National Assembly for Wales

Diolch, Cadeirydd. Good morning. I suppose to start off, the Bill actually introduces this new citizen voice body and it's effectively ensuring there's advocacy for the citizen in this situation. But the Bill does expand upon the current community health councils from the health sector into the health and social care sector. Now, both of your written evidence papers seem to indicate that you believe the social care sector is already adequately covered. In fact, you highlight that the care inspectorate for social care is doing a good job. Yet, they're happy themselves for this voice to actually have the responsibility for social care included with healthcare in the advocacy. So, why don't you think that should be the case?

This is about putting the citizen's voice at the heart of the health system. That's something, of course, we support. But there is that fundamental difference between the way that health services are delivered in Wales and social care is delivered in Wales. Social care is either delivered or commissioned by local authorities, and local authorities are directly elected by local communities, and the citizen's voice is provided by members like me who are directly accountable to their local communities. So, if there's a problem with social care in Bridgend, residents come and see me about it. I know about it and I'm expected to do something about it.

Healthcare in Wales, as you know, is delivered by health boards. Health boards are not directly accountable to the people of Wales. They are accountable in a less direct route through the Welsh Government. There is that difference in the system.

We also, in local government, as you will know, have an overview and scrutiny process. So, if that direct level of accountability, with me and my cabinet—if that is not satisfactory to the citizen, the citizen will often go to the chair of the overview and scrutiny committee. And they can, and they often do, call in a decision that has been made by my local authority about social services in Bridgend. Those meetings are public meetings, and we're held to account by that.

We also have a very powerful inspectorate, the care inspectorate. I've just been through the enormous pleasure of an inspection of our services in Bridgend, and I can assure you that we are grilled over a period of a week, and that that care inspectorate has significant powers that it will exercise if it does not believe that the services that we provide are up to scratch. And my authority, as has every authority, and as has every provider in Wales, been subject to the powers that are exercised by that body, and they will serve notice. I've had notices served on my authority—every authority has—where they will expect improvements in that service. I've had some on children's homes in Bridgend, and you can read the reports because they're public reports. Each and every one of those recommendations has been addressed because of the power and status of Care Inspectorate Wales.

Let me stop you for a second because we need to separate the role of the care inspectorate as an inspectorate and the role this body will have as an advocacy and a voice for the individual. Now, if I'm right, what you've just said to me is you believe that councillors are the advocates for individuals in relation to social care, which is a very questionable situation, and that's not necessarily the case across Wales either, possibly. And it also depends upon the individual councillors' workload, in some sense, as well. But shouldn't there be a voice for both health and social care advocacy? Because we are talking about a far more integrated health and social care system, and your colleagues across Wales, including my own council, are shouting and screaming for, actually, more relationships with health, and therefore there needs to be some form of co-existence that allows that joint consideration.

Sorry, you're saying advocacy. The role of this—. If you mean advocacy in that stricter sense, then already that's available in the social care system. That's quite clear; we have a statutory duty to provide independent advocacy in the system.

Angela, you've got a point here.

Yes. Mr David, with the greatest respect, I simply do not recognise the picture you paint. If councillors were stepping up to the plate and taking on the social care problems that my constituents experience, then my postbag would not be as full as it is and my surgeries would not be as full of complicated situations. Very often, the people they have the issue with is the county council. And very often, the councillors and the officials line up together so that you have people who do not have a very strong voice trying to get good-quality social care out of county councils, and I don't believe that it's just in the area that I represent. I hear it from my colleagues across the Assembly, across all parties, north, south, east, west. It isn't a perfect world.

And as for the advocacy system, I've been here now for, I don't know, 10, 12 or 13 years, and in every committee that I've sat on, right at the very beginning, we were pushing and pushing and pushing for independent advocacy services, and I could take you out of this room right now and introduce you to probably, oh, coming up for a dozen people who simply have not got that independent advocacy voice. And my staff end up having to do that job, which is not my role. So, please, I don't accept that everything is great because it's not, and people don't have a voice and not all councillors are prepared to stand against their officers and actually try to resolve some of these situations. When it comes to social care, the ordinary person is up against their local county council.

Well, can I just say, I haven't said everything's perfect? And if you're specifically talking about advocacy—as I said, we have a duty to provide advocacy, and certainly in my local authority, that advocacy has been provided to younger people and older people. So, if that isn't being provided, that's something I'm more than happy to take up because that has to be provided. We have a duty to provide it. I don't know whether my colleagues want to come in on that point.

Thank you. Diolch. As Councillor David has said, social care very much has statutory duties to deliver formal advocacy. But in addition to that, as local authorities, we have various roles that have advocacy within those roles. So, at the very heart of social care, social care practitioners are, by their very nature, advocates for their local citizens. And I think social care very much is grounded within local communities, within the context of local government, and as such has a very, very robust complaints process and is already within a fairly complex situation within the local government context. And there isn't the evidence provided within the information that supports the need for further complexity in bringing this proposal forward for health and social care.

Can I ask you, why do you say, 'further complexity'? What further complexity do you actually see this bringing in?

It isn't clear how this would operate within the context of social care. It's very clear from the documentary evidence that there are issues of concern around the citizen's voice within the health setting, within the health context. But within local government, actually my own local authority has seen a reduction in social care complaints. We're very much embedding the Social Services and Well-being (Wales) Act 2014 and the Regulation and Inspection of Social Care (Wales) Act 2016 as well. And they're very much about how, as local authorities, we listen to the voice of citizens, and that we understand what matters to them and that we advocate on their behalf. So, those statutory processes are there, they're in place for local authorities and for social care, and this proposal, whilst we recognise the principles and we fully support the principles, which very much fit themselves to the context of health, it's very difficult to understand how they would fit within what is already a process within local government and within social care.

So, you can't identify complexities, but you're not sure how it fits in.

I don't understand how these proposals would add to the citizen's voice—

So, you mentioned complexities, but you haven't got an idea what that complexity is; you just believe that you have a system already working.

There are complexities in as much as the local government provides a vast range of services to its local citizens, and that's a complexity. Social care is not in isolation within the local government context. We sit alongside our colleagues in housing and within education. It's that complexity. So, when an individual—

Let me put this question to you, then: we have a situation where an individual, who has had health treatment and healthcare, is transferred into the social care sector, but the whole experience they've had is an issue. Where do you come in and where do you actually work with the CHCs to discuss how that whole package has been addressed? Or where's your cut-off point?

Mr Pritchard?

I'm not going to answer that direct question, but I'd like to contribute to—

All right. Well, if Nicola's in a position to answer that direct one, it would be good.

Okay. Those individual citizens aren't just receiving health and social care services; there are citizens living within our communities who will have housing, they'll have issues with their local community, access to other local services. So, it isn't just social care and health. The complexity is within the multitude of the services that local government supports and delivers within its local communities. That's the complexity I'm talking about. And to take social care and health into this new proposal doesn't necessarily explain or understand how it would still operate within the context of those broader local government services.

Okay. Mr Pritchard, then.

Yes. Social Care Wales, just to clarify, has indicated that it supports the principle of the citizen voice body. It provides an opportunity to provide better citizen engagement and a voice, but we do see, alongside this opportunity, significant risks. And those risks will mirror, to some extent, what my colleagues have said here before. We have, since 2011, in sustainable social services, developed in social care quite a robust approach to a variety of ways citizens can engage, and, clearly, we're not at the end of that journey, but that journey is one that's been broadly bought into and owned across the sector. So, that includes things like the complaints processes now in law, and includes things like the public services ombudsman, the commissioners for older people and children et cetera. It includes the new requirements on advocacy. The inspectorate themselves have developed an avenue that has proved very popular, where people can bring their concerns as citizens through to them. The danger here—the risk that this presents—is that it will add something into that mix that will, perhaps, undercut some of those existing and successful arrangements. I'm not saying that they're all successful or all at the end of that journey.

So, the implementation of this body will have to be done with significant care. I don't think anyone is denying that CHCs, after 40 years—there needs to be a fresh look at that and it requires primary legislation to do that. So, that is understood. But the addition of social care into that needs to recognise the landscape that social care has developed. In the health context, we're replacing something with something new, so we're getting rid of something and replacing it. What's on offer here is adding something into an already existing system, and that's where the risk lies. That, I think, is something we think requires some care, as we move forward.

Okay. David, have you got a last question?

No, that's all right.

You've covered it. Right. Angela.

Actually, I just wanted to pick up, Mr Pritchard, on what you said, because I do take that point and I do accept it and I think that it is something that has to be handled with great care. I think the issue at heart here, though, is the fact that when it works it's fantastic. I have seen outstanding examples of social care—absolutely outstanding—where people have been in real trouble, and, literally, the state has come and scooped them up and really, really put their lives back together again, and where they've spoken to everybody involved and they've involved housing, moved people with very difficult care situations or very elderly and frail people and really helped combat the loneliness and isolation that some people feel, and have tied in care homes and relief and all the rest of it. When it works, it's fantastic.

The whole point of that citizen's voice is that it's for when it doesn't work, or when there is an issue. I think one of the problems I have is that everybody who has—the organisations that have been more concerned about the remit of any potential new citizen voice body are the organisations that could be the ones that are held to account, like some of the health boards and so on. We've done all this—we've done so much work, haven't we? We've done the parliamentary review, the vision for health, the whole social care and well-being Act—all about empowering the ordinary person, hearing the ordinary person's voice. I think one of the issues that I have is that it's not perfect, and I do appreciate that there will need to be changes made to these proposals, but surely, just having that independent citizen voice body does the one thing that we keep saying we want to do, which is make an easy route for the ordinary person to go and talk to somebody to say, 'I've got a problem in this particular area.' 

I'm not necessarily saying that the citizen voice body should be the people who fix it or organise it, or even inspect it, because they might call in Healthcare Inspectorate Wales, or bring it to the attention of Care Inspectorate Wales, or bring it to the attention of the council or the local health board, but the fact that there's a person there who can do that, or an organisation. So, that's what I think my overwhelming concern is: why don't we want to have that voice for the ordinary citizen?

I'm not clear—. When you say 'the voice'—. Just to be clear, what do you mean? Somebody do talk to? Because you've talked about advocacy, Mr Rees—can I call you David? David. You're talking about advocacy, and we've explained how there's a role for professional advocacy, and, sometimes, it might be over the language that we're using.

If somebody has a complaint, then, if that's what we're talking about, in the first stage, we'd want them to go to the local authority and try and resolve that at the earliest opportunity with the service manager. In most cases, that is what happens. If that can't be resolved on an informal basis, then, obviously, there's a formal complaints process, and every local authority has to have that formal complaints process in place. If they're not satisfied with that formal complaints process, and you know that some people aren't, and the majority of complaints are dealt with through that route, then there is the opportunity to go to the ombudsman.

Sometimes people go to the older people's commissioner, sometimes people go to the children's commissioner, sometimes people take up advocacy, independent advocacy at that stage. Sometimes they will come to you, sometimes they will come to me, sometimes they will go to their Member of Parliament, who will then refer it back to one of us, and sometimes they'll write to the Minister. So, there are lots of points in that process at which it will be escalated, so I suppose it's understanding where in that process this organisation would sit, and what difference it would make, so that if it can add value, great—we all want to improve the voice of the citizen even further.

But just in terms of that transparency, my authority will have a report on every complain and every compliment as well, taking on board the point that you made earlier, that most of the time the services in health and social care are of a very high quality, and we don't want this to be just a way of criticising staff that deliver front-line services. I've had a report—it's available for everyone to see in this room, a public report to my cabinet on every complaint and every compliment that Bridgend County Borough Council has received. We've been doing that for the best part of 10 years and we had fewer complaints this year than last year, and the ombudsman has written to me and said it's fewer complaints this year than last year. There's still a huge amount for us to do, but in terms of that voice, that voice is heard in the cabinet room of my council, but I'm more than happy—. We're always looking for ways of improving that, but can we do this in a way that doesn't add too much complexity?

Because I suppose my concern is at the moment, if I was a citizen that had a complaint but didn't know where to go, it's quite complex now. Do I go to the ombudsman? Do I go to my AM? Do I go to my MP? Do I go to my councillor? Do I write to the Minister? Do I go to Care Inspectorate Wales? Will I go to this new body? Do I go to the older people's commissioner, do I go to the children's commissioner? So if we are going to have new powers, I think we need to be very clear about where they sit and try and make it easier for the citizen, because absolutely when things go wrong we need to make sure that that person—. And I hold my hand up if it's gone wrong in Bridgend, but I want them to have the strongest voice behind them to try and fix that problem.

Again, I hear what you say, and I understand your absolute passion. You are the leader of Bridgend county council, so you run a ship that's obviously really on course. Not every council in Wales is like that, and you're also sitting here as the Welsh Local Government Association spokesman for health and social care, and so I'm asking you to recognise that best practice is not everywhere in Wales. The other comment I'd just like to make as an aside, really, is that, from my experience, the people who come with complaints and issues are usually either the most vulnerable or the most complex or the most exhausted, because they've been bashing their heads against a brick wall. They don't know about the children's commissioner and the older people's ombudsman. We all do, because this is our job, but they don't know about it. The people they tend to go to—they might try their local county councillor. They'll definitely try their Assembly Member, because they get the health bit. They'll often go to their MP, who usually bounces them back to the Assembly Member. And they do know and recognise the voice of the CHC, because that's quoted a lot, it gets lots of traction. And so those people don't know about all this other stuff that you've mentioned. And secondly, I thought that one of our directions of travel was taking the antagonism out of it, out of the relationship between the citizen and the state.

So, we've got the additional learning needs Bill, and one of the whole points of the additional learning needs Bill is to ensure that we don't have to go to tribunal, to try to stop that sort of escalation. So really we have a complete fail if one of our citizens is actually having to contact the older people's commissioner or the children's commissioner for the public services ombudsman. He came here and gave extremely credible and direct evidence about where his complaints come from and the things he sees, the lack of ability for cross-organisational working. And David's point was about the integration between health and social care. People shouldn't have to think, 'If I've got a health complaint, I complain there, and if I've got a social care complaint, I complain here'. It is about empowering that person. so, I just wanted to make the comment that the people who know how to complain, and who are bold and brave and can think things through, are already dealing with whoever it is they need to deal with; it's all the others who just don't understand the game, and it's empowering them so they've got a voice.   

Can we carry on with scrutinising this particular Bill now? 

Yes, indeed. All right. I also do want to challenge the citizen voice body; I want to make sure that whatever we end up with is the best it can be. So, I just want to pick up—yes, it's your joint response. Can you just explain how the regional partnership boards might fit into this better? Because you do talk about the regional partnership boards, believing that, in fact, maybe they could play a greater role in this integration work. 

All regional partnership boards will have regional citizen panels, and the citizen panels consist of citizens from across the region. And it's their opportunity to help shape future services, and also provide feedback about the services and the provision currently in place. I don't think there's an equivalent in the health service—correct me if I'm wrong—but, obviously, that's quite a powerful voice, as you've probably experienced yourself. These citizens are supported to have their say, and they will certainly have that. So, we would want to make sure that that isn't lost and is built on in the system and, again, that we don't have, I suppose, too much duplication, because they are relatively new, as RPBs are. Sorry, I shouldn't use the acronym—regional partnership boards are relatively new. But those citizen panels have been considered a critical part of that infrastructure, again, to try and boost the citizen's voice as much as possible, particularly—and this is in response to your point and David's point around that—those joint services that we're seeing more of. They're very helpful in that regard. 

In addition to that, actually, on the regional partnership boards, there are service user representatives, there are carer representatives, there are third sector voice body representatives. So, those structures are in place as well at a regional footprint, following the different structures across Wales. In addition to that, at a national level we also have the national social care partnership board, so there are so many places at which the citizen can raise their voice, and we absolutely recognise that and want to hear that. That is about how we learn, we develop, we improve. So, there are so many opportunities for individuals to raise concerns, to have a voice, to be represented both at a local level, a regional level and a national level.   

Okay. Moving on. 

From what you've said and your papers, I sort of already know your views on the right of access. Does anybody want to make a public comment on that—the proposal that the citizen voice body would have the ability to access people in care settings?

One note of caution in terms of powers of access in relation to health: most healthcare settings are not people's homes. The vast majority of social care is delivered in people's homes. So, when we're talking about power of access, we just need to be very careful that we're not talking about an institution; we're talking about someone's home. So, I just think that the lawyers need to give serious consideration to that, because there's obviously a right to people's privacy within their own home. So, it'll either be the person being cared for, their home, or their loved ones, their carers. So, we, or the National Assembly, or the Welsh Government, need to think very carefully about that. I understand the rationale and thinking about wanting it, but let's be very clear that we're talking about people's homes if we're talking about power of access and social care, and, even if they're settings, if they're residential settings, they're still people's homes. An older people's home is someone's home, and you just need to be very careful that you can't just say, 'We want power of access.' That individual, even if they're in an older people's home, has a right to privacy. And the same for children's homes. Of course, there are some instances—you know, respite places and day centres—where that isn't the case, but most of those settings, where there are settings, if we can use that term, are people's homes, and we just need to be very, very mindful of that. And I'm sure you will be. 

Okay. Mr Pritchard on this point.

Yes. I don't disagree that the power of access is a hugely significant power to give to any group of people or body and should be done with great care, and I don't think there's a case been made for this at this stage. But I do think that's different from the ability of the organisation to inspect and look at provisions, particularly things like care homes, and I think that's a different issue. We, I think, would support that in the context of empowering this body to work with CIW, Care Inspectorate Wales, to undertake their role. I don't think we should have two inspecting bodies, but we should make sure that the powers of this body allow it to work alongside and in partnership with CIW in their work. And that's a different issue, and we would support that. 

Okay, Angela?

I'm just about finished, Chair. I just wanted to—. I wanted to ask if there was anything else you would like to add to the Bill to make it stronger or change it, but I think, given the kind of conversation we've had and also the evidence—and you talk about moving towards world class, the review of community health councils, and the commentary you've put here about—. And you're right, there's variable performance; some have got a good public profile, some have got a less good public profile or a non-existent one—you know, the professionalism of the membership, and I don't mean they have to be a professional, but their ability to carry out their functions. So, as well as sort of just saying, 'Is there anything you would have preferred to have seen or not seen in the Bill?', do you think there's a need for it full stop, or do you think we should just get rid of CHCs?  

No. There's certainly a need for that citizen voice in both sectors—make no bones about that. I suppose what I'd ask is, if it will have powers over social care—obviously that's primarily why we're here today—that very serious thought and consideration is given to how that can work in partnership with the other agencies, if I can use that term, that work in this area, so that there's not duplication, so there's not confusion, and there's clarity around the different roles and responsibilities. And where, for example, there are citizens' panels or inspections, or whatever it is, that they're done on a joint basis, because there is a cost to everything, isn't there, and there will be a cost to this. And also we know that, any organisation that delivers services, the minute you mention an inspectorate or a citizens' body, they respond in a certain way and they've got to complete reports and—. And what we hear a lot of the time from the sector is that they feel very inspected and measured and held to account—and that's right. But, if we're going to do that, we want to make sure that it's done in the most effective way as well, if that makes sense. And also so that, if they're going to arrive at judgments about services, we don't want them arriving at a judgment at this point in time, and somebody comes along and comes up with a different judgment, say, six months later. So, there are ways, there are practical ways, that I'm sure that you'd want to consider to minimise that if it's going to be responsible for both.

Okay. And Mr Pritchard.

All I would say in response to the question is that I think that it needs to be remembered that this new body will be working in, effectively, two parts of a system that have different inspection regimes—two inspection bodies with very different powers. And Ruth Marks's review of 2014—

We're coming on to that, as separate things, in the next group of questions, the potential complexities of—

Oh, right. My apologies.

—multiple inspections. The power of foresight, in fact. [Laughter.] To that end, Jayne Bryant.

Thank you, Chair. Right. Coming on to inspectorates—[Laughter.] Mr Pritchard, in your written evidence, you say one concern is how the Bill helps to achieve parity between Healthcare Inspectorate Wales and Care Inspectorate Wales. Do you think it's a missed opportunity to reform and integrate health and social care inspectorates?

My understanding is that the Welsh Government have committed to bringing proposals in relation to that forward in due course, that this would be—. This isn't, if you like, an abandonment of that ambition; it's just about the timetable for delivering that. And we certainly would continue to support that basic intention to increase the parity between those two bodies, both in terms of their powers—and it is true that, in social care, the inspectorate is significantly powerful in terms of what it can and can't do, following the Regulation and Inspection of Social Care (Wales) Act 2016. But those powers are not reflected in Healthcare Inspectorate Wales, and I know that the Welsh Government recognises that, and seeks to address that. This Bill may have been an opportunity to do that, and, initially, I think that was the intention and the hope. It hasn't happened. So, we hope that it—you know, we continue to support that at a future date.

Okay. Jayne.

Okay. Thank you. Just moving on to the issues around duties of quality and candour, do you have any thoughts on that in the Bill? I note from the WLGA paper that, on duty of quality, it says legislation on its own is not particularly effective in addressing quality. Any points on that?

I think we recognise that the duty of quality and the duty of candour are really important. But we believe that there is already a duty of quality placed on local authorities. So, we already co-operate with our relevant partners, and we do that on a day-to-day basis. As has already been mentioned, we have a new regulatory framework within the Regulation and Inspection of Social Care (Wales) Act 2016, and that gives existing duties and frameworks, again. This would give those reciprocal duties to the health context, and we would welcome that in the context of health.

Broadly speaking, I think we support the duty of candour—I think it's the right thing. We all want more openness and transparency—that can be only a positive. I suppose I'm bound to make the point that, just placing that duty in itself is not going to change a huge amount—it has to come with a change in culture. That will come through comprehensive training, and leadership that will come. And I think we're travelling in that direction, but it will need to be supported in that broader sense around training and leadership and some resources, and it being across the whole system as well.

Do you see any merit in having any sanctions for non-compliance to enforce duties of quality and candour?

Well, I suppose at the moment, in terms of quality, the sanctions, certainly in terms of Care Inspectorate Wales, are already there and used appropriately, in terms of the notices that I talked about earlier and other powers, and, indeed, in the worst-case scenario, they can close settings down, and that has happened in the social care sector in a way that you could say has not happened in the healthcare sector. This is the point that I was trying to make earlier around that there are differences in the system.

But, that said, I think the duty of candour would be progress, and maybe we should consider the impact that it would have. If it doesn't, on its own, achieve as much of an improvement as we'd like it to, perhaps we could consider sanctions following its introduction. Does that make sense? Because I think that we need to be careful that we don't go in with an iron fist here, and we don't want people to be fearful, I guess. That's one of the issues around that candour. But I think that it's something that we should consider if the duty is put in place. That's my issue.

Mr Pritchard.

Just to say, on an individual and professional level, of course, regulation of workforce is a place where an open, honest approach to your work is one that is required. So, at an individual, professional level, for example, a social worker who is not honest and open about their work could face sanctions through their licence to operate, effectively. Clearly, for those in the health sector, that will be something that is done through UK-level regulators, their code of practice, their expectations. So, this work will need to link in with that and make sure that they reflect and understand these changes that are happening. That's at a professional, rather than at an organisational, level.

Okay. Jayne.

Just finally, Chair, I was going to ask if you thought that there were any other things that could be added to the Bill to help improve openness and transparency and address known barriers to disclosure in the NHS, and are there any lessons that can be learnt from social care?

My only reference is—. I haven't got anything to offer in direct response. It is a mixture of both culture and enforcement and legislation, and a range of things that will help encourage the culture that we want to see. The Regulation and Inspection of Social Care (Wales) Act 2016, for example, does place duties on the inspectorate and Social Care Wales to share information about the well-being of individuals if there's any concern that those individuals will be at risk. So, there are some—. In reality, that isn't the reason that the two organisations work closely together, but it does set out a message and, if you like, legal support for us to share that kind of information.

Okay. Thanks, Chair.

Okay. Lynne Neagle.

Thanks, Chair. Some witnesses have told us that they think there's—. They've called for extra provisions to address a perceived imbalance between clinical staff and non-clinical managers. Would you support a system of regulation for non-clinical NHS managers?

You can answer that one, Nicola. [Laughter.]

I'm a social care practitioner, not a health practitioner. I think if there's a recognised imbalance in the system then that imbalance needs to be addressed. So, I would support any imbalance being redressed.

Can I—? Apologies. As a regulator of social care managers, we obviously believe that that provides a benefit to the social care sector. It provides an opportunity for a line of accountability to be drawn at a professional level. We don't have a position as an organisation around healthcare management professionalisation, but clearly we would be happy to support any review or investigation into the benefits, or otherwise, it has provided into the social care sector.  

Okay. In relation to this, the RCN told us that they thought that the 'responsible person' concept in social care was a model that could be used in this area. Can you just tell us a little bit how that works, and whether you think that might be something that could be moved over to health service managers as well? 

Yes, certainly. The responsible manager—responsible adult—position is something that we've had for some time, and, again, it underpins the approach of social care and social work, which is really about putting the individual at the heart of any process that they're involved in—that what matters to them is at the forefront of any decisions, and that they are party to the decisions made and decisions are made with them, rather than for them. So, that would be something that could quite easily lend itself within other settings, not just health and social care, but within other contexts as well. 

There are a number of repeating definitions of what—. In the Regulation and Inspection of Social Care (Wales) Act 2016, of course, the idea of a responsible individual at a provider level was brought in, which provides a line of accountability at a senior level within an organisation for the services that are delivered. Now, I think for social care that provides a very welcome change, because what it does is it makes a clear connection between an independent private or third-sector provider and the services that are delivered in their name, as it were, and it makes that accountability very, very clear and helpful.

Of course, in healthcare, the majority—well, in terms of this, we are looking at a publicly provided provision. So, it is a slightly different issue, in terms of the accountabilities of those individuals. We have responsible individuals in local authorities who are representatives essentially of the director of social services, and I know, in Nicola's area, for example, that a responsible individual has commented on how positive it has been to go and visit those—. One of the requirements of a responsible individual is to go and visit settings, to make sure that they are running as they are, in addition to their other day-to-day work, and that has proved a positive engagement. But care needs to be taken with public servants, of course, working in that, because the responsible individual role primarily in social care is placed on the private or third sector owner or deliverer of services. 

Okay. Thank you. And just finally from me, are there any other barriers to implementation that you are concerned about that you'd like the committee to look at in relation to this proposed legislation? 

I think one has to—. Resources are important here, and the investment in making sure that—. Over the last 10 years, I think all of us who have worked in social care have genuinely worked hard to engage with the systems. It isn't necessarily straightforward. People are living their own lives. Let's say you're inviting them for a focus group; it is taking a day out of their time, they have to travel, they often—. It's not a straightforward process. I think understanding the implications in terms of resources of a genuinely engaged citizen voice is one that's important to make. And I suspect that if the ambitions of this are achieved we will actually see an increase in activity, in complaints, and hopefully compliments too. So, there will be I think a greater activity level than perhaps is forecast at this stage. 

Thank you. 

I suppose not a barrier, but just a concern—and I'm sure it will be a concern shared by you, and I'm sure you can get it right as well—is just that we're moving from local community health councils to a national body. And I see the value in that, in terms of scale, in terms of sharing best practice et cetera, but I just think we need to be careful that we don't lose that local level of expertise and accountability. Because, just as David said, people don't want to lose a day or an afternoon or morning of their life going to a focus group, but if they've got to come from Pembrokeshire and go to Cardiff for that, that's more difficult again. And also, let's face it, people in Wrexham may not be as interested in the issues in Cardiff, or people in Anglesey—. So, that's one of the concerns for me, but I do recognise that the body will try and reflect that. And that's again why it's important that it works with the other institutions and agencies that work in this area—so, it uses the citizen panels, for example. I think that's the main concern for me, aside from the areas that it's going to cover in terms of social care as well as health. But just making sure we don't lose the local in the national.

Thank you.

Okay. Just a couple of specific points—David.

I've just got one question, if that's okay, because it is important. In an earlier answer to Jayne Bryant’s question, Nicola Stubbins, you mentioned you already have a duty of quality upon you. Now, one of the questions we’ve been raising very much—and it's a concern for other bodies, particular in health—is what is the definition of quality by which they should be assessed, and should we be putting that on the Bill. Now, the question is: if you’ve already got a duty of quality, would a definition on the face of the Bill be more challenging to local authorities and the social care sector than perhaps to the health sector, which might need to have that definition?

You'll be aware as Members of the work following the social services and well-being Act, which, in a sense, set out what outcomes should be achieved for individuals. That Act did say, ‘these are the things that matter’, and over the last few years, there’s been a lot of work in the Welsh Government to develop indicators and an understanding of what that actually means in terms of individuals and the care that they receive. So I think that provides a useful good basis, and I wouldn’t wish to provide any advice to the committee on whether it should be on the face of the Bill or not, but I think what is now in place, and the work that’s going in terms of the social services and well-being Act, should remain. This shouldn’t cut across it—it should be in line and consistent with it. Because I think that’s the genuine way the sector is trying to deliver against, and we should be supporting that.

Just to add quickly that, at the heart of that Bill is that it’s down to the individual what outcomes they want. It’s very individualised, isn’t it, in the social care setting. So, to identify what is qualitative is more difficult. But, actually, we are trying to measure that, so there’s been a huge drive and a huge improvement in terms of—. So, again, I talked about that report that is available on www.bridgend.gov.uk, where—

Has it got your picture on the front of it?

We actually ask the citizen, ‘Are you happy with the service?’ and they define that quality, because it should be very individual in terms of how you define that.

I would just agree. I've written down 'Quality is about individual outcomes.' The individual has to set for themselves what they deem to be quality, as opposed to us setting what we believe is right for them, and that’s a difficult shift of power, but it’s the right shift, and we’re working on that.

I've just got a couple of points to round off, from evidence mostly from elsewhere, actually. It’s specifically about the citizen voice body itself. You’ve all touched on this anyway, but, obviously, when we’re talking about the workload for the citizen voice body—if it’s going to do all the health and social care and stuff—and the regulatory impact assessment says that there are going to be eight additional staff employed nationally to deal with that, what’s your view on that adequacy of that number and the challenge they would face?

For me, form follows function, and we really have to be clear what the function of this new body would be—the breadth and scope of that—until we can really understand that, and how it would interoperate with the other regulatory bodies, with the existing systems, both within health and social care. It’s very difficult to quantify the capacity that would be required, and I think you'd need something, obviously, to start that process, but it would need to be revisited on a regular basis. I think the worst thing we could do is establish something that then didn't actually meet the voice and the needs of our citizens. That would let them down dreadfully. 

The only thing I would add is that, clearly, this body will have both strategic input but also there was a suggestion it might have casework, essentially, working with individuals. As a body that, obviously, deals with individual issues, referrals and complaints, I think it's wise not to underestimate the time, effort and resources that need to go with dealing with individual casework in that way.

Absolutely. And a similar sort of point, but, obviously, many people from the CHC sector have said that, actually, powers for this new body should include a formal right of response, really, to any representations they make as a body. They may come up with some conclusions to whatever the event is, and they would expect some sort of formal statutory right of response from whichever body is facing the examination. What do you think about that? 

Within our existing complaints process within social care, which we said earlier is a very robust process, if we go into that formal process—and as Councillor David said, we do, in the majority of cases, resolve those issues informally before we get into that formal process—but where we do, then there are written responses to the individual and their representative with their consent. So, that's part of our process already and if it were to go on and to escalate into the ombudsman or other regulatory bodies, then those written responses would be provided as well. So, for us, that's already part of our process. 

Okay. And the final point from me is: obviously, as Councillor David expertly picked up in this legislation, it is a national body now, but, obviously, they're going to be appointed by the Minister. Some people have said, 'Well, actually, how about a greater degree of independence?'—how about these people being appointed, say, randomly, I would suggest, by the National Assembly for Wales a whole as opposed to just the Minister in charge. Have you got any feelings about the independence of this new national body? 

It's an interesting question. I think that once those individuals are appointed, I'm sure, as they are across all sorts of organisations—. We have many appointees of Welsh Ministers and, in the main, as far as I can see, they will discharge their duties in an independent way. But I do understand the point you're making about perception around that. So, there may be a different way of filling that—appointing to that body—but I haven't got any firm views. But I think it's an interesting point.

Okay. Any other views?

As a representative of a Welsh Government sponsored body, obviously you understand that I believe it could be perfectly legitimate and—[Laughter.]

Nobody is suggesting anything. 

I couldn't possibly comment. I do think, in a sense, what we do welcome is that this body isn't being placed in one of the existing parts of this—. If it was a part of the NHS, I think that would have been a problem for many people in social care. So, that was a key consideration, I think: that it would be able to be embraced across the two sectors. 

Thank you, Chair, and good morning.

Good morning.

I just want to talk, Minister, about the duty of quality because in the evidence sessions that we've had from various witnesses, one of the, not concerns, probably more questions that is raised on a frequent basis is how would quality be measured, and how would it run through the system in a way that might be different to the way it currently runs, because, obviously, we do have quality standards already in play. So, you talked about, in your evidence, that you'd want them to follow the:

'internationally accepted definition that outlines six domains of health care quality, put forward by the then Institute of Medicine.'

Could you explain just a little bit more about what those extra duties of quality are that you would see this Bill would be able to bring into play that are not in evidence at present?

Yes. So, it’s a broader definition than the way that the current quality duty currently works, and I think you've had some evidence on this from some of the NHS chief execs—I think Carol Shillabeer made the point about service provision around the broader understanding. And so, that definition that we've referred to is in the explanatory memorandum in paragraph 11, and it sets out a range of fields to be considered that I do think are broader and go beyond the current definition and the way it’s understood. And it’s also then about the duties to report on how that’s been considered at a decision-making point of view, about the way in which a service is organised and delivered. Whereas, actually, if you're just talking about the straight service provision—the front line and how you interact when a health professional is with you—it’s certainly much broader than that.

And then what we've tried to set out in the scheme is that we'll have not just reporting, so there'll be scrutiny. So, health bodies will have to turn their minds to how they have actually implemented the duty, as will Welsh Ministers. And I think there will be plenty of room for scrutiny of that, which I think will be helpful. And it’s then about being able to evidence and see through the way that our system works, if we see the shift that we're looking for. So, you'll have lots of different points of scrutiny that will come in. You'll also have the guidance we'll be producing. So, we're going to draw people in, not just to the Bill and the previous work we’ve done on the White Paper, but it will then still be about how we draw people to understand what that means for them in the way they provide their service, what that means for the way they interact and plan their service. And that also means, of course, drawing on other partners as well, because we're deliberately trying to build in a more integrated approach to health and care, and I think that this broader duty is a good way to help deliver that.

Could you give me an example? So, as a lay person, what you say here is:

'The new duty takes us beyond the current duty’s rather narrow focus on service standards and quality of services provided to the individual.'

So, if you are in receipt of some kind of help from either health or social care, or both, then I would imagine that service standards mean that you're going to be provided with this service at this particular high level, so, tick, you've already got that duty. And the quality of the service will be the outcome: are you receiving it not just in a timely manner, not just by a professional, which would be the service standard, but the quality would be, perhaps, are they kind and has it achieved what you as a person wanted it to achieve? So, what other quality are we adding with these—?

If I can pick up on that—. If we go back, perhaps, to 2016 when we had the Organisation for Economic Co-operation and Development review, one of its reflections was that, particularly within the LHBs, we hadn't realised the potential of the LHB model and particularly their population health responsibilities. So, I think where we are with the duty of quality at the moment is that we're still predominantly focused in the old provider model, if you like—the NHS trust world of providing services. And, obviously, LHBs have got a massive responsibility in terms of the provision of health and well-being to their population as a whole, and a huge commissioning role as well, actually. So, we want them to take a much broader approach to planning the services for their population to ensure that they secure improvements as a whole across the range of things they do, not just on the things they directly provide. So, that's really important in terms of the prevention agenda as well. So, making sure that—. And bringing in the equity of services as well.

So, I think we touched on last time the example around screening, that we know that one size does not necessarily fit all. We know that in some of the screening services there's not good uptake in some parts for some of our population. So, they need to look at that and say, 'So, how do we do it differently to secure the improvements?' So, you need to set the standards, but then it's how you deliver those standards. That's where I think it's making sure that there's much more thought given in the decision making in terms of, 'How do you deploy resources to actually meet some of those standards for your population as a whole, as well as the individual as well?' So, it's getting that balance between the population need and the individual need. 

Yes. I think that clarifies it, actually. Thank you very much. So, taking that point forward, then, I'm sure you'll be aware that a number of our witnesses would actually like to add to the Bill to ensure that some of these qualities—. So, for example, Public Health Wales and health bodies think that there's that insufficient focus on prevention, but they'd like to have it in the body of the Bill. The Royal College of Nursing, the British Medical Association, the Royal College of General Practitioners, they'd like to see a workforce planning and staffing level element, which, I kind of see, but I also recognise that the Nurse Staffing Levels (Wales) Act 2016 starts to address some of that. And, again, the Welsh Ambulance Services NHS Trust, they would like to see a bit more added to the Bill asking for more definition of quality in terms of social care collaboration. So, I just wondered if you've had any thoughts about that evidence, which you'll have gone through, that we've heard, and if you have reached a view on whether or not any of those organisations' suggested amendments or suggested comments about what could be added to the Bill have merit.

Well, look, there's lots of merit about how the duty of quality's actually delivered and you have to separate out what needs to be on the face of the Bill and what commitments you'll look for about how that duty of quality will be developed, because I've written to the committee setting out how we want to set out the scheme of the guidance that would accompany this and how we'd want to deliver that guidance. The danger is, if you think about all the different things you've just gone through, if we took on board all of those, we'd very quickly expand the front of the Bill and I'm not convinced that that is the right way to deal with the legislation because we'll end up having a book and we'll have to describe in that how you'd apply the duty of quality in a number of different circumstances. Well, actually, that's why we're talking about issuing guidance, because you can then describe a number of circumstances in an illustrative way and I don't think the front of the Bill is the place to do that.

So, that's why writing to the committee, I think, was important, to be able to set out that this is within our mind, this is how we consider how we want to implement the duty. So, the front of the Bill is the point where we set out that there will be a duty of quality, we set out the broader range of that, and the guidance will then come in and provide much more of the detail that people are talking about. If you look at the explanatory memorandum, that stuff about population health is very clearly in this, not just take the six fields, but it's the definitions that come under that. I think it's pretty clear, if you read paragraphs 11 and 12, I think that's really quite clear about how we're talking about wanting to see this broader duty delivered. But, I don't think you'd want paragraphs 11 and 12 to be translated into clauses in the Bill. So, that's why there's this balance: what's on the Bill, the commitments that we give and I'm sure you'll want us to re-give about how that guidance is developed, and how that provides a practical guide to how we expect that duty to be carried out. That will obviously then be taken into account not just by NHS bodies, but by the rest of the scrutiny architecture we have around the service, whether it's for elected Members or indeed our regulators and other stakeholders.

Should this guidance be statutory or non-statutory, in your view?

At the moment, it's non-statutory, but again, I'm interested in hearing from the committee and if you think there's a particular difference between the two. I don't have a closed mind to that, but I think in reality the health service will take proper account of guidance that we issue. I don't think they're just going to say, 'Well, we'll do it if we feel like it.' Otherwise, it'll just disappear into the recycling basket. But, look, if the committee have heard evidence and you think there's a view about the difference between statutory and non-statutory, then I'm of course happy to consider that. 

I'm certainly not implying that the health service would ignore guidance. However, I think it's very clear that, when organisations are under extreme pressure to deliver and they're short of staff and they're involved in doing the day-to-day job, guidance can come along that gets left to one side or doesn't get implemented correctly, particularly when it's to do with integration, i.e. having to go and talk to another set of organisations and make sure certain things happen, simply because of pressure of work.

We've had a fairly interesting session this morning with representatives from the local councils. There are many instances throughout Welsh public life where guidance issued by Welsh Government that's not statutory is on a pick-and-mix basis by different organisations throughout Wales. And if you are really going to effect the change that you, I, all of us, would hope this Bill would deliver in terms of quality and candour standards, then I would ask that you do consider that. Because statutory guidance does carry more weight, and we do not want to be left in a situation, surely, where the levers for change are not applied effectively and consistently throughout Wales at the same time.

I'm happy to consider that. Like I said, I certainly will take account of the report that this committee provides at Stage 1. Like I said, I don't have a closed mind that says, 'No, absolutely not, anything the committee says will get rebuffed.' So, I'll be interested to see the evidence that you've heard, because I haven't managed to listen to all of it. I've been in a different Government meeting this morning, so I've not had the opportunity to hear the evidence you've heard this morning. But, I will then properly consider the points the committee makes. And it's not just the debate that takes place in the Chamber, but it is what happens at Stage 1 and Stage 2 and 3 as well.

Can I just touch briefly on sanctions? Because again we've heard different levels of commentary from witnesses about sanctions. Has any of the evidence that we've taken so far persuaded you that we should look at some kind of sanctions regime? I think we should remember you said one of the actions within 'A Healthier Wales' was to introduce a range of levers for change. Would some kind of sanctions system be part of that? Because we do see change happening very slowly in some areas.

I would need to be really clear about what sanctions people are talking about. Because it's quite attractive to say, 'There needs to be a penalty if you don't do something', on the one hand, and yet actually to get that into practice in a way that will deliver the sort of change we want to, I think, is rather more difficult. Because we're looking for people to implement duties around quality and candour that are about a different way of working and behaving that requires more openness. The challenge I think then is that, if you have a pretty straight-line approach to sanctions, you can end up driving people away from that. Rather than being more open, you end up having incentives to try and avoid the sanction, which doesn't necessarily lead to the openness and improvement that we're looking for across the system. So, I'm not persuaded that we want a sanctions regime around this.

We already have quite a lot of scrutiny around the health service. I know that every now and again people like to talk about the fact that there's a democratic deficit in the health service, and yet I'm here today answering your questions, and I regularly get the opportunity to answer questions in the Chamber, which is very good of you. All of you have relationships with your own local healthcare providers as well, so there are quite a lot of politicians with a very direct interest in the health service, and there's quite a lot of scrutiny that takes place in the way that our health service functions. We also have the escalation framework. We have an inspectorate as well, we have a regular conversation about each of the healthcare organisations in Wales and what the status of their operation is in a variety of areas, so it isn’t as if there is a light-touch approach to understanding what the health service does already. If we want to have a sanction regime on top of that, I'd need to be persuaded, and I'm not at this point, that it would actually help us to deliver our objectives, because I don't think the regime of fines that takes place across the border has a great record in terms of delivering on quality and candour.

Could you perhaps just explain also how you think that the duty of quality can be percolated out to the services that are commissioned, and will it apply to those directly as well, in both health and social care, because of course not all of them will be, for example, directly employed by the NHS?

Well, yes, as a commissioner, they'll certainly have to consider how the duties apply. That's the point about having a broader duty to apply. You can't simply say, 'Well, actually I've commissioned this service, so I don't need to worry about quality or candour.' That is absolutely not the position, and, of course, on candour there are duties that already apply under social care, and it's about healthcare having matching duties as well.

So, we'd expect, obviously, to see within any commissioning agreements, commissioning contracts and so forth are absolutely built into that. As I said earlier, commissioning is a huge role that the LHBs play, so we need to make sure it then expands the duty beyond the direct provision of services.

Sorry—the duty of quality?

Yes.

Health boards commission care from each other anyway. We have specialist providers, largely Cardiff and Vale and Swansea Bay, but they also commission in terms of services outside of Wales, but also within the independent sector from time to time as well. So, quality has to be part of the way they turn their minds to it, otherwise we'll have a pretty big hole in the duty of quality that we're proposing.

Thank you.

Okay. Moving on, then, to David Rees.

Diolch, Cadeirydd. Can I just start by going back to your point on sanctions, and you highlighted you didn't think—you weren't convinced of the need for sanctions yet? You did mention the duty of candour and duty of quality in that area, but would you be able to confirm that the failure to meet those duties would be part of the consideration for escalation of those health boards, to understand whether they need to be escalated to a different level?

Yes, of course. It would be extraordinary if, having introduced these duties, an annual report from a healthcare organisation didn't match up with, for example, the way that Healthcare Inspectorate Wales viewed the service in its interaction with it, and that it wouldn’t form a significant part of the discussion that takes place regularly on the escalation status of each organisation. So, it's certainly not something that exists on its own in an entirely different part of our service. It's certainly going to be part of the intelligence and the conversation, not just about whether they've provided a report, but the adequacy of it and how that's evidenced.

Okay. That is an important understanding. You might not be an advocate of fines because you don't see how the fines might work, but you are ensuring that they are focused, and that, if there is an issue, that issue is considered in further consideration of the escalation status of the boards.

Yes. I've clawed back money where we've provided it for specific performance, but that's because it's been clear how the money's supposed to be used and to deliver an outcome. If they haven't delivered that outcome, then we've taken some of that money back. I don't think you can take that approach to the duty of quality, because it isn't that sort of straight line—'Here's money for a specific purpose, for a specific outcome.' That isn't the way that we're framing the duty of quality.

Okay. On the duty of candour, clearly we've received evidence that indicates that HIW believes the duty of candour is too narrowly focused upon persons suffering adverse outcomes as a consequence of the failure of their care, but not necessarily being able to reflect the situation where someone suffers an adverse outcome as a consequence of their inability to access care. Are you looking at perhaps widening the scope to ensure that it isn't just purely a situation where there's a situation where someone would receive an adverse outcome because of the care they've received, but actually they haven't received the care because of other circumstances, and that is also something that we should be reflecting upon?

When you look at the duty as it's framed, I'm not convinced that that's an accurate reflection of what's actually in the Bill, because if you look at section 4 as drafted, the first condition is—sorry, section 3(2):

'The first condition is that a person...to whom health care is being or has been provided...has suffered an adverse outcome.'

Well, if you are taking part in care and you're waiting for the next stage, you've already had a referral, you're already engaged in healthcare. For example, there's a difference between someone who is on a waiting list for a heart condition for further investigation or treatment, whatever that is, and someone who has an undiagnosed condition and suffers an adverse outcome, or someone who then has a healthcare problem at that point. One of those people is already engaged in healthcare and healthcare is already being provided, and with the other one it isn't. So, actually, the duty—

There is a difference there because one is engaged because, as you say, there's been a diagnosis and a referral, and the other one has not even had a diagnosis, and therefore is unaware of a condition. But the situation I suppose I want to look at is: are you therefore comfortable that the definition you have defined includes a situation where they've been given a diagnosis and they are awaiting care, therefore they haven't actually received that care yet, they are awaiting care? Is that part and parcel of your definition?

But they've already had care, haven't they, to get to the point of understanding—?

They're still waiting for treatment, then.

But that's the next stage of treatment, isn't it? Look, if someone's seen Dr Lloyd in their local surgery and he says, 'I'm concerned, I think it might be this, let's do something else, and I'll refer you to someone else'—so, say that's what he's said. Well, actually that person is a person to whom healthcare is being provided. So, it's the next stage in their treatment. Whereas if someone who's had no engagement at all and they suffer, for the sake of argument, a stroke or a heart attack—well, actually, healthcare hasn't been provided to that person. Whereas if something goes wrong in how they're treated, then actually the duty of candour would kick in, and I think that's the right approach to take. So, it is broad enough to cover those people if they're waiting. And we've changed a range of our performance measures on this—the single cancer pathway is a good example, the recent change in our eye care measures as well—because we recognise that our current performance measures didn't take account of those people who'd been in the system and waiting. So, we've changed some of our performance measures, and the candour duty would still cover those people in those circumstances.

You've given the committee your explanation and definition. I think that's quite clear on the record.

Can I move on to the—? If we do have a duty of candour report, what process do you envisage as to how these would be scrutinised to ensure that improvements are driven? Because one of the important things is that we drive improvement, we drive the levels of expertise and quality up. So, how do you see that process following on, and how will you be managing it?

In terms of the process we're going to follow, again we come to the point about the guidance and how it's drafted, to make sure we have guidance that draws stakeholders in, and I've written to the committee about that. I think that's important, about the way that all professional bodies want to engage in that as well, and then we've been very clear about what the regulations must include. So, we've been—. There's an element of prescription in the Bill about how that procedure is supposed to work already, and so we'll have people engaged about how the regulations work as well. I've already given a commitment—I think I gave the commitment when one of your members was in a different committee, in the Constitutional and Legislative Affairs Committee, about how we'd want to engage with the Assembly on the initial regulations that are produced anyway, because it will be the first time that they are provided. So, from the process of it, I think we're pretty clear about how we would expect that to work.

Okay, I'll leave that one for the moment. But we've also received evidence, particularly from general practitioners, in the sense of the burden that some of the processes may place upon smaller practices and smaller organisations, maybe even single-GP practices. Are you looking to assess the level of requirements upon different-sized organisations to ensure that it's not too burdensome to be able to undertake these duties?

Well, we have a balance to strike, don't we? Because if we say there's a different duty that applies if you have a single-handed GP than if you go to a general practice with four GPs and a range of other healthcare professionals, what we couldn't have is that there'd be a different duty and a lesser duty applying. We need to think of the proportionality and how people evidence they've considered and applied the duty, but I don’t think we're going to have different standards. But that's why we'll want to draw in different people. So, virtually every royal college have said they want to be involved in the consultation about how to draw up the regulations and the guidance, so we'll be able to work through those and, again, we'll have practical examples in the guidance we've produced about how we expect the duty to be applied.

To all levels—so, in other words, the practical guidelines you're talking about will be able to help a single-GP practice compared to, perhaps, multiple-GP practices and larger bodies.

Yes. If I can just pick that up, what we're trying to do with this is build on the requirements that are already in place under 'Putting Things Right'. So, primary care providers are already under that duty, and a reporting duty, so what we want to do is minimise the burden and add to that in terms of the reporting. But there are also quite a lot of other things that are happening across the system. There's a lot of work ongoing in terms of the 'once for Wales' concerns process, the system they use around data and how they record incidents. So, we're doing a lot of work to reduce the burden around actually the reporting itself, to make it easier to report and to give primary care providers access to that system routinely. Clearly, we expect the LHBs and the primary care teams within LHBs to provide sufficient support to help providers. We're very conscious of the fact that we need to help them to be able to do that, but sometimes, as the Minister said, we can't have a different standard, really. Individuals will already be under a professional duty of candour, so they're professionally required to be open.

I don't think it's a question of different standards; I think it's a question of how we ensure that the different size of organisations are able to deliver and meet those standards, basically. [Inaudible.]—in a sense, therefore, clearly you're talking about the fact there needs to be additional resources going into this to ensure that that level of support is there, and if you're asking health boards to provide that, I'm assuming you're going to be supporting health boards or financing health boards in that area as well.

Well, they should already be providing support already through the new requirements that are in place in terms of the PTR reporting. Again, we've dealt with that in the regulatory impact assessment in terms of what we see the difference being.

What about a situation where you provide a safe environment for staff to actually be involved in this? Because this is a culture change. There's clearly an intention to improve the culture within organisations, to make them more open, more transparent, but that takes time, but it also takes confidence of individuals. Are you doing anything to ensure that there is going to be that safe environment, and people have that confidence and they're able to undertake that duty of candour within that environment?

I think most of that comes down to the training and the awareness and the support, so we intend, as we've set out in the RIA, to provide a lot of training to different groups, different areas, and, again, as the Minister said, we've had lots of engagement with royal colleges, the BMA, General Practitioners Committee Wales et cetera, in terms of making sure that we do this in a co-operative and inclusive way, so we can get everybody to the table to come up with something that's fit for purpose. Clearly, we want to support people to do the right thing, so that's a big element in terms of our implementation plan that we'll need to put together.

It's underscoring the values we expect to see in the service, whether you're working in a hospital, or if you're a district nurse going to someone's home, or if you're a therapist operating out of a room in a general practice. The values that we expect to see driven through should mean that people are supported, and we recognise that our system isn't perfect in that sense. We recognise there are people who say that they've had concerns they've tried to raise and they don't feel that they've necessarily come out of the right side of that. So, this is something about saying we want people to be more open, there's got to be more acceptance. There's a challenge for staff on the front line, but also at leadership levels as well, to reinforce the values we expect in the service. And this is a culture change, so I wouldn't artificially say, 'It'll all be done and dusted within 12 months of the Bill being implemented.' I think it will take a longer period of time. For me, it's important that there's honesty about that as well and about the varying stages of progress we make to get to where we all want to be, regardless of which side of the political fence we sit on.

In a sense, some of the royal colleges talk about this freedom to speak up, the guardian type of approach. They have different approaches to this. Is the Welsh Government not going to be prescriptive in any approach that should being taken to support staff? I'm assuming there's at least an expectation, therefore, you're saying, that these things will be in place.

I think the freedom guardian is a bit of a different issue, isn't it? It's more about, generally, staff raising concerns. Obviously, that's one way in which you can do it, but there's a whole load of ranges in terms of ways staff can raise concerns—through trade unions and so forth. So, I think that's probably a little bit different to discharging the duty of candour, which is where we want to create the conditions for staff to be open. So, a lot of that will be around training. And, again, we're not starting with a blank sheet of paper; we've got some really good examples of how organisations already are being very open when things go wrong, and we pick that up through our serious incidents reporting process. So, we do need to be providing training to be able to support staff in how to have those difficult conversations. There's a whole load of things we need to do to make the conditions right for staff to feel safe to do that and for boards to support them to be able to do that as well. As I said, it's not a one size fits all, there's a whole load of things we need to put in the system to make it easier to have a more open, supportive culture.

Okay. One final question from me, and something separate: vice-chair roles. Now, clearly, various evidence we've received talks about extending the provisions of those within the Bill to special health bodies as well. So, it covers health vice-chairs of all. Are you looking to consider to ensure that you cover every aspect of health services, health bodies, to ensure that vice-chair roles are treated equally?

We already have the powers to appoint vice-chairs to special health authorities.

Okay. So, this doesn't take anything away from that power, but it basically adds to that power.

Yes, because we don't currently have the power to appoint vice-chairs to trusts. That's why we're taking it in the Bill, but we don't need to take the power because we already have the power to do so in a special health authority.

That isn't a view that I share. I appreciate the ombudsman has a particular view on this, and I know he's got a consistent view that he thinks more and more organisations should have an appointment process that goes through the Assembly and not Welsh Ministers. If you look at CHCs as they currently are, they're a hosted body within Powys Teaching Health Board. What we are proposing is a significant step forward in genuine independence, where they operate and undertake their functions. It's a proper public appointment process. So, it isn't going to be a Minister—whoever is in the ministerial chair at that point in time—deciding to appoint their favoured friend. It's a proper public appointment process, and it will work in exactly the same way as lots of other bodies, where you don't question their independence, have links in and around the Government as well. So, I actually think this is a proper step forward. It's consistent with the way that we do things. And I don't accept the line of argument that is run, and I assume will be run, at various points in the future as well, that says that you must move this away from a public appointments process where a Welsh Minister is the ultimate appointing person—after that, proper scrutiny and independence in the way that we undertake public appointments already.

So, you're not going to take the opportunity with this new body to make changes in the way public bodies are being appointed? As you say, a lot of them follow this process anyway, so you're not going to take the opportunity to do something different with this? So, that's clear.

Do you accept, though, that public perception is important, and really important in this field, especially, and that the public perception of a conflict of interest could arise out of Welsh Ministers making the appointments?

Well, one of the things that we do in some of our public appointments that I think may well be appropriate here is: there's a stage of stakeholders being engaged and involved in the interview process. It worked for some of the commissioners already, for example, where stakeholders give their view, and the views they have on the potential candidates is taken into account. We also do it with some of our chair and vice-chair appointments already. So, they have opportunities to take part in a scenario with stakeholders and they give their view on who the person is and how they think they're going to be able to undertake the function. And that is a real part of the appointment process. When I read through the different appointment recommendations, I definitely look at not just the recommendation and happily scribble my initials next to whatever is recommended; I do look through the comments that are made and the people who make those recommendations do genuinely take account of that stage in the process. I think that could be a helpful way to reinforce the fact that there'll be some proper stakeholder engagement in how the appointments work around this new body. But it is a definite and significant step forward in the independence of the new body that is being created, and I don't think we should lose sight of that. Because what we currently have—in terms of your point about public perception, I don't think the public are really aware about how CHCs are currently appointed and their hosting arrangements, anyway. So, a big and positive step forward.

So, just for the record, how are they appointed now, then? What's going to be the major difference?

Well, they're currently a hosted body within Powys Teaching Health Board, and in terms of the way that we appoint volunteers and a range of people, I have to sign off lots of the appointments that come through.

I think half of the appointments come through you. So, the other half, now, are volunteers not appointed by you.

Do you want to come in on the process, Rhian?

So, at the moment, the Welsh Ministers appoint 50 per cent of the CHC membership, a quarter come from local authorities and a quarter come from the voluntary sector. So, there's a mixed model. Then there's the CHC board that sits above the CHCs, and the Minister appoints the chair of that board and appoints two independent members to that board, and then there are seven CHC members on the board, which are taken from each of the seven CHCs, and there's a staff representative there, too, on the CHC board itself.

So, in your opinion, is the new body more or less independent than the present set-up?

It'll be significantly more independent.

I think the other important thing to add as well is that the chief officers, so the employed staff and their support staff, are all technically NHS employees, because they're employed by Powys health board, so that's a considerable step forward as well.

But, of course, if they were appointed by the Assembly, that would be an even greater—independence would be enhanced. But you're not going down that route, so that's fine. 

Well, we set that out in the general objective, in section 13. It's about representing the interests of the public, and I tried not to be, and deliberately made a choice not to be, prescriptive. Because the danger is we say we're setting up a body that we want to be independent, and we've just had a series of questions about how independent it will be, but I then take the opportunity to either prescribe in legislation, or to take powers to prescribe for them, what their objectives must be. So, there is something about saying we're creating this body, and they will have the opportunity and the responsibility for setting out how they expect to organise themselves, how they're going to engage with communities, with other stakeholders, with volunteers, including how they organise themselves on a national, regional and local basis as well.

So, you have no particular vision about how this body would work and what it should be actually focusing on. They're going to present their vision.

Well, the point is it's the citizen voice body. If you look at the sections we've set out, I think we're giving a pretty clear statement about our expectation for representing the voice of the public across health and social care and the way they get involved in both decision making and representation of individuals who engage in health and social care. So, I think, when you look at what we've got on the face of the Bill and in the memorandum, we've set out what we broadly expect them to do, but they then have to determine how they're going to discharge those functions. Otherwise, we come back to your point about independence.

Yes, and we've been clear that the overarching principle is to represent the interests of the public and that comes from section 13. We've also set out about them needing to raise awareness of their activities—that's in section 14—and we've put in the point about making representations to public bodies and the advocacy service in sections 15 and 16. So, we have set out what we expect the overarching function to be, to ensure that the citizen's voice is heard across health and social care, and it's deliberately drawn widely so that they then have to determine how they're going to carry out being the voice of the citizen. And there's a range of functions we've specifically set out, but this comes back to the balance, doesn't it, of do I say, deliberately, 'I'll prescribe for you how you need to be organised and how you need to operate', or do we say, 'These are your general objectives, the point of you'? The clue's in the title: the citizen voice body. We either have that wide, deliberately broad objective that we set for them, or we try to prescribe in more detail, and it's odd, on the one hand, for people to be saying, 'Don't appoint it, because we're concerned about the independence of the organisation', but then, on the other, to say, 'Why don't you prescribe in more detail what you want them to do and how you want them to do it?'

I was supportive of access initially at this committee and also when I was in the Constitutional and Legislative Affairs Committee as well. I'm interested in finding a way to properly describe how visits to where health and care are provided are part of the functions of the citizen voice body that they need to undertake, but I think a straightforward power of access is problematic to put on the face of the Bill. I've set out before—lots of social care is delivered in someone's home, there's quite a lot of healthcare that is delivered in someone's home, and we expect that to be a greater part of the case as well. So, you've got to be clear about—if you just have a blanket power of entry to wherever health and care are being provided, you're essentially saying that a citizen voice body can enter someone's home, and I don't think that's an appropriate balance to strike.

I do, though, think that we need to find a way through that sets out—and, again, I think we're talking about a code to do this—to properly describe how and where we expect health and care providers to behave, how and where we expect the citizen voice body to behave as well. There's a meeting coming up again within the next week with the current CHC movement to try and run through to see if we can find a way through, because I think there are challenges about how you determine if there's a dispute. Again, I don't think it'd be appropriate for Welsh Ministers to determine that, but we're talking through with current CHCs about how that would work. We'll also need to run through that with other stakeholders as well. You've heard this morning from the WLGA and others. So, we need to think about how it works, how it would work properly, but I think that would properly be described in a code to come alongside the Bill, because then you can describe the range of different circumstances where it would be appropriate for access to be readily provided, and other circumstances where the balance would be different. I just don't think you can do that in a single clause in the Bill, or a very complicated way to try and draft that, whereas a code gives you much more helpful flexibility to describe in a way that people can understand with properly illustrative examples.

So, you're in favour of the principle.

Yes, and I've been clear that visiting where health and care are provided is part of how we think the citizen voice body will need to take account of the views of the public to be the effective and proper voice of the public.

So, if there was a way of drafting a clause that would embody this in the legislation, you would have no problem with it. It's a matter of finding the wording that would, as you say—I understand that for people in their home settings, that's probably not appropriate. But if there's a way of finding a wording that would get around that, and putting it on the face of the Bill, you'd have no problem with that.

It'll always depend on what goes on the face of the Bill, and rather than saying whatever is provided, we'll agree to, it's still about—. I think the code is a proper place to do this, and I've written to the committee about this before, because you'll need to describe a range of circumstances where it would be appropriate, and a range of other areas about how you'd expect a citizen voice body and whoever is the provider of that health or care service to interact with each other around where visits would be appropriate, and there shouldn't be a problem in that access being agreed or enabled. So, it's about that proper discussion. We are still talking with current CHCs about it. As I said, there's a meeting within the next week, and I'm keen to find a way forward rather than simply just saying, 'It isn't possible, so the answer is "no".' It's about how we do something that is properly workable.

Yes, and that's been some of the work that officials have done, in conversations across the UK—in Northern Ireland, Scotland and in England—about the balance of powers and the practical use of those powers to make a difference, and that's what led us to the current scheme that you have in front of you. And we're still interested in the views of other people about how that's worked and how it hasn't worked as well, because that does explain why we haven't taken up some of the choices that have been made in the past for similar bodies in different parts of the UK. 

I want to come back to the point about what's on the Bill and what isn't. If we find a way forward, and I'd like us to, then I'm happy for the Government to bring forward an amendment during Stage 2 to try to set out how we'll try to reach a position that deals with some of the legitimate interests and how the balance is struck. Whatever the citizen voice body find is the voice of the public will obviously have an impact on the way that providers are expected to behave but also their interaction with inspectorates as well. If the citizen voice body is engaged in advocacy and representation, they should have access to where care is being provided in any event, because they're effectively representing and acting with and for that person. So we need to describe in a way that I think is helpful what happens there.

The face of the Bill is pretty clear about the services they provide in respect of advocacy, and what happens if there's a more general concern and how they would, or wouldn't, want to take an unannounced or a short-notice visit to a place where health and care is being provided. You've also got to build in the fact that there may well be times, quite legitimately, when, with the provision of that health and care, it may not be appropriate for someone to turn up announced on the doorstep. But that's why a code should properly describe how those different things work. I don't think it's a straight-line thing of saying, 'There must absolutely be a power on the face of the Bill for the citizen voice body to exercise unilaterally', or to say that there will be no circumstances where the citizen voice body should be able to visit health and care provision unless they give a month's notice, because I don't think that's appropriate either. So, I think talking around the extremes of it isn't helpful. That's why we need to have something that's properly descriptive, and I don't think you can do that on the face of the Bill. 

Thank you, Chair. The committee has taken evidence that, along with public bodies, the citizen voice body should have a right to make representations to Welsh Ministers. The RCN have told us that there's not much point in having a national body if it can't take a national perspective. Are you willing to amend the Bill to address that concern?

If the citizen voice body said, 'Here's what we think', and they wrote to whoever was the Minister, or they provided a briefing saying, 'This is our view on how the system needs to change', I don't think Ministers are going to ignore that and say, 'I'm not interested in listening.' So we aren't trammelling the powers of a new body to say 'You're not allowed to ever try and talk to the Government or the national health service', whether it's through the new NHS executive or anyone else. So I don't quite recognise the challenge about how the powers are drawn and what the body is and isn't prevented from doing, because they're going to be the voice of the public. And so the formal representations are one thing, because we're setting out some process points there about statutory responsibilities, but Welsh Ministers, of course, are going to take, as they would any stakeholder across health and care, seriously what the citizen voice body says at a national level. 

So, looking at that from the other side, then, we've also had evidence that the Bill needs to go further and require Welsh Government to provide a response to any representations made by the new body. What's your view on that suggestion?

Well, again, I think we need to work through what that means. For example, in an individual advocacy scenario, that's pretty clear. It may be that it would be appropriate to provide some responses in writing, some responses directly on the day, person to person, and then I know a point's been made about whether things have to be published or not. You can well imagine that there would be circumstances where it wouldn't be appropriate to publish representations that are made, and the response to them. So, again, I'm interested in how we work through what is that—is that an amendment on the face of the Bill trying to describe all those circumstances where representations could be made, and you'd then prescribe how people would have to respond, or a time frame for that? I think you'd get very process driven then, in a way that I don't think is necessarily very helpful. 

But say—you know, you were talking about service reorganisation—the new body had set out its concerns in writing to you about a particular service reorganisation, that's different to dealing with an individual's complaint, isn't it? Do you not think it would be reasonable to expect that there would be a requirement for Government to respond in writing in that instance, just as they have to respond to committees when we make recommendations? 

If the citizen voice body was making a representation to a local health board about a broader service issue, then I think it would be legitimate to expect that there'd be a response that would be in writing. But the challenge, again, comes with a number of these things about how much you want on the face of the Bill, and how much we then have either in guidance or in a code that says, 'This is how, in a range of scenarios, we expect different people to behave in responding to representations that are made'. If the citizen voice body wrote to Welsh Ministers and said, 'We think this is a significant concern; we want you to respond', you'd expect that, whether it's correspondence—well, we respond to lots of correspondence each and every day. It would be kind of weird if we said, 'We'll respond to letters that individuals write in about, but we won't respond to the citizen voice body if they write a letter to a Minister'. If they're making, if you like, public representations—because lots of these things are in briefings that are provided; they're essentially public—again, it would be unusual if Welsh Ministers said, 'We're not going to respond'. But that's the way the Government has to behave in any event, and I don't think that's really covered by what should be on the face of the Bill, because, again, you're talking about the mechanics of how does that work, and how you require things to be done on the face of the Bill. 

But you're talking now about what happens now, aren't you? We need to futureproof this for whatever Government is in power in the future here. Do you not think it would be better to enshrine that level of requirement for a response on the face of the Bill, so that if the national body makes recommendations about a service, there is a requirement on Government to publicly respond?

I still think you're coming back to what has to be on the face of the Bill and requiring the Government to respond to representations that are made, but what are those representations? Because if it's about a big national service issue, well of course you can say that that would be appropriate. If it's on a micro issue, actually, if you've then got a statutory requirement to respond to every single issue and provide that in public, I think, actually, that's difficult. It comes down to how you draw up the statutory powers. And again, I think it's why I think you can legitimately, and in a way that is reasonable, as opposed to trying to avoid this, describe, 'On these issues, this is how we would expect people to behave, and this is how Welsh Ministers would behave as well'. So, it's not about trying to avoid there being something on the face of the Bill; you need to think through, once you have that power, how is the power used and exercised in a way that meets the expectation that you're currently setting out. 

Okay. The older people's commissioner also highlighted a gap in the duty on public bodies to supply information to the new body, noting that most of the social care sector is run by private providers who wouldn't be covered by this duty. What's the Government's view on that? 

All the bodies that commission services are caught by the duties, and in terms of the way that providers work—. Sorry, are you asking about whether I think the current drafting of the Bill means that those providers would have a duty to respond to the citizen voice body? 

Yes, that they would be fully covered by the Bill. 

I would expect that they would be, and that depends on the information that they're requesting. So, if it's in their advocacy function in representing people in complaints, then I do think that in the way that the complains function works we would expect those providers to respond. If you think there is a genuine gap that exists, and there isn't the provision that we should have, then I'm happy to think about that in the report that's provided. But where the complaints procedures exist, and if it's individual advocacy, then I think it's pretty clear that the provider, whether it's commissioned or directly provided, would need to respond. 

Okay. Another theme that we've heard in evidence is the need to ensure that because this is a national body there is an element of local representation. For instance, in the last session with the WLGA, that was a concern that was raised, really—that that local connection is very important. How do you intend to enshrine the principles of localism in this Bill? 

I think that, again, I don't want to get into prescribing something on the face of the Bill, because, otherwise, if we prescribe that for all time, you might legitimately want to rearrange local, regional and national functions. I do think that in the setting up of the organisation, in an initial remit letter, we could set out an expectation that they set out how they'll deal with their national, regional and local functions. And they will need to provide a scheme to set out how they'll have that local, regional and national presence. So, I think, in practical terms, we could make sure that they will set out how they'll organise on that basis, but, again, if we want a body that's genuinely independent, there's the balancing. You either say it's got to be independent and they should be allowed to run themselves without Ministers crawling all over them, or we say, 'Prescribe—require them to set something out.' I think an initial remit letter would allow us to say 'You have to set out how you're going to do this.' In any event, you'd expect a new body would want to set out how they'll discharge the variety of ways they organise themselves—what's their public-facing presence, how do they organise their advocacy function, how do they run their national functions as well. So, I think we could give some comfort about how that's required, without needing to have a straitjacket on the face of the Bill. 

Okay. In terms of volunteers, the role of volunteers isn't mentioned on the face of the Bill, and that's something that the CHCs have called for a change on. Would you consider adding reference to volunteers on the face of the Bill?

Again, I think if we have additional references to volunteers and how they work that function, I think we're then, potentially, setting out—. Again, it's how many extra requirements we want on the face of the Bill. And, again, we could do this in the initial point, in the remit, about how they set out, how they're going to make use of volunteers, how they're going to recruit and encourage people to volunteer, because, actually, the additional flexibility we're giving around volunteers is one of the big pluses, I think, in the Bill. And that's a proper plus, and, actually, the current CHC movement want more flexibility in the way they engage volunteers in their work. And, so, not having to run through a prism of ministerial approval to do that, I think is a step forward. But, again, if it was helpful, we could think about how we could do that in a way, whether it's on the face of the Bill or not, that sets out that they will need to set out how will they engage volunteers in their work, how will they recruit them. And that's also part, I think, of their local function as well, because I'd want to local volunteers to be eyes and ears and to engage in the work that they do. 

Okay. Thank you. CHCs have also raised concerns with the committee about resourcing for the new body. They don't feel the allocations are sufficient for the new organisation to set up and take on a whole new sector. What's your view on that?

Well, the regulatory impact assessment we've provided is our best understanding of the costs they'll have, and some of the new functions they'll have. And, again, when you compare the current provision of CHCs, but also the additional moneys we're proposing to put in, and compare that to comparable bodies in Scotland, England and Northern Ireland, actually, the per-head funding is better than common bodies in the rest of the UK. So, everyone will, of course, make a bid for more resources, and I accept it would be unusual if they didn't say 'We'd like more resources to be able to undertake our functions', but we think that there is a fair estimate of what we'd expect them to do and the resources to enable them to do that. 

Okay. Can I just ask about the Welsh language then? Your plan is to amend the Welsh language Measure, but the Welsh Language Commissioner has suggested that it would be better to amend the Welsh Language Standards (No. 7) Regulations 2018. What are the reasons for going down the road of amending the Measure rather than the regulations, and is that something you'd be willing to look at?

This is a practical point about how we apply the standards sooner rather than later. We talked about this earlier and I know that Catrin may be able to help about the process to get to that point. And it isn't about a disagreement about our ultimate objective. I don't think we disagree with the commissioner on that; it's about how we get there.

Amending the regulations gives the Assembly the opportunity to specifically consider what goes in those regulations and what standards apply to the citizen voice body. It also enables an opportunity to really consider, given that the citizen voice body has additional functions compared to those of the community health councils, what standards really ought to apply in that circumstance. So, giving tailored and bespoke consideration to the regulations, as opposed to simply making an amendment to replace the name of the community health councils with the citizen voice body, enables it to be considered in the round. Also the regulations are subject to the affirmative procedure, so, therefore, obviously, require the approval of the Assembly. And that will give the Assembly the opportunity to really specifically consider the Welsh language standards issue discretely and separately to the Bill.

Okay, thank you.

Thanks, Chair. Public Health Wales have said that if HIW and CIW arrangements continue to go on a parallel track for another five years, while everything else is driving us forwards towards integration, that’s an unintended consequence that we really need to think about. And we’ve heard some other evidence from people who are concerned that the Bill does not strengthen the legal and regulatory framework of HIW, nor does it make any provisions for a single integrated health and social care inspectorate. What are your views on that?

Well, we did consider this in the policy stages around the Bill and in the various stages of the consultation that have taken place. And if we wanted to consider a single inspectorate—if we wanted to think about further integration between the two inspectorates, that’s a pretty significant piece of work in itself, and we’d have had a monster Bill, and I don’t think we’d have been able to bring forward that Bill as is. So, it’s not that there is no consideration being given; it’s that I don’t think you could actually shoehorn that into the Bill, and I really don’t think it would be appropriate to have an amendment to try and say, ‘You must do this’, because there’s quite a lot of work that would need to go into that. So, there’s a very practical point here about what we do, and Members, I’m sure, would want to be properly engaged in: is it desirable to have greater integration between the two inspectorates and the joint work they’re already doing? Do you need that on a legislative footing or do you want to have a single inspectorate? What does that mean? What are the requirements for doing that and how the two inspectorates will be set up?

So, it isn’t a simple matter of one clause added to the Bill; I think there’s quite a lot of work to do in that. So, the Bill, as it was potentially available in the initial Green Paper and then the White Paper, has been slimmed down because of the reality of getting all of that work done. So, it’s certainly part of what a future Government, I’m sure, will want to consider, but I’m not about to try and set out a requirement for a future Government beyond this Assembly.

Okay, thank you. We also heard evidence, including from the office of the public services ombudsman that the Bill doesn't progress the White Paper proposal for a single complaints process for health and social care. What would your comments be on that?

Well, officials have met with the ombudsman's office about a joint complaints procedure and what we want to be able to do is that we make sure that we take forward how our current complaints procedure in health works, and how that works in terms of the complaints processes in social care. So, we're interested in how we make the procedure simpler for the public to go through and that requires work between the NHS, local government and others, including ,obviously, the ombudsman. So, it's not a completed piece of work, but people are genuinely talking about how to make that a simpler process for the citizen.

Thank you. We've heard some evidence as well, particularly from the British Medical Association, about introducing a system of regulation for non-clinical NHS managers. What's your view on that particular aspect?

Well, again, I think that's not a straightforward matter. Who's a manager—you have to decide that first, about who it applies to. Then you need to decide, if you're going to do something, how you actually go about doing it. Do you create a new body to oversee the regulation of non-clinical managers, because you then have to put resource into that? And I think that's a difficult question to answer. And even if we weren't in the financially difficult times that we're living through, in the tenth year of austerity, I think you'd have to think very carefully about: is that the right way to use additional resource within our system. You'd also then have to think about: is it a prospective piece of regulation? Would you say that every manager, however you choose to define 'manager', has to have a qualification and essentially be a member of a body? That would add cost and size into what that body would look like. Or is it that you have a fit-and-proper-persons test, where people can be prevented in the future? I think, actually, given what we're talking about and the duties of quality and candour, about how we have a more open approach to recognising when things go wrong, I think it runs a bit cross-purposes to that. The way that this was initially set out was about whether you strike people off. And that runs in a different direction to wanting people to be more open about where things go wrong. So, I'm not persuaded that you'd need a regulatory framework set out in the way that's been proposed, but the points about the duty of quality and candour are about raising up the visibility of this agenda within the service, and managers and leaders needing to proactively respond to that and take that forward.

Okay. And finally from me, health boards have said that they'd like to see a revised code of conduct, training and development for managers—do you have any plans to address that?

I have had a discussion within NHS chairs and chief executives' meetings about how we invest in the future of leaders and managers and the values we expect them to have. So, there is already some active consideration about needing to invest in our leaders and managers, because the job that they do matters for allowing clinicians to get on and do their job. We all understand there are lots of clinicians who are leaders and managers as well. So, it's not wanting to lose the clinical input into the tiers of leadership and management, but at the same time these are big and significant organisations we expect people to take charge of. So, we do need to think about not just appointing the best clinician to a leadership or management role, because that may not be the skill set that they have. So, yes, there's active consideration of how we improve the quality of leadership and management within the health service, but I don't think that needs to feature in the Bill for us to get that right.

Thank you, Chair.