The
proceedings are reported in the language in which they were spoken
in the committee. In addition, a transcription of the simultaneous
interpretation is included. Where contributors have supplied
corrections to their evidence, these are noted in the
transcript.
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Dechreuodd y cyfarfod am 14:01.
The meeting began at 14:01.
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Cyflwyniad,
Ymddiheuriadau, Dirprwyon a Datgan Buddiannau
Introductions, Apologies, Substitutions and Declarations of
Interest
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[1]
Rhun ap Iorwerth:
Prynhawn da. A gaf i eich croesawu
chi fel aelodau’r pwyllgor i gyfarfod y Pwyllgor Cyfrifon
Cyhoeddus heddiw? Mae clustffonau ar gael, fel yr arfer, ar gyfer
cyfieithu ar y pryd ac ar gyfer chwyddo’r
sain—cyfieithu ar sianel 1 a chwyddo’r sain ar sianel
0. Mi wnawn ni atgoffa ein tystion o hynny wrth i’r prynhawn
fynd yn ei flaen. A gaf i atgoffa Aelodau i ddiffodd y sain ar
unrhyw ddyfeisiadau electronig, os gwelwch yn dda, a nodi yn fan
hyn os bydd achos i adael yr ystafell mewn achos o argyfwng, mi
fydd larwm yn canu ac mi fydd y tywyswyr ar gael i arwain pawb at
yr allanfa ddiogel a’r man ymgynnull agosaf?
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Rhun ap
Iorwerth: Good afternoon. May
I welcome you as members of the committee to this meeting of the
Public Accounts Committee today? The headsets are available, as
usual, for interpretation services and for
amplification—interpretation is on channel 1 and
amplification is on channel 0. We will remind our witnesses of that
as the afternoon proceeds. Could I remind Members to put their
electronic devices on mute, please, and note here that if there is
a reason to leave the room in an emergency, there will be an alarm
and the ushers will be available to lead everyone to the nearest
safe exit and assembly point?
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[2]
Mae ymddiheuriadau heddiw gan Nick
Ramsay, y Cadeirydd arferol, ac mae Andrew R.T. Davies yn dirprwyo
ar ran Nick Ramsay heddiw. A gaf i groesawu Andrew R.T. Davies
i’r pwyllgor? Ar gyfer y cofnod, mi wnaf i’ch atgoffa
fy mod i wedi cael fy ethol gan y pwyllgor o dan Reolau Sefydlog
17.22 ac 18.6 fel Cadeirydd dros dro ar gyfer y cyfarfod heddiw.
Roedd y bleidlais honno wedi digwydd ar 3 Hydref.
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There are apologies today from Nick Ramsay,
the usual Chair, and Andrew R.T. Davies is substituting on behalf
of Nick Ramsay. Could I welcome Andrew R.T. Davies to the
committee? For the record, I will remind everyone that I was
elected by the committee under Standing Orders 17.22 and 18.6 as
temporary Chair for today’s meeting. That vote happened on 3
October.
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[3]
Fel ym mhob cyfarfod, mae yna, wrth
gwrs, gyfle i Aelodau ddatgan buddiannau wrth i’r cyfarfod
fynd yn ei flaen a phan mae yna faterion perthnasol yn codi, ond mi
wnaf i, yn fan hyn, wahodd unrhyw ddatganiadau o fuddiant personol
gan aelodau’r pwyllgor.
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As in every meeting, there is, of course, an
opportunity for Members to make declarations of interest as the
meeting proceeds and when relevant issues arise, but I will now
invite any declarations of personal interest from committee
members.
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[4]
Lee Waters: Chair, I have a declaration. My wife works for
Cwm Taf Local Health Board.
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[5]
Rhun ap
Iorwerth: Diolch yn fawr iawn i Lee Waters, a dyna’r unig
ddatganiad o fuddiant y prynhawn yma.
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Rhun ap
Iorwerth: Thank you very much
to Lee Waters, and that’s the only declaration of interest
this afternoon.
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14:02
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Papurau i’w Nodi
Papers to Note
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[6]
Rhun ap
Iorwerth: Mi symudwn ni ymlaen at eitem 2, sef y papurau i’w nodi.
Yn gyntaf, mae cofnodion y cyfarfod a gafodd ei gynnal ar 3 Hydref.
A gaf i ofyn i’r Aelodau: a ydych chi’n cytuno ar y
cofnodion hynny? Diolch yn fawr iawn i chi. Mae un papur arall
i’w nodi, sef gwybodaeth ychwanegol gan Gomisiwn y Cynulliad,
yn dilyn presenoldeb Suzy Davies yn y pwyllgor ar 19 Medi. Mi
ysgrifennwyd at y pwyllgor ar 28 Medi yn rhoi rhagor o wybodaeth yn
dilyn y sesiwn tystiolaeth hwnnw. Felly, a gaf i ofyn i’r
Aelodau nodi’r llythyr hwnnw sydd wedi cyrraedd gan Suzy
Davies?
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Rhun ap Iorwerth: We’ll move on
now to item 2, which is the papers to note. First, there are the
minutes from the meeting held on 3 October. Could I ask Members: do
you agree those minutes? Thank you very much. One further paper to
note is the additional information from the Assembly Commission,
following the attendance of Suzy Davies at the meeting on 19
September. A letter was written on 28 September, providing further
information following the evidence session. So, could I ask Members
to note that letter, which has arrived from Suzy Davies?
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[7]
Mae gen i hefyd
bapur, nid i’w nodi—mi wnawn ni’r nodi mewn
cyfarfod yn y dyfodol—ond i dynnu eich sylw chi at lythyr gan
Gadeirydd y Pwyllgor Deisebau ynglŷn â bwyd yn ysbytai Cymru, sydd yn
berthnasol ar gyfer y trafodaethau a fyddwn ni’n eu cael y
prynhawn yma. Ond rwy’n tynnu eich sylw chi at y ffaith bod y
llythyr hwnnw wedi cyrraedd gan Gadeirydd y Pwyllgor Deisebau, sef
Mike Hedges.
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I also have a paper, not to
note—we’ll do note it in a further meeting—but to
draw your attention to a letter from the Chair of the Petitions
Committee about food in Welsh hospitals, which is relevant to the
discussions we’ll have this afternoon. But I draw your
attention to the fact that that letter has arrived from the Chair
of the Petitions Committee, namely Mike Hedges.
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14:04
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Arlwyo a Maeth
Cleifion mewn Ysbytai: Byrddau Iechyd
Hospital
Catering and Patient Nutrition: Health Boards.
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[8]
Rhun ap
Iorwerth: Rŵan, mae
hynny’n dod â ni at eitem 3 ar yr agenda heddiw, sef
ein hymchwiliad i gynnydd ym maes arlwyo a maeth cleifion mewn
ysbytai. Mae yna bump o dystion o’n blaenau ni heddiw ac
rwy’n gallu gweld bod yna offer cyfieithu yn cael eu
defnyddio’n barod, ond mi wnaf i dynnu’ch sylw chi at y
ffaith eu bod nhw yna—sianel 1 ar gyfer cyfieithu a
chwyddo’r sain, wedyn, ar sianel 0.
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Rhun ap Iorwerth: Now, that brings us to item 3 on the agenda, which is
our inquiry into hospital catering and patient nutrition. We have
five witnesses before us this afternoon. I can see that the
interpretation is being used already, but I’ll draw your
attention to the fact that it’s channel 1 for interpretation,
and that amplification is on channel 0.
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[9]
Rydym ni’n ddiolchgar iawn
i’r pump ohonoch chi am ddod atom ni’r prynhawn yma, ac
os caf i ofyn i’r pump ohonoch chi nodi eich enw
a’ch teitl ar gyfer y cofnod,
gan ddechrau efo chi.
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I’m very
grateful to the five of you for coming this afternoon, and could I
ask the five you to note your names and your titles for the
record, starting with you.
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[10]
Mr Phillpott: My name is Colin Phillpott. I’m a
facilities manager with Aneurin Bevan Local Health Board.
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[11]
Ms Waters: Hello. My name is Liz Waters. I’m a
consultant nurse and associate nurse director for Aneurin Bevan
health board.
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[12]
Ms Jones: Good afternoon. I’m Rhiannon Jones.
I’m the executive director of nursing for Powys Teaching
Local Health Board.
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[13]
Ms Williams: I’m Lynda Williams. I’m the
director of nursing, midwifery and patient services at Cwm Taf
Local Health Board.
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[14]
Mr Hayward: Good afternoon. My name is Anthony Hayward.
I’m the assistant director of facilities for Cwm Taf health
board.
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[15]
Rhun ap
Iorwerth: Diolch yn fawr iawn. Mi fydd yna lu o gwestiynau, rwy’n
siŵr, gan aelodau’r pwyllgor y prynhawn yma. Mi wnaf i
ddechrau yn gyntaf efo cwestiwn ynglŷn â gwella safon y
dogfennau nyrsio ysgrifenedig ac ansawdd asesiadau nyrsio mewn
perthynas â maeth cleifion. Mae e wedi’i nodi bod yna
arafwch wedi bod wrth safoni dogfennau. A gaf i ofyn pa gamau y
mae’r byrddau iechyd wedi eu cymryd yn y maes hwn? Caiff y
cyntaf i siarad ddechrau. Rhiannon Jones, mi ddechreuwn ni efo
chi.
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Rhun ap
Iorwerth: Thank you very much.
There will be a whole host of questions, I’m sure, from the
committee members this afternoon, but I will begin with a question
relating to improving the standard of written nursing documentation
and the quality of nurse assessments in relation to patient
nutrition. It has been noted that there has been a delay in
standardising documentation. May I ask what action the health
boards are taking in this area? The first to respond may begin.
Rhiannon Jones, we will begin with you.
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[16]
Ms Jones: Thank you. I think that from an all-Wales
perspective, there certainly has been a delay, but that
hasn’t meant that individual health boards haven’t
progressed with the development of local documentation. Certainly
from a Powys perspective, we have had a significant piece of work
where the documentation has been aligned to the health and care
standards, which includes nutritional risk assessments for
patients. There are ongoing discussions about the need for a
revision to the documentation for nursing, but a recognition that
we need an electronic solution, not more paper-based approaches. I
know that Jean White will be picking that up later, and there is
progress in terms of the NHS Wales Informatics Service taking that
forward.
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[17]
Rhun ap Iorwerth:
Lynda Williams.
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[18]
Ms Williams: I can endorse that. We met as a group of nurse
directors with the chief nursing officer on Friday, and we were
very pleased to hear about the appointment to NWIS of an individual
to take this forward. We confirmed that that would be part of her
work programme, including all of the nurse documentation, but more
specifically around the nutrition assessments. In Cwm Taf, we have
a similar approach with regard to a standardised nutrition
assessment tool for the whole of the organisation, which follows
the nutritional care pathway through, so that nurses are quite
clear about the next steps that need to happen for their
patient.
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[19]
Rhun ap
Iorwerth: Mi wnaf i eich atgoffa chi, yn enwedig efo pump ar y panel,
nad oes disgwyl i bob un ohonoch chi wneud cyfraniad ar bob un
cwestiwn. A oes yna unrhyw un arall sydd eisiau gwneud sylw
cyffredinol ynglŷn ag arafwch y broses hon? Na. Os felly, mi
agorwn ni bethau allan. Mae’n ddrwg gen i: a ydych chi am
wneud sylw? Na. Felly, Andrew R.T. Davies.
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Rhun ap
Iorwerth: I will remind you,
particularly with five on the panel, that you are not all expected
to make a contribution on every question. Does anyone else want to
make a general comment on the slowness of this process? No.
Therefore, we will open up the discussion. I’m sorry: did you
want to make a comment? No. Therefore, Andrew R.T.
Davies.
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[20]
Andrew R.T. Davies:
Thank you, Chair. Leading on from the
first question, if I may: is there a specific reason why
standardisation wasn’t brought forward by March 2103?
Obviously, I hear what you’re saying about your individual
health groups and that it hasn’t stopped you from
progressing, but Welsh Government gave a commitment, in response to
what the Auditor General for Wales found in 2011, that there would
be standardisation and that it would be completed by March 2013.
So, is there a specific reason why that date was missed? Now, we
are sitting here in 2016, you know. It’s not a couple of
weeks. We are talking a couple of years.
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[21]
Rhun ap Iorwerth:
Rhiannon Jones.
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[22]
Ms Jones: My understanding of the situation is that there has
been a gap in terms of a nurse lead within NWIS in terms of taking
that piece of work forward. There have been a number of attempts
via the all-Wales nurse directors to take that forward. One of the
nurse directors, Caroline Oakley, was previously responsible for
bringing together health boards, and us moving forward with
paper-based documentation. That is a challenge when it’s not
directed from the centre because each health board undoubtedly
thinks that their documentation is of a
standard—particularly, I think, when individual health boards
have done so much work to rationalise and standardise the
documentation in their own health boards. That’s a personal
view of maybe some of the reasons for delay, but one of the key
issues was a gap in nurse leadership at NWIS.
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[23]
Rhun ap Iorwerth:
Lynda Williams.
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[24]
Ms Williams: I think Rhiannon is right with regard to
standardisation of the nursing documentation, but what we have had
agreement over is the screening tool to be used. It is important to
know, never mind what the documentation looks like in each of the
organisations, that we all use the malnutrition universal screening
tool, or the MUST tool, to actually assess the patient, so that we
are all assessing against common criteria, which is the important
bit, rather than necessarily just the documentation.
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[25]
Andrew R.T. Davies:
So, if that position was filled—and
our briefing paper does point to the fact that this post has been
vacant—then you as health boards could see a far better
approach from Welsh Government, a joined-up approach, in
standardising it across the health boards. But the absence of
having that lead has led to slippage in the delivery time. Is that
a fair assessment?
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[26]
Ms Williams: I think that’s a fair assessment. There
was an individual in post, but the post has been vacant now
probably for about 12 months. So, our ability to be able to
progress the work, particularly in electronic form, has been sadly
very slow in that area.
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[27]
Andrew R.T. Davies: Could I just put two questions, if I
may, Chair? The two I’d like to ask are: one around training,
because again, the briefing paper does touch on the point about how
some staff obviously find it really difficult to get on to the
e-training model that you’ve put in place and—
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[28]
Rhun ap Iorwerth: We’ll want to talk about e-training
a little bit later on if—
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[29]
Andrew R.T. Davies: It’s in this briefing paper.
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[30]
Rhun ap Iorwerth: Yes. We will be talking about it,
certainly, but—
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[31]
Andrew R.T. Davies: Okay. Pass.
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[32]
Rhun ap Iorwerth: Okay. Oscar, you wanted to come in.
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[33]
Mohammad Asghar: Thank you very much indeed, Chair, and
thank you to the panel. With the Royal College of Nursing having
stated that nutrition was one of the very fundamental parts of care
and backed by the ‘Trusted to Care’ report in May 2014,
what actions are the eight health boards taking to ensure that
nutrition is being incorporated into the planning and monitoring of
patients? All of you.
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[34]
Ms Waters: We’ve undertaken quite a large piece of
work around our assurance processes in nursing and we’ve just
revised our assurance framework, as such. To use Tony Blair’s
expression, ‘Education, education, education’, I would
lead on that by saying we also need to, ‘Monitor, monitor,
monitor’. It’s about ensuring that you’ve got
structures in place to ensure that anything that’s picked up
at ward level, through any kind of audit, is fed up through the
organisation and back down again. Certainly, the structures that
we’re putting in in Aneurin Bevan mean that we will have that
very close monitoring from board to ward and beyond, where
necessary. So, it’s that assurance, that structure and the
metrics that go along with it, and the quality measures that go
along with it, as well, like patient surveys and how they find the
food. That information has got to be fed, board to ward, and
beyond.
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[35]
Ms Jones: I’d echo what Liz has indicated, but
additionally that we have got auditing processes within each of the
health boards, as was demonstrated in the Wales Audit Office
report. From a Powys perspective, we’ve got audits that are
called 360 degree audits, because they take in the full range of
review of the patient experience, but additionally nutrition and
the nutritional content of food—the catering service as well
as waste. So, that’s a full-blown multidisciplinary audit and
we use those results to triangulate information about patient
feedback as well, and there’s a patient feedback that’s
incorporated into that process.
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[36]
Rhianon Passmore: With regard to the question from Andrew
R.T. Davies, you mentioned that the post, for 12 months, had not
been filled, is there any reasoning for why that post has not been
filled?
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[37]
Ms Williams: I’m afraid I wouldn’t be able to
answer that question. But it is quite a rare set of skills that the
individual would require: to be both a professional nurse and an
informaticist is quite a rare set of skills. So, I would imagine
that there’s probably been a lack of applicants for the post.
I do know, from the conversations with NWIS around health and care
monitoring that we’ve talked to them about, that they did
take some time to decide what they wanted in that post, to be
assured that that post could deliver what was required of it by the
NHS.
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[38]
Rhianon Passmore: So, do you perceive there to be a lack of
urgency?
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[39]
Ms Williams: I don’t perceive there to be a lack of
urgency. As I said, it is a very specific skill set that’s
required and I think that they were right to take the time to make
sure that they had the right post to be able to deliver.
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[40]
Ms Jones: I think in terms of following that through, the
conversations that we’ve had with Jean White as CNO, clearly
identifying the priorities for that new person coming into post,
and one of those priorities being an all-Wales approach to the
documentation standards. So, we’re seeing that in place,
before the individual has even taken up post.
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[41]
Rhun ap Iorwerth: I would like to go on to staff training,
now, if that’s okay. If you’d like to come back in with
the question on e-learning, in particular.
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[42]
Andrew R.T. Davies: If that’s possible, thank you,
Chair. I’m very keen to explore the ability for staff to
train. Obviously, the briefing notes that we’ve had indicate
that staff felt unable to find the time to do that. I’m sorry
I’m looking at you, Rhiannon, but you’re in the middle,
so, if I’m scanning the whole row of people there—.
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14:15
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[43]
That’s deeply concerning, that is, because obviously people
being able to upgrade their skillsets is surely a vital part of a
modern workforce. So, is it a fair assessment to say that there
isn’t the time made available for staff to get that training
and, in particular, to make sure that they then have, because
we’ve heard about sharing of information, the ability to
assess that information? Because there’s no point taking
volumes of information in if you can’t assess whether that
information is actually what you want to be achieving on your
wards.
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[44]
Ms Jones: Shall I answer that first as you were looking at
me? I’m not taking it personally.
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[45]
Andrew R.T. Davies: You’re the chair.
[Laughter.]
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[46]
Ms Jones: Okay, thank you. I think it’s an important
point. The report does highlight the difficulties with e-learning
particularly, and that’s because of the availability of
computers. What I would draw the committee’s attention to is
that e-learning is only one approach to learning and education and
that classroom approaches are equally important. It’s the
e-learning that’s actually been monitored over the past few
years in terms of our compliance. I think Jean White, CNO, has been
very clear about the expectations of staff compliance with the
training.
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[47]
I know, from a Powys perspective, we have struggled with that. Some
of that is about the compliance that we’ve got with mandatory
and statutory training per se, not just in relation to nutrition.
An approach that we’ve taken to prioritise the importance and
have a prioritisation approach to mandatory and statutory training,
and I have to say, nutrition and e-learning were not prioritised
for Powys in terms of securing improvements to compliance. That
doesn’t mean that nutrition is not important, but it
isn’t just about the training compliance, it’s about
the ‘So what?’ as a result of that.
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[48]
If we were triangulating, that we had poor compliance with the
e-learning training but, additionally, we were having a lot of
complaints about nutrition, auditing was demonstrating that we
weren’t doing what we should have been doing, and I had low
compliance in terms of the assessments of patients within 24 hours
of admission, in triangulation, I would say that I would prioritise
training more. But, in this instance, for Powys, that isn’t
the case. I think it’s important to look at all the data and
what it’s telling us about the patient experience.
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[49]
So, the element of access doesn’t just apply to e-learning,
it’s much wider. I think that the capturing in terms of the
experience of our staff, which isn’t just about nurses,
it’s the wider, multidisciplinary team, is that there is
availability for other types of learning as well.
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[50]
Rhun ap Iorwerth:
But there was an expectation of
compliance, of course, with this. What is the Cwm Taf experience of
struggling to comply?
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[51]
Ms Williams: We do struggle to comply, as Rhiannon said, because
of the availability of computers. We’ve taken a slightly
different tack and we’re actually looking at how we can
enable our staff to use iPads and Chromebooks—mobile
electronic devices—to undertake their e-learning. We’re
also monitoring what the uptake of e-learning is from their home,
because they can actually access the platform from their own home
computers as well.
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[52]
So, we’re looking at that as being
a range of options. From next month, we’ll be able to monitor
our compliance directly through the electronic staff record,
because the learning platform will actually relate to the ESR
record and we’ll be able to—as we do for professional
development records—monitor that very closely to see if that
is an area that they haven’t actually picked up
on.
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[53]
We’ve also increased the nurse
inductions. So, at nurse inductions they will have a brief, if you
like, taster—although, pardon the pun—session of
learning around nutrition. The need to do nutritional assessments
will be part of that induction programme. So, we start the
education early and then the e-learning would be a top-up on that
to try and get everybody to that space. But, a bit like Rhiannon
said, that is only just one part of the process, really.
We’ve got a 94 per cent compliance with regard to the
nutritional assessments and the use of the MUST tool and the
nutritional care pathway. So, I’m quite confident that my
staff are doing the actual assessments. And, it is the ‘So
what?’ So what is it telling us? Are we getting it right? Are
people well-nourished when they’re in our care, which is the
most important thing, really?
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[54]
Rhun ap Iorwerth:
Perhaps the Aneurin Bevan experience
first.
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[55]
Ms Waters: I agree with my colleagues, mandatory training is
challenging. For all that we say nutrition is important, which it
absolutely is, so is infection control, so is dementia training, so
is fire safety—we can go on and on and on. So, we have to be
quite innovative in how we deliver the education. Again, my
colleagues have put forward some innovative ways of
delivering that education. Certainly in Aneurin Bevan, the
mandatory training issue has been picked up, and we will be putting
on three days in a row of mandatory training throughout the year
that staff can access because they find it far easier to access
mandatory training when they come off the ward and they’re
away from the ward for a whole day and they can truly engage in
that mandatory training. So, certainly that’s the approach
we’re using in Aneurin Bevan at the moment. There’ll be
mandatory training days run throughout the year.
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[56]
Rhun ap Iorwerth: Diolch yn fawr. Mae yna
gwestiynau—
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Rhun ap Iorwerth: Thank you. There are
questions—
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[57]
Andrew R.T. Davies: Can I just check something?
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[58]
Rhun ap Iorwerth: Yes, please.
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[59]
Andrew R.T. Davies: That training—the time that you
give the staff to train—has that
got to be done in work time or their own time?
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[60]
Ms Waters: Work time.
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[61]
Andrew R.T. Davies: So, it is work time.
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[62]
Ms Waters: Absolutely, yes.
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[63]
Andrew R.T. Davies: Hence that’s why we were getting
in the briefing note the interruptions that staff were referring
to, because obviously they’re juggling. So, it’s not
specific protected training time, it’s within the normal
working day and they might have 101 other things going on as
well.
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[64]
Ms Waters: Yes, absolutely.
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[65]
Rhun ap Iorwerth:
Mae yna gwestiynau penodol
ynglŷn â hyfforddi
gan Mike Hedges hefyd, ond un yn benodol ar
e-learning—e-ddysgu—gan Rhianon
Passmore.
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Rhun ap Iorwerth: We have specific
questions about training from Mike Hedges, but one specifically on
e-learning by Rhianon Passmore.
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[66]
Rhianon Passmore: In regard—. Sorry, I didn’t
quite catch that.
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[67]
Rhun ap Iorwerth: You have a supplementary on
e-learning.
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[68]
Rhianon Passmore: My questions. Okay. Can you talk me
through the actual process that the health board in Cwm Taf has
adopted around a patient satisfaction score? And obviously
that’s out of the patient survey element from the meal time
audit.
|
|
[69]
I might have leaped a bit forward there. [Laughter.]
|
|
[70]
Rhun ap Iorwerth: Yes, perhaps we—
|
|
[71]
Rhianon Passmore: Do you want me to shelve that?
|
|
[72]
Rhun ap Iorwerth: —can come back to that a little
later on. Mike Hedges on other aspects of training.
|
|
[73]
Mike Hedges: Yes. What action is the health board taking to
ensure that food and fluid intake are recorded appropriately for
all at-risk patients?
|
|
[74]
Ms Waters: Again, this is about audit. Again, I’ll be
honest and say that the challenge of audit is quite considerable,
because it’s not just nutrition and hydration that needs to
be audited, So, the audit tools that are currently in use in
Aneurin Bevan are under review, and we’re certainly looking
to utilise the quality checks document that has been produced from
the chief nursing office. What we want to put within that, though,
is some metrics, so we’re getting quality measures and
we’re getting metrics as well. And, again, that needs to
be—it’s the ‘so what?’; it needs to be fed
up from ward to board and back down again, and recognise where
there are deficits and, actually, and as we picked up with the
infection control, making sure the divisions are actually owning
their issues, owning their nutritional and hydration issues, and
that has been highly successful in bringing C. difficile down in
Aneurin Bevan health board, and we certainly expect compliance to
go up in terms of nutrition and hydration using that
methodology.
|
|
[75]
Ms Jones: I think, as Liz has indicated, there’s a
full suite of audit documentation that is employed across the
health boards, that that takes into account the quality checks
tool, which is as a direct result of ‘Trusted to Care’.
There are specific hydration and nutrition audits that are
undertaken; there are spot-check audits that are undertaken by
senior nurses and other members of the multi-disciplinary team. So,
it’s a full range of information, and not just the metrics
that are included within the health and care standards monitoring
system as well. I think there’s a full range of information
in terms of providing assurance.
|
|
[76]
Rhun ap Iorwerth:
Okay. Thank you. I should note that you
don’t need to press the buttons; they come on.
|
|
[77]
Mike Hedges: A couple more questions along this: you’ve got
dementia patients, and we’re talking to you, and I’m
sure you’ve got absolutely wonderful policies at board level.
I also know that a number of you have actually been ward managers
in the past. And that’s what actually happens, isn’t
it, that the ward managers are the ones who have responsibility on
a day-to-day basis, and you can audit them as much as you like, and
you can do all of these things as much as you like, but, if ward
managers are not complying, then it ain’t happening.
That’s the thing that concerns me. Now, dementia patients
quite often have serious problems with eating, et cetera. What is
being done to support patients in eating and drinking who have
difficulty doing it themselves?
|
|
[78]
Rhun ap Iorwerth:
Yes, Rhiannon
Jones—[Inaudible.]
|
|
[79]
Ms Jones: Thank you. It’s just because I’m in the
middle. [Laughter.]
|
|
[80]
Rhun ap Iorwerth:
All eyes on you.
|
|
[81]
Andrew R.T. Davies:
The two chaps either side are just
propping you up.
|
|
[82]
Ms Jones: It’s recognising it’s all about
Powys—no, not at all. [Laughter.]
|
|
[83]
I think they’re really important
points, and I’d absolutely concur that the role of the ward
sister and the charge nurse is critical. They are there with
24/7 responsibility for the quality of patient care. Auditing
provides additional assurance, though. For the care of patients
with dementia, those patients are identified on admission.
We’ve got something called ‘the red tray scheme’,
so, if people do need assistance, there’s a red tray
that’s given, and that provides a visual that the patient
needs additional assistance. Additionally, in terms of care of
patients with dementia, we’ve got the butterfly scheme, which
is about a butterfly that is placed above the patient’s bed,
and that gives additional indication that the patient needs
assistance, and, clearly, the nursing team will be aligned to the
patients who need assistance during the meal-time experience.
|
|
[84]
I think the additional element, which actually wouldn’t have
been captured as part of the Wales Audit Office review, is
John’s Campaign, which is something that is being adopted
across Wales in many of the health boards, and this is where
we’re particularly focused on patients’ relatives being
able to come in to hospitals outside of visiting times to assist
where necessary. That was picked up as part of the Wales Audit
Office report previously, in terms of protected meal times, but
John’s Campaign now is an additional initiative.
|
|
[85]
Mike Hedges: Have you ever thought of weighing patients? The best
indication of whether they are, or are not, getting sufficient
nutrients is whether their weight goes up or down. Surely, weighing
patients on a weekly basis who have nutritional problems would
actually give you an indication. You keep on talking
about—I’m just saying, you keep on talking about the
rules and the boards’ views. I can talk about ABMU: you can
go to two neighbouring wards, one of which will provide absolutely
perfect and brilliant support for people who have problems in
eating, and the other one will deliver the food and take it away
again—same rules, but it’s the
implementation.
|
|
[86]
Rhun ap Iorwerth:
Lynda Williams.
|
|
[87]
Ms Williams: And, I agree with you, that is one of the daily
challenges for senior nurses within the organisation and for
others: to make sure that we have standardisation, that everybody
works to a consistent standard across the organisation. In Cwm Taf,
additional to the things that Rhiannon has talked about with regard
to protected meal times, we are starting the John’s Campaign
as well, but we’ve always encouraged relatives and friends to
come in and make eating and meal times a social experience, as
opposed to just feeding, because that’s what it is for all of
us; it is a social experience.
|
|
[88]
The John’s Campaign is where we
have relatives actually staying on the ward, a bit like they do
with children and young people, and they stay with their relative
all of the time, to be with them. One of the other things that we
have actually got in place is volunteers, as well, to support the
staff in the feeding of patients. The registered nurse will
actually go to the food trolley and have the food dished out for
that patient, so they ensure that they have what they like and what
they feel that they can eat, and in the quantities that they feel
are appropriate for the individual.
|
|
[89]
Rhun ap Iorwerth:
We’re going to talk more about the
patient experience and what actually happens in the wards a bit
later on, but I’m just keen to keep a focus. Andrew R.T.
Davies wanted to come in.
|
|
[90]
Andrew R.T. Davies:
Just on that audit point, If I may,
Chair, because I did allude to it in an earlier question:
it’s wonderful taking all that information, but you’ve
got to be able to see if that information is being put to good use,
then, when it’s been assessed. And, in the papers we’ve
got, you’ve talked—or the papers talked—about
nurses sometimes looking at this information, as well as
dieticians—it’s not always the dieticians who look at
this. Are you confident that the procedures that you have in place
to look at the audit information that you’re getting back
from the ward are robust enough and that you can make the changes
where those changes need to be made—where you might find bad
practice being undertaken or the quality of the food isn’t
meeting the patients’ needs?
|
|
[91]
Ms Waters: This is a senior nurse responsibility, and
we’ve been very clear in Aneurin Bevan health board that the
senior nurses are there, first and foremost, for the fundamentals
of nursing care, be it nutrition, be it infection control, be it
dementia. Certainly, the audit results—and they do quite
intense audits, I have to say, the senior nurses, and they truly
are feeding back to the ward sisters where there are any deficits.
So, it’s a senior nurse responsibility, as well as a ward
manager, to really focus on those audits and to make sure that they
follow up on any deficits that are found.
|
|
[92]
Rhun ap Iorwerth:
Okay. Mike Hedges, you had another couple
of questions that you wanted to ask.
|
|
[93]
Mike Hedges: The only other one I wanted to ask, and I asked it
last time, was on weighing, weighing patients.
|
|
[94]
Ms Jones: We do weigh—so, we weigh patients on admission,
and it’s also part of the MUST assessment, which is the
malnutrition universal screening tool. So, weighing
is—. And then, depending on the patient’s score
depends on how often you would then weigh the patient, so that is
fundamentally important.
|
|
14:30
|
|
[95]
Rhun ap Iorwerth:
Is that standardised?
|
|
[96]
Ms Jones: Yes.
|
|
[97]
Ms Waters: One of the challenges, of course, is that, when
patients first come in, they’re very, very sick and sometimes
can’t even get out of bed. So, it’s about checking with
either the patient or the family what they normally weigh, so we at
least have that to go on with, and there’s also a way of
measuring a patient’s arm to understand whether they have
nutritional problems.
|
|
[98]
Rhun ap Iorwerth:
Okay. Briefly, if you could.
|
|
[99]
Ms Williams: Sorry, I was just going to say it wouldn’t just
be about weighing, it would be about body mass index as well. So,
it’s about, you know, their height to weight ratio, so that
you know what you’re—.
|
|
[100]
Rhun ap Iorwerth:
Yes. Mohammad Asghar, and I think
you’ve got some questions about the nutritional care
pathways.
|
|
[101]
Mohammad Asghar:
Yes, I’ll ask that question
afterwards. Linking into the hospital doing an amazing job for the
food and nutrition for the patient, I’ve seen a first-rate
experience with family members. But, the fact is: when the patient
is registering for the operation or treatment in the hospital,
weeks before they get all the arrangements done for them, what
about the nutrition? Are they involved, because there are cultural,
religious, there are different age factors involved, and the food
is there on a trolley, which is free for all, but some people are
not used to that sort of food. Is there any such sort of clause
there for you to look at to make sure that every patient is looked
after according to his or her needs?
|
|
[102]
Ms Jones: When a patient is admitted to hospital, as part of
the initial assessment, you will review what their cultural needs
are, what their dietary needs are, and then, if there are special
diets required, we will refer to the dietitian or indeed our
catering colleagues in terms of ensuring that we provide the food
that’s most appropriate for the patient.
|
|
[103]
Mohammad Asghar:
I’ve yet to see that there’s
somewhere with halal food—I
don’t want to touch it, but
that is an area that is not being covered, I think. That has got to
be considered. My question now, Chair, actually is related to the
panellist—
|
|
[104]
Mr Phillpott: If I may—
|
|
[105]
Rhun ap Iorwerth:
On that point, yes, absolutely, please
come in.
|
|
[106]
Mr Phillpott: I’m quite confident that we do meet all dietary
and cultural needs, halal included.
|
|
[107]
Mohammad Asghar:
I’m talking about Royal Gwent
hospital—I’ve been there quite regularly for a few
weeks, and there was no such thing I saw anywhere. So, leave it
now, because you are not from Royal Gwent.
|
|
[108]
Ms Waters: Yes, we are from Aneurin Bevan health board, and I
will certainly look into that aspect.
|
|
[109]
Mohammad Asghar:
Okay, thank you very much indeed. My
question actually relates to the nutritional care pathway, and the
current compliance with nutrition screening across the health
boards’ hospitals: what is the condition at the moment? And the second, in the
same one, is: what action are the health boards taking to improve
and sustain compliance in their hospitals in Wales?
|
|
[110] Ms Jones: Okay.
Thank you. I can confirm that that information is regularly
assessed—it’s assessed on a monthly basis with a
monthly audit to determine compliance. My latest figure for Powys
teaching health board is 97 per cent compliance for assessment of
the patient within 24 hours of admission, and, additionally, that
appropriate action has been taking place based on that
assessment.
|
|
[111]
Ms Williams: And that’s similar in Cwm Taf. Our monthly
compliance rate is running around 93 per cent, and it’s
reported from the clinical areas up to the board through the
quality and safety committee, so the board are advised of what our
position is.
|
|
[112]
Ms Waters: And I can confirm that ours is running at 94 per
cent.
|
|
[113]
Mohammad Asghar:
Wonderful to know, Chair, but the fact
is: who is responsible for ensuring that the compliance and
nutritional screening is improved and sustained, as you just
said?
|
|
[114]
Rhun ap Iorwerth:
Liz Waters.
|
|
[115] Ms Waters: As
discussed earlier, we now have an assurance framework. We have a
clinical nutrition and hydration committee, so that’s where
such data will be scrutinised and passed down, most importantly,
through divisional quality and patient safety forums. Again, I
talked about ownership earlier on—that’s an
absolutely crucial component in all of this—so, the divisions
themselves have their own quality and patient safety forums, and we
expect that kind of data to be discussed there.
|
|
[116]
Rhun ap Iorwerth:
Rhiannon Jones.
|
|
[117]
Ms Jones: In terms of nutrition and hydration, I would confirm
that, as the director of nursing of the Powys teaching health
board, I am accountable for the patient experience in terms of
nutrition and hydration, which is delegated from the chief
executive.
|
|
[118]
Rhun ap Iorwerth:
And, speaking of the patient experience,
Lee Waters has some questions about the patient’s
view.
|
|
[119]
Lee Waters: Yes, thank you. I’m interested in a
discrepancy, really. Oscar Asghar touched on the question with you,
Mr Phillpott, about special requirements. You said you were pretty
confident, in the Royal Gwent, that halal was catered for;
certainly, a patient’s experience here is different to that.
The petition that was presented earlier this year to the Petitions
Committee was precisely on this case: that special dietary needs
were not being met. I’ve certainly had my constituents raise
with me that, in their experience, diabetics are not being catered
for by the main service. Their family have to bring in additional
food for them. So, how do you account for the official view, which
is all is fine, when the views of patients that are coming
repeatedly through different avenues are that all is not well in
this regard?
|
|
[120] Mr
Phillpott: Well, I don’t actually work at the Royal
Gwent, but—
|
|
[121] Lee
Waters: It’s your health board.
|
|
[122] Mr
Phillpott: It is our health board, yes.
|
|
[123] Lee
Waters: And you are confident that halal meals were served, but
that’s not the experience that was had by a recent patient,
and I can give you several other examples of a disconnect between
the health board view and the patient feedback. So, I’m
trying to understand the mechanisms for getting patient feedback
and how you respond to that.
|
|
[124] Mr
Phillpott: Well, to take your point about diabetics, diabetics
should be catered for in the main amended menus that we
produce.
|
|
[125] Lee
Waters: But they seem not to be, from some of the feedback
I’ve been getting.
|
|
[126] Ms
Waters: In terms of some of the feedback that we have from our
own health board, I’ve not seen halal issues or cultural
issues coming forward, but I can certainly look into that to see
where the discrepancy is.
|
|
[127] Lee
Waters: So, what do you do to monitor the patient experience,
so that your understanding tallies with the patient experience?
|
|
[128] Ms
Waters: Well, again, we have bimonthly audits. They actually
finished in March and we now need to get them back on the agenda
again. And we’ve also got what’s called the Hootvox
patient experience, which picks up all patient experience issues,
not just nutrition, and then that gets fed into our nursing
committees. I can’t say that we’ve actually picked this
up at all, but I will certainly look into it.
|
|
[129] Lee
Waters: So, why do you think you aren’t picking that up,
if people are routinely saying there are problems in the system and
that special needs are not being met? Why aren’t you picking
that up?
|
|
[130] Ms
Waters: I don’t know. I think we will need to look into
that, most definitely, and see why that’s falling off our
agenda.
|
|
[131] Lee
Waters: Okay.
|
|
[132] Rhun ap Iorwerth: Lynda Williams.
|
|
[133]
Ms Williams: We have bimonthly patient satisfaction audits that
are fed back in through clinical areas and through to our nutrition
and catering group. They are currently running at between 90 and 94
per cent in Cwm Taf. We are launching an app for patients to be
able to download to assess their satisfaction around food and
catering when they get home. That app will come online in November
of this year. But, as I said, we’ve got an overall
satisfaction rate of between 90 and 94 per cent, and one of the
improvements that we did as a result of that satisfaction survey,
because patients were telling us that they didn’t have enough
access to snacks, so something that we’ve managed to
implement now are ward-based snacks, so food is available when
individuals need it, and clearly want it.
|
|
[134]
Lee Waters: But one in three patients said in the last patient
surveys that they found the meals unappetising. What are you doing
about that?
|
|
[135]
Ms Williams: In Cwm Taf?
|
|
[136]
Lee Waters: Well, across Wales.
|
|
[137]
Ms Williams: Across Wales—you know, I can’t comment on
what it looks like across Wales—
|
|
[138]
Lee Waters: So, what’s the Cwm Taf figure?
|
|
[139]
Ms Williams: —but I do know that, in Cwm Taf, as I said, we
have, overall, good satisfaction—excellent
satisfaction—from patients.
|
|
[140] Lee Waters: So, what’s the figure
for unappetising meals in Cwm Taf?
|
|
[141]
Mr Hayward: I don’t know that, actually, but what I do know
is that our satisfaction is running at 90 per cent.
|
|
[142]
Lee Waters: Okay. So, you don’t think the all-Wales figures
are relevant to Cwm Taf.
|
|
[143]
Mr Hayward: Well, I’d like to look at the detail, if that
was the case, because I can’t answer in the round, to be
fair.
|
|
[144]
Rhun ap Iorwerth:
Any information that you could pass on to
us after today’s meeting—
|
|
[145]
Ms Williams: Yes, absolutely. We can let you know what that would
be.
|
|
[146]
Mr Hayward: We can certainly look at the detail in relation to
Cwm Taf.
|
|
[147]
Lee Waters: I’d like to ask specifically about hydration.
The Water Keeps You Well campaign has been promoted as something
that should be rolled out and yet, again, the last survey showed
that 40 per cent of patients were not routinely being offered
drinks at meal times. Why do you think that is?
|
|
[148]
Ms Jones: It’s a key question. In terms of answering
that, I think there have been a number of discrepancies in terms of
the standards that came out about the offering of fluids across the
patient day, with a view that they weren’t to be offered with
the meals, but after the meals. So, I’m not sure whether
that’s had an impact in terms of the data there. The bottom
line is that the standards are quite clear: there are to be seven
to eight beverages every day and, certainly in Powys, we’re
compliant with that.
|
|
[149] Mr
Phillpott: As we are in Gwent.
|
|
[150]
Rhun ap Iorwerth:
Okay. Lynda Williams.
|
|
[151]
Ms Williams: The all-Wales campaign actually originated from an
idea that was taken forward in Cwm Taf. We call it the Drink a Drop
campaign. We’ve promoted it throughout our organisation,
where each and every individual who comes into contact with that
patient—be it a doctor, a porter or nurse—actually
offers the patient a drink, so that hydration is everyone’s
business, really.
|
|
[152]
Lee Waters: So, what can other health boards learn from that,
then? Why do you think that it is, across Wales, at 40 per cent,
and patients are not being routinely offered that?
|
|
[153]
Ms Williams: I think there is an issue with regard to whether
they’re being offered it with their meals, or whether it is
available for them. Not everyone wants to have a drink with their
meal. They might like it between meals. So, some of it will be
about personal choice. Rhiannon explained that there is a
requirement for us to have seven points at which drinks are
available. Certainly, from our health board’s perspective, we
do manage to hit that in the majority of cases. The area where
there is a deficit for us, and we do recognise that, is the evening
times, where the jugs are to be replaced by nurses. Often, the
water jugs are not a priority—well, I can’t say
it’s not a priority. It’s something that does get
missed in the round. So, that could be where that 40 per cent comes
in. It’s the evening drink that is an issue in our
organisation.
|
|
[154]
Ms Jones: And that good practice from Cwm Taf is being spread
across Wales to all health boards. We piloted the Water Keeps You
Well campaign in Powys, and we are now rolling that out across all
of our wards and departments.
|
|
[155]
Lee Waters: Okay. Thanks for that.
|
|
[156]
Ms Waters: We participated in the campaign as well.
|
|
[157]
Rhun ap Iorwerth:
Okay. Moving on to an associated area,
from the food to the meal time experience—Rhianon
Passmore.
|
|
[158]
Rhianon Passmore:
Diolch. What more needs to be done around
protected meal times?
|
|
[159]
Rhun ap Iorwerth:
Liz Waters. Shall we start
there?
|
|
[160]
Ms Waters: It certainly needs to be much more than a sign
outside the door, saying, ‘We have protected meal
times.’ Again, the auditing process is absolutely crucial
here. It’s about the quality of that protected meal time. So,
yes, it is about signage, which indicates that the ward is
protected. But that signage also needs to be very, very
clear—and it is—that relatives and family can come and
help their loved one during that protected meal time. But we really
do need to focus more on the quality—so, for example, if the
bed situation is poor. We’ve got doctors coming on the wards.
There are lots of competing priorities, and, certainly, in the work
that we’ll be doing, moving forward, through the nutrition
and hydration group, we’ll be looking at the quality of that
protected meal time experience.
|
|
[161]
Rhianon Passmore:
Before you come in, in terms of the
nutrition and hydration group, is that pan-Wales or are you just
talking about the local health board?
|
|
[162]
Ms Waters: No, this is our own health board.
|
|
[163]
Rhianon Passmore:
In that regard—I don’t know
who to ask this question to—is there something similar that
is pan-Wales on nutrition and hydration? A forum, group, person or
lead?
|
|
[164]
Ms Jones: There’s a multidisciplinary nutrition group
across Wales.
|
|
[165]
Rhianon Passmore:
Did you want to come in and answer around
protected meal times?
|
|
[166]
Ms Jones: I did. Is that okay? Thank you. Following up on what
Liz said, I think, from my perspective, there’s got to be a
constant focus on it. So, the very fact, as I think you’ve
raised yourself, that there’s a policy—that
doesn’t necessarily mean that, just because you’ve got
a policy, it is implemented. On a number of occasions, I’ve
been very disappointed to have feedback—whether it is through
the Wales Audit Office, which it wasn’t on this occasion, or
Healthcare Inspectorate Wales—that indicates that their
experience is that protected meal times haven’t been followed
to the letter. For example, a doctor may be taking bloods at the
time that the meals are being given. Now, there’s a
perception issue there as well, though, because those bloods may
have been critical. So, the very fact that a doctor was taking
bloods—there’s a perception that that shouldn’t
have happened. But, actually, it is about non-urgent clinical
activity. So, I think sometimes there are some discrepancies in
terms of how that’s being defined, to be honest. From my
perspective, it is about constant attention to this, and how we
monitor that. So, ward sisters’ responsibilities for ensuring
that’s happening—I think they’re critical. Liz
has mentioned the senior nurses, but I think it goes right through.
It isn’t just about nursing. It is everybody’s
responsibility. So, I think that needs to be the constant
focus.
|
|
[167]
Rhun ap Iorwerth:
Some further questions from Mike
Hedges.
|
|
[168]
Mike Hedges: Can I just say that I was very pleased with the
answer that Liz Waters gave regarding protected meal
times—that relatives were able to come in and help?
It’s not my experience. I can talk about Abertawe Bro
Morgannwg University Local Health Board, but I’m not sure
that it’s different to any of the other boards. I think that
this is where we have the disjoint between what you are saying here
and what ward sisters are doing on the ward. I can take you to a
ward in Morriston hospital where
it says, ‘NO-ONE’—in big capital
letters—‘to come in during protected meal times’.
I think that’s a problem. You’ve all got brilliant
policies; I have no doubt about the efficacy of your policies.
It’s making sure those are being implemented. If only every
ward had outside what Liz Waters just said, that we have outside,
‘In protected meal times, relatives may come in to help with
eating.’ That would probably be the one thing that would make
a huge difference. Perhaps, can I urge you to share that with
colleagues and bring it into your own organisations, so that every
time anybody goes outside a ward they see that?
|
|
14:45
|
|
[169] Ms
Waters: Yes, I agree. We certainly
have been reviewing our signage, and we’ve put some temporary
signs up for the moment, but we’ll be looking for permanent
signage. It’s absolutely crucial, moving forward.
|
|
[170]
Ms Jones: I’d probably just follow that up as well, in
that, from the highest levels down, that’s been cascaded and,
you know, there has—I wouldn’t say regular
correspondence—been correspondence from Jean White, CNO, to
indicate the importance of relatives being enabled to join at
specific times of the day. I’d like to sit here and say that
you would not have that experience in Powys. I know, through our
sisters’ forums and senior nurse forums, that the message and
the assurance that I receive is that the patients’ relatives
can attend.
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[171]
Rhun ap Iorwerth:
I’d like the experience of Cwm Taf
specifically in a second, but Lee, I know, wants to come
in.
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|
[172]
Lee Waters: Just to follow up on this idea of families coming in
and eating with their relatives, and I can see what you said
earlier about the need for it to be a social thing, and for there
to be an extra pair of hands. But there’s a balance,
isn’t there, when the families are feeling that they’re
expected to bring in food? Especially referring back to my point
earlier about special dietary requirements, the feedback I’m
getting from my constituents is that, often, if they do have
special requirements, the family are expected to bring food in for
them. That can’t be right, can it?
|
|
[173]
Mr Phillpott: No, I don’t think that’s at all
right.
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[174]
Lee Waters: The disconnect reappears.
|
|
[175]
Mr Phillpott: Well, you can pick on me if you like, but I think,
basically, we have policies that restrict and advise relatives on
exactly what they should be bringing in for their patients. The
basics, which you speak of, just simply shouldn’t
happen.
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|
[176]
Lee Waters: But it is happening, and that’s my
point.
|
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[177]
Mr Phillpott: Well, if you can give me the details, I’d like
to look into it.
|
|
[178]
Lee Waters: Okay. So, you don’t think that this is
happening in any great scale? You think this is just a nice
anecdotal example?
|
|
[179] Ms
Waters: It’s certainly not
anything that we’re aware of, as yet. But I would be quite
happy to look into it.
|
|
[180]
Lee Waters: So, there’s no policy of encouraging—.
I’ll happily pass on examples. But as far as you’re
concerned, there’s no policy encouraging families to bring in
food.
|
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[181]
Ms Waters: No, absolutely not.
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[182]
Lee Waters: Okay.
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|
[183]
Ms Jones: It’s the opposite, to be honest, because
we’ve got a clear protocol in terms of what food can be
brought in because of environmental health. I can give an example
from just last week of a complaint that I was involved in, where
relatives were complaining because they were stopped from bringing
food in, which is diametrically opposite to what you’re
describing. So, I think there’s mixed approaches,
probably.
|
|
[184]
Rhun ap Iorwerth:
Can I ask about the development of your
patient satisfaction scoring system, please?
|
|
[185]
Mr Hayward: Yes, sure. It’s based on SurveyMonkey, which
is—. When a patient leaves the hospital we’ll give them
a business card, and that business card’s got an optical
character recognition box on it, which you can scan with your
mobile phone. When you scan it with your mobile phone, it takes you
to a secure website where you can answer 12 questions based on,
‘Did you enjoy the food?’, ‘What did you think
about the food?’, ‘Can we improve the
food?’—any general comments, and a free text as well.
We’re doing that for our restaurants and we’re also
doing it for our coffee shops as well.
|
|
[186] Rhun ap
Iorwerth: How many respond to that? How do
you—?
|
|
[187] Mr
Hayward: It’s being launched in November.
|
|
[188] Ms
Williams: The app is being launched
in November, but we already do the patient satisfaction surveys
bimonthly while they’re in hospital. As I said earlier, we
then try and tailor the comments that we have to try and make the
improvements that are required.
|
|
[189] Mr
Hayward: What we try and do is
capture a wider audience, because when you try and speak to people
in beds it’s often difficult because, you know, their care is
the priority, not the surveys. Whereas, when they go home, they can
do it at their leisure. So, that’s why we try and do it
then.
|
|
[190] Rhun ap
Iorwerth: And, clearly, in doing
something like that you think that there’s a gap that needs
plugging. I think that some of the questions that Lee Waters has
been asking—you know, somehow, there’s a disconnect
between what people are thinking and, perhaps, that information
getting through to you. Is that what you’re trying to do
here?
|
|
[191] Mr
Hayward: Rather than suggest
there’s a gap, I would rather suggest that there’s an
improvement that could be made.
|
|
[192] Rhun ar
Iorwerth: Okay. Rhiannon Jones.
|
|
[193] Ms Jones:
I think that’s really important,
because the surveys that we undertake at the moment are when
patients are in hospital, and sometimes, they’ll give
a different view when they’re in hospital, for reasons that I
can understand, than, perhaps they would give once they’re at
home and they’re feeling better in themselves. Actually, when
they reflect on their experience, they might give us a very
different view. So, I think the very fact that we’re looking
at something outside of the in-patient setting is really important.
That’s probably a gap from a Powys perspective: we
don’t gain views when patients have been discharged. So, I
think that’s really important.
|
|
[194] Rhun ap
Iorwerth: Which is quite important, actually.
|
|
[195] Ms Jones:
Absolutely. It might link in with what you said, Mr Waters, in
terms of people’s views once they’re outside. I
don’t know, but it’s something, I think, to pick up
on.
|
|
[196] Neil
Hamilton: How do you conduct these surveys? Is it a random
sample of patients? Presumably, you haven’t got the staff to
interview everybody along these lines.
|
|
[197] Ms Jones:
It’s a sample of patients in Powys.
|
|
[198] Mr
Hayward: Certainly in Cwm Taf it’s the same.
|
|
[199] Mr
Phillpott: It’s the same—[Inaudible.]
|
|
[200] Rhun ap
Iorwerth: Is there an admission that the sample isn’t big
enough and that you’re trying to cast the net wider?
|
|
[201] Mr
Hayward: I think we’re trying to just open another
opportunity and another medium for them to actually provide the
information back.
|
|
[202] Ms
Williams: I was going to say that that sample will be across
all clinical areas. Obviously, we provide services for mental
health patients, we provide services in community hospitals, in
maternity services. So, that sample survey will be across the
clinical areas.
|
|
[203] Mr
Phillpott: I think we need to pick up on what they’re
doing in Cwm Taf and piggyback on what they’re doing, because
it seems a good system.
|
|
[204] Ms Jones:
I just wanted to follow through in terms of Mr Hamilton’s
question there in terms of the random sample. What’s
important is that it’s independent. It’s people going
into the ward and selecting patients, so it’s not necessarily
the nurses on the ward who are selecting, because you could select
positively, couldn’t you? So, when it’s independent
people, it can be any patients who they approach. Just for
assurance.
|
|
[205] Ms
Waters: Yes. And that’s what’s particularly good
about the CNO’s quality check tool: it’s peer
reviewing, which gives you a much more objective view of
what’s going on on a ward.
|
|
[206]
Rhun ap Iorwerth:
Mi fyddwn i’n dymuno symud
ymlaen yn eithaf buan at faes pwysig iawn, sef gwastraff bwyd a
chostau arlwyo. Mi ddown ni at gwestiwn gennych chi, Neil Hamilton,
mewn eiliad, ond un pwynt bach olaf neu gwestiwn olaf gan Lee
Waters fan hyn.
|
Rhun ap Iorwerth: I would like to move
on quite quickly to an important area, which is food waste and
catering costs. We’ll come to a question from you, Neil
Hamilton, in a second, but one final point or question from Lee
Waters.
|
|
[207] Lee
Waters: Diolch, Rhun. Just very briefly, to pick up on
something Mr Phillpott said about the spreading of good practice.
The auditor’s updated note in September pointed out that, up
until 2013, the all-Wales menu framework was reported to Welsh
Government twice a year, but since then, that’s stopped and
is now being dealt with within health boards. So, I wonder what
mechanisms now exist for the pan-Wales sharing of good practice or
raising of issues and whether or not you think things have changed
since that all-Wales twice-annual reporting has stopped.
|
|
[208] Mr
Phillpott: The all-Wales menu framework group meets several
times a year—three times a year—and there are work
streams that emanate from that group. You talked about training
earlier and we were focusing on, perhaps, clinical training, but
for non-clinical staff—ward hostesses and ward-based
caterers—this is a work in progress here, which is a
nutritional skills for life learner workbook. That’s just one
example of the things we’re trying to do to develop
consistency and standardisation throughout Wales. So, it
isn’t just the menus and the input there, we do work on other
streams.
|
|
[209] Lee
Waters: So, is that not right, then, that this group—?
The report suggested it stopped reporting twice yearly to the Welsh
Government in 2013. You’re saying that’s happening. Is
it?
|
|
[210] Mr
Phillpott: I’m not sure—
|
|
[211] Ms
Waters: They may have stopped reporting, but the group is still
in existence.
|
|
[212] Lee
Waters: Right, but it doesn’t report.
|
|
[213] Mr
Phillpott: I’m not sure. Judith John is the chair of the
group. She’s a dietician. I’m not sure
whether—
|
|
[214] Rhun ap
Iorwerth: Perhaps we can seek more clarification on that.
|
|
[215] Ymlaen at
wastraff bwyd a chostau. Neil Hamilton.
|
Moving on, therefore, to food waste and costs.
Neil Hamilton.
|
|
[216] Neil
Hamilton: I’m interested in the extent to which health
boards are confident that the food wastage statistics that are
being collected are accurate. The background to this is that, in
2011, the auditor general reported that there were significant
variations around Wales, and then, in 2012, a new model was
introduced for costing patient and non-patient catering services.
And although the wastage figures have improved significantly since
then, inconsistencies in the way things are measured, or indeed,
the possibility of measurement at all between health boards, still
means that we can’t necessarily rely fully on the statistics
that are collected. Can I use Powys as an example, not just because
you’re sitting in the middle? The average cost of a patient
meal throughout Wales is apparently £3.31, but in Powys the
figures appear to be nearly double that. We’re concerned that
that figure may be an overestimate because the responsibility for
catering budgets is not centralised within the facilities
management team, and therefore the way you cost food procurement
generally is not differentiated from the cost of providing meals
for patients. So, we can’t really tell, even when you
calculate the wastage figures, to what extent they can be related
to the other costs that are obtained overall.
|
|
[217] Ms Jones:
Shall I answer that one?
|
|
[218]
Rhun ap Iorwerth:
Yes.
|
|
[219] Ms Jones:
Thank you. Yes, the report does indicate that it’s probably
£6 per patient per day, which, as you indicate, would be
almost double what it is elsewhere, but there was a note of caution
against that because of the challenges of not a centralised
approach to the costing. Previously, it was a north-and-south
approach, and they were different. What I can confirm today is that
the restructuring has taken place in terms of facilities, and
we’ve now got that back-office function for facilities in
terms of now calculating that on a Powys-wide basis. I can’t
tell you today what the costs are that are associated with that
because that new structure has literally just come into being, but
a caution in terms of that figure.
|
|
[220] Neil
Hamilton: So, you’re confident now that the intended
benefits of this will be realised. How soon do you think
we’ll be able to get some indication?
|
|
[221] Ms Jones:
I think, speaking to the head of facilities, certainly within the
next three months you would hope to have a better position around
that.
|
|
[222] Neil
Hamilton: I see. Okay.
|
|
[223] Ms Jones:
And we can share that with the committee, if
that’s—
|
|
[224] Neil
Hamilton: Obviously, I didn’t mean to single you
out—
|
|
[225] Ms Jones:
No, that’s fine.
|
|
[226] Neil
Hamilton: [Continues.]—for the specific
questioning on that point, although I don’t know whether the
extent to which the other health boards had similar organisational
and management problems for the way in which their costs are
calculated.
|
|
[227] Ms Jones:
Shall I just—
|
|
[228] Rhun ap Iorwerth: Just before you finish, I think it is fair, by
the way, to single out Powys because of the discrepancy in the
figure. Rhiannon Jones.
|
|
[229] Ms Jones:
I didn’t feel it was unfair and I was probably expecting it.
So, that was fine. Thank you. I just wanted to add in there that
perhaps, certainly from a Powys perspective, our head of facilities
still raises concern about maybe some discrepancy in the way that
waste is being calculated on an all-Wales basis. So, I think that
that’s something that we do need to pick up.
|
|
[230] Rhun ap
Iorwerth: If I understand correctly, even though there was the
discrepancy—and presumably Powys would have wanted to sort
out what was going on, and there has been a restructuring—you
still don’t know exactly what the figure is for Powys.
|
|
[231] Ms Jones:
We will know that—
|
|
[232] Rhun ap
Iorwerth: But you still don’t know now what the figure is
for Powys, even though—
|
|
[233] Ms Jones:
Well, we’re reporting the figures. We continue to report in
the way that we’ve reported for years on that waste, but we
recognise that when we compare Powys to the all-Wales basis
there’s a confidence that that’s an overestimation.
Additionally, there’s concern from a Powys perspective about
how all health boards and trusts in Wales calculate waste.
|
|
[234] Rhun ap
Iorwerth: Shall we get the Cwm Taf experience first?
|
|
[235] Mr
Hayward: Yes, I’m happy to pick that up. In Cwm Taf, as
assistant director of facilities, we actually have those costs
contained within facilities; so, there are no discrepancies. Our
food production is through a central production unit; so, waste is
minimised that way. It’s at 2.1 per cent. Then, obviously,
you’ve got a different set of waste, where you’ve got
the plated waste, which is recorded at the ward level, because
we’ve got very low plated waste as well. Because, in the
process, we actually regenerate based on the patient’s choice
two hours before the meal time. So, as I said, we get low
waste.
|
|
[236] Neil
Hamilton: So, your 2.1 per cent figure relates to unserved
meals, does it?
|
|
[237] Mr
Hayward: It’s overall, that is. It’s overall, and
then that’s split down.
|
|
[238] Neil
Hamilton: Right. What do you see as the main causes of waste
from unserved patient meals? I notice from the figures that that
varies between 2 per cent and 10 per cent across NHS bodies in
Wales, and that overall cost is about £1 million, which could
obviously be better spent elsewhere. Why is it that meals go back
completely uneaten or unserved?
|
|
[239] Mr
Phillpott: I think there are a variety of reasons. I think
ordering near to consumption is something we could do to improve
it. In YYF—Ysbyty Ystrad Fawr—we’re going to do a
trial, starting next month, of same-day ordering so that patients
will order their lunch and their supper in the morning. We hope
that way we’ll have accurate figures.
|
|
15:00
|
|
[240] It’ll also
reflect the appetite of the patient on the day with their clinical
condition. It’ll minimise, I think, the number of ghost
patients—where patients have moved out of the ward. So,
hopefully, we’ll be able to tell you in not too much time
whether that was successful.
|
|
[241] Neil
Hamilton: Where patients are either elsewhere in the hospital
at the time meals are served or, maybe they’re asleep, or
whatever, what happens then to ensure that they do get proper
sustenance during the day, outside of normal mealtimes?
|
|
[242] Mr
Phillpott: We go back to them a little later on, when the
patient is ready to receive the meal. We also supplement that with
snacks, so the patients have got access to food 24 hours a day,
really.
|
|
[243] Rhun ap Iorwerth: Mr Hayward wanted to
come in on that last point.
|
|
[244]
Mr Hayward: Certainly, in Cwm
Taf—[Inaudible.]—introducing an à la
carte-style menu, so, rather than giving a patient a full
breakfast, a full lunch and a full tea and then sandwiches at the
evening meal—in reality, nobody wants to eat that much all
day—we gave them the option of a lighter lunch or a lighter
tea, which then reduces the waste levels and they also maintain
their nutritional values.
|
|
[245]
Rhun ap Iorwerth:
Before you continue, I think Andrew R.T.
Davies wanted to come in, just on a supplementary.
|
|
[246]
Andrew R.T. Davies:
Just on that point, you were saying that
a same-day ordering service—. I notice from the papers that
you’re one of the few health boards that has a computerised
system of ordering i.e. tablets on the wards. You’re more the
exception—I think Cwm Taf, as well, have it, if I’ve
read this paper correctly—but you’re one of only three
that are doing that, and there’s a business case at the
moment before the Government as to whether they want to roll it out
across the NHS. Is it having those tablets on the ward that offers
you the flexibility to have same-day ordering and that greater
flexibility in the system?
|
|
[247]
Mr Phillpott: It’s not so much that tablets will promote the
same-day ordering, we could do that with paper menus,
but—
|
|
[248]
Andrew R.T. Davies:
But it simplifies it, though, surely,
having it on tablets.
|
|
[249]
Mr Phillpott: Certainly. We want to roll it out right across the
board. We’ve had it for 12 months in YAB—in Ysbyty
Aneurin Bevan—and that’s been quite successful. The
beauty of it is you are asking the patient what they want at the
time of ordering and you can show them a photograph of the meal,
you can provide nutritional information and, basically, the
information then goes down to the kitchen and it collates all your
totals for production. But, the only thing with that at the moment
in YAB is it’s done the day before; it’s done the
afternoon before. We feel we want to move that to the same
day.
|
|
[250]
Andrew R.T. Davies:
So, that’s a procedural thing,
though, being done the day before. It's not a technology thing, is
it?
|
|
[251]
Mr Phillpott: No, it’s not.
|
|
[252]
Andrew R.T. Davies:
But, actually having that technology
within your health board has a huge advantage in the way that you
are able to deal with patient requests, food waste and getting a
better product to the patient in the first place.
|
|
[253]
Mr Phillpott: Yes—to all three.
|
|
[254]
Andrew R.T. Davies:
So that’s a win-win all the way
round.
|
|
[255]
Mr Phillpott: Certainly.
|
|
[256]
Rhun ap Iorwerth:
Hold your last questions for a second,
Neil Hamilton, here’s a question from Lee Waters.
|
|
[257]
Lee Waters: Just a quick follow-up to something you said about
when a patient misses a meal—that they are offered another
meal. Because the auditor’s report shows that from the
all-Wales survey only 12 per cent of patients were offered a
replacement when they missed a meal.
|
|
[258]
Mr Phillpott: Well, I can only speak for Gwent, but it is the case,
yes; we would look to replace the meal at the next convenient time.
It depends on the circumstances. It might be a sandwich; it might
be a snack.
|
|
[259]
Lee Waters: I wonder why we keep getting these discrepancies.
I’m wondering whether we can ask the auditor, because,
clearly, the experience in Gwent does not tally with the evidence
that we’ve been reported, and I’m puzzled by this
consistent picture.
|
|
[260]
Mr H. Thomas: We have the consistent picture from the all-Wales
nutrition standards. It is as the patients are recording. I think
the test is always how that is then measured against the experience
of individual hospitals.
|
|
[261]
Rhun ap Iorwerth:
Neil Hamilton.
|
|
[262] Neil Hamilton: In 2011, NHS bodies were subsidising non-patient
catering services quite extensively. It amounted overall to about
£4 million. That’s been reduced substantially to just
over £1 million in 2014-15. So, I’m wondering to what
extent you are able to tell us that you know whether you are
subsidising non-patient catering out of the catering budget
overall. In 2011, most authorities didn’t actually know they
were doing this, and I wonder whether the information
systems are now in place to enable you to be able to measure this,
and hence to give us the confidence to say that this isn’t
happening any longer, or is negligible.
|
|
[263] Mr
Hayward: Can I pick up on that from a Cwm Taf point of view?
After the audit report identified that, one of the main things we
did was we split the cost centres, which was the financial
reporting system, and we split patient catering away from
commercial catering. We actually set up a commercial catering cost
centre. Last year, we made a surplus of £86,000 on our
commercial catering. So, we set up a chain of coffee shops, and our
restaurants, and we’re managing those on a profit and loss
basis. This year we’re forecast to make £111,000
surplus. So, they’re set up completely differently.
One’s a service base and one’s a business base.
|
|
[264] Neil
Hamilton: Very good.
|
|
[265] Mr
Phillpott: Can I say that, in Aneurin Bevan, we’ll
probably break even this year. The larger sites will generate
income streams, whereas the smaller sites, the smaller hospitals,
might be working at a loss, at a slight deficit. But I think if you
take the health board view on its own, together we would be
breaking even.
|
|
[266] In terms of
subsidies, we’ve got a new director now, and he’s very
keen to maximise our commercial side with a view that—. For
example, we’re introducing chip and PIN in our restaurants
next month. It’s envisaged that that should increase income
by 10 per cent, maybe 12 per cent. His view is that this money
could be ploughed back into some initiatives for patient catering.
So, our view is to try and subsidise patient catering development
with income streams.
|
|
[267] Neil
Hamilton: I’d just like to go back to the point arising
from what Andrew’s just said about the use of tablets as
well. We’ve heard what Aneurin Bevan health board is doing.
Are other health boards following your example?
|
|
[268] Ms Jones:
I was going to say earlier, but we moved on with questions—we
have completed a business case. It’s about £30,000 of
investment and that’s going forward for a decision through
our capital allocation.
|
|
[269] Mr
Hayward: We’re actually in the process of building a
business case for our system, but we haven’t got one for a
paper-based system, where we do take meal requests two hours before
a meal time.
|
|
[270] Neil
Hamilton: So, what’s the timescale, then, for moving in
this direction?
|
|
[271] Mr
Hayward: We’re aiming to get the business case before our
financial director by the end of the financial year.
|
|
[272] Mr
Phillpott: I’d say that Abertawe Bro Morgannwg management
members have come up, and also Cardiff and Vale. Both have been
quite impressed and went away thinking that they were going to roll
it out as well. So, I think everybody’s keen to do it.
|
|
[273] Andrew R.T.
Davies: Could I just seek a point of clarification? In the
papers we’ve got, it does say that there’s an all-Wales
business case being put forward:
|
|
[274] ‘The Welsh
Government has indicated that the business case and its viability
as an option will be discussed by the NHS Wales National
Informatics Board in November.’
|
|
[275] I find new
boards all over the place when I come to meetings like this. So,
you’re in isolation in your health boards putting business
cases together, then there’s another business case
that’s going to this national board. You’ve already got
the technology. There just seem to be a lot of hares running here.
From a layperson’s point of view, can you help me make sense
of how, actually, you will get to the position that Aneurin Bevan
are in, where you will have a computerised system where you can
take the information straight off the ward, and offer the patient a
choice with pictures and all the rest of it? It just seems a
logical way to progress, to be honest with you.
|
|
[276] Mr
Hayward: I was of the understanding that the board you’re
talking about, which is run by the NHS Wales Informatics Service,
and was supported by shared services, didn’t come up with a
report. So, each individual health board has taken their own view
on board, I think, basically.
|
|
[277] Andrew R.T.
Davies: So, what I read out was incorrect, then.
|
|
[278] Mr
Hayward: Well, that’s my understanding. I think that was
identified in the Wales Audit Office report.
|
|
[279]
Rhun ap Iorwerth:
We’re running out of time. A quick
one from Lee Waters.
|
|
[280]
Lee Waters: Just a quick one to Mr Hayward on the question of
food waste. Andrew Goodall’s provided us with a note on how
different health boards are dealing with waste, and there’s a
mixed picture. It does seem that most health boards are still
relying on maceration of waste. Some are using anaerobic digestion.
Your health board in particular jumped out at me—in Royal
Glamorgan, where the waste goes to black bags.
|
|
[281]
Mr Hayward: No, that was at the time of the report. At the
moment, we’ve got a strategic partnership with Merthyr
council, so they take the waste from the north part of the health
board, and from the south part of the health board we’re
dealing with a private company that takes it to—it
doesn’t go to landfill anymore, it goes to anaerobic
digestion.
|
|
[282]
Lee Waters: Right. That’s out of date, then.
|
|
[283]
Mr Hayward: It was originally going to black bags, but it
doesn’t now.
|
|
[284] Lee Waters: Okay. But you’re still
using macerators as a primary means of disposing of waste, are
you?
|
|
[285]
Mr Hayward: No, it’s going in its constituents parts. We
don’t macerate it. It just
goes as a lump, and it goes off to anaerobic digesters.
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|
[286] Lee
Waters: Okay. Excellent, thank you.
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[287]
Rhun ap Iorwerth:
Oscar.
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|
[288]
Mohammad Asghar:
I’ve got a very short one. Thank
you, Chair. Reading this report, I come to the conclusion that some
of the health boards are doing a wonderful job, and some of the
health boards aren’t—on page 33, if you look at that,
but Neil mentioned it—on non-patient catering, with the
percentage of the costs recovered. So, in other areas also
you’re not the same. Why don’t you share best practice
amongst yourselves so that, in all the areas, you take the best
from there, and the best from there and share with each other? Are
there any barriers between you?
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|
[289] Ms Jones: I think that best practice is
shared. It’s shared through the all-Wales group, but,
additionally, there needs to be recognition of the differences
between the health boards as well. So, the issues in terms of the
costs from a Powys perspective is—. You indicated the
significance of the impact of the bigger acute sites, but
we’ve got 10 small community hospitals, so where we’re
providing staff meals, that’s quite challenging for us when
there are only small numbers of staff meals required and the
subsidy then is a different matter for Powys than it would be for
other health boards. So, it’s just recognising there are
differences, even though good practice is shared.
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|
[290]
Rhun ap Iorwerth:
Any more comments on that?
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|
[291]
Os caf i ofyn, gan fod yr amser bron
iawn ar ben, un cwestiwn yn gyffredinol i’r tri bwrdd
sy’n cael eu cynrychioli yma heddiw: i ba raddau mae materion
yn ymwneud â maeth a phrofiad cleifion o fwyd yn yr ysbyty yn
cael sylw digonol ar lefel bwrdd yn y byrddau iechyd, ac o le
mae’r arweinyddiaeth yn dod i sicrhau bod yna wellhad yn
digwydd yn y maes yma? Mi wnaf i ddechrau gyda Liz
Waters.
|
If I could ask, given that the time is running
out, one question generally to the three boards represented here
today: to what extent are issues to do with patient nutrition and
their experience of food in hospitals having enough attention at a
board level in the health boards, and where is the leadership
coming from to ensure that there is improvement in this area?
I’ll start with Liz Waters.
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|
[292] Ms
Waters: Again, it’s that board-to-ward reporting,
isn’t it? We’ve produced an annual report, which will
be presented to the quality and patient safety committee in
November, and I’ve no doubt that our non-independent members
will be challenging in terms of what we’re reporting.
It’ll be the first time that we’ve presented an annual
report, but it’s a good start.
|
|
[293]
Rhun ap Iorwerth:
Okay. Rhiannon Jones.
|
|
[294]
Ms Jones: Thank you. I think that, from a hydration and
nutrition perspective, there is a high priority within the health
board. As I’ve indicated previously, I am the delegated
executive with responsibility. What we’ve had is reporting to
our patient experience, quality and safety committee, which is a
sub-committee of the board, and information is fed from that
committee to the board. What we haven’t had, but what
we’ve put in place as a result of the Wales Audit Office
report through our action plan, is recognition that specific
information in relation to the performance around nutrition and
hydration against a range of metrics hasn’t been reported to
the board previously. As part of our plan, we will be taking, as a
minimum, an annual report to the board. So, that will be happening.
But, to reinforce, reporting does go through a sub-committee of the
board currently.
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|
[295]
Ms Williams: And it’s the same in Cwm Taf university health
board. We have a multidisciplinary nutrition and catering group,
which has representation from facilities, from dietetics and from
nursing. And that reports through the quality and safety committee
up to the board, and we regularly take reports from quality and
safety up to the board through our integrated governance committee
that we have, particularly around the fundamentals of care audit,
which happens on an annual basis, but also we will be looking to do
an annual report. A bit like Rhiannon said, as the director of
nursing, midwifery and patient services, I am the designated lead
for patient nutrition and hydration, and it is important to show
leadership throughout the organisation with regard to both aspects
of that, so much so that I actually followed a lasagne from our
central processing unit down to ward level and spoke to the
patients as they ate it, last year, to see what
they—
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[296] Neil Hamilton: You didn’teat it yourself?
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|
[297]
Ms Williams: I did eat it myself, actually, in the canteen
afterwards. But I talked to the patients about what their
experience was and talking to them about the fact that I’d
actually seen their food that day being produced, and was able to
assure them of what the standards were. So, it’s those sorts
of things that need to be publicly available, really, to show
ownership and leadership within the organisations.
|
|
[298] Rhun ap Iorwerth: I’m not sure where
that leaves us in relation to what we were talking about earlier
about giving patients peace and quiet to eat their meals. The last
word: Mike Hedges.
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[299] Mike Hedges: A very simple question: do
any of your boards have a non-executive director with
responsibility for catering?
|
|
15:15
|
|
[300] Ms Jones:
Certainly in Powys, we haven’t got that at the moment,
no.
|
|
[301] Ms
Williams: And neither have we in Cwm Taf.
|
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[302] Ms
Waters: And neither has Aneurin Bevan.
|
|
[303]
Rhun ap Iorwerth:
Diolch yn fawr iawn. Rwy’n
meddwl bod eich atebion olaf chi yn eithaf arwyddocaol i’r
cwestiwn gan Mike Hedges, ond hefyd y ffaith bod adroddiadau yn
cael eu paratoi i’r byrddau rŵan am y tro cyntaf. Mi
fydd yna syndod nad ydy hynny wedi digwydd o’r blaen, ond
croeso hefyd, rwy’n siŵr, eu bod nhw yn digwydd
rŵan.
|
Rhun ap Iorwerth: Thank you very much.
I think your final answers are quite significant to the question
from Mike Hedges, but also the fact that reports are being prepared
for the boards now for the first time. It will be surprising that
that hasn’t happened before, but very welcome that
they’re happening now, of course.
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|
[304]
Mae’r cloc wedi ein curo ni. A
gaf i ddiolch yn fawr iawn i’n tystion ni am ddod i siarad
â ni heddiw—Colin Phillpott, Liz Waters, Rhiannon
Jones, Lynda Williams ac Anthony Hayward? Mi fydd y clerc yn anfon
drafft i chi o’r trawsgrifiad i chi gael gwirio hwnnw am
unrhyw gamgymeriadau, yn hytrach na newid cynnwys yr hyn rydych chi
wedi’i ddweud. Ond, unwaith eto, diolch yn fawr iawn i chi am
fod yn agored efo ni heddiw. Mi fydd y pwyllgor rŵan yn cymryd
toriad tan 3.25 p.m. Diolch yn fawr iawn i chi.
|
The clock has beaten us. Could I thank the
witnesses for coming to speak to us today—Colin Phillpott,
Liz Waters, Rhiannon Jones, Lynda Williams and Anthony Hayward? The
clerk will send a draft transcript for you to check it for any
errors, rather than to change the content of what you’ve
said. But, once again, thank you very much for being so open with
us today. The committee will take a short break until 3.25 p.m.
Thank you very much.
|
|
Gohiriwyd y cyfarfod rhwng
15:15 a 15:25
The meeting adjourned between 15:15 and 15:25.
|
|
Arlwyo a Maeth
Cleifion mewn Ysbytai: Llywodraeth Cymru
Hospital Catering and Patient Nutrition: Welsh Government
|
|
[305]
Rhun ap
Iorwerth: Prynhawn da. Mae hi’n 3.25 p.m. erbyn hyn, felly rydym
yn symud ymlaen i eitem 4 ar yr agenda heddiw, sef sesiwn
dystiolaeth arall fel rhan o’n hymchwiliad i gynnydd ym maes
arlwyo a maeth cleifion. Rwy’n atgoffa ein gwesteion
ni’r prynhawn yma bod y cyfarfod yn ddwyieithog efo
chyfieithiad ar sianel 1 a chwyddo’r sain ar sianel
0.
|
Rhun ap Iorwerth: Good afternoon. It is
now 3.25 p.m. by now, so we will move on to item 4 on the agenda
today, which is another evidence session as part of our inquiry
into progress in the area of hospital catering and patient
nutrition. I remind our witnesses this morning that this is a
bilingual meeting and that we have the interpretation on channel 1
and amplification on channel 0.
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|
[306]
Y peth pwysig
i’w wneud yn gyntaf, wrth gwrs, ydy gwahodd ein tystion i
ddweud eu henwau a’u teitlau ar gyfer y cofnod.
|
The important thing to do to begin with, of
course, is to invite our witnesses to give us their names and
titles for the record.
|
|
[307] Dr
Goodall: Prynhawn da, good afternoon, I’m Andrew
Goodall. I’m the director general for health and social
services and the NHS Wales chief executive.
|
|
[308] Professor
White: Good afternoon, everybody. I’m Jean White and
I’m the chief nursing officer at Welsh Government.
|
|
[309]
Rhun ap
Iorwerth: Rydym yn eich croesawu chi yn fawr atom ni, y Pwyllgor
Cyfrifon Cyhoeddus, y prynhawn yma. Cyn agor y cwestiynau allan
i’r Aelodau, mi wnaf i ddechrau efo cwestiwn ynglŷn
â’r arafwch sydd wedi bod i ddatblygu dogfennaeth
nyrsio safonol i Gymru gyfan yn y maes maeth a bwyd. Pam yr
arafwch? Pam yr oedi?
|
Rhun ap
Iorwerth: We welcome you very
much to the Public Accounts Committee meeting this afternoon.
Before opening up the questions to Members, I will begin with a
question in relation to the delay that there has been in developing
standardised all-Wales nursing documentation in the area of
catering and nutrition. So, why has this delay taken
place?
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|
[310] Professor
White: I think it’s useful to take a stepped approach to
this. So, the health boards and trusts within Wales have
responsibility for nurse documentation, as we have for all patient
care. So, the all-Wales work that we have initiated and has taken a
pause, shall we say, is really to bring some governance and some
opportunity for an electronic approach rather than a paper-based
approach. So, it’s not to say that we haven’t had work
to do with nurse documentation, which is at board level, but there
has been a pause in some of the work at a national level. This was
being led by the nurse informaticist at NWIS and, unfortunately,
through personal circumstances for that individual, they were off
sick for a long period of time and it is only recently, since they
retired, that a replacement person has been found. So, you will
have been aware that we’ve shared with you the areas of work
that that individual—the new individual, who starts at the
end of the month—will pick up. So, we’d already set the
work in motion and then had this pause, shall we say, due to
personal circumstances with the project lead.
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|
[311] Dr
Goodall: Chair, I would also add that it’s important to
make sure that, although we’re focusing on nutrition
specifically, we are aligning that to the range of functions and
responsibilities that are carried out by nurses. Certainly, any
introduction of an electronic system needs to be enabling the
patient care rather than adding an additional burden. I think it
would be easy to look at the range of areas that nurses are having
to complete across Wales in all sorts of different settings, but
really importantly, we’re going to be looking to withdrawing
some of those to make sure that we don’t withdraw the wrong
types of levels.
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|
[312] I think
we’ve got an opportunity to focus on this on a country-wide
basis. It can feel a little fragmented when it’s being dealt
with by individual organisations, but certainly as part of the
support ultimately for even electronic patient records, this is an
area of progress that we would want to be taking forward for the
future. Again, very specific circumstances have got in the way, but
that is now being handled within NWIS, as our support structure and
information services, and overseen by Jean in Welsh Government.
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|
[313]
Rhun ap Iorwerth:
Mike Hedges.
|
|
[314]
Mike Hedges: Is there now a clear timetable?
|
|
[315]
Professor White:
Yes, there is. So, the new nurse
informaticist starts at the end of this month. As you saw in the
documentation that we prepared, there are already established
streams of work that we had identified with the previous
individual. So, once the new informaticist starts, we will refresh the timetable from that
opportunity for starting. There will be individual work streams
with their own timelines within it.
|
|
15:30
|
|
[316] As I say, this is not just about nutrition and
hydration; this covers quite a
wide range of areas. So, there will be offshoots of it that will
not necessarily relate to this area, particularly in terms of
escalation where you have a patient who is deteriorating.
We’re looking to embed some good practice within moving to an
electronic system that might help us drive improvements in that
area. So, some of this will be testing out new technologies; some
of it will have to be piloted first. So, we’re expecting that
some of it will have quite a short time frame. Others, probably,
will be quite long as we go through a testing phase with
it.
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|
[317] Mike
Hedges: So, will there be a plan that we could see—a sort
of PERT chart, or something like that—that shows the stages
at which things are occurring? And will be made available to
us?
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|
[318] Professor
White: Yes, as soon as the nurse informaticist has come in, we
will have to draw up a project plan for her to work on. So, what
you have here is the plan that was with the previous lead. So, it
would have to be refreshed, and I’m very happy to share that
with the committee.
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|
[319] Dr
Goodall: Chair, if you could allow us to just allow the
individual to settle in through November, and we can perhaps
respond to you after that, so that we’ve tied it together
within their job specification.
|
|
[320] Mike
Hedges: Well, I think the auditor general started this back in
2011, so a couple of months is not going to make a great deal of
difference.
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|
[321] One final
question. This new nurse informaticist; what will they be working
on as well as what we’re talking about here? Are they going
to be working solely on the Wales nursing documentation, or will
they be doing other things?
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|
[322] Professor
White: They will be employed within NWIS as the nurse lead, so,
they will be giving professional advice into other work streams
within NWIS. So, yes, they will have a much wider remit than this.
And, to bear in mind, we’re not expecting this individual to
deliver all of these things; they’re going to act as the
co-ordinator. Most of the work will be done in association with the
health boards and trusts across Wales. That’s how it was set
up originally. So, we’re looking to involve quite a number of
the people who are going to be affected by this.
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|
[323] Mike
Hedges: If a lot of this work is going to be done by the health
boards and others, why couldn’t that have been done when
there wasn’t an informaticist there?
|
|
[324] Professor
White: Because of its link to some of the IT infrastructure, we
felt it was really important to have a lead from the organisation
that understood how it fitted with the wider strategy. So, whereas
you’ve heard from previous members who have come before you
this afternoon about local innovation within a health board, we
wanted to look on an all-Wales basis to make sure that we were
sharing good practice. So, we felt it was really important to have
a central linkage into the IT infrastructure for Wales, and best
led by that person.
|
|
[325] Rhun ap
Iorwerth: Lee Waters.
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|
[326] Lee
Waters: One of my concerns, reading the whole material here,
is: where does the drive and the leadership come from within the
system to progress this agenda? The auditor general identified this
as a problem in 2011. At the very earliest, we’re going to
get a solution by the end of 2018, possibly later. That’s
glacial progress, and it doesn’t seem to me entirely
satisfactory to blame the fact that one person hasn’t been in
a post to account for that—you know, at least seven years
from identifying a problem to fixing it. It seems to me there is a
deeper problem here with leadership and drive for pushing this
within the system.
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|
[327] Professor
White: I go back to my earlier comment that the health boards
and trusts have a responsibility to ensure that they have
documentation. So, this is a way of us bringing some governance and
opportunity for movement from paper to electronic. So, it’s
not as if nothing has happened in that time; each of the health
boards already has a paper-based system that they have to do,
because it’s a legal requirement—all care has to be
documented. We were looking to try to bring some consistency across
Wales, and there were some opportunities there, too, to look at new
and innovative ways of doing it. So, it would be unfair to say
nothing has happened since 2011.
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|
[328] Dr
Goodall: I think, also, Chair, we’re trying to ensure
that it does tie in to areas where we have taken our national
overview, like the updated healthcare standards, for example, so
there is a chance for national frameworks. It is an area, as you
look across the NHS generally, where there aren’t just
consistent systems available; you’ve often found individual
organisations developing their own local products, choosing to make
investments. We just think that the approach in Wales should be
more countrywide oversight at this stage and to make sure that we
can follow through on these recommendations.
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|
[329] Rhun ap
Iorwerth: And we certainly realise, as a committee, that food
and nutrition is just one element of the wider remit of the NHS,
but we were told earlier today that reports specifically on
nutrition had been prepared for boards for the first time, when,
for the past five years, we have had a very specific focus on the
shortcomings of systems throughout Wales. That kind of delay seems
odd.
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|
[330] Dr
Goodall: I would say there’s been a lot of focus within
boards on the overall healthcare standards, of which nutrition fits
with one part of that. So, we can see the overview that’s
been taken across these professional responsibilities being
facilitated in quality and safety committee meetings, for example.
I think it’s right to ensure that as these reports and
recommendations have an area of focus nationally, we do need to
drive to make sure that boards can set it in a local context. I
hope, during the course of our evidence, we can show some of the
evidence of that happening in some of the individual organisations
in Wales, as well as our national oversight.
|
|
[331] Rhun ap
Iorwerth: Okay. Neil Hamilton.
|
|
[332] Neil
Hamilton: The experience of the NHS in England has been nothing
short of catastrophic in terms of centralisation of patient records
and so on. So, I’m well aware of the problems that any
monolithic organisation of the scale of the national health service
has in trying to bring all this together, given the history of the
way in which disparate systems have been developed at local levels.
But I’m quite surprised that the absence of one person,
albeit the lead informatics person within the NHS in Wales, could
have led to a complete halt effectively in the development of a new
system. Just following on from the point that Lee made, was there
no deputy or group of people collectively who could have
substituted for the person who’s been absent in this
time?
|
|
[333] Professor
White: No, there was no deputy. Just one nurse informaticist is
employed in NWIS. We weren’t able to source another person
with the skillset required to do that who was working within the
organisation. I think it would be fair to say that there have been
many calls on NWIS. The requirements are quite huge to be honest.
We are living in a digital age and seeking digital solutions for
practically everything. It is a tall order.
|
|
[334]
Rhun ap Iorwerth:
With hindsight do you think it may have
been a good idea to put something else in place?
|
|
[335]
Dr Goodall: I think certainly looking to improve the missing
documentation is a core part of business. To give some general
reassurances beyond just the sort of nutritional and the catering
side of areas, we are making progress on a range of different
fronts about how practitioners are able to use IT systems to enable
what happens right through from GPs with their own systems to the
current development of the all-Wales social care and community care
information system. So, I think it does sometimes come to a choice
of priorities when we’re investing in these very big areas.
We’re rolling out in emergency departments at this stage.
But, certainly, we need to promote the nursing documentation side
alongside the healthcare standards. I think there could have been a
chance for a different discussion, but there are some limited
resources and limited expertise that’s available in this
arena.
|
|
[336]
Rhun ap Iorwerth:
Rhianon Passmore.
|
|
[337]
Rhianon Passmore:
So, there is some acknowledgement with
hindsight that things could have potentially been different. I can
infer that from what you were saying. In terms of transitional
arrangements, as you move from a paper-based system to a more
electronic-based system, with reference to the local-based
projects, this is a ‘national’ project, how can we as a
committee be reassured that the monitoring of nutrition in
particular is going to be taken a step forward during this infancy
period, as we move from paper to electronic systems?
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|
[338]
Dr Goodall: Well, perhaps if I start and, Jean, you come in. I
think we have to emphasise the approach here being moving people
from a traditional world of where facility staff only would perhaps
in the background worry about these issues and focus almost on the
kitchen function aspects to where nutrition and hydration as well
are fundamental parts of the care pathway and the professional
approach on there. That is a change that has happened. So,
increasingly and, hopefully, through some of the evidence
you’ve seen here today, you will have seen that we’ve
moved it to three sets of professional groups talking through
together to make sure there’s a focus on the individual
patient. But it is also monitored on a local premise and we do hold
people to account for progress as well, Jean.
|
|
[339]
Professor White:
You will have heard from the previous
witnesses that it is an interplay of responsibilities between the
nurses on the ward to make sure that patients receive their food
and things to drink, the dieticians to give expert advice and then
the catering staff. The approach that has been taken so far is that
these groups have been working somewhat separately from one
another, and going forward we see that the power of three, if you
like, getting these people to bring their work closer together, is
really an important step. You’ll have heard examples of
same-day ordering as a good example of either a paper-based or
electronic system where you’re able to capture the
patient’s needs closer to the time they actually consume it.
You ask how we can be sure about not losing something in the
transition, well, the example you heard of some of them
having paper based systems, that
will be made electronic. This should be a seamless thing, if
you get the process right. I think there’s always a danger of
thinking that IT is the solution, if you haven’t got the
process right. So, I think that, once they’ve got the ideas
of what they should be doing, turning it then into an electronic
process should be fairly straightforward. But the biggest
conversation is to make sure that you’re doing the right
thing to start off with. I do think that bringing the people
together and bringing these all-Wales groups together to share good
practice is a really important step forward. They’ll be doing
that fairly soon.
|
|
[340] Rhun ap
Iorwerth: I don’t know if you’d like to go on to
some questions that you had on training and another electronic
development.
|
|
[341] Rhianon
Passmore: Yes, okay then. We’ve mentioned that, in 2015,
auditors found that, on some wards, food and fluid intake for
patients identified at risk was not always recorded. Based on the
information from NHS organisations provided, compliance with the
e-learning packages, which are fundamental, as you understand,
ranged from 25 per cent to 80 per cent in 2015. Now, as this is one
of the key monitoring mechanisms of how well we’re doing, how
concerned are you—yourselves, and Welsh
Government—about the relatively low levels of compliance with
the e-learning packages? If there is a concern—and it sounds
like there is a concern, from my perspective—how fit for
purpose is that e-learning package, if that’s one of the key
monitoring tools that we’re using to rely on, if patients who
are at risk are not being given the basic nutrition and fluid?
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|
[342]
Rhun ap Iorwerth:
Jean.
|
|
[343] Professor
White: Yes, I do agree that it is concerning that some staff
may not have had what we felt was mandatory training. We listened
to what the service was saying to us about why that was. Partly,
it’s to do with ease of access. So, I see my role and the
Government role to try to get systems in place to make it easy for
people to do the right thing. So, there was a difficulty in staff
accessing the electronic package itself, so, we arranged for it to
be placed on a platform—Moodle 3.0, I think they call
it—which means you can access it both in hospital and at
home. Some people didn’t have e-mail addresses, so we
arranged for them to have e-mail addresses or group accounts. So,
what we’ve been trying to do is make it easy for people to do
the right thing. But I do think it’s probably fair to say
that there is some challenge about attendance for all mandatory and
statutory training when the service is under pressure. So, having
people released to do it, and the willingness then to spend their
own time doing it, remains a challenge that this committee will
have heard previously when I’ve been here, because this is a
long-standing problem, to be honest.
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|
[344] Rhianon
Passmore: So, if it’s a long-standing problem, what are
we doing, and what are you doing specifically, to be able to
challenge (a) the platform—the tool in which we can access
that training—and also, really, if that training is fit for
purpose, bearing in mind the outcome if it’s not effectively
undertaken?
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|
[345] Professor
White: The feedback we’ve had is that the training is fit
for purpose. It is more around the access and the ability of staff
to access it. So, we’ve been focusing on making it easy to
do. In terms of compliance, one of the step changes that is
happening this autumn is that, when somebody has completed the
training, there will be an automatic report into the electronic
staff record. So, when they come to have their annual review, their
manager can say, ‘I see you haven’t done this. I
require you to do it’, or ‘Why haven’t you been
able to do it? What’s the problem?’ So, there’s
something about this next step change that, again, will make the
managers do the right thing, which is to say to the staff, ‘I
think it’s appropriate for you to do it’, or ‘I
think you’ve probably got the skill set, and we will perhaps
prioritise somebody else to do something else and I want you to do
this.’ It all depends on what the senior manager will say
that the person needs to do their job. So, I think this is an
important facility for managers to make sure that things are
happening.
|
|
[346] Dr
Goodall: I think the electronic staff record simply allows us
to ingrain it, rather than have something as standalone reporting.
So, it just becomes part of core business. I think that’s an
important shift at the end of this month that is occurring. I
think, equally, there is a responsibility within health boards in
respect of mandatory training, irrespective of the workload and the
busyness of the environment, to make sure that people do have the
time and the flexibility to be able to comply and to have time to
actually complete training as necessary as well. We will need to
keep an eye on that, too.
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[347] Professor
White: May I just add something, Chair, if that’s all
right? We have formal medical and surgical wards across Wales.
We’ve been looking at the nursing establishment—in
other words, how many nurses and nursing assistants are employed on
the ward. I introduced some principles in 2012, and the health
boards are now increasing their establishments to meet those
principles, and that does cover an amount of time to do mandatory
and statutory training. So, in some of the workforce planning
approaches that Government has been working with the health boards
over—it does pay attention to that. So, as I say, our
attention has been trying to make people easily be able to do the
right thing in this area. But it is a concern, to be honest.
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15:45
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[348] Rhun ap
Iorwerth: It’s these words ‘mandatory’ and
‘compliance’, isn’t it? I mean, if it’s a
matter of compliance, it’s a matter of compliance. Is it
important enough to be a matter of compliance?
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[349] Dr
Goodall: It is a matter of compliance. What we’ve at
least unlocked are, however, people describing problems with some
of the existing systems. And, as I said earlier, I think the change
to the electronic staff record is quite an important
change.
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[350] Rhun ap
Iorwerth: I apologise to Oscar for not calling you earlier. Do
you still have a question?
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[351] Mohammad
Asghar: Yes, please, thank you very much Chair, and thank you
to you both. Ruth Marks, the former Older People’s
Commissioner for Wales, said that National Assembly for
Wales’s Public Accounts Committee report on hospital catering
and patient nutrition said, and these are her words:
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[352] ‘Having
nutritional and appealing food is an essential part of getting
better’.
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[353] Quote closed.
Given this, what action is the Welsh Government planning to improve
nutrition services in hospitals across Wales? Just to Andrew,
now.
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[354] Professor
White: So, from the evidence that was previously given from the
Wales Audit Office on looking at menus, which we have reported on
here previously, there is an all-Wales approach now to looking at
menu development, both in nutritional terms, as well as in,
‘Does it look appetising? Does it look palatable?’ This
group meets two to three times a year and it has chefs, as well as
representatives from all the health boards, to look to see whether
or not the food is of the right quality and standard. I understand
from that group that they are adding nine extra dishes to the
all-Wales list this year, and that health boards are between 95 and
100 per cent compliant with using only those things that are on
this all-Wales menu platform. So, although the patient survey that
had been done in 2013 and 2015 shows that some patients are saying,
‘Okay, the food doesn’t look that attractive’,
when you drill down into some of the other comments they are
saying, three quarters of them were saying they were quite
satisfied with the food, and only about 10 per cent were saying the
food was poor or unacceptable. So, there are some things to go at,
I would say, that the menu group are very aware of. They get local
feedback, as well as feeding into the national group to see what
they can do with the all-Wales menu framework itself. I think the
involvement of all of the health boards with the chefs, the
dieticians, the catering staff, in looking at where they get the
material from—local procurement, that sort of thing—and
then looking at the nature of the menus that sit on the framework,
is an important driver for us in the quality and palatability of
the food that is being presented.
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[355] Rhun ap
Iorwerth: Okay. That brings us on to the patient experience and
the food that they get, and the screening of what they require. Lee
Waters.
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[356] Lee
Waters: It seems to me one way of dealing with this would be to
serve the food that’s served in hospitals in your own
canteen. Have you considered that?
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[357] Professor
White: I personally haven’t, no. I don’t think
there are any plans that I’ve heard of, of offering different
types of meals. I think you heard Lynda Williams from Cwm Taf
actually describe the lasagne journey from production, and she
herself then had it in the canteen. So, I think quite a lot of the
food that is presented to the patients is presented in the canteens
as well. So, I don’t think there’s any—.
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[358] Lee
Waters: No, I mean in the Welsh Government canteens. Because
you’re telling us that, since the Auditor General’s
report, things have moved along, that new things are being offered,
and in fact these figures that patients don’t like
what’s put in front of them aren’t accurate. So, a way
of doing real-time true progress tracking would be to serve it in
the Welsh Government canteen, so the Ministers and senior officials
could track it in real time. Would you consider that?
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[359] Professor
White: I didn’t think I said that it wasn’t
accurate. I’m just saying that there’s some evidence to
suggest that not all patients find the food disagreeable.
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[360] Lee
Waters: Well, a third of patients felt the meal was not
appetising.
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[361] Professor
White: But, out of that, three quarters did say that they were
satisfied with what they’d got. So, there are some nuances
within patient—
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[362] Lee
Waters: Indeed. And my sincere question to you is: if that is
the case, a good way of cracking it would be to serve that within
the Welsh Government canteen. Would you consider doing that?
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[363] Professor
White: I don’t know the logistics of that. I—
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[364] Dr
Goodall: I can reinforce from a health board perspective that
those sorts of taste tests are done at the board level, and they
are led on a local basis within those organisations and there are
mechanisms in place for patients. That’s not just an
oversight issue from Welsh Government, that’s from my
previous experience of having been a health board chief executive.
I recall my previous nurse director, for example, always going and
ensuring that, actually, the quality, from her perspective, was
being maintained actually at the ward level for patients’
experiences.
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[365] Lee
Waters: Do you like powdered egg?
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[366] Professor
White: Depends what it’s in.
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[367] Lee
Waters: I’m told on social media that, in Glangwili
hospital in Carmarthen powdered egg is served.
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[368] Dr
Goodall: Right.
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[369] Lee
Waters: So, back to the question I put to you, Mrs White, you
said that you weren’t sure about the logistics. Well,
I’m not being glib here—
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[370] Rhun ap
Iorwerth: You’re making a very interesting point. I think
there is an issue of logistics, that’s quite right, there. If
we can broaden it out from what happens in the Welsh Government
canteen—.
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[371] Lee
Waters: It’s a serious point, because the evidence
we’ve been given by the auditor general consistently shows
there’s a problem, the witnesses we heard before you, it
didn’t seem to be happening in their health boards, it was
fine, and the evidence you’re suggesting to us is that,
actually, it’s not as bad as we’ve been told, and
things have moved on and there’s progress. And I’m
saying to you there’s a disconnect between the data
we’ve been given and the evidence we’ve been presented
with. This is a massive operation, I fully sympathise with the
logistics involved, and I suggest, finally, to you
again—it’s a serious suggestion—one way to track
this would be that the food served under the all-Wales pathway is
also served in the canteens of the health boards and also of the
Welsh Government so that you can see what patients—. If
it’s good enough for patients, surely it’s good enough
for everybody else. Would you consider—? Could you look into
the logistics of that?
|
|
[372] Professor
White: I think it might be beyond my ability as a chief nurse
to fix it, but, certainly—
|
|
[373] Lee
Waters: Well, the chief executive of the NHS can look into the
logistics of making that possible.
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|
[374] Dr
Goodall: Chair, we can look at the sentiments of it, which is
why I reinforced about the taste test being an important aspect of
what happens at this stage. But, irrespective of the functional
issues of the way in which health boards run their own respective
organisations and the catering approach in there, I take the
sentiments of what you’re saying and we’ll look at that
for you.
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|
[375] Lee
Waters: Thank you.
|
|
[376] Rhun ap
Iorwerth: Okay. Further questions on this matter. Oscar.
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|
[377] Mohammad
Asghar: Yes. On the food and beverage service in the national
health service and whether the Welsh Government monitor the extent
to which NHS bodies are sticking to its all-Wales menu framework,
and does Welsh Government have any early evidence to suggest that
the Water Keeps You Well campaign is making a difference to
patients’ care across Wales?
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|
[378] Professor
White: We understand the feedback has been—from the
all-Wales group—that compliance with the menu framework is
between 95 and 100 per cent. So, it suggests to me that most of the
hospitals are fully compliant most of the time.
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|
[379] In terms of the
Water Keeps You Well campaign, this was introduced on the back of
‘Trusted to Care’, which was a review of the care of
older people into the hospitals in south Wales. We introduced a
national campaign earlier this year, which, essentially, encourages
people, whether it’s relatives or members of staff, that,
every time they go to a patient who is allowed to drink orally, to
offer them a drink. Anecdotally, when I go around talking to the
patients on the wards, it certainly has made a difference. I spent
30-odd hours this summer visiting wards across Wales looking at
this. The signage was clearly there and a lot of people have been
very actively engaged in it. There’s also a suggestion of
encouraging relatives, if they want to bring anything into hospital
for the patients, or for the patients themselves bringing it in,
they can bring in squash to make the water more palatable—not
everybody likes to drink water. So, there’s that sort of
thing as well.
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|
[380] We, on the back
of ‘Trusted to Care’, also introduced a spot-check
methodology, which focused on some very key areas and hydration was
one of those. The health boards now have a quality toolkit, which
they can use to do audits around this, and, when we did spot
checks, commissioned by the Government, looking at this, hydration
was not seen as a major issue from that process. However,
it’s one of those things you can never ever take your eye
off; it is absolutely fundamental. Nutrition and hydration are one
of those things that, to be frank, is almost as important as the
medication that people receive. It is that essential. So, there is
a constant drive to make sure that the health boards are doing
that, and the campaign is but one way to capture people’s
imagination about what they might do.
|
|
[381] The Water Keeps
You Well campaign also has one particular change agent element to
it, which is unusual, which is about getting patients to make a
commitment to drink. Whereas it’s all very well having
professionals come and say, ‘Have you had a sip? Would you
like a sip? Have you had a drink?’, there is something about
engaging with patients to say, ‘We’d like you to agree
to drink this amount in a period of time.’ So, that is being
looked at and evaluated as a methodology. When the campaign was
being developed, we engaged with the Bangor University change
management team to look at the methodology and the thinking behind
it, because it’s all very well having posters on walls, but
if you have a particular change methodology underpinning it,
we’re hoping that will make the difference, and that will be
evaluated.
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|
[382]
Mohammad Asghar:
Thank you very much. Another thing is:
the Welsh Government uses the patient survey findings to inform its
discussions with NHS bodies on scope to improve catering and
nutrition services across Wales. My question is to you, Jean: You
have a wonderful, we fully acknowledge it, NHS catering system, but
where there are some people with different ethnicities, religions
or beliefs, like halal and kosher meat, and all these different
reasons, the food is not served according to their needs. Most of
the cases—. I recently have been in hospital—not
myself, my wife—for weeks, and we took our own food, which
the patient likes. So, is there any provision that you can look at
to improve this way that people can bring food? The patient loves
to have food with their loved ones sitting with them and eating
together. Those who bring food eat less, but they give a patient
more, because they know there’s nothing in the
hospital.
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|
[383]
Professor White:
You are making a very important point
about patient choice and, particularly, if an individual has
particular, challenging dietary needs, it is essential that the
hospital provides that food for them. We don’t stop people
bringing food in, per se, however, there are certain things that
you have to be very careful of. So, you wouldn’t want to
bring in food that would go off in a warm environment, because you
could actually make the person ill. So, there is a health and
safety element to some of this. What we’ve always said around
things like protected mealtimes is it’s down to the ward
sister and charge nurse to agree with the family about how to
manage this sort of thing. So, I wrote out a couple of years back,
reinforcing the arrangements around protected mealtimes, which are
to engage with the family and if their loved one needs to have
support or would like to have a shared eating and drinking
experience at mealtimes, then that should be enabled wherever
possible. Now, obviously, on the ground, in certain areas,
it’s quite challenging to do that. Not all wards have dining
rooms and some of it is actually in the clinical area, so it is a
little challenging, which is why it has to be the ward sister or
charge nurse that makes that determination. But if there are some
suggestions for improvement, then I’d be very happy to look
at those to drive that.
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|
[384]
Rhun ap Iorwerth:
Oscar also raises the important point of
lack of availability, from his experience, of food that was
required because of a particular religion. We’ve heard today
discrepancies between patient experience, the anecdotes, and what
health boards, for example, are saying actually happens on the
ground. How do you monitor what is actually happening as compared
with what health boards are saying when they say, ‘Yes,
everything’s fine; there’s no
problem’?
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|
[385]
Professor White:
We rely on lots of sets of eyes, to be
honest. So, you’ve heard mention of an annual audit. Well,
annual audits only give you a snapshot in time. So, what instead we
also require feedback from is—the community health councils
go in. They talk to patients, they talk to their relatives. HIW
does inspections and there will be elements of that that will come
up through the inspection reporting. So, there are a number of ways
that we pick up data. It is a combination of audit at points in
time and then people being part of a CHC or HIW
inspection.
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|
16:00
|
|
[386] Most of the
feedback will go to the health boards, not to us within Government.
That, I think, is appropriate, because what you want is
on-the-ground action if there is an issue. So, if your
wife—and I do hope she’s better now—if you found
that things were not happening there and then, what we expect
people to do is raise concerns and have their concern dealt with
right at that moment. It’s no good waiting a year for me to
find out, and for Government to try to do anything.
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|
[387] So, there is
very much an emphasis now from Government on patient feedback. We
set out a service user framework, under which the health boards and
trusts are all required now to look at different ways of gathering
patient feedback, whether it’s real time, whether it’s
audit, whether it’s patient stories, and you will have heard
in your previous evidence different ways people are doing that with
apps, with paper questionnaires—three minutes of your time,
two minutes of your time. So, they’ve all got lots of
different ways of gathering the information. Is it perfect? No, of
course not. Is there more to be done? I would say yes, there is.
Because there are quite a number of interactions across the
services, not just in the hospital bed, and you need to be quite
creative about how you get to people. There is also a challenge: if
you ask somebody sitting in the bed, ‘So, how was the meal
today?’ will they honestly say what they think? They might
want to go home and reflect on it and give some feedback.
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|
[388] So, it’s
important for us to have real-time information, an ability to raise
concerns and have those concerns addressed, and then different ways
of feeding back about what my experience was like. So, there is
often a difference in terms of seeing what the levels of
satisfaction with the service are, and then drilling down into
elements of the experience, which is where I think sometimes we
have these conflicting stories, because it depends what
you’re asking, when you’re asking it and how
you’re asking it. You can play all sorts of games with
statistics, but the general feel we get is that people are mostly
satisfied, but there are elements there that they want improvement
on.
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|
[389]
Rhun ap Iorwerth:
I think Lee Waters might want to pursue
this a bit.
|
|
[390] Lee Waters: Just a related point: you said
that it’s right that the leadership on this lay at the health
board level. We have the regulations for which board members are
responsible for which subjects on the local health board. It
doesn’t seem entirely clear who’s responsible for
catering and patient nutrition. In fact, when we asked the health
boards earlier, they said nobody at a health board level was
responsible. They talked a lot about the importance of
ward-to-board accountability, but few of them reported routinely on
this at board level. So, I wonder what reflections you have about
that: if that’s where you want to put the responsibility,
what can we do to improve on the current level of the current
abilities?
|
|
[391] Dr Goodall: I’ve always seen the
patient experience side being very strongly held by nurse directors
and their function, both where I’ve worked in organisations
before and currently. But the facilities management aspects will
tend to be within the responsibility of chief operating officers,
and that’s why I think it’s important—in the same
way we’ve emphasised here, working across those operational
services with the professional team—that that’s done
within the health board environment itself. But certainly, I think
as we translate these approaches into improvement for the future, I
think it’s the patient experience aspect that probably drives
the concerns of this committee at this stage, and I see that firmly
on the professional side, but with proper operational support from
those overseeing and running these facilities services.
|
|
[392]
Lee Waters: Would it be useful for the Welsh Government to be
explicit about how often it expected this to be reported at board
level, and which director took the lead?
|
|
[393]
Dr Goodall: I think we can be explicit on that. We also have to
make sure that health boards are dealing with all of their other
priorities, so I wouldn’t see this as suddenly a monthly
area, other than on an exception basis. This was a really
significant area of concern, but certainly as part of our annual
reporting mechanism, the way in which the patient surveys come
through, we don’t see that as just a one-off annual process.
If there’s a need for clarity, we can make that clearer, I
think, for the individual health boards at this time. But I think a
regular contact on it to make sure there’s progress, but not
necessarily a monthly kind of occurrence—
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|
[394]
Lee Waters: Okay, but that’s not currently happening, is
it? So, what might you do to make sure that it happens
regularly?
|
|
[395]
Dr Goodall: I know that the oversight of this on the patient
experience side is held within more detailed quality and safety
committee meetings, but we can make sure, firstly, that we cover it
on the governance side. What we’re doing with all material
reports—whether it’s from PAC or Wales Audit Office or
external regulators—is making sure that they become visible
at NHS board level in Wales, but equally in terms of the reviews
that we do with individual organisations at their mid-year and
end-of-year reviews, so we can look to make sure that people
understand they have to account for it there also.
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[396]
Rhun ap Iorwerth:
Just to clarify, you said two or three
times there, ‘We can do this’. Is that a ‘Yes,
this is something we could do, and we are in the process of doing
it’, or have you any specific steps that you are already
putting in place to change the relationship between the board and
how it’s happening?
|
|
[397]
Dr Goodall: Having overseen at health board level, I would expect
the patient experience reports to come through very strongly
through the quality and safety mechanism, and that’s where I
would have wanted to have located those previously, and for it to
be taken on an exception basis to the board. In terms of more
national oversight of what we do here, and given the ongoing
importance of these issues, yes we can call that these are drawn in
to some of the supporting documentation and discussions around our
mid-year and end-of-year reviews with the organisations across
Wales, and we will commit to do so.
|
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[398]
Rhun ap Iorwerth:
So you are planning to do that, and that
would be a change to previous years.
|
|
[399]
Dr Goodall: We’ll commit to do so. The importance of these
national reports and the compliance and recommendations—.
We’ve been drawing them increasingly through the NHS board
mechanisms over the course of the last 12 to 18 months in
particular.
|
|
[400]
Rhun ap Iorwerth:
And where would we find reference to any
announcements that you’ve made in relation to
this?
|
|
[401]
Dr Goodall: Chair, I’m sure there’ll be a number of
areas that you want to highlight on the back of this report, not
least the nursing documentation side, and I think we’d be
happy to contain it in the same correspondence to you.
|
|
[402]
Rhun ap Iorwerth:
Okay, thank you. Shall we move on to
costs? Neil Hamilton.
|
|
[403]
Neil Hamilton: It’s six years, now, since the auditor general
highlighted the benefits of introducing computerised catering
information systems, since when some limited progress has been
made, with three NHS bodies using the Menumark system and the
remainder apparently waiting for a decision to be taken on an
all-Wales system—and, in order to get there, we have to get a
business case put together and some assessment of its viability. Is
the delay in doing this related to the same problem we were talking
about earlier on, namely the head of informatics not being
available?
|
|
[404] Dr Goodall: No, that’s a separate
issue, there. So, that’s not to do at all with the nursing
documentation discussion that we had earlier. There has been a need
to ensure that all health boards would sign up to a national IT
system here, and we’ve been emphasising increasingly the use
of national IT systems through our overall approach around digital
services within Wales. This particular product also needs to make
sure that, as well as just simply being a system to be used,
it’s a system that actually gains the benefits that are
expected as well, at the same time. Certainly, I think on some of
the provisional cases put forward, perhaps the value for money and
benefits were less explicit than they could have been at this
stage. It’s also about balancing the costs of introducing a
system like this in terms of other requests on the capital budget
for Wales.
|
|
[405] In and of
itself, it’s £3.5 million to actually roll this out
across all of the health boards and Velindre trust. It’s a
material amount of money. We have choices about how we spend
capital: should it be on this system, should it be on equipment at
ward level, should it be on implementing a community care
information system, or on three linear accelerators for cancer
services? So we do have to make some judgments here. However,
having said that, I’m now chairing the national informatics
board, and I have asked for the case to come through so that this
is properly reviewed, and it is going to our November board
meeting. I’m looking at the capital implications of that, and
I do want to make sure that it can achieve the benefits.
My view was that, amongst a whole series
of issues, it was intended to help to drive down the wastage
issues. Alongside other actions, we’ve been able to do that
as well, and it may well be that the information system is the
final piece to allow a further push again, but I can certainly
report back after our board meeting, which is taking place in
November, and confirm the outcome of that to the committee, because
I know you’ll have an ongoing interest.
|
|
[406]
Neil Hamilton: Yes. So, there won’t actually be a decision
taken in November, presumably.
|
|
[407]
Dr Goodall: No, the intention is that we’re receiving the
business case and we will look to make a decision, but I’d
like to make sure we take it on its proper benefits and the
outcomes that we expect, given the materiality of that particular
case. I would hope that that is resolved one way or the other, but
the hope will be obviously that it’ll be resolved positively
in order to allow implementation across the whole Welsh system. But
I would like to still see the benefits come through
strongly.
|
|
[408]
Neil Hamilton: Well, the waste figures show that there are
significant savings that could be made, even though no system is
going to be 100 per cent perfect, and that a cost of £3.5
million on your capital budget would produce, potentially, quite a
significant revenue return on the figures that we’ve seen so
far, which are themselves incomplete.
|
|
[409]
Dr Goodall: And I would like it not just to be seen, for that
reason, as just an addition to the system; I think it is to make
sure that we can actually drive those revenue benefits. I’m
pleased, at least over the time of all of the reviews that have
taken place, that we’ve managed to have a concerted focus to
get down from what was 16 per cent to 6 per cent. I actually hope,
alongside any discussion on systems anyway that, hopefully,
shortly, we can put out advice to the Cabinet Secretary to say that
we think that the target needs to be revisited. People are
operating well within the extant 10 per cent target; personally, we
feel professionally that that should at least be dropped down to 5
per cent in the interim, but we need that to be endorsed by the
Cabinet Secretary. If we could make more progress through a range
of actions, including the computerised system, we would be very
prepared, of course, to reduce that target further, because there
are some cost savings within that envelope.
|
|
[410] Neil Hamilton: As part of this evaluation
exercise, you will presumably be looking at the effectiveness of
the local IT systems, which are currently in existence, to see
whether it’s worth taking the risk of centralising, and all
the problems that we know can be caused by moving to a bigger but
more centralised system.
|
|
[411] Dr
Goodall: There are benefits of national approaches and systems,
and we’re rolling out on a number of other consistent areas
across Wales, in areas such as radiology and pathology services.
But you’re absolutely right, you need to have a very tight
local implementation to make sure it works, and, yes, we are
bringing in the expertise out in the service to give us that final
call.
|
|
[412] Neil
Hamilton: And the other aspect of that kind of analysis will
also be what will be the impact of not introducing a new IT system
and to what extent the existing system could be improved or better
monitored and have greater feedback or communication between
different systems.
|
|
[413] Dr
Goodall: Indeed, and I hope the case can be made. I think, as
long as we can look at the criteria, and, if you like, a return on
that investment, given the sense of materiality of it, hopefully we
can just have a positive outcome from that. I’ll report back
after November.
|
|
[414] Rhun ap
Iorwerth: Can I just pause for a second?
|
|
[415] Neil
Hamilton: Yes, sure.
|
|
[416] Rhun ap
Iorwerth: Lee.
|
|
[417] Lee
Waters: It’s been quite a long tale, hasn’t it?
Just looking at the auditor general’s report, it was in 2012
that the NHS Wales Informatics Service and shared services were
asked to come up with an outline business case. They prepared one
in 2013. There were then delays with it being shared within NHS
Wales. By the time it was considered, the figures were out of date,
and now, in 2016, you’re eventually making a decision. That
is then subject to the all-Wales capital programme, which, as
you’ve just implied, is under heavy pressure from other
demands. You said at the outset that you thought that NWIS was
under a lot of pressure, a lot of competing demands, and that it
had limited capacity. So, what are you doing to address that
capacity, and shaking up NWIS, but why on earth should it take so
long to reach a decision on a business case?
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[418] Dr
Goodall: I think, again, I go back to what was its intended
outcome. And it’s been possible to make progress on the
wastage, if you like, despite the system there. I think that,
alongside investing in a material system like this, if we
haven’t got the benefits coming through clearly, we have to
place it alongside many other choices that we’re making. We
always spend the all-Wales capital programme on the NHS side every
year at this stage. I certainly need to know that the case actually
is able to be defended at this stage, and some of the early work
that was done didn’t do that. From a NWIS perspective, they
have a much broader set of responsibilities. They oversee our GP
systems in Wales. They’re overseeing the implementation with
local organisations about their radiology implementation, and I
think we need to ensure, for them to keep making progress at this
stage, that they do have an infrastructure in place that allows
them to do so. And we are reviewing that, because, of course, our
digital approach is quite fundamental to the way we enable service
change and patient care for the future at this stage. But there
will always be choices within any annual work programme.
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[419] Lee
Waters: Of course there will, but it does sound like
they’re struggling.
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[420] Dr
Goodall: I think there’s a lot of expectations because
people want to have change happen very speedily, and some of our
roll-outs require a very expert team to be involved in every
individual health board area as they support this, rather than
spread and distribute it all in parallel at this stage.
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[421] Lee
Waters: But the trouble is, as your note to us makes clear, in
the meantime, individual health boards are holding back on making
their own arrangements because they’re waiting for a decision
that has taken four years to come to.
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[422] Dr
Goodall: Indeed. But it will come to a close now, and
hopefully—
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[423] Lee
Waters: Well, you say ‘close’, but it’s then
dependent on a capital decision. So, what’s the date that you
hope that a solution will be in place?
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[424] Dr
Goodall: I hope that we’ll have made a decision around
the national informatics board in November. That means that we can
actually make some progress against it, because the business case
is already written within the capital allocation mechanism.
That’s simply making sure that we have the funds available,
and if it was rolling out in 2017-18, for example, it becomes part
of advice up to the Cabinet Secretary.
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[425] Lee
Waters: So, that’s when you expect it to be rolled out,
is it, 2018?
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[426] Dr
Goodall: It won’t be rolled out during 2016-17, if we get
the go-ahead in November. What it can do is be considered as part
of the 2017-18 capital programme.
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[427] Lee
Waters: So, just briefly, Chair, assuming the go-ahead gets
given next month, when do you expect this to be live?
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[428] Dr
Goodall: I would expect that if the go-ahead was given on it,
we should be able to be implementing it through 2017-18.
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[429] Lee
Waters: And by the end of 2018, it should be in place
everywhere.
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[430] Dr
Goodall: It should be in place. It’s not got the same
implications as rolling out a patient administration system, for
example. It is a consistent backroom function that we can actually
put in place. So, I see that as an easier implementation than some
of our other technology.
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[431] Rhun ap
Iorwerth: Right, okay. Just out of interest, if capital
expenditure has been one of the barriers, have any attempts been
made to make a bid for some funding for such a programme through
invest-to-save, for example?
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16:15
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[432] Dr
Goodall: I think that’s partly where the case comes from.
The NHS has actually been able to make pretty good use of some of
the invest-to-save processes. I think, perhaps, danger of this is
that it almost emerged with more of a traditional, ‘We need
one of those and, therefore, let’s have the centralised
system’. I know it was a clear recommendation. I do think
that there’s an invest-to-save mechanism on here, when you
look at some of the underlying principles, and I think that it
should (a) help with usage, but actually it should help with some
of the streamlining of how the functions work in the individual
hospitals and sites as well. So, I personally feel that that would
be a possible avenue for us to use. But I’ll still be
looking, through advice to the Minister, to see whether we can at
least be making some provisional or notional allocations around the
system, knowing that it’s coming through the informatics
board.
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[433]
Rhun ap Iorwerth:
Okay. Back to Neil Hamilton.
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[434] Neil
Hamilton: Although the figure’s not entirely reliable, as
far as the auditor general can establish, the cost of food wastage
among served meals has been reduced from £4 million to
£1 million and the target is £1 million. Now that
things have improved, are you going to introduce more challenging
targets to keep the pressure on?
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[435] Dr
Goodall: Yes, I think we need to. I’m genuinely pleased
that we’ve been able to address the actual financial outcome
because that’s about making resources available back for
patient care. And I think that is a material shift, even though we
know that there’s more to go to. But, absolutely, if we can
account for the current level of wastage in what’s reported
within the report—. I’ve already indicated that we
would look to drop the wastage levels and I think that that should
be aligned, actually, with a refreshed target as well.
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[436] Neil
Hamilton: If you’ve got better tracking systems, you
should be able to make a lot of further progress.
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[437] Dr
Goodall: I agree.
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[438]
Rhun ap Iorwerth:
Okay. Oscar.
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[439]
Mohammad Asghar:
Thank you very much, Chair. Andrew, I
think, in my first term, in exactly the same room, one of your
officials said, in his words, that, ‘In the NHS, we spend 20
per cent of our budget inappropriately.’ That was said in
this room. Things have happened since then and I’m sure
things have improved—you might have read it. So, I’m
not saying that we’re wasting money in the NHS, but I think
that one third of our national budget goes to the NHS. It’s a
great ask and, as Jean said earlier, it’s like walking up a
hill to save the money. On what area are you focusing on to cut the
budget and give the best possible NHS service in Wales?
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[440]
Dr Goodall: Look, in this specific area, any opportunity to make
a saving for patients, where it doesn’t affect the outcome of
their care, is about support mechanisms and going at issues like
wastage. We should of course be ensuring that we continue to make
progress. So, in this very discrete area, with all of the attention
that we’ve had on it, I think we’ve still been able to
demonstrate some good progress. I think it is important to make
sure that we focus on outcomes for patients. One of the key issues
there is always trying to ensure as much as possible that patients
can be cared for in an appropriate environment. I think part of
that comes with looking at the underlying reasons for why people
come into hospitals in the first place. I think we have a
responsibility to, as much as possible, demonstrate that there are
alternative services available and around so that people are being
cared for as close to home as possible. I think we need to continue
to focus on that.
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[441]
Ultimately in the catering and nutrition
arena, we still provide a very high-volume response for the number
of patients who actually come through. You know, every year in our
hospitals, we have 0.75 million admissions who are being served.
So, it still remains an approach at an industrial level that is
going on. But I still believe that it’s possible to revive
personalised care, hence why, over the recent years, we’ve
been introducing a much greater focus on the patient reflection,
patient feedback and patient experience. We do need to ensure that,
despite the complexity and volume of our system, it does provide
something that feels more personal to people’s needs as
well.
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[442]
Rhun ap Iorwerth:
Okay. For the final three
questions—Rhianon Passmore.
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[443]
Rhianon Passmore:
Thank you. There’s been some quite
intense questioning today, and I’m sure you would agree with
that. In terms of how you’re obtaining assurances from NHS
bodies that are addressing the auditor general’s
recommendations, and those of the previous committee, how would you
outline how you’re obtaining that assurance?
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[444]
Dr Goodall: Do you want to pick up professionally first, Jean,
and I’ll pick up the organisations?
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[445] Professor White: As I said earlier, having food and fluid is really,
really important. So, there are tiers to assurance. At health board
level, it starts at the ward—a ward sister or charge nurse
must be assured that patients receive the food and fluid. The
senior nurses need to spot-check to make sure that the processes
are followed and so on and up the tree, which you’ve already
heard this afternoon. For us, to make sure that things are
happening, we rely on many eyes: community councils, Healthcare
Inspectorate Wales, that sort of thing.
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[446] One of the things that I didn’t mention was our
move to look at some of the essential care metrics in our NHS
delivery and outcomes framework, because in the past
we’ve, if you like, focused a lot on process. So, it’s
very easy to say, ‘Has this jug of water been changed three
times today, yet has the person had enough to drink?’ So,
making sure that we move from process, which is around the things
that you do that are easy to measure, to actually looking at
patient outcomes, in terms of food and nutrition, is quite an
interesting step for us to do. Most places focus on quasi-measures
of outcome and they’re mostly process. So, there is work at
the moment that will come in for the next financial year, which is
looking at attention put on patient outcomes. So, whether we look
at urinary output or levels of thirst, or blood chemistry, or
whatever it happens to be, we’re looking to see impact on the
patient and the outcomes of their care. So, we will have a complete
set of process as well as outcome measures, and that’s the
important next step for us to take. But it is quite challenging to
pick the right outcome, because you can you can end up doing lots
of interventions to people, which is also a bad thing. So,
there’s quite a healthy debate at the moment about how
we’re going to measure patient outcomes in this respect.
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