scrutiny upfront before decisions are made in terms of spending.

 

[14]           Aled Roberts: I think that there is a point here really. I think that the issue is not on the sense of building the M4. I think that the issue that Alun Ffred is raising is the actual costings process. If you remember, there was some criticism under the previous Government regarding costings for road schemes. I know that there is some concern regarding costings for the dualling for the Heads of the Valleys road, for example. I do think that there is some justification really—. Albeit, some of the increasing costs may be due to delays, but there may be some underlying weaknesses as far as Government estimates of schemes are concerned. I know that there are similar concerns, for example, regarding the arrangements with Network Rail, where figures are agreed and then the figures just seem to increase exponentially, really. So, my reading of what Alun Ffred was suggesting was that we look at the effectiveness of Government forward planning and costings of capital schemes.

 

[15]           Darren Millar: Of course, the cost of the scheme determines very much whether it is going to go ahead, does it not? Auditor general, do you have any advice for us as a committee—.

 

[16]           Mr H. Thomas: Well, I think—

 

[17]           Darren Millar: Sorry, I will bring Mike in first.

 

[18]           Mike Hedges: I have two points. One, I would have thought that looking ahead to schemes would be something for the Finance Committee rather than the Public Accounts Committee. The Public Accounts Committee is looking backwards and the Finance Committee is looking forwards. We really do need to come to some agreement on what fits in where. The second point is that, for anything we add, we need to get something out. I have said it many times that I do not like the idea of having one for and one against with us acting as jury without anywhere near the full information. If we are going to do a full inquiry—and I think that it should fall to the Finance Committee rather than us—I want something to come out in order to make room for it. It should not be the case that we have an hour of somebody one day and an hour of somebody the next and then we come to a conclusion. I do not think that that gets us anywhere.

 

[19]           Mr H. Thomas: I share Mike’s view that, actually, if you wanted to do this, it is perhaps not the PAC that is the appropriate committee but rather the Finance Committee. Secondly, I think that there is an issue with regard to the fact that, if a road scheme is subject to a particular process, which includes the Planning Inspectorate, that process ought to continue. The evidence in terms of costs is something that needs to be taken into account as well as the environmental factors in setting a road scheme. I do get quite a lot of correspondence from people who are opposed to various schemes, not just the M4, and who are seeking for the auditor general to intervene. In a sense, that is actually pushing me into an area that is not appropriate, as I consider it, simply because there is a formal process yet to be gone through.

 

[20]           Darren Millar: I wonder whether—. We are going to be discussing the auditor general’s letter in a few moments in terms of our suggestion for an inquiry moving forward on the trunk road network, and part of that work will look at the Welsh Government’s management of capital schemes, its forecasting of costs—in fact, the auditor general’s previous report back in 2011 touched on this—and then the delivery of those schemes against the budgets. It is quite possible that we could say some things after we have taken evidence, perhaps, on the Welsh Government’s planning that could be read into any significant capital infrastructure scheme beyond just the trunk road network, taking on board what you have just said about the rail network, for example, as well, Aled. Of course, while it does not touch directly on the M4, Alun Ffred Jones, it would allow us to comment at least on the processes that the Welsh Government has and perhaps make suggestions for their improvement. Are Members happy with that approach?

 

[21]           Sandy Mewies: That covers what I said about looking back rather than looking forward. That is the only way that you can see if it has failed, in fact. I would not have a problem, as long as we did not try to look at too many. I think that Mike’s point is really valid. We have to concentrate on turning out good reports, which are balanced, rather than just having an hour here and there on things.

 

[22]           Darren Millar: If we just have a quick look at the auditor general’s letter on this particular subject—it is helpful for us to do that at this point—there are some comments on reports that are coming through from the Wales Audit Office in terms of value for money reports. In terms of our inquiry on the trunk road network, there is a suggestion that the Wales Audit Office could provide an update on any action that has been taken by the Welsh Government so far, following its report in 2011, and that we might want to expand the scope of our work then to look at maintenance of the trunk road network as well as some of the capital costs. If Members are happy with that, we will ask the clerks to work with the Wales Audit Office in coming up with an appropriate scope for that work and a list of potential witnesses. Are Members content with that approach? Yes. We will bear in mind, through the process, that we want to look at its planning and budgeting and how it arrives at its costs, compared with the delivery against them whenever it embarks on a scheme.

 

[23]           A ydych chi’n hapus, Alun Ffred?

Are you content, Alun Ffred?

 

[24]           Alun Ffred Jones: Ydw.

Alun Ffred Jones: Yes.

 

[25]           Aled Roberts: A gaf i ofyn cwestiwn am wasanaethau orthopedig? Mae’n dweud bod gwaith archwilio lleol yn digwydd. A oes cysondeb o ran ymarfer rhwng y byrddau iechyd? Rwy’n ymwybodol bod prosesau newydd yn y bwrdd iechyd yn y gogledd lle mae cleifion yn cael eu cyfeirio at arbenigwyr nad ydynt yn ymgynghorwyr. A yw hynny’n fodd iddynt newid y ffigurau o ran amseroedd aros?

 

Aled Roberts: May I just ask a question on orthopaedic services? It says that local auditing work is being undertaken. Is there consistency in terms of practice between health boards? I am aware that there are new processes in place in the north Wales health board, where patients are referred to specialists who are not consultants. Is that a way of changing the waiting time figures?

[26]           Mr H. Thomas: Y rheswm dros wneud y gwaith fel hyn yw ein bod yn gwneud dau fath o adroddiad: un i’r bwrdd, sy’n delio â phethau lleol, ac un yn edrych ar Gymru gyfan, yn cymharu arferion mewn un lle â’r llall. Dyna’r math o adroddiad y byddwch yn ei gael.

 

Mr H. Thomas: The reason that we do the work like this is that we are doing two kinds of reports: one to the board, dealing with local things, and one on an all-Wales basis, comparing practice in one place with another. That is the kind of the report that you will receive.

[27]           Darren Millar: Are there any comments on the auditor general’s letter? You can see roughly what is coming through the pipeline. That will slot in to our forward work programme, as appropriate. We will take it that that paper is noted.

 

[28]           We also, of course, have a letter from the auditor general, copying us in on the review that the Wales Audit Office has undertaken on the regulatory impact assessments for the Well-being of Future Generations (Wales) Bill. That has, obviously, also been sent to appropriate committee Chair. I take it that that is noted. Excellent.

 

09:13

 

Gwasanaeth Awyr oddi mewn i Gymru—Caerdydd i Ynys Môn
Intra-Wales—Cardiff to Anglesey—Air Service

 

[29]           Darren Millar: We have had a response from the Welsh Government in respect of the interim report that we published in July of this year. We said that we wanted to revisit this particular issue and produce a final report on it at some point. The Welsh Government has since announced, last month, that it has awarded a contract to LinksAir for the period from December 2014 to December 2018. We have had a note to the committee from the director general of the service to give us that information. Are Members content to invite them back to talk about the process? I will bring the auditor general in in a second.

 

[30]           Jenny Rathbone: I think that it is a fascinating letter. A rather basic question is whether we were paying far too much more for the service previously. What is the magic that has enabled us to have a less expensive subsidy and, apparently, a better service in terms of marketing? Could the auditor general comment on that?

 

[31]           Darren Millar: I think there are a number of interesting things from the letter. One, we were told very clearly that the Welsh Government was not going to be able to turn around the retendering process within the timescale that they have managed to turn it around in. It also said that it would take onboard the committee’s views. It appears to have taken some of our views onboard in the retendering exercise. However, I think that there would be merit in bringing them back in to ask about this kind of process and what has happened since the publication of our report in particular.

 

09:15

 

[32]           Mike Hedges: Can we have some numbers? Sorry, I am boring on this, but I like numbers and I can actually understand them. How do they compare with Arriva train costs, per passenger? How do they compare with other flights going to places within Europe—going to Corsica, going to the Scottish islands, and others? How does it compare? Is it expensive or cheap? I have no idea. I know nothing about airlines at all. However, I know that there are comparators per mile that you can do against a rail journey, and comparators per mile that you can do against other trips to islands. I would just like to see that.

 

[33]           Darren Millar: It might be something that we can do as part of our work—

 

[34]           Mike Hedges: I do not think that we need to do anything. It is just that if we were to ask for this information from somebody—. This information must exist somewhere.

 

[35]           Darren Millar: Okay. Did you want to come in, Aled?

 

[36]           Aled Roberts: Mae cwynion wedi bod ynglŷn â’r broses dendro y tro hwn, ac os gwnaethon nhw fynd drwy’r Official Journal of the European Union fel y dywedon nhw yn y lle cyntaf. Rwyf yn gwybod bod yna gyfeiriad yn y llythyr at y ffaith bod 23 o gwmnïau wedi datgan diddordeb. Fodd bynnag, nid wyf yn gwybod faint aeth ymlaen i gynnig am y tendr. Mae hwnnw’n gwestiwn hollol wahanol. Byddwn yn awyddus i weld beth yn union yw’r sefyllfa. I ganlyn yr hyn a ddywedodd Mike, o’r hyn rwyf yn ei ddeall, mae pob  proses dendro yn yr Alban ac yn Iwerddon wedi mynd drwy ffynonellau Ewropeaidd, ac nid yw Llywodraeth Cymru wedi canlyn y ffynonellau hynny.  

 

Aled Roberts: There have been complaints about the tendering process this time, and if they went through the Official Journal of the European Union, as they said in the first place. I know that there is a reference in the letter to the fact that 23 organisations registered an expression of interest. However, I do not know how many went on to bid for the tender. That is a completely different question. I would be keen to see exactly what the position is. Following on from what Mike said, from what I understand, every tendering process in Scotland and Ireland has gone through European sources, and the Welsh Government has not pursued those sources.

[37]           Mr H. Thomas: There are a couple of areas where, as members noted, the letter is silent. It is silent on how many of the expressions of interest went forward to the tender stage. You will recall that, in our memorandum on the last procurement exercise, we identified only one company that was capable of providing the service, given the limitations on aircraft, and so on. So, I think that there are a few issues there. Some interesting points have also come from reading this letter together with the Links Air press release, which I am sure that Members have done. I feel that there is some more information that is needed for the committee to reach a view, and it would be as well to invite the director-general along.

 

[38]           Darren Millar: If Members are content, what we will do in respect of Mike’s suggestion is that we will see whether the Research Service can come up with some information on the costings and how things are arrived at elsewhere in the UK—working with the Wales Audit Office, of course. Then, in addition to that, perhaps we can also—picking up on Aled’s point—have a look at the processes in other parts of the UK as well for the tendering exercise. Alun Ffred, do you want to come in?

 

[39]           Alun Ffred Jones: Os byddwn yn cael tyst i mewn i drafod y mater hwn, dylem fod yn rhagrybuddio’r tyst am y math o wybodaeth rydym yn chwilio amdani, fel ei fod wedi cael ei friffio’n llawn. Nid wyf am glywed, ‘O, nid wyf yn gwybod hynny. Mi sgwennaf atoch wedyn.’ Hynny yw, dylem fod yn ei ragrybuddio, achos rydym am gael ffeithiau, fel yr oedd Mike yn awgrymu.

 

Alun Ffred Jones: If we have a witness in to discuss this, then we should forewarn the witness about the kind of information that we are looking for, so that he or she has been briefed fully. I do not want to hear, ‘Oh, I don’t know that. I will write to you afterwards.’ We should be forewarning the witness because we want facts, as Mike suggested.

[40]           Darren Millar: That seems sensible.

 

[41]           Aled Roberts: Hwyrach y dylem drafod y wybodaeth yr ydym yn ei derbyn cyn rhoi’r gwahoddiad, fel y gallwn ddweud pa feysydd yr ydym am ymchwilio iddynt.

Aled Roberts: Perhaps we should discuss the information that we receive before we put the invitation out, so that we can say which areas we want to discuss.

 

[42]           Darren Millar: Okay. If Members are content, we will make the appropriate arrangements, and we will see if we can get a paper outlining costs and process elsewhere to help inform the work. Okay, we move on to item 4.

 

09:18

 

Cynnig o dan Reol Sefydlog 17.42 i Benderfynu Gwahardd y Cyhoedd o’r Cyfarfod
Motion under Standing Order 17.42 to Resolve to Exclude the Public from the Meeting

 

[43]          Darren Millar: I move that

 

the committee resolves to exclude the public from item 5 and item 6 of the meeting in accordance with Standing Order 17.42(ix).

 

[44]           Are Members content with that motion? I can see that they are, so we will move into private session.

 

Derbyniwyd y cynnig.
Motion agreed.

 

Daeth rhan gyhoeddus y cyfarfod i ben am 09:19.
The public part of the meeting ended at 09:19.

 

Ailymgynullodd y pwyllgor yn gyhoeddus am 10:14.
The committee reconvened in public at 10:14.

 

Llywodraethu’r GIG: Tystiolaeth gan Gomisiynydd Pobl Hŷn Cymru
NHS Governance: Evidence from Older People’s Commissioner for Wales

 

[45]           Darren Millar: I am very pleased to be able to welcome to the meeting, Sarah Rochira, who, of course, is the Commissioner for Older People in Wales. Welcome, Sarah. The committee, of course, has already received a report from the Wales Audit Office. It was a joint report with Health Inspectorate Wales, which was published in respect of an update on the governance arrangements at the Betsi Cadwaladr University Local Health Board. We have taken evidence from the board, from the Welsh Government and from Abertawe Bro Morgannwg University Local Health Board in the wake of the ‘Trusted to Care’ report, which was published earlier this year, about the quality of care for older people in some of their dementia wards. We have also had a note or a copy of the letter that you sent to the auditor general in July of this year, in which you highlighted some of your concerns around board governance. We are up against the clock this morning, unfortunately. So, I ask Members and you, commissioner, to be brief and concise in your comments. I am going to come to Sandy Mewies first to start the questions off.

 

[46]           Sandy Mewies: Thank you, Chair. Good morning.

 

[47]           Ms Rochira: Morning.

 

[48]           Sandy Mewies: One of the concerns that you have raised is the consistency and clarity of definitions of quality of care. Bearing in mind that, I suppose, there can be a great variance in quality, but, in looking at good quality and bad quality, there is a vast difference. What sort of differences are you finding? What do you think people should be aiming for within boards and trusts, and so on? For example, one thing that has always concerned me is that there was great play made about people who go into any sort of care and then their nutrition is poor. There was a suggestion that they should always be weighed as they started any treatment. Is that happening? Are those sorts of things happening or is it patchy? Is it patchy across a board as well as across Wales? The other thing is the openness and transparency of board performance. I am talking now within the board itself, in your experience, and from the board to the ward and from the board to the public.

 

[49]           Ms Rochira: Okay, there is quite a lot in there. I will do my best to pick up on all of those issues. It is very important that I locate in context my comments in relation to this. So, as people will know, my first priority in my framework for action is improving the quality of access to and availability of health and social care, signalling very clearly early on as commissioner, on behalf of older people, that I had, if you like, my gaze on the quality of healthcare in Wales. My comments today come from a number of sources. These include my work in terms of ‘Dignified Care’, which was one of the first reports to highlight some of the issues within the NHS in relation to the treatment of older people, and my own case support. Also, last year, I reviewed all the annual quality statements, because those are some of the key documents for me, on behalf of older people, to seek assurance and reassurance from health boards. I am reviewing those again this year. I have also been out to a number of boards. I have had many discussions with colleagues in health, including Welsh Government. Other sources include responses to things like Mid Staffs and ‘Trusted to Care’. So, it is kind of based on those, if you like. They are also based on my observations, which I hope are helpful observations—they have certainly been received in that context by people in Welsh Government. I just wanted you to understand the context from which that is coming.

 

[50]           I am not a governance body, per se. I am not a health body nor am I accountable for the quality of healthcare, but I do seek assurance and reassurance on behalf of the public who are older people—those 800,000. In one way, what I look for is really very, very simple. I seem to spend my life as commissioner walking around asking very simple questions, starting from very simple premises. We are one NHS in Wales. We talk about this all the time. So, the question for me on behalf of older people is, ‘How does the NHS, as one body in Wales, define what ‘good’ looks like? How does it define what ‘quality’ is?’ I would expect to see a consistent model across Wales embedded at the heart of board scrutiny, particularly with non-executive members of the executive, about what that ‘good’ looks like if we are one NHS across Wales. However, the reality is that when I look across documents produced by health boards, when I look at those annual quality statements, when I review minutes and when I look at the dashboards that various boards use, there is huge inconsistency and variability. I do not understand why there is that inconsistency. I have been very clear with Welsh Government and with health boards when I have spoken with them. We should have one core dashboard that health boards use to evaluate how safe and effective care is, and the extent to which it is dignified and compassionate as well. We need that one standardised, consistent model across Wales. Within that, there are certain things—and I will come back to those—that I would want to see, on behalf of older people, reported on. However, the reality is that they are all different across Wales. Having looked at them, there are very few that I think address some of the fundamental issues that matter to older people, and in no small part, because they are not predominantly outcome focused. They are predominantly focused on process, and I will just give you some examples. I am doing some work at the moment on the 12 key things that I would want to see reported on on behalf of older people.

 

[51]           So, I would want boards to see in their performance dashboard, if you like, evidence—and evidence of debate at board level—around things like physical mobility. So, simple questions to me to boards are: how many people have lost their continence unnecessarily while in hospital; how many people have lost their mobility unnecessarily while in hospital; and how many people in hospital have their end-of-life wishes and their spiritual beliefs met when in hospital? These are the types of things that older people want to seek reassurance on. How many people have fallen unnecessarily? How many people have unnecessarily acquired hospital infections while in hospital? What older people want to see is a sense of what it will mean for them being within the hospital setting.

 

[52]           It is hugely variable. There is a lack of focus on outcomes, certainly outcomes that resonate with me on behalf of older people, and I think that is often very complex and difficult, even for me to understand when I read through dashboard and associated minutes. So, it is variable, and there is a lack of focus on outcomes. I think that makes it very difficult then for health boards, when they write their annual quality statements, to write statements that do reassure the public. That was very clear when I looked at those first annual quality statements.

 

[53]           Also, I am not convinced that the scrutiny of the boards is tight enough on those outcomes. I want to see board members asking those fundamental questions. Yes, the process is important, but so is a much stronger focus on outcomes. There was a lot in that question, and I have tried to touch on a whole range of things.

 

[54]           Darren Millar: I know that Jenny wants to touch on board scrutiny first, and then I will come to Mike.

 

[55]           Jenny Rathbone: What contact do you have with non-executive board members?

 

[56]           Ms Rochira: Well, it varies really. I have been to a number of board development days and I have been to a number of full board meetings as well. Those tend to be on the basis of conversations and discussions, and I am trying to add value to that.

 

[57]           Jenny Rathbone: Okay. So, you have put the point about the need for a focus on outcomes and performance dashboards to them. What has been the outcome?

 

[58]           Ms Rochira: I think, overall, there is general agreement, when I talk to people, that we need to move towards that position. I was at a board recently and I was asking those questions, specifically of non-executives—for example, ‘How many people have lost their continence when that could have been prevented?’ The answer that came was ‘none’, because actually they did not have eyes on what I think is a fundamental scrutiny question for a board. I also asked one particular board recently whether it had a standard set of metrics, if you like, that it used to assess performance—its dashboard—and the answer that came from the non-executives was, ‘There are none’. However, I actually had its performance dashboard in my bag. It takes me back to this very simple, fundamental point that we need to have a consistent approach as to what ‘good’ looks like. It should be the same across all boards, and that is what the scrutiny of the board should be focused on: ‘How are we against those very clear outcome performance metrics?’—not just in terms of ‘Are we improving?’ but ‘Where should we be?’, ‘What is the best practice in relation to that?’, ‘How far away are we from that?’ and ‘When will we be hitting that?’ Really importantly for me, from a board perspective, is this question of, ‘What are we doing to mitigate risk in the interim for individuals?’

 

[59]           Jenny Rathbone: Okay. So, you have got the performance dashboard for that area in your bag and you are telling me that the non-executives were not even aware of the performance dashboard.

 

[60]           Ms Rochira: I think it is a hugely variable, because I have not had the same conversation with every health board across Wales, as I said earlier—

 

[61]           Jenny Rathbone: Yes, but on this one specific instance, you have got board members who were not even aware of the performance dashboard for their own board.

 

[62]           Ms Rochira: Yes. I asked it basically, ‘Do you have a consistent standardised approach to how you would define quality?’ I wanted to know what it thought ‘good’ looks like, because people have different views, but could we just pick one view and have that as the standardised view, and could it have relevance to older people? Yes, I had it in my bag and, actually, I did not think until afterwards that it was a particularly bad dashboard; it was not good enough, but it was certainly a step in the right direction.

 

[63]           Jenny Rathbone: Clearly, all board members cannot do everything, or not to be effective they cannot. How often have you come across boards where a particular non-executive member will say, ‘I’m going to focus on older people’?

 

[64]           Ms Rochira: I have certainly met a number of non-execs—well, I say ‘a number’; I can think of two non-execs that I have met who have said to me, ‘I’m particularly focused on older people and older people’s issues’. I do not know across Wales how boards are embedding in somebody, if you like, who has a key focus on older people. I have to say that I have a differential or two-fold approach to this. On the one hand, it is good to have somebody who does, if you like, always have that key critical thinking around older people. However, the reality is that the average age of patients in Welsh hospitals is something like 80 or 85. I am not totally convinced that I want people to point to somebody and say, ‘Well, they talk about older people’s issues for us’. It should be rolled through and embedded in all of the thinking that we do. So, for example, when we look at delivery plans in relation to cardiac care, what will that mean for people who have a form of dementia? That is a question that should be cutting through a significant proportion of care.

 

[65]           Jenny Rathbone: There are lots of issues there; I do not know whether we have time to go into them. On those two individuals who said that they were particularly interested in older people, how did that translate? Did they regularly do unannounced visits to wards where there are a high proportion of older people?

 

[66]           Ms Rochira: I do not know the answer to that. I do not know how they take that forward as a board.

 

[67]           Jenny Rathbone: Are they not proactively coming to your office and saying, ‘I’d like some information on what’s best practice across the UK’?

 

[68]           Ms Rochira: No. I think I would say that, although I have had good engagement with health boards, non-execs, execs, and chief execs across Wales, a lot of it has been me pushing and driving the agenda on behalf of older people.

 

[69]           Jenny Rathbone: You say that you are pushing and driving the agenda, but how does it translate? If they have an idea of a trust in the UK somewhere that is doing well on the sorts of issues that you are obviously concerned about, how come that that does not translate into them then going to analyse their own organisation in relation to that?

 

[70]           Ms Rochira: I do not know. I think that that is probably a question that only the health boards could answer.

 

[71]           Darren Millar: May I just ask a couple of follow-up questions? Then I will bring Mike in, followed by Aled. You have mentioned the need for a consistent dashboard, if you like, of key performance measures across Wales, whatever those performance measures might be that everybody eventually agrees on. Is that something that the Welsh Government needs to drive forward, or do you see that as something that should emerge from one pioneering health board, which is then rolled out to everybody else?

 

[72]           Ms Rochira: Well, we have a chief executive of the NHS in Wales, do we not? It is Andrew Goodall. I think that that is absolutely part of his leadership role. Of course, there has to be an element of bottom-up discussion and debate, and that should also include older people, and, in no small part, me as well, representing older people as part of that. However, I have had a number of discussions with Welsh Government, going back quite a time now, and I have made it very clear that I think that we should have, and I want to see, that consistent dashboard. I have also made it very clear that there will be key areas that I want to see reflected in that on behalf of older people, such as, for example, issues to do with avoidable loss of physical mobility and ability to self-care, simply because people have been in hospital. I hope and anticipate, based on those discussions, that we will move to that position in Wales. That is not to say that, underneath that, there should not be, if you like, sub-dashboards. So, we know, for example, about the work coming out of ‘Trusted to Care’ in relation to frail older people. There will be other issues that should feed into it, but, fundamentally, the boards should have their eyes on probably something like 25 key markers, and those should be the same across Wales.

 

[73]           Darren Millar: You say that you have developed a suite of—I think it was a dozen that you said earlier on—key measures that you think are important as far as older people are concerned. Could you share that with committee? I do not mean list them now, but send a copy to the committee. That would be very interesting.

 

[74]           Ms Rochira: I would be very happy to. I have been discussing what those are with Welsh Government in detail in a number of meetings with it. They are outcome-focused. I will have finished that work just after Christmas, but what I want to see then, on behalf of older people, if you like, is those 12 issues reflected almost everywhere I look. So, I would want to see them in a standardised, if you like, strategic dashboard. I would want to see them reflected in the national quality statement. I would want to see them reflected in the annual quality statements. I would want to see them reflected in tier 1 quality indicators. I would want to see them reflected in the new healthcare standards that are being developed, so that we have a consistent approach that embeds, at least on behalf of older people, these key issues. I will just use these as an example, again, because these are the type of things that I am interested in. So, for example, avoidable incontinence. That is the issue that I am interested in on behalf of older people. How many people went into hospital who were continent and left hospital not continent, but who, actually, with better care and support, could still have been continent? That is the type of thing that older people want to know about.

 

10:30

 

[75]           Mike Hedges: I want to talk about the disconnect: you have board policies and you have ward action and they are not necessarily the same. Boards often, in lots of organisations, come up with really good policies, but, if they are not implemented somewhere lower down the line, they are nothing but nice words on paper. I have two things that I am interested in; we all have our little interests. Mine is hydration and making sure that patients are eating. That is different from providing water on a table that patients cannot reach, and putting food in front of them that is then taken away half an hour later untouched. We have had a report from the auditor general about this, and we also know that hospitals are supposed to allow patients’ relatives and friends to come in and help them eat. I could also take you on to hospital wards where it does not happen. Are you noticing any of this?

 

[76]           Ms Rochira: In terms of issues to do with hydration and not being able to eat?

 

[77]           Mike Hedges: And not being supported with eating by staff or by friends or relatives.

 

[78]           Ms Rochira: Older people will tell me about issues like that. I have also seen really good practice where there have been volunteers on the wards, for example. As you know, one of the key recommendations from the ‘Dignified Care?’ report was that we should have more volunteers on the ward, such as in the Robins scheme. It is a high-impact way to mitigate risk on a very busy ward. It is almost A Tale of Two Cities, and, again, that is always the point, is it not? If we have so much good practice, why is that not standard practice across Wales?

 

[79]           The issue about nutrition and hydration is one of those key areas for older people. Linking back to your point, Chair, I would want to see really robust reporting and debate around the state of nutrition and hydration of people: is it worse after admission or when people are discharged? For the vast majority, it certainly should not be worse. So, people raise issues around that, but I have seen good practice as well.

 

[80]           It takes us back to some of those most basic fundamental things, which are often not clinical, but which are hugely impactful on the outcomes for people in hospital.

 

[81]           Mike Hedges: You say it is like A Tale of Two Cities; I see it as ‘a tale of two wards’. I can take you to a hospital in the Swansea area where you can go to one ward where it is done exceptionally well, and, on the ward next door to it, just a tiny corridor apart, it is done appallingly.

 

[82]           Ms Rochira: This is the fundamental governance question, is it not? How good is our nutrition and hydration of patients in Welsh hospitals? We should be able to answer that question if we are one NHS; it should be an aggregate answer of what those eight boards across Wales are looking at. Yet, we cannot answer that simple question at the moment, because we do not have eyes on the right things necessarily at board level. That should be a really simple question for us to answer in Wales. We should see that being reported on in the annual quality statement by the chief executive of the NHS in Wales, not in terms of, ‘We have a new hydration policy’, important as that is, and not in terms of, ‘We have a new metric for nutrition and hydration’, but just answering those very, very simple outcome questions.

 

[83]           Just to go back to your point about policies and procedures, one of the things that I want to see health boards—. I can only go in no small part by their annual quality statements, so what they write in there I will use to judge and assess what they are doing, because those are designed to provide reassurance. They might be doing miles more besides, but those are key documents. One of the areas that I am concerned about is what is in the staff survey. Some of the figures that come out in the NHS staff survey are really shocking, yet I do not really see, when I read those annual quality statements, a robust and strong enough response and concern. What does that tell us? We might have policies and procedures, and those are important, but those staff surveys tell us something about what it is like on the front line. Some of those figures are very concerning indeed. Any business that had those kinds of figures coming back from its front line should be able to evidence how seriously it is acting. Will we see those figures change significantly in the next staff survey? We should expect to see them do so, but I would be surprised, I am afraid to say, if we were to see them change.

 

[84]           Darren Millar: Okay, thank you for that. Aled is next.

 

[85]           Aled Roberts: Yn amlwg, rydych chi wedi bod yn mynychu cyfarfodydd y byrddau iechyd, ac rydych hefyd wedi sôn eich bod wedi bod yn mynd i ddiwrnodau datblygu, ac yn y blaen. Fodd bynnag, rwyf eisiau gofyn i chi ynglŷn â’ch perthynas chi efo cynghorau iechyd cymunedol. Rydych chi’n dweud eich bod yn gwthio, ond rhan o’r strwythur o fewn y gwasanaeth iechyd i fod yw bod y cynghorau iechyd cymunedol hefyd yn dwyn y byrddau iechyd i gyfrif. Felly, beth yw eich perthynas chi efo’r cynghorau iechyd, ac a oes tystiolaeth bod nhw yn cwyno ar ran y cleifion ynglŷn â rhai o’r pethau yr ydych chi wedi bod yn sôn amdanynt y bore yma?

 

Aled Roberts: Evidently, you have been attending meetings of the health boards, and you also mentioned that you have been going to development days, and so forth. However, I want to ask you about your relationship with community health councils. You say that you are pushing, but part of the structure within the health service is supposed to be that the community health councils also hold the health boards to account. So, what is your relationship with the CHCs, and is there evidence that they are complaining on behalf of patients about some of the things that you have mentioned this morning?

[86]           Ms Rochira: I want to strengthen my relationship with community health councils; in fact, I have written to the new chief exec suggesting that it would be good for us to meet and talk about the areas of alignment that we have. I am very careful not to duplicate the work of community health councils; they have their role and I have my role within that. We both have a huge amount of intelligence, if you like, that I share, and I suspect they would share as well, through our support to people who have complaints, grievances or issues that they are unhappy with to raise. I would like to see the relationship stronger than it is at the moment; I think there is more that we can do as two bodies to share the information and advice that we give, and also the pressure that we have to drive forward on that change. I hope that that is something that I can build with the new chief executive of community health councils in Wales. I have been really clear that we need to have strong community health councils in Wales. We need to resource and invest in them properly. They are the patient ‘watchdog’, if you like; they have a hugely valuable role to play, not just when things go wrong but also in terms of those early warning signs when things are not as good as they need to be, or when there is a risk to people. Health boards should be using that as a valuable source of intelligence.

 

[87]           One of the things that I looked at in terms of the annual quality statements was whether there was, if you like, a sign-off from community health councils. I would like to see community health councils put out a statement of opinion on those annual quality statements. I will be doing that this year. I have said that this year in the second round I will make public commentary on the annual quality statements as to where I think they are good and where I think they need to be strengthened. I want to see community health councils have a strong voice and a voice that is used to drive strategic improvement as well—they have a wealth of knowledge and information—but we do need to invest in and resource them properly to be able to do that.

 

[88]           Aled Roberts: A ydych chi wedi gweld unrhyw dystiolaeth o fewn cofnodion cyfarfodydd y cynghorau iechyd cymunedol eu bod nhw yn cwestiynu perfformiad y byrddau iechyd ynglŷn â rhai o’r canlyniadau o ran cleifion o gwbl?

 

Aled Roberts: Have you seen any evidence in the minutes of CHC meetings that they are questioning the performance of the health boards about some of the outcomes for patients at all? 

[89]           Ms Rochira: I have not looked at the minutes of community health council meetings. I have looked at health board minutes, but not at those of community health councils.

 

[90]           Darren Millar: Julie Morgan is next.

 

[91]           Julie Morgan: Thank you very much. I am struck by what you say about the staff surveys and how shocking you say they are. Could you give us some examples?

 

[92]           Ms Rochira: I could, if you just give me one second. This is from the NHS Wales staff survey of 2013, and these were figures I particularly highlighted with the Minister for health and with Welsh Government. Only 52% of staff would be happy about the standard of care in the NHS if provided to a loved one. Twenty five per cent of staff say that they are unable to deliver the standard of service they aspire to. When errors, near-misses or incidents are reported, only 56% of NHS staff believe that action will be taken to ensure that they do not happen again. If we are a never-event industry—if we really understand how critical and what the impact of getting things wrong upon individuals can be, those figures should be very worrying indeed. I am not necessarily saying that health boards do not take those figures seriously, but when I read things like the annual quality statements, they do not provide that really relentless drive and focus that I am looking for.

 

[93]           From an older person’s perspective, older people understand that sometimes it goes wrong and that sometimes it goes badly wrong. What they say to me is quite simple: ‘We just want people to listen to us and to make sure it doesn’t go wrong again for anybody else’. Again, I am looking for that really clear evidence, again at board level, that there is a debate around where our high-risk areas are, what we are doing to mitigate that risk from crystallising, and, if it has crystallised, what we are doing to make sure that it does not happen again.

 

[94]           When I spoke publicly about the ‘Trusted to Care’ report, I said that one of the most shocking things for me was the amount of time it had gone on for. It was going badly wrong and it should have been put right very, very quickly indeed.

 

[95]           Julie Morgan: So, these particular results were from a national survey of staff, but these were reported to the boards. The boards all had copies of this survey. Did they discuss the survey?

 

[96]           Ms Rochira: I am sure that all boards did discuss the survey. However, again, if I go back to the annual quality statements, which are designed to provide that reassurance, I did not get a strong enough sense from those that that debate had been robust, that they had identified where their own personal weaknesses were, because you are absolutely right that every health board has its own figures, or what action they were taking to ensure that there was significant improvement in those figures in years to come—

 

[97]           Julie Morgan: So, you are unable to trace any movement within the health boards to address these critical issues that come up from the staff surveys, for example.

 

[98]           Ms Rochira: I have to say that I find it like looking through a dark glass to try to understand what the debates at boards are. I look at board minutes and, even having spent 25 years in the NHS, some of those are really hard to understand. If I link that back to the openness and transparency agenda, which I strongly welcomed as a key driver for change, boards should not just be reporting clearly through their annual quality statements, they should be doing that on a quarterly basis as well. Again, I have been very clear with the Welsh Government that I want to see this standardised set of metrics about what ‘good’ looks like reported on an annual basis. I also want to see clear evidence that it has been discussed by the board on a quarterly basis and I want to see board minutes published that I can understand and that the public can understand. Sometimes, it is even really hard to find board minutes. It is really difficult to know how good care is, and, in no small part, that probably does a disservice to how good it is as well, but if boards cannot answer those simple questions, how can they then provide that reassurance to the public?

 

[99]           One of the fundamental questions, I would suggest, for boards to be asking themselves is: if these are what our figures are now, what will they be next year and what will they be the year after that and when will we see our figures? I will take one health board as an example: only 52% of staff thought that when errors or near misses were reported the employer took action to ensure that it did not happen again. That is only 52% in a critical care setting such as the NHS. The board should be asking itself, ‘When will that 52% be 75%? Will that 75% be near-on 100%?’

 

[100]       Julie Morgan: You have no evidence that anything like that happens.

 

[101]       Ms Rochira: I am sure that it does happen, but I cannot see easily where it happens, because the reporting on it is not strong enough.

 

[102]       Julie Morgan: So, if it does happen, the public is not able to see that it happens.

 

[103]       Ms Rochira: Yes, absolutely.

 

[104]       William Graham: Could you expand on your concern about the boards’ sources of assurance regarding identification and remedy of unacceptable care?

 

[105]       Ms Rochira: Yes, I can; thank you very much. When ‘Trusted to Care’ was published, I wrote to health boards and I asked them what I thought were three very simple questions: their views on the relevance of ‘Trusted to Care’ to their health board—I wanted to make sure that we saw it as something that we should all be considering and learning from; whether, as health boards, they were able to provide me with assurance that patients on all their wards were receiving care of an acceptable level, which is a very straightforward question; and, if not, what they were doing to remedy that. They were, I thought, simple, and if you have a key grip as a board on your core business, which is quality of care, they should be simple to answer. There are a number of things that I learned from that: one was this lack of focus on outcomes, and I really did not want to be told that we had new incontinence newsletters in place, if I am truthful. One of them was in relation to assurance mechanisms and the other was in relation to language use, and perhaps I can touch on two of those.

 

[106]       The first was about the language used. When I correlated the responses that I had on ‘Trusted to Care’ and my review of annual quality statements, I saw something about language. There were a number of statements: ‘wards causing concern,’ ‘some areas need improvement,’ ‘areas for continuous improvement,’ ‘some shortcomings,’ ‘some variation between clinical areas which are being addressed,’ ‘potential for these standards not to be maintained in all wards at all times’ and ‘subject to further assurance work’. So, the question for me then is: what sits behind those? If I give you an example, going back to an annual quality statement, in ABMU’s first annual quality statement, at a time when ‘Trusted to Care’ issues were live, it talked about poor care towards older people. We now know what sat behind that in ABMU. What sits behind those other statements? That is my concern as commissioner. Maybe it is something fairly small. Who knows? Another phrase that came back was ‘systemic failures,’ and we like to use this phrase in Wales, saying, ‘We do not have systemic failures’. I am not sure what constitutes a ‘systemic failure’. How bad does it have to be before we have a systemic failure? This opaque language is used and we just do not know what sits behind it. I do not think that we should use opaque language like that.

 

10:45

 

[107]       The second thing when I asked health boards in relation to the assurances was that a number of them came back to me and told me a huge amount about the processes that they were using, yet I had asked quite simple, outcome-focused questions. I had three comments back, which I then raised with the chief exec of the NHS in Wales. Those three comments were: ‘we cannot guarantee that the assurance model would pick up every instance of poor care’; ‘assurance mechanisms may not, in isolation, prevent unacceptable levels of care’; and, the third was, ‘assurance systems must be developed further’. So, two questions arise for me. First, you have, or we should have, a standardised approach to what ‘good’ looks like. The second question is: how robust are your assurance mechanisms behind it? How good are the data that are leading you, as a board, to take a view on that? Once again, we are not where we need to be yet in Wales. That is not to take away from the huge amount of work that is under way, but what I am interested in is the finish line on behalf of older people across Wales. Having seen that phrase, ‘poor care towards older people’ in the ABMU annual quality statement, what should I think as the commissioner when I see these other phrases? The only way that I will really get reassurance now is through reading those annual quality statements. If those are designed to reassure the public, they should be quite crisp and clear, and state, ‘This is what good looks like; this is where we are now; this is where we need to improve; this is when we will have improved; and this is how we are mitigating the risk to patients in between’.

 

[108]       William Graham: In your study, were you confident that boards were able to deal well, particularly with older people, after incidents involving their partners or relations had actually happened?

 

[109]       Ms Rochira: I cannot give a view—and this is the answer to all of it, really—on any of these issues across Wales, because we do not have the aggregated-up answers because we are not focused on the right questions. I would say that it is hugely variable. In some parts of Wales, from talking to people, I know about really good practice, where something went wrong, it was put right quickly, the person’s dignity was restored to them quickly and it did not go wrong again for somebody else. That is what it should be like everywhere, yet we know from the report in relation to complaints, ‘Using the Gift of Complaints’, and I know from my own casework and from talking to older people that, all too often, they get lost in the maze of making complaints, they do not see how anything has particularly changed as a result of it and, actually, fundamentally, all they wanted was somebody at the beginning to say, ‘Do you know what, I am really sorry, we got it wrong, and we will make sure that it doesn’t happen again to anybody else?’

 

[110]       If you lift that up to a board level, there are some really interesting scrutiny questions that boards should be asking. Boards should be asking questions such as: how many POVAs do we have being reported from Welsh wards? That is an interesting question for the NHS in Wales. Another really important question is: how robust are our data and our assurance mechanisms that we are picking up POVAs from Welsh wards? I should say that ‘POVA’ and ‘Welsh wards’ should never be expressed in the same breath. How good are we, not just at the whole process and the timescales of dealing with complaints, but at making sure that the same thing does not happen again? That is a board question. That is a question for the non-executive and executive directors. What are the three things that we are continually not getting right; when will we stop getting those wrong; and what is going wrong in the same way time after time?

 

[111]       I go back to the point about ‘Trusted to Care’; that went on for years. That should have been absolutely stopped in its tracks when those concerns were raised. That it went on for such a long time is indicative of not having eyes on the right things. Of course things go wrong sometimes; listen to the person or the member of staff, put it right and stop it from happening again to anybody else. Those are the questions that the boards have to be asking.

 

[112]       Darren Millar: May I just pick up on two issues, in closing? Earlier on, Jenny Rathbone was questioning you on the role of non-executive members. We do know from the evidence that we have received that we have had concerns about the ability of non-executive members to scrutinise what is going on in the health boards in which they operate and, sometimes, the capacity, frankly, of those non-executive members. Is there anything that you would change in terms of the selection, perhaps, and appointments process? Aside from the training and upskilling of somebody, you expect certain people to have a set of skills without having to retrain them, if they are being appointed to such an important role. What is your perception of the effectiveness of the appointments process?

 

[113]       Ms Rochira: Might I rephrase that slightly and talk about investment? Many health boards are billion-pound organisations. These are big never-event industries, and when it goes wrong it goes badly wrong. I often talk about parallels with the airline industry. We all do. We understand what that looks like when it goes wrong. There is something to me about the extent to which we are prepared to invest in the skills and competencies, but most importantly the time, of non-executives and also the safety committees, which sit under the board and are a crucial pivot point that triangulates a huge amount of data that are then fed up to the board and which the board should be scrutinising. I am not convinced that we are investing in that sufficiently. It is such a critical care sector. The impact of when it goes wrong is so significant.

 

[114]       Does the model we have really work in terms of investment and time? I am not convinced it does, either at board level or in relation to those safety committees underpinning it. I think that they need to be bigger and more impactful. The skills that people have are incredibly important, and it is important that we take people from certain backgrounds so that we have a breadth of experience and knowledge. However, the ability to scrutinise is a key competency. I would want to see really competence-focused recruitment. I should not be the only one who sits at board and asks questions such as, ‘How many people lost their continence when they should not have done?’, ‘What is the gold standard, the best practice, for this?’, and ‘When will we be meeting that standard?’ We need very clear, standardised competency profiles.

 

[115]       Darren Millar: So, time, the size of boards and competency-focused recruitment are the three key things as far as you are concerned as commissioner that you would like to see more investment made in.

 

[116]       Ms Rochira: Yes, I would. I would also like to see two things. One is more willingness to challenge—real willingness to challenge and not accept. I think that there is culture in Wales of high-fiving on improvement when actually the job is only done when you meet the best practice standard across Wales. I would also like to see boards fully understanding what their duties look like—that openness, duty to report and of candour and accountability. That must really be made real at board level, because fundamentally that is what older people do: they put their trust in boards to act on their behalf when they cannot raise and ask questions. I want to see boards held accountable for how good their scrutiny is.

 

[117]       Darren Millar: I have just one final question before we close this session. The Welsh Government has indicated that there is going to be an NHS governance and quality Green Paper, which is due to be published next year. What would you like to see in that paper, and what discussions have you been having with the Welsh Government to date about that paper? Where do you sit in the discussion and development of it?

 

[118]       Ms Rochira: Clearly, I have had a number of discussions with Welsh Government based on what I now want to see, drawing together a whole range of concerns, which I published first of all on the back of the Mid Staffs report. I am very happy to send you those because those are fundamentally the eight key questions. The things that I have been very clear about with the Minister and the chief exec of the NHS in Wales that I want to see are: strengthened reporting against those key outcomes—I want to see those in a number of key areas; staffing levels; the ability of staff to be able to respond to the needs, particularly of people with dementia; clear standards that cover basic care, by which I mean continence care, hydration and mealtimes and late-night discharge—an issue not often talked about, but hugely important; learning from and the prevention of repeat failures; use of volunteers; and basic standards of care. I want to see that published on a quarterly basis and I want to see it evidenced in board minutes as well. I also want to see some of it disaggregated out from the health board level down to hospital level. I want those issues to be reflected in the national annual quality statement. I want to see strengthened responses in relation to staff surveys and those issues identified. I also want to see the same in relation to patient experience. I want to see that standardised dashboard across Wales, and I want to see greater accountability for those health boards.

 

[119]       Darren Millar: And a duty of candour.

 

[120]       Ms Rochira: Absolutely a duty of candour. It is one of the key things that we will do to reassure the public. First of all, health boards have to understand how good their care is—‘How are we doing?’ Then they must report on that in a way that the public and I can understand. Where they are not in line with best practice—the very best it could and should be—they should be very clear and explicit on what they are doing to mitigate the impact.

 

[121]       Darren Millar: Sarah Rochira, thank you very much for your attendance at the committee today. You will receive a copy of the transcript of proceedings. I am sorry that we have not had the opportunity to have more time with you, but we do appreciate you coming in at short notice to be with this. Thank you very much indeed.

 

[122]       Ms Rochira: Diolch yn fawr. Thank you.

 

[123]       Darren Millar: That brings us to the end of today’s meeting. Thank you.

 

Daeth y cyfarfod i ben am 10:55.
The meeting ended at 10:55.