Cynulliad Cenedlaethol Cymru

Thank you very much, Chair, and thank you for the opportunity of making a brief opening statement. I thought it right, actually, to set out why the community health council should be supportive of the notion of establishing a new people's voice body when, in effect, it will mean that the community health council movement, which—we're very proud and we think we're leaving quite a legacy, should the new body be established. But I think it's important to understand that our pride in the organisation, and what we think of the achievements of the organisation, is about meeting the needs of individuals and communities, but not being helped by, quite frankly, what are very messy governance arrangements behind the scenes. So, we can see that if a new, stronger people's voice body could do the job better than community health councils, then we'd be in favour of it; it's about meeting the needs of communities rather than ourselves. But there is a 'but' in there, and I know this won't come as a surprise to you, because of the written evidence we've submitted, but we think it's important that we clearly establish that we believe there are ways in which the Bill, as currently drafted, needs to be strengthened. Otherwise, there's a danger that it will not be a stronger, independent body. And if I could, Chair, just briefly go through these areas. I'm sure they'll come out through questioning.

They'll come out, yes.

Firstly, there's the issue of right of access where—. You'll be aware the community health councils currently have a right of access, and it would seem somewhat odd to us that the new organisation wouldn't have the same right of access—not into areas that you would regard as individual homes, but the right of access into the properties where they are so we could hear from them about their experiences, so we could learn from them and understand how we can better meet their needs. We don't think that's an unreasonable expectation.

And then directly related to that is the issue of the right of response. If individuals are going to share their experiences with us, it seems reasonable that, as a result of that information, they should have an understanding of what an organisation does as a result of that. So, the providers—they may agree with the issues raised or they may not agree. If they don't agree, we should understand why; if they do agree, we should understand what they intend to do and the timescales attached to that. There's a thread running through all of these, Chair.

And then almost directly related to that is the right of co-operation, because, if there's going to be a proper relationship between the new organisation and the providers of social and health care, then the right of co-operation should be part of that arrangement, so that we're dealing with parity of esteem rather than almost a master and slave situation.

The Bill does rightly set out that the new organisation should operate nationally, regionally and locally. And this may sound pedantic, but please bear with me a moment. We think that should be expressed the other way around, and should operate locally, regionally and nationally, because, if the organisation doesn't have an effective local identity, why would people want to be volunteer members, why would they use the organisation to help them through problems, and, also, how would the organisation have a proper understanding of local needs to establish local priorities, which would then to inform regional and national priorities?

And, again, directly attached to that is the issue of resourcing. It would be a shame if the new organisation made those local, regional and national choices based on the available resources, not based on the needs of local communities. 

And then, lastly, the Bill is silent about how disagreements would be resolved. So, we think it would be appropriate to have some form of independent mechanism in the event of disagreement, and we're not necessarily referring here to a referral to the Minister, as community health councils currently have if there's a disagreement over service change, just some form of mechanism that could act to resolve disagreement. So, hope that was brief, Chair. Thank you. 

So, the thing for us that we would want to see moved into the new organisation is that principle of somebody acting, on a daily basis, to represent the interests of patients and the public in local communities. CHCs currently are involved, and volunteer members are involved, on a daily basis, at a variety of different levels, whether that be visiting healthcare premises to hear from people about their experiences of those services, engaging with people more widely in the local community, whether that be in the supermarket or by meeting with groups of people to find out what they think about their services. It's taking that information and using that to feed into service providers, and to challenge constructively whether or not their plans and their performance are responding to those things that are important to people.

And the other area, obviously, is driving the health boards to focus on developing and changing the services that the public think need to be developed and changed, and not just that health services decide they need to do to meet their own requirements. All of those things that volunteer members do for nothing, every day, is something that we think needs to be important and key principles for a new organisation. Geoff, do you want to give some examples?

Yes, certainly. We spend a lot of time visiting health service premises, and we talk to people about the issues that they're concerned about. And sometimes they appear to be minor issues, but, if you're in hospital for a long time, something like being able to open a window to have proper ventilation, to have access to cold drinks, is a really big issue. And we found this over this summer at Wrexham Maelor; for various estates reasons, a lot of the windows had been sealed. And, as a result of our visit, within a few hours, ventilation had been restored to those wards. They feel like minor issues. You will know that we've dealt with much bigger issues with a health board that's been in special measures for nearly five years now. 

Are you talking about Tawel Fan?

Tawel Fan and many others. But this right of entry allows us to talk to people about what it's like to be in hospital, what their experience is, and health service professionals don't necessarily understand those personal experiences. We've had health service professionals who've ended up in hospital who have come to us to say, 'I never knew it was like that.'

Can that be retained within the new body?

If the new body has a right of entry, I think it certainly can. I think it's absolutely essential that they have that and that it's not in the gift of someone. The new body should be able to go and speak to patients or clients at the point of service delivery, because you'll learn a lot of things there. And sometimes people don't want to speak to us there, but they make arrangements to speak to us afterwards.

Can I just—? I'm sure my colleagues will be chomping at the bit to come in about this as well. I think Geoff touched on it a little bit. It's about understanding the experience that somebody is going through at that point in time. So, if a concern is raised, currently, for instance, community health councils would organise, on occasion, a same-day or a following-day visit and is able to speak to someone about the issue that's being raised. And it's unfettered access to an individual who wants to share their views. Now, if the new organisation is in a situation where they would have to have permission to enter and that permission took time, then you're actually witnessing and receiving an account from someone that's not necessarily coterminous with the issue that was initially raised. We think that ability to have unfettered access to an experience as it's happening is critical to having a proper understanding to then challenge the provider.

I think that's right. It's useful to be able to see the dynamic of care—how staff interact with patients. In certain settings, people are there against their will and they're there for a very long time. And, really, you can't substitute having a presence in those settings and seeing what the interactions look like.

I think one of the really important things from my point of view is that the aspiration for the new body is that it strengthens the citizen's voice in their health and care services. It's fundamentally going to be a body that engages to hear from people and then represents their interests. In order to do that, it will need to engage in a variety of different ways. We very much like the proposal and the understanding in the Government's proposals that the new body will need access to the right kind of IT-type support to help it reach and engage more broadly, but we know that, for some of the most vulnerable people, who may be living in care homes, who may be there for a long time, they are often less likely to be more proactive about sharing their views in those online types of ways. For us, it's really important that we give people who are in the most vulnerable circumstances their opportunity and their chance to give their views and experiences, not only of the care that they're receiving now but what they think about how services should be delivered in the future as well. And there isn't any other way in which that new body will be able to do that.

I've been involved in a number of major investigations around patient care. When I was chief officer at Chester community health council, we were visiting long-stay psychiatric wards—at that time, people with dementia were kept in wards. They didn't go out of the NHS—they stayed within the NHS. We discovered some really dreadful issues, and the only reason we discovered them was that we were there at mealtime. In every other ward, patients were sat in groups and they were served by the staff and the domestic staff—they had a choice of menu. We noticed in this ward that people stood in a line with their plates in front of them. There was no choice, even though choice was provided, and they were being given the meal that was easiest to hand out. From there, that made that a site of interest for us, and we discovered a lot more concerning issues. But that was only because we were able to be there and talk to patients and see how they interacted.

Okay. Siân, moving on.

Chair, if I may come back about that one—again, I touched on it briefly in the introduction—we would recognise that if we were saying that the new organisation should have the right of access to, effectively, where people live, or what they would regard as their home, their personal dwelling space, we would understand entirely that concern, but that's not what we're pressing for here.

We should say as well that, within healthcare settings, most health boards actually welcome the idea of community health councils making unannounced visits—it's not an issue for them at all. But we do recognise that when we come to social care settings—. Of course, as time progresses and as health and social care become more intertwined, we recognise that there's an issue, but I just want to stress the point that what we're looking to do is simply to be able to access premises to be able to engage with individuals who are, effectively, receiving a service there—they're living their lives there. Now, if that individual wants to invite a member of the new body into their personal dwelling space, that's a different issue—that's a matter for them, as an individual—but that right should not be in the hands of the provider of the facility. Does that make sense?

Indeed, yes.

Well, we wouldn't be seeking to be—sorry, I'm sure my colleagues will want to come in as well. We wouldn't be seeking to have that sort of confidential conversation. It's about beginning the engagement and about making a connection. That's why I said that if somebody then wants to invite us into their personal area, that's a matter for them to do it.

Just to be clear, CHCs do this all of the time currently. They exercise judgment about what's appropriate in sets of circumstances—they take advice. So, it's really, really important that this is not about a new body forcing its way and then demanding to hear people's views, it's about providing people—

Mansell, have you got a view? I've known you for many years, and like me, you're defined by your shyness, but don't let it hold you back.

It's just that I think we need it in the armoury of the types of things that we do. We don't just talk to the patients. Very often, the relatives of the patients are there, and they particularly want to speak to us about particular issues, because perhaps the patient feels a little bit unwilling to say too much about what's going on.

But I think that where we've seen a difference, just to give some examples again, is that you go from the very small, which is maybe insignificant to a lot of the public but extremely significant to the patient—things like, 'We can't get a drink after 5 o'clock—a hot drink', and that sort of thing, and bigger ones like discharge: the fact that doctors only go round—in community hospitals, sometimes the doctors are not there for a long time, so we've suggested perhaps you should use the Skype. And all this has been taken on board. And big issues are talked about in our service planning as well. And sometimes we pick things up from other areas, such as engagement at Pembrokeshire show—that sort of thing. And we look at that, and we will go in and have a look, just to see what it's like in real time, rather than going in a lot, lot later, and not—. Having said that, and I've been on both sides of the fence, so to speak, and the fact is that I've found that bringing the community health council on to project boards was very powerful indeed, because the lay members actually asked the simple questions that perhaps clinicians and other bodies may not think about. And there are numerous examples of that, where things have changed because of the membership.

So, you'd see your work as preventative—you know, getting in there at an early stage. And is this also—when we're talking about inspectors going in, and inspections, but would your work entail the problems becoming more apparent before an inspection, or what is your relationship with the inspections?

So, what we carry out is very different to what the inspectorates do. There is some read-across, but it's very different. So, what we will do, and what CHCs currently do, we will go in and we'll ask people to tell us about their experiences on the things that matter to them. We don't have a checklist—we're not checking against standards that have been set by health and care organisations; we are just focusing on the things that matter most to people. Sometimes, that complements what inspectors do. We use that information, then, to feed back to health boards, to ask for improvements where needed. Sometimes, people will share with us concerns that appear to us to be of a clinical nature, and which we can't exercise any judgment on. In those circumstances, what we will do is share that information with Healthcare Inspectorate Wales, so that they can determine whether they might need to take action, in response to that kind of information.

And there's a flow of information backwards and forwards, from HIW and CHCs. Every CHC has a relationship manager within HIW, and I think that works very well. We often get requests—'What do we know about?', or HIW has had a concern from a member of the public, and maybe we've just visited, maybe we're just going to visit, and we'd share that information. It's different and it's complementary.

Thank you, Chair. And at this point, I should say that my mother is a member of a community health council in Aneurin Bevan University Health Board. Your evidence stated that any remaining concerns about the right of access could be addressed through appropriate safeguards or limits on the power. Do you have any suggestions on what safeguards or limits on power could be and could look like?

What we were thinking of is framing—in a similar way to the arrangements in England—the circumstances in which the new body might need to use its right of access for unannounced visiting, as opposed to announced visiting. So, it's setting the kinds of circumstances, and making sure that the new body thinks about what it needs to do in response to concerns it's received or outcomes it wants to achieve. That's what CHCs currently do now: they think about the issues that they're facing, and how that CHC would be best placed to find out information. Sometimes, it's through unannounced visiting—so, sometimes, you might want to hear people's experiences over a period of time, you might want to put a survey in place and visit, so you would announce it. Other times, you've had three calls in the space of three weeks, and you think, 'Do you know what? We need to go and move quite quickly on that one.' And in those kinds of circumstances, where you have some real concerns, that's when you'd need to act quickly, and maybe do an unannounced visit.

And I think the difference with the new body would be that it includes social care settings. But that's the case currently for Healthwatch. I set up Healthwatch in Cheshire, and there's lots of good information and lots of good policies that can be learned from and improved on. So, I wouldn't see that as being particularly difficult.

Can you expand a bit more on Healthwatch and how it works in England? I think Northern Ireland as well have similar checks at the moment.

I can certainly expand on Healthwatch in England. The local Healthwatch organisations get lots of support and training from Healthwatch England, and the volunteer members of Healthwatch would need to go on a training course before they started visiting. So, it wouldn't be possible for an untrained member to go on a visit. But that's what we do in CHCs now. There's training available, people do that, and there would be a lead in, buddying up, and other arrangements.

I think the thing is, in terms of both Healthwatch and the Patient and Client Council in Northern Ireland, like the proposals for the new body, they are fundamentally engagement bodies, they are there to hear from people and then represent their interests in relation to health and care services. In both those bodies, they have powers that are known as 'enter and view' powers, which means that they can visit health and care premises on both an announced and an unannounced basis.

In reality, Healthwatch and most of the local Healthwatch organisations that we've heard from have told us that they use that power of unannounced entry on a limited basis. Most of their visiting activity is planned well in advance as part of a prioritised programme, but there are circumstances, such as the ones that we've talked about earlier, when actually it's necessary to use that power to go and check how things are, or if they're getting difficulty perhaps with a care provider, who's not really aware of what the role of Healthwatch is, having that power in your back pocket is quite important to develop that relationship.

I should say, it's really important to recognise that the NHS currently has a really good understanding of CHCs' role in relation to visiting and the use of announced and unannounced. We rarely have any problem, but we do recognise that the new body is going to be creating a new relationship with the care sector and with care bodies, and, actually, it's useful to frame that relationship and develop that relationship on the right basis. So, having that enter and view power, Healthwatch tells us, is really important in that regard.

The training module for Healthwatch visiting is pretty much the same for healthcare and social care—they don't have any big division on that. Like CHCs, what Healthwatch is doing is looking to speak to people at the point of care delivery. On some visits, that's not possible, because people lack capacity, perhaps. Really, one of the things that the Care Quality Commission have said, and Healthwatch England, is that they're there to do the mum test: would you want your mum to be here; would you want a loved one to be there? Because we're not an inspectorate, we can then say, 'Well, yes, you're complying with all regulation, but the patient experience is not good, and you need to do something about that and think about that.'

John, you mentioned in your opening statement about the right to co-operation and the right to representation. I don't know if you want to expand on that or if anybody else has any comments.

Yes, I'm happy to respond. I think I mentioned—at least I hope I mentioned—in my opening statement that, if someone is sharing their experience with the organisation, then it would seem only right that they have an understanding of how that organisation then uses that information. So, the right of response from the provider actually gives you that opportunity to say, 'This is how the information was used, and this is what that organisation is now prepared to do as a result of that to actually improve the experience of having that service or make it safer.' And we need to make it clear as well—and Alyson has already done so—the power of lay members going in is that it's not a clinical conversation. It is about the experience, and it always humbles me to see how good our members are at engaging with patients, to get a proper understanding of what it is that's making their life either good or bad in that experience. So, that response and the power of response—if we can say clearly that there are four areas where the provider is now going to work on and we've got timescales, then that allows the organisation to follow that up and to make sure that it’s doing what it said it was going to do, and also that we’re looking to follow that up in terms of the patient or the individual’s experience.

Just to add to that, when we’re creating the new organisation, it’s going to be really important that, if we are to expect the public to share their views with us, they do need to believe that we’ve got the ability to act on the information they provide; otherwise, they’re less likely to give us that information again in the future. So, they need to believe it’s going to lead to something.

Yes, because I find this area really interesting because it moves the CHC from being a complaints-based organisation into a lesson-learning organisation or driver. What happens currently when you make representations on behalf—? Is it a mixed bag across health boards or—?

I'd say it is, and it’s also a mixed bag in terms of the subject matter. So, sometimes, you find yourself pushing at an open door, and other times there are difficulties stated and—. So, it wouldn’t be possible to say that one particular health board behaves in an obstructive way. It really depends on the issue. Sometimes, it’s resources. You may be saying to the health board, ‘Well, this is a real problem, you need to sort it out’, and they’re saying, ‘Well, we’d love to, but we haven’t got the money.’

I was going to say that, from a Hywel Dda perspective, all our reports are on the website. The health board responds with an action plan. We monitor that action plan, but I think the most crucial part for us is that we’re also a member of the quality board of the health board and we actually scrutinise our reports through that quality board, which all the directors sit on, and if we don’t see that there’s any action, then, obviously, it’s flagged up at that meeting. In certain CHC health boards, that may not be the case, but a lot of CHCs do sit on the quality board of their respective health boards, and I think that’s a very important part, because, then, those are also published on the health board’s website and the public can see that we’ve taken some action.

Can I just say that I think that's really interesting and I've read quite a lot of the report that the Hywel Dda CHC have put out? What I'm interested in, and my challenge back to you, because we're going to be looking at this and perhaps putting together amendments or suggestions about how this Bill might go forward, is that one always accepts that there's going to be the dramatic case, the awful case, which is a one-off; something absolutely horrible happens and it's a combination—it's a perfect storm. But there are also going to be the events that are systemic, which point to a particular issue that's building up, and building up, and building up over time. So, rather than just having a nebulous amendment that might say something like, 'We want you to really try hard to listen to what the CHCs are doing', I wondered if you could come back to us with perhaps an example of a best-practice scenario, which we could try and embed then in the direction of travel of this legislation, so that we don't just say to all the health boards, 'You must demonstrate that representations are being listened to', but that it is much more about, 'And this is how you need to demonstrate it—this is the level; this is how high up the tree it must go', because then I think we might have a chance of catching any of those systemic problems before they become truly horrendous.

I think we're seeing some of that. So, we have very strong links with the transforming nursing care team. We also are part of their quality assurance framework. So, that framework will refer to items raised by the CHC, and then it will list what has been done.

Perhaps you can come back to us and tell us where you think, in the health board organisations, you should be pitched at, so that we can actually then take that under our thought processes as a committee.

Yes, that's really helpful, and it does pick up on that issue about the Bill currently saying 'will have regard to', which is why we're saying, 'No, there should be a requirement of a response'. That's really helpful.

And I think if we can send you some supplementary information that sets out exactly how we make representations currently, because it's much more than producing a report and expecting a written response, it's actually being in a room and being part of a conversation with planners et cetera—so, we can set that out for you. 

Chair, could I just add to that, because I think that's a really important point? As a past chair, in fact, of Aneurin Bevan Community Health Council, I can say that every single report that we put through had a response, but also, where we weren't convinced about the speed of the response or whether the response was appropriate, we always had a seat at their full board meeting, and it was always accepted that, as the chair, or if the chief officer was attending, we would make the point that we were not satisfied with the response. And it was that kind of exchange that led, then, to their independent members joining us on visits to wards, so they could see for themselves why we were unhappy or didn't believe that they'd escalated a particular concern in an appropriate way.

Okay. Mansell. 

I was just going to say, on the flip side of that as well—you can turn that on its head—the Hywel Dda health board have invited us, when they do their ward visits, as independent members. So, there's quite a good relationship coming in there, and we don't accept actions ongoing in the action plan, and that I think is another key element. 

Okay. Jayne, had you finished? You've finished. Right.

Diolch, Cadeirydd. John, you mentioned the question about regional and local, and you talked about it being pedantic, but a change of words gives a different emphasis. But the change of wording or the order of the wording in the Bill wouldn't necessarily deliver what you want. So, how would you see the Bill needing to be reflective of the importance of putting the local voice in the whole process?

We think that the new organisation should be required to demonstrate how it will operate locally, regionally and nationally. So, we're not looking for a prescription, because, quite frankly, the prescriptions that apply to community health councils are some of the difficulties that we're dealing with in trying to meet the needs of individuals and communities. But a requirement of the new organisation to demonstrate that they will be operating appropriately at a local level, we think would be one of the safeguards that's absolutely required, because an idea that the organisation could operate top-down is, quite frankly, misplaced. It needs to be a bottom-up approach, and it needs to have a proper local identity. And we are talking about volunteer members engaging with individuals. People have said to me, 'Are we talking about a computer screen? Are we talking about a telephone?' If that's what we have, then it'll be a failure, because it is about being able to engage with individuals to gain trust for them to share their stories with us, so we understand what's important, and how then the new organisation can direct responses into the providing bodies.

You've mentioned, obviously, the patient voice on this—the duty to respond, in a sense, effectively. If it's not prescriptive, but you expect the organisation to describe how it will respond locally, who will they respond to? Will they respond to local organisations and local sub-groups, regional groups, the national body? How would you expect that right to respond or duty to respond to be delivered and to whom?

In the first instance, I think the business about the structural side—the local region—that response needs to be to Government, because I think Government needs to be clear about whether this new organisation is actually doing what it says on the tin. But in terms of the duty of response that you referred to—that, to me, is a very clear duty of response from the provider back to the new organisation. But I'm sure Alyson would want to pick up on the governance side of that.

The reason I ask about the new organisation is, at the moment, my CHC puts a report into Swansea Bay, then they will expect a response from Swansea Bay back to that CHC. So, who's going to be the one who puts in the report to the local health boards? Is it going to be structured so that the local groups can do that or is it going to be the national body that will do that? Who do they respond to? So, how do you see—? If it's not prescriptive, how do you see that working?

Sorry, I misunderstood the question. I think it's really important that as we're talking about the new organisation having a local identity, it actually is empowered to operate locally, because those relationships will make the difference between the effectiveness of the organisation. Those relationships exist now with local health boards, and by and large, they're very constructive and positive, but there's a good degree of challenge in there. But that same relationship needs to evolve in the social care sector and with local government as well, with the local councils. So, there needs to be—. That organisation needs to empower the localities to operate in that way, but then, as it escalates up through the organisation, where you've got clear commonality of issues in more than one area, that's when you see the regional and the national part of the structure coming together.

So, if the Bill is going to identify the fact that this new body should have a regional structure, it should almost be indicated that the body should be then able to empower those structures to act on its behalf in those areas? Okay. Because you mentioned in your written evidence the local involvement networks approach in England, and that's not how to do it. So, if that's not how to do it, is there any specific way in which it should be done? If you take that one out, then, is there any other good practice you think we can see, other than what currently exists? 

The LINks approach was quite chaotic. You went from patient forums, which were locally based organisations—. The way they did it was there was a patient forum for every NHS trust, and there was an overarching body called the Commission for Patient and Public Involvement in Health and they provided standards, training, all sorts of things. You then went over to LINks, which was commissioned by local authorities, but there was no overarching body, and it was chaotic. The current model of the local Healthwatch—again, you have local bodies that are quite autonomous, but there is an overarching body in Healthwatch England that provides standards, training and performance indicators and so on. So, for me, that's a good model.

I think there are lessons to be learned from other bodies that have made changes in relatively recent years. So, the Patient and Client Council, when they were set up they mirrored the current structures of CHCs. So, they retained local committees in each of those areas. They've now moved away from that because they found that the set-up needed to be more dynamic and responsive to the issues that were being discussed. So, they're moving to a system of pulling together local people and third sector organisations in that area to come together as working groups to take forward a particular piece of work and to take decisions around proposals that relate to changes in a particular area so that they could get the right members of the community who are really interested and have something to say about those elements to really focus hard on a particular thing, rather than having static committees that look to everything. So, I think there's lessons to be learned from a variety of different places. 

Can I just get my mind clear? Is your position that you would want to see a Bill provide the national body with the powers to establish regional and local organisations and to empower those? I'm not going to say, 'Upon which footprint?', because, clearly, if we were to include social care, that might then actually change the footprint, for example—but that the body should have those powers to make those establishments in place to ensure it provides local support to local groups and has the ability to work on the ground in the area where it needs to be. 

Absolutely. I think it's our understanding that there's quite a broad power in that Bill that essentially says that the organisation can do what it needs to do to carry out—. It was our understanding that that gives that body flexibility to set up its structure. I think the key thing for us as a CHC movement currently is that however that body organises itself, it needs to enshrine the principles of localism. It needs to be embedded in communities. It needs to be able to work in an alliance with third sector and other community representative organisations so that it can genuinely engage with, hear from and represent the widest possible number of people. We also think that it needs to enshrine that principle of decisions being taken as close as possible to the people impacted. So, if we are talking about something that affects people in a particular community, then the decisions around that that the body makes should be close to that and not at a national level.

I think, certainly for health issues, and I'm sure for social care issues, there are no real national-level issues, or not many. All parts of Wales have their own local concerns—particular local conditions and problems. I know that in north Wales, there is this feeling that they need a local presence, as John has described—that it needs to be focusing on what's important to people in north Wales. If you have, as has been described, an organisation where its priorities are national, regional and local, it really is the wrong way round.

I think I'd echo that from a Hywel Dda perspective, and I think it's all about the cultures, as well, within the community. I think it's very important that decisions are taken locally, because they understand that culture and what the public are expecting. There are certain projects that we look at from a national perspective, but then they're delegated down to localities as well so that we understand where they are. So, I think there's a possibility of overcomplicating this, to a certain extent, in my view. 

The bottom line for us is that if a citizen voice body—if people are going to have a sense of ownership of that citizen voice body, it needs to be accessible to them in terms of sharing their views, but also in terms of providing them with specific services. For example, a complaints advocacy service needs to be an in-person service. People need to be able to access that locally. So, that's fundamental, from our point of view.

Thank you, Chair, and thank you very much for your submission, which I found very surprising because of one particular omission. Now, the evidence that we have heard to date has been clear—passionately clear, actually—about the need for the new body to be independent of Government. But you don't mention this in your—you don't take a view in your submission about whether or not the Minister should have the right, or the Welsh Government should have the right, to appoint the entire body. I just would like to try to get to the bottom of your views on that.

You're absolutely right; we were silent on it. Part of the reason why I wanted to make an opening statement is that in those areas we've picked up, what we were more concerned about initially was that the new organisation wouldn't have the tools to be able to do the job as we saw it—it wouldn't have the teeth to make a difference in communities. But, you're absolutely right. We would be very content, as an organisation, if it could be seen to be as independent as it possibly could. Maybe that was an omission on my part, and I take responsibility for it, but the focus for us, initially, was about making sure that—. I think, Mansell, you used the term 'armoury', which sounds quite nice—it sounds better than 'teeth', in a way. But, it's about making sure that the organisation is properly equipped to make a difference. I suppose, for my own part, I took the view that the organisation is being established in a way that I recognised, but if there is a mechanism where that organisation can be more independent, then we would welcome that.

Surely that is fundamental.

Absolutely.

The beauty of how the structure is now is that independence of inquiry and independence from Government. And if it's going to be pulled more into Government, it surely begs the question, well, Government are just doing it because they're avoiding scrutiny. And that is particularly true in an area where the health board is under special measures.

And you write it off as, 'Oh, perhaps that was an omission on my behalf', but, you know, the evidence that we heard last week—I mean, this is more than just an omission. I would challenge you and say this is more like a body swerve.

From our point of view, I think it's really important to understand the current CHC structure and how the current CHC movement operates. So, as we are set up currently, and as we have been for a number of years, all of the CHC staff are employed by Powys Teaching Health Board. So, we are hosted by a health board. That creates issues and challenges in everyday working.

Half of the volunteer members of the CHC movement are currently appointed by the Minister through the public appointments process and the other half are derived from third sector and from local authorities. So, for us, the proposals in the Bill are more independent than our existing arrangements in terms of taking the body outside of the NHS, where it currently sits, and in terms of giving the body the power to recruit its own volunteer members who will be the boots on the ground. So, the Bill shifts the independence and makes it more independent.

What we would absolutely welcome, if it is possible to do, is to have that body even more independent outside of Government. But we do recognise that—. And we don't know, because we're not legal experts. We don't know whether it's possible to do that. Because we know the Public Services Ombudsman for Wales and the auditor general—that their arrangements are currently set up through the Assembly. But they are powers that are vested in an individual rather than in a whole board. So, we don't know if it's possible, but if it is, we'd like it, thank you very much.

Well, I mean, anything is possible, but, of course, the way that it runs at present is that, basically, all your board members would be appointees by Welsh Government. So, therefore, you may—I'm not saying you would—but you may lose that statutory right to have the third sector involved, and of course the third sector are key in the NHS and the delivery of services, both social care and through the NHS here in Wales. You would lose the right to have some of those independent voices. Now, I'm not saying for one minute that that's the intention or that that's what will happen, but once you set something up in law, it is extremely difficult to go back and undo it.

So, I've just been genuinely, incredibly surprised—. And given the—. And I can't speak for other Members, but I know I've received an awful lot of personal lobbying by people very concerned about what's going to happen to the independence of the CHCs and the localism of the CHCs. There's a real concern that this will be a body that's appointed by Government, will be Cardiff central, and will just sort of ask people a few questions every now and again. There's a real, real concern by the people locally who deal with me. And then, I've had a lot of lobbying by other stakeholders, and then we as a committee have taken a huge amount of evidence where people have been very, very strong on this. So, to find the organisation that's in question being so lukewarm about it, actually, I've found a real surprise. And I'm not sure I really get to the heart of why you're so lukewarm on it.

I know you've found it difficult to accept my answer, but it was actually a very honest answer. We came upon it from the viewpoint—. And I think Alyson has tried to explain that we're not as independent as maybe some people like to think we are. I referred earlier on to the messy governance arrangements that are a difficulty. And yes, in retrospect, perhaps we should have gone down the route that you've so eloquently described, but I think our focus was really on how will this organisation make a difference in communities. I fully accept all the points you've just made, but I can only give you the honest answer, and that was that our focus was on how do we make a difference in communities. As Alyson said, we actually aren't experts in this area. We come from a lay background. This new organisation will be a body corporate and would have a very different set of skills around it. But we would—I will say it again—be very happy if we went down a route that this organisation would be more independent. 

Okay. Well, I'll leave it there, but I would say that I appreciate that you're not experts in it, but it doesn't take four seconds to Google 'How is Estyn set up?', 'How is the Public Services Ombudsman set up?', 'How is the children's commissioner set up?', 'How are all these bodies set up?', 'How is the national adoption service set up?' You can see all the different ways that it can be done. So—yes. Okay. 

Workload. Now, of course, I know this must be a very difficult question for you to answer, because we don't know what this body will look like. We don't know where it'll be centred, and we don't know how regional and national it is. I think that some of the feedback that I'm hearing is that perhaps the intent might be quite regional, and we had that—I draw a corollary with the education consortia that we have. They represent a number of different county councils and so on, and sort of pull that together. So, it's hard, I appreciate, to sort of say, 'Well, we need 10 people here, and 20 people there', or this, that and the other. But, do you have any views on whether or not you think that the proposal is resourced enough that there will be enough people, that the volunteers will still—? Because, again, it's not really that clear about whether or not volunteers will still be needed, or whether the whole body is going to be turned into a paid organisation, like Health Inspectorate Wales or Care Inspectorate Wales, and that this paid organisation will just travel out to different places. And that's why, actually, going back to what we just talked about, I find it really worrying, because I just don't think—. There just seems to have been no thought about those consequences. Because, actually, there's nothing in all this legislation to say that this isn't going to be 20 people sitting in an office in Cardiff who pop out once every couple of months to a particular area to ask how things are going on. 

So, there are a couple of things that we are really clear about in our response. The things that you are worried about are the same things that we are worried about. From our point of view, and from the CHC movement's point of view, the volunteer members, and the volunteer membership, is critical to the success of a new body that's going to cover health and social care. The reference to volunteer members needs to be enshrined on the front of the Bill. We recognise that there's lots of talk about it in the explanatory memorandum, but, actually, we think that needs to be enshrined on the front of the Bill. Similarly, as John said earlier, we think that principle of localism needs to be enshrined on that Bill as well—it's fundamental. 

In terms of your question on resources, the simple answer from the CHC movement's point of view is, no, we don't think the proposals currently provide sufficient resources to establish and run a new organisation that is going to work across health and social care. So, the arrangements in the Bill, or the suggestions in the Bill, that the new body would need to have eight additional people in relation to a complaints advocacy service—we recognise that's a starter for 10 from the Welsh Government, but we don't think that's enough. Fundamentally, what you cannot expect a new organisation to do is to set up and work across, take on a whole new sector, with the same resources, fundamentally. What you'll end up doing is stretching yourself so thin that you won't be covering that which you need to cover. You'll be doing less across a much wider area. Whilst we recognise that, currently, CHCs cannot possibly cover all aspects of the NHS, what it does is prioritise, and it responds to the things that people have told us are more important. There'll be some of that in the new organisation. We also recognise that the new organisation will be equipped with IT that can help it access people in different ways and in new ways, and that will be helpful, but that will absolutely not be enough. 

We also know that, fundamentally, if we are to attract and retain volunteer members who we're asking a lot of, in terms of engaging with people and representing their interests, they really, really need to be equipped and supported, and that comes with quite an extensive support, learning and development programme, and that’s fundamental. That’s not covered off in there either. The other element that’s not covered off is the kind of infrastructure that you’d need to have to operate as a single, stand-alone body. Currently CHCs access a lot of corporate services from different places and some of that might be possible to do for the future, but that strategic thinking—that strategic control over that agenda—needs to be properly resourced and that’s not there either.

When CHCs were abolished in England, insufficient regard was given to the role of the volunteer members. I think that there was a view—well, I know there was a view, because I was working at the Commission for Patient and Public Involvement at the time—that CHC members were not required. They had plans that they were going to—. And they had a huge television advertising campaign—an advertising campaign over three months that spent more than the CHCs' budget in a year. They envisaged having about 0.25 million volunteers across England. A few weeks before the official launch, they had about 2,000 and they had to write then to former CHC members, asking them if they would be interested in getting involved.

We will, as Alyson said, through technology and other means, reach out to new people, or the new body will reach out to new people, but the core of people that we have is really important, and if we’re going to be carrying out engagement activities—. One of the things that has changed over the years is that with young people working zero-hours contracts, firms now don't give people time off to get involved in voluntary activities. The other thing is that older people now play a huge role in childcare and it’s vital to family economies that they do that. So, we're fishing in an ever-decreasing pond of volunteers. So, we really need to take care of our membership. One of the things that I like very much about the new body is that members will be able to participate—. Currently, there’s an eight-year limit, with a couple of years as co-option at either end maybe. But the idea that we can keep people for a longer term—I think that’s really good.

I think the other thing that we would see as being important for the new body is—. Our existing volunteer membership arrangements are quite prescriptive, and there’s an expectation that volunteer members carry out all of the functions of the CHC. That can be quite limiting. So, for example, younger people, people who are working—they find that quite difficult to become a full member. What we want that new body to be able to do is to create a volunteer membership model to allow people to engage and get involved at a variety of different levels, according to their interests, according to their availability and to be equipped to do so on any of those levels. We think that will give that organisation much more flexibility to build a volunteer cadre that’s truly representative of the people who they will serve and that is a true conduit to the wider population and wider communities.

Okay, Angela?

I've just got one more question really, Chair, and that's: I think you touched on it a little bit earlier, but can you just please go through again your concerns over the joint, or lack of joint, complaints procedure that's being proposed by the Bill?

Shall I start with that one? It's as simple as this, really, with this one: for individuals who are in receipt of services, service boundaries don't mean anything at all. And we think that creating a situation where individuals have to navigate different complaints routes just doesn't make any sense, especially when we're likely to see these services becoming more closely linked. But nevertheless, as we all know, even within the existing NHS structure, the provider boundaries are a nightmare for individuals who are navigating their way through it. So, we would have hoped to have seen a simplified complaints procedure that would have embraced a much broader church than the one we're seeing. But I'm sure you'll have much more to say about that.

Yes, I think—

And also could you just—? Can you also perhaps identify what the Government thinks is a barrier to that? Because, if we are to sway the Government's mind, we need to understand what their objection to it is and how we might counteract it.

Okay. So, the first part is I don't know what their objection is to it. From our point of view—

There's nothing structural that's obvious and we have missed.

From our point of view, it's fundamental—if this Bill is going to make things easier for people to address their concerns quickly, but, fundamentally, if it's also going to mean that organisations can learn lessons from that across the health and care boundaries, then it makes absolute sense that a complaints system should be common across both. The public shouldn't need to have to understand which bit of the system they are accessing and therefore which bit of the system they need to go to to complain, and the new body's complaints advocacy service can help and support with that, but it shouldn't need to; there should be a single complaints system. We're also concerned, if you're operating two separate complaints systems, who looks at the complaints where some things fall between the gap between health and social care provision? Where's that being picked up? So, we think it's a real missed opportunity, and a real missed opportunity to drive that learning and improvement that needs to be done to help improve services for people.

Fine.

We've very much focused upon the citizen's voice section of the Bill—understandably, because that, really, reflects yourselves, but I suppose—. Two other aspects are the duty of candour and the duty of quality within that Bill, and to some extent the duty of quality is critical to perhaps some of these service issues you will be looking at. Do you think those two areas are sufficient within the Bill, and is 'quality' sufficiently defined within the Bill?

I think that there's an opportunity to have a wider conversation about what quality is to people, so I think that that wider conversation needs to take place. I think, fundamentally, we welcome any proposals that provide an opportunity to improve the focus on delivering quality services for people and to be honest and open when things go wrong. Most of the complainants, for example, who come to us for support, what they tell us is that (1) they want to understand what happened, (2) they want an apology, and (3) they don't want it to ever happen to anybody again. So, the opportunity presented by the duty of candour to actually drive that cultural change that is needed, so that individuals and the whole organisation behave in the way in which we would want them to behave and the public have a right to expect, is really important. And the focus on quality improvement is also really important and vital. But, as with all of these things, from our point of view, legislation is only as good as it drives the cultural change needed and doesn't become over-bureaucratised. So, the way in which those arrangements work in practice will be really key, so we think there's scope for a much broader conversation about how this is going to happen to make the real difference in practice on the things that matter to people.

So, operational questions rather than changes to the actual Bill. 

Yes.

Okay. John, in your opening statement, you highlighted dispute resolution as an area that's missing. Are there any other areas other than dispute resolution that are not in the Bill that you think should be in the Bill and would have helped you undertake the job you're currently doing now or what the new body would be able to do?

I think, just dealing with the resolution element of that—I don't want to rehearse, because I think you're probably clear about the CHC position now, in terms of service change—but the ability to have an independent mechanism to resolve disputes, given the scope, et cetera, we think will be critical in this. Are there other areas? We, I think, are quite convinced that, if the Bill can embrace these suggested amendments, we would actually get an organisation—albeit understanding some of the other issues that were raised, we think it could actually be an organisation that could better meet the needs of individuals and communities than we are currently able to do as community health councils. 

Are we missing a trick anywhere, I suppose is the question: is there something that is missing from the Bill that would give you that stronger opportunity?

I think one of the things for us is that the Bill as currently framed gives a right to representation with health and care bodies and local authorities. We are also asking for a right of representation to Welsh Ministers. We think that's really important. If the aspiration of the parliamentary review and 'A Healthier Wales' of actually putting the citizen's voice at the centre and driving the development and delivery of health and care services—we think the new body should have that right of representation at a national level, to be—. It's more than about making written representations and getting written answers. It's about being in the room when conversations take place. It's about driving the agenda with policy makers and with planners about what health and care systems need to look like in the future. If we're not in that room, if we don't have that right of representation when those conversations take place, the new body is left responding to consultations when planners have decided what needs to happen, and we think it's really, really important that we are having those national conversations on policy development, on planning, on a national basis, otherwise, the benefits that are identified from that Bill are not going to happen.

Which I think strengthens the argument for an independent body from Government, where you have the right to representation to be the voice at the table with Government. 

A final point, I suppose, is that we all—every time we see a Bill we ask the question of unintended consequences. Are there any unintended consequences that you have identified within the Bill as it stands that you might want to point us to to ensure that we address those with the Minister?

I think the key issues for us are the things that are not in there, because the unintended consequence for us of that is that you'll end up with a weaker body across two sectors rather than the stronger people's voice that we're all looking for. 

I think the resourcing issue is really important. As has been said, we can't deal with everything in the NHS. We prioritise and we plan based on what people tell us is important. If we're taking on a whole new sector with the same resources then we're going to be dealing—that cut-off is going to be higher up, really, because we're taking the same resources and covering a much bigger area. 

Like setting up any organisation, Chair, it's a case of knowing the detail so that then your resources can be looked at in more detail. 

So, we like the element in the Bill that places a responsibility on health and care bodies to promote the activities of the new body. So, that's good. But we also know that the direction of travel in terms of health and social care services is that more and more services will be provided in people's homes. If we are to access and hear from people who are receiving services in their home, we're going to need more from health and care bodies. We're going to need them to help and support us. So, that duty of co-operation is about helping and supporting us to access people who are receiving care who we might otherwise not be able to access. 

I would also say that co-operation shouldn't be in the gift of any individual, that there should be a duty. We currently—and, I'm sure, all other CHCs at the moment—have very good co-operation from Betsi Cadwaladr University Health Board. That's not always been the case in the past, and sometimes we have to have difficult conversations, but we need to continue our relationship after we've had those. So, a duty of co-operation I think is really important. 

Diolch, Cadeirydd. Morning. I suppose the first important question is: the White Paper that accompanied the Bill, or before the Bill, highlighted perhaps the need to look at the integration of the social care inspectorate and the healthcare inspectorate. The Bill doesn't see that happening. Do you think that's a mistake— not to take the opportunity of actually putting the two bodies together—based upon the fact that this is a Bill looking at the quality of health and social care?

Okay. I think what I'd probably start by saying is, that, if we're serious about a direction of travel towards more integrated models of health and social care, and thinking about integration in terms of the way services are being delivered to the public, then it's probably fair to say that I think an associated direction of travel would be towards more integrating the inspector and regulation system to oversee those services.

I think there are some challenges with doing it at the moment, and I think I've articulated those, as well, in front of committee. So, some of the challenges: for example, the care inspectorate—and I'm sure Margaret will say more about this—have moved over, under the Regulation and Inspection of Social Care (Wales) Act 2016, to a different system of regulation of the independent sector, whilst we remain underneath the Care Standards Act 2000, so we're still establishment-based regulation. So, we operate within very different legal frameworks. There are also very different cultural standards, environments, for health and social care. So, I think there's a piece of work to be done to look at all of that, and I do see that, potentially, as a direction of travel. Having said that, where there are integrated services, we do already work very closely together. We have quarterly joint senior management team meetings so that we can share common issues and join up, where appropriate. We are both members of the heads of inspectorate group, so we meet regularly, both with each other, and with Estyn and with the Wales Audit Office, to make sure that we are as aligned as possible in the work that we undertake. We do undertake joint projects—so, we've worked together on community mental health the teams. I'm working with Care Inspectorate Wales at the moment and supporting their work in re-ablement services. We've worked together on substance misuse services. So, where we feel that it is necessary to come together to join up to do the work of the inspectorates, then that is what we aim to do. And I think to bring us together, to think about us as a single joint inspectorate, could be complex, and it's really important that we get it right and that we make sure that the legal underpinnings for that work are right.

So, to go back to your question, really—am I disappointed that it's not in this Bill—I would rather we took our time and we got it right in terms of thinking about the direction of travel and how we make this work.

Margaret.

Well, I'd support what HIW have said. Where you've got integrated health and social care services, of course it makes sense to have integrated inspection of those services. I don't think anyone—it wouldn't be sensible to argue against that. But bringing two inspectorates together in and of itself is probably not going to deliver seamless health and social care services for people. And we know, as Kate has said, that the Minister has indicated we want to look at that further in the next phase of this work, and we really do welcome that. We think it would be sensible, as part of that, to look at what the experience has been in other jurisdictions that have gone down, to some extent, this line, and what the outcome of that has been for experiences and outcomes for people.

I think another aspect to think about in terms of just the two organisations is that—CIW, we cover a lot of services that do not involve integrated health and social care services. So, what I mean by that, for example, is, where we regulate 5,000—let me get the number right—5,946 services, of those 5,946 services, 4,073 of them are childcare and play services. So, therefore, for example, we do a lot of work with Estyn on those services; we've just developed a joint integrated inspection framework. So, it is possible to develop integrated inspection frameworks—it's very hard work, particularly when you're operating under different frameworks.

So, Kate has mentioned the two different frameworks we're operating in social care and healthcare. Local authorities are, rightly so, very focused on the outcomes framework. And the regulated services in social care, of which there are a lot more in social care, are under the Regulation and Inspection of Social Care (Wales) Act 2016, which is a new piece of legislation—all of that legislation towards well-being outcomes, what matters to people. On the health side, you've got the healthcare standards, and the regulated services on the health side, of which there are fewer, are under the Care Standards Act 2000. So, what that means is that you've got—. It's not just a case of two different Acts, because you would imagine that, for people, their experience and their outcomes should be the same, and rightly so, no matter where they are receiving care. But, when you've got two different legislative frameworks, the standards, as they're set out within them, the structure of registration is different, the sanctions are different, the escalation routes are different. So, we think it's right to take time to look at that and see where that can be aligned.

But, in the meantime, HIW are quite right, there is a lot of opportunity for us to work together, and we are working together. So, recently, we've done a piece of thematic work on services for older people, promoting independence and reducing the risk of escalating need, and HIW have worked alongside us on those inspections, and that makes sense, because that work covers multidisciplinary teams, where health and social care are working together.

So, is it fair to say, then, that, in both your opinions, the longer term possibility of integration of the inspectorates is still a viable option, but, at this point in time, you are saying that, because there's a need to understand and clarify the legal jurisdictions that you both work under, and the implications of those upon such an integrated services need to be resolved, but that does not stop you working together on the occasions where there is integration of those services to ensure that the care is provided to patients and individuals?

Absolutely. And I think I would add to that that that work will need to look at what happens to the other areas of work that we both work on. I've mentioned the childcare and play and the education side, which we have got—a lot of our work is focused there. We also work with HMI Probation; I know that HIW do all sorts. So, there are other areas. For us, the predominant bit would be the childcare and play. So, it's how you—if you're talking about two organisations, you'd have to sort that bit out as well.

So, you'd have to sort out which areas of your work really do cross over with the healthcare to ensure that that's the agenda for integrated inspectorate areas.

Yes.

Okay. I can understand that to a point. Does this integration affect your capacity—? Because, Kate, when you first took up post, one of the first things you said to me when I was chairing was that you didn't think you had the full capacity at HIW. Does the capacity of both HIW and CIW—does it provide you with sufficient resources to actually meet your requirements now in your separate inspections but also in your joint inspections?

That's a really interesting question, because I think it goes to the heart of what the expectations are of an inspectorate. Now, we've talked here, I think, before about the idea of being the third tier, and, certainly, we work on the basis of an expectation that health boards will—particularly in the NHS now, health boards will themselves be responsible for managing the quality of delivery of their healthcare services on a day-to-day basis. So, they will do it on an ongoing basis. They will be expected—we would expect them to understand what the quality of services are that are being provided. Our work, therefore, is to go in, I believe, and test— quite often, on the basis of intelligence and risk information that comes before us—whether what we're seeing on the ground accurately and appropriately reflects what we would expect to see based on what we're hearing from the health boards and from others.

I know we'll get into discussions about how we might work, for example, with the new citizen voice body, and I think the information and intelligence coming through from patients is absolutely vital to help us focus our work. So, to the extent that we can do that, I think there will always be challenges; we will always have to prioritise where we go. I've said on numerous times that I've changed my plan around and places where I had been planning to go and test have had to be replaced with other places, because other information has come to my attention that I feel we need to test. It's always possible to say that you could do more, but I think it's important to be clear about the expectations. So, it's the health boards that need to be everywhere. We simply need to be in a position to be able to test where we think that is appropriate.

Do you think the Bill will increase the demand for your resources?

Sorry?

Do you think the Bill will increase the demand for your resources?

Do I think the Bill will increase the demand for our resources? I think, if you think about areas such as the duty of quality and the duty of candour, the Bill talks about introducing reporting arrangements for those. Again, that is part of the health boards being able to demonstrate how they are fulfilling those duties and being accountable for doing so. One of the things that I'm thinking about at the moment, for example, is whether there is a need for us to do possibly more frequent work in the area of clinical governance in each NHS organisation, which may allow us to test, for example, the information being presented in that reporting. So, it's possible that whilst the reports here will be a valuable source of intelligence for us, they may throw up more questions that I would want to go in and probe in more detail in those organisations. But it's difficult, at the moment, to know whether that's the case.

I'll come on to the duty of quality in a short while. I suppose, in a sense, we've been talking about the White Paper and the change from the White Paper to the Bill, which doesn't include this merger. Are there any other proposals that you've found in the White Paper that are not in this Bill that you wish were in the Bill?

Not necessarily that I wish were in this Bill, but the issues that were in the White Paper that have not been tackled in the Bill I do think need to be addressed and taken forward. There are issues such as the whole thing—. We've alluded to it already: the issue of common standards, commonality. If we look at this through the eyes of a member of the public, a patient or a service user, they should have clarity on what they can expect, they should have a clear understanding of what to expect from healthcare, from social care, from public services, from the independent sector. There shouldn't be lower standards set in one setting, necessarily, than in another. So, I think this idea that we—. And it's not just about the standards, because, quite often, there is an alignment between them, but they are expressed in very different languages, and that can make them, at times, impenetrable or very difficult to reconcile in the eyes of the public. I think we need to be much clearer in the way that we communicate with the public what is reasonable to expect. Because, again, going back to the overall system of assurance and the role that patient views can play in focusing our activity, they are the only people who are present in every interaction with their services, and the intelligence that they can provide, if we capture their experience well, will be invaluable in focusing our activity.

I think I would echo what Kate has said. I talked earlier on about social services working towards well-being outcomes. We really support that, because we can see that making a difference already. There's a way to go, but we can see it making a difference. And then there's the healthcare standards on the health side. Scotland have recently developed some joint health and social care standards, so it's been achieved elsewhere, and I think that would be a good thing to aim for.

I understand that, and that links back, to an extent, to the definition of 'quality' as well, because we need to understand what is meant by 'quality', and we have a duty of quality that links into your standards. Should the definition, therefore, be placed on the Bill or should there be, perhaps, regulations to basically define quality? Which would you prefer to see? Because we think definitely there is a missing element here, which, as you say, does links into standards. But do we need something specifically on the face of the Bill, or should we have something in the Bill that requires Ministers to make regulations that define 'quality' and the criteria on which bodies will be assessed?

Shall I start? Stuart, you may want to add something on this, because it's something we were talking about earlier. I think, in terms of the definition of 'quality' that's in the Bill, it is positive that it is broad enough to embrace quality in terms of safety, in terms of the effectiveness of services, but also, really importantly, in terms of patient experience. That breadth, I think, is really to be welcomed, but if you want to get some—. The Bill, in and of itself, will not make the difference; it is about the cultural change that it supports, and within that, it's about the discussion and the guidance that goes alongside it. I don't know if you want to say anything about that.

Yes, it's something that we raised in our evidence around the importance of being quite specific about what health services need to report on in their reporting to help us in our own work. It becomes intelligence that we look at in our own work, but how does it work with the current annual quality statements? That's two sets of reports. We don't want to be overburdensome on reporting. Should they come together to explain how the duty is being met but actually the outcomes as well of meeting the duty in terms of those services? So, we do feel that in the guidance there should be something a bit more specific about what exactly that reporting mechanism is, what should be reported on and who passes judgment over that, the answer to which is probably a number of organisations as part of our current work, feeding up through our reporting on health boards and ultimately to escalation and intervention arrangements. That's how we see it would integrate into our current working practices. 

I was going to ask that as the next question. Who assesses the reports, I suppose—and you mentioned this earlier—is a crucial consideration, and what accountability for the failure of either producing a report, or a poor report, shall we say, and where are they accountable. Does the Bill, in your view, take those into sufficient consideration to ensure that, as a body has a requirement and a duty to produce these, there is also an understanding of who actually will decide whether those are appropriate or not and, if they're not, what action they will take?

To develop what I started to say, the way we're seeing it working is that a number of bodies will be considering both reports on candour and quality as part of their current business model. So, as an organisation, our relationship managers would be considering annual reports on quality, assessing whether that actually is the picture, balanced against our inspection findings and review findings, testing that, and then feeding that into our discussions at escalation and intervention meetings, which I would assume the Wales Audit Office and the Welsh Government would also be doing, and they'd be discussed there. And any non-reporting or failure to comply would be highlighted there, discussed, and that is the way in which—

Can I ask a question on that? It's an interesting point on how you say that would work, and I'm looking at the transparency then as to how we would be able to see how that all fits together. Because if you are saying something, but, in that discussion, you're overridden by perhaps somebody else's opinion, how do we actually understand that type of discussion and why that occurred? Should there be a more formal process where we can see the consequences of that type of discussion, so that, if you've highlighted something but somebody else says, 'I don't think that's relevant', we understand the discussion as to why that's the case?

For me, this is something that, thinking about our powers and the way that we work, we're already starting to see what we can do without legislation in terms of increasing the accountability of some of the NHS bodies. Previously, we have done a report to each health board as HIW. We take it to the health board, we discuss it at a public meeting, it's there, it's in the public domain. Now, last year, we didn't produce a stand-alone report in the same way, although we did do our summary pages within our annual report. But I'm not comfortable that actually gives the transparency of accountability in terms of what we are saying to the health boards about whether we think they are doing what we expect of them and therefore what actions to take. 

One of the things that we are considering at the moment is introducing something like an accountability letter, which would go back to us, which again would help to give some of that transparency to you. It's something that we're thinking about developing. Obviously, we're not just going to suddenly throw it into the mix. We will consult people on it first. But I think you're right; it is important that there is transparency about what we think, what we are saying and where we are holding those health boards—those NHS bodies; not just health boards, including the trusts—to account. 

Okay.

Thank you, Chair. Both of you—both HIW and CIW—are broadly supportive of the aims of the duty of candour. How effective do you think the duty of candour provisions are in the Bill and do you think they're likely to achieve the aims?

We are definitely supportive of the duty of candour, because it's got to be right that people can raise issues when they happen and, when something goes wrong, that they get transparency, they get a response, they get an apology, and that lessons are learnt, more importantly. Therefore, we're very supportive of the duty of candour in the Bill and I think that can only be a good thing. It does also align with what's happening on the social care side. There is a duty of candour in the Regulation and Inspection of Social Care (Wales) Act 2016. It's a slightly higher-level duty, but there is a duty in there, and the statutory guidance sets out more clearly what that means for regulated services. The key difference, probably, would be that because that duty of candour is in the Regulation and Inspection of Social Care (Wales) Act 2016 and it's regulated services, then that gives us powers to impose sanctions if it's not adhered to. 

From HIW's perspective, yes, we welcome the duty of candour and its application across the whole organisation. It needs to play its role in a number of different interventions, legislative or not, on developing the culture for openness and transparency; I don't think it will do that on its own, as others have said in giving their evidence. 

We welcome the need, again, for reporting, and that will help us as an organisation in the evidence and what we're considering. We do think we need to be a little bit careful about how that is done specifically to make sure, again, that we don't overburden some of the smaller healthcare providers—primary care providers, for example—who may well provide healthcare to a number of health boards, and they may need to report through different mechanisms there. So, that needs to thought through carefully.

And then, on the matter of triggers, we welcome the triggers that have been put into the Bill, although, as you will have seen in our evidence, if we are shooting for the prudent healthcare principles and co-production of one's healthcare and that kind of thing, a presumption of openness and transparency is what we are aiming towards, rather than the need for a trigger to be open and transparent. So, whilst we recognise the triggers, really, there should be a presumption of openness and transparency in designing and co-producing care. 

And then, on the second trigger, we feel that there was perhaps a level of breadth around—rather than just services provided. So, harm coming from services provided—that harm coming from inaccessibility of care was something that might be explored as part of the Bill. So, perhaps if there is acknowledgement that waiting times are too long and that harm can come to somebody because they can't access the care that they need, perhaps that can be considered as part of that trigger. That's just an explanation of our evidence.  

If I can just add one thing. I'm not sure this will help you or not, because it's really something that struck me when we were talking about the duty of quality. The duty of candour, as expressed, is about where something has happened with regard to an interaction with a service user in some way. We've talked a lot about openness and transparency in terms of the duty of quality as well, but because this is an organisational duty, there is very much an interaction between this duty and the duty of quality—almost a requirement of the organisation itself to be open and honest about the implications for its service users if it feels that, in some way, in defining its duty of quality, that may have an adverse outcome on service users generally. I think there is something here about—. Which is why I said it's not so much about the specifics of the legislation, it is about the culture that underpins that, and the expectations that we have of organisations and professionals in the way that they deal with the people that they are there to support. 

We've heard some evidence that some people have mentioned around sanctions on non-compliance for breaching the duty. Do you have any views on any sanctions for any breaches of the duty of candour? 

As I said, on the social care side, we do have sanctions because of where it is. I guess on the health side, this is similar to how we would be with social—. We regulate regulated services. It's a different thing slightly to inspection and review of local authorities. In local authorities, the route there is the escalation route. I'm wondering on the health side with this: would that be the appropriate route through if this wasn't being adhered to? 

For me, it's about where you escalate these issues to. One of the biggest levers that we have within the NHS in terms of achieving change is the fact that we place what we find openly and transparently in the public domain, which is why I made the point I made about the accountability of health boards for what we find. Where there are issues that arise—and we wouldn't be the only people who would be forming a view on whether these duties are being adhered to, for example. So, in NHS bodies, the Wales Audit Office also undertakes a structured assessment where it looks at governance of those bodies—the Welsh Government will also have a view—then those matters would be taken through the escalation and intervention framework, and actions to be taken would be determined then by the Welsh Government, having recognised the level of concern that exists about that body. 

You've been clear around the importance of being open and transparent. Do you think there's anything else that could be added to the Bill to help with that?

Oh, gosh.

Put you on the spot there.

Yes. Not specifically, partly because I haven't sat here and sort of thought about what the drafting might address. And, as I said, the only thing that comes to mind at the moment is the matter that I raised earlier that I haven't got my head around yet, which is the interaction between the duty of quality and the duty of candour, and what that means in terms of an organisation's planning and reporting. It may be that there is something that could be added to the Bill that might make that sort of cultural interaction more explicit, but I think it would be wrong of me to attempt to draft in committee. 

And, just finally, Chair, we've had evidence from the British Medical Association, who've called for additional provisions to be added to the Bill to address the regulatory imbalance between clinical staff and non-clinical managers in the NHS. Do you have any views on introducing a system of regulation for non-clinical managers?

I think one of the things that underpins for me the regulation of a professional is the ability to define the body of knowledge and competence that is required of that profession. I'm not necessarily persuaded that that is sufficiently well defined on a consensual basis for a health service manager, as distinct from, potentially, any other sort of manager. That doesn't mean that there isn't the potential, through putting in place very good development programmes, leadership programmes, performance management programmes, peer support programmes, due diligence in the appointment of appropriate individuals to ensure that their development in their career is properly understood when the decision to appoint is made—it doesn't mean any of that is not possible. Almost the first stage of that could be, for example, consideration of a code of practice. Many professionals have codes of practice sitting alongside their requirement to register. So, a code of practice, again, would make it very explicit what they're expected to do. 

There might also be the potential to explore maybe some of the explicitness of posts, such as responsible individuals and registered managers in the independent sector, and think how that might translate across into a public service area. But, those are my first thoughts; I wouldn't claim to have researched them in any detail. But I think a leap to a register without having done some of that preliminary work would be difficult to sustain. 

Okay?

Thanks, Chair, yes. 

Thank you, Chair. Kate, I listened with interest to your comment about you believe health boards are there to manage the quality of their delivery, and that HIW are there to test that delivery. And I can totally see that. So, do you think that there is actually a need for a citizen voice body to run in tandem with those two objectives?

Absolutely. Would it be helpful if I explained—? I've almost—. I'm really encouraged by some of the things that I see about the citizen voice body; I just wonder if it might be helpful to explain how I think that might work—

Yes, please do. 

—and how it might add value to what we do. One of the things I think we've struggled with, both the community health councils and ourselves, is getting public recognition for what we do to get the public to understand why they should come to us, to get them to understand how they can share their experiences. And if I put to one side for a moment that I absolutely think health boards should themselves be engaging and seeking the views of the patients that they look after, I still think, or I also think, that there is a very strong case for having a body out there that can go and actively seek those views. I don't think—and this is reflected in the explanatory memorandum as well—the citizen voice body would be the voice of the patient per se. I think it could very valuably and strongly be a co-ordinating voice, because we need to recognise there are a lot of other people and third sector bodies—the Stroke Association, Diabetes UK, the public services ombudsman, the older people’s commissioner, the children’s commissioner—all of which will be understanding what people’s experiences are of public services. And, by bringing those perspectives together, there’s a very rich vein of intelligence that could be out there.

But, in terms of their actual activities, I think I really welcome the fact that they will be using a wide range of ways to go out there and capture information on people’s experience, and hopefully both good and bad. I would hope that the new body would be able to feed that back to us in such a way that, where concerns are coming up, it will help us to focus our work. Going back to what we do, when we go out and we do one of our inspections, we are looking at what’s happening on the ground as we see it at a point in time. And that’s the case with any type of visit—you are seeing what’s there at a point in time. The value this will bring is that much broader perspective on what’s happening over time for a wide range of different patients, relatives, carers, and capturing some of that.

And a very real example of how we can work together in this field is we’re working very closely with the community health councils at the moment on our national review of maternity. So, we’ve worked together to design a survey, which we’re both promoting, to encourage people online and through groups to come back with their views to help us understand not just the people who are there when we inspect, but wider views.

We are also working very closely with community health councils so that they can help us identify how we can engage in the second part of the work, though focus groups, and actually meet with mothers and babies, and those who’ve had experience of services recently to gain first-hand experience.

Now, I think that is a really valuable contribution to the work of the inspectorate, which highlights the very complementary and supportive roles that we can play. And that’s what, again, I’d like to see more of in the citizen voice body. It’s a way that they can help us make sure that we ourselves don’t have to overlap their functions by becoming an engagement body, but we can work together to use their capacity and their skills.

I have to say that your answer makes me incredibly nervous for the future of the citizen voice body, or rather makes me incredibly nervous for the voice of a single, lonely person stuck somewhere in the Welsh NHS system. Because you talk about the ability for a citizen voice body to perhaps bring together the wide variety of stakeholders, and talk about the strategic elements of the engagement, and I buy into that, and I think, if they were resourced, then I think that would be a very valuable element of their role, but what I don’t hear and what I am concerned about is the citizen voice body being able to respond, or somebody, anybody, out there being able to respond, directly to a particular person who has a grievous problem in the here and now.

And you mentioned that there are lots of other bodies that could get involved. Well, to be frank, from my experience, I would say that the bodies that most get involved are AMs’ offices, because actually—and we’ve taken evidence to this effect, committee—we’ve heard more and more from some of these organisations that you’ve talked about that they are rolling back from front-line delivery and that they’re becoming all about policy, strategy, objectives and influence, which is vital. 

If the citizen voice body goes down that route too much, then you actually lose the person who can come by the side of Mrs Jones who’s just had a dreadful experience, or is having a dreadful experience, in some form of delivery of health or social care. And there are not many bodies out there. We’ve talked to bodies that are out there to perhaps counter loneliness and isolation and things like that, where you have a bunch of volunteers trying to make it happen. But I do worry about sucking the citizen voice body back a level, because I think it could leave people very exposed. And, as we all know, by the scandals that rock some elements of the NHS, our health boards are not always great at delivering quality. So, do you see that that might negate some of their ability to sort out a problem quickly or immediately or bring it to the attention of a health board?

I think the fact that I didn't mention there individual support is not that I don't think they should do it in any way. Actually, when I was talking about a clear message out to the public in terms of who they contact on what, one of the things that we really value is that, very often, we will get people coming to us with individual complaints, individual concerns, which we like to hear about but are not geared up to support them with on an individual basis, and, in those cases, we would always refer them back to (a) the 'Putting Things Right' process with the health boards, but also signpost them to their local community health council, who can support them in addressing the concerns that they've raised with us. So, the fact that I didn't mention it up front doesn't mean that I don't think it is an incredibly valuable role of the existing community health councils, and I would very much like to think that they are there working with individuals, capturing those individuals' stories and helping individuals get their concerns addressed. 

Because, of course, your very excellent report on Cardiff and Vale that we've referenced before here was as a result of a CHC visit, and then they flagged it up to you and then you went and inspected and now there's a 'Putting Things Right' process going on. So, given the comments you've just made—and, sorry, I will bring in social care in a minute—and given the more strategic objectives you'd like to see the citizen voice body being involved in, do you think that they will have the adequate resources and funding and training and support to be able to deliver that as it's currently laid out in the Bill, or do you think more needs to be done?

I think the new organisation is going to face some interesting challenges in terms of how it balances what it does and uses its capacity well. I would expect them to experience some challenges. I think this may be something that needs to be addressed over time, because whilst in the first instance we're talking about not needing to do some things seven times, as maybe goes on at the moment, but thinking about how these things can be addressed once in support of the local teams, which may free up a degree of capacity—. I've heard the discussion about volunteers. I would hope they would continue to have local volunteers' feet on the ground who can support them in their activities. Of course, that's not part of that overall capacity, but I think there remains an unanswered question, which is, if they are very successful at raising their profile, raising awareness of what they're there to do, it's at the moment unclear exactly what that might mean in terms of the demand for their services. And I think they will need to be, from the beginning, keeping very careful tabs on how the nature of demand and volume of demand is changing in order that they can, if necessary, make the case that this is going in that direction.

I think it's also quite strong in the Bill that there are provisions for both health boards and local authorities to help in that promotion of the role. I'd be quite interested to see how and the extent that that happens, because, whereas a visit is a way of understanding a person's quality of care and their experience, the ability to know about the CHC, how to go and communicate with the CHC, and how to enact that support, is really important. So, I see in the explanatory memorandum there's a budget for communications and to market itself as a new organisation and what it does. I'd be quite interested to see how the other bits that are on the face of the Bill in terms of the health boards and local authorities' responsibilities to promote those services of the CHC will play out. 

On the social care side, we're quite excited about and really support having a citizen voice body that goes across health and social care. And, as Kate has said, we can really see huge opportunity and how they can add value. When we do our inspections, whether that be in regulated services or in statutory social services, the thing that's the most important to us is what are outcomes like for people, and you can only know that if you speak to people and ask them what their outcomes are. During our inspections, that's a big part of what we do. So, if I can look at the statutory social services and the recent work that we did with Healthcare Inspectorate Wales around older people, as part of that, we go to big efforts to try to reach out to people before we go in, telling them that we're coming, asking them what their experiences are like. Then, when we're there doing inspections, we are having focus groups—any opportunity we can get to actually get to the people who are receiving those services. So, having a body that could help us with that and enrich that conversation. I could see really great added value in that. I think that's why it would be important to have good partnership-working arrangements so that we can plan that engagement activity. Again, that will be about speaking to individuals to hear what their experience is like. So, yes, we do really welcome this body and we can see that it can add value to our inspections.

Given your commentary about how they could add value to help engage with people and understand the reality on the ground, and given your comments, Kate, about the pressures HIW are under—you've got a lot of things to inspect and limited time and limited resources—why are both organisations uncomfortable with the CHCs continuing their role, as they have now, of being able to inspect or do unannounced visits to some healthcare settings? Surely, that's more boots on the ground that can feed back to you. I go back to the University of Wales example again—they found something you didn't know was going on, flagged it up to you and you went in there and sorted it.

For me, there is a challenge in terms of making sure that we use the combined capacity that's in the system as well as we can. I think it depends on what the nature of those visits is. I don't have any problem with the members of the new citizen voice body actually going out and talking to patients. I'm not sure why the lack of a right of access necessarily constrains them. In fact, I saw part of the evidence that you had this morning, and part there was about community health council members going around with independent members, and actually going out and speaking to people with independent members.

I think the idea that you need a right of access and to turn up unannounced almost presumes that there is a resistance to your presence, and you've somehow got to—

There is in some quarters.

There may be, actually, but that is a really important cultural indicator when it comes to things such as duty of candour and duty of quality—the openness to those sorts of views. I cannot see why there is not a way for this body to engage with people in that way and to seek the support—because, after all, these bodies are supposed to be promoting their activities, to set up their stalls or to be present at a particular place in order to talk to patients, if that's what they need to do. I don't see why that couldn't happen without this. This almost feels like an unnecessary—you know, why would you want it? That's the bit that I can't quite get my head around, because whilst I'm not an expert in what's going on in similar bodies in other administrations, from my brief look at it I understand that even those that have it don't need it, very often, and very rarely use it.

That's what I was going to ask you, actually, because I know that in England and Northern Ireland they have the right to access. I just wanted to know if you had any experience of that and any feedback on how that works. I do understand, Margaret, that there might be some issues with it in certain social care settings. Of course, one can always exclude or include whatever you wanted, but I do think, actually, that you touched on the culture point, and I think it is fair to say that in a number of health boards there has been a real lack of trust that's developed over the years, and that this all about enabling the citizen to actually rebuild that trust, or the communities to rebuild the trust, with their health boards. I think it affects social care settings marginally less, because they tend to be much more personal and perhaps have slightly more longevity. So, whilst you say, 'Why would you want to do it?', I think others on the other side of the fence might say, 'Well, why won't you want to do it? What are you trying to hide? What are you trying to keep away from us?'

The danger is that we shape our discussion of what the new citizen voice body should do by focusing on what the previous role of the community health councils has been. I think one of the challenges, actually, with visits is that they face the same challenge that we face, which is: when you rock up for a visit, you see only what is present on that day and you see only those patients and relatives that are present on that day. I think that, to me, there are better ways of getting at some of that. Talking about what Margaret was saying, if you are working with the organisation itself to say that you are coming, you are able to encourage so many more people to engage with you. You're not limited to those that happen to be present. So, you can actually tell patients, relatives, carers that, 'We're going to be here next Tuesday. Anybody that wants to come and speak to us can come and speak to us—we'd really welcome that.' We could ask the organisation itself to make, maybe, a confidential room available to them so that they've got somewhere private that people can go and talk to them, or they can manage it in such a way to get the broadest range of views possible. I'm not going to say I'm not convinced what value it can add by going in, because, clearly, there is a value, but I'm not convinced it maximises the value that you can get by maybe approaching the similar challenge in a slightly different way.

I do understand that corollary, but I'd also use the corollary of, perhaps, Estyn inspections in schools. We've all been and know schools where they absolutely go hammer and tongs for a few weeks because they know the Estyn inspection's going to happen, to make sure everything's absolutely perfect, and then you have to ask yourself, 'Does that raise the standard? Does it allow it to be maintained afterwards?' So, the assessment unit at University Hospital of Wales—if they'd known that the CHC were going to come in, would they have just put on a bit more of a show that day and would that have actually picked up any problems? I don't know, but I think one can argue it both ways. I don't know if Margaret would—.

Yes, I've got a lot I'd like to say about this. I think, in terms of that—and I know there's been a lot of discussion around the powers of inspection and entry, and in our written response we have said that we don't feel that the body necessarily needs that in order to fulfil their role. From a social care perspective, that is principally around, but not only, the fact that in social care you're talking about people, whether they're receiving domiciliary support or, indeed, in a care home—a care home is someone's home; every aspect of it is their home. And I know some people can look at them as kind of like mini hospitals, but it is someone's home.

So, we feel strongly that people have the same right as everyone here has in terms of how they manage their own home. That's not to say that we don't think that the citizen voice body shouldn't be able to access people. Now, if the citizen voice body were to tell us that a provider was preventing them from seeing people, if they wanted to see them or if people wanted them to come in, we would certainly see that as an issue and we would take that as a concern about that particular provider, because we'd ask the question, 'Why? Why would you not want people in the home to be able to represent their voice?' Providers have, under the Regulation and Inspection of Social Care (Wales) Act 2016, a duty around quality and around having systems in place so that they can check the quality, and those systems—this could be an added value for the providers themselves in being able to test out what the quality is like.

I'm also aware that some people have shared concerns around—I think you described it as, 'In that moment where someone is having a very difficult experience, an ability of the body to act quickly.' And I suppose our feelings on that would be that where something is going wrong for somebody and something needs to happen, my worry would be that you've got a middle person then, and I would prefer that to come directly to us, so that we can use the powers that we have, not just of entry but also to do something about it and to get action.

And if you'll indulge me for a moment, we've got a very well-developed concerns process where people can raise concerns with us, and that would be the people themselves, their families, or, indeed, if the citizen voice body was to go and meet with somebody, they could raise a concern with us. And I've got two particular examples of what we do with those concerns. Last year—I have the number here—I think it was 2,150-something—excuse me, I can't remember the exact number—of concerns we received. As an example of what we do with those, last week, we had a concern from somebody who visited their loved one in a care home and were concerned about the level of activities that were on offer and they reported that people had said to them that they were not happy because they had nothing to do. Now, what we did with that concern: the inspector that's linked to that particular provision called the provider, spoke to them about activities and asked them what activities they had available and asked them to e-mail us to put down in writing what they were doing, and because we've got that relationship with providers and because we're the regulator, sometimes even a phone call can impact change. The next day, the person who raised that concern came back to us and said they could see a marked difference—the provider had reacted. Now, I don't want you to think that we just phone providers when concerns are raised. I can think of another example, and I was involved in this particular example, because I happened to be there. A concern came in on 23 December about significant concerns around people being got up early in a care home. At 5 o'clock in the morning on Christmas Eve, we were in that care home. So, we've got the ability to react quickly.

What I'm trying to say here is that, when things are going wrong, I would want those concerns to come directly to us so that we can go out, and when something needs to be done, we can use the powers we've got, not just to enter but also to make changes. And what that looks like is we can issue statutory notices to providers, giving them actions they have to take and timescales within which they have to take them. And in those circumstances, our view is that that would be a better way to deal with those. Again, that's not to say that we—. We can see that the citizen voice body could really add value in the social care sector, but in those instances, I think it's best for those things to come to us.

Just one final, hopefully really small question. We all know that the parliamentary review made great play about the importance of people, of the citizen actually now being involved in the delivery of their healthcare, whether that's at home or in a hospital setting. So, given that and given that the citizen voice body is supposed to be the voice of the people, do you have a view as to where their access into particularly health boards, I think, because they tend to be such huge organisations with so many different access points—do you have a view on where they should sit, where that voice of the citizen should sit? Should it be at board level, should it be on some kind of offshoot at the side, some patient quality engagement department? Do you have any thoughts on that?

My personal view is that, certainly, their local presence has to have access at the highest levels within the organisation. Now, that could be through potentially maybe being offered opportunities to talk to a board on a regular basis. I would hope that it wouldn't be an infrequent method of engagement, and I think, quite often, the quality and safety committees are those committees that are really in a position to hear what is coming out from the citizen engagement that's going on through the citizen voice body and act on it. But I'm not suggesting it needs to be an either/or. I think the information they will hold will be such valuable information and evidence for an organisation, I would expect them to have an interest in it at the very highest level, both with the executives and independent members, who, I would think, would also have an interest.

Margaret, I don't know if it applies so much to your area.

Of course, social services are rooted in local democratic accountability, so whether there's something there—. That was something we put into our response, about where would they report and would it be to—? Would they produce reports for scrutiny, perhaps? You've also got regional partnership boards, which have got health there as well, so maybe there's something there.

Yes, okay, thank you.

Could I possibly add one thing to that? Again, there is something to me about getting the maximum value from the citizen voice body, and they may not always receive information that is directly related to either health or social care. And I think we made the point in our evidence that actually they may be collecting information that is relevant to housing, which is relevant to transport, and I think it will be important for the new body as well to think about how it uses that to help improve public experience of those services more generally.