Item 8 on our agenda this afternoon is a debate on the general principles of the Health and Social Care (Quality and Engagement) (Wales) Bill, and I call on the Minister for Health and Social Services to move the motion—Vaughan Gething.

Motion NDM7203 Vaughan Gething

To propose that the National Assembly for Wales in accordance with Standing Order 26.11:

Agrees to the general principles of the Health and Social Care (Quality and Engagement) (Wales) Bill.

Motion moved.

Thank you, Deputy Presiding Officer. I'm happy to move the motion before us today and the debate on the general principles of the Health and Social Care (Quality and Engagement) (Wales) Bill, which I introduced on 17 June this year.

I'd like to place on record my thanks to all stakeholders and members of the public who engaged with us and contributed to our thinking. The Bill reflects the findings of the parliamentary review from 2017, which found that there needs to be a continuous focus on quality across the board and a strengthened citizen voice. It reinforces our priorities set out within 'A Healthier Wales', our long-term plan for health and social care. It outlines how quality will be key to making the health and social care system in Wales both fit for the future and one that achieves value. The Bill's objectives address four issues designed to ensure that the citizens of Wales are placed at the heart of high-quality services.

The first is the duty of quality. This goes to the heart of what we are trying to achieve. The duty is more than just cultural change. It requires NHS bodies and Welsh Ministers to think and act differently by applying the concept of quality and improved outcomes, not just to services being provided, but to the whole process and across all functions, within the context of the well-being and health needs of our population.

The Bill introduces a duty of candour that will support increased openness, transparency, and the continuing development of a learning culture across our NHS. The Bill also modernises and strengthens the way in which the voice of the citizen is heard. We will replace existing community health councils with a new citizen voice body that, for the first time, will operate across both health and social care. And finally, it introduces a power for Welsh Ministers to appoint vice-chairs to NHS trusts, putting them on the same footing as local health boards.

The four elements of the Bill make a step forward to better quality improvement and support, more integrated working between health and social care and improved citizen engagement. I'm grateful to members of the Health, Social Care and Sport Committee, the Finance Committee and the Constitutional and Legislative Affairs Committee for their scrutiny of the Bill so far, and for their recommendations. But, in particular, I want to thank the Health, Social Care and Sport Committee for their support of the general principles of the Bill that is set out in their report.

I do now want to turn to address some of the points raised in the committee reports. Firstly, the health committee recommends that there should be statutory guidance on the duty of quality. Now, I have already indicated that there would be guidance on the duty. However, I'm content that making it statutory would add weight to this, and I will table an amendment to do so.

There are a number of recommendations about the detail of the duty of quality, what the focus of the duty should be and how it should be implemented. Again, I've been clear that, in my view, many of these are actually dealt with better in the guidance, which I now propose to make statutory, rather than having a long list on the face of the Bill. This approach should ensure that full consideration is given to all those issues that enable the duty to be discharged. We'll be better placed to describe a range of circumstances in an illustrative way and to be much clearer about what is meant in different scenarios.

On both the duties of quality and candour, we will describe and explain in that statutory guidance the consequences for non-compliance. We need to strike a balance between clarity around what will happen if an organisation doesn't comply with the duty and the ability to take appropriate and proportionate steps. I want to think about the circumstances, and, importantly, to ensure that we take every opportunity to learn and improve.

There has, of course, been significant interest in the proposals relating to the new citizen voice body, with a number of recommendations, most notably on providing the body with the right of access to health and social care services premises; ensuring the body is not a remote national body that is inaccessible and unable to represent the interests of people across the whole of Wales; and a requirement for NHS bodies and local authorities to respond to representations made by that body.

I agree that the body needs to be able to seek the views of people at the point at which health and social care services are provided. I believe that the best way to achieve that is through a code of practice on access to health and social services premises. One of the principal benefits of this approach is its flexibility to apply to the huge variety of settings where health and social care services are provided. Vastly different forms of care, support and treatment are delivered across these settings, responsive to individuals' needs and wishes.

The code also has the benefit of being a living document, capable of responding to changes in practices and people's experience of applying the code. It will carry with it the necessary weight to ensure that all parties discharge their respective responsibilities. It will, of course, be the subject of engagement and consultation in its preparation to ensure that, as a document, it is fit for purpose and clearly understood by all those who will need to apply it. We've taken this approach in developing and publishing codes of practices under the Social Services and Well-being (Wales) Act 2016, and I believe it's the most appropriate way forward to proceed here.

I also agree that the new body needs to be able to represent the interests of people across Wales and be accessible to people in all parts of Wales, so I will bring forward Stage 2 amendments to address both the concern around the ability of the body to represent people across the whole of Wales and access to premises.

I note the health committee's comments on the representations that the citizen voice body will be making and what can be done to ensure not only they are listened to, but that the body and the public can see that they are being listened to. The report recommends a requirement to respond to representations be included on the face of the Bill. Now, I believe the current wording already requires NHS bodies and local authorities to have regard to representations, and that carries considerable weight. However, I have taken account of what the committee has said, and I do intend to bring forward a Government amendment at Stage 2 to require Welsh Ministers to issue again statutory guidance on how this will work in practice.

Again, having listened to the evidence presented on the topic, it's clear that the citizen voice body will need to be kept up to date with how a public authority is dealing with their representation, and, importantly, the outcome of that representation. The publication of statutory guidance will enable us to set out how this should happen in a proportionate way that reflects the different types of representation that may be made. 

I've read what the health committee have to say on the independence of the new body, as well as some of the evidence that was used to form its view. We need to be clear when talking about the appointment of members—the Bill gives Welsh Ministers a power to appoint members of the board of the new body. An appointment of board members will be subject to the rules of the Commissioner for Public Appointments. That requires open and fair competition for posts. I did, though, indicate during my appearance before the health committee that I am more than happy to include an additional stakeholder stage in the appointments process. 

Unlike the current position with community health councils, where Welsh Ministers appoint 50 per cent of the volunteer members, under the new arrangements in the Bill, the citizen voice body itself will be able to directly recruit all of its volunteers, which increases rather than decreases its independence from Government. There are also sufficient safeguards on the face of the Bill to ensure the body's independence from Government, such as a requirement to produce an annual plan containing the body's priorities and objectives for the year, which is produced following consultation and without the need for permission or approval from the Government. 

Turning now to the Constitutional and Legislative Affairs Committee, I'm happy to accept the committee's recommendations. All of the elements, and therefore the meaning of the duty of candour, are set out on the face of the Bill. The Bill is clear that the duty is triggered when there is more than minimal harm. An explanation of this will be set out in the statutory guidance, which we will develop in conjunction with both clinicians and the wider public. That's important as it will enable us to guide healthcare staff, patients and service users about how the duty works in a way that is accessible and user-friendly. I understand the committee's point about the need for a clear explanation of what the duty of candour means, and that that should be accessible to the public. I think statutory guidance, again, provides the best way of doing so. The explanatory memorandum with the Bill, on pages 19 and 20, includes a clear explanation of what is meant by a duty of candour and why we are introducing such a duty. 

Regarding their second recommendation, I can say now that I have no current intention to use the powers in section 26 in respect of amending primary legislation. The power is there to ensure we can respond appropriately to any unforeseen future developments, such as UK Government legislation. This is a standard provision in Assembly Bills. If the Government were to bring forward amendments to primary legislation, the regulations would be subject to the affirmative procedure and Assembly scrutiny. 

I've reflected on the discussion in the committee about the use of the word 'expedient' in the English and the Welsh, and I'll be bringing forward a Government amendment to replace the word 'expedient' with the word 'appropriate'. I'm also grateful to the Finance Committee for their constructive and helpful recommendations. I will bring forward a revised and strengthened regulatory impact assessment to reflect the report where appropriate, including sensitivity analysis for some parts of the Bill and a range of costings covering different scenarios. 

Finally, I'd like to reiterate my earlier comments and once again thank all committees for their input to date and engagement throughout Stage 1 scrutiny of the Bill. As citizens of Wales, I believe we are genuinely fortunate to enjoy some of the best health and social care services provided by committed and compassionate staff at all levels. The successful passage of this Bill will help futureproof these services for generations to come. As the health committee's report recognises, there is considerable support from a broad range of stakeholders for the aims of the Bill, and I hope that Members will give their support to it today. 

Thank you. I call on the Chair of the Health, Social Care and Sport Committee, Dai Lloyd.

Thank you, Deputy Presiding Officer, and I'm pleased to contribute to this Stage 1 debate to outline the main recommendations and conclusions of the Health, Social Care and Sport Committee in relation to the Health and Social Care (Quality and Engagement) (Wales) Bill 2019.

The committee held a public consultation exercise over the summer and took oral evidence from a range of stakeholders. I’d like to thank everyone who contributed to our scrutiny of this Bill. The Bill is one component of a suite of measures aimed at improving and protecting the health, care and well-being of the population of Wales. It would be difficult to disagree with its principal aims, namely: to ensure that quality becomes a driver of a system-wide way of working in the health service; to require health organisations to be open and honest when things go wrong; and to strengthen the voice of citizens across health and social care services.

Overall, we broadly welcome the proposals in the Bill and believe it represents an important step towards greater transparency and accountability across health and social services in Wales. Therefore, the committee recommends that the Assembly should agree the general principles of the Bill. That’s recommendation 1.

However, we have considered the evidence from stakeholders and made a number of recommendations to the Welsh Government for amendments to the Bill. I hear the words that the Minister has said about that and I would urge the Minister to give his full consideration to these recommendations as the Bill proceeds.

First of all, the duty of quality. The Bill introduces a new broad duty to require Welsh Ministers and NHS bodies to exercise their functions in relation to health with a view to securing improvement in the quality of health services. Quality includes, but is not limited to, the effectiveness of health services; the safety of health services; and the experience of individuals to whom health services are provided.

Many respondents told us that, while they welcome the aim of the Bill and recognise the need to improve quality, there should be clarification and strengthening of the duty of quality, that there was a need to define the quality more explicitly on the face of the Bill, and that there should be provision for sanctions for non-compliance.

As a committee, we are fully supportive of any measures that seek to improve the quality of services provided by the NHS to its patients. To this end, we support the shift in focus, proposed by the Welsh Government via this Bill, to a system-wide way of working that will require Welsh Ministers and NHS bodies to exercise all of their functions with a view to securing improvement in the quality of health services.

We were, therefore, disappointed to hear from stakeholders, particularly NHS bodies, that the Bill was not strong enough in setting out how quality in service provision would be assessed, how an organisation would demonstrate an improved outcome, and how a failure to deliver improvements in service quality would be addressed. These are matters that must be dealt with by the Welsh Government. To this end, we note the Minister’s intention to issue guidance about the duty of quality to support and assist NHS bodies in the implementation of this duty, and that he has provided a draft outline of that guidance. We accept his argument that guidance is the most appropriate vehicle for the level of detail he intends to provide on this matter.

However, we believe that the guidance to accompany the duty of quality provisions in the Bill is central to the success of these provisions and, as such, they should have statutory authority. Currently, there is no provision in the Bill for the Welsh Government to issue guidance specifically on the duty of quality. Again, I hear the Minister’s words today.

We therefore recommend that the Bill be amended to make provision for the issuing of statutory guidance and I welcome what the Minister said relating to the duty of quality. This guidance should clearly set out how the duty of quality in service provision will be assessed and how an organisation would demonstrate an improved outcome. It should also include details of how innovations and improvements designed in one area will be spread and scaled across the whole of Wales. That’s recommendation 2.

We heard strong evidence about the need for a clear link between service quality and the workforce. We support this. In our view, it’s impossible to separate out the issue of quality from the provision of appropriate staffing levels—they are inextricably linked. In order to deliver quality in service provision, we must have the requisite staffing. Therefore, the Bill should be amended to make specific provision for appropriate staffing levels and workforce planning as part of the duty of quality. That’s recommendation 4.

Further, we believe that there is an inextricable link between improving service quality and reducing health inequalities, and that this link must be more clearly provided for on the face of the Bill. That’s recommendation 5.

In relation to sanctions, we heard strong evidence of the need for a clearer indication of how to address failure to deliver service improvements. To this end, we believe there should be clear consequences for non-compliance with the duty of quality, and that this should be provided for on the face of the Bill. Such sanctions should not have a detrimental impact on the financial position of the organisation. We agree with the Minister that the NHS escalation and intervention arrangements are an appropriate mechanism.

I move on now to the duty of candour. We fully support the policy objective of a duty of candour, and the cultural shift towards greater openness and transparency within the health service that should flow from it. When things go wrong in health settings, patients and their families should be able to expect to be dealt with in an open and honest way. Equally important is that organisations have a culture in place that encourages and supports the principle of learning from mistakes and that creates the right conditions for this to happen.

Although the Bill sets out the conditions to be met to trigger the duty of candour, so much of the detail about the practical operation of this will be a matter for regulations and guidance. The regulations will set out the process to be followed once the duty has been triggered. As such, we welcome the commitment from the Minister to hold a public consultation on the regulations and to provide supporting statutory guidance. 

As with the duty of quality, we heard strong evidence of the need for sanctions for non-compliance with the duty of candour. We heard very real concerns from stakeholders about barriers to disclosure and legitimate fears for health service staff about speaking out. It is vital in delivering the sort of cultural change promoted by this Bill that staff have a safe environment to be open and transparent, without fear of recrimination. Whilst we support these actions, we are not fully persuaded that they are sufficient. We believe there is merit in further exploring a support system for staff that is more independent and robust and that enables them to feel safe in raising concerns and whistleblowing.

In relation to the citizen voice body, there are a number of challenges with the existing statutory framework. As such, reform is needed in this area and therefore we support the proposal to replace the community health councils with a new citizen voice body that will cover both health and social services. However, we must acknowledge the invaluable role that community health councils have played over the past 45 years in reflecting the views and representing the interests of their local communities in the delivery of health services in Wales. We must not lose the strengths of the CHCs, including their ability to represent the voice of local people, in any new structure, but we must built upon and develop them. A number of witnesses suggested that the appointment of members of the citizen voice body should be entirely independent of the Welsh Government. As a committee, we agree with that.  

We also heard concerns about the ability of the citizen voice body to undertake announced and unannounced visits, and we support that. This has been a very valuable and inexpensive way of checking on service quality and provision. We recognise that there are issues around access where people are receiving services at home, especially where this is in a residential care setting. However, we are not proposing unfettered access to people’s private rooms, rather reasonable and proportionate checks should be possible to do. 

Drawing to a close, and thank you for your patience, even though we agree that it would be unlikely that Welsh Ministers would ignore the representations of the citizen voice body, establishing the right to respond in legislation would ensure that the body has sufficient powers so that the public can be confident that it can make a difference. In that, we recommend that it should be included in the Bill. 

There are a number of other recommendations and comments that I would like to make but, of course, time is against me. To conclude, I hear what the Minister has said today. There are a number of amendments necessary to this Bill. I have listened to what the Minister has said, that he is to introduce certain amendments and I would suggest that he should listen to all the remarks made this afternoon. I welcome the Minister's intention to bring forward some amendments, but we do need amendments that do respond to the health committee's report to ensure that this is a Bill that is fit for purpose. Thank you very much. 

Thank you. Can I call on the Chair of the Finance Committee, Llyr Gruffydd?

Thank you very much, Deputy Presiding Officer. I'm pleased to contribute to this debate. The Finance Committee, of course, has made nine recommendations. The committee heard from the Minister that the Bill is about leading cultural change and is required to introduce a series of reforms to strengthen health and social services. He said that it wasn't possible to put a monetary value on every single part of the change.

Now, the Finance Committee accepts that the benefits of the Bill may be varied and difficult to quantify, but we have highlighted on numerous occasions the importance of the fact that regulatory impact assessments should contain the best estimate possible for the costs and benefits of a Bill in order to ensure that the committee is able to fully scrutinise the overall financial implications. We have, therefore, recommended that the Welsh Government undertakes further work analysing and estimating the benefits of the Bill, which are identified as key drivers for implementing the legislation, and I acknowledge the comments that the Minister made to that end in opening this debate.

The committee is pleased that the health sector has been involved in developing training materials on the duty of candour, and we believe that this will aid the cultural change that the Bill is seeking to achieve.

However, we are concerned that the Minister considers that it's feasible for NHS bodies to absorb the additional costs that will be imposed on them as a result of the Bill, particularly as the regulatory impact assessment does not quantify all costs to fall on NHS bodies. We recommend, therefore, that further information on the additional costs should be included in the RIA, once again.

In regard to the duty of candour, an adverse outcome is described as one that has, or could, result in more than minimal harm and the provision of healthcare was, or may have been, a factor. The committee is concerned that the estimate of ongoing costs for the new duty of candour reflects the number of incidents classified as moderate. If the definition of 'more than minimal harm' is to reflect a low level of harm, then it's likely, of course, that the cost could be significantly higher. We recommend the Welsh Government prepares a sensitivity analysis to show the impact of changes in the number of incidents on the ongoing costs arising from the introduction of the duty of candour. Once again, I recognise the Minister's earlier statement in that respect.

Now, the RIA quantifies the legal services arising for the duty of candour as £30,000 for NHS bodies, which is based on the existing legal costs for Putting Things Right—the campaign that was used, of course, to launch the new NHS complaint procedure back in 2011. This equates, on average, to an annual cost of £3,000 for each local health board and NHS Trust in Wales. However, the Public Services Ombudsman for Wales has told the Finance Committee on a number of occasions about his concern regarding the volume of health complaints that are made to his office. Therefore, we have concerns that the legal costs could be significantly higher and recommend the Welsh Government undertakes further work, including a sensitivity analysis once again, to demonstrate a range of costs.

Finally, the majority of the total cost of the Bill, £6.1 million, is associated with establishing and running costs of the new citizen voice body, including, of course, significant information and communications technology transitional costs. The citizen voice body will replace the seven community health councils in Wales and will be set up to represent the interests of the public in health and social care.

The ICT cost estimate in the RIA is reflected in the net cost of the Bill, and that's £2.13 million. However, the supporting information includes costs that range from £2.13 million up to £3.12 million. Whilst we acknowledge that ICT can enable and facilitate flexible working practices, the RIA doesn't set out sufficient evidence to demonstrate this. Therefore, we don't support the use of the low cost estimates in the assessment of the financial implications. We recommend the regulatory impact assessment should reflect the potential range of ICT costs rather than the low cost estimate. As I said, I acknowledge the Minister's intention to provide much of the additional information—financial information—that we have requested as a committee, and we look forward to seeing that in due course.

I'll briefly conclude my comments in my capacity as an Assembly Member for North Wales, because the Minister will know that there is strong support for the North Wales Community Health Council. It's been a strong and effective advocate for patients and citizens in north Wales over the years. It's been at the forefront of the debates on the Tawel Fan scandal; on the special measures debacle; and on the loss of the special care baby units, which eventually came back, subsequently, after quite a long campaign. It made 500 unannounced visits to wards across north Wales last year, helping to hold the health board and the Welsh Government to account and ensuring that patients in north Wales get the services that they deserve. 

This Bill, as we know, proposes to scrap the North Wales Community Health Council. It'll diminish the voice of north Wales's patients and it'll centralise that important scrutiny function to a, potentially, far away and more remote body, no doubt based in Cardiff. If there is going to be a new body, I, for one, would like to see it based in north Wales. So, I urge you, Minister, to scrap your proposal, to retain the North Wales Community Health Council and to ensure that patients and citizens in north Wales have the strong and independent voice and advocate that we all deserve.

Can I call on the Chair of the Constitutional and Legislative Affairs Committee, Mick Antoniw?

We reported on the Bill on 15 November. We made three recommendations. Our first recommendation relates to the definition of the 'duty of candour'. Part 3 of the Bill makes provision for and about a duty of candour in respect of health services. While the Bill sets out the procedures to be followed when the duty of candour is triggered, it does not define on the face of the Bill what the duty of candour means. As a consequence, we took the view that citizens unfamiliar with such terminology may not understand how the legislation would affect them, so we recommended that the Minister should use this debate to explain why the definition of 'duty of candour' does not appear on the face of the Bill, and, in its absence, where citizens could find information about its meaning. I very much welcome the comments that have been made by the Minister in respect of the face of the Bill and the introduction of a commitment to the issue of statutory guidance in this area.

Our other two recommendations concern section 26. It provides the Welsh Ministers with the power to make regulations to make supplementary, incidental or consequential provision, or transitory, transitional or saving provisions. We expressed concern at the breadth of powers being taken by the Welsh Ministers under section 26, particularly when such powers can be used to amend or repeal primary legislation, and there is no clarity about if or how they will be used. In such circumstances, applying the affirmative procedure to these powers does not validate their use. Regulations cannot be amended and we do not consider that regulations capable of wide yet unspecified changes to primary legislation should be subject to a 'yes' or 'no' decision to approve or reject them.

On that basis, our second recommendation was that the Minister should use this debate to set out clearly and in detail how he intends to use the powers contained in section 26, and I note the comments by the Minister that he has no intention to use these powers to amend primary legislation. However, whilst we ask for clarity on how the Minister intends to use the powers, there's one change we would also like to see made, and that is under 26(1), the power to make regulations can be exercised where the Welsh Ministers consider it expedient or necessary for the purpose of the Act. Now, we have, as a committee, repeatedly expressed concerns about the use of the term 'expedient' and the use of similar terms when applied to regulation-making powers, and we drew attention to some of our previous reports that had done so. It remains our position that Welsh Ministers should adopt a more targeted approach, rather than taking the widest powers available to them. So, we believe that a regulation-making power should be taken for a clear purpose; drawing powers too widely always runs the risk of them being used in the future in ways that were not originally intended or anticipated when the Bill was introduced. So, we recommended that the Minister should table an amendment to the Bill to delete the words 'or expedient' from section 26(1).

I note the intention of the Minister to bring forward a replacement to use the term 'appropriate'. Now, the term 'appropriate' appears to be 'expedient rather than appropriate', and therefore 'not appropriate', and is, in our view, superfluous, and that the appropriate means of proceeding would be to actually delete it completely so that the section just reads that the Ministers have the power to make regulations when they consider it necessary for the purposes of the Act. Thank you, Dirprwy Lywydd.

Thank you. Angela Burns. 

Thank you, Deputy Presiding Officer. The Welsh Conservatives are pleased to support the general principles of the Bill before us. However, there are areas that we would like to see either added to, amended or improved, and I'd like to touch on three specific areas.

I'd like to start with the duty of quality. Minister, there does need to be more clarity as to how the provision of quality would be measured. The statement says that that duty of quality is about the effectiveness of health services, the safety of health services and the experiences of individuals to whom health services are provided is very broad brush, and I'm concerned that this duty of quality could be interpreted as being done by putting quantitative processes in place, such as quality assurance methodology, but what is really needed is quantitative measures to underpin that duty of quality: do people feel that they're getting the service that they deserve and want? Do they feel good about it? Do they feel safe? Do they feel treasured? Do they feel well cared for? And many, many stakeholders have raised concerns over this. Indeed, Public Health Wales themselves said that an annual report on quality improvement appears to be a relatively weak control, and many stakeholders felt that the quality as currently described simply isn't robust enough. So, Minister, I would ask that over the next few stages that we really address this and tie this down.

With regard to the duty of candour, I think this is a really interesting step forward by you, Minister. I mean, let's be honest, you'd think our NHS would be candid enough, but as most of us have casework that demonstrates that that is not so, we absolutely need a duty of candour because it's about trust and honesty with patients, particularly if a service user has suffered unexpected or unintended harm and where the provision of healthcare may have been a factor in that adverse outcome.

And, again, Minister, stakeholders raised concerns over how the duty will be defined. Will it sit? How will it sit with prudent healthcare? Will it tie in with wider organisational processes? What about proportionality? What about training and integration between health and care or other partnership arrangements, such as GPs? Why is this duty so delayed on an organisation? Where is the individual duty? Because if there is no other lesson to be learned from Cwm Taf, it is that individuals failed to act openly and with transparency.

Both the duty of quality and the duty of candour as currently prescribed give little detail on how they will be measured, monitored and reviewed, and, to be frank, a yearly report is neither here nor there. I'm really pleased, Minister, to hear that you're going to make the guidance statutory, but I think then we need to have an involvement process as to what goes into that guidance. There needs to be a consultation and I'd like you to assure us that all of that will happen so that the guidance that goes forward that is statutory on these organisations to provide duty of candour and a duty of quality do sit well with us as an Assembly and with the wider stakeholders.

I'd like to just turn to the citizen voice body. I agree that some reforms are required of the existing CHCs. However, we're not seeing evidence that moves us from the Welsh Conservative position that citizen voice bodies must be independent. And that's not only us and the current CHC organisation that obviously believes they should be independent, but also the seven health boards, the three NHS trusts, Health Education and Improvement Wales, the Public Services Ombudsman for Wales, the British Medical Association Cymru, and numbers of other organisations who are also very keen that a new national body should have local representation.

Minister, the recommendations of the parliamentary review are clear: the citizen's voice should be put front and centre in the development and delivery of health and care services. And your 'A Healthier Wales' aspirations echo this ambition, but make no mistake, engagement with the public isn't about form filling but is about voices around the table where policy is made or reviewed.

A citizen's voice body has much to add to the discourse, provided their national branches are firmly rooted in the local communities that they represent. There is a genuine concern that a nationalised Government-run citizen voice body will be staffed by people unwilling to tell it as it is, unwilling to stand up for people's rights, unwilling to deviate from Government process, unwilling to challenge health boards, unwilling to take on local concerns. Minister, therefore, I ask: would you be willing to amend the Bill on that? I did hear what you said. I'm really pleased about some of the commentary you made. I did take on board your point that because it's going to be a wider pool, there's more for people to draw from, but, as you said, it's not enough to be independent. You need to be seen to be independent.

Deputy Presiding Officer, I have one more very important quick point to make—I'm sorry, I know I'm over time—I am of the view that the Bill must not be silent on how health and social care services support and protect those who raise genuine concerns. I've met health and social care professionals from all over Wales who have witnessed, reported and challenged bad practice, poor practice, inappropriate practice, but many of those healthcare professionals have not been listened to. Instead, they've often been blamed. They've been hounded, vilified, marginalised and have felt their careers have stalled. Too many of them suffer inordinate amounts of stress for trying to do the right thing. I started raising this concern some eight years ago, and I would like to ask you, Minister, and say to you, if you truly want the duties of quality and candour to be game-changers in our NHS, you absolutely must address this issue on the face of the Bill. If you're going to lead culture change, which is what you say you want to do, we've got to really protect our whistleblowers and give them the voices and that they know they can raise their concerns. We've seen so many cases where they've been ignored. Thank you.

I rise to participate in this debate somewhat conflicted. There is much to commend in what this Bill seeks to achieve: the strengthening of the citizen voice, introducing a duty of candour, a duty of quality. But as the committee's report highlights, and as referenced by the other committee report, and is clear in evidence from stakeholders, as it's actually drafted at the moment, it's a missed opportunity. It risks, I'm sure unintentionally, weakening the citizen's voice by centralising a body that currently delivers locally, by removing or unreasonably restricting the right of access to settings that we know has been pivotal. Llyr Gruffydd has referred to Tawel Fan. People being able to come in to see what's going on without having to ask—absolutely crucial, and by reducing the independence from the current community health council sitting. If these people are Government appointees, as Angela Burns has said, there is a risk that even if they are truly independent, they may not be perceived to be, and people may not trust them.

Thank you for taking an intervention. And just to emphasise the reasonable request, if you like, of the community health board in north Wales, they're not even arguing against not scrapping it as an entity in itself. What they're keen on doing is protecting the functions that it provides so well, so independently, and its ability to react, without notice, to concerns on the ground in the north.

Rhun ap Iorwerth is absolutely right in what he says, and this, of course, is why the committee recommends that it should be, on the face of the Bill, set out how these organisations will operate regionally. I don't think anybody in the committee is arguing that there shouldn't be change, but we don't want to be throwing the baby out with the bath water. And while that may not be the Minister's intention, that is the risk as things stand.

I do acknowledge that the Minister has said that he will agree to some of the amendments that the committee is recommending, and I welcome that. But what he hasn't done at all is to address the issues raised in section 7 of the committee's report about all the things that could have been included in this legislation that have not been. Angela Burns has already referred to what whistleblowers too often face in our NHS. We need strengthening, truly independent international whistleblowing processes that are completely outside the health bodies in which people work, and this Bill doesn't offer us that. Again, some of these things are addressed here. A single, strengthened, independent health and social care inspectorate—we could have had that included in this legislation. We could have included the alignment of health and social care complaints procedures. We could have looked at the regulation of non-clinical NHS managers and revised codes of conduct and training for development of that management workforce. And none of that has been done.

When the committee discussed this and came to its conclusions that we should recommend that this Bill be allowed to proceed, I agreed with that recommendation. And, again, as I've said, I'm glad that the Minister has accepted some of our concerns. But I have reflected on that agreement. I've discussed again with stakeholders, and I've come to the conclusion, and my group has come to the conclusion, that this Bill is just too much of a mess and too much of it is left out for it to be allowed to proceed as it is. We will abstain as to whether the Bill should proceed; we will not oppose it. But I would ask the Minister to consider withdrawing the Bill, taking on board all the comments that the stakeholders have made, taking on board the evidence from the different committees, and coming back with something much more comprehensive, much more inclusive. Now, were he to take that approach, I can give him the guarantee that Plaid Cymru would support him in that and would work with him to try and address the gaps that we see in the current legislation, because I think there is some consensus around supporting what the Minister's legislation is seeking to achieve, but it just doesn't do it.

Now, if the Minister won't withdraw the Bill, and I'm sure he won't, we will of course seek to address some of these gaps by moving on with amendments to the legislation, if he won't withdraw. But this really is not good enough. It is such a missed opportunity. This could have been internationally groundbreaking, and there are some really good things in it—the duty of candour is a really good thing; the duty of quality, now I understand it. When I first heard of it I thought, well, what's all that about? But once that was explained by the Minister and his officials, I can see the value of that. But there are just so many gaps. We could lead the world on this, Deputy Presiding Officer, and, instead, we're potching around at the edges. Now, I just really think that isn't good enough, and I'm also concerned that it happens too often—we get an inadequate piece of legislation brought forward by this Government that then has to be extensively amended, and that's not good parliamentary practices.

So, as I say, if the Minister won't withdraw the legislation and start again, which we believe he should, we will seek to amend it. But, really, this Senedd, our Parliament, the staff of our health and care services, and, more importantly, the patients and citizens of Wales, deserve better than this. We can do better than this.

I've listened with interest to the reservations of Angela Burns and Helen Mary Jones, and I hope that we can iron out any inconsistencies and issues across the Assembly, because it seems to me that health and social care are something that we really do have to try and seek consensus on, because they're very large-ticket items, and it's a question of getting it right. It's very easy to put a duty of quality as words on the page, but I think it's the how do we achieve that quality that is the main issue.

In terms of the duty of candour, it's absolutely my view that, unless the complaints system is fully integrated into the plans for continuous improvement of professional development, it is absolutely not fit for purpose, and we've seen countless horror stories happen all over the UK where this has not been the case.

One of the most important things about the current community health councils is their right to inspect, their right to enter premises, health premises, and see what is there that the patient is experiencing. So, whatever replaces the CHC has to have that capability to stand up for the citizen, and we all can agree that there is a need for a culture change, because too many of us are dealing with issues in our constituencies where people simply haven't been properly informed about what is going to happen to them.

I'm not on any of the committees where the committee Chairs have spoken, so I want to probe how this Bill empowers stakeholders to reshape services to better meet people's needs, obviously in line with prudent healthcare, because, otherwise, we will continue to have a bottomless pit from our health services. It's very good to read in the explanatory memorandum that we have to have a system that's 

'person centred and seamless; without artificial barriers' and

'where NHS bodies are not just there to manage or deliver care but to improve it every day' and we need to ensure that the voice of the citizen is clearly heard.

The Minister will know I have a particular interest in Buurtzorg as a radical new way of working to better meet the needs of citizens. I don't know if you've all seen the report that was published in one of the national newspapers last week about the way in which Buurtzorg has been applied to children's social services in England, and where there's been an absolutely dramatic improvement in the amount of time that social workers are able to spend with families—so, instead of it being a little more than 20 per cent of their time, as opposed to form filling and other bureaucratic tasks, they're now able to spend at least 60 per cent of their time with families, which surely must improve the outcomes for those families. So, in relation to the healthcare needs and the social care needs of the elderly, this seems to me an entirely important way of looking further at how we better meet the needs of our elders towards the end of their life.

So, I want to probe how this Bill is going to advance the voice of the citizen being heard, and how it will enable professionals to be able to change the way they're working without having to have a fight with bureaucrats at the top of the tree. What do the three Buurtzorg pilots of the last 12 months tell us about their ability to ensure that the citizen's voice is much more centre stage? The chair of Cwm Taf health board, which is one of the three Buurtzorg pilots, reports that the trial is progressing well. It's too early to tell, but the encouraging signs are that this will enable us to have a change in the way people are using unscheduled care. Patients and nurses report feeling that the nature of the conversation they're having is changing, and that the conversation is now focused on what the patient wants to achieve and how the patient and the nurse can work together to achieve that. The conversations are becoming more co-productive and relationships are being restructured.

So, that's a very positive message coming from Cwm Taf, but it would be very good to know what's happening in the other two pilots. What is the potential for the other two pilots to indicate—for improved job satisfaction and capacity of professionals to take their own initiative to better meet the needs of patients? How does this Bill eliminate the barriers to rolling out this way of working—for example, the transfer of data from one agency to another, so that patients aren't simply having to tell their story time over? And does the Bill allocate sufficient resources for the continuous professional development required for self-managed teams? Are senior managers going to let go to enable that to happen?

My party will be supporting the general principles of the Health and Social Care (Quality and Engagement) (Wales) Bill, as there are aspects of the proposed legislation that are badly needed. However, the Bill will need a lot of amending before it is wholly acceptable. The duties of candour and quality are both needed, and are long overdue. These duties will instil an honest culture of openness and transparency in health and social care in Wales. Whistleblowers must have the confidence to come forward when things are not as they should be—how else are we able to improve or correct mistakes? I've spoken many times about the need for a no-blame culture in health, a culture in which we accept that mistakes can happen, and, rather than hiding them, we learn from them.

A duty of quality can help deliver continual improvements in the quality of care, both in health and in social care. However, as drafted, there is much uncertainty about how the duty will work in practice. The NHS Confederation have asked for greater clarity on what is meant by 'quality', not just in health but also in social care. Social Care Wales have criticised the focus the Bill gives to NHS performance. NHS managers have stated that the duty of candour needs further clarification.

There has been widespread critique of the Bill. It's a good idea, but it lacks direction. The health committee have requested that the Government heavily amend their Bill in order to provide greater clarity and greater bite to the duties. If the Welsh Government can strengthen this aspect of the Bill, then my party will support it. There is, however, one part of the Bill I cannot support as is, and that is the decision to abolish community health councils and replace them with a new citizen's voice body. I'd like to know if this body will have local representation, because this is extremely important, and local issues are important, because transparency can only help bring about best practice. I fully support efforts to strengthen the citizen's voice and completely accept that the CHCs were far from perfect. However, I feel we need reform and not replacement. CHCs could have been reformed to enable them to work in social care as well as the NHS. As it stands, the new body will lose local representation, and, most importantly, lose the right to conduct unannounced visits and demand a response from public bodies. As constituted, the citizen's voice will be confined to a whisper and will have no teeth at all to back it up.

I hope the Minister will accept the health committee's recommendations and bring forward substantial amendments at Stage 2. We have an opportunity to deliver true improvements to the quality of health and social care, and this Bill provides a starter for 10, but we have a long way to go before we can deliver a truly transformative piece of legislation. I support the general principles of the Bill and look forward to working with all parties in this Chamber to improve this proposed legislation. Diolch yn fawr.

Thank you. Can I call on the Minister for Health and Social Services to reply to the debate?

Yes. Thank you, Deputy Presiding Officer, and thank you to Members who have contributed in today's debate, but, more than that, as I say, to the ongoing scrutiny process over a period of time.

I should start, perhaps, with the comments made by the Plaid Cymru spokesperson in indicting that their whole group had changed their mind post the committee's report. That's obviously disappointing, but you're allowed to change your mind and take a different position and cast a vote in that way. I don't agree with her comments that the Bill is inadequate or potching around the edges—I think this will make a substantive and material step forward for health and social services.

In terms of some of the points made by a number of Members about community health councils, I should just point out that I don't think it's helpful for the community health council movement to talk about one community health council that should be saved. That's almost damning everyone else with faint praise or absence, and it's also worth noting—[Interruption.] It's also worth noting that the current community health councils are hosted by Powys Teaching Health Board. The suggestion that moving them to a position where the entire board goes through an independent public appointments process, that that somehow lessens their independence, is not one that I think stands up to the evidence.

I'll take the intervention, but I will need it to be brief.

Yes. I just wanted to refer to the North Wales Community Health Council, because it is greatly appreciated, and I think what the problem is in our community health council movement, if I may put it as a problem, is that there's an inconsistency between the quality and the depth of the work in some community health councils when compared to others. So, for example, the value that's attributed to the North Wales Community Health Council is because of the excellent work that it does on advocacy, on speaking up for patients, and being a very effective patient watchdog. In my years as the shadow health Minister—I know that others in this Chamber will agree—I found there to be a great inconsistency in the way that community health councils engaged with members of the public, and the way that they supported them in raising their concerns. And, when you have a good model, you want everybody to have access to that model—you don't want to scrap it.

Well, I think that reinforces two points. The first is that I still don't think it's helpful to try and say there is a good community health council and that others aren't. I think that's problematic. It's not a view that the national board of community health councils themselves take.

And the second is, of course, that, in talking about wanting to have different ways of working, there's a point about whether you want to have a national model, where you say you want some consistency on a national level with local standing, or whether or not you want to have different ways of working across the region. The approach we're taking is actually to say that we want a national model that is consistent, with local standing and local representation. I've indicated I'll bring forward amendments to set that out. And, again, to underscore the independence of the new body, it will be significantly more independent than current community health councils, and I don't believe it will be remote.

I will confirm, briefly, in terms of Angela Burns's point, that the consultation responses—there will be a consultation and it'll be published, as is the normal matter of working, on the statutory guidance that I've indicated.

On your point about whistleblower protection, I don't think that the face of the Bill is the place to do that, actually. You're talking about employment rights in some of the cultural change. It is important, though, that the duties of quality and candour move us to a position where people are more likely to raise concerns and the organisational response will actually make real the current rights people are supposed to have. And I say that as someone who used to be a former employment lawyer and dealt with the reality of people who had been whistleblowers and the way that they'd been dealt with in their workplace, in the public and the private sector.

I hope that in the opening I did demonstrate that I have listened to what committees have had to say, and I'm genuinely interested in developing the best possible piece of legislation. Of course, other people may not agree, and that is part of the point of the scrutiny process and the votes that we cast in this place. But I do hope we'll have the best possible piece of legislation, the response to the recommendations and the approach I've set out for statutory guidance, and I look forward to continuing this debate into Stage 2, and I hope we can have a proper, modern and fit-for-purpose piece of legislation on the statute book here in Wales. 

Thank you. The proposal is to agree the motion. Does any Member object? [Objection.] Therefore we'll defer voting on this item until voting time. 

Voting deferred until voting time.