The next item is a statement by the Cabinet Secretary for Health and Social Services on the 'Services fit for the future' White Paper. I call on the Cabinet Secretary to make the statement. Vaughan Gething.

Diolch yn fawr, Dirprwy Lywydd. I'm pleased to make today's statement and publish the outcome of the consultation on the 'Services fit for the future' White Paper published earlier today. This is an important piece of work, forming part of the picture for the future of health and social care services here in Wales.     

The Government remains committed to supporting practical steps that build closer links between health and social services to meet future needs. We restated our commitment to that ambition in the national strategy 'Prosperity for All'.  

As part of our ambition to develop, improve and integrate health and social care services, I launched the 'Services fit for the future' White Paper for consultation on 28 June last year. I asked for views on a range of interrelated proposals for potential legislation.  

The proposals contained in the White Paper looked at how we might futureproof aspects of the health and social care system, with a focus on person-centred care and greater integration across the health and social care system. There is wide agreement that the health and care systems here in Wales need to work differently to deliver those services and outcomes that people across Wales will want to see. That’s why the White Paper looked at a whole-system approach and examined several areas where future legislation might help to achieve this in a new way of working.  

The proposals in the White Paper covered stronger governance and leadership at board level, new duties of quality and candour, and areas such as standards and complaints handling where common processes could support a more integrated approach. There were also proposals relating to citizen voice, pace of service change, regulation and inspection.   

During the consultation a number of stakeholder meetings and focus groups were held across Wales. These included approaches to reach some people who do not traditionally respond to and take part in consultations. The consultation ran until 29 September last year. There were 336 submissions from individuals and organisations, as well as 1,328 pro-forma responses relating to proposals for citizen voice and representation. 

It is clear from the responses and the report of the parliamentary review that we need to act now to preserve our health and care services for generations to come. Responses to the consultation reflected the view that joint working between organisations is essential in order to promote well-being, to identify people’s needs and to plan and provide quality services to a robust and consistent standard. Many respondents agreed in principle with what was being proposed in the White Paper. However, some respondents asked for more information and detail on how some of the proposals might work and be implemented in practice.  

There was support for more effective leadership, for having the right skills and experience at board level and for robust action to be taken if organisations were seen to be failing. In terms of service change decisions, respondents were keen to ensure clinical evidence was considered and that the views of citizens were given real weight, together with experts. 

As in the previous Green Paper consultation, some respondents remained unconvinced about the use of legislation to promote behavioural change such as collaborative working. Some wanted to see the more effective use of provisions set out in existing Assembly legislation. However, many respondents saw the value of the proposed new duties of candour and quality and felt that these could provide further impetus to integrated working and better outcomes for people in Wales.  

There was significant support for an independent voice for the public across the health and social care system. That aligns with the findings of the parliamentary review that Wales must be a listening nation, to accelerate change and improve quality, not just by paying full regard to citizens' experiences of health and care, but actively seeking out diverse views and experiences.

The proposal to replace community health councils with a new national body to represent citizens has, of course, drawn much comment and debate. There was a broad consensus that reform in this area is needed if we are to strengthen the voice of citizens in health and social care. However, we must be careful not to lose things that work well, including representation at a local level.

Linked to this, there was also support for the idea of more common standards across health, social care, the independent and third sectors. We will therefore consider how to develop and take forward proposals on: board leadership, scrutiny and membership; an informed process for service change; duties of candour and quality; a new citizen's voice body across health and social care; and common standards.

There were mixed views in relation to a possible merger of the health and social care inspectorates and making them independent of the Welsh Government. We will not be looking to make these changes at this time, but will instead explore an approach that addresses the regulatory gaps that exist, and futureproof the underpinning legislation for Healthcare Inspectorate Wales. This will allow for more closer working with Care Inspectorate Wales. This very much aligns with the recommendations in the parliamentary review around joining up inspections.

Of course, the outcome of the consultation is of great interest in the context of the recently published final report of the parliamentary review, where aligning actions to continually drive up quality was a key theme. I will of course consider how we link the White Paper consultation to the recommendations of the review.

In light of the responses to this consultation, the Welsh Government will now undertake further policy development. We are actively considering whether legislative solutions are the most appropriate way to meet the challenges identified and commented upon in the consultation. I will of course be happy to continue to update Members in the coming months. 

Good afternoon, Cabinet Secretary. There are a couple of questions that have sprung to mind having read your statement and, indeed, the 'Services Fit for the Future' White Paper. I'd like to firstly and mainly address appointing members to the board in regard to underperformance. The consultation states that there was significant support for the principle of introducing time-limited ministerial appointments where health boards or NHS trusts are found to be underperforming.

Cabinet Secretary, four of seven of Wales's health boards are underperforming to the point of either being in special measures or with targeted interventions. Most recently, for example, we've learnt of the acute financial challenges faced by Hywel Dda, which has accumulated an overspend of some £149 million over a three-year period—the greatest of all the health boards. When recently asked, via a written question, about the Welsh Government's knowledge of this, the Welsh Government said they were only made aware of this deterioration in December. Furthermore, in regard to stabilising the financial situation of the health board, the Welsh Government only issued general guidance.

Back to this consultation and about the appointing of members to the board in regard to underperformance, could you please clarify what is the role and function of these Welsh Government levels of intervention? Because it seems to be completely unclear as to what part Welsh Government really takes in understanding what is going on in a health board when you have had to put people in for either targeted intervention or special measures.

I raised this issue in November 2017 in quite a wide-ranging debate on this subject, because I think that it is right and proper for Welsh Government to put extra people on the board in order to ensure that we have health boards brought back into the fold, meeting the targets of service delivery and financial management that you set upon them. What I fail to understand is what we've been doing so far in terms of putting those targeted interventions in and the people in, who can then turn around and say, 'Gosh, we didn't know £176 million-worth of debt, for example, was being racked up.' And there are examples in Betsi Cadwaladr that I have raised with you in the past. 

The second area of concern I have coming out of the 'Services Fit for the Future' White Paper is about the public presence on the board. Again, the consultation talked about the fact that there was a general consensus that the public and their representatives should be able to make meaningful contributions to board meetings and that board members should understand local people's needs and local issues. I find that quite staggering in a way, that there should be any doubt over that, because if the board does not represent the needs of the local people, then surely they are a board that is not fit for purpose, because their function is to ensure that local people have the healthcare that they need. So, could you please just expand on that a little bit more, about what you intend to do about that and whether or not you think that there's been a sufficient or fairly significant shortfall in that provision of public presence?

I'd like to tie that in with the proposal to scrap community councils. Again, I note your comment in your statement about the community councils, but there has been a lot of criticism of the perceived lack of details around the proposals. On the one hand, we talk about the need for the public to have a strong and considered voice that is able to be heard by all. The parliamentary review talked enormously about how the public need to take responsibility and be part of the game changer that we need to see in the NHS. This 'Services Fit for the Future' White Paper talks about the same thing, yet the policy that appears to be coming out talks about dilution, diminution and making it more difficult for the voice of the public to be heard on boards. Can you please reassure us as to what the Welsh Government's intention in this area is going to be?

The last area I'd like to talk about is the duty of candour. It's a very interesting concept, to put forward a duty of candour. There was a considerable amount of support in the White Paper, or in the consultations that came in. What I don't quite understand is how you believe we can incentivise being truthful and open. What is the best means to encourage openness and honesty? We firmly believe that our NHS should have, without a question of doubt, an inbred culture of shared responsibility, openness and learning, but I don't think that this can be achieved simply by legislating for it. So, what are the measures that you think you might be able to look at, or bring forward, to ensure that this duty of candour, which, as I said earlier, I think is actually a very interesting concept, can be translated into a real deliverable? It's very hard to legislate for honesty. We just need to inculcate that into every single person who works in the NHS and for the NHS, and indeed in us, as the general public, when we deal with the NHS, that there is that openness and transparency that we all crave and expect to see in the NHS going forward. 

Thank you for those questions—I'll take them in turn. On your point about ministerial time-limited appointments, we're always looking to review not just our ability to have a transparent framework for intervention and escalation, but the tools that we then have to intervene and support boards that are not performing as they would wish to or as we would wish them to as well.

On your point about those organisations in heightened stages of escalation, of the three organisations in targeted intervention, two of them have made real improvement in their financial management over this year. I said earlier in the committees that I don't expect them to break even this year, but I think they've made real improvements from the start of this year over the course of the year.

Now, for Hywel Dda, the deterioration reported in the Assembly is obviously a problem. To be fair to the board leadership, they've had enough recognition and insight to say that that is a challenge that they themselves need to do something about. They've been supported by the Government with the reviews that we've had done of their financial management, and of the zero-based budgeting review as well. The first report will be taken through the public board, I think, if not this month then next month, so there'll be, again, public board conversations—[Interruption.]—I'm dealing with your question—about how they will deal with the financial challenges they have got.

Part of our challenge is that having additional ministerial time-limited appointments could help us to deal with some of the specific challenges that exist in different organisations. For example, if you have a challenge in financial management, is it about appointing someone to deal with that particular aspect, to sit either on the board or be part of the executive team to help them to get over that particular issue if other parts of that organisation are running and working well? As you know, in north Wales the organisation is in special measures, but much of healthcare in north Wales continues to be performed and delivered at a high quality across different communities. It's about how we have enough tools to be able to support organisations that need to improve.

The point about the escalation framework is that it is both about intervention and scrutiny, so it's about what we need to do to intervene to support organisations and having a heightened level of scrutiny as they go about their business. So, this is a proposal about the potential for time-limited appointments to help fix some of those potential individual skills gaps in an organisation, in addition to what we already have. 

And on the point about public voice and the way in which the public can make meaningful contributions to board meetings, there's a challenge here about the different roles we expect the board to cover. So, we want a board that's got the skills and the oversight to be part of the challenge and support that the executive team need and that we require, so that's where we have all of our independent appointments that take place on those boards. These are organisations that typically have a budget of around about £1 billion, and you and I know that the NHS is a wonderful and complex organisation, multifaceted, so, actually, that's quite a challenge, and so we set high standards for the board members we want to see come in. That means, though, that those boards don't often reflect the nature of the local population.

Some of that is understandable, because if you have a limited number of independent members, unless you're going to expand that massively, then in whichever board area you choose, you'll find that those independent members don't necessarily represent all the people within that community where that citizen's voice matters. That's why the proposals we've been looking at are if you're going to have something else around that, would that be about having associate members to try and have a greater representative voice around that board table when those discussions are taking place, and not just about, if you like, the essence of having those board meetings taking place in public?

Because if you look at boards around Wales, actually, on a leadership level across chief executives and chairs, women are well-represented, but not everywhere in all of the independent members or all the executive leadership positions, and, actually, the position on black and Asian origin communities is certainly not one that reflects the country that we are. So, there are challenges about our diversity as well as, frankly, the people that are the greatest participants and users of healthcare services. So, we do have socioeconomic challenges about a lack of diversity in board membership too, so we need to think about how to manage that appropriately, as well as boards themselves going out and being proactive in talking to and wanting to listen to communities. I think there's something different there about the role of a citizen's voice body. So, what do we expect boards to do regardless of the citizen's voice body, and then how do we expect them to work alongside those, and they obviously have a scrutiny role as well? 

And I say again: you know, I recognise the points you made about the parliamentary review. The review understandably didn't say that community health councils must stay or must go. That wasn't something that we particularly asked them to do, but they recognised the need to have citizen engagement. I've said on a regular basis in this place and outside it that if we want to have a strengthened citizen's voice body with a clear mission and purpose across health and social care, then we need change the legislative footing on which CHCs operate, and the title should change as well, because it's about looking at how they go across health and social care. The challenge is that CHCs are actually set out in primary legislation, so we've got to be able to change that. This isn't abolishing something and not replacing it; it's what comes in to take on board the citizen voice across health and social care, and how we properly engage with the very constructive conversation we had with the national board of CHCs about a change in their potential role and remit for a successful organisation across the health and care sector. And that remains our objective within the Government, rather than seeking to diminish or avoid having a voice for the citizen. 

On the duty of candour, again, this goes back to the point that I made in the statement. There are different views about how far legislation can change organisational culture, although we all recognise that legislation can have a part to play in that. Other parts of the UK have a duty of candour, and part of what's been interesting commentary in response to the White Paper has been about whether that should be a duty on individuals. Of course, lots and lots of individual healthcare professionals already have duties in this area, but in particular it's an organisational duty of candour about the decisions and choices that it makes. So, I'm keen, as I said, that we take forward that policy. We have to think about whether legislation could and should be part of that answer, but that is about promoting an organisational culture, rather than being the only thing that we could and should expect.

I thank the Cabinet Secretary for the statement today. I am trying to assess how much recognition that there is in truth of the concern that has been raised in the wake of the publication of this White Paper. There is a description by you, as Cabinet Secretary, of the broad-ranging nature of the responses, and we have to remind ourselves how short the consultation period was over last summer, and that the public meetings were last-minute steps as were the public forums that were held around Wales. It’s important to remember that. But, even though there is, as you said, quite a response that's been received, it's quite superficial what we’ve heard from you on what exactly came out. Maybe that’s inevitable in quite a brief statement, but a lot of those who responded you say agree in principle with what was proposed by the White Paper, but some who responded have asked for more information and details. I do appreciate the positive spin you’ve put on that, but we have to remind ourselves that there is a very deep concern that’s been voiced about some elements of what was in the White Paper.

I will start with the concern on the intention to get rid of the community health councils. I will make the point again, as I’ve done previously, that we’re not asking for the CHCs to be kept forever—that’s not what people are asking for—but for the retention of their function and the purpose that was and is delivered, as the voice of the people.

I hope that it has become clear to you as part of this consultation that there is a feeling that the health inspectorate and the CHCs or any new body can’t be doing the same work, because the purpose of the body that represents the patient is to measure and to assess and evaluate the experience that the patient has within the NHS, and what was recommended in the White Paper wasn’t going to deliver that on behalf of patients in Wales. So, I would like to have confirmation from you, while you say that you’re going to develop and take new proposals forward in terms of a body to give the patients a voice, that getting rid of CHCs or something similar to them is now off the table, because patients in Wales deserve far better than that.

Two other questions. The statement says that support has been voiced that very robust steps should be taken against health bodies that fail. What does that mean when we’re talking about organisations that are already in special measures? Are you talking about introducing very special measures or hugely special measures? Please give me an explanation of that.

Finally, in terms of the representation on health boards, are you as Cabinet Secretary in agreement that more balance in terms of gender across the health boards is necessary and that we have an example of the need for that balance in order to prevent decisions such as getting rid of perinatal services back in 2013? I think that decisions could have been different if there were more women on the boards at that time. Possibly, we could talk about decisions regarding gender identity and so forth too, but I would appreciate more comments from you about that important balance on our health boards.

I don't broadly accept much of what Rhun ap Iorwerth said in his contribution to be frank. When it comes to the consultation, I think this was a full public consultation over a reasonable period of time. We deliberately chose to have additional events for those people who don't regularly take part in consultations. We engaged Communities Connected to do so. I realise that the Consultation Institute wanted to run their own event. We said we would not engage with that because I don't believe that the Welsh Government should send Ministers or officials along to events where our stakeholders pay for that access. I do not believe we should help the Consultation Institute to run their business. This is about how the public engage and how we have gone out proactively for the public to engage in those events more generally and then specifically for those people who regularly do not get engaged in consultation. 

On the point about the future of community health councils, again we've been around this track many times before and I continue to say I want to have a citizen-voice body across health and care with a strengthened role in representing the citizen across the health and care sector. That means reforming CHCs. It means you have to remove CHCs as they currently are, given they're in primary legislation, and replace them. This isn't about having a period of time where no citizen-voice body exists for a period of months or years before I then genuinely need to replace it with something different. It is about, if we were to move forward with legislation, we would have to then set out what that new body would look like and how it would replace at the same time when CHCs are then superseded by that new body.

This goes back to, whether innocently or not, not reflecting on what has been said on several occasions in this place and outside it. I understand the concerns that are raised, but the national Board of Community Health Councils themselves have recognised that they want to see an expansion in their role across health and social care. As we have more integrated care, it must be sensible that a citizen-voice body doesn't just stop at an artificial line between health and social care. It's also that they recognise that they want to see a reform of their place within the service reform conversation. They also want to see a reform of their role as regards inspection. When CHCs were created, of course, we didn't have Healthcare Inspectorate Wales. We now have a professional inspectorate undertaking one part of inspection, but CHCs themselves are very clear that they would like to have a successor body still having the right to have unannounced visits to areas where care is being administered, and that's something that we are talking constructively about, about what could happen in the future. So, this isn't a case of abolishing and doing away with CHCs and not replacing them at all. That simply isn't the perspective that the Government takes. It isn't the proposal we've set out. It isn't what I've said time and time again in this place and in others as well.

And, on the points about intervention, I thought your comments were somewhat flippant about where we are and looking to intervene in organisations that are struggling in some aspects of their performance. This is, as I've said to Angela Burns, about how do we have additional tools to intervene in and support bodies that are not meeting all of their duties. Sometimes, there will be a corporate challenge and not simply an individual service area or functional challenge, but sometimes even that service area or functional challenge may require support in a time-limited way in which Ministers could act promptly by appointing someone to work alongside the board or the executive team. And that is a proposal that has been well received in the consultation, and I just don't think that's particularly difficult to understand.

On your point about board representation and gender and the gender split, actually, as I said earlier, we actually, on a leadership level for chairs and chief executives, do rather well in the health field. A really good example is the recent appointment of Alex Howells to be the new chief executive of a new body, Health Education and Improvement Wales, and, in addition, Tracy Myhill moving across to be the chief executive of Abertawe Bro Morgannwg. She did that not just as someone from our system here in Wales but actually as someone the external assessor also agreed—and a high quality external candidate as well—Tracy Myhill was the best candidate, not just the best Welsh candidate but the best candidate, and that is someone who has done a significant job in turning around the ambulance service as well, and that is a real positive. This is being done on merit and it's being done because there's been some determination about how we develop and promote people, but we recognise actually, in other tiers within our service on executive-level leadership that we have a real challenge about the next tier down, about the middle tier and who is coming next. That is something that I'll have more to say on, but this is only partly about—. It's also then, of course, about our public appointments process, and I dealt with those comments in response to Angela Burns.

I just don't think that the decision around the previous in-patient mother and baby unit was driven by representation of women on boards. Actually, the concerns came from the staff in the unit at the time that they were not able to provide the care that they could and should have been able to. Those staff were women themselves who were saying, 'We don't think we can do the job that we could and should do.' We've looked again at the position. I said right at the outset of this particular inquiry—and thinking about the debate we had in this place two weeks ago, that brought to a close the inquiry of the committee, but the work of the Government and the health service certainly doesn't stop at that point, because we've committed to having in-patient care within Wales, not because of the number of women on boards across Wales but because we think it's the right thing to do and we have a way to deliver that care in a way that meets the needs of citizens across Wales, and this White Paper is about doing that. How do we meet the needs of citizens across Wales? Can we resolve some of our challenges by taking forward proposals for legislation in the White Paper? And that's what I'm committing to do, as I've outlined in my statement.

Can I thank you, Cabinet Secretary, for your statement? The consultation on services fit for the future was very wide-ranging, and it covered significant areas of governance and, as you say, sits alongside the parliamentary review looking at how we ensure that services are delivered in the right places by the right teams of people. From the responses that were received, it's clear that there was a support for more effective leadership and for having the right skills and experience at both board and corporate level, and, in that regard, I wanted to specifically raise with you the invaluable contribution of therapists to the Welsh NHS, a group of professionals that I think are sometimes overlooked when we're having the talk about doctors and nurse recruitment, training and service delivery, and ask you whether you'll recognise the benefits that they deliver by including a role of director of therapies and health sciences within the executive leadership of LHBs and whether it is the case that the recognition of such a strategic corporate lead—a lead that, of course, can straddle both health and social care—is an invaluable contribution to securing services fit for the challenges ahead, and, finally, whether you therefore agree that in the vital areas like rehabilitation, prevention, early intervention and then securing a strong corporate lead on these matters, that that surely will help to deliver the type of transformational change that we know we need in our health and social care services.

Thank you for the focused question around our colleagues in the therapist end of health and social care. Many of these roles can either be employed within a health board or in local government, and that's part of their value. I think therapists are real can-do practitioners as well; they're often at the heart of making things work regardless of the institutional barriers—a bit about that point about culture and the way in which people work. And there was lots of comment about the particular roles and whether there should continue to be a core executive membership that we prescribe, broadly, as we do now, or whether, in fact, we want to have a smaller number of core roles and allow more flexibility for boards to have executive-level leads. That's some of the work that we're going to continue to consider and I know that therapists themselves are particularly keen to see an executive-level role that combines, at the moment, therapy and health sciences. So, that's something I'm actively considering, but what I certainly won't ever want to lose is sight of the fact that our therapists are a really important part of making the healthcare services work, because people who need to move through different parts of our system—often a therapist will be a really important part of doing that. You mentioned rehabilitation—prehabilitation as well, getting people ready for healthcare interventions, as well as the roles that, for example, occupational therapists take and undertake within the health service, but also within local government as well.

I just want to use this opportunity to welcome in the Chamber Ruth Crowder, formerly of the college of occupational therapists in Wales, who is now the chief therapies adviser to the Welsh Government. So, there's real value placed on that within the Government and we'll continue to have a conversation to make sure that continues to be the case in the way in which we organise and deliver health and care services across Wales.

Thank you for your statement, Cabinet Secretary. Like many of the respondents to the consultation paper, I am generally supportive of the intent behind your White Paper. I fully support the intention to introduce a legal duty of candour that will extend to other parts of the health and social care system, the same codes of conduct that apply to doctors and nurses. This will also ensure that Wales is in line with other parts of the UK. So, Cabinet Secretary, do you anticipate that the duty of candour will apply to everyone working in health and social care in Wales? Doctors, nurses and midwives are trained to abide by the GMC's good medical practice guidelines. What guidance and training will be made to NHS managers and social care managers to ensure that they abide by the principles of being open and honest with patients? Can you expand further upon what sanctions could be imposed for any breach of the new duty? I would also be grateful if you could outline the timeline for the proposed introduction of the new legislation. With regard to replacing the CHCs, whilst I support this in principle, any replacement must strengthen the patient voice and not dilute it. I accept that not all CHCs were effective, but there were some very good examples that fought for patients' voices and rights. Whatever the form of the new national arrangement, it is important that we don't lose these patient champions. So, can you assure us, Cabinet Secretary, that this new national arrangement to represent the citizen's voice will not only be comprised of mainly citizens but also truly independent from Welsh Government?

Finally, Cabinet Secretary, I welcome the decision not to proceed with the merger of HIW and CIW. We have to first develop a consistent approach to inspection and ensure that the changes introduced by the RISC Act are given time to bed in before we seek organisational change. We have to ensure that both organisations work closely together in future and we have to ensure that there are no regulatory gaps. When can we expect to see legislation to address these gaps, Cabinet Secretary?

Thank you once again for your statement. I look forward to your proposed legislation and working with you to ensure that our health and social care systems have the needs of the patient at the forefront. Thank you. Diolch yn fawr.

Thank you. I'll take those three broad points in reverse order. On inspectorates, as I've outlined in my statement, we're not taking forward proposals to merge the organisations. The challenge, again, comes with any legislative underpinning, as I've indicated. There'd be a real opportunity to resolve some of the challenges Healthcare Inspectorate Wales have about their legislative underpinning to allow them to do a more effective job, but this goes into your point about the duty of candour and a timescale for legislation. I can't give you a timescale for legislation because it's up to the First Minister to stand up in this place and indicate the new legislative programme and the timetable for new Bills to come forward. But everybody knows that, even with Bills that we may want to bring forward, the reality is that the discussion we've just had before this statement on Brexit—well, that may take up more time than this place has to undertake every other piece of legislation we may want to and think there's value in. So, there are real caveats about our ability as a legislature to get through all of the pieces of legislation that we want to, and I'm not in a position to give you any kind of commitment on a timescale because it simply isn't my place to do so.

On CHCs again, I make the point that this is a new body that we're seeking to create to cover health and social care. I recognise her points about independence, however the Government funds the CHCs, so we provide a budget for them. It's a significant budget; well in excess of £3 million to undertake their work. The chair of the national board is a ministerial appointment undertaken through a transparent public appointments process, so we need to think about what people mean by 'independent of Government'. In effect, though, I don't interfere, and I'm not particularly interested in interfering in the way in which the national board of CHCs operates, or, indeed, the way those functions are carried out to support people on the ground in their very important advocacy role.

On the duty of candour, the healthcare professionals already have their own duties; they're not all covered by the GMC. So, the Nursing and Midwifery Council, the Health and Care Professions Council as well—including, of course, Dawn Bowden's question about therapists—they have different professional and regulatory bodies, but they all have, essentially, broadly the same duty as healthcare professionals that looks like a duty of candour. What we don't have is one that covers all staff, because not all staff are in those groups, and we don't have an organisational duty as well. That, again, is some of the work that I'm committing to take forward, and, obviously, any conclusions that we reach we'll come back on, make a statement to this place, and if there is to be legislation, I'll have to front up in front of a committee at Stages 1, 2, 3 and 4 to do so.

Thank you very much for your statement, Cabinet Secretary. I've just got three questions here, I think. I've been looking at responses from those who have contributed to the consultation from within my own region, so this is where this is coming from. Can I just start with common standards to achieve person-centred care? As you know, the NHS is currently characterised by standards reflecting a medical model, whereas in social care, it's very much an alignment with a social model, and I note Rhun mentioned earlier this focus on experience and what we might mean by experience.

Now, I personally still have some underlying anxiety that social care priorities may struggle to compete, if that's the right word, with some medical priorities in an increasing merger. I just wonder if you can explain whether that kind of anxiety is what's at the core of preventing the two inspection regimes coming together at this stage? I recognise the stalling, but I think it'd be quite useful to have a slightly fuller explanation of that. And beyond that, what safeguards are you considering now to ensure that both the patient voice—however that's articulated, and I'll come to that in a minute—and the views of social care professionals are appropriately weighted against those clinicians who are traditionally seen as experts when we come to conversations of this nature? I want to make sure that there is a genuine equality between these voices, rather than the NHS being the loudest and the proudest.

Just briefly on CHCs—I don't want to go through what everyone else has said—I take you completely at your word that it's not your intention to leave a gap at any point in the advocacy, but you've repeated this phrase 'a national body' a few times now, and I think what concerns me in this is it sounds very much like the statement we've had previously earlier today on the comparison between the UK Government trying to take responsibility for imposing a framework and the devolved bodies having to put up with that. Don't you think there's an argument that if you're looking at a national structure here, then, actually, the voices that should be at the forefront of designing that should be the CHCs as modified to cover social care, not a top-down model? I appreciate that you'll want one voice to communicate with Government, but that shouldn't be something that you design, and that CHCs are subsidiary to that. It should be the other way round, surely.

Then, finally, I'm just picking out a few quotes from the responses that I've looked at, where people—and these are individuals, now, rather than big bodies—say that '“Trust” is a misnomer', that they expect to see 'actual penalties' imposed on boards, not people 'pensioned off', and that the whistleblower provisions in existence at the moment don't seem to be very effective. I presume the duty of candour will go some way to addressing that. But I heard what you said to Angela Burns about Government and the stages at which it knows about problems. These responses are more about what does Government do when the working together bit fails and, actually, there is still a problem. There's a genuine sense, in these responses, that nobody gets to carry the can when there's a problem that can't be resolved. If you're hoping for this to create a greater trust in our governance system, which I'm sure we all agree would be great, I think you need to really consider—I say it with a heavy heart—a punitive element at some point, and I'm not getting a sense of that within the statement to date, anyway. Thank you very much.

Thank you for those questions. I'll try and run through them as briefly as possible, but as directly as possible.

On common standards, I recognise what's been said. There's an impression that in the history of the health service there's been a more paternalistic medical approach, as opposed to a more engaged social model within social care, and actually it's part of the movement within healthcare, in any event, to have a more social model to understand what that really means—seeing that person in their context and that person having a real voice. I recognise that, in the field of social care, more progress has been made on the citizen having more voice and control in those choices. That's actually why co-production matters so much within the healthcare system. It really, really matters for people to be informed, for people to make choices and to say what matters to them. That's where we're trying to get in the way we design our system, as well as they way in which individual interactions take place.

I hope that also helps in terms of the point about health being seen and heard over other voices, especially social care. So, if we're going to have, in a whole range of things, the parliamentary review and others, there's got to be more genuine partnerships, and something that is genuine in the way that health deals with others. If we don't do that, then we recognise we'll just see more pressure coming into the health system in any event. So, this isn't just budget choices, this is the way in which we organise and run our wider system, and there'll be more to talk about with that as we take forward the parliamentary review and a long-term plan for health and care in Wales.

I'll deal with your point about the national bodies. The national body for the citizen voice—it's about having a consistent national body, but one that does have local standing and engagement. This is about not doing away with all the things that work in CHCs. I've been really impressed by the way, from the outset, through the consultation, the CHCs initially engaged in this and told us that they were particularly unhappy with the national board. There have been a number of meetings that have taken place with officials, and then, the ultimate response was when, actually, they recognised there were some things that could and should change, but they want assurance that a new voice for the citizen across health and social care will still have an entitlement to organise its business, which must include—. You know, any sensible national body would want to have a local way of communicating and engaging with its citizens. That's what we would expect to be the case. Now, there's something about what we set out on the face of legislation, should we bring that forward, what should be in secondary legislation, what should be in guidance about how a body should organise, where you can be much more descriptive, frankly, than legislation sometimes allows you to be. But I recognise the challenge that Members on all sides have about making sure you don't lose sight of having a local locus for that national citizen voice body, rather than, if you like, a top-down organisation that's based in Bangor, Cardiff or Aberystwyth, that could be remote from local communities.

On your point about the merger of inspectorates, there was a real divide in opinion. Some people thought that the inspectorates should merge and do so as quickly as possible, others felt it was an incredibly bad idea for a range of different reasons. Some think it's about the sprawling nature and how broad health and social care are in any event. The care standards inspector, of course, rubs up against early years and Estyn, in any event. So, actually, there are links between the three inspectorates that matter as well, and having a new superinspector is something that not everybody thought was the right thing to do. So, we'll develop how we have further joint working between those inspectorates, deal with the legislative underpinning for Healthcare Inspectorate Wales, but it's possible, of course, that a future Government may come back and say, actually, the time is now right to think about having a merged inspectorate, not just an inspectorate that works on a more complementary basis.

And finally, your comment about carrying the can. I think the easiest thing is to call for somebody to go, and as a Minister it's much easier to get rid of someone—although that's sometimes difficult—than to then replace them with someone who will improve the position you find yourself in. And I think there's a real challenge about the culture that we have within health and social care and more broadly across public services. So, we don't simply tolerate failure. There is accountability, but equally, we don't move to the extreme end where people recognise their time is limited and they can expect to have a tap on the shoulder or be shown the door within a brief period of time. I heard Bruce Keogh give his leaving speech, and I think it was interesting. It was his leaving speech to the NHS Confederation conference in Liverpool last summer. He said, 'We must recognise there is something wrong in our system if the average life expectancy of a chief executive within an NHS trust in our system—England—is less than two and a half years.' Two and a half years is not a period of time for a chief executive in a large, complex organisation to understand it, to get on top of the challenges, and to be able to make real and lasting change. Now, that's one end of our spectrum. We need to think about what is appropriate here, how much tolerance we have, our ability to get different and better people if we recognise there is a problem, and also how we work to support organisations that are going through difficulty. So, I want a generally rounded approach—one that has real teeth and real accountability within it.

Thank you very much, Cabinet Secretary.