Cynulliad Cenedlaethol Cymru

Diolch, Cadeirydd. Bore da. Good morning, all. My first question: we read in the report about one seamless system of care and support for Wales. I'd like to know the thinking behind this. Can you tell me to what extent the system is a practical one, given the continuing health and social care divide?

Thank you very much.

I think, from our interim report, we set out the case for change very clearly, and the pressures that are present now and predicted to continue to grow into the future. What we considered in coming to our conclusion was that the system in Wales needed to be different. This wasn't just about joining up what exists now, but actually envisaging a different way of working that met the needs of the population as they are now and are likely to continue to develop into the future. We set out that one seamless system of health and care for Wales.

I'll bring colleagues in, and particularly ask Keith to comment about the structural elements behind your question, but we were clear that there isn't one set of providers that has all the answers to this. We also emphasised that there is a whole range of people who need to work together to meet the health needs of the local communities. So, we're talking about health and care providers, we're also talking about housing, and there are other civic services, voluntary organisations, the independent sector—they all have a role to play in shaping what's needed to best meet the needs of the local community. We felt, by focusing on the front line and changing how that system works, it would better meet the needs of the population and also achieve better outcomes for people. Perhaps you also wanted to explore the organisational question. Do you want to comment, Keith?

Yes, as Ruth said, this is a challenge of mobilisation and focus, rather than a challenge simply of policy and organisation for us. That means, as Ruth said, that driving change at the front line is absolutely fundamental to our recommendations here. We would like to emphasise that we have seen some fantastic, brilliant, wonderful services across Wales—right across Wales, not just in one particular area or one particular part. What we are concerned about particularly is ensuring that exceptional best becomes standard. That's why we've concentrated so much on the front line. The word 'seamless' is very deliberate. We don't see a concentration on changing structures and organisation as likely to produce the level of improvement that we're talking about, as we do about driving change at the front line, and that is driving us towards a seamless health and social care system. 

Thank you. My next question is: it's important to provide services as close to home as possible, therefore how should, for example, housing services, including Care and Repair and adaptations, be better integrated into social care services, planning and provision? 

Again, I might ask Keith to comment specifically, but just to say we do highlight in the report—. The  fundamental model that we advocate is to build from where people live in their communities, and therefore housing becomes a critical factor in enabling people to have choice about care at home and being able to live independently for as long as possible. A locality also needs to look at the local population and work out what sort of other types of care people might need. It's not just about everything at home. There also is a need for residential care and for nursing care and it's about being clear, working with local communities, about the range of options.

So, we talk in the report about actions that could be taken to help that integrated planning and we talk about integrated capital funding, so trying to develop models of care that actually incorporate naturally the things that people need to work together, so that the individual isn't having to go around trying to get one sector to do something and then another sector—that it is naturally organised in a way that properly meets the outcomes that people are looking for. 

So, how do you plan on improving the communications channels between the various departments, because, obviously, there has to be an extremely linked-up approach here between departments, and sometimes one department may fall down, and if one structure falls down, then the whole structure will fall? So, how do you plan on bringing this improvement about, really?  

I think there are a couple of things that we'd emphasise there: one particularly is that within the framework you'll have seen we talk about the importance of locality-based service development. What we are not talking about there is localities left to get on with it. We see a central role for Welsh Government and national bodies in setting principles by which localities, local areas, should be working. And if we don't have that, then the danger is you end up with the same pattern that we've got at the moment of different levels of quality. So, for us, that's absolutely fundamental. So, that's one thing. 

Secondly, at a regional level, we think that there is a very strong argument for saying that regional partnership boards, and the arrangements that sit underneath those boards, should be held responsible for ensuring that localities are supported to deliver good services and appropriate services. 

Then, finally, one other thing that we recommend specifically in that area is around joint commissioning and joint planning. For us, the days that health can commission in one direction and local authorities can commission in another should be gone—this should be a joint enterprise.   

Thank you very much. My final question: what do you think we need to ensure that the third sector can make a full contribution as a service provider and innovator?

In the report, we do talk about the role of the independent sector, the third sector, in a number of different ways, as key partners in understanding local communities, involving the local community in options on how to provide the best care. We also talk about strengthening the commissioning function, being clear how to go about properly involving the third sector, particularly highlighting the social value that comes out of working with communities in a different way, and there is a number of ways in which that can happen.

I think that the first starting point is being clear what role they can offer and how best to build that relationship. It's clear that the system in its entirety needs everybody to play a part in this. The solutions are not all in the hands of clinical solutions—they are social solutions. We hear about the problems that people face in local communities of loneliness and many other things, so there are a real range of ways in which the third sector can play a part and we try to point to the importance of that and also mechanisms. Again, I'm going to turn to Keith, I think, on this, unless other colleagues want to come in. 

I'll pitch in. 

Eric will come in. Do you want to say any more?

I think that's absolutely right. Those sectors—the third sector obviously has a hugely significant role to play here. We've seen really good examples. I'll pick out one from children's services in Newport. Newport and Barnardo's have worked very closely together to develop very, very impressive early intervention and early help services for children and families on the cusp of needing safeguarding or substitute care support. It seems to us that that's one of many really good examples of how we see different sectors working together seamlessly without having to spend our time concentrating on structural change. 

Okay, thank you. 

Can I just ask Eric?

I'll just take up a couple of other aspects of how the third sector can be better engaged. If you look at our recommendations around governance, I think we're quite clear there that Wales needs more holistic governance arrangements and it's really important that the third sector is formally involved in that and has clear accountability and authority within that. To pick another example, the digital arena, for example—they have a lot to offer there, they've got some really interesting innovations. So, that kind of partnership working isn't just exclusive to health and social care in Wales. It really needs to be broader than that and involve the third sector too. 

And when you answered—going back to my first question—you said that you'd looked at this system as being for now, working for now and in the future. So, obviously, you are confident about the sustainability of this system. 

I think one thing we'd want to emphasise is that the challenge and the scale of change that's needed to best meet the population is substantial. This is not going to be easy. You know, just setting out the population shift alone, the projected reduction in people of working age—the balance is going to change in society. People are living with multiple chronic illnesses—that needs a different solution. What we've done is to look at the system as it's constructed. We've debated whether there are structural things that need to change, and we make one or two smaller suggestions, but, actually, what we realise is that this has got to be a fundamentally different way of organising care at the front line, as experienced by the people who use it and participate in it. I think the organisational elements should only follow if they get in the way of reimagining a different way of working at that local level. 

Thank you. Diolch, Cadeirydd.

You've got question 4 as well, on the quadruple aim. 

Right, yes. The first element of the quadruple aim focuses on prevention. Given the pressures on services to meet existing demand, what is needed to ensure prevention is given the priority that it deserves?

Thank you. Again, colleagues may want to contribute here, but if I start off. We're clear that a large proportion of the chronic diseases that people face today are preventable. The need to have investment in a range of public services is also evident. We know that some of that ill health starts in early years and therefore there needs to be attention to prevention right through the age span. Understanding that and organising services, making sure there are the conditions for people to be healthy, continue to be a priority or importance. The second element we talk about is the need for the services themselves to be preventative, and that's both in health and in social care—spotting the problems early and working through what those issues are. There seemed to be a very good example of how services could do it differently from the Welsh ambulance service recently, which I was very interested to see, where they looked at people who were presenting repeatedly to services and got underneath what was happening in people's lives. Now, that is a preventative approach. Certainly, from the accounts I read, it helped people actually get the right support they needed and ensured that they got a better outcome for themselves too. So, I think prevention is—at multiple levels, it's the root cause of poor health in the first place, it's helping people through policies and practices to have choices about a healthy life, and it's also about the services thinking prevention in what they do.

Now, to secure that, first of all, it's being clear in the quadruple aim, we say that all four are interdependent. This is not about picking off one or two and thinking, 'Oh, we're doing those ones, and we won't worry about the others.' All four are essential and work together synergistically. So, if you put prevention in the context of better outcomes, it leads you to thinking, 'Well, actually, we need to organise our service response differently, because we'll get a better outcome and it's better value for money.' Looking for solutions where those things work together is part of what we expect to see as part of implementing the quadruple aim. Does anybody want to add anything? Jennifer, I think you will comment.

Yes, just to say that this is an international trend—to try to think more about prevention and to move health services over from being reactive to being actively managing people before, and spotting people before. Also, as we say in our report, there's a big task to be done to craft all of the environment that the health service is working in—the incentives, for example—to make sure that people are motivated to do that within the service, rather than just react when someone arrives in casualty or whatever. That takes quite a lot of technical thinking to work out what kind of milieu is best, but I would say that everybody across western Europe is very actively trying to do that.

A big key here is data, as Ruth says. You've got very good data infrastructure here to be able to spot and assess the risk of people to target for support early, well before people become ill. That's entirely possible, and that's a huge asset that you've got here.

Thank you.

Jenny has got a supplementary on this point. 

Nobody would disagree with what you're saying, but we are so poor, starting at the beginning: our breastfeeding rates are much worse than in England, and we don't provide women with the support they need to ensure that breastfeeding is properly engaged. We know that this is one of the greatest ways to prevent babies from becoming ill and improve the health of the mother. So, what is it about the culture that prevents us doing the obvious? 

I think Keith wants to come in, but I'll just comment specifically. I think it's about being clear what the health and social care services are there to do, and having a very clear way of measuring whether or not they're doing it. So, through the quadruple aim, what we're saying is that this should be a golden thread through everything that the services focus on. So, actually holding people to account for preventative actions, and working it right through the inspection process and the performance management regime for the care services, while at the same time building that coalition—that understanding—in local communities in support.

It's all very well the health sector saying, 'This is really important', but if women don't feel comfortable breastfeeding in their local community, then that needs attention too. It then becomes a question of how the services work together to create the right environment for people to make those choices. It's not just about giving people advice on what to do; it's paying attention to things that may not seem to be part of the services' responsibility, but it's creating that understanding and then holding the system to account.

We talk about the public services boards' responsibility for health and well-being, and they have well-being plans. So, again, that's the public services in Wales expected to come together to prioritise the things that actually make a difference in those local communities. I understand there's some work developing in Wales around the focus on the first 1,000 days—creating the conditions so that babies are born into an environment where they can have the best chance of the best possible start in life.

Part of that example you gave is of those agencies working together to say, 'These are the things that matter to us; these are the things we're going to change and work together on to show that we can do it.' I think Keith wanted to come in on that.

Go on, Keith.

Just more generally, our brief was to step back and look longer term at where we want to get to over the next period of time. For us, being given that privilege of being able to do that has allowed us to say that, essentially, the relationship between the citizen and the state actually needs to change, in terms of health and social care.

You've got a policy framework here that other countries would probably admire hugely. The Social Services and Well-being (Wales) Act 2014, 'Prudent Healthcare' and so on—it's all there. It's about changing that actual pattern of behaviour and relationships at the point at which somebody comes into contact with the state and its representatives, the third sector and so on.

For me, that's three things, and we do say this in the report, and we do say how important it is to be looking at this at a public level as well as at a professional level: responsibility, choice and control. Those three areas need to be hand in hand when we're exploring the questions of that relationship.

Diolch yn fawr. Thank you for the question. I think we go back to what we say in the report: first of all, that the scale of change needed to better meet the needs of the population is clear, and really keeping an eye on that strategic context, that carrying on doing the services in the same way and not meeting the needs of the population will be under increasing strain for the future. So, really understanding that situation, and ensuring everybody understands that situation. We talk in the report about the need for a national public engagement about the new models of care, what they mean in practice. So, I point to that recommendation first.

We also need to be, I think, mindful of setting the context of those national principles that we've talked about in the report and Keith mentioned. What should people expect in the local community to be available 24/7? Those things are changing. Science has moved on, clinical skills have changed, the needs have changed. So, it's again starting the conversation from a position of, 'What are we trying to offer here?'; being clear that the quadruple aim should work its way through all of it—how do we get the best mix that meets the needs of the local population; and build it with the local communities to have that understanding of what's needed. It's where we have set out what we think is necessary. But I'm going to look to my colleagues, who might want to add some observations on this.

I'm not here to comment [Correction: 'comment on west Wales']. I don't know what the plans are in the example that you've mentioned, but I think we have set out some very practical things that are needed: set out the vision, set out the national principles, but encourage local communities to have the conversation about, 'What is the particular mix in a local area that's necessary to better meet your needs?', and understanding what people are concerned about. We have a recommendation called 'people in control', and that is about really getting behind their concerns. It's natural for people to be concerned about change, but I think it's also important to be absolutely open about the challenges that are facing people in trying to organise the best blend of services to better meet the needs and concerns of local communities, and that has to be a very strong and a different way of engaging with communities to really get a mutual understanding of the choices. I'm going to ask colleagues to add a little bit before we come back.

There's no need to touch the mike—it works automatically.

Oh, okay, thanks. In the report, we talk about three shifts: one is a shift into the community of care, as described; another is to think about hospital services and specialised services; and the other is population health. With each of those, there's no magic ingredient for how to do it well. It's a combination of expert consultation; absolutely expert, transparent analysis that has to be scrutinised very, very carefully; and then, of course, leadership. There's no way of getting around those three things, so whatever you want to do in those three areas, it has to be that combination. And the analysis—certainly from my experience—in parts of the UK, is often lacking. I don't know about this particular case, but transparency in that analysis to enable people to look at it and see where the holes are is absolutely critical.

Maybe I can ask it in a more general way. Should there ever be a consultation on the shape of health in a particular area in future? Or should it always be a consultation on the shape of delivery of health and social care?

We, obviously, have set out our recommendations, which are for a seamless system of health and care. We've also recommended that front-line services should be organised in a way that it is seamless—and not just health and social care, but primary and secondary care as well and mental health and physical health. This is not about starting from a position of, if you like, the current model. It's starting from how those things should all come together for the future. That would be my starting point and what we talk about in the report. So, I think setting out that model of care is important in the debate, but not having the artificial barriers that exist now, which is envisaging a service that is built on the current building blocks of how it's organised.

And, for us, many of those partners go beyond health and social care—so, as you mentioned, housing, education, learning, adult learning, are all key factors, particularly in the desire to support people more effectively before they need substitute or acute care and support.

But there's another example that springs to mind, which is—it's been dubbed 'the Welsh highlands', which is an area around Blaenau Ffestiniog and over the Crimea towards Ysbyty—. There is a big block of land mass that's going through a series of changes that aren't going down well with the local population, because it means you have a very wide geographic area without the kind of, what they would term, 'basic' health hubs that you would have in other parts of north-west Wales. How does that discussion happen on the delivery of health and social care in that area under your proposals? Use it, if you like, as an example of what you're saying about the delivery of health and social care in rural areas.

We were very mindful that one size doesn't fit all in Wales—very clear about that—which is why we've emphasised that national principles are [Correction: 'are to set out'] what people should expect in the local community, but also to have the freedom to innovate in different ways, have a different mix of services, a different mix of staff, depending on the particular needs of local communities and the particular challenges of local communities. There will be continued pressure on workforce for some time to come. Just the logistics of the change in the population structure will mean that it's difficult to get the right blend that people want, so freedom to try different models of care, freedom to use more technology—we could bring in examples around that where you can supplement some care or offer it in a better way. The starting point, I think, which is a point that Jennifer made, is a clear understanding of what it is that local communities need—what the data tells you and what people talk about themselves—and a realisation that it has to be a dialogue about what is possible, and a willingness to try new things but evaluate them, test them and work out whether there are better ways of meeting those needs.

Again, I'm using a particular example, and I realise you don't want to be sucked into a particular example, but in that example it's clear to me that the local authority feels it is having this health board model imposed on it that it is not particularly happy with. The scrutiny committee on that local authority is not happy. Under your model, that wouldn't happen. You would have to arrive at a point where that local authority and the health board, and other bodies as well, would co-devise a new model for that area.

I'm going to bring Eric in, because I think you're starting to touch on some of the governance points that we make. We are very clear that to follow through on the seamless model of care there are some governance questions to address on that. Do you want to come in on that?

You raise the point of co-production, and that's so important. We've already talked about it earlier on in terms of involving the third sector. What we've tried to avoid in this report are any radical suggestions around the reorganisation of governance bodies, because form should follow function, and this is much more focused on what the end-to-end model should be. That's where you should start. I think the kind of dialogue that we're having at the moment, that we're talking about, is that we've got some principles that have been set out in this report. So, we've advanced principles for good governance in the future rather than new governance restructuring. And there's a lot in there around behaviours, which is really important; a different behaviour set to be able to set yourself aside from your natural bias to your function or organisation and think rather more holistically about what's right for the greater good. That's certainly where I'd highlight that way of working. A lot of that is collaborative, and that's what we've tried to do here. So, give clearer guidance about how governance bodies should work together. That would include closer allegiance and more open and honest working between local authorities and local heath boards, for example, rather than restructuring.

I'll just add a couple of things, if you don't mind. We did look at the regional partnership boards. We did think that there is the potential there to be very valuable in this system in driving forward improvements at a local level. It's early days with those. They are settling down. They're a couple of years in, now. We think they should be encouraged and supported with responsibilities. And then a specific thing underneath what Eric was saying: a joint responsibility for key targets between local health boards and local authorities seems to us to be an important element of ensuring that local authorities and health boards are required to work effectively together. 

I would just add one more point. Ruth talked about national principles but flexed locally for local delivery. But that should not inhibit other localities learning from the results of what's been delivered in that particular one, because that's an area where I think we all feel a lot more could be done. There are lots of isolated examples of excellent practices in Wales, be they new models of care or digital, but there is not the sharing of best practice, or even worst practice, if the results aren't successful. It's just as valuable to share that. So, although we say that these new models of care should be flexed for localities, there should definitely be a feedback loop and sharing of the results, or otherwise, of those.

Okay, thank you.

Angela.

I just wanted to pick up a quick question on a comment you made, Keith, about how the regional partnership boards have been settling in and they've had a couple of years and so on. Could you just give us an indication of what you think are reasonable timescales for organisations the size of the NHS and the social care sector in Wales? We have some thousands of people and quite a convoluted structure in some ways, and I do appreciate that we're going to have a one-year review—you suggested—and a five-year review. But actually, you see, I think a couple of years for a regional partnership board to settle down and start pulling against the traces seems to me quite long, and I just wondered if you had a feel for what we should be expecting. How fast should this pace of change be?

What this panel is saying is that the pace of change needs to ratchet up very significantly, and it won't be enough to leave that to regional partnership boards to do. It won't be enough to leave it to localities. There is a national agenda here, which is needed to drive change more effectively, I think.

But, you've obviously—. I know you've all worked with organisations external to Wales as well. When you're implementing these kinds of changes, do you have a feel? Would you say that we would hope to see a refashioned NHS in 10 years, a decade, or are we looking for five years? I couldn't quite get that sense out of the report. I could see the check and balance, but I couldn't see the overall timescale.

It's not something we've come to a panel—. I would be very disappointed if we hadn't seen major shifts in the next three years. 

Okay, thank you.

Is that a fair—?

It is, and to add, I think we do actually make a reference that, in three years' time, it's worth coming back to the recommendations and reconsidering some of the shift that's needed to try and expedite further progress if it's not progressing in the way that people expect. We also talk about the need to prototype models of care quickly. We recommend that people scale up, test out, at least two examples—substantial examples—in each of the major areas in Wales to actually learn by experience as well, quickly, rather than just set out and hope something's happened in two years' time. It's actually about: start showing how you're going to do it, plan it, and demonstrate progress towards it as well.

Yes. You've obviously covered some of the areas. My questions are about staff and citizens. Could you just give your vision of how you're going to put the people in control?

So, again, I'll look to colleagues to join in. This is quite a fundamental issue for us. We talk in the report about people being, first of all, in the position to have the health information that they need to be able to participate. So, we emphasise health literacy and are pleased to hear about health and well-being being a part of the school curriculum, building a foundation of understanding about health and well-being. So, that's a sort of building block and that needs attention, not just in children, but also through adult life to help people have the knowledge they need to participate.

There is a strong movement in Wales towards co-production. It's in the legislation and it's part of 'Prudent Healthcare'. There's a movement called shared decision making and in social services, people talk about voice and control. What we talk about is, at that individual level, helping professionals and the public to build the confidence they need in terms of what information people need to have the ability to make those choices. So, we talk quite a bit about health information and care information in a way that's accessible to people as well, and that both professionals and those who use services have a responsibility to come together to mutually understand that information.

There is an information revolution—Jennifer, my colleague, could talk about this. The services need to be on the back of that; make it very straightforward for people to know what their choices are. Could we—

So, you think information is the key to people being in control. 

Meaningful information and then meaningful ability to act on that. So, if somebody says, 'I've looked up my condition. I actually think I could be cared for at home and I'd like to make that choice.' It's more than just having that information. It might be something about, 'Actually, you need to train my carer to be able to help me with some of my treatments at home and I can do more at home.' So, it's actually then marshalling the services to listen to that choice that people want to make, but also offer support and training to enable that to happen. Colleagues may want to add more about the user importance.

I'll make a couple of points. There are a number of dimensions in which the public can be involved. So, again going back to governance, we've talked about having meaningful involvement of citizens on governance bodies. By meaningful, we mean that they have genuine influence and authority on those. In terms of changes, be they new models of care or, for example, digital innovations—and perhaps there might be a project team organised around that—the sort of thing I'd be expecting to see is very early involvement with the public in testing prototypes and getting feedback from them and refining the new models or the new systems accordingly. I think we've got some really good examples. It would probably be helpful from the work that we've done, particularly that which has been led by Keith in terms of involving citizen panels in the work that we've done in generating the principles for new models, because that's a really good, practical example of how it can be done and how it's proved effective. So, that's a bit of a baton pass to you there, Keith. 

I'd just like to give you one example actually. This is not from Wales and it's not from the work of this panel, but colleagues and I looked at a situation in a local authority area a couple of years ago and talked to all of the people who were in residential care in one particular area, and asked them did they want to be there and did they need to be there, and looked at the professionals' view on that. A large proportion of those people neither wanted nor needed to be there. Of those who didn't, 100 per cent of them had come through hospital discharge.

When we looked at it in detail, what became very clear to us was that, at the point of hospital discharge, those people were in a very difficult and scary situation and needed some very intensive support. But by almost inertia, they'd ended up staying in residential care long beyond the time that they actually needed to. Now, for us, that's a good example of where information—yes, that's important—choice and control are important in helping people make decisions at the time that are right for them in the longer term, but also the management of risk, because I can quite understand how, as a medical professional or a social worker, you don't want to be sitting there feeling responsible for having placed somebody at home and something unfortunate happens. So, we've got to shift, if you like, the public's and patients and carers' perspectives, as well as professionals' perspectives, about what choice and control actually means on a day-to-day basis. Does that make sense as a way of describing that?

The other element is budgets. So, obviously, there are experiments going on where you give people money as well as information, particularly when they have social needs. And it's surprising what they use, and therefore many spend beneath the budget that otherwise would have been spent, so it's the same thing.

Yes, very much so.

Jayne, did you want to ask something on these? We'll come back to you now, Julie.

Yes, thank you, Chair. Keith, I take your point and that example is really powerful. I think the other point, perhaps, would be what facilities and what access to, for example, step up, step down care is available to look after those people for that short space of time. I think something like that—. How does that fit into the models of care that we'd be looking at in the future?

It's fundamental. Absolutely fundamental, and not just that they are there, but that they are trusted and understood by people, so when it comes to questions around what is the best configuration of services, people are able to say, 'Actually, this level of care is equivalent to me being in a hospital bed,' or, 'This is as good as or as effective as.' That's a matter of trust, and at a point where you're really scared or worried about yourself or your family member, you need to be able to trust those resources. 

Could I just add? We saw a very powerful example when we looked at the Bridgend example. Staff themselves talked about the support they got to take risks, to be able to do what people were hoping for, and the support they got from each other. They knew that they could rely on specialist advice if they needed it and it was readily accessible. But they also emphasised the importance of that seamlessness between the hospital and the community, and how organising that differently made it a better experience for the staff, but also for the people using the services. They were able to mobilise a response quickly. But you have to set out to want to do it in that way. They, clearly, are one of the examples we've seen in Wales where people are able to do this, and it really gave us confidence that the front-line staff can find a way of working that will bring some of these options to life for people—the things that they're really looking for.

Yes, good. It's turning the clock back, really. I remember being on several barricades defending my local community hospitals about step up, step down care and about convalescence/rehabilitation care and that need for flexibility, but it didn't stop the hospitals closing and that's why we end up in the situation where people end up inappropriately in care. Julie, carry on.

Yes. Obviously, we know that there are huge inequalities in access to healthcare and outcomes. How will you tackle that through engagement with people? You're talking about people having their say and that's a great example, I think, of speaking to people who have been inappropriately placed after hospital. How are you going to tackle the fact that there are such huge ranges in the services and the outcomes in just one city between two different wards? How will that fit into this way of approaching it?

Again, I'll bring colleagues in. We were very mindful, if you look at the health of the population, that there is a wide inequality in health experience and outcomes in Wales. We're also mindful of the science and the evidence that says that the vast majority of the action needed to address health inequalities is outside the care system. So, again, we emphasise the importance of having the other public services available to support people. Addressing the social determinants of poor health was really crucial, and working together with the health services. However, we did point to where the health and care services could make a particular contribution. And, again, it comes back to this theme we have, which is clarity about the national principles of what people should expect, but flexibility to organise them differently in different communities. So, where you might have a community with very severe needs, perhaps not always being actively supported or involved, then we talk about making different efforts to engage people, working in different ways. You might rely on written information or data in one type of community. In other communities, you might actually want to go into the communities, work with community workers—we talk about working through local government and the people they have working on the ground in communities—to understand the real issues that people are facing. The solutions, sometimes are to bring other sectors alongside the health service, not just looking for the healthcare angle on that, but understanding how those services can work together in the round. Again, do colleagues want to comment?

There's some good work, although it's limited at the moment, going on in Wales around PROMs and PREMs—patient-reported outcome measures and patient-reported experience measures. I think it's really important to get more traction behind that. We talk about Wales being a listening nation, but it needs to be a responding nation, as well. Certainly, it needs to respond to the output of genuine patient feedback, and that is one area that would help you to identify where there are, perhaps, what we call inappropriate variations across sectors, and be able to address them. So, it's that patient feedback and response loop that is really important as part of this, as well.

The other thing is obviously data, because the more data you have, you can then spot highest users. Highest users are often coming from the more deprived communities, and when you do the analysis, it's just so transparent what's happening. And then you follow the demand, go out to those communities and do what it takes to engage them and understand what's going on. It may be nothing to do with healthcare, as just described. So, data can really surface quite a lot that you wouldn't have necessarily realised.

That's why we say this is a three-level issue. One level is at a national level, the distribution of resources to regions. The next level is at a regional level: what's the distribution of resources across the region? Then it's at a locality level; and all of those things are significant and important. One other area that is important is about inspection and improvement support. So, inspection has to be looking at how effective are services together as a whole across an area, as opposed to concentrating only on the individual services. That, for us, is a very fundamental underpinning of a real analysis of the effectiveness of local care.

There's a need for greater agility, team, otherwise you're likely to spend the whole day here. We would love to, but, obviously, other matters intervene. Jenny.

You mentioned the raft of legislation we've got, which is all exemplary in terms of how we ought to be doing things differently. But how do we get front-line staff to not just talk the talk, but walk the walk, get out of their comfortable silos and start developing their leadership skills? What examples of good practice have you identified in terms of people not just praising things that have gone well, but also analysing thoroughly where things have gone wrong and how we might do things differently next time?

That's a really fundamental question, and one of the areas that we point to in the report, which is that Wales should set out a strategic direction to build on some of the work it's doing, but really set out to be a learning system, and that is cultural as much as anything else. So, if you start to unpick what are the areas that need attention, first of all it's talking and listening to staff. We felt that the fourth element of the quadruple aim, actually, is that staff are engaged, focused on their well-being, focused on their capacity and capability and their training—you will hear the things that they see day in, day out, that need to be changed. We heard clear evidence that people know some of those things, but they need help to make those changes happen. So, really understanding the conditions that people need—the time, the training, the support—to have time to reflect on what's happened, whether it's worked really well or hasn't worked so well. We talk very clearly in the report about the need to align all the improvement services and support that is available in Wales to be clear what it's aiming towards—in other words, the quadruple aim—and to support and engage front-line staff to have the freedom and time to do some of those necessary improvements. I'll turn to others.

One of the most poignant moments in this review was when we were in a room with 50 junior doctors and other clinical staff in Cardiff. These were very well motivated, very talented people—you couldn't wish for more motivation and potential leadership—and they were very disgruntled. They basically said, 'We're not supported, we'd like to make changes, we'd like the skills, the management in our organisations isn't forgiving enough to help us do what we would like to do.' We were in a room with Don Berwick, who's one of the US's former gurus in this particular area.

There are a lot of answers to how you move forward and none of them are quick, but one of them is to try to skill up local junior front-line staff where all this change is going to take place with what are called quality improvment skills. Wales has developed a system of doing this but it's fairly tentative, we think, and it's kind of lost a bit of power in recent years. So it's to have a strategy to skill up the front line in some of these change skills that they need. But there's also something there about the management culture in places and the leadership in these institutions where they're working that somehow treats them as junior, transient, not-necessarily-contributing staff, so it's also to try to somehow boost the support of that management and skill up the leadership to support the front line.

I think that throughout all of our report what we think is that through the front line and through patients, that's, in a sense, the route to acceleration and improvement in the future, not the top-down reorganisation or restructures, as you've heard, that we've had in the past. To do that, you really have to start with these front-line workers. So, a proper strategy for supporting them coupled with leadership management, particularly in the health boards and in the hospitals in which they work, is absolutely crucial. There are signs here, but it needs to have rocket boosters on it to get where we need to get to.

I will give you a couple of examples. You asked for examples here of ways forward. There are two or three things that we thought were quite impressive in different places—we're not saying inevitably so. The integrated care fund: there look to us to be some very interesting developments in different regions about how they work together to ensure that services are effective. We were impressed with many of the initiatives by local authorities on the implementation of the Social Services and Well-being (Wales) Act 2014 and the shift in assessment practice that is required there, and we think that there's more that can be done in health boards. And I'll pick out west Wales and north Wales, who are both working on shared strategies for workforce development around the care force, and what they mean by that is residential, domiciliary, auxiliary nursing and, crucially, the informal family carers as well, because what they say is that that care force is an absolutely fundamental part of an effective system, and they need support and development as much as anyone else. So, there are some areas there to build on, I think.

Can I just add that the other place where we saw a lot of zip was the GP clusters? A lot of entrepreneurialism and energy, unleashed actually by fairly small amounts of money. So, I think how those are supported going forwards is another critical thing that we notice in the report.

Angela, and then I'll come back to you, Jenny.

I wanted to pick up, actually, Jennifer, on your point about driving the change from the front and the juniors and the front-line staff actually seeing that change, being able to implement it and being supported, because you don't think that the block coming down is going to be get-through-able. My concern with that—and I totally understand your view behind that—. My concern though, and you've mentioned GP clusters and we've just recently done a report on GP clusters, is that actually, inevitably, that block at some point does kill. It kills green shoots and kills innovation; it doesn't allow it to spread. And the front line are so busy trying to cope with the enormous pressures they're under that I worry—and we talk about staff motivation, about changing everything—that if we then say to them, 'Oh, by the way, you're responsible for starting this transformation because we hope that it'll eventually filter through to top management'—. I really worry that (a) we're putting the front line under immense strain and (b) when is the transformation going to happen in the management? Personally, I think that they are paid the big bucks to run the service, to make these changes to make this happen, and I just think that, by putting the onus on the front line, we're letting them off the hook. That's a concern I have. 

Well, I think if you try to support the front line, as you need to do, and give them space, that will require some investment, but that doesn't negate the need for making strategic decisions. So, the leadership has to be facilitating an understanding that a lot of the changes will be coming from the front line, but then there will be big decisions to be made that the front line simply can't see. There's no answer to that other than leadership, but in turn, it means that those leaders also feel that they are covered for making those decisions, and that's where the politics comes in—that if they are making difficult decisions, based on, hopefully, good data, that they're supported in doing so.

But it's not just structural change. So, if we take GP clusters, one of the things we constantly heard from them was that they had that entrepreneurial spirit, they had lots of great ideas, but, inevitably, at one point, when it came to trying to get that best practice they develop and get it to be grown out, that's when they'd hit the block, and the block was either financial or just sheer management—that block of the health service, or the NHS trust, saying, 'Ah, you are the GPs. You're an arm's-length organisation', and it's just stop, stop, stop. I think someone is going to talk about transformation, but that's my real worry about how we're going to do the doing of it. Because this tells us where we should go, and has got lots of signposts. I still feel that one of our big failures is we're just not getting that doing happening.

You have to have that high-level leadership. It has to be authentic leadership. One of the key facets of leadership is having the vision and taking people with you, and that has to be there. Jennifer's touched very well on how you then involve the people—the service users and, indeed, the citizens, which we talked about earlier on—in actually creating that change, designing their own futures, which is something we talked to you about last time we were here, and actually delivering the change. The change should be landed by them, not by the NHS Wales Informatics Service or whoever else it might be. Then it becomes that much more compelling and much more likely to succeed. But without true, open authentic leadership at the top, with a clear vision and taking the staff with you, that won't happen.

Just to emphasise, sometimes there are multiple ideas, but if you're not clear about what shared outcomes you're working towards, then you have a mismatch in understanding. What might seem a great idea to solve a local problem but doesn't contribute to the wider strategic goals makes it very difficult for somebody in the middle there saying, 'Well, actually, my priority is that I've got to meet this target' or whatever it might be. So, I think creating a mutual understanding as well in that translation from the clear leadership of what's expected—the shared outcomes you're working towards so that everyone applies the same understanding. Then the point that came up before is risk. It's very easy to hang onto the current model of working even though it carries risk, because people are wary of moving to something different. So, again, giving permission to take those risks. 

And that's why we do not see this as a locally led initiative. This is a national transformation programme, and that's what's required, as opposed to leaving it to localities. I was in Aneurin Bevan in Gwent last week, talking about the review, and I was really impressed with the GPs and their colleagues there who are their local clinical network leads. They were saying, 'The report—that's good. It's grist to our mill. It fits with where we're going.' They're ahead of us on this. They are thinking well down the line about how they work together as agencies. They want to have that time and energy to put in to working up 12 or 13 local health and social care locality arrangements that are going to work for them. So, we were really impressed with that. 

Okay. Back to Jenny.

Speaking with these junior doctors who are frustrated, who have a good tour d'horizon over the whole system, how do we empower them to stop doing the things that are pointless or duplicating effort in order to then be able to do things differently? Because there is no more money in the system. It's about shifting it. So, you say, obviously, we have to have leadership from the top, but we also need to—. How are we going to make that leap forward?

I think it's partly back to skilling them up, partly beginning at medical school—that their job is not just the medicine and the science, but it's also to improve everyday work as well, and that's an everyday issue. There are change skills—. Wales actually has gone down, through it's 1000 Lives campaign and other related things, to try to help skill up juniors in this way, but they need the space, they need support, and they need some cover to do these changes that they see. As you say, they tour around the system, they see inconsistencies everywhere. It's skills, training, permission, a bit of space, data—they will make those changes, they've got the leadership, but they can't if their consultant is frowning on what they're doing or treating them as a transient workforce, which is what they described as happening. Similarly, the consultants can't give cover if their chief executive is not giving them cover. So, it's a knock-on effect. It can't just be done by the juniors, as described.

So, how do you think we're going to achieve this systematic move forward, because you talk about rationalising the range of improvement service support activities into a unified system? How, practically, is that going to happen, because these junior doctors are desperate for the plan into which they can work?

Well, I think you need to get back to basics with a good strategy for Wales about how this can be done at all levels, and insert into that strategy some practical things that could be done. I think junior doctors across the country are required to do audits, as they're called, as part of their training, but those are often very meaningless. Those could be translated into meaningful change, and there's a way of assessing that. We're getting into detail now, but this isn't difficult, in a sense, it's just a question of looking at it coherently, having a proper strategy and not loading everything onto the juniors, but giving them space in their six months, wherever they are, to do something meaningful to change this or that part of the pathway of care that they see is irking everybody but that they've come in with fresh eyes to try to change. So, it's permission, it's a bit of space and its cover, I think, and skills.

Within a common national set of principles and standards for each locality.

Where do health boards sit within this strategy? Are they part of the solution or part of the problem?

Well, they have to give permission, don't they, to enable this to happen and invest in some of it as well? It's not that expensive, but it's a recognition that improvement is part of everyday work—that is the issue—not just firefighting and dealing with what comes. Actually, your job is also to see how things can improve. The patients will be telling you every day how things can improve, and it's often very, very obvious. So, that's the—.

Thank you.

Moving on to another field now—Jayne.

Thank you, Chair. The report clearly highlights the importance of technological advances in achieving reforms and a seamless system. To what extent are the current digital infrastructure arrangements hampering service remodelling and improvement, and how do you think this can be addressed?

I think I'm going to go straight to Eric on this one. [Laughter.]

I'll take that. No surprise that's been asked. First of all, I'm not comfortable with just talking about digital in splendid isolation, because it is an enabling function that has to work with all the other organisational bodies within health and social care, and it's not just about the NHS Wales Informatics Service either. I think more than half of the budget that is expended on digital goes to local health boards, so there's that, and then, of course, there are local authorities as well. So, just as we've talked about having a cohesive view and an end-to-end view of new models, you need to do exactly the same about digital. I don't think the dialogue has been sufficiently holistic about looking at the totality of the digital assets that you have—the people, the systems, the infrastructure—across the piece. It's still too compartmentalised. So, first of all, you need to step back from that and think about it more broadly.

There are so many recommendations on digital it's gone into an appendix, so I hope there's enough detail here. What we tried to do in the report was not be technical, to take two perspectives on it—firstly, a rather more horizon-scanning type thing about health technology in Wales, life sciences—there are some great opportunities there—the digital ecosystem—. Wales has the infrastructure to deliver some fantastic advances here. The second element of this is what's currently in place, the infrastructure, the systems that are currently being delivered. There are some very good things that are happening in Wales. We highlighted that in our interim report and, to an extent, in here. They're not happening, necessarily, at the pace at which they should be happening, and there are all kinds of reasons for that around resourcing, around the challenge of delivering change to a very risk-averse and very sensitive environment without disrupting it. That's a really important aspect of making substantive change in health and social care in Wales.

I think there's tremendous potential. We've tried to look at this whole area from the top down, so starting with the strategy and going right down to benchmarking. I hope there's sufficient substance in there, if it's agreed, to help move digital forward, but I must emphasise, it cannot operate in isolation. It has to work with service users, and it has to work with the end users, the patients, the customers of the services themselves. I think there are various moves in that direction. I'm not exactly sure what the reaction of the digital teams will be to this. I would hope that they're not that surprised. There's quite a lot of resonance with the WAO report, which only looked at the NWIS, by the way. We've cast our net rather more broadly there, and what we've tried to provide here are solutions rather than just stating a problem.

Thank you for that. I think ICT is something this committee's talked about in all our inquiries, I think, and I'm sure we'll continue to do that. So, I take your point about not operating in a silo. But is there a particular problem of compatibility at the moment of the ICT systems—I don't know if you'd like to comment on that—and between the NHS and health and social care? It's something that we've identified.

There are challenges within the NHS, less so than elsewhere, and there will be challenges in terms of the interface with the local authorities, but things can be done. So, the community care information system is an example of a really good initiative that does involve the NHS and local authorities and is delivering great benefits. So, one of the things we do highlight here is having common platforms [Correction: 'common standards'], open platforms, and indeed that kind of thing has been emphasised well since 2011, when I think there was a report—let me just remind myself—'ICT Strategy for the Public Sector Wales', which was seven years ago now, which was all about closer collaboration, looking at ICT, as it was then called, across the piece, having open and common systems. So, that is really important.

The more you move to that environment, the greater flexibility and agility you have to introduce systems from other providers. Because you've got to remember, with digital, you have to make decisions about whether you make, whether you buy or whether you commission. A community care information system, for example, was commissioned from another organisation, and you can't possible build it all internally. But the more you move to that open-system environment, the more opportunity you then have to add apps, for example, onto that and interface with them. So, it gives you much greater flexibility.

It also gives your systems much greater longevity. That's the other thing. There's the constant challenge of what are called legacy systems, and having to replace them. So, you need to ask a number of questions every time there's a candidate system, and one of them is, 'What's its potential reach?' Another one is, 'What's its potential longevity?' as well, so you're not constantly having to replace systems. We cover all of that in the report, if that's helpful.

Yes. Thank you, Chair. That's fine.

The final couple of questions are from Dawn, bearing in mind a lot of the issues have already been covered.

Thank you, Chair. Yes, a lot of these have been covered. I wanted to talk a little bit about service governance and improvement. I was thinking particularly around the NHS, but I'm not sure, given Rhun's point earlier that the NHS can't really do all of this stuff in isolation—I was going to talk to you about what incentives need to be put in place for the NHS to start delivering some of this stuff. In your report, for instance—and it's information that we've already had—only four out of the seven health boards have actually achieved the objectives set out nationally in the last year. So, what's going to change, and what is needed to change, to make that happen? Is it a change that is needed across health and social care, not just in health?

I think probably all of us will have a contribution to make on the points that you've raised—really important ones. I think first of all, coming back to that point about clarity, about what's expected, it's building from the front line, making sure the systems behind people are fully integrated, and that expectations are clear in terms of culture and behaviour. So, a lot of what we've looked at are, really, examples of needing to align systems and processes and follow through in holding people to account for both how the systems are working and the behaviours that are adopted around those systems. I'll say that in general—I don't know if someone wants to come in. Keith.  

We've mentioned some of these already, but I'll re-emphasise them—it's in particular response to what you were saying. For us, one starting point is a shared medium-term plan across health and social care. So, each of the regional partnership boards should be responsible for that, and it should be requiring that of other local health boards and local authorities in their region; performance indicators that look at the whole experience, as opposed to separate health and social care indicators, for which chief executives need to be jointly responsible; and, thirdly, inspection arrangements that look, for example, at how effective regions and regional partnerships are and, for instance, at how effective localities are in achieving— 

Joint inspection arrangements? 

Yes. The delivery of inspection, yes, jointly, very often. Now, that might vary according to the particular population that you're looking at for any one inspection, but the general principle for us should be joint. And, you know, you're looking at the whole system as opposed to one particular part of a system, and inspection agencies are moving towards that. We'd encourage that to be stronger. And then, finally, improvement: a rationalisation of the improvement agenda so that we're not seeing lots and lots of relatively comparatively small improvement activities or programmes across the country aimed at a particular professions or particular services, but you're looking at the improvement agenda on an integrated health and social care basis. So, for us, just some very practical things that could be— 

So, we're talking about the whole process being jointly planned with joint accountability and so on. 

Yes.

So, are those the key measures from your point of view—those particular points that you raised about performance indicators, improvement, shared plans and stuff—is that what you think possibly sets this report aside from other reports, going back so many years? 

Just to add, at a national—. The NHS in all parts of the UK have a certain blend of incentives in them—whether they are described or planned or whatever, they are inherent in them. And so, what we try and say in this report is that it's time maybe to look at the blend in Wales at a national level—the blend of regulation, the blend of targets, the blend of performance management, the blend of other forms of incentives, of the contractual levers that you've got—to look at it all in the round. That requires quite a lot of technical expertise, which is why we also talk about boosting the national NHS Wales technocracy, if you like, in order to try to do this. 

So, it's a kind of warming the ground so that the change that you want to see is more likely, rather than just relying on one or two levers that can happen. But then, when you have your models of care that you think are the most likely ones that in your vision should be worked towards, to listen to the front line to say what the barriers are then that are getting in the way, and that the national system can re-tool to make sure that this holistic seamless care can happen, or the specialised care, or whatever it is—population health. And that's the dialogue over time. The centre can't just take the blend, unfreeze it, redesign it and re-freeze it for another few years. It's a constant iteration, and just as Keith says, looking at it in the round. The incentives on hospitals might not work for the incentives on the GP clusters, which might not work for the incentives on social care. 

So, that's why—. It sounds rather abstract, but it's absolutely critical to warm the ground to the kind of change you need, otherwise you're then painted into a corner, using just one or two levers to excess, and we know what that produces. 

Just on your point about what makes this recommendation distinctive—we're very mindful, and we've looked back at the history of issues around health and social care in Wales. We've tried to set out a strategic direction that will stand the test of time, because it's flexible and adaptable to the needs that are clearly set out for the next 10, 20 years. And it's crucial that the report is used to build a consensus about the actual understanding of the issues. And then it becomes a debate, as Jennifer said, about how you blend and mix the responses so you're getting that continuous improvement in health and well-being, continuous improvement in experience and quality of care, continued drive on value and the continued support of staff. So, keeping that guiding line. And to do that not only have we set out a strategic direction, but we're also trying to point to really specific practical things there [Correction: 'actions'], and a real focus on transformation. And, again, in the report, we talk about the need for a clear [Correction: clear statement to] 'set out what you want to do', and a clear method for implementation, where all of these issues create the whole picture. People said to us, 'You know, we get the general direction, but what's the vision?' So, it's about actually saying, 'That's where you're heading. We're going to move together, we're going to adapt and test ideas as we go along', and the transformation programme sets a structure and a clarity and a pace about the things that must be prioritised to do first, what you can do in a year's time and two years' time, and it's about setting that out. 

And how do you see that being scrutinised, monitored? How will we know that what the report is setting out to achieve has actually been achieved?

So, the first thing I would be looking for is the clarity. We've said, in the first three months, 'Set out the vision.' So, looking at whether that has materialised, what's it saying, and then looking at the transformation plan, would be the first thing. We talk about looking at everything in a year's time, and in a year's time it's reasonable to expect that there'll be clarity about the long-term direction, clarity about the things that necessarily need attention to help to make progress towards it. We've talked about setting up example projects in each area, looking for progress around those types of activities. So, you can break down this report into, 'Are the big steps in place?' and then, 'What are the supporting steps that need to start, and are they starting to happen and are they in the right order and is there clarity about who's doing what?' That would be my summary. Eric's the expert on transformation. 

Expert—well, thank you, Ruth. [Laughter.] It is interesting and quite instructive to look back at a series of reports with probably very valid recommendations that haven't gained traction in Wales, and there's a question about why that might be, but maybe that's for another time. What we've tried to do differently here is to talk more about the 'how'. So, this could have been a very high-level, shorter report, with just a series of high-level recommendations, but there are supporting actions for each of the recommendations, which we know will support, should you and the Welsh Government decide to take this forward. 

Going on to the transformation, transformation programmes are very complicated and very challenging, but it is absolutely what health and social care in Wales needs. So, there needs to be an awful lot of thought at the outset as to how that is structured, how that is populated, the skills and competencies of the people involved, engagement with professionals—there's a lot of thinking that needs to go around because these things tend to go wrong at the beginning. If you get the basis for it right, it could turn out to be a great success. Start with creating a sense of urgency, which I think we already did with our interim report—I hope so. You do need a guiding coalition—let's use that in its loosest possible sense—of leadership to take it forward across all the sectors. You need clear vision, clear strategy, clear objectives, programmes and/or projects that will flow from that. They need to be properly resourced. They need to have the right kind of competencies of the people who lead them, and competent project and programme leaders are absolutely at a premium in the private and public sectors, so that's something to bear in mind. And then you need very clear metrics and milestones, not just to measure the end or the conclusion of a piece of work, but whether it's tracking to plan. Whenever you can have any interim benefits, that's really valuable as well because it energises everybody who's working on it. So, the sort of thing that we've recommended, based on a lot of Keith's work, about galvanising the work on new models and having some in place in a period of time, that creates a sort of energy and enthusiasm of itself—that you're actually seeing something being delivered rather than waiting three, four, five years for something. So, it's a lot of thinking to go around all of this, but it absolutely is needed and there's fantastic potential. 

Just to round this off, I think we will be very disappointed if, over the next few months, we see more than one plan—so, we see plans from different places. And, ultimately, we would be very disappointed if we see lots of actions and lots of activities but no shift in outcomes, and that means the right care from the right people at the right time.

Sure, and from the point of view of a politician, what my constituents will be wanting to see is reductions in waiting times, quicker appointments at the GP and better outcomes in terms of diagnosis and treatment. So, ultimately, that's the measure of success, isn't it?

It has to be translated into individual outcomes.

Yes.

Just to add to that, in terms of traditional measures of success, I think we'd be expecting to see the performance indicators, if you like, taking a broad view of the whole pathway of care and not just about how long they waited for a hospital appointment, but as much about what access they had in the community. Was it joined up? Did they have to do a lot of work to get access to services or were they readily available? So, as Jennifer was describing, relooking at the blend of the different measures and different approaches to make sure that it's actually picking up and focusing on what people have said matters to them.

Right, two final quick points—Angela first and then Rhun.

Eric, I was delighted to hear you lay out what a transformation strategy should look like. Actually, you raised something that I have a concern about. So, my question to you as a panel is: do you believe that we have the capacity within the NHS and social care structure at the moment in terms of capability and competency of people? Do we have the right skills? Do we have the right experience and do we have sufficient leadership? Because although we may ask Welsh Government to deliver a vision in three months, if we don't have those people within our structure who can carry out this transformation at national level, regional level and local level—those are the three I've picked up from you very clearly; those are the three different, distinct levels—and we don't have the right calibre of people who can drive this through with passion and commitment, then it ain't going to happen and we've got to go out and find those people, and where do we find them? So, I just wanted to know if you thought we already have now, today, to get running, that capacity within the NHS and social care to deliver this.

I’d say that it’s really difficult to engineer that kind of capacity. I think that when you start putting a transformation plan together, you need to be really clear about how you’re going to resource it in terms of the number of individuals and, more importantly, the competencies. You need to identify the gaps that you’ve got, and you probably will have some. You need to make some tough decisions about whether you buy in for a temporary period and get knowledge exchange from people from outside to help and support you doing this, or do you develop your own cadre of leaders and programme and project managers?

You need to look at what you are doing and stop doing some of it, because it won’t be part of this. So, if you’re talking about freeing up resource and freeing up competencies, I think there are probably quite a lot of projects and programmes, when you look at the overall strategy, objectives and scope of this, which won’t necessarily form part of it. It’s a very difficult decision to stop a piece of work, but it’s an important one, because that will give you some scope and capacity for redirecting your efforts and focusing on what’s really important. So, that’s the sort of thinking that you need to do, but you should never, ever embark on something as significant and substantive as a transformation programme without having it properly resourced and planned at the outset.

I think the balance between business as usual and transformation needs to be looked at. People are incredibly busy and they’ve had a very busy period trying to maintain services to the best of their ability, and so just to say on top of it, 'By the way, here’s a report and we want you now to do this as well’—

'Go off and do it.'

Yes, exactly. So, I think Eric's points are really important—clearing out anything that really isn't going to help in the short and medium term to help the direction that we set out here would be important as part of that process. Freeing people up to have the time to think and engaging people takes time. So, it's really about having a hard look at what we are doing currently that we can reshape or reform to give people that time to do it.

And we wouldn't want any of that to be suggesting that you lose confidence and go outside and not draw on the skills and knowledge and credibility that there are in Wales, because there are—there are fantastic qualities and skills, which can be supplemented, I think, is the—.

It's about where the vision comes from. The Cabinet Secretary for health and social care has done an interview—it's been broadcast, it's one of the main stories in the news today—saying that there are tough choices ahead of us, there are challenges that we face and that we need a mature debate, et cetera, et cetera. We know all that. I did an interview last night saying, 'Yes, but where's the vision around which we have a debate?' Is it Welsh Government that has to lead the formation of that vision?

I think we, rather boldly, feel that we've had 12 months of engagement. We have done a wide range of activity, talking to people who use services, talking to staff on the front line, senior staff, a whole range of sectors, independent and so on. Somewhat boldly, we have put forward a proposal here in our report that says the vision should be a drive towards this one seamless system of care. I think the question now, with the support that we had throughout the process from you and colleagues across the political reference group, is really about saying, 'Are we clear now? Is this it? Does it need further work? Are we clear? Is it accepted that this is the direction of travel over the next 10, 15, 20 years? Can we agree that this is the approach to go forward?' So, I think it calls upon everybody to be part of that discussion. I don't know if colleagues might want to add anything.

No, I'd agree with that.

No, I think that's perfect. I think that's absolutely right.

Okay, that seems a moot point to draw things to a close.

For Members, we're moving on.