Cynulliad Cenedlaethol Cymru

Diolch, Gadeirydd. Good morning. I suppose we all agree with the aims of the Bill to ensure that we look at improving the quality of the service. I suppose the first question is: in your view, is there a need for legislation to actually deliver the aims of the Bill, or can it be done in other ways? Putting legislation through is a critical process, and it is possible perhaps to do it in other ways, but do we need legislation because are you concerned that if we don't, we might not ever get there? 

The phrase I'd like to use to respond to that, David, is one of necessity rather than sufficiency. So, legislation might be necessary to improve the culture of the NHS and the integration between social services and health services, but it doesn't necessarily mean it's going to be sufficient. So, I think legislation is one tool, but it doesn't forsake the need for leadership, for investment, and for the other issues that should shape the culture of the NHS and social services, particularly given some of the significant demographic challenges that lie ahead. 

In that case, do you think this Bill—whether it's necessary here or not—actually, as drafted, delivers on what you think is needed? 

Not entirely. I think our written evidence does point to some issues. First of all, I have met health officials recently to discuss the Bill, and I do appreciate the huge amount of work that they've put into this and would not wish to be overly negative, but I do think that there are certain aspects where perhaps a little bit more ambition could have been appropriate. We allude to issues in our written evidence, including the need to have an integrated complaints system. That isn't in the Bill, unfortunately.

I think as well, following the consultation on the White Paper, the rationale for failing to integrate the inspection agencies was that there was a lack of appetite. Well, you know, we could all decide perhaps—it was good of us all to turn up this morning, a lie-in might have been nice, but we can't go around public business simply on our appetite. I think it's got to reflect the need for change.

I think one area where, again, we think there could have been greater clarity as well as ambition is on this issue of the citizen voice body. I think, again, that's great in terms of delivering more integration for social services and health—I really, really do applaud that—but why should that body be appointed by Ministers? I say this as somebody who is accountable to the Assembly. That job is inevitably going to involve the need to speak truth to power. If you do that with the knowledge that a Minister controls your purse strings, regardless of the fact that you have a board, a non-departmental body, or whatever else, inevitably there's going to be a public perception perhaps of conflict. It means that, despite the ambition behind creating that body, for some people, it might be interpreted as being a poodle rather than a real advocate or voice of the people—

Or any other dog breed.

Well, I'm not here to argue just for poodles. But, you know, for others, there might be a perception that it's not so much a poodle but a turbulent priest. Some things might happen where there's a view that almost—like Henry II and Thomas à Becket, it's impossible. As Thomas à Becket told Henry II when he agreed to be Archbishop of Canterbury, 'I can't serve God and you', and look what happened.

Inevitably, I think there will be conflicts between the voice of the citizen and Government business, inevitably. Anybody that deals with health does come across those conflicts from time to time. I think as well this is about voicing the concerns of citizens. The fact that that should be quango-ised in some way through a public body strikes me as a little odd. There are other ways of doing this.

I report to committee annually in terms of what we've done with the resource. I seek resource on an annual basis from the Finance Committee. So, I think if it can be done for my office and it's done as well for the auditor general, why not do it for the citizen voice body?

I'm going to leave questions for Angela afterwards.

Angela will drill down.

But perhaps I'll focus upon two points, in a sense. The integration of health and social care and the definition of quality and how do we assess quality, in that sense. You've already highlighted you can't understand why this hasn't been— impact and effective within this Bill. Let's talk about the quality first of all. Do you think the Bill has a sufficient definition of quality and a sufficient indication of how the criteria for assessment of quality is within it, so that people who are required to abide by this Bill fully understand what's expected of them?

I think that the general emphasis on quality going forward is to be welcomed. The degree to which you want to have detail within a Bill is debatable, but I think the broader message to individuals and also to corporate entities in both health and social services—. I think that's an important cultural message shift for them. I think sometimes that cultural point is more significant than some of the detail that you might find in the legislation, particularly when you're talking about some of these organisations and their size. Chris, anything you'd like to add?

What the Bill refers to is the safety of patients, the effectiveness of health services and the patient experience, and I think those are key points. And I think there potentially is value in having the legislation framed at that quite high level, because, apart from anything else, it encourages NHS bodies in Wales to have to engage with that detail and think what that means in practice, rather than blandly refer to a set of standards in a four-volume book on the shelves. So, I think there may be value in pitching it at that level, and I think broadly our view would be, from the casework that we receive and the issues that members of the public have with health services in Wales, that those are the things that concern them. 

I understand that, and I also understand that within the context across Wales there are going to be different perhaps focuses by health boards on different areas. Let's take Powys, for example. It hasn't got a district general hospital, so they're having to focus upon their service. But does it also provide the opportunity for inconsistency, because one of the arguments we've had very many times, not just in this committee but in other committees, is consistency of delivery across Wales? Does the higher level allow the greater possibility of inconsistency across Wales to occur?  

I think it does, I think it does, but I think it perhaps goes back to what Nick said in his opening comments, which is that, on its own, the legislation is not enough, but it provides a framework within which other things can happen, and I think if there is a real focus in NHS bodies across Wales on the principles of quality, that is helpful. It doesn't mean that it's enough, and I think there's a lot that would be expected in terms of working across health boards and trusts in Wales to make sure there is some consistency. I think that there may be benefit though in that not actually being on the face of the Bill or Act, as it will become, and being something that is developed outside that, apart from anything else because it is likely that there will be change over time and the expectations will change, and it may be that quality isn't just defined at one moment in time, but develops.     

Okay. Can I therefore go back to this question of integration, because you've mentioned integration between health and social services and social care? Should the Bill therefore be amended to actually expand this responsibility and this duty upon both sectors so that they would work more collaboratively in delivering care for patients? 

Well, yes, we certainly think that there is scope to go further, in terms of the ambition for integration. So, for example, I think I've alluded to it already, I'm not convinced that the failure to integrate inspection bodies, for example, should simply stop, because there sounds to be a lack of appetite amongst those two respective organisations. Well, I'm sorry, that's a producer interest. The overriding interest here should be the citizen's interest, so I think that has to be satisfied, and I think that should be the test. And, likewise, in terms of the two complaints systems, the fact that two sectors have two different approaches to complaints is immaterial. It should be the experience of the citizen in using those services that really counts. So, I think that's where the test for making a real difference should be applied. 

I'll take the integration of the two inspectorates out of this for a moment, and look at the complaints processes. In a sense, the care for a patient doesn't end when they leave the hospital. They go into another form, whether social care or other means and the care of the patient continues. So, there is a reasoned argument to say that this definition—this Bill—should apply from the time the patient enters the system to the time the patient leaves the system, which includes both sectors. If that's the case, should there more strengthening of the argument for consistency of the complaints process across both sectors, because, clearly, you deal with the complaints I assume from across both sectors— 

Yes. 

And, therefore, you can see how the differences are. Should we be using the Bill to take the opportunity to actually say, 'Well, this is the consistent across both sectors, so if the complaints process is similar, the experience is similar irrespective of which part of the system you're in'? 

Yes. Our evidence does refer directly to the disappointment that we feel that what was suggested in the White Paper hasn't been pursued, as yet, in the legislation. If it doesn't appear in the legislation, we will still try to work with both sectors to make sure that there is a more citizen-centred approach. I can do that, we hope, because we've had new legislative powers through the new ombudsman Bill. So, that includes the rather grandly titled complaints standards authority. But that will allow us to certainly produce more data to look at the performance of different health and local government bodies so that they can improve their complaint handing. We will also be trying to train public bodies so that they’re more responsive to citizens, wherever they are in terms of the continuum of care provision. So, I don’t think it is all about legislation, but it would have been good to have had that single approach, and, absolutely with you, I think that has to be the challenge moving forward—to view this from the user’s perspective rather than from the producer interest of either of those sectors.

And, from a commonsense perspective, it would have been obvious to do this.

If I can just add to that, some of the most difficult complaints that come to us are ones that span health and social care, and it is clear from our experience that complainants have found it difficult to navigate through that. And the fact that there are not just two or sometimes more bodies involved, but two different complaints systems, really does not help. And, whilst the complaints standards authority does give some greater scope to work with public bodies, it doesn’t allow the ombudsman to overrule the complaints procedures within 'Putting Things Right' or the social services complaints procedures—quite reasonably; I’m not advocating that. But what that means is that, in a way, this is a missed opportunity to bring things together in legislation. And, whilst we will use the complaints standards authority powers to do what we can to bring things closer together, they are actually limited by the regulations that govern the two complaints processes.

I think—. Sorry, Chair, if I may—I think the other issue here as well is that it’s not just about the White Paper is it? It’s about the complexity and the structure of local government and other public services in Wales. If we’re not going to see local government reorganisation—. Regional working is the preferred way forward, I think I’m right in saying. Well, that can look very opaque. From a citizen’s perspective, 'Right, come on: in terms of accountability, who made this decision? How do I do challenge them and how do I get rid of them? It’s the wrong decision', and all the rest of it—that can look very, very hazy if there’s a front door for north Wales or mid Wales or west Wales. And, below that, there might be some quite intricate arrangements between different public bodies. And something— we’ve had some cases before now where there’s been a partnership in place and responsibility tends to ping pong a bit, and the individual doesn’t get satisfaction there. So, I think that’s the other issue here, which I think is broader than just the White Paper. I think there’s a broader issue that partnership working—it might be more efficient, I’m not criticising it, but I think, again, it’s about not just focusing on the interest of the partners, but on the people those partners are there to serve.

Okay, David?

Yes.

Jayne Bryant.

Thank you, Chair. Good morning. 

Good morning.

Do you think that the duty of candour provisions in the Bill are likely to deliver the intended outcomes? 

Well, I certainly hope that they will increase the chances of achieving those outcomes, but I think, as I alluded to earlier, there is a difference between what’s necessary and what’s sufficient. Clearly, the duty of candour does already exist in terms of General Medical Council guidelines—it already applies. But, I think, again, it’s about this cultural issue of this additional push towards achieving greater candour. I think it’s good to see this in the legislation. I think the annex does refer to the very high-level case—Robbie Powell's case—and I have been in contact with his father, Will Powell, this year. He certainly feels vindicated in the sense that they forwent, I think, £300,000-worth of compensation in order to, effectively, campaign for the duty of candour. So, I think for some people who have been through those types of experiences, they will, I think, feel some level of reassurance if that’s in the legislation. But, certainly, for Mr Powell, he still feels that he hasn’t had the candour that he deserved. We’re still trying to put pressure on Government in Wales and in Whitehall as well, because we think we need an inquiry there, and it would be wrong of me to come here today and not mention his case, given the fact that it is alluded to in the annex as well. 

So, I think reference to the duty of candour is certainly a good thing, but the fact that it simply exists in a piece of legislation isn't enough. I think it comes back again to some of those broader drivers that you have, and some of the conflicts you can have, particularly in health organisations as well, where perhaps candour hasn't always been at the forefront. And, certainly, if we look at some of the health cases that we've dealt with over the past five years, certainly there have been times when we would have welcomed a greater emphasis, cultural emphasis, on candour from the health boards we were investigating.

Thank you. Some have suggested a system of regulation for NHS managers would be required. Do you think that should be added to the Bill?

I have some awareness of calls for this from certain quarters. I think we have to be clear, moving forward, about where responsibility really does lie in terms of the chain of accountability, and, obviously, we would expect managers to currently be accountable for their actions through the health board system and the broader NHS structure. So, I'm not saying that I'm against further regulation, but we're not short of bureaucracy in Wales, currently, are we? I think sometimes actually stripping away some aspects of regulation and perhaps focusing a bit more on what you alluded to earlier in terms of outcomes rather than inputs and processes would actually create a greater deal of clarity so that true accountability can be achieved, but that's a personal view.

Do you think it's an issue that there are no sanctions included in the Bill?

Sanctions—.

Sanctions for breaching the duties of quality and candour.

Well, I think that would be an issue where perhaps you might get more input from the regulatory bodies and other interests, but, certainly, this will affect the way in which we go about our investigations. So, for example, the greater emphasis on quality would make a difference perhaps to the type of clinical advice that we seek for the future. So, where we do find service failure and we do find in favour of the patient, in that sense, there would be, certainly—not sanctions, recommendations, redress and other issues that would be as a direct result of this legislation. Duty of candour, I'm not so sure, because, as I say, we would take that into account currently because of GMC guidance.

Okay. Yes, David.

You were querying the word 'sanctions', but I suppose the actual outcome is the Bill puts a duty, whether it's a duty of quality or a duty of candour, upon the health sector. You've said you can actually put—. You can investigate complaints, you can look at it and see whether they've met those duties. I suppose what I'm trying to say is: should the Bill put some form of enforcement in place so that, if they don't meet those duties, there is something that's going to happen as a consequence of that, and not simply a letter from you saying, 'You haven't done this' and make it all go public, but some responsibility, some accountability—something happens to say, 'Well, you haven't done this; now this is going to happen'?

Well, I think some of that, certainly in terms of the way in which our legislation operates, where we make recommendations—they're not binding, but we have the right to shame the public bodies that fail to comply with our recommendations. And there have been occasions during the past five years where I've had to deliver special reports, where we've found health boards that were not complying with recommendations that they'd previously agreed to. So, that would bring me back, really, to the independence of the citizen's voice, because surely that body is going to be looking at some of these general themes that emerge from the legislation in terms of duty of candour and duty of quality. And if there are some hard truths there—and some of them are bound to be emanating from that body, and, again, I think it's important that we have a greater institutional assurance of the independence of that organisation and the way in which it would be able to come—perhaps be accountable—to this committee, and to report on what's really going on.

The reason I ask that is because, clearly, recently, we've seen some serious failings identified, and there have been attempts—I suppose I say 'attempts', but it seems to give the impression that senior managers have tried to hold back and stay in position and not necessarily be—actually, they haven't been sanctioned by anybody.

Well, I think, ultimately, you can put sanctions in legislation, of course you can, but I think we're all aware of the fact that, if somebody has failed to deliver their public duty, then, ultimately, there is a sanction—there's a sanction for all of us who are involved in public life. We all know that. Obviously, okay, some through the ballot box, but there are other steps, as well, which will affect us all in the way in which we undertake our public duties. So, I'm not sure that you need to have a high level, a specific—or a menu, if you like, of sanctions. I think it's more important to have these duties clearly and loudly having an impact on the culture of these significant organisations and, again, this emphasis on the independent—the citizen's voice. Obviously, for somebody from our office's perspective, we have to be independent and impartial. But, often, when you do look at an individual case, it's this countervailing power, as it were—what Galbraith would call a countervailing power—you know, who's there for the small individual? These might be public bodies, but they can look very big and very intimidating for the individual. So, I would not downplay the issue of openness, pluralism, having a voice there that is not appointed by Government but is accountable to the citizen. That will have, I think, a countervailing impact over time—not immediately, but over time—so that perhaps this committee or other committees of the Assembly could shine a torch into some of these issues and have a look, in the fullness of time, at the way in which we hopefully see a step change when it comes to both candour and quality. And, where people are failing, I'm sure that there will be sanctions available; there always have been. But I think it's about perhaps raising the bar in terms of when those sanctions might apply.

Okay. Thanks.

Thanks, Chair. Good morning to you both. Before I start on the citizen's advice body—and I have a few questions to ask you on that—can I just row back a little bit, because I've been listening with great interest to your answers to both Jayne and David? I think we all cleave to the ambition behind this potential Bill, but, for me and my dealings with the health boards that I engage with, there's a real opacity in play and it all comes down to having a change of culture. Do you think that, with this Bill in general, we are missing a trick and that there might be a smarter way to achieve that cultural change that enables people to actually feel they can tell it straight, they can say when they've got it wrong without this overriding fear and back protecting that goes on, or the rest of it? I just wondered if you felt that we've gone about this in slightly the wrong way.

I wouldn't say that, but I think—. Was it Peter Drucker who said that culture eats strategy for breakfast? How long does it take to change a culture? Is it at least seven years, or something? Legislation might well be part of that—you know, those big, clear messages. But when I look at this, one of the issues for me would be how we make sure that that interplay between the experience of the citizen actually drives up the standards. Some of this I talk about in terms of complaints. I know complaints can be seen as being negative, but if we're told that—was it the clear red water thing, and all the rest of it—it's about voice not choice, well, if we're not going to use market mechanisms, how do we access the experience of the citizen? I think some of that is about looking at the way in which complaints can actually drive up standards and improve standards. I think, as well, from the citizen's voice perspective, one would hope over time that they'll have positive as well as negative experiences that can help broaden good practice and make sure that performance is on the way up.

So, I think for me to do that, there has to be a commitment to ensuring that everyone is up for pluralism—that it isn't just about public bodies and Government; it's about individuals, it's about patients. And again, I would argue that putting a citizens's body, making it part of the state, is post-Hegelian, isn't it? I just think there's an irony; it's almost oxymoronic to be quango-ising the individual. So, I wouldn't underestimate the importance of having that accountability here rather than with the Government, because clearly this body will have some substantial resource. Over time, I would hope it will have a lot of valuable information to share with the committee to improve scrutiny, to improve accountability. And whilst I don't doubt for a second—. I have discussed it with officials and they're absolutely clear about the need for it to be independent and that there will be checks and balances, but, to me, that kind of underlines the point, doesn't it, that there will be this perception that it's perhaps poodle-like for some; they won't have the teeth.

Of course, a lot of us agree with you, or agree with that point of view. A lot of us believe that there should be real independence in the citizen's body and that, actually, if we gave the citizen's body the power it should have, then that rings true with the ambitions of the parliamentary review, which was all about loving our staff more and loving our patients more, which seems to have gone by the board. But if we are to convince the Minister, who is set against this so far, that this is something worth revisiting, we have to deal with his concerns, and I think one of his concerns is that some citizen's bodies—you know, community health councils as they currently are—are not very effective, they don't work very hard, they're very amateur in their outlook and what they achieve. So, do you have any views on how we might be able to retain the localism, retain a citizen's body that is for the citizen, but give it that strength so that they have that ability to be able to punch at the weight that the other guys are dealing their punches? 

Yes. I would say, again—. I would suggest—I hope for some reassurance here—for the Minister, there are other corporate entities—the auditor general, and myself included—who are accountable to this place but clearly independent of Ministers to give public confidence. 

So, they might be professionals but they're independent, rather than—. Because at the moment, CHCs are literally made up of a range of people, including Mrs Bloggs and Mr Bloggs, and so on and so forth, but you actually see raising the professionalism—. Would you like to see a citizen's body that's a lot more professional, perhaps more trained, has more support and can therefore work better, and is therefore a separate organisation, like your own organisation, as opposed to what it is now, which is very much, if you like, brought together from local people who are committed to it?  

I think, certainly, there will be aspects of this reform that should be welcomed, and I think we would certainly welcome a more uniform approach. Sometimes, there can be a variance, going back to this good practice. There can be a variance between the different CHCs. I've also discussed this issue of independence with them. They actually feel that the proposals are, in some ways, an improvement on existing arrangements, but I still feel that this does not go far enough. And it's not a question of professionalism; it's a separate issue. It's an issue of institutional independence; the fact that someone can lead that body, can be accountable to the legislature rather than the executive, is a fundamental issue in terms of the separation of powers. That's why I think it goes to the heart of having confidence in that body moving forward. So, Mr and Mrs Bloggs might be perfectly professional. Who pays them? Who sacks them? That's the issue. 

Okay. Of course, one of the things that is being proposed to be changed is that the new body won't have the right to enter hospitals when they see fit in response to issues that are raised with them. What is your view on that? 

Again, we have discussed it with the CHCs. Obviously, we understand it's an issue of great concern for them. Chris, is there anything you'd like to add to that? 

I think it potentially is a concern, in that it reduces their ability to access patients, potentially. I think the reason for its removal is presumably because of the loss of the inspection part of the role, which is understandable. But whilst welcoming a national framework, a national body, our response is clear that there should be very much a local presence and local representation. And whether or not that needs to include unannounced visits is debatable, but it certainly needs to include arrangements so that the citizen voice body has got access to patients and patients have got easy access to the citizen voice body. I don't think that necessarily needs to be unannounced visits, but there does need to be a facility there to allow the interaction between patients and the citizen voice body.  

Because what the Minister argues is that they wouldn't be allowed, for example, to go into a care setting in a private home, and therefore that's the reason to get rid of the whole shebang. I fail to understand that, because I think that you can still have a Bill that gives you rights in one area but not in another area. But I just wondered if, in your experience in the casework that you've seen, whether that ability for a CHC, or a citizen's advice body, to be able to be quite fast on the ground has been one of the reasons why you've been able to successfully look at something, or that it has brought something to light.  

I don't know if we can answer that question, on the basis that we don't know exactly how complaints that reach us are originated, but what I can say is that we get very few complaints about social care, far fewer than I think we probably should, which might be an indication of what you suggest. 

Right, okay. Thank you. You've talked a lot about the fact that you believe that the citizen's advice body should be independent at a national level. Can you just expand on how you might like to see it be fleshed out in reality? Because we're taking about a national body at the moment, and, of course, for those of us who don’t live there and are not Cardiff centric, we immediately think that everything's going to happen in Cardiff and nothing's going to happen around the edges of Wales. How do you see it playing out in terms of regionalisation? Do you think there should be elections to the citizen's advice body, or do you think it should be something where people are recruited into it and then work to a purpose?

Well, I certainly think that the body does have to reflect the fact that Wales is a community of communities. I say this as a north Walian who resides in Cardiff and who likes going to west Wales as well. I think, for anybody, it has to show a sensitivity to the different communities and regions of Wales. It's an interesting one: should there be elections? Again, I would want to see something that is really focused on being independent, and I just worry sometimes that the democratic input would be lost if you have that competition between existing institutions, and I think there's a real role for the Assembly and committees such as this to actually undertake the democratic aspect of scrutiny. So, I wouldn't advocate democratic elections for that reason.

Okay. One of the things that does worry me is that any organisation can very quickly become very insular and all about itself rather than about the job that it does, and we can see it with the NHS. So, if we were to have some kind of national citizen's body, even if it's one that is independently chaired, and has an independent board, independent of the Government, I'm really concerned that, as it's spread out across Wales, it really does retain that boots-on-the-ground feel. For example, if you look at the education consortia, they very quickly have become quango-ised and sucked up the line a bit, and they're further away from the teachers, the schools that they're supposed to be interacting with. They've suddenly become 'them' rather than 'us', and I'm really worried that the citizen advice body might become a 'them' very quickly rather than an 'us'. At the moment it is seen as an 'us'.

I think that's a real risk in creating the new body. Again, in terms of accountability, I would have thought this committee—. I think you've got representatives from the south-east, north-east, south-west Wales. Surely, when you have critical stakeholders you have to account to that do represent the different communities of Wales, it would be imperative to demonstrate the way in which that new body isn't simply something that's located in the capital, talking within a bubble, but is real, is out there and can pick up on real experiences, real stories from across Wales. So, I think that's got to be a very important part of the narrative early on.

I think, as well, perhaps there's a role there for third sector bodies. That was certainly part of the Ruth Marks review and was alluded to in the White Paper. Where's that gone? I think that would be a critical input, moving forward as well—that this isn't just a public sector construct. The input of the third sector and the voluntary sector to health and social services has been critical, and is critical moving forward, and perhaps that needs some status in the new organisation as well.

Thank you.

Yes. I don't know how long you've been the public services ombudsman, sorry—

Five years. Five years and two months.

Five years and two months. Well, I've been an Assembly Member for just over 10 years and it's groundhog day. My poor constituents come into my office and I hear the same complaints about the NHS. And even the ones that are dealt with are dealt with on a solo basis. So, we've sorted out this person's problem, we've sorted out that person's problem. And one of my real frustrations is that there's no real learning curve. Now, if you had an aeroplane that was flying in the sky and you found a problem with it and you went and mended that problem, you'd make sure that every single aeroplane that flew in the sky had that problem mended because you wouldn't want the aeroplanes all falling out of the sky, but we don't learn that lesson with the NHS, and it's a very similar thing.

So, part of my frustration with the whole citizens body and part of my frustration with the CHC and the way we set it up is that we deal with complaints as complaints, rather than complaints as a learning process. And I would like to see—and this is my little thing here, sorry—some sort of point of this where, actually, the complaints that come in are really put on a board, because the people who come in and see me and say, 'This has gone wrong', they're not after money. They want a 'sorry' and they want to make sure it never happens to somebody else again. And so I just wanted to ask you, in the scale of the issues that you see that cross your desk—and you said, or I think I read somewhere in your evidence that over 50 per cent now of the issues that you deal with are to do with health—how much of it is groundhog day for you and do you feel that, actually, the whole point of this should be about the learning curve? I'd much rather see a panel where this problem comes here and we say, 'Wow—Cwm Taf maternity, but now we make sure that never happens in any maternity'. Because we don't know; we don't know if it's bubbling away somewhere else. And that we really learn, embed and make a change, because that's the way, surely, to drive down complaints.

I can sense your frustration, but, actually, over five years, groundhog day might actually be an attractive proposition. It's been getting worse every year. To give you some historical perspective—sorry, I do worry Chris and others when I go on about him—but Sir Idwal Pugh was, I think, the only Welshman to become UK ombudsman. He was very worried about the fact that the number of health complaints coming to his office in London in the 1970s increased from about 500 in 1974 to 740 in 1976. His successor, my good friend Rob Behrens, will get 27,000 health complaints just in England this year. I'll get more than 1,000 in Wales and, I'm afraid, the numbers are increasing year on year.

However, there are at least some reasons to be cheerful, I hope. I think there are issues here that could drive things, but it's got to be independent and it's got to be acted upon. And I think that independence would put a bit more grit in the system so there's a bit more challenge and somewhere to focus those frustrations. We also feel that some of the legislation that we've had will give us scope to be a bit more citizen centred—the fact that we can take oral as well as written complaints and deal with private healthcare issues as well, where there's been an aspect where people might take both public and private healthcare. 

Significantly for us as well is the complaints standards role, because we share the same frustration: why is it these numbers go up and up and up? There have been cases where we've seen a decline, a very welcome decline on occasion, in the proportion of complaints coming from some health boards. We want to redouble our efforts. This new legislation will give us scope to do that, and to give you more open data. So, why is it—? I think currently you have to ask an Assembly question in order to find out health board performance on 'Putting Things Right'. I think that there's scope—. This has been done in Scotland; I'm sure it can be done here, not just for health but local government and other areas. Why is it that 95 per cent of complaints are dealt with effectively in Edinburgh, but it's only 80 per cent in Dundee or something? Let's make sure—. Again, it's this issue of if we're not going to go for the market, it's not about choices about voice, how can we make sure that we use data intelligently? How can we make those voices count, magnify them and take the patient experience so that it does actually drive up standards, and make sure that we are in a much more plural environment where there's an emphasis on continuous improvement, and there's a culture that supports that? 

We did produce one thematic report called 'Ending Groundhog Day'. I'll have to send you a copy. But some of the issues around improvement there certainly do relate to, I think, some of the ambitions here about the need for candour, and a need to move away from a blame culture in which it's, 'We're coming after you—you're to blame for this', and looking at systems and making sure that we're actually putting the experience of the service user at the centre. 

Thank you, Chair. Good morning. Do you believe that the legislation is necessary and appropriate to achieve the desired aims and objectives? Who'd like to kick off? 

Shall I kick off with that? I'm Rob Morgan, as I've been introduced, from RCGP. I think the Bill in itself—it's an opportune time to bring things together from both a health and social side of things in terms of care of patients, and it ties very much in with other things that are going on in legislation to try and meld together both the medical side of what we're offering patients and the healthcare side.

In terms of the overall intent of the Bill, I think we as a college welcome that, and it gives an opportunity to solidify some elements that we're already doing in terms of providing good-quality healthcare. It solidifies elements that we are already doing in terms of candour and probity, being open and honest with our patients, and, additionally, it's welcomed in respect of the citizen's voice, in as much as that brings together opportunities for an organisation that has an umbrella responsibility for health and social care. 

In terms of the legislation to achieve the Government's aim around duty of candour and the citizen voice body, then clearly it's doing a necessary task. And obviously we've got some comments on that, but we can see the necessity for the legislation. Now, in terms of the first section on quality, who could disagree, in a sense, with the desire to improve and provide quality services? So, what we've tried to do, as the Royal College of Nursing, is we've tried to seize the opportunity to make this as meaningful as possible, and what we think to make it meaningful is it needs an explicit link to workforce planning, and that's the suggestion that we have put forward. We feel that that will really aid the Welsh Government’s intentions, it will aid Health Education and Improvement Wales’s intentions, and it will indeed aid the health boards in providing those kind of quality services. I’m happy to expand on that now, or later if that’s more helpful, but that would be the answer to your question, generally.

Great, thank you.

I completely agree, and I think it’s absolutely essential. I think, particularly on Part 2 about improving quality and services, health boards and other providers of services already have duties on them—they have duties to balance the books at the end of the year, and they have duties to provide safe and efficient and high-quality patient care, in equal measure. And this Bill, to me, is about ensuring that there’s a legal duty to improve the quality of the services, continually seeking to improve services through a duty to improve services. And I echo the statement that you can’t talk about quality without talking about staffing levels.

Well, that’s what I was going to come onto next, actually. So, around quality I think the BMA have made some statements in their written evidence as well, and perhaps you can expand on your views on quality of care.

Yes, sure. So, I think I’m going to find myself a lot drawing on the important but simple analogy with the airline industry. Their pilot turns up, ‘Morning', 'Morning’, goes and sits down in her seat, turns to the left and there’s an empty seat. You can imagine what the conversation’s going to be—it’s going to be, ‘Where’s my co-pilot?’, ‘Well, they’re not here—they haven’t turned up for work’, ‘Well, where’s the replacement?’, ‘Well, it’s really difficult getting a locum co-pilot and they seem to be charging more than we’re prepared to pay, so it seems like you’re on your own today.’ That pilot’s going to take five minutes to decide, ‘Well, okay, I’m going back to my hotel, and this plane isn’t going anywhere today. I’ll be back for work tomorrow, unless, of course, you can find me a co-pilot. In which case, we can take off.’ Obviously, in the NHS, things work slightly differently. We’re the only provider of services, so we can’t rebook our patients on to another provider. So, we have become habitually used to turning up for work, no co-pilot, switching up all the lights and taking off, flying the plane all day and landing it without the co-pilot. And, obviously, that has an impact on the level of the quality of care that we’re able to deliver to patients and the whole patient experience.

Sorry, I'd just like to come in there. Although it didn’t figure in our written submission, I think we would totally agree with our colleagues, in as much as what we’re trying to provide is a service for patients and ensure that they're seeing the right person in the right place at the right time, and I think we’re very good at that. But that basic tenet of the service relies on enough people, enough qualified staff, to be present in the community, to be present in the hospital, so that the service we’re aspiring to is actually delivered. And I think if we don’t have correct staffing levels, either a non-suitably qualified person trying to step up to a role, not enough people, or not enough people in the right place to provide that service, the system’s going to creak very much.

Yes, obviously, that's our intention, because you cannot provide a quality, safe, clinical service without the right level of skill and the right number of people. The evidence is really clear on that. I and my colleagues in the royal college spent a very interesting summer going through all the integrated medium-term plan and public board papers of the health boards in Wales, which is a very instructive experience. And I think one of the things that we have struggled with and has caused us great frustration is that, very often, you will see the description of what services can be provided, or more importantly in a way, the description of what services intend to be provided in five or 10 years—'Well, we’ve got staffing issues, this is what we can do' or 'Because of the staffing issues, this is what we can do', 'We have to do this because of staffing issues.' You very often see in the board papers, very starkly—and this is obviously the board; it’s the most senior level possible. You very often see, ‘We haven’t got enough nurses to fulfil this Act’ or ‘Well, there’s no possible way we could do that.’ The workforce situation is very often presented as a fait accompli—it's just one of those things that we all have to negotiate around. I think what we're trying to do with the suggested amendment—we're trying to lift the level of strategic discourse about workforce. Yes, you clearly do have a problem, in that you can't currently provide this service because you don't have the people. Now, let's work backwards. Let's say, 'What are the ideal clinical services we'd like to provide? What would be the ideal workforce? Right, how can we work backwards to try and obtain that?'

There's very little, if any, discussion, even in IMTPs or workforce discussions at board level, of strategy. In fact, I would go as far as to say there's probably no discussion of strategy. There is very little discussion of activities. So, you often see recruitment activities include attendance at fairs and advertisements on Facebook. Those are activities—it's not a strategy, and it's certainly not something I would be expecting to see just as a quick bullet point as the solution to something as fundamental as this crisis. There certainly is almost no discussion at all of retention strategies, yet we can't keep putting people into the system when they're actually leaving. You can see that very specifically with the nursing profession around burn-out. Some health boards, laudably, have said, 'Perhaps we should pay more attention to exit interviews.' Yes, that would be great. We need that kind of thing going on consistently and at a national level. We know what the major reasons are for nurses leaving and working for agencies—they want control of their hours—yet it's too impossible to change the rota system, except it isn't.

So, it really is quite important that we have these strategic national discussions, and that the attention of the senior people at board level is focused on these kinds of big workforce-planning questions, so that they're not just answering the question, 'What can we provide with what we've got?', but they're answering the question of, 'What do we need and how can we work nationally to obtain that?'

In fairness, I think we see with the creation of HEIW and we see with the creation of the workforce strategy that's out for consultation—we can see the Welsh Government is trying to move in that direction, and we really welcome that. And that's why we feel that this opportunity for a legislative amendment would really focus minds. To be clear, our intention in this amendment is that, in terms of fulfilling that obligation—it can be fulfilled in the way that is set out here, around the statements and around demonstrating active participation in that kind of workforce planning. So, our suggestion is for a high-level strategic start to the process.

Thank you. I was going to come on to that part about staffing levels and workforce elements. You've suggested, I think, to follow the Scottish legislation to amend the Bill. Does anybody else have any comments on that part? Do you have anything to add on staffing levels?

I would echo what's been submitted—the outline that's been submitted in the RCN written evidence, which is taken from the Scottish legislation passed this year. But I think it possibly needs to go slightly further and to actually spell out all of the steps, as it does in the Scottish legislation, behind how you actually assess the staffing levels in real time, how you escalate clinical concerns, how you mitigate those risks and how you then take it back to the clinicians and say, 'Are you happy with what we've done here—is this now safe?' That's all included in the Scottish legislation, and I think that would give it a bit more teeth.

We really think the Scottish legislation is excellent—it's a great way forward and it's a fantastic example of how devolution should work, in the sense that we can learn from policy developments across the different countries. Having said that—. So, we would like to see that replicated—we absolutely support what my colleague has just said there. Having said that, I can understand that, potentially, that might require a full Act to achieve an Act. So, if we can pave the way towards achieving that by what we've described as a starting point—this high-level attention on workforce planning—then that would be a good step. But, eventually, yes, I completely agree—I think we need to arrive at a comprehensive Act in the same way that the Scottish legislation sets out.

We did deliberately set out to examine the Scottish legislation for reasons of trying to make sure that the suggestions we made were practical, in the sense of—are they possible to do legally? And, obviously, I know that's, necessarily, a great concern of committees in putting forward amendments to legislation, and for the lawyers from both sides, and we really wanted to look for a form of words that has been done, so it is possible. Clearly, there will be legal advice and guidance to draw on from Scotland, hopefully, that can make this a practical suggestion.

Thank you. And just finally from me: it's been suggested that amendments are made to add on a duty on health and social services to collaborate and co-operate to secure quality improvements. Do you have any views on that?

For health services to co-operate?

Yes. Health and social services to collaborate or co-operate to secure quality.

Sounds very reasonable; it sounds like a strong principle we'd support. I mean, obviously, you see the question of, again, the practicalities of how you demonstrate that and in what form that looks, but, yes, absolutely, that sounds like a very good principle.

Diolch, Cadeirydd. Can I move on to the duty of candour agenda? All three submissions clearly support the concept of a duty of candour, with some reservations, which I will go on to in a short while. But I suppose I want to try and highlight whether the current Bill, as drafted, delivers the open and transparent approach that you believe a duty of candour should be bringing. My other concerns—I'll come back to the concerns, I promise you. So, does the Bill, as drafted, really reflect the open and transparent agenda that every one of those submissions says you welcome?

Can I—?

Yes.

I think it's really important that there is a legal duty to ensure that each provider is complying with their responsibilities to be open and transparent. I think the one area of concern I have is with primary care services, where there might be a single-handed practitioner. I think that could easily be dealt with in the legislation by making it explicit that it's the local health board that has the duty of care to those patients and is responsible for commissioning those services. And whoever and wherever they find a provider to provide those services, they have the duty, the ultimate duty, of candour, to the patient. So, it's their responsibility to make sure that they're complying with that through the processes that they have with the provider that they're contracting from.

I'll ask the question, then, which I understand, because I was going to expand upon it as to whether—not just GP practices but any commissioned service that needs to be applied, in that case, because the health board would have a duty of candour, and they would expect that of any of its commissioned services, whether that's a GP practice or not. You mention GPs, but it obviously is clearly true that the practice—because there are various other professionals within the practice—but is that possibly letting the practice off the hook?

No, because most of the clinicians that work in that practice will have professional—

You mention clinicians again. I said 'practice off the hook' because there are other professionals within that practice.

I think it's important to enforce that at the practice level, but, ultimately, the responsibility for ensuring that that happens lies with the local health board.

But shouldn't it be if a practice is commissioned—I'm talking about—[Inaudible.] If a practice is commissioned, it is the responsibility of the practice to ensure it also meets the obligations the health board expects of it.

Shall I—? If I can just come in. I take your point that, nowadays, a practice is made up of multidisciplinary teams, and I think that's the way forward. From a medical point of view, from an RCGP point of view, we welcome this part of the document because it really just reinforces what we should be doing with patients anyway, which is having that sense of openness and honesty, particularly when things go wrong.

GMC guidance is that we should do that, and within our practice teams, that ethos is something that the practice would take on. And, certainly, in our work around the MDT, you'd assume that the practice ethos is the whole thing, regardless of what discipline you're in, so I hope that would reassure you.

In terms of the way that we've read the document, I think we have taken it that practices themselves would have that duty of candour, and there would be a mechanism by which that information would be submitted to the local health board in a timely fashion. The details of that, though, can be quite challenging for practices, particularly small practices. No-one is trying to take away from the fact that, when things go wrong, GPs are very keen to identify the problem, regardless of what member of staff has been at the root of that, and rectify it. The challenge will be, for the duty of candour, trying to decide at which point does the duty of candour kick in at a level that would otherwise have been dealt with on a day-to-day basis through the practice governance systems. That's probably the same—and I can't say for definite—for other primary care practices like optometrists and dentists, because, when you think of primary care services being commissioned by the LHB, it's not general practice but other services in the community that will fall under this.

I think the Bill needs to be very clear at which point—. It says, and I think the phrase used was, 'more than minimum'. I appreciate that, in the documentation, it referred to case studies and further work to define what that is, but what we don't want to do is develop a system that is so onerous on reporting that it actually takes away from patient care. So, I think we need to be very clear on what we're actually asking people to do and the level at which we're asking them to do it.

So, in your view, it's more important that we identify at which point who is accountable for the duty of candour and that the consequences of that are not overburdensome so that we actually impact upon the quality agenda.

Most definitely, because everything that we're being asked to measure in general practice, if it's not light touch, must have the potential of taking clinicians away from clinical care. Even with the aspect that you've just mentioned around the quality agenda, if we're just relying on simple outcome measures, those measures can be easily collected in terms of data crunching, but someone has to do that, and someone who understands the data will have to do it. Just taking away data and data crunching takes no account of the people who walk through my door on a day-to-day basis. And in terms of effectiveness and quality, if all you're measuring is prescribing drug A for drug B, that information rarely takes account of what Mrs Jones thinks about that, and so, trying to dissect out those elements, for the clinician, can take time. And anything that is developed that takes time away from patient care—. You know, that's what we're there for essentially, isn't it, and although it's important for us to prove that what we're doing is effective and safe for the patient, to spend so much time measuring it in a system that may be burdensome will be detrimental to the patient. So, our feeling is that whatever is developed needs to be as simple as possible, it needs to be clearly defined in terms of, 'Well, at which point would this need to kick in to fall under the Bill?', and to provide enough training so that everyone within the multidisciplinary team is familiar with their roles and responsibilities and when to act.

I think, from our perspective, there does need to be more clarity on this point. We've said in our written evidence that we weren't clear whether this section applied to commissioned services or only to directly provided. In conversation with officials, I think the impression we've gained is that it is intended only to apply to those services directly provided. So, I'm not sure if that's the case, but certainly it's something we need to clear up, and equally that relationship with already existing duty of candour, for example in the complaints process that applies in the NHS.

Having said that, anything that improves that culture of candour is obviously to be welcomed. I think we are interested and we welcome the fact that we are looking at this at an organisational level—so, about the organisation being candid and forthcoming with information. Because, very often, the issue is not individuals; the issue is the organisation as a whole, and the interests of the organisation as a whole as may be perceived or misperceived. So, it's about changing that culture. 

One of the reservations we've put down is, for example, what consequences result from a breach of the duty of candour for the organisation? It's not clear. So, those were some of the reservations we had, but obviously the aspiration is clearly something that we would support.

On that last point, clearly, we've just had the Public Services Ombudsman for Wales as a witness, who didn't seem to stress too much about what sanctions would be put into place, but more that there was this duty, and there was an ability to assess, I suppose, and publicly hold to account someone's failure, and the belief was that perhaps that would cause someone to either be dismissed, or whatever. But do you think there should be sanctions in the Bill in relation to this if they fail to actually meet the duty, particularly for the organisation?

There certainly need to be consequences, because otherwise—. That's the nature of legislation, isn't it? There has to be a consequence to doing it or not doing it, otherwise there's no incentive to do it, in a sense, at the most basic level. One of the suggestions we've put forward, for example, is you would imagine that this would be something that would be considered when people are considering the escalation status of the organisation. Maybe it's as simple as making that explicit, because clearly if an organisation has not fulfilled its duty, there has to be some kind of process where people say, 'Well, you didn’t fulfil it; this is what you should have done, lessons learned, you need to implement that,' and so on. So, it may be something as simple as that. It's not so much that, from our perspective, our concern is that there ought to be sanctions of individuals singled out; it's that, if we are going to change this culture, there needs to be some kind of lesson-learning process. So, 'there need to be consequences' is the expression I would use, rather than 'sanctions'.

You gave an analogy there. Let me give you another analogy in another sense. I keep hearing about rugby games, 'Oh, we played badly', or 'Lessons need to be learned', and the following season we see that the same lessons still need to be learned. So, is there a situation here where we need to enforce lessons learned so that, if something happens and it happens again, they have to do something about that, because lessons aren't being learned?

Yes, and the escalation status, for example, is one suggestion we've made to solve that. I think another suggestion we've put forward is potentially around the appointment process for chairs and vice-chairs. Our understanding—and as we've said, we'd welcome more clarity—is that it reads as quite a high-level duty that is invoked at a certain point. So, we are talking about quite serious incidents, we're talking about quite a serious level of issues here. So, if we were in a situation—and let's hope we wouldn't be in that situation—where it is discovered that an organisation has not fulfilled its duty of candour, then absolutely that's a very serious issue and something should happen as a consequence of that. So, that's why we've made those suggestions. That's not, perhaps, our area of expertise, but we would totally agree with the principle statement that you've made.

Do you think, in the Cwm Taf example, where clearly there's a question of whether the duty of candour would have actually brought these issues to the fore sooner, that this Bill would have actually brought this to the attention of the public and to people sooner than actually it had? As things were, it seems to have been—I'll use the word 'alleged'—hidden as a consequence of information being given.

I think that would be an excellent question to put to the team that's examining those issues, because I think the specifics of those issues are beyond me. But I do think that the principle that you allude to, of consequences, is an excellent one.

In terms of the idea about sanctions, I think we ourselves are coming at it from a point of view of perhaps looking at smaller organisations within this, and having a duty of candour at primary care level. I think we've got to be very careful about stating that, as a consequence, there will be sanctions. There need to be consequences to any event that identifies gaps in services or gaps in learning, and, if anything was to be enhanced in this Bill, it would be preferable to use consequences in a constructive sense rather than in a negative sense. I think there's an opportunity for learning all the time, and even for Warren Gatland, lessons are still going to be learned even though we're chuffed with what's happening. So, to say that lessons will never need to be learned I think is little bit more of a challenge for us, because we will always learn things from our day-to-day practice.

If we need to repeat the lessons time after time after time, it’s a very serious question and obviously an issue. Perhaps one other point on this, then, because I just mentioned Cwm Taf, and it's been mentioned before that many professional bodies already have that expectation of a duty of candour of their members. Managers, at the moment, don't have a regulatory body. Should the Bill be used to introduce some form of regulatory body for non-clinical managers so that there is, again, a requirement for them also, under some form of regulatory approach, to do that, or should this Bill step away from that and do something different?

Our members certainly have some sympathy with the concept that there should be accountability for managers. I think it can be very difficult for professional registrants to see—. Quite rightly, the heavy sense of responsibility is on them, the scrutiny is on them, and yet the circumstances they're operating within can be outside their control. The analogy of the co-pilot earlier is one that's very familiar to nurses that go onto the ward and find that they don't have the colleagues there that they would wish to have to provide the care. So, certainly, the concept of trying to have some kind of accountability, whether that's corporate accountability or some kind of accountability at the managerial level, is something that we as a royal college would support. And I think part of what we were trying to do with the Nurse Staffing Levels (Wales) Act 2016 was to try and make those issues corporate. It's part of what we're trying to do with this suggested amendment in quality, to say, 'That's part of your corporate responsibility to address the circumstances in which those clinical services are delivered.'

I suppose the question is: how do you do that? And one of the suggestions, again, we've made in our evidence here has been to examine the responsible person concept that's used in social care. That might be an excellent way forward for senior management, potentially. It seems to be effective and understood in the social care sector. So, that might be a way forward. We would have some concerns about the concept of a new regulatory body. And that isn't necessarily to say that we would disagree, but we would want to explore issues such as dual regulation, how it would operate, all of those kind of mechanics, the detail of it. It strikes me that, potentially, that might be best served by a separate, new piece of legislation, rather than possibly an amendment. But that would be how we would consider the situation. 

Thank you for that. 

One would hope so. I think part of our evidence that we've put in is a little bit of frustration that a lot of attention has been focused on the duty of candour section, and not enough on the duty of quality section. I think it's more important to prevent the situations from arising in the first place than to spend a lot of time trying to perfect with policy attention, perfect a system of what will happen when things go wrong. Well, let's address the underlying issue here.

And your point about the systematic failure is exactly what our members experience. So, if they are on a ward and more patients are coming in with dependencies and needs, and are clearly suffering in front of them and they do not have enough staff, that is incredibly difficult for them. Because of that difficult situation, we know that leads to burnout and they leave. That's creating even more shortages, and that's creating a situation where the health board is, 'Well, we can't possibly provide clinical services over here, so we'll just reconfigure and not provide them', rather than actually addressing the underlying issues.

Really, that's why our suggestion—. If we're going to alter that cycle, our suggestion is that it needs much firmer legislative attention in the first section, and that is what will make the difference to the culture, not the precise detailed process of, 'What do we all do when something goes wrong?' Well, let's go upstream and I think that's what we're trying to say in answer to this. That's where you can make the difference in terms of a legislative framework—over here—because that's what's missing.

Yes. Good. 

Yes, I concur with that. I'd just say that we tend to focus more now, or we try and focus more now, on, when something goes wrong, being open and honest, and what we can learn from it to try and improve the system, recognising that a lot of errors are due failures in the system rather than an individual.

And, just to come back to the point about managers and whether or not they can be held to account professionally in the same way as the clinicians delivering the service, I think that's an important part of it, because, to invoke a Trumpism, it's not necessarily guns that kill people, it's people—and managers can kill people because of the decisions that they make; it's a question of how you hold them to account. Yes, you can sack them, or you can move them to somewhere else, or you can even promote them, but you can't invoke a professional investigation.

Obviously, I'm coming at it from perhaps a microcosm of general practice and primary care. And I think if the Bill was developed in a way that removed any ideas of sanctions as a result of an event that resulted in going down the route of duty of candour, I think it would feed back into quality improvement. I think, as a profession, we are very keen not to dissuade younger people coming into medicine, coming into general practice, from being open and honest, because in reality you're only going to learn by having an insight into the things that go wrong, and there can be multiple reasons for that, but it might need an individual to change the whole system. If that individual keeps it to themselves because of fear of reprisal or sacking, then that would be detrimental to them.

It'll also have a significant detrimental effect, as far as I'm concerned, if we develop something that seems so draconian for anyone who holds their hand up—we're going to start dissuading people from coming here. So, whatever system is developed in terms of being open and honest, it has to be seen as part of the developmental cycle and improving quality.

That's fine. 

Thank you very much indeed. Thank you for all of your responses to this Bill. What I'd like to just quickly try and understand from you all on an individual basis is the depth of your views on whether or not the citizen voice body should be independent of Government or not, because in some of your submissions you've been quite strong. Other submissions that have come in have very much—have had a much less strong tone on this. 

Yes. Well, I think we do feel that it is important to make sure that it is independent, and we would question the wisdom of having Welsh Government appointments to the citizen voice body and whether that can be truly independent in that situation.

We've made quite a number of suggestions to really strengthen the powers and the independence of the body. We think it should be as independent as possible. In fact, one of our suggested amendments is—. We were very taken, and we think it's an excellent idea, that the duty of quality in the first section applies to Welsh Ministers. Actually, I think that's really quite laudable. Well, let's extend that principle all the way through, then. So, let's make sure that the citizen voice body can also make representations around that. And this goes back to the systems issue we were discussing earlier, about where—different levels of responsibility for situations that arise.

Thank you. I'm just looking at our very short one line, which is that the new body is suitably independent. So, I think—I'd agree with my colleagues, really. I think this is—we think, rather—it's a great idea and it is a citizen voice, so my only thought on that when I was reading the documentation was, 'Where are these citizens being derived from?' I think it's quite right that patient citizens have a view on the services that are being delivered by practitioners in their own community. The citizens that are having that view ought to be drawn from that community and have some sort of mechanism by which they ask citizens to be part of that visit or group that is taking their voice to a higher level. So, I think the independent nature—I was a bit confused as to the detail of how it would all work in practice, personally, when I was reading things. It would be important to get it right so that, once the organisation is formed, it doesn't spend a lot of time trying to work out who it is and who should its constituent members be. 

Do you think that we should just scrap that whole idea and give the CHCs a bit more teeth and support?

We've been very supportive of the existence of CHCs in the past. From our perspective, we feel that a system should exist that allows people to give their voice and views on the services. The question is what structure is best capable of doing that. If this were to go ahead then we think it needs significantly strengthening. We need things like the right of access, we need things like some element of locality or regionality. There needs to be some mechanism of making sure, exactly as you've described, that local communities and local community groups work with this body. It's not just a question of—. It's a question of knowledge; it's also a question of trust and building that trust and relationship. This body not only has to be independent; it has to be seen to be independent. That's a very important point. We do think that the current legislation does not provide for the body to be strong enough. So, either it needs to be significantly strengthened, or we need to return to the current system we have now and strengthen that one.

One of the other suggestions I just want to mention, which I do think is important, is we do think there's an opportunity here for a duty looking at equality issues. And I think that's quite significant, because local communities need to have access to high-quality clinical services and they need to have their views respected. But also we know that there are groups in the community—veterans, people with learning disabilities—that struggle with access to health services and also have less than optimal outcomes. Therefore, it would make sense for any new body to be able to do a thematic review as well as a specific local review. So, we do think it's an incredible opportunity to promote that kind of equality. So, that's the other key suggestion that I would just draw to the committee's attention.

I thought your amendments were very interesting. I always recoil slightly over the word 'regionality', because every regionality in my region seems to be further away than anything ever. So, it never feels very regional. But I do think that there should be a real local 'boots on the ground' feel.

I was quite interested in your providing for the annual plan and how to consult. And, of course, that is one of the problems, isn’t it? It’s about how to consult, particularly with those who don’t really want to be consulted with. But it’s their opinions we need the most, because we always get the usual suspects, don’t we, who answer every consultation, so how you get that out into the general public is quite a tricky one.

I just wanted to come back, though. If we’re going to try to change the Minister’s view, there are two things that he’s quite strong on, I think, in terms of his view. One is that he doesn’t feel the current CHC set-up is strong enough and that he feels that some CHCs have perhaps not been as dynamic as others and haven’t really got to grips with what their job could be. And I think the other thing that he believes is that the inspection element of the CHC is now no longer necessary, or inconvenient, and the reason used is because of the incorporation of social care into this, and the fact that, whilst it may be appropriate for a member of the CHC to go and inspect ward 10 at Withybush hospital, it may not be appropriate for them to go and inspect a care setting in someone’s home. And I just wondered if you’d like to give your views on those points.

I think, with the inspection issue, sometimes it’s a question of language. Inspection can be seen as the domain of the inspectorate, but visiting and understanding what’s happening in healthcare is very important. If you want to form a view on how the local community used or did not use a particular service, then it'd be difficult to understand how you could do that without visiting and meeting people and having a look around. So, we do feel that the right of access is important. Now, having said that, I think we’ve recognised the issue about, 'Oh well, healthcare is delivered everywhere' and, obviously, you can’t have people having a right of access to people’s personal homes, but let’s not let the perfect be the enemy of the good, as Kirsty Williams often used to say in the other legislation. So, why not simply restrict the access to hospital premises, if necessary? Yes, you would need, then—if you were looking at home care services, you’d need to do that in a different way. Well, okay, so that’s quite practical, isn’t it? So, let's take a practical—. I think we’re just saying, ‘Let’s take a practical approach to this, and make sure that if the body—'. If the desire is for the body to be strong, then it needs to have certain powers in its remit. So, for example, we've made an important point, which I think other people have echoed, that there needs to be a power of response. It’s all very well people making representations, but there needs to be some kind of formal response from the people to that. Just as in the same way that Welsh Government responds to committee reports, you would expect health boards to have to respond formally to a report. So, if the aim is for a stronger body, then this needs to be significantly strengthened to reflect that aim.

Does anybody else want to—?

Yes. We broadly support the idea of a citizen voice body. It’s their NHS and they should absolutely be involved and have a statutory connection with the health Minister in shaping services, et cetera. We also value the locality of the community health councils. But what they miss out on is that universal—it is one NHS, and it should be one NHS—and to have that ability to, across Wales, to be able to influence the commissioning of healthcare, I think, is quite important, but retaining some kind of locality.

I accept some of that argument, but I'd just like to challenge you slightly, because you're right, it is one NHS, but we have seven health boards, if you don't count Public Health Wales. And they don't all act cohesively, do they? What you can do in one health board is completely different to what you can do in another health board in some instances. There's no cohesion there. There's no transference of—very little transference of best practice from what we see when we bring the health boards in. So, would it not be better to have the CHCs really reflecting their particular health board? Or do you think that by having a national overwatch as well, that that might be able to strengthen them and perhaps professionalise them?

I think if you have all of those community health councils in effect brought together, they will see what's happening elsewhere. As I said earlier, most patients only have one provider to turn to. They don't have the opportunity to go and inspect services in north Wales if they live in south Wales, for example. But that body would have the overview to be able to say, 'Actually there are things that we can learn, and these things that we've accepted because our health board told us that's the way it is, it's not the way it is over there, and maybe we need to be pressing the health Minister to act on this'.

I was just going to say that one of the suggestions we've made in the schedule is the allowance of committees. Maybe that could be developed into a specific issue about local committees as opposed to regional committees. Maybe that's one way of solving the conundrum, because a national approach is very helpful, for the reasons that have been outlined, but you're lost without the local knowledge of what's actually happening on the front line, and you can only gain that through local connections.

And one of you said—and forgive me, I can't recall who—but you mentioned the 'trust' word, and of course, as you know, we've all become more world-weary, more cynical, patients are much more understanding of their rights, there's a little bit more anger around the system these days, there's a little bit of this, and trust is at an all-time low, whoever, and across all spectrums of society. To rebuild—. My view is that if you had a truly independent body that was able to be effective and had teeth, I think that might start to help rebuild some of the trust, and trust is the oil, isn't it, that allows the wheels of the NHS to really work well. It's when people stop trusting and say, 'Well, I don't believe you. I want another doctor. I want this, I want that', and there's an awful lot of that going on, and I do fear that this will take away from that element of trust. So if we were not to have a Minister making the appointments to the new citizens' body, do you have any views on who should make the appointments, or where the members of the board should come from?

I'm not sure who, but I believe I read in some of the written evidence a suggestion that it would be the National Assembly rather than the Welsh Ministers. Potentially that's a way forward, because certainly our concern would be exactly what you described—not just the robust independence of the body, but that perception of that. That is very, very important, and I think the body needs to be establishing that from the get-go: that it is a body that is prepared to be rigorous and robust and take evidence from all the communities equally, and engage with all communities equally. I think that's very important.

Robert, did you have any—?

Yes, in relation to the previous point about visits and point of access. I just wanted to bring it to everyone's attention that a team visiting a ward in a massive hospital—the disruption that brings is a different type of disruption completely in a practice, in a community that might be slightly understaffed, might not have had an opportunity to alter rotas or bring anyone in from outside. So, whilst we see merit in visits, I think its important for people to grasp that the impact on service delivery during a visit is very much different in primary care than it is in secondary care.

I'm not sure I've got the answer, but I do think it is important that it is seen as independent, and I would echo the other points that have been made that it also needs to, in its totality, be seen to be representative of all citizens. That's going to be something difficult to achieve.

Could I just go back to the RCN just for one moment? You made quite a point about the fact that you believe the body should have the right to make representations to the Welsh Ministers as well. Do you want to expand on that at all, Lisa?

I think it goes back to the point about levels of responsibility, and also what added value, in a sense, to the system is such a body to bring. It could be doing a plethora of different things. It could be reviewing the provision of services in a local area, it could be—. We've suggested taking a more thematic approach, like taking a particular group, like the accessibility of the NHS to people who are hard of hearing. It could be taking that kind of thematic approach, and at that point you start to think, 'Well, what are the recommendations it would want to make? What are the comments it would want to make?' and they maybe fall within the remit of some of the bodies—like we've mentioned HEIW, we've mentioned Social Care Wales. Maybe they fall within the remit of the health boards, maybe they fall outwith, if we're talking about independent providers. Maybe their appropriate recommendation is direct to the Welsh Government. That would seem to be a constructive way of looking at it, because otherwise you would be very much constraining the actions if you were just saying, 'Well, you can only comment on what the health board can do'. Well, that's potentially easy, then, for the health board to say, 'Well, we can't do anything about that', so you can't comment on that. So in terms of their ability to investigate and look at the evidence and come to some sort of a conclusion, then it would seem helpful for them to be able to—. Again, what's the point of creating a national body if it can't take a national perspective? That's the advantage, isn't it, of a national body—that it can take that national perspective?

Could I just perhaps add an additional point to that? We often think of CHCs as performing inspections or making recommendations when things go awry. There might be an opportunity with the citizen's voice to actually be a bit more proactive and be involved in planning things at an earlier stage before those situations do arise. I think clusters are developing. An organisation like this might want to try and tag itself on to cluster developing and think, 'Well, what projects would a patient voice be very strong in, that we could promote?' So I think there's an opportunity there to perhaps develop something new.

I take that point on, because I do think that up until now, it's been a reactive service because it's all about dealing with a problem, and one of the things I'd really like to be able to see is that—it's about getting things right, isn't it? So if we can identify a problem, rather than just solve it for that particular individual, make sure that that problem is learnt throughout the whole NHS, so actually with that one tick, that one goes away, and we move on to the next, and that's how we can bring down the levels of dissatisfaction or the levels of complaint or the levels of mistakes.

Can I just ask—? Is there anything else that you would like to have seen in this Bill that is currently just not there, apart from the commentary that you've made in terms of recommendations? Are there missed opportunities? Do you think this will really get to the heart of the culture change we need?

Are you talking about just the citizen voice body?

No—I think I'm the whole Bill, aren't I?

Yes, you are the whole Bill now. 

The other thing we were going to say about the citizen voice body is that, as it's currently drafted, it does seem a bit vague about—. We've mentioned some of the roles that it might have. I think those were more fully addressed in the White Paper that preceded the draft Bill, and perhaps going back to some of those and spelling them out would be helpful. In terms of other things, I haven't specifically got anything.

I think for us, we would summarise by saying that the citizen voice body should be strengthened, including that duty of quality, which I think is very important, with clarity around some of the aspects of the duty of candour. But for us, critically, it would turn to this idea of putting the workforce into the duty of quality. It's part of the quadruple aim. You cannot deliver clinical services without people. People are essential to this and we need to get that strategic level of workforce planning more mature in Wales, more sophisticated, more able to tackle the real big issues that are going to come up over the next 10 years. So, this is an ideal opportunity to strengthen that approach.

I want to pay tribute to the RCN, because when I read the result of the investigation that you did over the summer that said that, in all of the health board minutes and agenda items, the workforce planning just didn't feature on any of them, I was absolutely appalled, followed fairly quickly by quite cross, because I stand in front of my health board every three months and talk about the fact that we do not have enough doctors, nurses, specialists, and that our health board in west Wales, and our services, are really under pressure, and in some of our key areas we cannot and do not get people. Yesterday, we had a debate about the proposed changes to the staffing and pay levels in Betsi, and we also talked about endoscopy services. Again, I highlighted Glan Clwyd where there was a team of three gastroenterologists. One retired, one moved, no plan B, nobody could be bothered to look at it, so it withered on the vine—a really, really good service. And all along we’ve always, in all of our discussions, had the impression that right up there in their heads is workforce planning—how do we get more people, how do we keep them—and boy, have you exposed that to be an absolute sham, and well done RCN.

Sorry—you're finishing on a high, are you? 

I'm going out on top. 

Right. Okay. Well, just to wrap up this session, then, a couple of tidying up questions. When you mention specifically about things in the White Paper, Rob, as regards to a citizen voice body that you'd like to see, can you spell it out a bit, just to beef it up?

I don't have details to hand, but it just seems to be, as it's drafted, left up to the body itself to decide what its function will be, and I think it would benefit from spelling out all the things that we had envisaged that it would have a role in. 

Great. And my final question would be: do you foresee any unintended consequences arising from this Bill? It has a level of welcome, obviously, and lots of people have been saying some positive things about it, albeit with all the caveats that you've heard and you yourself have elaborated this morning. Further to all of those points, are there any unintended consequences potentially arising from the Bill?

I think the risk of unintended consequences would be lack of clarity in the duty of candour section—it could have consequences. I think the risk of not strengthening the citizen voice body would be exactly that further loss of trust in the process. And the obvious risk from the quality section is an incredible missed opportunity to actually address those workforce issues. So, the risk, for HEIW and Social Care Wales, is that they're putting a great deal of work into this 10-year strategy that many people are contributing to the development of, and for that to succeed, it needs to take root and embed in the health boards. So, there's a huge risk that all of that work that's going on at the moment—by HEIW and Social Care Wales—will not actually have the desired benefits that it should have.

Okay. Any concluding remarks?

In terms of concluding remarks, I think there are risks that we've mentioned in terms of clinicians perhaps becoming more closeted and feeling that they're going be sanctioned if they do admit to problems and bring those to light. I think there is a danger if the Bill isn't developed properly, in terms of the duty of candour, that those outside Wales will perceive that as perhaps a little bit more draconian than where they're currently working. And though I mentioned that earlier on, it's obviously important to us that we recruit doctors, not from just within Wales, but from outside Wales as well. Other than that, from a general practice specific point of view, I think any systems that we develop to measure quality and provide report have to be constructed in such a way that it’s not so complicated that we stop delivering what we should be doing.

Rob.

It depends on your perspective whether you see this as a risk, but, obviously, in trying to provide safe and effective services, you’ve got quality, you’ve got timeliness and you’ve got cost. And clearly, if you make interventions to improve the quality, then it’s either going to push up the cost or perhaps have an effect on waiting lists, for example. Using the analogy of the missing co-pilot again, if a consultant turns up to one of his cancer clinics, he’s not infrequently told, 'Oh, it's just you today, but we haven't cancelled any of the patients, because they're all cancer patients.' So, that consultant then sees twice the number of patients that they would normally expect to see and can safely see, and obviously they cut out on quality, because they don't want to turn anybody away, they all need to be seen. If you then start saying, 'Actually, I can only see this number', then potentially that could have an effect on waiting lists.

Okay. Diolch yn fawr. Thank you very much indeed, obviously, for both being here and answering the questions in a very delightful, professional manner, which has improved our understanding of what's in front of us. So, thank you very much indeed, and also to reiterate the thanks for the excellent written evidence that we received beforehand. It's really excellent, and it improves our ability as a committee to be able to truly scrutinise this piece of legislation. So, thank you very much indeed. You'll obviously receive a transcript of the deliberations, just to make sure that they're factually correct. But, with that, thank you very much indeed.

And to my fellow Members, we'll say we'll break now for an hour for lunch, until 12.45 p.m. We'll see all my co-pilots back here at 12.45 p.m. Thank you very much.

Diolch, Cadeirydd. Your written evidence, overall, highlighted various points, but some of the written evidence we received from health boards has highlighted whether there's actually a need for this legislation, whether you actually need to have a legal duty placed upon you because the quality agenda is important for health boards per se. So, I suppose the first question is: are you supportive of the legislation?

If I could start and say that, I think, yes, we really welcome the continuing focus that this Bill provides because service quality and quality improvement are absolutely fundamental to what we try and do in health boards, and we welcome the opportunity to contribute to the discussion. Obviously, we all know that for very many years, there has been a duty of responsibility for improving quality on health boards and previous health bodies, and I think that this continuing and increasing concern about how we really put quality right at the front of everything we do is really important to people who both work and receive healthcare. So, yes, I think we do welcome it. It re-emphasises the things that we believe are really important.

Chair, may I add to that? I think from a Public Health Wales perspective, both as an NHS trust and the public health institute in Wales, this Bill is really important. There is reference to the promotion and protection of public health in the Bill, but we would like to see more explicit reference on the face of the Bill because public health, public protection, is the bedrock of any effective health system to make sure that we do what we can to mitigate any avoidable harm and to promote health and well-being. So, if you think of the functions that Public Health Wales has, in addition to our clinical services around prevention—health and well-being, screening, our protection services, immunisation, environmental threats to health—we really want to see that duty on all our public health functions reflected on the face of the Bill, particularly now, as we're facing so many global health threats. So, as it stands, whilst there is a focus on quality, the Bill really concentrates on healthcare, and we would like that broadened to the whole raft of public health functions that we have, as that's the basis of an effective health system.

I was going to come back to that, as it happens, so you've pre-empted the question. But can I come back to the question? What I want to ensure is that there's an understanding between the difference of the improvement of quality and quality assurance, because many people think quality assurance does exactly that, but that's not necessarily the case.

No, and I think that, as the Bill will require us to actually put in a report every year—although, of course, we will do it far more frequently than that—but as it requires us to put in a report about how improvement has been made, I think that's an important focus, because it isn't just about assurance giving a certain array of standards, but it is actually, 'What issues have arisen? What innovation has been implemented as a consequence of the issues?' It will allow us to scrutinise, I think far more effectively, actually what is the quality of care that is being provided, what innovation is being implemented within our services, where we could learn from the best. It just moves the agenda around from assurance, which is important, but actually to thinking all the time about how things can improve and what evidence we are going to test our care against. And I think that is a real fundamental leap. As you know, Aneurin Bevan has been at the forefront of value-based healthcare, and that has allowed that slight change in focus to come into effect at the health board level and throughout our divisions and our specialties. But to make it part of a Bill, which is an absolute requirement, I think is really, really important.

So, you don't think, then, the additional changes to the—. Because you're already doing some of the work now, as it stands, but with the additional changes, there won't be any difficulties for you—you will actually thrive on and look forward to addressing some of those issues as a consequence of the Bill.

Yes. It will depend what outcomes we are trying to measure and how we are held to account for those outcomes. So, we feel collectively that it's really important that quality is defined more explicitly—

Well, that is one of the questions I was going to ask—

Oh, sorry. [Laughter.] Sorry about that.

It's important, because you've just said how quality is defined—do you think the Bill should be identifying regulation, making it clear within the Bill that regulations will be set out to identify the criteria for how quality will be defined?

Yes.

Because I think that's missing from the Bill at this point in time.

Yes, I think that's important.

Can I go back to the public health agenda? I'd like to ask Ann, if that's okay—Jan's already told us clearly that she thinks there's something missing here and it was in your written evidence that you thought there was something missing. Do you agree with the fact that the Bill could be expanded to look at and reflect upon the public health agenda as well as what we traditionally consider the health agenda?

Yes, I think so. The health boards will be clear about their populational health improvement and protection side of the business in which they're engaged, but public health is almost a much more seamless service than that. We integrate well with Public Health Wales itself; it provides us with a really helpful service. But we know we're responsible for the population's health and the prevention of ill health within our own areas, which we take very seriously and you will see that in our integrated medium-term plans. But population health is a bit more than that and we look to Public Health Wales to provide us with that additional resource, which will help us to do our part of our job better. So, yes, I think it should be made explicit.

So, how would you—? Jan, perhaps—what type of amendment would you want to see put into the Bill to reflect that?

I want more reference to the public health functions of Public Health Wales and an explicit focus around everything we do in relation to prevention and health protection. One lever, for example, at the moment—we are really strengthening the national health protection service, both in relation to the internal environmental and health issues we face, but also more globally. So, I think that might be a useful lever to use, because we are really upping the investment and upping the expertise—world-based expertise on a national health protection service. So, I think that would be useful.

We had some health professionals in this morning who highlighted also the issue of quality—we talked about the definition of 'quality' and what criteria would be used—and who also highlighted the concerns that workforce and staffing issues should be reflected in the criteria. Do you agree with that?

Staffing is fundamental to the provision of quality service, and I think that when we were looking at this, we took it as read that the quality and scope of the care that can be provided by the workforce are fundamental to those quality outcomes, and if it requires being more explicit, then fine, but we would assume that a fundamental element of providing a quality service is that you have the right skills for the range of patients and clients that you are dealing with. That is part of it.

Can I add to that? Clearly, as Ann said, we'd like a very explicit definition on the face of the Bill concerning quality planning, quality improvement, quality control and assurance that are internationally recognised definitions. Part of our quality planning around setting standards, and particularly setting, for example, population health standards, as Ann has already referred to, those quality planning arrangements will include the workforce requirements to deliver against the standards. We can, of course, make it explicit, and we're very happy to do so, but it's an integral part of our planning and our commissioning of services from wherever. We would agree with our professional colleagues—it's really important, but it's worked into our quality planning ready for our commissioning and provision.

Is there an international definition of 'quality' for healthcare services? There may be no ISO or some sort of number, but is there one?

There are a number, but I think the one that the vast majority would recognise is that relating to the American institute's, which actually reflects many of the fields that we already have to comply with, like effectiveness, et cetera.

Okay, that's interesting. I suppose it's a question relating to—. This is going to hang over our heads, but I'm going to ask you about this: the question of regulatory issues for non-clinical managers. It's been discussed, it's been mentioned. Clearly, it has implications for you, very heavily. Should the Bill include that, or should we ensure the Bill doesn't introduce or just gets separated into a regulatory function and this requirement of the duties of quality and candour and the civic voice?

Might I take a couple of minutes to explain what we've tried to do, because this is something that has occupied much of our attention over very many years? Managers used to have a very, very clear structure of education and experience that they had to have before they were able to venture up to the top of the tree. We had our own professional qualifications that meant that it didn't matter what your other degrees and diplomas might be; you had to have the health service management qualifications before you started on the track of being a manager. You also had to have a particular range of experience, and we took that one step forward in the 1990s, to have the accreditation of managers and their re-accreditation. So, you had to do your continuous professional development, you had to be able to comply with the standards, and I issued a code of conduct for managers in the mid 2000s—

It was 2007.

—with which people had to comply. We spent a very long time, because Jan, at that time, was the head of the—. What was it called?

NLIAH.

NLIAH—trying to get the regulation of management on the statute book and a charter to be granted to the Institute of Healthcare Management. Jan will tell you how she spent two years on our behalf trying to do this.

Shall I carry on? So, obviously, when Ann was the director general, Ann was very, very strong on code of conduct, continuing professional development, standards of leadership and behaviour, and wanted to see how we could codify those in regulation. So, I spent many hours trying to see if it was possible to gain chartered status for the Institute of Healthcare Management. The obstacle we faced was that there is no exclusive body of knowledge for management. If you think of medicine or nursing, there's an exclusive degree that you need to attain before you can be admitted to a professional register. That is not the case for management.

We can track it back to 1985, when general management was introduced to health service management in Wales. Prior to that time, we had very clear training and education requirements through what was then the Institute of Health Service Administrators. You could not advance beyond a scale 4, which was really quite junior then, unless you had the institute qualification and you were on the institute's register. In 1985, when we brought in general management, we opened the gates to people coming in from different professions to general management, and we welcomed our colleagues coming in from professional disciplines different from management, but we then lost that exclusivity in terms of the IHSM qualification being the one, and we've never really got that back. Because if you think now, when we advertise for executives or chief executives, we ask for a postgraduate qualification, but there's no explicit or exclusive degree or postgraduate degree that we can ask for.

Therefore, when we made a business case to try and gain chartered status, we were turned down time and time again. After two years, I did say to Ann, 'I can't get anywhere with this. We are falling on the hurdle of not having an exclusive body of knowledge, we don't have an exclusive register to which we alone can aspire to enter.' But what Ann was very clear on was we would have a code of conduct, a requirement for CPD, and, for example, I was professionally accountable to Ann for eight years. Every year, for my annual appraisal, I had to turn up with my compendium of evidence, and I had to demonstrate to Ann how I had discharged the code, how I had delivered my leadership responsibilities against objectives that she set. Now, we have lost that in the NHS in Wales in the last eight or nine years, and we would be able to bring that in with appropriate investment, because we've actually lost the investment that we had in NLIAH for the leadership development of our senior leaders. We can bring it all back in; what we can't achieve because of this lack of exclusivity is to get ourselves an exclusive register.

You can't get chartered status.

Yes.

But would you therefore see—? The question is, as it was, is this Bill a means by which we can introduce such a requirement, whether it is chartered or not, but a requirement for that, or should that be separate? Would that be for the purpose of this Bill?

I think that it would be extremely useful to reinstate the codes of conduct and the training and development opportunities for managers from whichever discipline they come because it was a very, very good way of ensuring that the standards were maintained, that people were properly mentored and supported, and because being a middle manager is a very, very difficult job. You seem to be in the middle and being squashed a lot of the time, and it was really helpful in that there was this cloak of support and you had to do your CPD, and you had to display the skills that were required. Whether that needs a Bill or not, it would be for you to provide the advice, but I think it would be extraordinarily helpful for the management of the future to reinstate the types of systems that used to be extant.

That's interesting, thank you.

Lynne.

Thanks, Chair. That sounds like a really good system. I would just like to understand why it stopped, and you may not know that, Ann.

I don't.

Was it just because it was like a personal thing that you were committed to, so, when you left, it stopped? And also whether, as well as what you were doing, that was then being rolled out—so, were you doing that with all your managers in your organisation so that it was trickling down?

I think it was because the institute collapsed. The institute itself collapsed, and although it's been sort of reinstated in the past two to three years, it's more of a members organisation now, not a professionally driven organisation. And I think that, rather than me going, was the catalyst to all this ceasing. But it was valued. It was a protection for us as managers, too, and for the patients that we were serving. All the health boards are doing all sorts of things to institute much better and more comprehensive middle manager programmes and this, that and the other, but this was a driver against which everybody in Wales who was a manager was adjudged. And it also allowed you to do all sorts of things, like succession planning and moving people from one element of management to another so that they knew and you knew what they were best able to do and contribute.

You can carry on with your own questions now, Lynne. 

Okay, thank you. Moving on to the duty of candour provisions, then, what's your general view about those provisions in the Bill?

I think candour is absolutely essential to everything we do and therefore we welcome the duty of candour. I think it might be perceived, as it is drafted, to be slightly limited, because we need, both for quality and for the duty of candour, those requirements to apply to both the commissioning responsibilities that we have and to the people from whom we commission—so, the third sector, you name it. So, I think it needs to be slightly widened and the duty of candour is really important. 

I think that some of the issues are, 'Okay, so what happens if you breach the duty of candour?' and I think that needs to be worked out very, very carefully indeed. We do not want a punitive system, because we want to encourage people to be absolutely open and honest. I know that we have suggested that—. Whistleblowing has been quite difficult, really. There have been some very, very unfortunate experiences in terms of whistleblowing, certainly within England. But we need to create a culture and a set of values within every single health organisation in Wales where the duty of candour is of course exercised and that staff really do feel safe to admit to mistakes or to point out where things might be going wrong. As health board members, we cannot be everywhere. These health boards are very large, they're complex organisations, complex services. And we need to be absolutely assured that our staff are going to be the protectors of the care for people and therefore do feel free to express concerns or, if something's gone wrong, to tell us immediately, because we can't do anything about it unless we know. 

Okay, thank you. And in terms of the scope of the duty, the NHS Confederation has said that greater clarity is needed in terms of how this duty will apply in practice to social care, but the Minister has said, 'Well there's already a duty of candour in social care.' What are your thoughts on that and do you think that's sufficient, really, or would you like to see it extended to cover health and social care?

I think we would wish to see the conjoining of the duties as we're providing more, and are encouraged to provide more and more integrated services. Somebody trying to use two systems could be quite confusing and, especially, how do you explain that to the public? So, if they could be aligned, I think it would be important. 

Okay, thank you. Public Health Wales said in the consultation response that the duty appears to apply to organisations and not staff, and you've said it's not clear how staff would be protected if they raise concerns about the quality and safety of services. Is this a concern for the other witnesses, or is this just a Public Health Wales view?

Shall I just explain what it is? We'd very much like to see a blended approach. We really welcome the focus on organisations, because, as the leadership of the boards of organisations, it is our responsibility to make sure that our staff feel safe in speaking up, that they know that they can raise concerns in an open, transparent way, there'll be no comeback on them, and that the culture of the organisation is such that we will act on those concerns. So, we welcome that.

A number of our professional groups already have a professional duty of candour to their respective professional bodies, and we want to ensure that both work properly as this legislation goes through, because a professional duty of candour and open disclosure, they're slightly different things. But we want on the face of the Bill reference to both, so that staff are quite clear what protections they can expect, and organisations are quite clear what's expected, and particularly of us on boards of those organisations.  

Okay, and is that a view shared by—? 

Yes.

Yes.

I would add to that, yes, Chair, that when board secretaries discuss the Bill—and I'm representing not just Aneurin Bevan today, but the board secretaries network as well across NHS Wales—we need to ensure that we do promote a positive set of values and culture within our organisations, as Jan and Ann have mentioned. But we have to put in open and trusted mechanisms, and the staff need to be sure that those systems and mechanisms are trusted, and that they know that, if they do speak up—and they have a responsibility to speak up every day and to make their concerns known—if they do that, they will be supported and they will be enabled to effect the change, maybe, that they've identified that they think needs to be made in relation to a part of our system that is currently delivering services in a certain way. 

So, it's making sure, really, that we have trusted systems in place, and that we promote that understanding amongst the staff within our organisations to enable them, ultimately, to be able to speak up. As Ann has mentioned, whistleblowing has got somewhat of a negative connotation over the years, and individuals within organisations are fearful, I think, in relation to potential implications if they do speak up. So, therefore, the duty of candour and openness and further transparency in organisations, I think, that the Bill proposes should be welcomed, and that was the view of the board secretaries in terms of that area when we discussed it. 

Okay, thank you, and, Ann, you said you didn't want to see a punitive regime. So, I'm assuming that means that you wouldn't want to see sanctions, then, such as exist with the duty of candour in England, for non-compliance with the Bill. 

Their duty of candour almost seems to be a monetary-based system. You can have the best system architecture in the world, but, if the values within the organisation are not the right ones, then strengthening the architecture possibly will not solve a problem.

The question of sanctions is interesting. We already have an escalation process, which, in its own way, has sanctions built within it because there is a limitation of action. Basically, if everything else has not worked, then you have to think about, 'Well, what is the final step that needs to be taken to ensure the protection of the public?' So, I think that sanctions have to be used with great care but, at the end of the day, have to be used, because there must be a power to act. But, if we can get the duty of candour in, if we can get a quality system in that builds on what we have already and people are very clear, then that is what you hold them to account for, and you should be able to pick up the issues without having to go into punitive sanctions. 

Okay. So, if this Bill had been in place, how confident are you that we wouldn't have seen a Tawel Fan and a Cwm Taf maternity scandal? 

Well, as I said, the system architecture can be absolutely fantastic, but, if the culture is not as you would expect, if there is—and we don't know what the causes are of those two difficult situations, you've got to focus on the culture. You've got to focus on what are you hearing from the staff. Is it what you would expect to hear from staff? You've got to be open to criticism. So, it's almost an impossible question to answer. 

Shall I add to that? Because, as Ann has said, you can have the most immaculate system architecture, but you're always going to have an interplay between the architecture and human agency, the people who deliver the services, and those responsible for the organisation, the leadership, the governance of those services. And that's where the interplay comes in. And it's really important, those of us who are in the leadership position, as Ann said, that we set the right culture, we set the right tone, we set the standards expected of service, of behaviours, of attitudes. And some architecture is more helpful than other architecture, but, on its own, it won't work because of that interplay. And what we want to do, in terms of our contributions, is optimise the opportunities in this Bill to help us, as the leadership of organisations, help our staff to get things right. 

Okay. And, just finally from me, we know that there are barriers that prevent being open when they've made mistakes and things. So, you've got professional repercussions, legal liability, blame more generally. Is there anything else that you would like to see in this Bill that you think would break down some of those barriers?

In relation to issues around potential legal action and liability of individuals, I think that is again an area where members of staff in our organisations are fearful of what the implications might be if they do speak up. Again, organisationally, and across NHS Wales, we need to think about the mechanisms that we can have in place to support individuals that do speak up. Inevitably, when things go wrong, there are implications, and some of that may be recourse to legal matters in relation to prosecutions, et cetera. But I think some of the work that we've done over the last few years, particularly around redress, and how that's helped us in relation to organisational learning, and some of the ways in which colleagues feel enabled to report within the system, but also then share the learning of their experience when things have gone wrong, I think that's helped, culturally, organisations to be—or individuals within those organisations—more satisfied that they are now enabled to speak up. 

I think some of the issues that Jan and Ann have mentioned around governance architecture—governance arrangements are often seen by many as about compliance and control and limiting people being able to do things, rather than enabling them to do things. And I think what we need to do—and I think this Bill offers us a further framework to do that—is to look at our governance arrangements as enablers in relation to people feeling confident to be able to engage with that, and, for the organisations, and the NHS more generally, to deal with things when they do go wrong, but make sure that we've got a mechanism and support to help individuals through that, because it's not just an individual responsibility; much of this, I feel, should be an organisational responsibility too. And I think some of our systems previously have focused a lot on individual action, and not necessarily in relation to organisational responsibility and accountability for some of the areas. 

Can I just give you perhaps one example? Because one of the things I think we need to do—and maybe it's not for the face of the Bill, but perhaps for the guidance, or even more the wider work around 'A Healthier Wales'—is a new conversation with the people of Wales. And, if I give you an example, in Public Health Wales, we provide all the national screening programmes for the population. All our different programmes have various tests, none of which are a 100 per cent accurate. For example, you could get a false positive, you could get a false negative. And our professionals involved in delivering the programmes will produce aggregate data—it's aggregated up, never patient identifiable. But, in terms of the publishing of that data, there are concerns: (1) because it's a very complex issue. I am not a scientist, and I don't profess to understand the detail of the specificity and sensitivity of the tests, but, in terms of opening up this issue around barriers to a different engagement with the population, that's exactly the type of new engagement, new conversation, we need to have. And whether that's for the Bill, the guidance, or wider work—but a number of these issues do require that new conversation with the public.

Thank you.

Okay. David, you had a supplementary, before we move on.

It's partly been answered, but I want to go back to the sanctions question. In the situation where we are now—Ann mentioned that you don't believe, necessarily, that sanctions are required, but then you talked about, ultimately, there might be a need for something.

Yes.

Are we in a situation—? Because it is an enabling Bill, I think this does enable you to actually move forward as to how you can actually ensure quality improvement takes place. But, if there's a situation where a public body is not actually being seen to be delivering on the duty—whether it's the duty of quality, or the duty of candour—do you think, therefore, that should be part of the criteria when we talk about escalation measures to health boards and other organisations?

Yes.

Okay.

Okay. Moving on to the citizen voice body, and young Angela.

I just want to quote back a comment you made about having open and trusted mechanisms. So, I wondered if the witnesses would care to tell us what they think the new citizen voice body will be, and do you think it will be able to become that open and trusted mechanism that the citizen needs?

We have currently a very constructive and challenging relationship with our CHC. And I think that what would concern us about the citizen voice body is how is it going to connect with our population to enable us to triangulate with our quality data what the citizens think about our services, and how are they going to help us to engage more effectively, in terms of service change, service development, et cetera, because that is not at all clear. And I think that the loss of a local focus is of great concern. I know that—. I had to write a report in 2014, which is a long time ago, on consultation and general behaviour within the health service. And, when it came to the CHCs, I believed that they have to amplify the voice of the public—they couldn't be the voice, because they were not the public—and that the public needed to be better engaged in the continuing dialogue and become genuine partners in the design and delivery of care at a local level. And the need for the proxy voice, then, could become unnecessary. So, I'm a firm believer that it is for the health boards to really improve the way in which they can connect more effectively with their populations, how we really can use the expertise within local government and their systems to connect with the general public. And what I would wish to question is what's the citizen voice new organisation going to do, and be enabled to do, to ensure that I as a health board Chair can connect more effectively with the local population. And that, I think, is important.

I'm actually quite relieved to hear you say that, because, when reading the response from the NHS Confed, I sat there and thought, 'Well, yes, they would say that, wouldn't they?' Because it was a little bit—it's definitely been the most positive towards the new citizen's body of all of the consultation responses that we've seen to date. And we do worry about the silencing of that voice of challenge, and we definitely were perhaps concerned that there would be the—as somebody earlier on today said, 'Let's get rid of that turbulent priest'; it was that kind of analogy. How do you think, then—if we were to go down that route that the Minister has laid out in the Bill, how can we retain that focus on a local level, whilst cleaving to everything else that he says he wants to achieve with the citizen's voice?

Perhaps I could just pick up on that one. Because, of course, in principle, we've welcomed the national body and coming under its jurisdiction, because our board is very keen on external scrutiny. Of course, we need to understand what added value it can bring to us given we have very sophisticated local engagement arrangements for each of our different screening programmes, for example. So, one of the ways we'll be wanting to work with a body when it comes in is to map for that body all the different mechanisms we have now, and, of course, as a national body we have 51 different locations of service across Wales. For example, our Breast Test Wales services, the aortic aneurysm screening programmes—we all have our user groups, focus groups, at different parts of the country. So, we will need to understand where that can provide added value for us, and where we think it will be is lifting up the big issues, for example access, coverage, uptake, feedback across Wales on our screening programmes—that will blend and enhance the arrangements we have locally. But we are intent on not losing those because they inform where we can improve the service on the ground. Does that help?

Yes, and I can kind of see from your perspective, because the screen programmes are positive interventionist models. Therefore, I would suggest to you that perhaps the level of kickback or concern or distrust that might come from the public will be a lot less because it's an exceptionally positive thing, whether its bowel cancer screening or breast test screening or whatever. Whereas I think in the NHS as a whole, especially as the levels of cynicism and weariness and anger have risen, that that whole level of trust has gone. I think one of the things we're trying to understand is whether or not this new citizen voice body will be felt by the citizen that it belongs to them and whether it's just a dilution of their voice, despite the promises made in the parliamentary review about making sure that the patient really was at the heart of it all.

I think in terms of reflections, Chair, that we welcome, I think, the standardisation and consistency of approach that a national body may bring, but we recognise that if it's organised nationally it does have to operate regionally and locally in relation to its relationship with citizens, communities and the bodies within which it should be advising and supporting. But I think in relation to building trust, a new citizen voice body would have to be able to demonstrate its independence of the NHS system and of Welsh Government, I would suggest, in relation to the possibility of the new body reporting directly, say, to the National Assembly for Wales rather than to Welsh Government, in relation to demonstrating quite clearly its independence from Government and the way in which it could potentially genuinely represent the views of citizens and communities locally. Also, in terms of establishing it, we would need to think about, I think, the body seeking to be representative of the communities that its serving. Obviously, in the proposals thus far they talk about the structure of a new health body in relation to establishing a board and the leadership of that, but for me the important and key stages are how that body then will be engaging at a local community level and be able to work with the NHS organisations and communities as a bridge in relation to some of these major concerns and issues, and maybe some of the breakdown of trust that you talked of earlier.

I've got two questions—one is going to be harder to answer and politically probably more difficult to answer than the other—but the first is: could you perhaps just outline a couple of the issues that you see with the system as it is now and why, therefore, a national body would be a little bit better? Are there any key things that a national body might be able to achieve that having disparate CHCs can't? And the second is that, almost without exception, people have said it has to be independent of Government and it has to be independent of the NHS. So, if we are to persuade the Minister of our case, of that view, if we as a committee come to that view, what do you think the barrier is that we would need to overcome for him to actually say, 'Yes, I can see that it should be independent, like the children's commissioner is, or whoever else'? Because there obviously must be a reasoning, and I assume that this Bill was talked a lot about within the NHS before it came forward, and there's been lots of stakeholder engagement. So, there must be a reasoning behind why the Government feels it needs to be the one who appoints to this.

I think the issue is that this body must add value. It must really help the health service and its partners to reflect on the quality and outcome of care—for me, that's the whole point of this—and to gain the trust of the general public. And, as you say, they've been somewhat disillusioned from time to time about engagement, even though a huge amount of time and effort goes in from the health service to try and ensure that people are given the opportunity to comment and help design services, but, nevertheless, people are very suspicious. And sometimes people don't bother to turn up, because I think that they're a little jaundiced about what we might mean by engagement. And I think that if this body is to be really successful and add real value, both to them and to the health bodies, it has to be seen to be independent. It has to have a different function and a different reporting line so that people really do believe that it could act as an advocate for them, either individually or collectively. The importance of independence I think is what people talk about out in the streets, and they want something—if it's going to be created—that they believe belongs to them and will listen to them and have a line of accountability and responsibility, which is quite uncluttered.

I'd echo that and just add that, in terms of the added value we'd be looking for, there's the opportunity at the all-Wales level to really drive good practice, innovative practice, in meaningful ways of engaging individuals, families, communities across Wales to assist both the national bodies and health boards and social care—that's another thing that we think is very important. This body needs to reach across, because so many people receive integrated care across the health and social care arena. But for us, being part of Government doesn't bring that ability to stand outside and look at disruption, look at different ways of doing things, look at promoting innovation. That's why this body needs to be freed up to do all that, without the constraints of being part of or aligned to Government, from my perspective.

Moving on, Angela.

Yes, sorry—that's his gentle cue that I'm taking too long. What's your view on the proposed change in the inspection powers of the citizen's advice body? As in there are no longer visits to hospitals and all of that. Do you think that should be part of their function?

I think it's certainly useful, as part of their function, if they use those visits to listen to the individuals who are receiving care. I would have thought that that is part of their role. We have always found that the community health council visiting has been very useful, particularly when you look at the winter pressures that we've all gone through. The CHC in Gwent was extremely helpful in conducting interviews in accident and emergency to find out what people thought about waiting and their treatment and this and that, and that was a really helpful triangulation of data for us. We did not interfere with what they were doing. We knew why they were there, because the information that they were gathering was far more valuable to us than anything if we'd have just put our own people in there, because it really felt a little more independent and people spoke more freely. So, I think that it's important for them to be able to access our services and our patients and clients if they are to represent the voice of the people.

Do you think their inspection potential powers could also, or should also, include the social services element?

Yes, because a lot of our services now are becoming far more integrated.

One of the push-backs from the Minister is that you can't have people going into a social-services setting to do an inspection, which I find an interesting comment. Okay, vice-chairs—I just wondered if you could set out your view on the provisions within the Bill on vice-chairs to boards.

Shall I start, because I know you've—? Vice-chairs—. [Laughter.]

Yes, my trust chair colleagues have indicated to me that I really must get these points across. If we go back 10 years, when health boards were set up, vice-chairs of health boards were introduced for a particular purpose, so that the new health boards could not become acute and secondary care dominated. That's why the vice-chairs came in with a remit around primary, community and mental health. As trusts at that time weren't in that situation, there was no provision for the vice-chair role. Over the last 10 years, the vice-chair role has grown across both health boards and trusts. The vice-chair role of trusts now is much more akin to the chair role. Because if you think, at a trust level, a number of our independent members are bespoke—third sector, academia et cetera. Our vice-chairs carry a lot of our load as chair, in terms of chairing committees and deputising for chairs. For example, for the three of us, as we're national bodies with locations across Wales, chairs and vice-chairs will share visits—the ambassadorial role—and will also, as part of the peer group of vice-chairs, undertake their own dedicated work programme.

So, from a trust perspective now, the vice-chair role is as important as it is, and has developed, in a health board. It's no longer appropriate to try and tag that vice-chair role onto an existing independent member role. The role and responsibilities of the vice-chairs are wider than that, and they warrant their own role on the boards of the three trusts.

Okay. Right, time is charging on, but Jayne is the very queen of agility when it comes to asking lots of questions in a short space of time. Jayne.

Thank you—well, that's a challenge. First of all, Chair, I think I should declare that my mother is a member of a community health council in the Aneurin Bevan health board area. Just moving on to my questions, the White Paper included measures to promote stronger governance and leadership, with a proposal about the composition of NHS boards as well as statutory protection for the board secretary role. Those measures aren't included in the Bill. How do you feel about that?

Thanks. We, again, have discussed this in relation to the board secretaries' network, which I'm here to represent today. We have welcomed the engagement that we've had with Welsh Government colleagues through the development of the Green Paper and White Paper in relation to the proposals. We understand that there's further work being undertaken in relation to the composition of boards and other elements that were covered in the White Paper that didn't make it to this Bill. But in relation to the composition of boards for health boards themselves—Ann may wish to speak on this a bit more than me—they are quite large bodies in themselves, in relation to them being stakeholder boards. A large board isn't a challenge in itself, if it's well led and well managed, but in terms of the range of individuals and interests around the table, it can be a challenge in relation to such extensive composition of boards. Nonetheless, as I said, that can also work in your favour, because you also get a range of expertise, knowledge and perspectives, which will help.

We are skill-based boards, as well as independent members representing a range of interests. So, it's making sure that we balance those interests with the skills that we require as NHS organisations to deliver against our accountability and responsibilities, in terms of boards. So, I still think there's some further work to do in relation to the composition of boards and their shape moving forward.

In relation to the role of a board secretary and the proposal around statutory protection, we had quite a lot of conversations with Welsh Government colleagues and the Bill team around some of this, going forward. I must admit that the board secretaries' network wasn't that convinced, really, around the need for statutory protection for the role itself.

We felt that with the board secretary’s role having been identified specifically in 2009 at the time of NHS reorganisation, and it being quite clearly specified within the standing orders of our health boards for the first time, really, that it’s crucial that the role is impartial, that individuals in that role are able to speak up and are not compromised in relation to their role within organisations. There have been some challenges in that in relation to ensuring that board secretary roles don’t have operational responsibilities too. It’s quite difficult for board secretaries to comment on a service that they also have responsibility for. So, if we’re seeking impartial advice on governance and the functioning of the organisation to the chair of the board and the chief executive in their accountable officer role from a board secretary, the key areas we felt in discussion was that it needed to not be compromised by operational leadership activity.

We weren’t necessarily, as I said, convinced by it requiring statutory protection for the very reasons that we talked of earlier in relation to everyone’s responsibility to speak up in the NHS system, but that the board secretary had a key role in relation to advising the board on any issues in relation to governance and the governance and accountability arrangements within an organisation. There’s further work being done on that, again with Welsh Government colleagues, and we’re continuing in conversation, particularly around some of the areas regarding compromise positions regarding the portfolio of board secretaries. At the moment, I think those conversations are still in development. I believe that they will be able to be taken forward appropriately, but I don’t think necessarily at this stage in this Bill as outlined.

Okay. Were there any other proposals in the White Paper that you thought should have been included?

We think that it would have been helpful if the issue of HIW and the social care inspectorates reform and being brought together more would have been included. We think that that would have been a very helpful measure.

That's very helpful. That was going to be my next question. You've pre-empted me on that, so that was very good. You touched on it a bit earlier, around managing the imbalance between clinical and non-clinical managers. The BMA have called for additional provisions to be added to the Bill to address that regulatory imbalance, and they've noted that a manger who presides over a significant failure may go on to secure a new management position in a different part of the NHS. What are your thoughts on introducing a system of regulation for NHS managers? 

In theory, it's great. In practice, I don't think we will be able to do it. But I don’t think that that should stop us improving the system through which managers are evaluated in terms of their work and their contribution and their skills, and I would advocate that. As for managers moving from job to job, I think that we have to be very clear that there are fit-and-proper-person tests here, and that it serves nobody and no organisation well at all if there is a belief that you can just get yourself another job. That really is the last thing, I think, that the body of managers would wish to be assumed.

Thank you. The ombudsman is disappointed that Welsh Government has decided not to proceed with the proposals for an alignment of the NHS and social services complaints procedure in Wales to have required joint investigation of complaints. What are your thoughts on that?

Well, I think as we are increasing the number of integrated services that we have, it would be extremely helpful if there was a greater alignment and that it was quite clear to everybody who’s using these services how you did go through a complaints procedure, because it must be nothing but frustrating if you’re in an integrated care system to have to complain about one element to one set of bodies and another element to somebody else. I think a greater alignment would be really helpful.

And are there any other potential barriers to implementation that we haven't touched on today? Anything else we've missed?

I think the only thing we've identified that we haven't talked about that would need to change subsequent to legislation is the whole approach to performance management and performance management across the system, because the definition of quality—the approach to quality—will be much broader, all the different duties will be much broader, and the whole performance management regime will need to be redesigned to ensure that bodies are held to account against the new requirements.

Thank you. And finally, are there any unintended consequences from the Bill that you feel the committee should be mindful of? 

We've just talked about the regulation, and, for us, I think a fundamental principle should be the integration of the regulatory arrangements, given that all other legislation and policy frameworks are driving us towards greater integration in the interests of the people of Wales, because of the integrated nature of service provision. So, I think, if the HIW and CIW arrangements continue to go on a parallel track for another five years whilst everything else is driving us towards integration, that's an unintended consequence that we really need to think about.

Okay. Just one final point: we've had evidence from elsewhere that suggests that the duty of quality provisions should be amended, really, to specifically include workforce and staffing levels as an indicator of quality. What would you say about that?

Well, staffing levels, and the skills levels more than, actually, the staffing levels, are already integral to the way in which we evaluate the quality of our services. So, we would see that as continuing and being strengthened. 

Diolch, Gadeirydd. I suppose I'll ask the question first of all to Carol and then to the others, because the written submission from your chair of the health board clearly states that she doesn't believe the Bill is necessary, because, in her words,

'Numerous policy documents contain statements which are evidence of this strategic direction, and there is a strong argument to the effect that a duty to bring about improvements in the quality of health and care services already exists and that additional statutory duties of the kind stated in the Bill are unnecessary.'

Do you agree with that?

Well, thank you very much for asking me that question. I obviously knew that you would, because the chair submitted such a comprehensive view, drawing on her legal experience. I think the thrust of some of her response was that we already have a number of mechanisms in place and the focus on quality has absolutely been part of the NHS.

I was reflecting earlier on my time in the NHS, now moving into many decades, and the distance travelled over that time in terms of the focus on quality. I think the paper of Professor Harpwood goes on to really encourage a clarification and a definition of quality and being absolutely sure what we mean by that, and being aware of some of the unintended consequences of the definition, potentially, being too broad. But also, that this becomes a rhetoric rather than a very clear and focused Bill. So, I agree that the thrust of this Bill is to try and get us on the next stage of development around the focus on quality.

I think there's a really important element here for me, and I want to get it out straight away, which is about the place that we are in in Wales now, with the focus on integrated care and integrated services, and that's about health services and social care in particular, ensuring that quality goes across both of those elements. I'm sure we're going to come on to that later. So, from my own perspective, this is about getting on to the next step of the journey, but it's about getting the Bill and the definition and the measurement, outcomes, judgements, sanctions, and all of that absolutely right, because, potentially, it could be a very wide Bill.

Okay. I'll come on to the definition and I'll come on to the relationship with social care in a second. So, I'll ask Alex whether she still sees the need for such a Bill.

I think we understand Professor Harpwood's points around the other measures that are in place to measure specific aspects of quality, but this is about that broader perspective on quality, but also that focus on improvement so you can monitor quality and keep quality at a good level. But, actually, this is about what we are doing to take quality forward and improve outcomes for people and I think that's the difference. But I think that's also probably the challenge in looking at what measures would be most appropriate for this without being, again, too specific and too narrow and getting away from the point of this, which is about improving outcomes for people.

Because, if I'm right, the considerations to date have been very much focused on quality assurance and this is about quality improvement, and there is an understanding of the difference in the boards, I'm hoping. I've left Mandy quiet, at the moment.

That's right. I think what I would say is that, certainly, as a board and as a representative of the directors of nursing, we do welcome this Bill because it will bring quality onto an equitable footing with the other measures with which boards are focused in terms of performance and financial aspects. I think, as you've alluded to, the detail is going to be around the definitions, but importantly, having standardisation across organisations, which the Bill has the potential to bring, is going to be extremely helpful not just for us as boards and board members, but actually for the public as well.

Can I ask, then, should the Bill, on the face of it, have the definitions, or should it have regulation-making powers given to the Minister to give those definitions and the criteria with which you would be assessed on the process?

I think there is an opportunity to be really clear about what quality means. There's a sense, also, that, with the health and care standards that have been around for a number of years now, we can start to move our definition of quality and our measurement system for quality to a new level. I think it would be quite helpful to put that very clearly stated on the face of the Bill. There is a balance in here because, over time, of the need to refresh in terms of our learning.

If I can just pick up one key element about where the quality is focused in the Bill at the moment, it is on the provision of services. I have a strong view that, particularly in the Welsh system, where we've got integrated health boards and we're moving much more to integrated health and social care partnerships, the duty of quality also needs to be focused on our planning and commissioning of services, not just our direct provision. So, we do just need to make sure that the scope of that is right as well as the definition, and there are lots of examples of definitions; there's work being done in each of the home countries and internationally on that. But it provides an opportunity to refresh and reaffirm where it is that we want to go in Wales. I don't know if Mandy wants to add.

Yes, I just want to add that whilst I think that it's really important that we have clarity regarding the definitions of quality, because of the changing and evolving landscape within which we're operating, and the greater move, as Carol has said, towards integration, there's a question, really, about whether it's best placed on the face of the Bill, or whether, actually, it rests within the guidance and the regulation that will follow. Because I think that we've got to make sure that whatever we do, we futureproof the Bill and everything that supports its implementation, going forward. And as Carol and Alex have alluded to, the changing nature, the relationship with social care, is actually going to help us shape that quality framework within which we're going to operate, and particularly the definitions—I think that they will continue to evolve. I don't know whether you want me to pick up on the definitions and some of the opportunities that we have there.

Well, yes, I suppose. That's what we're trying to explore is how you see the Bill could be improved.

I think, certainly, from a directors of nursing perspective, which is why I'm here today, we feel that there is a real opportunity for us, as professional leaders within organisations, to be able to work, shape and influence the definitions that sit within the legislation. The examples that we're particularly focused around are those that have been provided through the Institute of Medicine from the US—the STEEEP definition: safe, timely, effective, efficient, equitable and patient centred—because we believe that those would be the key definitions that would enable us to drive and improve quality, regardless of the setting in which care is provided for our patients and our population.

Okay. Can I go back to the question of integration of health and social care? Just focusing on health, the patient's journey starts from the time they enter the health system and, then, when they leave the health system, at some time in that journey, they've also been involved with the social care system. Have we missed a trick in not ensuring that we cover the whole journey, and, at the moment, we're just covering part of that journey?

I think we should really encourage this opportunity to make sure it fully joins up. We're in danger, and you may well ask us about inspectorates and regulatory bodies later—

Somebody will. Somebody will. [Laughter.]

Great. We're really in danger of pushing very hard on the ground to make sure things are joined up. We just need to make sure that the frameworks that surround us are also joined up, so if there's an opportunity to make sure there's full alignment, then this would seem to be that. 

Should this be a part of the definition of quality, as well, or an element of the duty of quality, so should we make sure that that includes social care?

I know that in other pieces of legislation and regulations in relation to social care, there's already an emphasis in there, but we're trying to move much more towards a single system for the citizen to manoeuvre. So, it would be common sense, I think, to me to ensure that we can align them so it's not one system in the health service and one system in social care.

Would this help HEIW?

Yes, I think one of the key things that is coming out of our work on the workforce strategy, which we're doing jointly with Social Care Wales, is the fact that there are already differences that make it difficult for staff to work together, so the more that we can make things consistent across the sector, I think the easier it is for us to really maximise the impact of our staff and to help them make sure that they're delivering the right quality for the people that they're providing care to.

The Chair wanted to come in.

Angela has a supplementary on a point here.

Yes. Sorry, I just wanted to absolutely make sure I had heard you right, Mandy, as representing the directors of nursing. Can I just double-check: did you say that you agree that embedding the workforce would be an essential part of the quality standard?

I didn't.

You didn't, no.

I didn't. [Laughter.]

So, would you agree with the Royal College of Nursing that it should be part—would the directors of nursing agree with the fact that embedding the workforce would be an essential part of the performance and duty in the duty of quality, and making sure that the environment is the right environment for people to be able to carry out their tasks?

I think if we start from the premise that we can only deliver quality if we have a workforce that is fit, capable and competent to deliver the care that is required, that it understands the responsibilities, it understands the framework—. Plus, as well, there are a significant number of health and social care professionals who are actually registered with bodies that already impose a duty of quality—it may be expressed slightly differently in the various codes—but also of candour as well, which I know we will come on to. So, for me, there is something about how we make sure that we reflect the needs and the vital role of our workforce, regardless of whether they're clinically registered, or they are non-clinical, whatever member of staff they are, and that they understand their roles. That's where, certainly, Alex and the team in HEIW have a key role to play in helping our staff take that forward.

Can I respond to that? I think that, as Mandy said, safe staffing is clearly a hugely important part of how we deliver quality and certainly how we improve our services. I think what, again, we're learning from the workforce strategy is, actually, we are going to see some huge changes in our workforce over the next 10 years, because (a) we know at the moment we haven't got a sustainable system, (b) technology and digital opportunities are increasing at an unprecedented rate and will continue to do so, and so, actually, the workforce models that we've got will change quite significantly over that period. So, it's a way of making sure that we capture the importance of having safe staffing arrangements, but recognise, actually, that's got to be quite flexible to withstand the different challenges that we're going to have over the next 10 years, so that there is scope for us to develop and respond to that, not be straitjacketed by perhaps something that is right at the current time but, actually, is very, very quickly out of date. Certainly, that multiprofessional aspect of most services today in order to deliver prudent healthcare principles and to meet the needs around the person really requires us to be much more flexible in how we look at competencies, not roles, not individual professional groups. So, I think something that strengthens the importance of it but doesn't straitjacket us by being too specific about it is something that would help shift the agenda forward.

Okay. David might want some clarification on that point.

Angela asked my question for me, but, there's a point there, because Mandy talked about skills and fits, and Alex talked about safe staffing, and there is a difference, because it's not just about having a qualified workforce who understand that their own responsibilities and duties for quality in their own professions, but it's also having the right levels of workforce. So, in a sense, should we in the definition of quality also be reflecting upon the levels of staffing within the services to ensure you have safe care and the quality of service is provided? Because as was highlighted this morning by some of the professions, if you don't have sufficient levels of staff, it impacts upon the quality of service you give. So, should we expand that a bit more?

I think there's a risk of becoming really quite narrow if we were to get to the level of identifying a numbers issue—just a reflection of other parts of legislation that help us to do that to some extent. There are so many factors that will influence quality. I'm sure we'll come on to the issue of culture as well, the professional standards of behaviour, et cetera. So, we must be careful not to isolate it down to the things that are always the easiest to count—numbers, and—

There's a difference between numbers and the concept of appropriate levels, and therefore the concept of quality in the context of sufficient levels to ensure you can deliver that shouldn't be a requirement. In a sense, for example, as the RCN told us in their paper, they were deeply concerned over the lack of workforce strategy discussions in papers, or minutes, they were getting—those discussions may have taken place as consequence of some other topic, for example, and it might not have been recorded. But, as to the fact that you don't then have it, it could be argued that you're not actually looking at the workforce strategies and levels not by numbers, but to ensure that, in the future, you have the staff available to deliver the quality of care you want.

If I could just connect the workforce numbers, types, et cetera to the point I made earlier about when we're planning and commissioning services, having due regard to the workforce numbers, safety, availability, skill set, I think that is key. I think what I'm trying to get across is there are a range of indicators and issues that relate to workforce, so for us just to be careful it's not seen just a numbers game, really, which I'm sure you're—

I don't think it can be a numbers game; it's a question of: are you taking this into consideration?

Yes.

I think that's part of the rationale behind the development of the workforce strategy that we're currently producing, and we're coming back to the committee in October to talk to you about the progress that we've made on that, because it is seen to be such a critical issue in terms of delivering improving services for people. What that is telling us, however, is that actually things are changing every day in terms of workforce, and what we need to do is to keep agile to that. I think, as a result of the workforce strategy, we will be recommending, for example, some key areas where we need to develop more robust workforce plans at a national level to support the local work that health boards are doing, and we will need to do some work to improve workforce intelligence and data because we haven't got the right workforce intelligence and data to make sure that we've got a sustainable system for the future, and we will need to develop capacity to incorporate workforce planning more effectively in how we're planning service improvements. So, I think we're already on that journey in terms of the workforce strategy, and we can talk about that in a bit more detail later on. So, in principle I absolutely agree it's definitely part of how we see quality. Actually, we've already got a process to take forward a number of the actions that will help us deliver on that agenda.

Just a final question: Public Health Wales were concerned that perhaps elements of the Bill didn’t highlight population health as an issue. Do you have any similar views and concerns that this Bill could be strengthened with more population reflection?

Yes, indeed—an idea which also reflects the comments around planning and commissioning when we think about what the health boards in particular are responsible for. We're there to improve the health and well-being of the population, so the quality duty really should cover all of our key purposes.

Okay, moving on to duty of candour, this is Lynne now.

Thank you, Chair. Can I just ask what your general views are on the duty of candour provisions in the Bill?

I think Mandy was going to start us off on this.

I think so. I welcome the duty of candour. Having worked not that far away, two years ago, now, in England, where I was the responsible person in relation to the duty of candour, for me, there are real benefits. I think that, for me, the duty of candour is absolutely building on the work that's gone before around being open, the Putting Things Right regulations. I think how we actually go about implementing it and, again, defining it, looking particularly around the triggers for when the duty is required to be enacted, that is going to be critical. And, again, whether that's more appropriately placed in the guidance that support the regulations around candour is probably where I would see it fitting, because I think, as professionals and those on the board who will be responsible for reporting against the duty of candour, we will want to support and influence what actually is appropriate so that we can effectively be measured on it. 

Okay. Thank you. We've heard from the Welsh NHS Confederation that they feel that greater clarity is needed in terms of how the duty will apply to social care. The Minister said there's already a duty of candour for social care, so what's your view? Do you think that the provisions in this Bill should be extended to cover social care as well?

If I may, I think there's going to be a theme to my responses, I'm sorry. I think we need to use this opportunity to be really clear across the board, particularly as we're moving through much more integration and mobility of the workforce, just to simplify what the duties are would be very helpful indeed. And just on that, we recognise that many of our clinical professionals are already regulated and therefore already have duty of candour as part of their professional regulation. And it would be quite important to see whether there could be some regulatory alignment around that. 

Okay. Public Health Wales told us that the duty appears to apply to organisations and not staff, so they feel it's not clear how staff would be protected if they raised concerns about the quality and safety of services. Is that a concern that you share?

I think what's important around the duty of candour is making sure that we get the balance right, because, actually, if this is about driving a culture of learning, of improvement, of the openness and honesty, then we need to make sure that organisations understand the framework within which they're operating and adequately prepare and support staff when they feel that either they need to raise concerns about the service within which they're working, or when patients and members of the public raise concerns about the standards that we're providing for them. So, I think that the board has the overarching responsibility in terms of the duty and, as Carol has quite rightly pointed out, many professionals already operate under a framework within their code of practice around candour, so they will be very familiar with that. 

Okay.

Just to add, I think the thrust of Public Health Wales's views are absolutely right. We've gone so far, we've got a raising concerns policy that enables a very clear framework to be set out for people raising those concerns, but putting the duty on takes that one step further. And I think that needs some careful handling in terms of ensuring that environment is right and people will feel that it can be a trusted system, which is what we would aspire to as organisations. 

Okay.

Okay. Alex.

I think, linked to that, it's really important that we don't underestimate the kind of training and the level of training that is going to be needed to support the implementation of that duty, because although it is building on what individuals might be used to in terms of their professional requirements and what you would hope is good practice, I think we have to avoid a situation where we have that sort of tick-box approach to training. We have to use it as an opportunity to really shift behaviour. So, perhaps, e-modules are useful for some things, but I think this is definitely the kind of thing where we need those conversations with people to make sure that we are shifting behaviour and not just giving people an extra bit of knowledge, because that's really what's going to be fundamental to making this a reality: not a bit of legislation or an e-module piece of training but that it's actually the culture that somebody's working within and that opportunity to really properly learn and to properly develop how people are applying their practice. 

Okay. Thank you. In England, they have sanctions for non-compliance in the Bill; is that something that you think we should have in Wales?

My personal view, and I'm sure the view of my colleagues, is that we've got to be extremely careful. We already have a framework through the performance management framework around escalation for organisations that are not performing at the level within the standards with which they're expected to perform. I think whilst the concept of sanctions is an important one for us to be cognisant of, what we've got to remember—and I go back to my point—is that this about driving change in culture, in attitudes, in behaviours, and there's a fine balance to be had. But I think, from an organisational perspective, if we're utilising the existing arrangements of escalation, then that would appear adequate, but I'm sure colleagues may have an alternative view.

No, I largely agree with that. I think we've got the escalation arrangements, intervention arrangements clearly laid out. In fact, I had my recent letter this morning. So, that's part of the routine. I think there's just something to offer on this, which is really taking the view about organisational health and the level of openness, honesty and transparency—i.e. duty of candour—being assessed as part of, 'What's the organisation's health?' How does it respond when there is an issue? Is it open, is it willing to learn? What do staff feel about their own sense of trust and confidence in being able to raise issues? I think there is already a mechanism there. It would be about ensuring this is very clearly a part of that.

The previous panel told us that although they thought sanctions should be used with extreme caution, they did have to be in there somewhere. Is that your view? Yes. Okay.

So, if this Bill had been in force, do you think that we would have had a Tawel Fan or a Cwm Taf maternity scandal?

If I start with that one, I think that my honest view is that, on the Cwm Taf position, I think it's too early to say. My own level of knowledge about what happened and what the systemic lessons are to be learned, we're still awaiting some of the further findings of the Wales Audit Office and Healthcare Inspectorate Wales work, and the oversight panel that's in there. I think it's a very reasonable question and a reasonable test as this Bill proceeds, as we learn more about that, to do that check. But if we look at the core components of the Bill—the focus on duty, the focus on that being part of a performance escalation and sanction regime, the focus on candour—those are the core components that you would absolutely expect to be able to drive improvements. So, without having the detail, knowledge and understanding, they do seem very reasonable things to be able to help us to push forward on.

Okay. And just finally from me then, the Government's acknowledged that there are barriers to disclosure in the NHS, such as professional repercussions, legal liability, et cetera, but it could be argued that the Bill does not deal with these issues. What do you think we should be recommending to tackle those barriers, and do you think that the Bill needs to go further in that regard?

If I start in the context of going back to culture, because we've got to make sure that we have got, and invest in, the right tools and resources to enable our staff to feel confident. Nobody goes to work to do a bad job. We have a responsibility as organisations to make sure they've got all the tools, and part of that is about the skills, the knowledge, the confidence and support to actually be open and honest.

I don't know whether Alex wants to pick up.

I think this goes back to making sure we have a really effective training programme around what this means for individuals, where we can have those discussions with staff about concerns they may have about issues around their own professional requirements and obligations because, quite often, there isn't a barrier, but there is a perceived barrier. That's what I mean, I suppose, about not having more of a tick-box approach to the training. It's actually having proper fundamental training that does enable people to learn and understand that, actually, this is very different, and to make sure that we're clear on what we're expecting from people.

Just a quick one on that point. Alex, you will know because of 'Trusted to Care' and the Andrews report. Do you think this Bill will introduce that power, keep it focused and force that culture, because I'm not convinced the culture is changing as quickly as we want to see it change at this point?

I think, with any of these issues, whether you take the two examples that we've had today or my experience, it's never just one thing. It's usually that Swiss-cheese effect, where lots of different things line up together and develop into that situation which becomes that crisis. So, it is difficult to say that individual things will help. I think, clearly, this strengthens the focus on quality improvement, the duty of candour. So, if there was any confusion about that fact that we want people to be reporting things, and making sure that we are acknowledging where harm has occurred, this enables us to be absolutely crystal clear about that. But this is not going to work without that parallel development of culture, which comes from more focus on leadership development, and that is key. And that's close to my heart, because, as an organisation, we've been set up to reinvigorate that for NHS Wales, and working jointly with social care again, which is important. But we've got a huge piece of work to be doing, and we are being encouraged by the director general to accelerate that. How do we reinstate an awful lot of the programmes that we used to have, that we used to benefit from in the NHS, around developing managers and leaders at all levels and across all professional groups, and using a consistent approach?

So, there's a lot of work going on locally. What we don't have at the moment is that real consistency of an all-Wales approach to what we're expecting from people, and whether we're quality assuring those programmes, and whether we're really following up on people when they've come through those programmes, in terms of alumni, and making sure that people have got CPD et cetera. So, for me, that's probably the bit that we need to do in parallel with the Bill. They are connected, and I think, together, could be a really, really effective combination. So, one of the things that we'll be talking to you about, again, in the context of the workforce strategy, is how we want to take that work forward.

Okay. Turning now to the citizen voice body. Angela. 

I was just wondering if you thought that the new citizen voice body proposal in the Bill will increase the public's trust in local health boards. 

Oh. It's very—

'Yes' or 'no' is fine. [Laughter.]

It's a very big question, isn't it, because does a body, in and of itself, do that? It's about how it's established, and I know that there are some very strong views about the level of independence, or even perceived independence around such a body. You might want to ask me about that. 

No, that's actually what I said. As it's put in the current Bill, do you think that's going to increase the public's trust?

My own sense is that there's a perception that if the body is not independent, there may be a missed opportunity about really creating a high level of trust and confidence. It may be that such a body, if it was in Welsh Government, would not be fettered. I'll just draw on my own experience in a moment, if I may, as the current host of the community health councils in Powys, but it may be that there is no fettering of the role and function, but the perceived connection may, in fact, contribute to that sense of whether there's enough trust and confidence in the organisation.

So, you may be aware that Powys Teaching Health Board currently hosts the board of community health councils, and it's been an awkward relationship, in that, clearly, the role of the board of community health councils is to challenge organisations, and my role has also been to ensure that the board of community health councils is run appropriately given that it's using public money. So, we've had to build some walls between some of those arrangements, and it's really important that anything moving forward, the opportunity for a new body, is seen to be independent. And I know that that's what many members, in relation to the existing community health councils, are calling for. So, I think it may not be—