Cynulliad Cenedlaethol Cymru

Yn ôl i Chwilio

Y Pwyllgor Cyllid

Finance Committee

03/07/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Alun Davies AC
Mark Reckless AC
Mick Antoniw AC Yn dirprwyo ar ran Mike Hedges
Substitute for Mike Hedges
Nick Ramsay AC
Rhianon Passmore AC
Rhun ap Iorwerth AC

Y rhai eraill a oedd yn bresennol

Others in Attendance

Rhian Williams Arweinydd Polisi, Bil Iechyd a Gofal Cymdeithasol (Ansawdd ac Ymgysylltu) (Cymru), Llywodraeth Cymru
Policy Lead, Health and Social Care (Quality and Engagement) (Wales) Bill, Welsh Government
Sioned Rees Uwch Swyddog Cyfrifol, Bil Iechyd a Gofal Cymdeithasol (Ansawdd ac Ymgysylltu) (Cymru), Llywodraeth Cymru
Senior Responsible Officer, Health and Social Care (Quality and Engagement) (Wales) Bill, Welsh Government
Vaughan Gething AC Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol
Minister for Health and Social Services

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Joanne McCarthy Ymchwilydd
Researcher
Leanne Hatcher Ail Glerc
Second Clerk
Samantha Williams Dirprwy Glerc
Deputy Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

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.

Dechreuodd y cyfarfod am 09:46.

The meeting began at 09:46.

Penodi Cadeirydd Dros Dro
Appointment of a Temporary Chair

Bore da. Good morning. Welcome to today's Finance Committee meeting. In accordance with Standing Order 17.22, I call for nominations for a temporary Chair for today's meeting. Can I ask for nominations, please?

Thank you. Are there any other nominations? I see that there are no other nominations. I therefore declare Nick Ramsay has been appointed temporary Chair, and I invite him to take the Chair's seat.

Penodwyd Nick Ramsay yn Gadeirydd dros dro.

Nick Ramsay was appointed temporary Chair.

3. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
3. Introductions, apologies, substitutions and declarations of interest

Thank you, and welcome to today's meeting. We've received apologies from Llyr Gruffydd and Mike Hedges, and can I welcome Mick Antoniw, who is attending as a substitute for Mike Hedges? Rhun ap Iorwerth is also joining us via Skype. As usual, headsets are available for translation and sound amplification. Please ensure that any phones are on silent. Do Members have any interests to declare? No? Okay.

4. Papurau i'w nodi
4. Papers to Note

Item 4—some papers to note. First of all, a letter from the Minister for Finance and Trefnydd—amending the Government of Wales Act 2006 (Budget Motions and Designated Bodies) Order 2018; and also, a paper again from the Minister for Finance and Trefnydd to Suzy Davies—amending the Government of Wales Act 2006 (Budget Motions and Designated Bodies) Order 2018. Happy to note those papers? Good. Okay.

5. Y Bil Iechyd a Gofal Cymdeithasol (Ansawdd ac Ymgysylltu) (Cymru): Sesiwn dystiolaeth
5. Health and Social Care (Quality and Engagement) (Wales) Bill: Evidence session

Turning to item 5 and the Health and Social Care (Quality and Engagement) (Wales) Bill evidence session. Can I welcome our witnesses? Thank you for being with us today. Would you like to give us your name and position for the Record of Proceedings?

Rhian Williams, policy lead on the Bill.

I'm Sioned Rees. I'm the senior responsible officer for the Bill.

And I'm Vaughan Gething and I'm still the health and social services Minister.

Thank you. Thank you for being with us today to help us with our inquiries. We've got a number of questions for you. I'll kick off with the first. Can you give a brief outline of the objectives of the Bill? Why is legislation required to achieve the policy objectives, rather than drive transformation and improvement in the quality of NHS services under the existing legislative framework?

Well, obviously, we set some of this out in the Bill statement when we introduced it in the Senedd recently, and you'll actually see that through the journey of this from the Green Paper to the White Paper, we're still looking for some of the policy objectives, but we recognise that on some of those we can achieve them through existing legislation so they don't form part of the Bill, but what we have in the Bill are things we can't do without primary legislation. So, for example, the most non-controversial element is appointing vice-chairs to NHS trusts. We need to amend primary legislation to do that. To introduce a broader duty of quality, again we need to use primary legislation to do that, and the same thing with introducing a duty of candour. Now, those three elements are not that controversial. There has been broad support through the Green Paper and the White Paper for those, and people on this committee will be aware that the duty of candour, for example, has already been introduced in other jurisdictions around the UK. So, those things do require primary legislation.

And the same thing with the objectives around having a new citizen voice body to cover health and social care, which I know has been part of the controversy. But again, the current statutory footing of community health councils is such that they're only able to work across the field of health—they can't work in social care—so you do need to amend primary legislation to do that as well. So, the purposes behind the Bill, I think, have been explained on several occasions, and I'm completely content that it does require primary legislation to do that, but we will be considering some of our powers that already exist—for example, to consider the way that the inspectorates work together. So, that was originally a White Paper proposal. The policy is still there with the intent to do that, and it's also a much bigger piece of work, because if we tried to do everything in the one Bill, it would have been a much, much bigger Bill as well. So, this is still a significant piece of work with lots of interest in it. We'll use the powers we currently have. And I look forward to questions in this and other committees.

09:50

Can I press you a bit on that, Minister? Because I was reading the Bill and it felt very much like a first course. I felt that I was looking for the main course, quite honestly. I was thinking there's a lot of this that can be achieved, in the way that you've just described, in fact, without the need for legislation. I'm sure that a Minister could write to various bodies to ask them to work more closely together, to look at how you deliver on a remit, to ensure that people are working in a more coherent way. You know, you already have significant powers over the appointment to health boards, and it just seems to me that it's a Bill in search of a purpose.

No, I don't think so. If we continued to have in some of the areas, for example, on the way that our inspectorates work together, then you might have said, actually, you don't really need primary legislation to do all of these, but to introduce a duty of candour and quality, to expand those, then we do need to change primary legislation. To give me the power to have proper public appointments for vice-chairs of NHS trusts, again you need to have a statutory change to do that too. And certainly, to have a citizen voice body across health and social care, you absolutely need to use primary legislation to achieve that aim and objective. Otherwise, we'll have a body that is still restricted and only able to deal with the health field. And some of this is about wanting to see the cultural change we think will come from the legislation, because the duties of candour and quality, whilst not being controversial—. You know, if I simply wrote out and said, 'I want you to do this' or 'I'm issuing a set of directions', that doesn't have the same force as saying there is a primary statutory duty to consider the duty of quality and a broader duty of quality in all the decisions that are made about the way in which you organise and re-organise services, and for Welsh Ministers to have that duty as well. I think it will mean that the quality part of our conversation is front and centre. And there's evidence we refer to in the impact assessment from outside of the Government—the King's Fund, I think, who are a useful group of people to turn to, who say that actually they think that this is the right sort of thing to do. The same thing on the duty of candour. If you want to have a proper duty of candour, then I could write out and say, 'This is my expectation.' Once it's a statutory duty, then it bites and affects every organisation as well as engaging the professional duties of individual staff.

There are some costs associated with the Bill, obviously, and the new regulatory impact assessment quantifies these for a period of six years, and says

'the costs and benefits...are expected to reach a steady state quickly.'

I'm just wondering if perhaps you could just summarise what you think the cost of the legislation is going to be, and where the savings are, and how the savings are actually going to be achieved, because the basis of them seems to be somewhat nebulous—whether there are savings there or whether there aren't et cetera. If we could just have a summary of your current thinking of that.

Okay. So, for some of the areas, we've managed to provide some headline costs on the savings, but part of the challenge is that we can only quantify some of the improvement that we want to make, and we can only quantify some of the cost. So, we're able to quantify, for example, the additional cost of IT systems for the new citizen voice body. We're able to quantify some of those things, but actually, when you talk about what happens if you improve the system of quality and candour, you can't quantify all of that. For example, if you make quality-based improvements—. We know that across the UK, the NHS is estimated to have about £1 billion in costs from healthcare-acquired infections. That's a cost, but you don't really quantify, around that, the human cost of that.

Equally, on adverse drug events, there's a really wide range of cost quantification across the UK of £0.5 billion to £1.9 billion. And so, we know that, actually, you've got wide estimates of what the benefits are if you make improvements in quality, but what you don't do is you can't really quantify the human cost or the human benefit of that improvement or of not making an improvement. So, if we have improved quality across the health service, we're delivering care that is more person centred and is more responsive to the needs of individuals, making better, broader use of resources. To quantify that, I think if we'd gone through an exercise to give you figures, you'd be asking the alternative question of, 'How on earth can I believe this?' because you're providing figures out of the air, whereas we know there's a real impact in not delivering that improvement in quality, but you can't quantify all of that in human terms, where it matters.

And again, when the duty of candour has been introduced in other parts of the UK, you [correction: they] haven't really been able to quantify, in monetary terms, the value of doing so, but we're all convinced that it is the right thing to do because it's part of making cultural change. And sometimes, we have legislation that is about leading cultural change and having duties that we think will help to do that, and other times we have rather more specific duties. I don't think you're going to be able, through this, to put a monetary value on every single part of the change and the value that we want to deliver. I don't think that's a helpful way to look at the conversation about quality and candour, but I'm absolutely convinced it will mean that we have a better health and social care system as a result.

09:55

Like many things, there are potential benefits you identify from actually having this legislation and making the changes—the cultural, organisational changes. In many ways, the issue of cost benefits and so on are a bit of a distraction from the purpose, because they really are aspirational, expectational and really serve no purpose trying to evaluate what that is at the moment—and it could turn out that it's quite minimal.

We're committing to do post-implementation reviews to understand the shift that's been made. If the Assembly agrees to pass and we introduce the duties, we want to say, 'Well, what difference is it making?' And you may then be able to understand and to describe more the value in real terms, but we know that, even if you did that, you won't catch all of it; you won't put all of it in monetary terms. If we have a citizen voice body that can take up complaints and that can listen to people across health and social care, there's real value in doing that, but you can't really quantify that in monetary terms. But you can say that actually, we think this is part of delivering a better health and care system and we think we have a more responsive and proactive system when it comes to the quality of health and care when decisions are made about the way that we spend money and decisions are made about the way that we organise and reorganise services.

You know, thinking about Alun and Rhianon and colleagues in Gwent, we've spent lots of money, in real terms, in building a new hospital to change the whole system, but you won't really be able to say what's the whole value to the whole system and do that all in monetary terms, but we're convinced that's the right thing to do to help re-engineer the whole system. We can tell you how much we've spent, but actually, to then say, 'Here is the financial benefit that we've delivered in changing the way that healthcare is delivered in Gwent', I don't think you could do that in a way that's honest or, indeed, helpful. But actually, in five years' time, after the hospital has been there for a few years—and the doors are supposed to open before 2021 if any nervous AMs are wondering; it's all still on time and on budget—you'll then be able to see some of the benefit in better care and better facilities, but you can't give a monetary value to all of that. But I certainly think that patients and staff will say that this has been an investment that makes sense and that we are providing better care as a result. 

But, in terms of the stakeholders, then, that are impacted and so on, I wonder if you could perhaps outline a little bit about the engagement with them and what the response has been from them in terms of potential issues with regard to cost and so on. Because presumably they will have concerns, particularly where costs and expenditure are, in some ways, unidentifiable.

10:00

Yes, so there are opportunity costs, where there'll be requirements for training, for engagement around the purpose, about what that means for each organisation. But, in terms of understanding the different costs and what that means for different organisations, there has been, obviously, the internal conversation across different parts of Government, with knowledge and analytical services, to underpin what we're doing. But with external stakeholders, there have been regular conversations with the community health councils there currently are and with the Welsh Local Government Association, for example, and even on some of the areas that—thinking about the past life that you've left behind now, being a lawyer, well, there's been engagement about what it means for legal costs too as well. So, you'll see figures in there that come from conversations with the health service, with local government and with other partners too, including CHCs and the wider voluntary sector. So, they do help to underpin and inform the cost estimates that we've got, and it's fair to say that those partners, those other stakeholders, agree that the estimates we've provided are reasonable assumptions to start from. 

The WLGA, for example, have been really clear on a range of Bills that they're anxious about how accurate some of the cost estimates are, but on this they agree that this is a fair basis to move forward. Obviously, as we go through an understanding of what's happened in influencing the system, they'll I'm sure want to make a case in the future about whether or not there are additional real costs. But at this point in time, they agree that this is a fair basis to estimate the costs for them and others.

In terms of their anxieties, then, about costs, because you can understand that there may be implications for them that are unidentifiable, how have they been reassured on that, bearing in mind that so many of these things are imponderable at the moment?

'Yes' I think is the straight answer, but if you want some more detail, then Sioned or Rhian can provide some information about how the conversations worked with the WLGA, because there has been genuine engagement—we haven't just sent them a letter saying, 'Here's what we're doing.' It has been a bit more than that.

We went and spoke to the WLGA, and there was one area that we hadn't been able to cost in the RIA, and that was the cost to local authorities of looking at the representations that the citizen voice body can make to them. We had a very honest conversation with the WLGA, and we said, 'Well, the representations could range from very minor representations that would take a few minutes to consider to something that is far more substantial.' So, we said we didn't feel as if we could give an accurate cost in the RIA, because whatever cost we came up with was likely to be a complete guess, to put it bluntly. So, we said we'd prefer not to put anything in the RIA to say something that wasn't really capable of quantification at the moment, but to engage with the WLGA and local authorities once the duty had been in place for a little while to look to see what the actual costs were, and they agreed that was an appropriate way to proceed, rather than to just try and come up with a figure for the RIA. So, it was something that we considered with them before finalising any of our documentation, to ensure that they were content.

In that regard, and I've heard what you've just said, what is the anticipated scope in regard to representations from the new proposed body to local authorities, because, as we all know, local authorities are suffering from the same issues around public-purse austerity and the finances coming in to Wales? So, you said you'd had those discussions, but there must be some scoping, surely, as to how onerous or not that workload will be, because the proof of this is in the eating, I would have thought. But there must be some comment around that from local authorities.

I think, with regard to the discussions we've had on the representation with local authorities, they understood the position we're at, and we did ask them if there were other ways that we could look at that and assess that. They feel very comfortable that we can do that as part of a post-implementation review and that would be the right time to do that. We've also had other conversations with the WLGA as well around—because, obviously, with regard to the new model, we're looking at a different way of attracting and recruiting volunteers in order to support the work of the new citizen voice body that is less onerous with regard to the local authorities who now are involved in a third [correction: a quarter] of the recruitment of those volunteers. So, in that way, they were feeling—

There was a counterbalance to some of this as well, which they were really appreciative of and felt that was a much better way with regard to how they could engage with this.

Okay, that's interesting. And finally, if I may, Chair, could you very briefly encapsulate for me how this Bill will actually improve quality? I hear the different elements that you've outlined, but, practicably, how is it going to shift culturally where we are at? I'm struggling a little bit.

10:05

It goes back to the first point in the conversation with Alun Davies, and that's about having a statutory duty on all of our providers, so not just hospital-based providers, but primary care providers too, in the way that they deliver services, and quality being a central consideration and an expanded duty of quality. Because part of the challenge is about—there's a narrower interpretation of the current duty of quality than we would wish to see, and, equally, that duty applies [correction: not applying] to Welsh Ministers and organisations currently produce quality statements as something to build upon, but Welsh Ministers will also have to set out how our decisions have been made, and how we've actually advanced the duty of quality in doing do. So, we're going to require people to turn their minds to quality as a regular part of their decision-making process. In a way, whilst we've made improvements on quality, if we just leave it to a quality improvement function, that isn't going to deliver what we want to see. So, that's what I set out in the statement, that's what we set out in the policy intent around the Bill as well, and I think that as we go through scrutiny of this you'll find that it isn't just the Government saying that this will help to deliver improvement, you'll find the NHS themselves will say that, you'll find that the third sector and others will say that that's a useful thing to do, and, again, there's objective evidence from outside the Government that changing the statutory duties around the duty of quality is something that should deliver a real improvement in the way that our health service functions.

Minister, you've set out—and I accept your explanation as to the difficulties of quantifying the benefits of the Bill—I wonder, though, whether that goes to the regulatory impact assessment process as a whole in terms of: you can set out costs, but not benefits, often, so how useful is it as a process to assess proposed legislation?

Well, it goes a bit into the question that Mick Antoniw asked, and it is about—there are times when we need to be upfront and say we can quantify more of the costs than the benefits, but, equally, if you just see the benefits in monetary terms, then you're rather losing some of the point. If you have a different example of something that is already in place—the Bill that changed the way that we undertake the conversation around organ donation has had a real benefit, and you see that in terms of the number of people who have donated, and the change in the conversation nationwide, the level of support for organ donation, the number of people who have volunteered to go on the register, and, actually, we now have the best consenting rates to donation of any UK nation. So, we've made real and significant change, and, actually, I think without that piece of legislation, we wouldn't have shifted our national conversation, and there's more still to do. Now, you can provide some financial costings, for the benefit of that, but, actually, that doesn't capture everything, and it couldn't do, could it?

Ministers are, I think, keen to promote legislation and do things in their role and deliver change in the projects they believe that will be beneficial. Is the RIA therefore a useful and appropriate check to make sure that they consider the costs of that process rather than something that, of itself, we should expect to give us a cost-benefit assessment of whether it's a good thing to do?

Well, I think it's always useful, I would say, having—. I still remember being a backbencher and serving on two and a half committees at the time, which was an interesting challenge. You do want to see what is the cost of what the Government proposes to do, and I think that's an important check. But it depends what the piece of legislation is there to achieve about whether you'll be able to see the same level of detail about financial cost benefit, because that depends on the purpose of the legislation. So, I don't think it's an entire catch-all, but I think the regulatory impact assessment is an important aspect for us to go through, the work with stakeholders outside of this place as well, as well as a proper exercise for scrutiny, as I think every Minister and every Bill should go through, whether it's a Government Bill or, indeed, a backbencher's Bill. Because we've been through this before—people expect the same level of scrutiny to a backbench Bill as they would to a Government one.

Given the financial challenges that the NHS faces in Wales, is it realistic to expect local health boards and other NHS bodies simply to absorb the extra cost that this will be imposing on them?

Yes, in a word. We've gone through, we've worked with and we've met with NHS bodies as part of coming up to this point in the Bill to understand what we're trying to do, what we're trying to achieve in terms of improving the way our health service is delivered, and you're right—there are real financial challenges in the health service. Without getting into an argument about the impact of austerity, some of those changes and challenges are driven be demographics, they're driven by advances in the way that we understand healthcare can be delivered, and they're also driven by the fact that we're deliberately changing and shifting our system. If we want to have a more integrated health and care system, we need to make sure that the duties around that system are consistent with the way that we are reorganising our system. For example, if we left CHCs as they are whilst we're deliberately delivering more integrated health and social care, we'll actually stop them from doing their job with the citizen. And so, actually, there is some change that is entirely necessary. The duties, I think, are appropriate and they are proportionate, and you'll have an opportunity in this committee and in the subject committee as Assembly Members to test that for yourselves.  

10:10

And finally from me: in assessing the costs for the duty of candour, assumptions are made of half an hour of recording and potentially speaking with the patients and others' time, for each incident where there is more than minimal harm, and the base level is 7,318. And I just wondered, given this Bill's intended change of behaviour, certainly with the duty of candour, may that itself impact the number of occasions when people assess that there has been an incident causing more than minimal harm, and a requirement to assess it and deal with it according to a specific duty of candour, and may that change recording practices in terms of the number of incidents that are identified as that, given the shades of grey in judgment issues that are involved in assessing whether an incident is one that causes more than minimal harm?  

There's always a bit of forecasting about behaviours, but given that it's a statutory duty that's going to apply to organisations, a statutory duty that's going to apply to the way we expect people to do their jobs, there is a price for avoiding that. And if people are deliberately avoiding undertaking their duties that the Bill and then the Act, as we hope it will be, requires, well, that's part of what you'd see in a range of areas—a citizen voice body helping to pursue issues for people as part of our complaints process. You'd expect to see that in the way that the inspectorate delivers their work, and you'd expect to see that if people end up with the ombudsman. So, I think there'd be pretty significant challenges for organisations who are trying to avoid the duties that are required to report on where harm is done, and that would run wholly contrary to the purpose that we're trying to achieve in introducing the duties of candour and quality. You can never entirely legislate for human behaviour that goes in the opposite direction, but, actually, we think this will build on the way that the great majority of staff undertake their function, including leaders and managers in the service and their commitment to the way it works. We think this will be a useful way of adding to that, and providing a greater amount of clarity and scrutiny.   

Okay. Turning back to my questions now, Minister, what assurance can you give that the cost estimates for developing course materials and the public awareness campaigns for the statutory duties of quality and candour are accurate? 

Well, they're as accurate as we can possibly make them, based on our previous experience of other legislation. It might be helpful if Rhian or Sioned give you some examples of the different examples we've used in the past to try and give us an estimate. I know that we've looked at, for example, the way that we used minimum unit pricing [correction: the Public Health (Wales) Act and Putting Things Right promotional materials] as one of the ways we've tried to estimate what the future cost would be for this legislation.    

We've also looked at things like the Putting Things Right campaign, the campaign that was used to launch the new NHS complaints procedure back in 2011. So, we've used some of the modelling work from that as a basis for some of the costing, particularly as we see the duty of candour as building on some of the 'being open' principles that are already contained within that legislation. We think that is a good starting point to build our cost estimates and, again, this is something we've discussed with the service. 

With regard to our engagement with health, with regard to the duty of candour, I think what's been really pleasing is that there has been a real positive engagement from the health sector with regard to the duty of candour, and wanting to be involved in the development of the training materials, and be involved in the development of the guidance, so that it's co-designed with them, and it's been really positive. It will be how we can manage the whole calls that we've had to be involved in that process. So, it's that positive engagement. And that's been built into how we've looked at the regulatory impact assessment and the cost with regard to that as well, which will aid us, I think, with regard to the culture change that we're looking at with regard to the duty of candour and quality.

10:15

It is a positive, of course, that virtually every representative professional group wants to be involved in taking forward the duty of candour, and what that will mean, not just in the way they're looking to protect their staff, but actually how you have something that supports them in exercising their professional duties and the overall service.

But as you said earlier, you're as accurate as you can be on the costs of delivering this.

Thank you. In regard to the reportage if this Bill carries through its passage of 'more than minimal harm', can you outline to me an example of what would take place if that was to be reported? I'm just trying to understand that process.

We're looking to have a relatively low bar, so you don't have to have arguments about what triggers a duty itself. And I deliberately say that that's our ambition, and we'll need to work that through in the guidance. And in this, we've learnt from legislation in other parts of the UK, where a more prescriptive approach on the face of the Bill has actually been unhelpful. And so I've committed to the way that we shape the guidance around the duty, the involvement of different groups, as you've heard, and what that will mean in practice. Because if you are turning your mind to, 'Well, does this reach the bar of being moderate or severe harm?', I think you're more likely to under-report, and you'll have variants in the way that people engage in the duty. So we're deliberately looking to set a low bar and to actually deliver the detail of that in guidance and in engagement with stakeholders around the service. And not just healthcare professionals; we would look to—. The CHCs, as they're currently formed, would be an important part of that, as well as direct engagement with patients themselves.

And in regard to this good practice, which should happen anyway, and the whole raison d'être, it seems, to be able to improve that scenario, and that cultural shift, so that we have a more mainstreamed approach—that, I think, is a very positive thing for Government to be doing. So, going back to costings, can you explain how the annual cost of £30,000 for legal advice for NHS bodies in respect of 'Putting Things Right' and your estimate of the increase as a result of the Bill were determined? I think we have touched a little on this. So, is there, again, around costings, a risk that costs will be higher?

There's always a risk that actual costs will be higher, but this comes from a conversation with NHS legal shared services. It costs approximately £30,000 for them to engage the legal fees around 'Putting Things Right' now. They said that would be a reasonable cost estimate, and in the RIA there's a 10 per cent [correction: 20 per cent] uplift in the first year, and five per cent [correction: 10 per cent] thereafter. So, again, it's an estimate that's based on engaging with stakeholders in the area, and we've actually added a little bit more to try and account for that. If you want to know more detail, then Rhian is the third lawyer in recovery in the room, so could talk more to you about this if you want to.

Thank you. We've touched already upon this. You told Plenary on 18 June that you were looking at the 'relatively low level'—and you've given a narrative around that already—when defining 'more than minimal harm'. However, the cost of notifying service users reflects incidents classified as 'moderate' and more severe as reported to the national reporting and learning system. So, could you give a little bit more narrative around that, please?

We've looked at moderate and severe harm or death in terms of looking at what NRLS reporting standards are, and we've taken those numbers. But as we go through the process, when we meet with the stakeholders, and we start to develop the detail of the guidance, if we think that we'll be bringing in lower levels, that's something that we can look at, in terms of maybe reframing the RIA as we go forward.

Well, we're making contact with stakeholders now. Realistically, we're probably not going to be able to get people together through the summer, but we'll get them together as soon as we possibly can after recess. But the cost implications are something that we'll keep under review constantly as the Bill goes forward, and even, I suppose, after the Bill, hopefully, has passed. The cost of it is something that we'll obviously keep an eye on during the implementation phase as well. It's just we feel that we need to develop this aspect of the guidance with stakeholders to learn from the experience that they've had in England and in Scotland, where they have tried to be very prescriptive on the face of the legislation, which has caused some practical difficulties in interpretation.

10:20

And to be fair, colleagues on either side of you have taken Bills through the Assembly and are familiar with the requirement or the good practice in looking to update the RIA as the Bill progresses through its scrutiny process. That is entirely normal and I would expect us to provide an update.

I have a couple of questions on transitional costs and the running costs of the new citizen voice body. If you look at the table of transitional costs, it has IT costs at £2.13 million, but actually table 68 of the explanatory memorandum sets out costs that range from £2.13 million to £3.12 million. That's quite a difference; one's 50 per cent more than the other. Why have you identified the cost at the very lower end of the range?

That's related to the capital costs of the IT proposals with regard to—. So, that's estimated on the current structure that we have with regard to the CHCs, which have 12 offices, so it's a full refit of those offices. With regard to that, we think there are elements that we can build in around efficiencies around some of that, but we wanted to give some flexibility as well to the implementation board in relation to how they move the work forward. So, that implementation board will include key stakeholders in relation to the development of the new body, which will include representatives from the CHC board, CHC and other representatives as well.

We wanted to give enough scope with regard to that, but we do feel that we have gone for the lower because it's based on full costs around the current structure of the CHCs. But we also have built in ongoing IT costs as well, because we see IT as an enabler for the new body moving forward as well. So, with regard to the ongoing revenue cost for IT, it's calculated as £520,000 per annum, because we see that as a really important enabler for the organisation in the way it engages and the way it can flexibly work within communities across Wales, and that's a significantly greater amount than currently the CHCs have on an annual basis for ICT support.

You can understand, I'm sure, why you see me slightly concerned about the lower end being identified. And perhaps now is a good time for you to tell us: have you identified other figures in transitional and running costs that are actually towards the lower end of what could be a range of estimates?

With regard to the costs, we have looked at a balanced range of costs. Obviously, we're looking to increase the costs with regard to the new citizen voice body, moving forward. So, it's an increase from £3.9 million to £4.7 million, which is a significant amount of investment from Welsh Government, because we see the importance of citizen voice and engaging with citizens on this, and it's significantly more than other regions of the UK provide for these types of functions.

So, we've looked at it from the point of view of what's happening in other regions of the UK and in other countries as well. Because, obviously, with regard to the new functions of the new body, it will need to think about how it approaches and looks at how it engages. But we think, with regard to the funding that we've looked at with regard to the citizen voice body, it is significant and it will make a difference, and it is appropriate to what we can do with regard to the implementation board moving forward.

Okay. On a more general point on running costs overall, presumably a successful new citizen voice body would encourage more people to engage with it. That could lead to an increase in the number of cases being dealt with. How do the estimated running costs of the new body reflect the findings, for example, of Ruth Marks, who said that CHCs needed to offer much more advice and support to people who have concerns and wish to make complaints about their healthcare? So, you could be increasing capacity, which would clearly have potential oncosts. 

10:25

There are two things. One is that part of what Ruth Marks was saying was about refocusing the mission of CHCs as the voice of the public, and they have a mixed mission at the moment. So actually, the new citizen voice body would have some clarity that it's not there to replicate the role of the inspectorate. Actually, we think that would help in the way they use some of their resources already. When CHCs were formed back in the 1970s, we didn't have the same regulatory and inspectorate structures that we do now. There is a point of modernising and updating the point and the purpose, and to be the voice with and for the person.

It's also worth reflecting that the costs that we've added in—when you compare what the citizen voice body would have in its budget, both in cash terms but also in terms of per person, it is significantly better funded than comparable bodies in Northern Ireland and Scotland. England, again, has a much lower funding per head for their patient watch body—significantly, though; it's about three times higher here in Wales per head, and roughly three times higher per head than Scotland. They have slightly different missions, but even when you take account of that going across health and social care, actually we compare very well with the resource that we provide in this area compared to any other part of the UK. So, a refocused mission, the voice of the person, how that's achieved, and there is more resource to help them achieve that. 

Would there not be a case to argue that you do have some inherent savings in the fact that you are delivering things locally through the current CHC system, and that the more direct contact, if you like, with health issues in a locality leads to savings and the level of knowledge on a local basis means you don't have to invest in capacity on a national level to understand what's happening at a micro level from one part of Wales to the other?

The Bill suggests [correction: does not suggest] that we won't have a local presence for the new citizen voice body. It is one of the issues that I know there is concern about. But we're actually giving a new national body much greater independence than it currently enjoys now. The current CHC movement is a hosted body within Powys Teaching Health Board, which doesn't make sense. So, it'll have its own ability to decide its own affairs, including its own structures. Again, I don't think it would be the right thing for a Minister or a Bill to say, 'You must have these particular structures', because actually as health and care changes the way its delivered, the new citizen voice body may decide it needs to change the way it operates as well, and it would have the flexibility to do that within the general purpose in the Bill and its purpose working with and for the citizen. I think that's the important point: it has a real purpose that will be fit for purpose now and as the system moves forward. It will have control of its own destiny and much more genuine independence in a way that CHCs at the moment don't have. And I appoint lots and lots of people to the boards of local and regional CHCs, which again I don't think makes sense.

I'm very tempted to stray into policy areas rather than Finance Committee matters. I'll stop there. Thank you.

In assuring cost-effectiveness, don't citizens also need a voice to Welsh Government as well as to local health boards? Why is that excluded by the Bill?

The duties of the citizen voice body—and again we are straying a bit into policy not finance—

Well, that's a bit of a stretch, isn't it? The reality is that we have a citizen voice body now that has a point of purpose that is mixed, and actually the national board of CHCs don't want some of the national interaction that they currently have because it's difficult for them practically in terms of the points about referring in to the Minister. Actually, they want to have a focused mission around people, around the services as they're delivered, around challenges, opportunities for improvement, opportunities to listen to what the person has to say, whether that is about good, bad or indifferent care as well, and the general objectives we've given will allow them to do that.

In terms of representation to the Government, I can honestly say, as a Minister in a job that no-one else wants to do, that there is certainly no lack of scrutiny or interest of people wanting to raise issues with the Government when it comes to health and care provision, and I certainly don't see that reducing in the past. We have 22 local authorities that provide social care services and commission those already, and they're certainly not shy about raising issues with me, and I'll have that tomorrow, when I see colleagues in local government at the social services policy group. So, there's plenty of interaction and scrutiny on a very detailed level that the Government has, and none of that will move away. Actually, we think it'll enhance the ability in having a more focused citizen voice body to raise those concerns. So, if people come to you, as elected representatives, saying that they've got concerns that have been raised through the citizen voice body and here's a response, I think it will improve and join up the level of scrutiny that you, and, I'm sure, your successors, whoever they may be come the next election, will look to provide for whichever fortunate person that occupies this seat in the Government. 

10:30

You do tempt me to stray into all sorts of different areas there [Laughter.] In terms of where we're going, I have some doubts, as I explained earlier, about elements of this legislation, but, putting that to one side, I recognise that in any system that is publicly owned, publicly controlled, publicly managed, without the pressures of privatisation, which we're seeing wrecking the national health service in England, then it is important, and the voice of the citizen or the patient becomes more and more important, in terms of delivering service and in terms of quality of service delivered, and I think that's absolutely essential.

One of the things I am in favour of actually is the new citizen voice body. I think replacing the community health councils is a good move. I think it is important that you do extend the range and the breadth of this body to look at that junction, if you like, between the social care and the NHS, and those are all important policy objectives. So, how do you know if you've got it right? And this is what concerns me, because there are a number of questions here about individual cost basis within it, and, as you've sort of indicated in answer to earlier questions, sometimes the objective isn't so easily quantifiable in financial terms. But this committee has, on a number of different occasions, sought to ensure that the executive comes back and reviews the legislation in terms of the objectives set for it, and I think that's a good thing to do. So, what are the objectives that you would set, in terms of costs, the effectiveness that we're looking at here? How are you going to ensure that, first of all, the legislation is monitored for that, and, secondly, how will you review the legislation when it is in place to see how far you have achieved your objectives?  

Well, we're committed to a post-legislative review, and I think that's important. I think it is good practice when you're introducing legislation to change the systems and delivery of services, particularly if we say, 'We think this will benefit and improve the way that health and care services work'. So, there's a clear commitment, and I'm sure I'll have the opportunity to remake that again, and I think that's important too. And I think that's a general point about legislation and I accept the point you make on that.

When it comes to how we'll know, well, the fact that there's going to be an annual statement from Welsh Ministers on the duty of quality will be an obvious point where people will take interest. Members, I'm sure, will want to ask questions about that. I expect that the first time that that duty is provided there'll be a demand to have either a debate or a statement in the Chamber, for Members to ask questions about it, and I'm sure there'll be lots of wider public interest as well. So, every year, we will be providing that statement and there'll be an opportunity, when we're doing that post-legislative review, to look back on what those statements have shown and set out, and how we track through any level of improvement. For example, the way in which the duty of candour is engaged, and not just the numbers of time but whether we can actually then point to improvements that have been made, as a result. So, I do think you, and other Members, will be able to see that over time, deliberately set out, in making sure there's a very obvious opportunity to  scrutinise whether the duty of quality has made any difference. 

And if I can just ask, when is the Welsh Government going to carry out a review of the Act? 

I think it would be set out in the post-implementation review that the group would be looking at. Obviously, we would want to see some of the reports coming through before we undertook that evaluation. As we discussed earlier as well, it has been difficult to quantify some aspects of this, because it’s based around the human aspect of this and the personal nature of this. And I think this also links here with regard to—. Obviously, the Bill provision supports 'A Healthier Wales' as well, especially the quadruple aim, and I think there’s work that we would want to do with regard to the 'A Healthier Wales' team, in relation to how we build in and work within that as well. So, we would be looking to start that process, but, obviously, with regard to the first report. So, we’d be looking at it after three years of implementation in order to get some real figures.

10:35

Great. Unless any Members have any further questions—no, all content—you're released 10 minutes early, Minister. Thank you for attending, and your officials.

It's been a pleasure to see you, comrade temporary Chair, and I look forward to seeing you in the Chamber later.

Thank you. I look forward to seeing you as well. It's been an interesting experience, particularly with Skype as well. All these compliments. I'm going to send you a transcript of today's proceedings for you to check for accuracy. Thank you.

6. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod
6. Motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Okay, as temporary Chair, I move Standing Order 17.42, to meet in private for the remainder of today's meeting.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 10:36.

Motion agreed.

The public part of the meeting ended at 10:36.

Archwilio Cynulliad Cenedlaethol Cymru