The first group of amendments relates to the duty to secure quality in health services—workforce planning and appropriate staffing levels. Amendment 21 is the lead amendment in the group, and I call on Angela Burns to move the lead amendment and to speak to the other amendments in the group. Angela Burns.

Amendment 21 (Angela Burns, supported by Caroline Jones) moved.

Thank you, Presiding Officer. I formally table the amendments here in my name. I would like to, at the outset, Minister, say that these are by way of probing amendments. You do have the opportunity, by your response, to ensure that we don't have to spend time in voting from 21 to 34. 

These amendments have been retabled by us from Stage 2. They were previously tabled as a mix from Helen Mary Jones and from me, and they are in support of committee recommendation 4, because I think it is necessary to remember the Royal College of Nursing's comments on the Bill at Stage 1, saying that this Bill is an ideal opportunity for the Welsh Government to progress with the principles of the Nurse Staffing Levels (Wales) Act 2016 and to broaden its applicability. It's particularly relevant to section 25D of this Act, which is about making sure that local health boards and NHS trusts may undertake these provisions in order to enable them to comply with their duties under this Act.

Now, surely this chimes with what the Minister also said at Stage 1, when he said that the duty of quality is more than just a cultural change, and I agree with him. To have a cultural change, all clinical staffing groups should be part of sufficient workforce planning. Amendment 33 outlines that the Welsh Government must take reasonable steps to ensure that there are a sufficient number of specific healthcare staff, including nurses, midwives and medical practitioners. As I noted at Stage 2, it was heartbreakingly clear in the case of Cwm Taf that a number of factors, including an insufficient level of midwives, caused the catastrophic collapse in the provision of safe care that we saw there.

So, we believe it's the Welsh Government's duty to ensure that it's not repeated again, and we think that this Bill is a very good vehicle to do that through. There is no routine reporting of midwifery vacancies, and Healthcare Inspectorate Wales's national review of maternity services in Wales won't be published until later this summer. So, without this key data on an ongoing basis, rather than a one-off review, we're not aware of whether there are enough maternity staff in every health board in Wales.

The first part of amendment 34, a duty to ensure appropriate staffing, is intended to hold the Welsh Government to the same standards and expectations as an NHS body. It does require the Minister to demonstrate what action has been taken to achieve this. Now, let me be clear, with the cases that we're now seeing of COVID-19 appearing in Wales, and noting the potential pressures on staffing that a full outbreak will have, now is the time to monitor pressures within the health system, so that we know whether our health boards are able to deliver those safe levels of care.

The second part of our amendment, the duty to have a real-time staffing assessment in place, will ensure that staffing levels are regularly monitored so that NHS bodies and Ministers actually respond to issues as they happen in real time, instead of only responding to agreed procedures from months or years before. As I noted at Stage 2, there are already issues with safe nursing levels, as the Royal College of Nursing is still concerned that neither the Welsh Government nor NHS Wales publish national figures for nursing vacancies using an agreed definition of what constitutes a vacancy. And annual data published by the Welsh Government on nursing levels does not adequately reflect patient need or service development, including comorbidities and an ageing population. 

The third and final part of the amendment, the duty to have a risk escalation process in place, will give every single member of staff a clear mechanism to raise concerns if they are working in settings where they feel the levels of available staffing are not conducive to safety. 

At Stage 2, it was noted by the Minister that he would not support these amendments—so, I understand that at the moment—as the Bill would not be the appropriate mechanism for enacting a change of this magnitude, and that applying any principles of the nurse staffing levels Act to all other clinical staffing groups in Wales without the same degree of consideration and scrutiny would be inappropriate and inconsistent. Yet, as we have so often said before with Welsh Government legislation, the Bill's provisions on the duty of quality are overly broad. It therefore risks becoming an aim rather than a duty, without specific mechanisms for health boards to undertake the necessary action to ensure it is upheld and monitored routinely. 

I do also, Minister, dispute your concerns about the financial considerations, as having appropriate staffing levels in place will cost NHS bodies and Welsh Government less money in the long term due to less sickness and stress-related illnesses, as well as improved mental health for all staff. The amendments also recognise that the onus is not solely placed on NHS bodies, and that Welsh Government have a role to play in the long-term secure future of staffing levels for NHS bodies.

I do note the points that you raised in Stage 2 in your letter to the Chair of the Health, Social Care and Sport Committee on 26 February, in which you said that Schedule 3 to the Bill amends subsection 47 of the Health and Social Care (Community Health and Standards) Act 2003 to require NHS bodies to take into account the healthcare standards. However, as will be outlined in my amendments in group 7, these standards have not been updated since 2015. Since then we've had a rapidly ageing population, as well as advances in technology that mean they are fast becoming obsolete. Therefore, I would be grateful if the Minister could outline a timeline on the refreshed standards, as well as placing on record his commitment to a clear mechanism to review these standards regularly.

Minister, should you be prepared to answer these questions on the health and care standards, as well as commit to supporting amendments 36 and 37, I would be prepared to withdraw these amendments.

We on the Plaid Cymru benches will be supporting these amendments, but I would like to take a few moments to explain how we will engage with this Bill more generally at the outset.

There are a number of reasons why we believe we're unable to support the Bill as currently drafted and that it's unlikely that we could support the Bill after we've gone through the process that we're going through today. There are a number of reasons for that, and the main reason is that this Bill would weaken the voice of the patient by abolishing the community health councils, which have been strong advocates for patients, and that's certainly true in the part of Wales in which I live, in north Wales. And there's also a failing in the Bill in providing instead of what we have now a model that would provide the same independence and the same understanding of the reality and the needs for health and care services in various parts of Wales.

But there are other parts of the Bill that we also think are inadequate. What we have here is a Bill that appears to be putting quality at the heart of service planning, but then fails to sufficiently, clearly and robustly define what the expected quality and standards are, referring rather to health and care standards, and the latest document that defines those is dated 2015, I believe. Therefore, there are fundamental weaknesses here that we regret that we haven't been able to tackle in an appropriate manner during this Bill's processes through the Senedd. And here I pay tribute to Helen Mary Jones for the work that she did as health spokesperson for Plaid Cymru during the earlier stages of this Bill's progress through the Senedd.

Turning to the specific amendments, the Minister, I know, will no doubt say today that the health and care standards already consider the need for workforce planning. Standard 7.1 says that

'Health services should ensure there are enough staff with the right knowledge and skills available at the right time to meet need.'

Is that enough in itself? There are also a range of criteria that are used to explain what that means. That includes matters like attending training programmes, that the workforce are able to raise concerns, that health boards have effective workforce plans. That's what we're told currently. But I'll ask you, as Members: do we genuinely believe that these criteria are being adhered to at the moment? The evidence I see is that they are not, and we have an opportunity in this Bill to strengthen that. We need something more robust. I would suggest a direct reference to the workforce on the face of the Bill.

So, we'll support these amendments on the workforce because you cannot have an NHS without a workforce, and I sincerely hope that these amendments will pass.

I thought long and hard about whether to table my own amendments to this Bill, and in the end, I opted to support amendments put forward by my colleagues. The whole point of amending legislation is to improve it, to ensure that the resulting Act will benefit the people who chose us to represent them. Instead of us all going our own way with competing amendments, it was better to put aside party differences, and at the end of the day, it matters little to the people of Wales whether amendments were put down by the Welsh Government, Welsh Conservatives, Plaid Cymru or the Brexit Party. All that matters is that this legislation delivers upon its stated aim of improving quality and engagement in both health and social care.

I chose to support Angela's amendments in this group because, like her, I don't believe the Welsh Government has gone far enough in its duty to secure quality in health services. A lack of strategic workforce planning has left our NHS short-staffed, which, in turn, has had a dramatic impact on services in recent years. If we are to improve quality in health and social care, we have to ensure that our excellent staff have the time to care. Because Governments of all colours failed to do any adequate workforce planning, we have staff shortages across the board. Many hospital departments only function because of the heroic levels of determination of staff. Unfortunately, burn-out is all too real. We can only secure quality if we have our health and social care services staffed with sufficiently and suitably qualified and competent individuals, and I urge Members to support the amendments in this group.

A constituent wrote to me last month after publication of the report on hospital vascular services' overhaul leaving people fearful in north Wales, this was written by the north Wales community health council, the public watchdog that holds the Betsi health board to account, and which the Welsh Government is considering disbanding—exclamation mark. As the sector has told me, only independent bodies give true challenge.

Community health councils were abolished in England in 2003. Abolition took three years against much opposition. The fate of English community health councils was sealed when the then UK Government did a deal with the Welsh, Scottish and Northern Irish administrations at the time, allowing them to keep their own community health councils if they supported the abolition of English community health councils.

The Francis report found that community health councils in England

'were almost invariably compared favourably in the evidence with the structures which succeeded them. It is now quite clear', the report said,

'that what replaced them, two attempts at reorganisation in 10 years, failed to produce an improved voice for patients and the public, but achieved the opposite.'

And Andy Burnham, who was then an MP, doubted in retrospect the wisdom of abolishing community health councils. He said their abolition was not the then UK Government's finest moment:

'It seems we failed to come up with something to replace CHCs that did the job well.'

Well, the hands-on experience of those who worked in the organisations that followed community health councils in England was that effective monitoring and scrutiny was lost for a substantial period of time on each occasion there was a reorganisation.

As I said here three years ago, in terms of staffing, for year after year after year, Labour Welsh Government has dismissed warnings that we faced a GP crisis in north Wales, given by professional bodies, including BMA Wales, the Royal College of General Practitioners Wales, and by myself and shadow Cabinet colleagues on behalf of the NHS Wales staff and patients who've raised their concerns with us.

Speaking here in January, I noted that, at the end of 2019, the Royal College of Nursing launched its 'Progress and Challenge' report on the implementation of the Nurse Staffing Levels (Wales) Act 2016, which said that:

'The nursing workforce in Wales is facing a national crisis. The high number of vacancies...estimated...as around 1600 at a minimum'— quote—

'are compounded by greater shortages in the care home sector and the prospect of significant losses to retirement over the next...10 years.'

They pose questions for the Welsh Government, including:

'How are the "special measure" arrangements'— for Betsi Cadwaladr University Health Board—

'monitoring and supporting the board to be compliant with the Act?'

'Will you increase student nursing numbers as Betsi Cadwaladr University Health Board has requested?'

'Will you support the placement of non-commissioned student nurses'— from Glyndŵr University—

'as the Betsi Cadwaladr University Health Board has requested?'

Well, BMA Cymru Wales is now calling for safe staffing to be enshrined in Welsh legislation, supported by the Royal College of Nursing Wales, Royal College of General Practitioners Wales, Academy of Medical Royal Colleges Wales, the Royal College of Physicians Wales, the Royal College of Surgeons Edinburgh and Royal College of Midwives Wales. They say the safety of patients depends on doctors and healthcare staff working in a safe system, but, due to the ongoing treatment and retention crisis in the NHS, doctors no longer feel this is the case, and fear the health of their patients is at risk. They say Wales has recognised the importance of legislating for safe nurse staffing levels with the Nurse Staffing Levels (Wales) Act. They say that Scotland has taken action to legislate on safe staffing with the Health and Care (Staffing) (Scotland) Act 2019, passed with cross-party support. They say that doctors are facing increased pressures, medical staff are being pushed to breaking point, and that vacancies continue to climb. They say there aren't enough doctors to fill rota gaps, and the inevitable knock-on effect is a drop in standards of care for patients.

Collectively, they strongly welcomed recommendation 4 from the Health, Social Care and Sports Committee report referred to by Angela Burns, recommending

'the Minister amends the Bill to make specific provision for appropriate workforce planning/staffing levels as part of the duty of quality.'

They said, 'We believe the guidance must be included in Part 2 of the Bill so that, at the very least, Welsh Government can introduce guidance to NHS bodies that informs them how they can achieve the duty of quality. This guidance should address the need for effective workforce planning.' A similar guidance process is set out in the section on duty of candour.

I therefore urge this Assembly to support Angela Burns's amendments. I welcome the support from across the Chamber, but note that, if the Minister is able to bring forward his own proposals to address these concerns, Angela would withdraw her amendments. We wait to hear what he might have to say. Thank you.

Thank you, Llywydd. I want to thank, at the outset, people who have worked on this Bill to date, both the scrutiny we've had through the committee process, as well as officials and all those who engaged in the White Paper stages and wider consultation. We will have various points of disagreement, and some points of agreement, through the passage of this evening. I won't respond to some of the broader comments about the future arrangements to replace community health councils; we'll come to that group later in the Bill.

In terms of staffing, of course, this Government supports the principle of having sufficient staff in our health service: having the right staff in the right place with the right skills.

I want to address the amendments in this group in two parts: firstly, whether the definition of quality should explicitly include staffing levels itself, and, secondly, amending the Bill to include a staffing duty.  

I want to be clear: the duty of quality, as drafted, is deliberately broad. It captures all aspects of the health service and relates to everything the health service has responsibility for. Workforce considerations are clearly a key enabler to meet the duty of quality. No body can ensure it secures services that are, for instance, safe and effective and provide a good experience unless they've given consideration to the types and the numbers of staff needed to achieve that.

And we are deliberately using the internationally recognised definition of quality put forward by the former Institute of Medicine in the states, and the person who went on to lead that institute was Don Berwick, who took part as one of our international experts in the cross-party endorsed parliamentary review. As I have said, having the right staff in the right space with the right skills is, in effect, the resource needed to secure improvements in quality. Staffing in and of itself is not defined as meaning quality. The workforce is there a key and most significant enabler in being able to secure improvements in quality.

Now, as has been said, Schedule 3 to the Bill links the duty of quality to the health and care standards, which have a whole theme, with detail on them, on staff and resources. NHS bodies will therefore need to demonstrate that full consideration has been given to workforce matters in discharging the duty of quality.

As I've indicated previously, and in particular in the useful and constructive discussions we had after Stage 2 with other parties, the standards are kept under regular review, and, in fact, a review is about to take place within this year. The passage or otherwise of this Bill will obviously help to inform the review of those standards and the framework we expect people to respond to.

The statutory guidance will deal with the application of the duty across all functions of the health service, and will undoubtedly highlight the importance of workforce planning, alongside the requirement to consider securing improvements through areas such as prevention, health improvement, and taking action to address inequality in outcomes.

I'm pleased to confirm that the RCN and the BMA have offered to work with us on developing the guidance, and of course I very much welcome that offer. The amendments on staffing levels being included in the definition of quality are not, therefore, in my view required.

Turning to the amendments that seek to extend the staffing duty to Welsh Ministers, I have to say at the outset that I'm firmly of the view that making a change of this magnitude by way of amendments to a Bill is simply not the right approach. The Nurse Staffing Levels (Wales) Act 2016 benefitted from significant planning and considerations of the financial ramifications, and was subject to the full scrutiny that we would all expect for such a landmark piece of legislation. And it was important to ensure that it was done in the right way. Applying any of the principles of that Act to all other clinical staffing groups in Wales without the same degree of care, consultation, consideration and scrutiny would be wholly inappropriate.

The Royal College of Nursing in their own evidence to the health committee acknowledged that a change of this magnitude is not something that they believe is suitable to try and achieve by way of an amendment. When you consider not just the headline measures, but also the process measures as set out in the highly detailed amendments for reporting mechanisms, you would have to do a considerable amount of financial work on the workforce implications as well as the availability of staff and having the tools to calculate staff—the appropriate levels of staff—in different settings.

In the case of inserting a section 25AA, as set out in the amendment put forward by Angela Burns, it would inappropriate and impracticable to level such a duty on Welsh Ministers when it is health boards and trusts who have that operational responsibility for those staffing considerations. The proposed amendment is in essence an extension of section 25A of the Nurse Staffing Levels (Wales) Act 2016 to all clinical staff, and it's very clearly a duty for health boards and trusts.

It is important to recognise that NHS bodies already have arrangements in place for ensuring that managers and senior decision makers are informed of staff shortages where this is likely to present a risk to patient safety. These arrangements include decisions to be taken 'in-hours' and 'out of normal working hours', and that includes arrangements for informing executive board members where appropriate, for them to make choices.

I am therefore unable to support the amendments put forward in this area, and ask Members to oppose them.

I call on Angela Burns to reply to the debate.

Diolch, Llywydd. I guess your answer's no real surprise, Minister, to any of us who believe really passionately that, to have a duty of quality, you need to have the right staff in the right place at the right time. And I think to those of us who've seen over the last few years again and again the instances where there haven't been enough staff and they haven't been in the right place and they haven't been at right time, and it has led to some very, very sad and demoralising situations within the NHS—.

That initial legislation, when it first came in, as introduced by your Cabinet colleague Kirsty Williams, was groundbreaking. But we've done nothing to build on it, and we've done nothing to really take it forward. Now this supports a recommendation in the health committee. This was a recommendation where we took an awful lot of witness evidence. This is what the specialists are saying. This isn't just Angela Burns, Welsh Conservative, or Rhun ap Iorwerth, Plaid Cymru, or Caroline Jones, Brexit Party, just trying to be difficult and invent something. This is actually as a result of really considered evidence by the specialists. And if you ever say it once when you stand up in this Chamber, you say it many, many times: 'We must listen to the clinicians. We must listen to the professionals.' We did. We did, hence these amendments.

I've never been one for legislation lite—I do believe, if you do legislation, you have to do it really well, so it has a really effective part. And the whole point of this Bill is about quality and about candour and about patient representation. And I fail to understand how you can possibly hope to deliver that level of quality if there are chances that you do not have the right staff, whatever they are, in the right place at the right time.

And I will just add one last thing, which is you make the comment that health boards are already supposed to be doing this. Well, we know that they're not, so I would like to move these amendments tabled in my name.

The question is that amendment 21 be agreed to. Does any Member object? [Objection.] We proceed therefore to a vote on amendment 21. Open the vote. Close the vote. For 23, no abstentions, 28 against. Therefore, amendment 21 is not agreed.

Amendment 21: For: 23, Against: 28, Abstain: 0

Amendment has been rejected

Amendment 22.

Angela Burns, is it being moved?

Amendment 22 (Angela Burns, supported by Caroline Jones) moved.

Yes.

The question is that amendment 22 to be agreed to. Does any Member object? [Objection.] We therefore proceed to a vote on amendment 22, tabled in the name of Angela Burns. Open the vote. Close the vote. In favour 23, no abstentions, 27 against. Therefore, amendment 22 is not agreed.

Amendment 22: For: 23, Against: 27, Abstain: 0

Amendment has been rejected