The next item is the debate on a Member's legislative proposal, and that is on health service management, and the motion is from Helen Mary Jones.

Motion NDM7102 Helen Mary Jones

To propose that the National Assembly for Wales:

1. Notes a proposal for a Bill on health service management.

2. Notes that the purpose of the Bill would be:

a) to establish a professional body for NHS managers in Wales to set core professional competencies for managers at all levels, ensure the development of appropriate initial training programmes and continuous professional development, and with the power to take sanctions against managers for poor or unsafe performance;

b) to ensure true independence of Healthcare Inspectorate Wales;

c) to establish a legal duty of candour to apply to all health professionals including managers; and

d) to establish a genuine, robust and transparent complaints system that supports parents and families.

Motion moved.

Diolch yn fawr, Llywydd, and it's my pleasure and privilege to present this legislative proposal to the Senedd today. It has been a bit of a habit amongst politicians in Wales sometimes to say, 'We have too many managers in the NHS; they're not doing their jobs properly'. I've probably been guilty of that in the past myself, but the truth is that we will not deliver the kinds of services that our constituents—every single one of our constituents—want and need unless we have a service that is effectively managed.

Now, it's also absolutely true that we have many excellent managers working at all levels in our NHS in Wales, and they strive and succeed in planning and delivering, with their clinical colleagues, excellent services. But there can be none of us in this Chamber who are not aware of the widely shared concerns about capacity, sometimes about competence, and certainly about consistency of performance in the management of our services. And there are very valid concerns about accountability. So, this is why I propose to us today a Bill on health service management. What exactly we might call it—an NHS accountability and transparency Bill—that could be for further debate. But the purpose of this Bill, its main purpose, would be to establish a professional body for NHS managers in Wales. Now, this has been portrayed in some sections of the press and by some responding to the debate as an attack on the service. It is definitely not that. What it is actually doing is acknowledging the huge importance of managers to the effectiveness of the service, and, if we gave them a proper professional body that registered them, we would be putting their contribution on a par with their clinical colleagues, and I think that definitely deserves consideration.

So, I'm proposing a role for this professional body to set core professional competencies for people in management and administration at all levels, that these competencies should be value based. If you're training as a nurse, the very first thing you get is training in the values that the service expects for you. We don't currently offer that consistently to those administering and managing the services.

The Deputy Presiding Officer (Ann Jones) took the Chair.

We would need core competencies set at every level, and those competencies would be based on this value-based training. A professional body could require continuous professional development to ensure that those managing our services are able to keep up to date with all the requirements on them and all the developments that go around them. Some, particularly middle management managers, say to me that they are overwhelmed, sometimes, by change. They don't resent the expectations of Welsh Government of the service that they're going to deliver, but they need to be empowered to do that properly.

So, this is about valuing those who manage our NHS. It's about giving them the tools to do the job and it's about ensuring that everybody else knows what can be expected in terms of competence, knowledge and skills from people managing at different levels in our service. Now, of course, one aspect of this registration would be that, if a manager persistently failed, or if a manager was having trouble doing their job, their professional body would, as it would with a nurse or a doctor, step in and prescribe advice, prescribe training, prescribe support. But, if that was not successful, in the end, this professional body would have the right to strike a manager off and say, 'You are not a fit-and-proper person to undertake the management of our service'. That is not the main function of the legislation that I'm proposing, but it is a sanction, and it would end a pattern that we've seen—and I have no intention today, Presiding Officer, to name names—of persons in very senior roles in parts of our service failing to manage those services effectively, disappearing for a while and then popping up somewhere else managing another aspect of the service and not doing it well. That is totally unfair; it's totally unfair to the patients, it's totally unfair to the clinical staff, but it is also totally unfair to those working in management in the service who want to be able to do that effectively.

I realise that this is a huge piece of work—this is not something that could be achieved by a private Member's Bill—but just because it's a huge piece of work does not mean to say that we shouldn't set out to do it. I remember being told in this place that it would be impossible and much too complex to register healthcare support workers. Well, we're doing that now. And I think we need to be equally ambitious around what we offer to those who manage our services.

I would also see this legislation properly establishing the independence of Healthcare Inspectorate Wales. Members will remember that the committee, back in 2014, was very concerned that it hadn't received reassurances about the role of the inspectorate, that it wasn't suitably independent. Now, I know the Minister has got some long-term plans to do something about this, but I would remind him that he said that the NHS quality Bill that would be coming forward would address this issue of HIW independence and the draft we have before us does not.

My proposed legislation would also place a duty of candour, not just on organisations, which, of course, is commendable, but on individuals. Where we most need that duty of candour is where people need to be empowered to speak up within organisations that will not exercise their duty of candour. And simply putting that responsibility on organisations will not deliver what I'm sure the Minister intends. We also need a robust, consistent, transparent complaints system that is truly independent and trusted for patients and we need to look again at how successful our whistleblowing policies are, because my experience and my postbag tells me that they are not.

This is a matter of the utmost seriousness. In some circumstances, this is a matter of life and death. I believe that this is a problem that needs a radical solution. I believe the people who work in our service deserve to have their professionalism recognised, deserve to be properly trained, deserve to know, through a set of core competencies, exactly what is expected of them. And they need to know too that they will be held accountable for delivering the planning and the management of our services in coherence with that core set of competencies.

I look forward, Llywydd, to hearing other Members' comments in this debate. I am not expecting—although, of course, I would be delighted—the Minister to say here that he will take on this legislation, but I do hope that he will feel able to acknowledge that there are serious issues that need to be addressed and that we can explore on a cross-party basis in this place to ensure that we have the best, most transparent management system that our NHS needs and deserves.

Thank you. Can I just remind speakers that it is three minutes for your contributions to this proposal? Angela Burns.

Thank you, Deputy Presiding Officer. I'd like to thank Helen Mary Jones for bringing forward this proposal for a Bill on health service management. I can assure you that the Welsh Conservatives would not only support your proposals, but seek to strengthen and increase some of the proposed Bill's provisions, because it ties in very much with a five-point plan for health that we announced in March. Three of the points that we covered have been partly encapsulated in your Bill, and we'd like to take them forward further.

Because we called for there also to be a radical overhaul of Healthcare Inspectorate Wales to make it entirely independent of Welsh Government and to give it new powers to intervene quickly when problems are identified. By making it truly independent of Government, as Helen Mary proposes, I believe we could achieve this objective, but I would ask the Member for Mid and West Wales to also consider a financial provision, because we believe that HIW's budget must be trebled in order for it to be able to expand its programme of unannounced inspections and to ensure that requirements for improvement are implemented.

The evidence session the health committee held this morning with Cardiff and Vale University Health Board bears this out. It was an unannounced visit by HIW to the University Hospital of Wales emergency unit and assessment unit that highlighted unsafe standards of care, poor medication practices and inappropriate staffing levels, amongst other areas that needed addressing. Yet, despite insistence that senior managers visit the departments, the health board did not seem to recognise that the emergency unit and assessment unit needed additional support, and to paraphrase what the chief executive said today, people see the situation or the problem so much, they no longer recognise it as such, and we need an independent organisation that can come in.

Furthermore, I think the proposed professional body for managers is, again, something that we'd be very supportive of. Again, we suggested this in our idea, but we'd like to see it go further and become an NHS leadership council that requires registration, and those deemed incompetent would be removed. As you mentioned earlier, there are people—I've got here six examples of people who've repopped up in the system, having done an absolutely shocking job somewhere, and they've managed to survive and go on again.

We totally support a new, robust complaints system. Let's again remind ourselves of another health committee when the chief executive of Cwm Taf said, and I quote,

'To be absolutely frank, the extent of the feedback from the families, which has been the most distressing element of this, was a complete shock, even to me, and I sign off complaints in the organisation.'

Really.

Finally, may I just say you've made an absolutely interesting point on the duty of candour? It should apply to individuals as well as organisations. We've been calling for a duty of candour for six years, since it was introduced in England after the Mid Staffs scandal and in light of Robbie's law. However, the health Minister at the time, Mark Drakeford, implied it was not necessary for Wales. He said in 2013,

'The redress regulations passed here by the Assembly in 2011 place a duty of openness on health boards now. In a sense, a duty of candour is already implicit, if not explicit, in those regulations.'

We've seen that it doesn't work. We would absolutely support you, and I would like to work with you in bringing forward such a Bill to the floor of this Chamber.

May I congratulate Helen Mary Jones for taking the lead on this? I fully support her intentions. There’s no doubt that systems in the health service are under a huge strain—not enough staff, not enough resources, not enough beds, and nurses and doctors being extended to the very limits to provide an acceptable service most of the time, an excellent service often, but on occasion, the quality of the service does fall short and mistakes can happen, almost inevitably, in a system under such strain.

There are a few points that need to be made. The duty of candour is challenged when lawyers become involved, and even apologising under such circumstances can be interpreted as an admission of fault, and the honesty of the nurse or doctor then will take them to a court of law. And when a nurse or a doctor does decide to speak up to highlight some weakness in the system, then they should be truly protected. Very often, as a whistleblower, they will be persecuted by managers, and will face criticism from colleagues, and they may even be suspended from work or see their careers ended for raising those concerns. The expert who blew the whistle on the deaths of babies in Bristol in the heart operation scandal over 20 years ago—ultimately, that specialist had to move to Australia in order to find work and to continue with his career, just for being a whistleblower.

And the second point: we need to recognise failings in the system that can lead to individual mistakes when doctors and nurses have to do more than one crucial thing at the same time because of pressures of work—not always the doctor or the nurse being persecuted, but looking at the responsibilities of managers too, as Helen Mary has stated, because everybody has a responsibility here. Everyone—doctors, nurses and managers—should be treated the same. They should be registered by their professional bodies, and they should face being struck off and going into to a court of law to face very serious charges where necessary. That’s what faces every doctor and every nurse now; that is what responsibility for patient looks like. Managers should face the same.

Ultimately, we need a no-fault compensation system as a nation when things do go wrong, or some unexpected event happens to a patient. This happens in a number of other countries because a patient doesn’t necessarily have to access an expensive lawyer, the patient wouldn’t require a court of law, and wouldn’t need to prove blame, because, on occasion, it’s a sheer case of being unlucky—there is no-one to blame. No-blame compensation takes away many of the costs, and all of the compensation goes to the patient. Support the motion.

I welcome Helen Mary's proposals for NHS management and I support her Bill proposal wholeheartedly. As I've said many times in this Chamber, we must ensure health service managers abide by the same obligations as clinical staff. Clinicians are covered by duties of care placed upon them by their royal colleges and the various professional bodies. Managers are an essential part of our modern NHS, and they can often play a role in ensuring the quality of care provided to patients. It is therefore essential that NHS managers belong to a professional body that will help them ensure that there is no room for poor performance or unsafe practices in health service management.

I also welcome measures in the proposed Bill to place a truly independent Healthcare Inspectorate Wales at the heart of a complaints system that puts patients first and ensure they and their families are supported throughout. Placing an explicit duty of candour on NHS managers will hopefully form part of the code of conduct set by the new professional body, ensuring that in future mistakes are seen as learning opportunities and not something to be covered up and evaded. Helen Mary's proposed Bill recognises that our NHS is just as dependent upon managers and administrators as it is upon clinical staff.

We must ensure that those managers and administrators are bound by the same legal duties to the patient as clinical staff. We will never totally eliminate mistakes—we must accept that—but we can ensure that we eradicate unsafe practices and do not reward poor performance. For our NHS to thrive, every part must function well. NHS managers are there to ensure clinical staff have the necessary tools to treat their patients. This proposed Bill will help ensure that healthcare managers have the necessary skills to support clinical staff in a truly patient-first NHS. It has the full support of my group and I look forward to helping Helen Mary in any way I can to ensure its swift passage into law. Diolch yn fawr.

I also support the introduction of this Bill and thank the Member for introducing it. We're all familiar with the horror stories. Babies have died because of NHS mismanagement. Thousands of young people have had their lives put on hold because metal health waiting lists have quadrupled. Patients have died waiting hours for an emergency ambulance to arrive. Lives have been hugely blighted for people waiting longer than they should for surgery, and cancers have grown while the capacity to diagnose and treat them in this country has shrunk. It's not the fault of the clinicians and the front-line staff that this has happened in Wales, but it is someone's fault, and if this Government is to be believed when they deny culpability for the increase in needless deaths and suffering caused by poor responses and outcomes, then it has to follow that it's the fault of certain NHS managers. 

Managing finite resource in an organisation that has to respond to what could be considered an uncontrollable demand is no doubt difficult, but brain surgery and complex cancer treatment is no doubt more difficult. Yet, the highly trained, registered and licensed brain surgeon is subject to the decisions of an unlicensed, unregistered NHS manager whose role requires no statutory qualification whatsoever. The decisions of some NHS managers have caused some serious problems, as I've discussed, yet we don't know of any NHS manager who has had so much as one day's pay docked, no-one sacked, no-one told to publicly account for their fatal failings. 

For years, I have supported calls for NHS managers to be registered or licensed in a similar fashion as those clinicians who are subject to the NHS managers' decisions. Too many times, we see that managers who fail in one public sector setting simply leave with a big pay-off and then pop up somewhere else in the public sector to wreak their incompetence on another group of unsuspecting taxpayers. Our own experience in this place shows that without a change in the rules of engagement we can't expect any significant improvement. For example, how many times have we in the opposition cornered the health Minister Vaughan Gething about the continued abomination that is Betsi Cadwaladr health board and asked him if anyone has been sacked for their huge failures or the ruining of people's lives, only to see him squirm and almost apologise for his own inability to do anything about it? 

This Bill stops short of a licensing system for NHS managers but it's a big step forward in the right direction. Many people would be surprised that there's not a professional body for an occupation as important as NHS management, yet there's a professional body for things like estate agents, advertisers and football coaches et cetera. An independent health inspectorate that's not full of political appointments is also vital. It's long past time that NHS managers should be held to account for the deaths and suffering that their bad decisions cause. It's clear that, since Vaughan Gething doesn't have the skills to solve the problems by himself, we now have to build the solutions into Welsh law. Thank you.

Can I now call the Minister for Health and Social Services, Vaughan Gething?

Thank you, Deputy Presiding Officer. I do want to acknowledge at the outset the concerns and issues that have been raised by a number of speakers in their contributions, and that lie behind the motion and the proposal, but I do believe that the draft Health and Social Care (Quality and Engagement) (Wales) Bill addresses a number of the points in the motion. Of course, we have just started the scrutiny process on that piece of legislation. I had the opportunity to appear before the Finance Committee today. The passage of that draft Bill through the Assembly will provide an opportunity for these ideas to be debated and discussed, including opportunities for amendments and improvements to be made. Quality is the central concept underpinning the provisions within the Bill. By placing duties at an organisational level, the Bill takes a whole-system approach to quality improvement.

The motion today does include proposals to strengthen the independence of Healthcare Inspectorate Wales. A strong regulator able to act independently of the NHS and Government is an important part of our quality landscape. The arrangements currently in place ensure the inspectorate can and does operate independently. As the health Minister, I am not involved in its oversight or in setting its budget. It is responsible for setting its own programme of work within the broad scope of its remit letter. These are essential factors in ensuring that HIW can and does speak out when it needs to. We do, though, recognise that the existing legislative framework for Healthcare Inspectorate Wales is complicated and does need reform. In the interim, there is a need to incrementally develop HIW's capacity to ensure it is equipped to respond to a future legislative framework. I've made available over £1 million of extra support for the organisation to develop its capacity.

The motion calls for a more transparent system of complaints. We have no evidence of a need to change the 'Putting Things Right' arrangements. A review by Keith Evans found it to be fit for purpose, and his recommendations focused on the need to ensure that the application was consistent. The 'Putting Things Right' arrangements do include the NHS redress scheme, which is innovative and unique within the UK. Claims worth less than £25,000 are dealt with under the scheme, which is far quicker than the litigation process and operates at no cost to complainants.

The Bill that I've referred to will establish a new citizens' voice body and I'm sure there will be lots of opportunities for comment and questioning about that through its passage. That new citizens' voice body will support people or their representatives if they need to make a complaint about health or social care. Additional staff will be funded to enable the new body to extend its services to provide a complaints service, advice and assistance to a wider range of individuals.

The Bill proposes a statutory duty of candour at an organisational level. This will mean that all staff, including managers, will be subject to the duty. There will be training for all staff, at all levels of organisations, whether clinicians or not. And that training will be done in partnership with clinicians. Virtually every professional group within the service is keen to sit down with us, to work on the guidance for the duty of candour, to ensure that it is delivered effectively by individuals and organisations across Wales.

I think perhaps the most important points in the conversation today have been about the challenge of having a blame culture, and the cross between blame and accountability. Now, I recognise that, if we are to deliberately move our healthcare system towards a system more properly based on learning and reflection—if that's not to be an aspiration, but something that is made real—we need to see culture change within organisations. And that applies to clinicians as well as managers. And part of my concern is the language around this potential proposal, which does sound rather more like the ability to get rid of managers, rather than to learn and reflect when things go wrong.

Earlier today, I was at the launch of the maternity vision for Wales. And, again, there, within the maternity profession in Wales, there is real reflection on the things that have gone wrong in different parts of the country—obviously, in the former Cwm Taf area—but there's also real pride in the deliberate choices that they are making, and they are recognised as making within the UK and further afield. And I would not want to see a new system of conduct introduced that moved us away from the ability to learn and reflect. And so, the proposals for a new compulsory regulatory body for NHS managers would introduce a level of cost and complexity, but of course that's always the case when introducing new measures. But we should recall the experiences of nurses in the care homes regulations, when having to attend to two regulators. That did not improve our system, it did not make a difference to those members of staff or the people they're working with or for.

We would need to have detailed finance and policy consideration to reflect the diverse nature of the workforce and their roles, including the point the First Minister made yesterday about defining who or what a manager is to be caught within the ambit of a new regulatory body, whether it is prospective regulation, where everyone must appear on a register to be able to work, or whether it is a retrospective test as to whether someone is a fit-and-proper person. Those are issues that the potential mover of the legislation would need to address, and that balance of responsibility between the employer versus the regulator, and how we ensure that those healthcare professionals, who are the great majority of managers within our system, how they are dealt with, and indeed the mobility of the workforce across borders if we were to introduce this requirement in Wales alone. The British Medical Association, for example, have called in the past for a UK-wide approach to this issue. I'm not persuaded on the case for compulsory regulation for managers, but I'm happy to listen to detailed proposals that address the very real and practical challenges.

Thank you. I call on Helen Mary to reply to the debate.

Diolch, Dirprwy Lywydd. I only have two minutes to respond, so I can't possibly respond to every single point that people have raised. But I'm very grateful indeed for the level of support there has been across the Chamber, and I'm also grateful, actually, to the Minister for acknowledging that this is an attempt to address issues that are real and are meaningful, and for his willingness to look at more detailed proposals.

I want to touch on a couple of points that Angela Burns raised. I think the financial provision for HIW is absolutely crucial. I'm not sure that you deal with that in legislation though, though there may be some ways to do that. And I absolutely support what you say about registration involving the right to, potentially, remove somebody. But I want to challenge the Minister and say that I was very clear in my contribution that that's not where I'm starting from. What I'm starting from is empowering people to do their jobs properly, and only having to come back to them, and deal with not doing the job properly, as a last resort, as is the same for doctors, nurses, and other clinical professionals.

Nobody will be surprised to hear me say that I agree with everything that Dai has said. In the context of this Bill, I think, crucially, moving to a proper no-fault compensation system is, in the end, the only way that we will enable professionals to be able to admit mistakes and learn from them. And an equity of treatment for managers and clinical staff is crucial.

The Minister's Bill is not entirely useless, and we will, of course, seek to amend it, but it doesn't address the bulk of the concerns. I do believe we need to regulate our managers, particularly to stop them appearing, disappearing and reappearing when things have gone wrong. We will, of course, co-operate through the Bill's progress, but we need to do more.

Now, I happen to believe that we do have the ability and capacity. We have enough bright people in Wales to provide really effective management of our public services, but we're not providing them with the training and the structure to enable them to do that. I will work with Members across this Chamber to seek to move this agenda forward. We may perhaps consider, for example, a cross-party group on public service accountability that could address some of these issues.

I'm very grateful for the opportunity to raise these matters here today. Some of the feedback that's come back to me, very clearly, from, actually, managerial staff is that they are glad to know that people know that everything isn't all right and that they're taking it seriously. I look forward to co-operating on this agenda to deliver the best management and the best outcomes for patients.

Thank you. The proposal is to note the proposal. Does any Member object? [Objection.] Okay, therefore, we defer voting on this item until voting time.

Voting deferred until voting time.